The relationship between the surgical Apgar score and postoperative complications in patients admitted to an intensive care unit after surgery

BACKGROUND: Surgical Apgar score (SAS) is a 10-point system that measures estimated blood loss, lowest heart rate and lowest mean blood pressure during surgery, and is known to be associated with postoperative complications. The purpose of this study was to evaluate the relationship between SAS and postoperative major complications in patient admitted to intensive care unit (ICU) after surgery. METHODS: We retrospectively reviewed 543 patients who were admitted to the ICU for 8 months. SAS, patient's demographics and postoperative outcomes were collected and analyzed based on anesthetic record and several medical records in an electronic chart system built in hospital. The patients were divided into three groups based on their SAS. The postoperative major complications, duration of ICU stay and duration of hospital stay were compared among the three groups. RESULTS: In the low score group, the rate emergency, trauma and hepatobiliary operation were high. In this group, the duration of ICU and hospital stay, use of mechanical ventilation and inotropic in ICU, and postoperative complication were also increased. SAS also had a weak negative correlation with ICU stay and hospital stay. Postoperative complication and mortality rate doubled when compared to reference group (SAS 7–10) according to univariate logistic regression. CONCLUSIONS: In patients admitted to ICU after surgery, SAS, which can be measured during surgery, is closely related to postoperative parameters including major complications, mortality, and ICU stay. In other words, it is thought that the postoperative outcomes can be improved through appropriate monitoring and intervention for patients with low SAS score.

Impact of Central Line Insertion Bundle on the Adherence of Bundle and Central Line-Associated Bloodstream Infections in the Operating Room

BACKGROUND: This study purposed to examine how the incidence of the central line-associated bloodstream infection (CLABSI) in a operating room (OR) is affected by bundle application on central line insertion (CLI) practice. METHODS: The study design was a pretest-posttest experimental trial. The subjects were 83 patients before the bundle application on CLI and 70 patients after. RESULTS: The compliance(%) of bundle on CLI of among those who observed all of the five items increased from 7.2% before the intervention to 72.9% after. By items, compliance with the maximal barrier precaution was 100% for the use of a mask and cap before and after the intervention, but increased from 73.5% before the intervention to 88.6% after for the hand hygiene, from 73.5% to 88.6% for the use of a sterile gown, and from 9.6% to 75.7% for the use of a sterile large drape covering the whole body. CLABSI did not happen on CLI either before or after the application of the bundle intervention. CONCLUSION: Bundle application increased compliance with the use of a sterile gown and the use of a sterile large drape. However, its effect in the prevention of CLABSI was not clear probably due to the short period of intervention in a single hospital.

Change of QT variability index during general anesthesia / 대한마취과학회지

BACKGROUND: The QT variability index (QTVI)-a non-invasive measure of beat-to-beat QT interval (QTI) fluctuations-is related to myocardial repolarization lability. The QTVI represents the relationship between QTI and the RR interval. Elevated QTVI is associated with an increased risk of malignant ventricular arrhythmias and sudden death. We investigated the influence of general anesthesia and tourniquets on the QTVI. METHODS: We studied fifty patients who received total knee replacement arthroplasty under sevoflurane anesthesia. We measured QTI, corrected QTI (QTc), T-wave peak-to-end interval (TPE), QTVI, and heart rate variability. All variables were calculated at baseline (B), 30 min after general anesthesia (A), 30 min (TQ1) and 60 min (TQ2) after tourniquet inflation, and at tourniquet deflation (TQR). RESULTS: Prolongation of QTI was detected at all times, and QTc was significantly prolonged TQR. TPE was unchanged during general anesthesia. The QTVI was significantly decreased and more negative during anesthesia and tourniquet inflation. After deflation of the tourniquet, the QTVI was restored to preanesthetic values. Low frequency (LF) was significantly decreased during general anesthesia, but high frequency (HF) was somewhat maintained, except at TQ2. The LF/HF ratio was significantly decreased at A and TQ2. CONCLUSIONS: Sevoflurane based general anesthesia induced repolarization stability and, more negativity of the QTVI, in patients undergoing total knee replacement arthroplasty.

