Infections in Lung Transplant Recipients during and after Prophylaxis / 감염과화학요법

Background@#The timeline of infections after lung transplantation has been changed with the introduction of new immunosuppressants and prophylaxis strategies. The study aimed to investigate the epidemiological characteristics of infectious diseases after lung transplantation in the current era. @*Materials and Methods@#All patients who underwent lung or heart–lung transplantation at our institution between October 29, 2008 and April 3, 2019 were enrolled. We retrospectively reviewed the patients' medical records till April 2, 2020. @*Results@#In total, 100 consecutive lung transplant recipients were enrolled. The median follow-up period was 28 months after lung transplantation. A total of 127 post–lung transplantation bacterial infections occurred. Catheter-related bloodstream infection (25/84, 29.8%) was the most common within 6 months and pneumonia (23/43, 53.5%) was the most common after 6 months. Most episodes (35/40, 87.5%) of respiratory viral infections occurred after 6 months, mainly as upper respiratory infections. The remaining episodes (5/40, 12.5%) mostly manifested as lower respiratory tract infections. Seventy cytomegalovirus infections observed in 43 patients were divided into 23 episodes occurring before and 47 episodes occurring after discontinuing prophylaxis. Of 10 episodes of cytomegalovirus disease, four occurred during prophylaxis and six occurred after prophylaxis.Of 23 episodes of post–lung transplantation fungal infection, 7 were aspergillosis and all occurred after the discontinuation of prophylaxis. @*Conclusion@#Lung transplant recipients experienced a high burden of infection even after 6 months, especially after the end of the prophylaxis period. Therefore, these patients should be continued to be monitored long-term for infectious disease.

Infections in Lung Transplant Recipients during and after Prophylaxis / 감염과화학요법

Background@#The timeline of infections after lung transplantation has been changed with the introduction of new immunosuppressants and prophylaxis strategies. The study aimed to investigate the epidemiological characteristics of infectious diseases after lung transplantation in the current era. @*Materials and Methods@#All patients who underwent lung or heart–lung transplantation at our institution between October 29, 2008 and April 3, 2019 were enrolled. We retrospectively reviewed the patients' medical records till April 2, 2020. @*Results@#In total, 100 consecutive lung transplant recipients were enrolled. The median follow-up period was 28 months after lung transplantation. A total of 127 post–lung transplantation bacterial infections occurred. Catheter-related bloodstream infection (25/84, 29.8%) was the most common within 6 months and pneumonia (23/43, 53.5%) was the most common after 6 months. Most episodes (35/40, 87.5%) of respiratory viral infections occurred after 6 months, mainly as upper respiratory infections. The remaining episodes (5/40, 12.5%) mostly manifested as lower respiratory tract infections. Seventy cytomegalovirus infections observed in 43 patients were divided into 23 episodes occurring before and 47 episodes occurring after discontinuing prophylaxis. Of 10 episodes of cytomegalovirus disease, four occurred during prophylaxis and six occurred after prophylaxis.Of 23 episodes of post–lung transplantation fungal infection, 7 were aspergillosis and all occurred after the discontinuation of prophylaxis. @*Conclusion@#Lung transplant recipients experienced a high burden of infection even after 6 months, especially after the end of the prophylaxis period. Therefore, these patients should be continued to be monitored long-term for infectious disease.

Long-Term Outcomes of Adult Lung Transplantation Recipients: A Single-Center Experience in South Korea / 결핵및호흡기질환

