Analysis of Anesthesia-related Medical Disputes in the 2009-2014 Period Using the Korean Society of Anesthesiologists Database

Using the Korean Society of Anesthesiologists database of anesthesia-related medical disputes (July 2009-June 2014), causative mechanisms and injury patterns were analyzed. In total, 105 cases were analyzed. Most patients were aged < 60 yr (82.9%) and were classified as American Society of Anesthesiologists physical status < or = II (90.5%). In 42.9% of all cases, the injuries were determined to be 'avoidable' if the appropriate standard of care had been applied. Sedation was the sec most common type of anesthesia (37.1% of all cases), following by general anesthesia. Most sedation cases (27/39, 69.2%) showed a common lack of vigilance: no pre-procedural testing (82.1%), absence of anesthesia record (89.7%), and non-use of intra-procedural monitoring (15.4%). Most sedation (92.3%) was provided simultaneously by the non-anesthesiologists who performed the procedures. After the resulting injuries were grouped into four categories (temporary, permanent/minor, permanent/major, and death), their causative mechanisms were analyzed in cases with permanent injuries (n=20) and death (n=82). A 'respiratory events' was the leading causative mechanism (56/102, 54.9%). Of these, the most common specific mechanism was hypoxia secondary to airway obstruction or respiratory depression (n=31). The sec most common damaging event was a 'cardiovascular events' (26/102, 25.5%), in which myocardial infarction was the most common specific mechanism (n=12). Our database analysis demonstrated several typical injury profiles (a lack of vigilance in seemingly safe procedures or sedation, non-compliance with the airway management guidelines, and the prevalence of myocardial infarction) and can be helpful to improve patient safety.

Analysis of Anesthesia-related Medical Disputes in the 2009-2014 Period Using the Korean Society of Anesthesiologists Database

Using the Korean Society of Anesthesiologists database of anesthesia-related medical disputes (July 2009-June 2014), causative mechanisms and injury patterns were analyzed. In total, 105 cases were analyzed. Most patients were aged < 60 yr (82.9%) and were classified as American Society of Anesthesiologists physical status < or = II (90.5%). In 42.9% of all cases, the injuries were determined to be 'avoidable' if the appropriate standard of care had been applied. Sedation was the sec most common type of anesthesia (37.1% of all cases), following by general anesthesia. Most sedation cases (27/39, 69.2%) showed a common lack of vigilance: no pre-procedural testing (82.1%), absence of anesthesia record (89.7%), and non-use of intra-procedural monitoring (15.4%). Most sedation (92.3%) was provided simultaneously by the non-anesthesiologists who performed the procedures. After the resulting injuries were grouped into four categories (temporary, permanent/minor, permanent/major, and death), their causative mechanisms were analyzed in cases with permanent injuries (n=20) and death (n=82). A 'respiratory events' was the leading causative mechanism (56/102, 54.9%). Of these, the most common specific mechanism was hypoxia secondary to airway obstruction or respiratory depression (n=31). The sec most common damaging event was a 'cardiovascular events' (26/102, 25.5%), in which myocardial infarction was the most common specific mechanism (n=12). Our database analysis demonstrated several typical injury profiles (a lack of vigilance in seemingly safe procedures or sedation, non-compliance with the airway management guidelines, and the prevalence of myocardial infarction) and can be helpful to improve patient safety.

Postoperative delayed hypercapnia and respiratory failure after robot-assisted lower anterior resection / 대한마취과학회지

No abstract available.

Postoperative delayed hypercapnia and respiratory failure after robot-assisted lower anterior resection / 대한마취과학회지

No abstract available.