Sudden cardiovascular collapse after platelet transfusion during liver transplantation: flat-line thromboelastometry and inferred pulmonary thromboembolism: A case report

Despite the well-known bleeding diathesis in patients with end-stage liver disease, inappropriate hypercoagulation is also emerging as a major concern. Pulmonary thromboembolism (PTE) is a major cause of perioperative morbidity and mortality during liver transplantation (LT). Flat-line thromboelastography is reported to predict PTE during LT. In this case, a 52-year-old woman with hepatocellular carcinoma underwent living-related LT. During the pre-anhepatic phase, one unit of apheresis platelets was transfused because of thrombocytopenia (32,000 /ml). After 20 minutes, blood pressure became unstable and circulatory collapse suddenly developed. In the middle of cardiopulmonary resuscitation, transesophageal echocardiography was immediately conducted, which revealed flail thrombi in the right atrium. Rotational thromboelastometry (ROTEM) conducted at that time was surprisingly flat in 4 channels, contradictory to the finding of hypercoagulation. This finding lead to a management dilemma during LT. Flattening in ROTEM requires caution in interpretation of severe hypocoagulation or ongoing PTE.

A comparison of systolic and diastolic time variation with pulse pressure variation as a predictor of fluid responsiveness during pediatric liver transplantation

BACKGROUND: In pediatric patients, dynamic preload indices to predict fluid responsiveness remain controversial. Because each beat of blood pressure (BP) - waveform - contains evidence of a systolic and diastolic time interval (STI, DTI), we compared pulse pressure variation (PPV) with respiratory STI and DTI variation (STV, DTV) as predictors of fluid responsiveness during pediatric liver transplantation. METHODS: A total of 61 datasets from 16 pediatric liver transplant patients (age range one month to seven years), before and after an inferior vena cava clamp was applied, were retrospectively evaluated from electronically archived BP and central venous pressure (CVP) waveforms. STI and DTI were separated by a beat-to-beat blood pressure waveform. STV, DTV and PPV were calculated by averaging three consecutive respiratory cycles. Averaged CVP was used as a static preload index. A PPV threshold of > or =16%, a known cutoff value in pediatric surgery, was used to discriminate fluid responsiveness in the receiver operating characteristic (ROC) curve analysis. RESULTS: PPV showed correlations with STV and DTV (r = 0.65 and 0.57, P < 0.001, respectively), but not with CVP (r = -0.30, P = 0.079). The area under the ROC curves (AUC) of STV, DTV and CVP were 0.834, 0.872, and 0.613, respectively. Cut-off values of STV and DTV were 7.7% (sensitivity/specificity, 0.80/0.83) and 7.7% (sensitivity/specificity, 0.70/0.88), respectively. CONCLUSIONS: This study demonstrates that STV and DTV from a BP waveform showed the potential to predict fluid responsiveness as a surrogate of PPV during pediatric surgery.

General anesthesia in a patient with multicentric Castleman's disease: a case report / 대한마취과학회지

Castleman's disease (CD) is a rare lymphoproliferative disorder of undetermined etiology. Unicentric Castleman's disease is confined to a single lymph node; it is usually asymptomatic though sometimes has local manifestations related to mass effects. In contrast, multicentric Castleman's disease (MCD) typically presents with lymphoid hyperplasia at multiple sites; it is associated with systemic symptoms and abnormal laboratory findings, with a less favorable prognosis. In case of anesthesia in CD, an exhaustive preanesthetic evaluation is essential to identify associated clinical manifestations which may influence the management of the anesthesia. Perioperative careful monitoring and proper anesthetic management are both important. We report a case of general anesthesia with anesthetic management in a patient with MCD that has not been documented in the literature.

Intraoperative very late stent thrombosis in patient undergoing arthroscopic shoulder surgery / 대한마취과학회지

No abstract available.

