The effect of early extubation on postoperative delirium in patients with liver transplantation: a propensity score matching analysis

BACKGROUND: Maintenance of tracheal intubation is associated with use of sedatives, stress due to mechanical ventilation, or respiratory complications. The aim of this study is to compare the incidence of delirium between early and late extubation groups after liver transplantation (LT). METHODS: Medical records from 247 patients who received LT from January 2010 to July 2017 in a single university hospital were retrospectively reviewed. Patients were divided with 2 groups: Those who underwent early extubation after LT (E group, n = 52) and those who underwent extubation within few hours of intensive care unit (ICU) admission after surgery (C group, n = 195). The patients’ demographic data, perioperative managements and postoperative complications were collected. Early extubation was defined as performing extubation in the operating room after LT. A propensity score matching analysis was performed to reduce the effects of selection bias. RESULTS: Among them, 4/52 (7.69%) in E group and 30/195 (15.38%) in C group occurred postoperative delirium after LT, respectively (P = 0.180). After propensity score matching, there was no difference of the period of hospitalization in ICU (P = 0.961), time to discharge after surgery (P = 0.117) and incidence of delirium between groups (P = 1.000). CONCLUSIONS: Although this study is a retrospective study and limited by the small number of subjects, early extubation does not affect the incidence of delirium after LT. Therefore, further prospective studies on this were needed.

Dantrolene treatment in a patient with uncontrolled hyperthemia after general anesthesia: a case report of suspected malignant hyperthermia: A case report

Fever (body temperature above 38℃) is relatively common during the first few days after general anesthesia. Postoperative fever is usually caused by the inflammation induced by surgery and resolves spontaneously; however, it can be a manifestation of a serious complication such as malignant hyperthermia. We report a case of postoperative hyperthermia (body temperature > 40℃) that was refractory to conventional anti-pyretic measures and finally resolved with dantrolene administration.

Successful early application of extracorporeal membrane oxygenation to support cardiopulmonary resuscitation for a patient suffering from severe malignant hyperthermia and cardiac arrest: a case report / 대한마취과학회지

Malignant hyperthermia (MH) may lead to metabolic crisis of skeletal muscle in susceptible individuals following exposure to triggering agents such as volatile anesthetics or depolarizing muscle relaxants. MH is a rare and a potentially lethal disease, which can lead to cardiac arrest. We report a case of severe MH, in which the rapidly evolving signs of hypermetabolism eventually resulted in cardiac arrest. Despite conventional treatments following cardiopulmonary resuscitation, the patient's vital signs did not improve. Therefore, we applied extracorporeal membrane oxygenation for providing hemodynamic support.

Propofol Infusion Associated Metabolic Acidosis in Patients Undergoing Neurosurgical Anesthesia: A Retrospective Study

OBJECTIVE: Propofol and volatile anesthesia have been associated with metabolic acidosis induced by increased lactate. This study was designed to evaluate changes in pH, base excess (BE), and lactate in response to different anesthetic agents and to characterize propofol infusion-associated lactic acidosis. METHODS: The medical records of patients undergoing neurosurgical anesthesia between January 2005 and September 2012 were examined. Patients were divided into 2 groups : those who received propofol (total intravenous anesthesia, TIVA) and those who received sevoflurane (balanced inhalation anesthesia, BIA) anesthesia. Propensity analysis was performed (1 : 1 match, n=47), and the characteristics of the patients who developed severe acidosis were recorded. RESULTS: In the matched TIVA and BIA groups, the incidence of metabolic acidosis (11% vs. 13%, p=1) and base excess (p>0.05) were similar. All patients in the TIVA group who developed severe acidosis did so within 4 hours of the initiation of propofol infusion, and these patients improved when propofol was discontinued. CONCLUSIONS: The incidence of metabolic acidosis was similar during neurosurgical anesthesia with propofol or sevoflurane. In addition, severe acidosis associated with propofol infusion appears to be reversible when propofol is discontinued.

An unexpected increase of entropy in a sleepwalking disorder patient during propofol and remifentanil anesthesia: a case report / 대한마취과학회지

We report a case of increased values of entropy parameters Response Entropy (RE) and State Entropy (SE) during intravenous general anesthesia in a sleepwalking patient. An ASA class II, 64-year-old woman with stress incontinence underwent mid-urethral sling surgery. Prior to surgery, the patient had been administered paroxetine, valproic acid and clonazepam for the treatment of sleepwalking disorder. After 10 min of target-controlled infusion of propofol and remifentanil, entropy values increased up to 94 (RE) and 88 (SE) for 10 min. The target effect-site concentrations of anesthetics increased from 4 to 7 microg/ml propofol and 4 ng/ml remifentanil, at which point values fell back to adequate anesthesia levels. Episodes of recall or of explicit memories did not occur during the anesthesia. In conclusion, sleepwalking patients with long-term use medications may need increment of anesthetic dose caused by the anesthetic drug metabolism activation or impairment or immaturity of inhibitory circuits in brain.