BACKGROUND@#Recently, the number of lung transplants in South Korea has increased. However, the long-term outcome data is limited. In this study, we aimed to investigate the long-term outcomes of adult lung transplantation recipients.@*METHODS@#Among the patients that underwent lung transplantation at a tertiary referral center in South Korea between 2008 and 2017, adults patient who underwent deceased-donor lung transplantation with available follow-up data were enrolled. Their medical records were retrospectively reviewed.@*RESULTS@#Through eligibility screening, we identified 60 adult patients that underwent lung (n=51) or heart-lung transplantation (n=9) during the observation period. Idiopathic pulmonary fibrosis (46.7%, 28/60) was the most frequent cause of lung transplantation. For all the 60 patients, the median follow-up duration for post-transplantation was 2.6 years (range, 0.01–7.6). During the post-transplantation follow-up period, 19 patients (31.7%) died at a median duration of 194 days. The survival rates were 75.5%, 67.6%, and 61.8% at 1 year, 3 years, and 5 years, respectively. Out of the 60 patients, 8 (13.3%) were diagnosed with chronic lung allograft dysfunction (CLAD), after a mean duration of 3.3±2.8 years post-transplantation. The CLAD development rate was 0%, 17.7%, and 25.8% at 1 year, 3 years, and 5 years, respectively. The most common newly developed post-transplantation comorbidity was the chronic kidney disease (CKD; 54.0%), followed by diabetes mellitus (25.9%).@*CONCLUSION@#Among the adult lung transplantation recipients at a South Korea tertiary referral center, the long-term survival rates were favorable. The proportion of patients who developed CLAD was not substantial. CKD was the most common post-transplantation comorbidity.

Bronchial Thermoplasty in Patients with Severe Uncontrolled Asthma: First Korean Cases

Bronchial thermoplasty is a nonpharmacological treatment for severe asthma that delivers thermal energy to the bronchial walls and reduces hypertrophied smooth muscle mass. Previous studies have shown its efficacy and safety, resulting in approval from the Food and Drug Administration in 2010. In Korea, the first bronchial thermoplasty was carried out in 2014; 4 patients have undergone the procedure so far. This case series presents the medical history and treatment outcomes of these 4 patients. All patients presented with uncontrolled asthma despite optimal medical treatment. Bronchial thermoplasty was performed at the right lower lobe, left lower lobe, and both upper lobes in order at 3-week intervals. All procedures were performed under general anesthesia. Two patients had significant decreases in exacerbations and required a lower dose of inhaled corticosteroids after the procedure. One patient had slightly fewer exacerbations but failed to reduce the use of systemic corticosteroids. One patient had no change in symptoms. One limitation of bronchial thermoplasty is the difficulty of predicting clinical responders. However, since more therapeutic options are needed in the management of severe asthma, especially T2-low asthma, discussion with experts about the feasibility and necessity of bronchial thermoplasty will ensure the best possible care.

Long-Term Outcomes of Adult Lung Transplantation Recipients: A Single-Center Experience in South Korea / 결핵

BACKGROUND: Recently, the number of lung transplants in South Korea has increased. However, the long-term outcome data is limited. In this study, we aimed to investigate the long-term outcomes of adult lung transplantation recipients. METHODS: Among the patients that underwent lung transplantation at a tertiary referral center in South Korea between 2008 and 2017, adults patient who underwent deceased-donor lung transplantation with available follow-up data were enrolled. Their medical records were retrospectively reviewed. RESULTS: Through eligibility screening, we identified 60 adult patients that underwent lung (n=51) or heart-lung transplantation (n=9) during the observation period. Idiopathic pulmonary fibrosis (46.7%, 28/60) was the most frequent cause of lung transplantation. For all the 60 patients, the median follow-up duration for post-transplantation was 2.6 years (range, 0.01–7.6). During the post-transplantation follow-up period, 19 patients (31.7%) died at a median duration of 194 days. The survival rates were 75.5%, 67.6%, and 61.8% at 1 year, 3 years, and 5 years, respectively. Out of the 60 patients, 8 (13.3%) were diagnosed with chronic lung allograft dysfunction (CLAD), after a mean duration of 3.3±2.8 years post-transplantation. The CLAD development rate was 0%, 17.7%, and 25.8% at 1 year, 3 years, and 5 years, respectively. The most common newly developed post-transplantation comorbidity was the chronic kidney disease (CKD; 54.0%), followed by diabetes mellitus (25.9%). CONCLUSION: Among the adult lung transplantation recipients at a South Korea tertiary referral center, the long-term survival rates were favorable. The proportion of patients who developed CLAD was not substantial. CKD was the most common post-transplantation comorbidity.