Airway obstruction after biopsy by cervical mediastinoscopy in a patient with a mediastinal mass: A case report / 대한마취과학회지

Biopsy, using mediastinoscopy is commonly employed for accurate histologic diagnosis of a mediastinal mass. However, since the mass is not removed during the procedure, it may cause compression of vital structures such as major airways, the heart, the pulmonary artery, and the superior vena cava after surgery. We observed a case of a 66-year-old man with a mediastinal mass that caused severe airway obstruction during recovery from anesthesia following mediastinoscopic biopsy, probably caused by upper airway edema which seemed to originate from compression of the superior vena cava. Therefore, we suggest that unexpected airway obstruction in a patient with a mediastinal mass can be due to superior vena cava compression.

Severe bradycardia during suspension laryngoscopy performed after tracheal intubation using a direct laryngoscope with a curved blade: A case report / 대한마취과학회지

There are a few reports about bradycardia or asystole caused by direct laryngoscopy. However, we encountered severe bradycardia in response to suspension laryngoscopy for laryngeal polypectomy after safely completing tracheal intubation using a direct laryngoscope with a curved blade. The tip of the curved blade of the direct laryngoscope is positioned at the vallecula (between the base of the tongue and the pharyngeal surface of the epiglottis) during tracheal intubation, while the blade tip of the suspension laryngoscope lifts the laryngeal surface of the epiglottis or supraglottic area during surgery. Therefore, suspension laryngoscopy can be said more vagotonic than curved-blade direct laryngoscopy. Because of the possibility of bradycardia induced by suspension laryngoscopy, clinicians must be careful about severe bradycardia even after safely completing intubation using direct laryngoscopy.

Administration of large fluid volumes decreases the incidence of postoperative nausea and vomiting as effectively as ondansetron / 대한마취과학회지

BACKGROUND: The possibility that large fluid volumes reduce postoperative nausea and vomiting (PONV) remains unclear due to conflicting data. We examined if administering large fluid volumes to high risk patients would decrease the incidence of PONV and compared the results with ondansetron administration. METHODS: Ninety ASA I, II patients who presented for laparoscopic cholecystectomy were randomized to 1 of 3 groups. They received either (group I) 5 ml/kg/hr of Hartmann's solution, (group II) 30 ml/kg/hr of Hartmann's solution or (group III) 4 mg of ondansetron and 5 ml/kg/hr of Hartmann's solution. The incidence of PONV and severity of pain were assessed at 1, 12 and 24 hours postoperatively. RESULTS: The number of PONV episodes was significantly reduced in group II and III compared to group I during the 1-12 hr postoperative period and for total incidence. However, there was no significant difference between group II and III. There were no differences among groups regarding the severity of pain. CONCLUSIONS: Intraoperative correction of intravascular volume deficits with 30 ml/kg/hr of Hartmann's solution decreases the incidence of PONV as effectively as administration of ondansetron.

Effect of A Kappa-opioid Receptor Agonist U50488H Given at Early Reperfusion Phase in Isolated Rat Hearts / 대한마취과학회지

BACKGROUND: The experiment was performed to determine the role of kappa-opioid receptor (OR) agonist U50488H given at early reperfusion. METHODS: Isolated hearts were subjected to 30 minutes of regional ischemia and 120 minutes of reperfusion.Hearts were assigned randomly to one of the three groups:1) Control (n = 9), 2) U50-1 (n = 8); 10micrometer of U50488H, and 3) U50-10 (n = 8); 10micrometer of U50488H.U50488 was perfused for a period of 5 min before and 30 min after reperfusion. RESULTS: U50488H significantly reduced infarct size as a percentage of ischemic area (12.2 +/- 1.9% in U50-1 and 7.2 +/- 1.7% in U50-10, P < 0.001) compared to the control hearts (27.2 +/- 1.2%). After 2 hrs of reperfusion, left ventricular developed pressure was significantly recovered by U50488H (62.6 +/- 5.7% in U50-1 and 68.6 +/- 4.7% in U50-10, P = 0.018 and 0.002, respectively) compared to the control (46.3 +/- 4.4%).Rate-pressure product was improved by 100micrometer U50488H (62.3 +/- 5.5%, P = 0.007) but not by 1micrometer U50488H (50.0 +/- 4.1%) compared to the control (44.7 +/- 4.5%).U50488H significantly increased the + dP/dt(max) (77.9 +/- 5.5% in U50-1 and 78.0 +/- 4.3 in U50-10, P = 0.005 and 0.001 vs. control, respectively).The -dP/dt(min) also improved by 10micrometer U50488H (64.7 +/- 4.8%, P = 0.003) compared to control (47.0 +/- 2.7%). CONCLUSIONS: U50488H given at early reperfusion phase reduces both infarct size and myocardial stunning in isolated rat hearts.