Alteration of the QT variability index in end-stage liver disease / 대한마취과학회지

BACKGROUND: A prolonged QT interval can lead to malignant ventricular arrhythmias and sudden cardiac death, and has frequently been found in end-stage liver disease (ESLD). However, myocardial repolarization lability has not yet been fully investigated. We evaluated the QT variability index (QTVI), a marker of temporal inhomogeneity in ventricular repolarization and an abnormality associated with re-entrant malignant ventricular arrhythmias. We determined whether QTVI is affected by the head-up tilt test in ESLD. METHODS: We assessed 36 ESLD patients and 12 control subjects without overt heart disease before and after the 70-degree head-up tilt test. The electrocardiography signal (lead II) was recorded on a computer with an analog-to-digital converter. The RR interval (RRI) and QT interval were measured after recording 5 min of the digitized electrocardiography. Then, the QT intervals were corrected with Bazett's formula (QTc). QTVI was calculated through the following formula: QTVI = log10 [(QTv/QTm2)/(RRIv/RRIm2)], QTv/RRIv: variance of QTI/RRI, QTm/RRIm: mean of QT interval/RRI. RESULTS: Cirrhotic patients exhibited an elevated QTVI. In particular, Child class C patients had a significantly increased QTVI compared to Child class A patients and the control subjects in the supine position. However, the head-up tilt test did not cause a significant difference in QTVI in relation to the severity of ESLD. CONCLUSIONS: Myocardial repolarization lability was significantly altered in end-stage liver disease. Our data suggest that the severity of ESLD is associated with the degree of the alteration in the QT variability index.

Transient left bundle branch block associated with hypoxia during monitored anesthesia care: A case report

Transient left bundle branch block (LBBB) is uncommon during anesthesia. It is mainly related to the changes in blood pressure or heart rate. Its occurrence can be confused with acute myocardial ischemia or ventricular tachycardia, therefore differential diagnosis is important. We report a case of transient LBBB which developed with hypoxia during monitored anesthesia care. LBBB is reversed to sinus rhythm after recovery from hypoxia.

Relation between preoperative autonomic function and blood pressure change after tourniquet deflation during total knee replacement arthroplasty / 대한마취과학회지

BACKGROUND: Tourniquets are used to provide a bloodless surgical field for extremities. Hypotension due to vasodilation and bleeding after tourniquet deflation is a common event. Hemodynamic stability is modulated by the autonomic nervous system (ANS). Heart rate variability (HRV) is a sensitive method for detecting individuals who may be at risk of hemodynamic instability during general anesthesia. The purpose of this study was to investigate ANS function to predict hypotension after tourniquet deflation. METHODS: Eighty-six patients who underwent total knee replacement arthroplasty (TKRA) were studied. HRV, systolic blood pressure variability (SBPV) and baroreflex sensitivity (BRS) were analyzed. We assigned two groups depending on the lowest systolic blood pressure (SBP) or mean BP (MBP) after tourniquet release (Group H; SBP 80 mmHg and MBP > 60 mmHg). RESULTS: Fifteen patients developed severe hypotension and ten patients were treated with ephedrine. Of the parameters of HRV, SBPV, and BRS, only BRSSEQ was significant being low in Group H. BRS and high-frequency SBPV were correlated with the degree of MBP change after tourniquet deflation. CONCLUSIONS: Preoperative low BRS is associated with hypotension after tourniquet deflation, suggesting the importance of baroreflex regulation for intraoperative hemodynamic stability.

Experience without using venoveno bypass in adult orthotopic liver transplantation / 대한마취과학회지

BACKGROUND: Venoveno bypass (VVB) has been used to achieve hemodynamic stability and decrease the incidence of renal dysfunction. However, VVB has many complications. The purpose of this study is to verify the safety of total clamping of the suprahepatic inferior vena cava (IVC) without VVB during orthotropic liver transplantation (OLT) in terms of anesthetic management. METHODS: Twenty-five patients without preoperative renal dysfunction who underwent primary OLT were enrolled in this study. Hemodynamic data and blood gas measurements were collected 1 hour after incision, 30 minutes after IVC total clamping and 30 minutes after reperfusion. Postoperative laboratory data, including blood urea nitrogen (BUN), creatinine (Cr) and glomerular filtration rate (GFR), were assessed at postoperative day (POD) 0-7, 30, 90, 180 and 1 year. RESULTS: Mean blood pressure was well maintained during IVC total clamping with infusion of inotropics. There was no case of severe acidosis (pH < 7.2) during the anhepatic period. The immediate postoperative Cr and GFR were not significantly different from those of the preoperative values. BUN increased from POD 1 and decreased after POD 6, while Cr increased at POD 90 only. CONCLUSIONS: In patients without preoperative renal dysfunction, when IVC was totally clamped, VVB does not need to be routinely performed to maintain hemodynamics during the anhepatic phase and renal function after OLT.