The First Living-Donor Lobar Lung Transplantation in Korea: a Case Report

Lung transplantation is the only treatment for end-stage lung disease, but the problem of donor shortage is unresolved issue. Herein, we report the first case of living-donor lobar lung transplantation (LDLLT) in Korea. A 19-year-old woman patient with idiopathic pulmonary artery hypertension received her father's right lower lobe and her mother's left lower lobe after pneumonectomy of both lungs in 2017. The patient has recovered well and is enjoying normal social activity. We think that LDLLT could be an alternative approach to deceased donor lung transplantation to overcome the shortage of lung donors.

Application of Ventilating-Bronchoscopy-Adaptor by Fusing a Laparoscopic Trocar during Bronchial Thermoplasty under General Anesthesia

No abstract available.

Infections after lung transplantation: time of occurrence, sites, and microbiologic etiologies

BACKGROUND/AIMS: Infections are major causes of both early and late death after lung transplantation (LT). The development of prophylaxis strategies has altered the epidemiology of post-LT infections; however, recent epidemiological data are limited. We evaluated infections after LT at our institution by time of occurrence, site of infections, and microbiologic etiologies. METHODS: All consecutive patients undergoing lung or heart-lung transplantation between October 2008 and August 2014 at our institution were enrolled. Cases of infections after LT were initially identified from the prospective registry database, which was followed by a detailed review of the patients' medical records. RESULTS: A total of 108 episodes of post-LT infections (56 bacterial, 43 viral, and nine fungal infections) were observed in 34 LT recipients. Within 1 month after LT, the most common bacterial infections were catheter-related bloodstream infections (42%). Pneumonia was the most common site of bacterial infection in the 2- to 6-month period (28%) and after 6 months (47%). Cytomegalovirus was the most common viral infection within 1 month (75%) and in the 2- to 6-month period (80%). Respiratory viruses were the most common viruses after 6 months (48%). Catheter-related candidemia was the most common fungal infection. Invasive pulmonary aspergillosis developed after 6 months. Survival rates at the first and third years were 79% and 73%, respectively. CONCLUSIONS: Although this study was performed in a single center, we provide valuable and recent detailed epidemiology data for post-LT infections. A further multicenter study is required to properly evaluate the epidemiology of post-LT infections in Korea.

Effect of remote ischemic preconditioning on cognitive function after off-pump coronary artery bypass graft: a pilot study / 대한마취과학회지

BACKGROUND: Several studies have shown in animal models that remote ischemic preconditioning (rIPC) has a neuroprotective effect. However, a randomized controlled trial in human subjects to investigate the neuroprotective effect of rIPC after cardiac surgery has not yet been reported. Therefore, we performed this pilot study to determine whether rIPC reduced the occurrence of postoperative cognitive dysfunction in patients who underwent off-pump coronary artery bypass graft (OPCAB) surgery. METHODS: Seventy patients who underwent OPCAB surgery were assigned to either the control or the rIPC group using a computer-generated randomization table. The application of rIPC consisted of four cycles of 5 min ischemia and 5 min reperfusion on an upper limb using a blood pressure cuff inflating 200 mmHg before coronary artery anastomosis. The cognitive function tests were performed one day before surgery and again on postoperative day 7. We defined postoperative cognitive dysfunction as decreased postoperative test values more than 20% of the baseline values in more than two of the six cognitive function tests that were performed. RESULTS: In the cognitive function tests, there were no significant differences in the results obtained during the preoperative and postoperative periods for all tests and there were no mean differences observed in the preoperative and postoperative scores. The incidences of postoperative cognitive dysfunction in the control and rIPC groups were 28.6% (10 patients) and 31.4% (11 patients), respectively. CONCLUSIONS: rIPC did not reduce the incidence of postoperative cognitive dysfunction after OPCAB surgery during the immediate postoperative period.