Cardioprotective signaling cascade of A2 adenosine receptor agonist 5'-N-ethylcarboxaminidoadenosine against myocardial reperfusion injury / 대한마취과학회지

BACKGROUND: This experiments investigated the signaling cascade responsible for anti-infarct effect by an A2 adenosine receptor (AR) agonist 5'-N-Ethylcarboxaminidoadenosine (NECA). METHODS: Langendorff perfused isolated rat hearts were subjected to 30 minutes of regional ischemia and 120 minutes of reperfusion. Drugs were perfused for a period of 5 minutes before and 60 minutes after reperfusion. For comparison of cardioprotection among groups, area at necrosis (AN) and area at risk (AAR) were measured by triphenyltetrazolium chloride staining. RESULTS: NECA significantly attenuated AN/AAR (14.1 +/- 1.9%, P < 0.001) compared with control hearts (30.7 +/- 2.8%). Anti-infarct effect by NECA was attenuated by an A(2A)AR antagonist 8-(3-chlorostyryl)caffeine (23.7 +/- 3.4%, P < 0.05) and an A(2B)AR antagonist MRS1706 (29.9 +/- 3.3%, P < 0.001). Cardioprotection by NECA was blocked by a guanylyl cyclase inhibitor (23.1 +/- 2.9%, P < 0.05) and a protein kinase G (PKG) inhibitor KT5823 (30.3 +/- 3.2%, P < 0.001). Glycogen synthase kinase-3beta (GSK-3beta) inhibitor SB216763 attenuated the AN/AAR in both NECA with MRS (17.8 +/- 2.7%, P < 0.01 vs. control) and NECA with KT5823 treated hearts (8.2 +/- 1.8%, P < 0.001 vs. control). The mitochondrial permeability transition pore (mPTP) opener atractyloside also aborted NECA's anti-infarct effect (24.7 +/- 2.4% P < 0.05). CONCLUSIONS: The signaling pathway by NECA administered at reperfusion involves the activation of both A2AAR and A2BAR and cGMP/PKG pathway, which in turn depends on inactivation of GSK-3beta and inhibition of mPTP opening.

Ischemic Postconditioning Inhibits Mitochondrial Permeability Transition Pore via Opioid Receptor Activation in Intact Rat Heart / 대한마취과학회지

BACKGROUND: Ischemic postconditioning (Post-C), brief cycles of myocardial ischemia and reperfusion during the early phase of reperfusion, is considered as a novel adjunct strategy to protect myocardium.However, the exact mechanism remains unclear and should be determined. METHODS: The hearts of male Wistar rats were subjected to 30 min ischemia and 2 hrs reperfusion.Control rats had no intervention either before or after left coronary artery occlusion.Post-C was elicited by 6 cycles of 10s reperfusioninterspersed by 10s ischemia immediately after onset of reperfusion.Subsets of postconditioning rats were treated with drugs as followings; naloxone (non-selective opioid receptor antagonist), naltrindole (a delta-opioid receptor antagonist), SB216763 (a glycogen synthase kinase 3beta inhibitor, GSK-3beta inhibitor), or atractyloside (a mitochondrial permeability transition pore opener, mPTP opener). RESULTS: Post-C significantly reduced infarct size (15.9 +/- 2.4%, P = 0.003) compared to control (29.9 +/- 3.7%).The anti-infarct effect by Post-C was blocked by both naloxone (25.5 +/- 3.9%, P = 0.044) and naltrindole (26.9 +/- 2.3%, P = 0.022).Infarct size limiting effect by Post-C was also abolished by atractyloside (30.6 +/- 3.6%, P = 0.003).In SB216763 with naloxone treated animals, the infarct size was decreased (17.4 +/- 3.2%, P = 0.007) but not in SB216763 with atractyloside treated animals (27.4 +/- 2.6%) compared to control. CONCLUSIONS: These data suggest that Post-C may protect myocardium by inhibiting mPTP opening via delta-opioid receptor activation.GSK-3beta is a downstream mediator of opioid receptors and an upstream mediator of mPTP opening in Post-C.