An unexpected increase of entropy in a sleepwalking disorder patient during propofol and remifentanil anesthesia: a case report / 대한마취과학회지

We report a case of increased values of entropy parameters Response Entropy (RE) and State Entropy (SE) during intravenous general anesthesia in a sleepwalking patient. An ASA class II, 64-year-old woman with stress incontinence underwent mid-urethral sling surgery. Prior to surgery, the patient had been administered paroxetine, valproic acid and clonazepam for the treatment of sleepwalking disorder. After 10 min of target-controlled infusion of propofol and remifentanil, entropy values increased up to 94 (RE) and 88 (SE) for 10 min. The target effect-site concentrations of anesthetics increased from 4 to 7 microg/ml propofol and 4 ng/ml remifentanil, at which point values fell back to adequate anesthesia levels. Episodes of recall or of explicit memories did not occur during the anesthesia. In conclusion, sleepwalking patients with long-term use medications may need increment of anesthetic dose caused by the anesthetic drug metabolism activation or impairment or immaturity of inhibitory circuits in brain.

The determinants of official development assistance for healthcare in Korea

This paper aims to examine the factors that affect the amount of official development assistance (ODA) a developing country receives for healthcare by the Korean government. We empirically tested to what extent the amount of Korea's ODA in health care services, infrastructure, HIV/AIDS, and tuberculosis are affected by the relevant demand factors in the recipient countries. To do so, we carried out country-level multivariate regression analyses by setting the amount of ODA for four health care sectors as dependent variables and the relevant demand factors and economic factors as independent variables. A panel dataset was constructed by combining ODA data from the Organisation for Economic Cooperation and Development and World Development Indicators. The analyses showed that the ODA for health care in Korea is partly meeting the recipient's health care needs. In particular, the recipients with a smaller number of physicians are likely to receive more ODA for medical services. Meanwhile, the amount of international trade with Korea is likely to affect the amount of ODA for medical services. However, disease factors, such as prevalence of HIV/AIDS and tuberculosis, did not positively affect the amount of ODA for those diseases. These results indicate that Korea's ODA system for health care needs to be improved to meet the demand of the recipients in order to achieve the humanitarian objectives set by the international community. We hope that the medical community and the government of Korea can cooperate in setting the global policy agenda for health care ODA based on concrete evidence-based healthcare policy research.

Central pontine myelinolysis in a patient with persistent mild hypernatremia following cadaver donor liver transplantation / 대한마취과학회지

No abstract available.

Bispectral index decreased to zero for a patient undergoing orthotopic liver transplantation / 대한마취과학회지

No abstract available.

Iatrogenic intramural esophageal dissection secondary to insertion of nasogastric tubes and the transorally inserted anvil during robot-assisted total gastrectomy / 대한마취과학회지

No abstract available.

Single pretreatment of remifentanil may reduce pain after propofol and rocuronium injection in rapid sequence induction / 대한마취과학회지

BACKGROUND: We designed this double-blind, placebo-controlled study to compare the efficacy of remifentanil in reducing the pain of both propofol and rocuronium injection during rapid-sequence induction. METHODS: Ninety-five patients, scheduled for elective surgery under general anesthesia, were divided into 3 groups: saline (Group S, n = 31), remifentanil 1 microg/kg (Group R, n = 32), and lidocaine 1.5 mg/kg (Group L, n = 32) were administered after tourniquet application. The occlusion was released after 1 min and 5 ml of 1% propofol was injected over 10 s. Pain on propofol injection was evaluated by a 10-point verbal numeric rating scale (VNRS). The rest of the induction dose of propofol and 1 mg/kg of rocuronium, were injected. Pain on rocuronium injection was evaluated by a four-point score (FPS). RESULTS: The VNRS of propofol injection was as follows: R (0.78) = L (1.34) < S (4.26). The incidence of withdrawal response due to rocuronium was as follows: R (6.3%) < L (53.1%) < S (83.9%). The FPS of rocuronium injection was as follows: R (0.81) < L (1.78) < S (2.93). CONCLUSIONS: Pretreatment with a bolus of remifentanil was effective in simultaneously reducing injection pain of propofol and rocuronium. In addition, remifentanil pretreatment was more effective in suppression of withdrawal response by rocuronium than lidocaine.