Effects of Ethyl Pyruvate on Allodynia, TNF-alpha Expression, and Apoptosis in the Dorsal Root Ganglion after Spinal Nerve Ligation Injury

BACKGROUND: It has been demonstrated that the expression of tumor necrosis factor-alpha (TNF-alpha) and apoptotic cell death in the dorsal root ganglion (DRG) following spinal nerve constriction injury play a role in the initiation and continuation of hyperalgesia and allodynia. The present study was designed to investigate the effects of ethyl pyruvate (EP) on mechanical and cold allodynia, TNF-alpha expression, and apoptosis in DRG after spinal nerve ligation injury. METHODS: Rats were divided into 3 groups: control, pre-EP, and post-EP. EP (50 mg/kg) was intraperitoneally injected 30 minutes before (pre-EP) or after (post-EP) surgery. Behavioral tests to determine mechanical and cold allodynia were conducted before surgery and 4 and 7 days after surgery. Seven days after surgery, TNF-alpha protein levels in DRG were evaluated by enzyme-linked immunosorbent assay, and DRG apoptosis was determined by immunohistochemical detection of activated caspase-3. RESULTS: Treatment with EP significantly reduced mechanical and cold allodynia following spinal nerve ligation injury. TNF-alpha protein levels in the pre-EP (4.7 +/- 1.2 pg/200 microg; P < 0.001) and post-EP (6.4 +/- 1.8 pg/200 microg; P < 0.001) groups were 2-3 times lower than the control group (14.4 +/- 1.2 pg/200 microg). The percentages of neurons and satellite cells that co-localized with caspase-3 were also significantly lower in the pre-EP and post-EP groups than the control group. CONCLUSIONS: These results demonstrate that EP has a strong anti-allodynic effect that acts through the inhibition of TNF-alpha expression and apoptosis in DRG after spinal nerve ligation injury.

Arterial to end-tidal carbon dioxide pressure gradient increases with age in the steep Trendelenburg position with pneumoperitoneum / 대한마취과학회지

BACKGROUND: Several factors affect the end-tidal carbon dioxide pressure (PETCO2) and increase the arterial to end-tidal carbon dioxide pressure gradient (Pa-ETCO2) during general anesthesia. We evaluated the relationship between age and Pa-ETCO2 during pneumoperitoneum in the steep Trendelenburg position in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). METHODS: Ninety-two consecutive patients undergoing RALP were divided by age into a middle-aged (45-65 years) and an elderly (> 65 years) group. Anesthesia was standardized. Heart rate, mean arterial pressure, peak inspiratory pressure, lung compliance, minute ventilation, PaO2, PETCO2, PaCO2, and Pa-ETCO2 were measured 10 min after intubation in the supine position without pneumoperitoneum (T0); and 10 (T1), 60 (T2), and 120 (T3) min after pneumoperitoneum in the Trendelenburg position. RESULTS: Although PETCO2 did not change significantly during surgery, PaCO2 and Pa-ETCO2 increased gradually with time during pneumoperitoneum in the Trendelenburg position, and both parameters showed greater increases in the elderly than in the middle-aged group. Simple linear regression analyses revealed significant correlations between age and Pa-ETCO2 at T0 (P = 0.018), T1 (P = 0.006), T2 (P < 0.001), and T3 (P = 0.001). Linear mixed model analysis showed that Pa-ETCO2 was associated statistically significantly with age and duration of pneumoperitoneum in the Trendelenburg position, but age and duration of pneumoperitoneum in the Trendelenburg position were not associated (P = 0.090). CONCLUSIONS: The magnitude of Pa-ETCO2 during pneumoperitoneum in the steep Trendelenburg position increased with age, which could be attributed to age-related respiratory physiological changes.

Temporary bilateral sensorineural hearing loss following cardiopulmonary bypass: A case report / 대한마취과학회지

Sudden sensorineural hearing loss has been reported to occur following anesthesia and various non-otologic surgeries, mostly after procedures involving cardiopulmonary bypass. Unilateral sensorineural hearing loss resulting from microembolism is an infrequent complication of cardiopulmonary bypass surgery that has long been acknowledged. Moreover, there are few reports on the occurrence of bilateral sensorineural hearing loss without other neurologic deficits and its etiology has also not been determined. We describe here a rare case of bilateral hearing loss without other neurologic deficits in an otherwise healthy 27-year-old woman who underwent cardiopulmonary bypass surgery for repair of severe mitral valve stenosis. The patient suffered from profound sensorineural hearing loss in both ears that was recognized immediately upon extubation, and audiometry tests confirmed the diagnosis. Without any treatment, her hearing recovered almost completely by the time of her discharge one week after surgery.