Experience with inhaled nitric oxide therapy in patient with neurogenic pulmonary edema: A case report

Neurogenic pulmonary edema is known in patients after head injuries or other cerebral lesions. Typically, this form of pulmonary edema occurs minutes to hours after central nervous system injury and may manifest during the perioperative period. It is always a life-threatening symptom after increased intracranial pressure (ICP), where immediate therapeutic interventions are imperative. Rapid initiation of strategies aimed at ameliorating hypoxia including support of oxygenation and ICP reduction is paramount. We report a case that responded dramatically to inhaled nitric oxide (NO). This therapy, to our experience, seems to provide a way not to reduce pulmonary hypertension, but to improve ventilation-perfusion mismatch for the treatment of refractory hypoxemia in neurogenic pulmonary edema patient.

Pleural effusion caused by extravasation of irrigation fluid during arthroscopic shoulder surgery: A case report / 대한마취과학회지

Arthroscopic shoulder surgery has become a common and routine procedure because it provides several advantages for the diagnosis and therapy of shoulder injuries. However, shoulder arthroscopy is not a technique that's void of complications. We describe here a unique case of a patient who experienced pleural effusion caused by extravasation of irrigation fluid during arthroscopic shoulder surgery, and this surgery was done under general anesthesia.

Modelflow method versus continuous thermodilution technique for cardiac output measurement in liver transplant patients / 대한마취과학회지

BACKGROUND: In critically ill patients, cardiac output (CO) is used as a parameter for assessing hemodynamic status and efficacy of treatment. Continuous CO (CCO) could facilitate this assessment during general anesthesia. A new method of arterial pulse wave analysis has been introduced, which estimates beat to beat CO from arterial pressure via Modelflow. It remains uncertain how well this method performs in high output states. We analyzed the relationship between CCO and Modelflow computed from radial and femoral pressures (MFCO(RA), MFCO(FA)) during liver transplantation (LT). METHODS: Measurements were performed in 100 liver transplant patients. Groups A had 36 patients, and group C had 64 patients with both groups composed of Child-Turcotte A, B and C patients Eighty patients had CCO 10 L/min (group E) during anhepatic phase. RESULTS: CCO ranged from 5.0 to 15.4 L/min (MFCO(RA) 3.2 to 10.7 L/min, MFCO(FA) 4.3 to 11.8 L/min). Bland-Altman analyses showed the limit of agreement of MFCO(RA) (-1.5 to 5.2, bias = 1.9 L/min) and of MFCO(FA) (-2.6 to 4.4, bias = 0.9 L/min). CO measured by the two methods was significantly different in groups, except for MFCO(FA) in group C. In group D, bias was 1.5 L/min (SD 1.3 L/min) for MFCO(RA) and 0.9 L/min for MFCO(FA) (SD 1.4 L/min). In group E, biases of 3.5 L/min and 2.4 L/min were obtained for MFCO(RA) and MFCO(FA), respectively. CONCLUSIONS: These results suggest that the group-average value of MFCO is not an accurate parameter for estimating CO during LT, with the exception of MFCO(FA) in groups C and D.

Factors Predicting Prolongation of the Prothrombin Time after Liver Donor Hepatectomy / 대한마취과학회지