Association of Hyperlactatemia and IL-6 Hypercytokinemia after Cardiopulmonary Bypass: A Preliminary Report / 대한구급학회지

BACKGROUND: In cardiac surgery with cardiopulmonary bypass (CPB), hyperlactatemia (HL) is common and is associated with postoperative morbidity and mortality. At present, the cause of HL during CPB is proposed to be tissue hypoxia. Tissue perfusion and oxygen delivery can be impaired to varying degrees during CPB. Although surgery involving CPB apparatus is associated with increased pro-inflammatory mediators, such as TNF-alpha and IL-6, tissue hypoxia that occurs during CPB may be an additionally potent stimulus to inflammation. We hypothesized that hypoxic patients during CPB that experience elevated serum lactate levels, may be related to higher serum cytokine level after CPB than normoxic patients during CPB with normal serum lactate levels. METHODS: Levels of TNF-alpha and IL-6 were measured by ELISA in a) Time 1; before initiation of CPB, b) Time 2; 30 min after aortic de-clamping, c) Time 3; 24 hrs after aortic de-clamping. Levels of lactate was measured at a) Time A; before initiation of CPB, b) Time B; 30 min after aortic de-clamping. Postoperative ICU stay, intubation time and oxygen index were evaluated as postoperative morbidity scale. RESULTS: There were no statistical differences between HL (n = 43, lactate > or =3 mMol/L at time B) and normal lactate group (NL) (n = 63, lactate <3 mMol/L at time B) in demographic data, preoperative left ventricular ejection fraction, CPB time, and aortic cross-clamp time. Level of IL-6 in HL at time 3 was higher than that of NL. The ICU stay and intubation time were longer in HL. The oxygen index on 1st postoperative day was lower in HL. CONCLUSIONS: Our results suggest that hyperlactatemia after weaning from CPB may be related to IL-6 hypercytokinemia, and therefore related to postoperative morbidity.

Effect of remifentanil or esmolol on bispectral index and entropy to tracheal intubation during propofol anesthesia

BACKGROUND: The bispectral index (BIS) and entropy (response entropy, state entropy; RE, SE) have been used to monitor the anesthetic depth, and the difference between RE and SE (RE-SE difference) may represent the nociceptive stimuli during general anesthesia. This study was designed to determine whether BIS or entropy (RE, SE, and RE-SE difference) represent the response to tracheal intubation with iv bolus of remifentanil or esmolol forstable hemodynamic control during propofol anesthesia. METHODS: Eighty-nine patients were randomly divided into three groups (the control, esmolol, and remifentanil groups). Patient received propofol by target controlled infusion with air 2 L/min and O2 2 L/min. After the maintenance with target effect site concentration of propofol 5 microgram/ml for 5 min, patients received normal saline or esmolol 1.0 mg/kg or remifentanil 1.0 microgram/kg iv bolus according to group. And rocuronium 0.6 mg/kg iv bolus was administered and tracheal intubation was done. We measured mean arterial pressure (MAP), heart rate (HR), BIS, and entropy (RE, SE, RE-SE difference) during tracheal intubation. RESULTS: Changes in MAP or HR after tracheal intubation were greater in the control and esmolol groups than those in the remifentanil group. Although BIS, RE, and SE did not increase after intubation in all groups, but RE-SE difference significantly increased at 1 min after tracheal intubation in the control and esmolol group, but was unchanged in the remifentanil group. CONCLUSIONS: Among BIS, RE, SE and RE-SE difference, RE-SE difference is the good indicator for estimate of nociception during tracheal intubation.

Posterior auricular pain caused by the trigger points in the sternocleidomastoid muscle aggravated by psychological factors: A case report / 대한마취과학회지

Psychological factors play a significant role in the pain mechanism, and psychological approaches may be useful complements to traditional medical and surgical treatments in pain management. The authors report a case of recurrent severe posterior auricular pain caused by trigger points in the right sternocleidomastoid muscle and influenced by stressful psychological situations (e.g., family affairs, job loss) in a 50-year-old man.

The effect of intermittent levator massage with caudal block on management of levator ani syndrome: A case report / 대한마취과학회지

Levator ani syndrome (LAS) is a functional disorder of the pelvic floor muscles in which recurrent and persistent distressing pain is felt in the anus without detectable organic pathology. Eighty one percent of coccygodynia was alleviated by the levator massage when the massage motion was repeated 10 to 15 times on each side of the pelvis daily for 5 or 6 days. The authors encountered the LAS patient for whom successive visit to pain clinic was economic burden. Therefore, the authors managed the patient by intermittent levator massage with caudal block, once a week for 3 times, resulting in two years of pain free status. Intermittent levator massage with caudal block may be as effective as successive levator massage and induce longer painless period in the management of LAS.