Tumor Necrosis Factor-alpha and Apoptosis Following Spinal Nerve Ligation Injury in Rats

BACKGROUND: Spinal nerve ligation (SNL) injury in rats produces a pain syndrome that includes mechanical and thermal allodynia. Previous studies have indicated that proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-alpha) play an important role in peripheral mediation of neuropathic pain, and that altered dorsal root ganglion (DRG) function and degree of DRG neuronal apoptosis are associated with spinal nerve injury. The present study was conducted to evaluate the expression of TNF-alpha and the extent of apoptosis in the dorsal root ganglion after SNL in rats. METHODS: Sprague-Dawley rats were subjected to SNL of the left L5 and L6 spinal nerves distal to the DRG and proximal to the formation of the sciatic nerve. At postoperative day 8, TNF-alpha protein levels in the L5-6 DRG were compared between SNL and naive groups using ELISA. In addition, we compared the percentage of neurons injured in the DRG using immunostaining for apoptosis and localization of activated caspase-3. RESULTS: SNL injury produced significant mechanical and cold allodynia throughout the 7-day experimental period. TNF-alpha protein levels were increased in the DRG in rats that had undergone SNL (12.7 +/- 3.2 pg/100 microg, P < 0.001) when compared with naive rats (4.1 +/- 1.4 pg/100 microg). The percentage of neurons or satellite cells co-localized with activated caspase-3 were also significantly higher in rats with SNL than in naive rats (P < 0.001, P < 0.05, respectively). CONCLUSIONS: SNL injury produces mechanical and cold allodynia, as well as TNF-alpha elevation and apoptosis in the DRG.

Anesthetic considerations of percutaneous transcatheter aortic valve implantation: first attempt in Korea: A report of 2 cases / 대한마취과학회지

Conventional aortic valve replacement for severe aortic stenosis is associated with a high operative mortality in the elderly patients with significant comorbidities, including severe respiratory dysfunction, renal insufficiency, and compromised cardiac function. Human transcatheter aortic valve implantation was first reported in 2002 and has become a valid alternative in selected high-risk patients in Europe and North America. This article describes the first attempt of transfemoral transcatheter aortic valve implantation in Korea. The procedure was applied in two consecutive patients with severe aortic stenosis. Despite several intra-operative complications during procedure, the post-operative outcomes were good for both patients. At post-operative 30 days there was satisfactory prosthetic valve function and hemodynamic stability.

The prophylactic use of recombinant factor VIIa in a patient with DeBakey type III aortic dissection: A case report / 대한마취과학회지

Little is known about the prophylactic use of recombinant factor VIIa (rFVIIa) in patients undergoing surgery for a bleeding aorta employing cardiopulmonary bypass. We report the successful use of rFVIIa in a patient undergoing hypothermic circulatory arrest and prolonged cardiopulmonary bypass for repair of a DeBakey type III aortic dissection.

High Frequency Jet Ventilation of One Lung using a Bronchial Blocker of Univent during Carinal Resection

Airway management during carinal resection should provide adequate ventilation and oxygenation as well as a good surgical field, but without complications such as barotraumas or aspiration. One method of airway management is high frequency jet ventilation (HFJV) of one lung or both lungs. We describe a patient undergoing carinal resection, who was managed with HFJV of one lung, using a de-ballooned bronchial blocker of a Univent tube without cardiopulmonary compromise. HFJV of one lung using a bronchial blocker of a Univent tube is a simple and safe method which does not need additional catheters to perform HFJV and enables the position of the stiffer bronchial blocker more stable in airway when employed during carinal resection.

