Reliability of Marked Scales on Intravenous Fluid Plastic Bags

Precise fluid administration is important to prevent hypo- or hypervolemia. However, the accuracy of scales marked on intravenous (IV) fluid plastic bags had remained unknown. Ten 1 L sized IV crystalloids were prepared from each of three manufacturers (H, J, and D). At each scale, the actual volume of the IV fluid was measured. Differences with the measured volumes for each scale were investigated between the three manufacturers. All initial total volume was greater than 1 L. Except for the full-filled level, H overfilled, whereas J and D filled less. For J and D, the maximal differences between the scale and the measured volume were about 200 mL. Fluid volumes of each scale were significantly different among the three manufacturers (P < 0.001). It is inaccurate to measure the amount of fluid depending on the IV bag scales. Clinicians must use electronic infusion pumps for accurate fluid administration.

The Effects of Intravenous Fluid Viscosity on the Accuracy of Intravenous Infusion Flow Regulators

Intravenous infusion flow regulators (IIFRs) are widely used devices but it is unknown how much the difference between the IIFR scale and the actual flow rate depends on the viscosity of the intravenous (IV) fluid. This study evaluated the effects of viscosity on the flow rate of five IV fluids (0.9% normal saline, Hartmann’s solution, plasma solution-A, 6% hetastarch, and 5% albumin) when using IIFRs. The viscosity of crystalloids was 1.07–1.12 mPa·s, and the viscosities of 6% hetastarch and 5% albumin were 2.59 times and 1.74 times that of normal saline, respectively. When the IIFR scales were preset to 20, 100, and 250 mL/hr, crystalloids were delivered at the preset flow rate within a difference of less than 10%, while 6% hetastarch was delivered at approximately 40% of the preset flow rates and 5% albumin was approximately 80% transmitted. When delivering colloids, IIFRs should be used with caution.

Medicosocial Conflict and Crisis due to Illegal Physician Assistant System in Korea

The Korean Medical Association opposes the illegal attempt to implement the physician assistant (PA) system in Korea. The exact meaning of ‘PA’ in Korea at present time is ’Unlicensed Assistant (UA)’ since it is not legally established in our healthcare system. Thus, PA in Korea refers to unlawful, unqualified, auxiliary personnel for medical practitioners. There have been several issues with the illegal PA system in Korea facing medicosocial conflicts and crisis. Patients want to be diagnosed and treated by medically-educated, licensed and professionally trained physicians not PAs. In clinical settings, PAs deprive the training and educational opportunities of trainees such as interns and residents. Recently, there have been several attempts, by CEO or directors of major hospitals in Korea, to adopt and legalize this system without general consensus from medical professional associations and societies. Without such consensus, this illegal implementation of PA system will create new and additional very serious medical crises due to unlawful medical, educational, professional conflicts and safety issues in medical practice. Before considering the implementation of the PA system, there needs to be a convincing justification by solving the fundamental problems beforehand, such as the collapsed medical delivery system, protection and provision of optimal education program and training environment of trainees, burnout from excessive workloads of physicians with very low compensational system and poor conditions for working and education, etc.

Medicosocial Conflict and Crisis due to Illegal Physician Assistant System in Korea

The Korean Medical Association opposes the illegal attempt to implement the physician assistant (PA) system in Korea. The exact meaning of ‘PA’ in Korea at present time is ’Unlicensed Assistant (UA)’ since it is not legally established in our healthcare system. Thus, PA in Korea refers to unlawful, unqualified, auxiliary personnel for medical practitioners. There have been several issues with the illegal PA system in Korea facing medicosocial conflicts and crisis. Patients want to be diagnosed and treated by medically-educated, licensed and professionally trained physicians not PAs. In clinical settings, PAs deprive the training and educational opportunities of trainees such as interns and residents. Recently, there have been several attempts, by CEO or directors of major hospitals in Korea, to adopt and legalize this system without general consensus from medical professional associations and societies. Without such consensus, this illegal implementation of PA system will create new and additional very serious medical crises due to unlawful medical, educational, professional conflicts and safety issues in medical practice. Before considering the implementation of the PA system, there needs to be a convincing justification by solving the fundamental problems beforehand, such as the collapsed medical delivery system, protection and provision of optimal education program and training environment of trainees, burnout from excessive workloads of physicians with very low compensational system and poor conditions for working and education, etc.