Factors associated with the outcome of transforaminal epidural steroid injections / 대한마취과학회지

BACKGROUND: This study was undertaken to assaythe effectiveness of transforaminal epidural steroid injections (TFESIs) for sciatica and to identify potential predictors related to treatment outcome. METHODS: TFESIs were performed in 150 patients between August 2006 and March 2007. Seventy-five patients (35 women, 40 men; mean age, 59.1 years), who met the inclusion criteria, were studied. Therapeutic effects were evaluated twoweeks after injection. The following potential outcome predictors analyzed were as follows: one level vs. two level injection, Beck depression inventory score (20), Beck anxiety inventory score (16), cause of radiculopathy (spinal stenosis vs. herniated disk), gender, duration of radiculopathy (6 months), and Oswestry disability index score (60). The relationships between possible outcome predictors and therapeutic effects were evaluated. RESULTS: Forty-nine of the 75 patients (65.3%) had a satisfactory result two weeks after TFESIs. Of these, twenty-four of the 46 patients (52.2%) were treated by a one level injection and 25 (89.3%) of the 29 patients were treated by a two level injection. This outcome was statistically significant (P < 0.01). None of the other potential outcome predictors showed any statistical difference. CONCLUSIONS: TFESI is recommended as an effective method of managing radiculopathy. Two-level injectionsmay result in a better outcome than a one-level injection.

Pharmacotherapy of the Failing Heart and Shock / 대한구급학회지

No abstract available.

Optimal Dose of Remifentanil to Attenuate Cardiovascular Responses to Laryngoscopic Double-lumen Endobronchial Intubation / 대한마취과학회지

BACKGROUND: The purpose of the present study was to determine the optimal dose of bolus remifentanil to attenuate hemodynamic changes to laryngoscopic double-lumen endobronchial intubation. METHODS: A total of 80 ASA I or II patients requiring double-lumen endobronchial intubation were randomly assigned to receive normal saline (NS) or one of the three different doses (0.5microgram/kg (group R0.5), 1.0microgram/kg (group R1.0) or 2.0microgram/kg (group R2.0)) of remifentanil. Study drugs for each group were administered over 30 seconds after induction of anesthesia with thiopental sodium and rocuronium. Laryngoscopic endobronchial intubation was carried out 90 seconds after the administration of study drug. Arterial blood pressure and heart rate were recorded at preanesthetic baseline, preintubation, postintubation, and every one minute during the initial 5 minute period after intubation. RESULTS: Mean arterial pressure at postintubation period increased significantly compared to baseline value in group NS, R0.5, and R1.0, but there were no significant changes in group R2.0. Heart rate showed significant increase in comparison to baseline value at every postintubation period in group NS, R0.5, R1.0, with no significant changes in group R2.0. CONCLUSIONS: We suggest that 2.0microgram/kg of remifentanil attenuate the hemodynamic changes to double-lumen endobronchial intubation without adverse effect.