BACKGROUND: The increasing shortage of liver donors has resulted in exponential growth of living donor liver transplantation (LDLT). There are obvious concerns about the increased risk to the donors. There has been study on the impact of donation as a function of the degree of resection. However, the effect of inhaled anesthetics combined with the degree of parenchymal loss on the liver function has not been quantified. We analyzed the prothrombin time (PT), as hepatic synthetic function, after donor hepatectomy (DH) with the recipient undergoing general anesthesia with different types of inhaled anesthetics. METHODS: One-hundred thirty-four patients who underwent DH were enrolled. The patients were randomly divided into four groups: enflurane (group E), isoflurane (group I), sevoflurane (group S), and desflurane (group D). Anesthesia was performed according to institutional standards. The PT was measured for 7 days before and daily after DH (POD). Total liver volume and resected liver volume were measured and fraction of the graft volume was calculated. RESULTS: The PT peaked on POD 1 in all groups. A significantly lower PT was observed in group D compared to the other groups until POD 3. The fraction of the graft volume showed significant correlation with the PT change. PT abnormalities were affected by the preoperative PT, the graft fraction and inhaled anesthetics. CONCLUSIONS: Desflurane induced lesser elevation of the PT than did the other inhaled anesthetics until POD 3. The preoperative PT, the graft fraction and the inhaled anesthetics may be key factors for inducing postoperative PT abnormalities.

Effects of Fluid Therapy on Serum Glucose Level in Pediatric Outpatients / 대한마취과학회지

BACKGROUND: Whether intraoperative fluid therapy should contain glucose for the pediatric outpatient surgery remains controversial. This study was designed to compare the effects of glucose and glucose-free solutions on perioperative blood glucose change. METHODS: Healthy pediatric outpatients (n = 130) for minor procedure were randomly assigned to one of two fluid therapy groups. Patients in the group H (n = 65) received lactated Ringer's solution, and patients in the group D (n = 65) received 5% dextrose perioperatively. Blood glucose was checked before infusion (a), 10 minutes after induction (b), 30 minutes after induction (c), and at the time of discharge (d). RESULTS: The preoperative fasting glucose concentrations were 97.6 +/- 12.1 mg/dl and 97.7 +/- 11.3 mg/dl for the group H and D, respectively. The patients in the group D showed significantly increased blood glucose level after induction (135.9 +/- 42.7, 150.3 +/- 36.0, 123.6 +/- 26.8 mg/dl). The patients in the group H also showed significantly increased blood glucose levels (112.2 +/- 14.0, 121.4 +/- 11.4 and 105.8 +/- 18.3 mg/dl). The glucose level of group D was significantly higher than the glucose level of group H at b, c and d. Seven patients in the group D showed hyperglycemia (> 200 mg/dl). CONCLUSIONS: Dextrose containing fluid therapy resulted dangerous hyperglycemia in the pediatric outpatient surgery. We recommend lactated Ringer's solution or other glucose-free crystalloid for the healthy outpatient pediatric population undergoing minor procedures.

Assessment of Cardiovascular Autonomic Function in Patients with Liver Cirrhosis Using Heart Rate Variability, Blood Pressure Variability and Baroreflex Sensitivity / 대한마취과학회지

BACKGROUND: Liver cirrhosis is associated with several hemodynamic abnormalities, including an impairment of autonomic nervous system reflexes, but very few have compared the disease severity with cardiovascular autonomic dysfunction assessed by spectral analysis of blood pressure and electrocardiogram. The aim of this study was to investigate the relationship between Child-Turcotte-Pugh (CTP) score and autonomic indices in patients with liver cirrhosis using the heart rate variability (HRV), blood pressure variability (BPV) and baroreflex sensitivity (BRS). METHODS: Fifty patients scheduled for liver transplantation recipients under general anesthesia were enrolled in the study. Beat-to-beat blood pressure and RR interval were measured for five minutes before anesthesia induction. HRV and BPV were estimated by power spectral analysis of RR interval and systolic blood pressure. BRS was estimated by both the sequence method (Sequence BRS) and high frequency (HF) gain of transfer function analysis (HF BRS). RESULTS: Significant inverse correlations between CTP score and Sequence BRS (r = -0.61), HF BRS (r = -0.59), low frequency (LF) and HF power of HRV (r = -0.57, r = -0.46), LF power of BPV (r = -0.37) were found. However, no significant correlations were observed between CTP score and LF/HF ratio of HRV (r = -0.02) and HF power of BPV (r = 0.27). CONCLUSIONS: These results showed that autonomic dysfunction assessed by spectral analysis was associated with increasing severity of liver cirrhosis. Further study will be needed to clarify relationship between our findings and hemodynamic fluctuations during anesthesia for liver transplantation.