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.

Operation room management in Korea: results of a survey / 대한마취과학회지

BACKGROUND: The current state of general hospital operation room (OR) in Korea and how these ORs are being operated remain unclear. Therefore, the aim of this study was to investigate and assess the current state of OR management and surgical scheduling in general hospitals of Korea. METHODS: A total of 92 anesthesiology training hospitals and 2 equivalent hospitals in Korea were targeted for the survey. Anesthesiologists in hospitals received questionnaires for OR, anesthetic managements and surgical scheduling directly or by phone from the beginning of October 2015 to the end of December 2015. RESULTS: Of the 94 hospitals that were targeted, 59 hospitals (62.7%) responded to the survey. Of the 59 hospitals, 40 (67.8%) had 500–1,000 beds, 36 (61.0%) had 11–20 ORs. Most OR arrangements were made by residents and specialists in Anesthesiology Department (90%). Most hospitals (47.4%) in the response set performed total surgeries in the range of 10,000 to 20,000 annually. The proportion of emergency surgeries in the total surgeries was 2.8–55.0%. Methods for predicting expected surgery time were arbitrarily decided by surgeons (61%), anesthesiologist's experience (20%), or by analyzing historical data using software (5%). CONCLUSIONS: This survey study could trigger active operational researches for OR efficiency. It might help hospital policy makers manage OR resources more efficiently.

The Effect of Pulsatile Versus Nonpulsatile Blood Flow on Viscoelasticity and Red Blood Cell Aggregation in Extracorporeal Circulation

BACKGROUND: Extracorporeal circulation (ECC) can induce alterations in blood viscoelasticity and cause red blood cell (RBC) aggregation. In this study, the authors evaluated the effects of pump flow pulsatility on blood viscoelasticity and RBC aggregation. METHODS: Mongrel dogs were randomly assigned to two groups: a nonpulsatile pump group (n=6) or a pulsatile pump group (n=6). After ECC was started at a pump flow rate of 80 mL/kg/min, cardiac fibrillation was induced. Blood sampling was performed before and at 1, 2, and 3 hours after ECC commencement. To eliminate bias induced by hematocrit and plasma, all blood samples were adjusted to a hematocrit of 45% using baseline plasma. Blood viscoelasticity, plasma viscosity, hematocrit, arterial blood gas analysis, central venous O2 saturation, and lactate were measured. RESULTS: The blood viscosity and aggregation index decreased abruptly 1 hour after ECC and then remained low during ECC in both groups, but blood elasticity did not change during ECC. Blood viscosity, blood elasticity, plasma viscosity, and the aggregation index were not significantly different in the groups at any time. Hematocrit decreased abruptly 1 hour after ECC in both groups due to dilution by the priming solution used. CONCLUSION: After ECC, blood viscoelasticity and RBC aggregation were not different in the pulsatile and nonpulsatile groups in the adult dog model. Furthermore, pulsatile flow did not have a more harmful effect on blood viscoelasticity or RBC aggregation than nonpulsatile flow.

Easy airway management using the i-gel(TM) supraglottic airway in a patient with Treacher Collins syndrome / 대한마취과학회지

No abstract available.