Tension Carbon Dioxide Pneumothorax Developed during Laparoscopic Partial Hepatectomy: A case report / 대한마취과학회지

Pneumothorax is a rare and potentially serious complication that can be occurred during laparoscopic surgery. This is a case report of a 34-year-old man who underwent elective laparoscopic partial hepatectomy under general anesthesia. About 45 min after carbon dioxide pneumoperitoneum, hypotension, tachycardia, decreased oxygen saturation, increased peak inspiratory pressure, increased end-tidal CO2 tension, hypercapnia, and hypoxemia were suddenly developed. Altering for the worse vital sign was owing to tension pneumothorax by accidental CO2 influx through inadvertently perforated diaphragm. Repairing diaphragm under open laparotomy, positive manual bagging was effectively applied enough not to require surgical drainage. Therefore, closed observation and careful monitoring is essential to prevent tension pneumothorax during laparoscopic surgery.

Beck Depression Inventory Score and Associated Factors in Korean Patients with Lumbar Spinal Stenosis / 대한통증학회지

BACKGROUND: Depression is a frequent comorbid disease of chronic pain patients. This study was conducted to evaluate the prevalence of depression and to correlate associated factors and depression in patients with lumbar spinal stenosis. METHODS: The data of this survey was collected from 97 patients that visited our pain clinic for the management of lumbar spinal stenosis. Depression was examined by a self-reported survey using the Korean version of the Beck Depression Inventory (BDI). The Oswestry Disability Index (ODI) and the life satisfaction scale score were also obtained. Demographic and clinical characteristics (including spouse status, employment status, smoking status, the number of patients with multiple painful areas, the number of patients with combined disease, pain duration, visual analogue scale, Roland 5-point scale and walking distance) were obtained from an interview with the patient. The patients were divided into group N (BDI 14, n = 54) according to the BDI scale. Of the 97 patients, 55.7% had a high BDI score. RESULTS: The patients in group N had a higher rate of employment (48.0%, P < 0.05) and had higher life satisfaction scale scores (9.4 +/- 2.5, P < 0.01) as compared to group D patients. The BDI score showed a close correlation with employment status and the life satisfaction scale. CONCLUSIONS: Many lumbar spinal stenosis patients had high BDI scores. Employment status and the life satisfaction scale were closely correlated with the BDI score.

The Effect of Fenoldopam Administration Followed by Unclamping of Supraceliac Aortic Cross-Clamping on Renal Ischemic Injury / 대한마취과학회지

BACKGROUND: The overall rate of renal complication after surgery on the suprarenal aorta remains high. In this study, the changes in renal blood flow (RBF), urinary oxygen tension (PuO2), renal vascular resistance (RVR), and urinary volume following fenoldopam administration were investigated in supraceliac aortic cross-clamping and unclamping animal model. METHODS: Twelve dogs were divided into two groups; control group (n = 6), fenodopam group (n = 6). After brachial, femoral, and pulmonary arterial catheterization, midline abdominal incision was made. For the aortic cross-clamping the supraceliac aorta was exposed. A doppler flowmeter probe was placed around right renal artery. A ureteral catheter was positioned at the right renal pelvis to measure urine volume and urinary oxygen tension (PuO2). In fenoldopam group, 0.5microgram/kg/min of fenoldopam was administered immediately before suprarenal aortic reperfusion. Systemic hemodynamics, renal blood flow, renal vascular resistance, PuO2, and urine volume were compared between two groups. RESULTS: The systemic hemodynamics were not significantly different between the two groups throughout the experiment. After aortic reperfusion, the RVR significantly increased in control group, but the RVR in fenoldopam group remained to baseline level. The urine output, RBF, and PuO2 significantly increased in fenoldopam group compared to control group. BUN and serum creatinine were not different between the two groups. CONCLUSIONS: High dose of fenoldopam administration reverse ischemic renal insufficiency after supraceliac aortic cross clamping.