The interaction of intrathecal neostigmine and N(6)-cyclohexyladenosine on anti-allodynic effects in rats with a nerve ligation injury / 대한마취과학회지

BACKGROUND: Nerve ligation injury in rats produces a pain syndrome that includes mechanical allodynia. Intrathecal administration of cholinesterase inhibitors or adenosine receptor agonists have anti-allodynic effects in this model. Therefore, we tested the interaction between intrathecal neostigmine and N(6)-cyclohexyladenosine (CHA) in a rat behavioral model of neuropathic pain. METHODS: Male Sprague-Dawley rats were prepared with tight ligation of the spinal nerves for producing allodynia and with a lumbar intrathecal catheter for drug administration. Allodynia thresholds for hindpaw withdrawal against mechanical stimuli were assessed and converted to percent maximal possible effect. Neostigmine (0.3-10 microgram) and CHA (0.03-3 microgram) were administered to obtain the dose-response curves and the 50% effective dose (ED(50)). Equal fractions (1/2, 1/4 and 1/8 ED(50)s) of the two drugs were administered to establish the ED(50) of neostigmine-CHA combination. Side effects were also assessed. The drug interaction was evaluated by isobolographic and fractional analyses. RESULTS: Neostigmine, CHA, and the neostigmine-CHA combination dose-dependently produced anti-allodynia effects. Side effects such as sedation and motor weakness were similar in the three groups. In the isobolographic analysis, the experimental ED(50) for the combination of neostigmine-CHA lay far below and to the left of the theoretical additive line. Fractional analysis indicated that the total combination fraction of the two drugs was 0.39. CONCLUSIONS: Intrathecal co-administration of neostigmine and CHA showed a synergistic anti-allodynia effect.

Anesthetic management of a child with Apert syndrome : A case report

Apert syndrome involves abnormal growth of several bones such as craniofacial abnormalities, craniosynostosis and syndactyly of the feet and hands. Apert syndrome often demonstrates to the operating room for craniofacial and extremity operations. Previous reports reveal that children with Apert syndrome suffered difficulties in mask ventilation and difficult airway management during anesthetic management.We report our experience with anesthesia of a 26-month-old female patient with Apert syndrome who underwent syndactyly for separation.

Amplatzer septal occluder found in the thoracic descending aorta by transesophageal echocardiography: A case report / 대한마취과학회지

Percutaneous device closure of atrial septal defect (ASD) has proven to be safe and effective, and become a widely accepted option to the surgical repair. However, the embolization of Amplatzer septal occluder (ASO) occurs in about 0.55% to 3.5% of cases, regardless of ASD size, device size, or the physician's expertise. We report a case of embolization of an ASO into the thoracic descending aorta, successfully removed through a surgical approach.

The Effect of Intradermal Norepinephrine on Allodynia in a Neuropathic Pain Rat Model / 대한마취과학회지

BACKGROUND: A spinal nerve ligation (SNL) injury may produce a neuropathic pain syndrome that includes tactile allodynia. This pain state may be diminished by sympathectomy. Intradermal (I.D.) injection of norepinephrine (NE) evokes pain in patients with sympathetically maintained pain. Recently, we reported the effect of intrathecal (I.T.) brimonidine and rilmenidine on the sympathetic nervous system. Therefore, we conducted a behavioral test to investigate the effects of sympathetic stimulation by I.D. NE on mechanical allodynia in rats with a SNL injury. METHODS: Male SD rats were prepared with ligation of the left lumbar 5th and 6th spinal nerves and lumbar I.T. catheter implantation. NE 10ng I.D. was administered in normal and SNL rats to investigate the change of cutaneous sensitivity to tactile stimuli. NE 30ng I.D. was administered before and after I.T. injection of brimonidine 3ng and rilmenidine 30ng in SNL rats. Using a von Frey hair (VFH) test, we examined the effects of NE on the withdrawal threshold. Allodynic thresholds for the withdrawal response of the lesioned hindpaw to VFH stimuli were assessed. RESULTS: Intradermal NE produced a reduction of the withdrawal threshold in normal and allodynic rats. An allodynic state induced by a SNL was aggravated by NE. In allodynic rats, the baseline threshold of a lesioned left hindpaw was markedly low and such a state was maintained during the behavioral experiment. The antiallodynic effects of I.T. brimonidine and rilmenidine were produced in both pre- and post-treatment of NE. CONCLUSIONS: The results suggest that a sympathetic component is likely involved in the mechanism of mechanical allodynia produced by a SNL injury.