Idiopathic acute eosinophilic pneumonia in a 14-month-old girl / 소아과

Idiopathic acute eosinophilic pneumonia (IAEP), characterized by acute febrile respiratory failure associated with diffuse radiographic infiltrates and pulmonary eosinophilia, is rarely reported in children. Diagnosis is based on an association of characteristic features including acute respiratory failure with fever, bilateral infiltrates on the chest X-ray, severe hypoxemia and bronchoalveolar lavage fluid >25% eosinophils or a predominant eosinophilic infiltrate in lung biopsies in the absence of any identifiable etiology. We present a 14-month-old girl who was admitted to our pediatric intensive care unit because of acute respiratory distress. She had a fever, dry cough, and progressive dyspnea for 1 day. Chest X-ray showed multifocal consolidations, increased interstitial markings, parenchymal emphysema and pneumothorax. IAEP was confirmed by marked pulmonary infiltrates of eosinophils in the lung biopsy specimen. Most known causes of acute eosinophilic pneumonia, such as exposure to causative drugs, toxins, second-hand smoking and infections were excluded. Her symptoms were resolved quickly after corticosteroid therapy.

Pneumocystis jiroveci Pneumonia in a 5-month-old Boy with Agammaglobulinemia: A Case Report / 대한구급학회지

Pneumocystis jiroveci (P. jiroveci) pneumonia is known as a common opportunistic infection in patients with impaired immunity. Underlying disease or conditions related to the development of P. jiroveci pneumonia include acquired immunodeficiency syndromes, as well as malignancies and congenital immune deficiency disorders. We describe a 5-month-old boy without significant medical history who was admitted at our hospital because of fever, tachypnea, vomiting, diarrhea, and lethargy whose condition became worse within several hours after admission. A chest X-ray showed bilateral diffuse infiltration and high resolution computed tomography showed diffuse bilateral ground-glass opacity. The patient was diagnosed with P. jiroveci pneumonia by direct immunofluorescent antibody staining from lung biopsy and he was later diagnosed with agammaglobulinemia. Although the boy was treated with antibiotics, high-dose corticosteroids and mechanical ventilation, he expired on the 5th hospital day. Here, we report the case of P. jiroveci pneumonia in a boy with agammaglobulinemia.

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.

The Analgesic Effect of Remifentanil on Propofol Injection Pain / 대한구급학회지

BACKGROUND: Pain is a common side-effect of propofol injection. A remifentanil pretreatment has been reported to decrease the incidence and intensity of pain during a propofol injection and has been suggested to act through a central or peripheral effect. This trial was designed to explore the action site of remifentanil on reducing propofol injection pain, using the venous occlusion technique and a time interval between the applications of remifentanil and propofol. METHODS: This randomized, double-blind study was designed to explore the action site of remifentanil on reducing propofol injection pain in 200 patients scheduled for elective surgery. The peripheral properties were examined using the venous occlusion technique for 30 s while a 1 min time interval between remifentanil and propofol injections was allowed for the central effect. Before the propofol injection, group A was pretreated with remifentanil (0.5 microg/ kg) with a venous occlusion, group B with remifentanil and a 1 min interval, and group C with remifentanil with a venous occlusion and a 1 min interval. Pain severity was assessed using a four-point scale. RESULTS: 40 patients (80%) complained of pain in the placebo group compared with 35 (70%) in group A, 20 (40%) in group B (p < 0.05) and 17 (34%) in group C (p < 0.05). The incidence and severity of propofol injection pain were lower in groups B and C than in group A (p < 0.05). However, there was no significant difference between groups B and C. CONCLUSIONS: The remifentanil mediated analgesic effect occurs mainly through the central effect.