Occurrence of iatrogenic pneumothorax during laparoscopy-assisted distal gastrectomy: A case report / 대한마취과학회지

The occurrence of a pneumothorax during laparoscopy-assisted distal gastrectomy (LADG) is rare. A pneumothorax was developed during a LADG under general anesthesia in a 67-year-old woman with gastric cancer. About 140 minutes after CO2 insufflation, sudden hemodynamic collapse occurred. A defect was noted in the diaphragm. After immediate repair under laparoscopy, hemodynamic stability was achieved within several minutes. In the anesthetic management of a LADG, the anesthesia provider should be aware of the possible occurrence of a pneumothorax.

Left Ventricular Rupture Immediately after Mitral Valve Replacement: A case report / 대한마취과학회지

Rupture of the left ventricle is a dreadful complication after mitral valve replacement.It is infrequent but potentially lethal. We have experienced a case of sudden hemorrhagic shock immediately after arriving at intensive care unit postoperatively and revealed left ventricle rupture on resternotomy.The possible mechanism and surgical maneuver are reviewed and the preventive measures in aspect of anesthetic management are discussed.

Influence of the Head Posture on Central Venous Catheter Position during Right Subclavian Catheterization / 대한마취과학회지

BACKGROUND: Confirmation of central venous catheter position with chest X-ray is recommended, but frequently omitted in clinical practice. It was suggested that the head posture during right subclavian catheterization affects the incidence of catheter malposition in infants. We evaluated the influence of the head posture on catheter position during right subclavian catheterization in adults. METHODS: Two-hundred and seventy four patients scheduled for thoracic or neuro-surgery requiring central venous catheterization were enrolled. Patients were divided into 3 groups depending on the head posture during catheter insertion: the neutral group (n = 109), the turn away group (n = 72), and the turn toward group (n = 93). The catheter position was confirmed with postoperative chest X-ray. RESULTS: Central venous catheterization was failed in 5 patients. There were no differences in the incidence of catheter malposition and the complications among the 3 groups. CONCLUSIONS: The head posture during right subclavian catheterization did not affect catheter malposition and immediate complication rates.

Association of Tissue Factor Polymorphism with Fibrinolysis and Excessive Bleeding after Open Heart Surgery: A preliminary report / 대한마취과학회지

BACKGOUND: Fibrinolysis, which commonly occurs following cardiopulmonary bypass (CPB), may be related to the excessive bleeding (EB) and morbidity after CPB. It is known that tissue factor (TF), which is triggered by CPB, plays an important role in the initiation of fibrinolysis during and after CPB, however, EB and fibrinolysis after CPB show inter-individual variance. Therefore, in this study, TF -603A/G polymorphism was evaluated to determine if it is associated with fibrinolysis and/or EB and morbidity following CPB. METHODS: RT-PCR was used to determine the TF genotype of each patient. In addition, the amount of blood loss that occurred during the first 24 hours following surgery was documented, and EB was diagnosed when more than 1 L of blood was lost during the first 24 hours following surgery. The D-dimer levels were measured at; a) Time 1; prior to initiation of CPB, b) Time 2; 2 hours after CPB, and c) Time 3; 24 hours after CPB. The oxygen index (OI) was calculated at; 1) OI1; upon admission to the ICU, b) OI2; 24 hrs after admission to the ICU, and c) OI3; 48 hrs after admission to the ICU. The intubation time and the length of the ICU stay were also documented. RESULTS: The serum D-Dimer level of the TF -603AA group (n = 72) measured at time 3 was higher than that of the TF -603GG/GA group (n = 25) measured at the same time. In addition, the incidence of EB and the intubation time of the TF -603AA group were higher than those of the TF -603GG/GA group. Finally, the OI3 of the TF -603AA group was lower than that of the TF -603GG/GA group. CONCLUSIONS: The G allele that is associated with TF -603A/G polymorphism may be protective against fibrinolysis following CPB, therefore, it may also be protective against EB and morbidity following CPB.

Perioperative Hypotension due to Systolic Anterior Motion of the Mitral Valve with Left Ventricular Outflow Track Obstruction during Off-Pump Coronary Artery Bypass Surgery: A case report / 대한마취과학회지

Systolic anterior motion of the mitral valve (SAM) is well known in the concentric left ventricular hypertrophy or post mitral valvuloplasty. However, SAM has not been reported in Off-pump coronary artery bypass surgery (OPCAB). Preoperatively, SAM in combination with a left ventricular outflow tract obstruction leads to severe cardiovascular destabilization. Moreover, a diagnosis of SAM is very important because the administration of conventional therapy to hypotension can aggravate SAM. We report a patient with un-identified left ventricular wall hypertrophy or mitral valve regurgitation, who was diagnosed with SAM by TEE during OPCAB. This report describes the diagnostic and therapeutic strategies for the perioperative management of SAM.