Comparison of Blood Loss according to Different Anesthetic Technique for Total Hip Replacement / 대한마취과학회지

BACKGROUND: The mean blood loss is about 500-1,700 ml by general anesthesia technique in total hip replacement (THR) and the amount of blood loss is dependent on the degree of induced hypotension. We performed this study to evaluate the differences on the amount of blood loss and the number of transfused patients according to different anesthetic technique under the similar hypotension level. METHODS: Forty-seven patients of ASA physical status class 1, 2 and 3, scheduled for THR, were randomly assigned into epidural anesthesia group (E group), combined general epidural anesthesia group (GE group) and general anesthesia group (G group). G group was maintained with sevoflurane anesthesia and the monitoring of central and arterial blood pressure was performed. The remifentanil (0.1microgram/kg/min) was infused continuously for the target mean arterial pressure of 60 +/- 5 mmHg. GE group received general anesthesia with the same technique of G group and epidural anestheia was combined after general anesthesia. The remifentanil (0.1microgram/kg/min) was infused continuously for the target mean arterial blood pressure of 60 +/- 5 mmHg. E group received epidural anesthesia with 0.75% ropivacaine and additional bolus dose of local anesthetics was injected if the mean arterial blood pressure did not reach 60 +/- 5 mmHg. RESULTS: The mean volume of blood loss and the number of transfused patients was significantly less in E or GE group at 24 hour after surgery (P < 0.05), however we could not find any significant differences during intraoperative period. CONCLUSIONS: Epidural or combined general epidural anesthesia technique is a good method to reduce bleeding and the number of transfused patients.

Effects of Remifentanil and Fentanyl on Postoperative Nausea and Vomiting in Laparoscopic Cholecystectomy with using Propofol / 대한마취과학회지

< 0.05; n = 8 vs. n = 1, fentanyl and remifentanil, respectively). However, the incidence of PONV at 0-1 hr and 12-24 hr and the total incidence of PONV were not different between the two groups. CONCLUSIONS: The use of ultra-short acting remifentanil instead of fentanyl can reduce PONV at 1-12 postoperative hours in the laparoscopic cholecystectomy patients.

Entrapment of Pulmonary Artery Catheter in the Purse-String Suture at the Inferior Vena Cava Cannulation Site: A case report / 대한마취과학회지

A 63-year-old female with mitral stenoinsufficiency (stenosis and insufficiency) underwent mitral valve replacement. Under general anesthesia, pulmonary artery catheter (PAC) was inserted via the right internal jugular vein. Because the PAC function was normal in perioperative period we didn't recognize the entrapment of the PAC. But on attempting reposition of catheter in postoperative period, we encountered resistance, and postoperative chest X-ray revealed the catheter formed acute angle near right atrial wall. We suspected entrapment of PAC and decided to repeat sternotomy to release the PAC. We found the PAC encircled in the purse-string suture at the inferior vena cava cannulation site. The PAC was removed without any complications.

Preventive Effect of Conduit Vessel Spasm after Coronary Artery Bypass Grafting Surgery / 대한마취과학회지

BACKGROUND: Use of radial artery (RA) for coronary artery bypass grafting (CABG) is an increasingly common practice. The objective of our study was to compare the effects of two drugs as antispastic agents in patients undergoing CABG. METHODS: Sixty patients, submitting to CABG using the RA, were randomly assigned to two treatment groups (n = 30 in each group). Following the induction of anesthesia, the two groups were administered either 0.2-2microgram/kg/min nitroglycerin or 0.05-0.1 mg/kg/hr diltiazem as a continuous IV infusion. CABG in both groups was performed as per standard surgical protocol. RESULTS: The peak serum creatinine phosphokinase-MB level (59.3 ng/ml for nitroglycerin treatment versus 57.7 ng/ml for diltiazem treatment), postoperative ejection fraction (52.3% versus 48.4%), duration of stay in the ICU and total length of hospital stay were not significantly different between the groups (P > 0.05). However, the need for inotropic agents to prevent or treat intraoperative hypotension was less for patients in the nitroglycerin group than for patients in the diltiazem group (60.0% to 83.3%). CONCLUSIONS: Our results indicate that nitroglycerin is superior to diltiazem as an antispastic agent. We suggest that nitroglycerin should be the agent for choice for the prevention of conduit RA spasm.