Postoperative renal function in patients is unaltered after robotic-assisted radical prostatectomy / 대한마취과학회지

BACKGROUND: Pneumoperitoneum with an intra-abdominal pressure (IAP) of 14 mmHg is known to decrease renal function. Robotic-assisted radical prostatectomy (RARP) requires an IAP of more than 15 mmHg for operation. Therefore, we retrospectively investigated whether patients who underwent RARP experienced renal insufficiency during the postoperative period (at postoperative days 7 and 30). METHODS: One hundred patients who underwent RARP were enrolled in this study. Preoperative serum blood urea nitrogen (BUN) and serum creatinine (Cr) levels were measured. Creatinine clearance (CrCl) was calculated using the Cockcroft and Gault formula. CrCl was calculated at 1 day before surgery (baseline), 2 hr postoperatively, and at 1, 3, 7, and 30 days postoperatively (POD 1, POD 3, POP 7, and POD 30). Patients were assigned to abnormal CrCl (n = 52) or normal CrCl groups (n = 48) on the basis of these measurements. RESULTS: Significant inter-group differences in BUN, Cr, and CrCl were observed at all postoperative time points. BUN and Cr decreased significantly at postoperative 2 hr and POD 1, 3, and 7 versus baseline in both groups, whereas CrCl increased significantly at postoperative 2 hr and POD 1, 3, and 7 versus baseline in both groups. However, BUN, Cr, and CrCl were similar at POD 30 and preoperatively in the two groups. CONCLUSIONS: RAPR, which requires an IAP of 15-20 mmHg for more than 4 hr, does not induce renal dysfunction during the postoperative period, and even in those patients with an abnormal CrCl.

Feasibility of ultrasound-guided posterior approach for interscalene catheter placement during arthroscopic shoulder surgery / 대한마취과학회지

BACKGROUND: Continuous interscalene block has been known to improve postoperative analgesia after arthroscopic shoulder surgery. This was a prospective study investigating the ultrasound-guided posterior approach for placement of an interscalene catheter, clinical efficacy and complications after placement of the catheter. METHODS: Forty-two patients undergoing elective arthroscopic shoulder surgery were included in this study and an interscalene catheter was inserted under the guidance of ultrasound with posterior approach. With the inplane approach, the 17 G Tuohy needle was advanced until the tip was placed between the C5 and C6 nerve roots. After a bolus injection of 20 ml of 0.2% ropivacaine, a catheter was threaded and secured. A continuous infusion of ropivacaine 0.2% 4 ml/hr with patient-controlled 5 ml boluses every hour was used over 2 days. Difficulties in placement of the catheter, clinical efficacy of analgesia and complications were recorded. All patients were monitored for 48 hours and examined by the surgeon for complications within 2 weeks of hospital discharge. RESULTS: Easy placement of the catheter was achieved in 100% of the patients and the success rate of catheter placement during the 48 hr period was 92.9%. Postoperative analgesia was effective in 88.1% of the patients in the post anesthetic care unit. The major complications included nausea (7.1%), vomiting (4.8%), dyspnea (4.8%) and unintended vascular punctures (2.4%). Other complications such as neurologic deficits and local infection around the puncture site did not occur. CONCLUSIONS: The ultrasound-guided interscalene block with a posterior approach is associated with a success high rate in placement of the interscalene catheter and a low rate of complications. However, the small sample size limits us to draw definite conclusions. Therefore, a well-designed randomized controlled trial is required to confirm our preliminary study.

Pleural effusion after microtia reconstructive surgery: A case report / 대한마취과학회지

Microtia reconstructive surgery is usually a multi-stage repair procedure that involves the use of cartilage and skin grafts. Complications can arise at both ear reconstruction sites and cartilage donor sites. In particular, pneumothorax, atelectasis, chest scars, and chest deformities are known to be associated with the harvesting of costal cartilage. However, delayed pleural effusion can also develop. Our patient complained of a cough and chest pain at 5 days postoperatively, and pleural effusion was detected by chest radiography. However, thoracentesis was not performed and the effusion resolved spontaneously and completely.

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.