Anesthetic Implication of Hemoglobin-M: A case report / 대한마취과학회지

Cyanosis in children is most often caused by pulmonary disease, or cyanotic heart disease but is rarely caused by hematological problems such as methemoglobinemia and sulfhemoglobinemia. Abnormal hemoglobins with a reduced oxygen affinity are an exceptionally uncommon cause of cyanosis in children. Hemoglobin-M (Hb-M) is rapidly auto-oxidized into the met-form resulting in the loss of its O2-binding ability. This hemoglobinopathy is inherited in an autosomal dominant pattern and is characterized by marked cyanosis. Hb-M affects the anesthetic management because of the anomalous absorption spectrum of Hb-M in standard pulse oximetry. Sufficient O2 delivery should be maintained by keeping a high FiO2 and intermittently checking the O2 delivery state using arterial blood gas analysis. We reported our experience of the anesthetic management of a patient with hemoglobin M.

Assessment of the Mechanism of Arterial Blood Pressure Change during Sevoflurane Induction: Beat-to-Beat Analysis of Hemodynamic Variables Using a Modelflow Method / 대한마취과학회지

BACKGROUND: A modelflow method provides beat-to-beat analysis of cardiovascular variables based on arterial pulse pressure analysis. In this study, we assessed the mechanism of arterial blood pressure (ABP) change during sevoflurane induction by the analysis of beat-to-beat hemodynamic changes using a modelflow method. METHODS: Beat-to-beat ABP was measured during a stable conscious state (baseline) and vital capacity induction with sevoflurane 6 vol% and oxygen 8 L/min in 18 healthy living liver transplant donors. Alterations of beat-to-beat systolic ABP, mean ABP, diastolic ABP, heart rate (HR), stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR) by sevoflurane induction were estimated noninvasively using a modelflow method simulating aortic input impedance from an ABP waveform. RESULTS: After sevoflurane induction, ABP, SV, CO, and TPR decreased significantly (all P < 0.05), but HR did not change significantly. After tracheal intubation, ABP, CO, and TPR did not change significantly compared with baseline, but HR increased and SV decreased significantly (both P < 0.05). CONCLUSIONS: Using a modelflow beat-to-beat analysis of cardiovascular variables, we found that ABP did not change significantly compared to baseline after tracheal intubation during sevoflurane induction, indicating the counteraction of increased HR and decreased SV, and that the reduction of SV by tracheal intubation suggests the suppression by increased HR and TPR compared with that after sevoflurane induction.

Comparison of Prophylactic Antiemetic Therapy with Patient-controlled Epidural Analgesia after Thoracotomy / 대한마취과학회지

BACKGROUND: Patient controlled analgesia (PCA) has become an important means for treating postoperative pain. However, postoperative nausea and vomiting (PONV) are a major problem for patient using PCA system. This study was designed to evaluate the efficacy of two prophylactic antiemetic regimens on PONV during PCA after lobectomy. METHODS: Sixty five patients, who underwent lobectomy and received a mixture of 0.18% ropivacaine at 0.5 microgram/kg/hr of fentanyl (2,000 microgram) via thoracic epidural catheter. The study design was a prospective, randomized, double-blinded, placebo-controlled study. Group C was saline control group. In Group A or B, Nasea(R) (ramosetron) or Zofran(R) (ondansetron) was administered as an intravenous bolus at completion of operation. We assessed the frequency and severity of PONV at 6, 24, 48 hours after anesthesia. Postoperative pain was assessed 6 hr after the operation and everyday for 6 days on visual analog scale (VAS). Postoperative side effects and patient satisfaction for epidural analgesia were assessed by 4 grades. RESULTS: PONV occurred in 20%, 20%, and 35% of patients in Group A, B, and C at 6 hr after anesthesia, and 12%, 30%, and 30% at 24 hr after anesthesia. There were no significantly statistical differences among three groups. The VAS scores during coughing were higher than those of resting state without intergroup difference. There were no serious clinical adverse events caused by the study drug and epidurally administered drugs in any study groups. CONCLUSIONS: This study found that ramosetron and ondansetron for preventing PONV during epidural PCA after lobectomy was not different from placebo control.