Retrospective Analysis of the Postoperative Patients Admitted to General Surgical-Medical Intensive Care Unit / 대한구급학회지

BACKGROUND: The present study was designed to examine the purpose of intensive care unit (ICU) admission and the prevalence of disease in postoperative patients admitted to general surgical-medical ICU. METHODS: Between 1 January 2007 and 31 December 2007, 646 cases of 612 patients admitted to a general postoperative patients admitted to general surgical-medical ICU were examined. The patients were classified into two groups, ICU treatment and ICU monitoring groups according to Knaus' suggestion which defines the kinds of treatment done exclusively in ICU. Patients' demographics, preoperative American Society of Anesthesiologists physical status classification (ASA) grade, prevalence of disease and emergent operation rate were analyzed. RESULTS: 255 patients (39.5%) were included in the ICU treatment group and 391 cases (60.5%) in the ICU monitoring group. The prevalence of respiratory, gastrointestinal, and central nervous diseases was higher significantly in the ICU treatment group. In addition, the average of ASA grade and the duration of operation were higher significantly in the ICU treatment group. CONCLUSION: Admission rate only for monitoring was higher than one for intensive treatment. An alternative strategy should be considered to care for postoperative patients who need just close monitoring.

Effect of Positive End Expiratory Pressure on Intra-abdominal Pressure and Abdominal Perfusion Pressure at an Increased Intra-abdominal Pressure / 대한마취과학회지

BACKGROUND: Increased intra-abdominal pressure (IAP) leads to adverse effects on most organ systems and is associated with significant morbidity and mortality in surgical and trauma patients. The purpose of this study was to determine the effect of positive end expiratory pressure (PEEP) on IAP and abdominal perfusion pressure (APP, mean arterial pressure, MAP minus IAP) at normal and increased intra-abdominal pressures. METHODS: 15 patients requiring a laparoscopic cholecystectomy were included. IAP was measured indirectly using a transurethral catheter, and APP was calculated for each patient at 0, 5, 10, 15, and 20 cmH2O of PEEP, while the insufflator pressure was maintained at either 0 or 15 mmHg. RESULTS: At each insufflator pressure, IAP increased with higher PEEP levels (P < 0.05). At 0 mmHg insufflator pressure state, MAP substantially decreased according to increasing PEEP levels, however, at 15 mmHg insufflator pressure state, MAP substantially increased despite increasing PEEP levels. Meanwhile, APP decreased with increasing PEEP levels at an insufflator pressure of zero while remaining constant at a 15 mmHg insufflator pressure. CONCLUSIONS: We found that IAP increases in response to higher PEEP levels (10, 15, and 20 cmH2O) at insufflator pressures of both zero and 15 mmHg in patients anesthetized for laparoscopic cholecystectomy. However, APP did not decrease with increasing PEEP levels at a higher intraadominal pressure (15 mmHg).

Does Epidural Clonidine Decrease the Sevoflurane Concentration for Maintaining the BIS 50? / 대한마취과학회지

BACKGROUND: The aim of this study was to investigate the influence of epidural clonidine on the BIS, and its potential dose-sparing effect on the sevoflurane requirement for maintaining the BIS 50. METHODS: Forty ASA I or II patients aged 20 to 65, undergoing lower abdominal, gynecologic surgery under general anesthesia, were randomly allocated to either a 10 ml epidural normal saline injection group (n = 20) or a 10 ml epidural clonidine 3microgram/kg mixed with normal saline injection group (n = 20). They received 5 mg/kg thiopental sodium and 0.1 mg/kg vecuronium bromide for induction, with no premedication. After surgical incision, the sevoflurane concentration was controlled to maintain the BIS 50. Epidural saline or clonidine was then injected and end-tidal sevoflurane concentration to maintain the BIS 50, the heart rate (HR) and mean arterial pressure (MBP) were measured every 5 min over a 20 minute period. RESULTS: The end-tidal sevoflurane concentration in the clonidine group decreased by 27.5% after the epidural clonidine injection (1.49 +/- 0.23 vol% vs. 1.08 +/- 0.27 vol%; P0.05). There were no changes in the heart rate and mean blood pressure in either group. CONCLUSIONS: Epidural clonidine causes a significant decrease in the BIS, and lowers the end-tidal sevoflurane concentration required for maintaining the BIS 50.