Modified Cardiovascular Sequential Organ Failure Assessment Score in Sepsis: External Validation in Intensive Care Unit Patients

Background@#There is a need to update the cardiovascular (CV) Sequential Organ Failure Assessment (SOFA) score to reflect the current practice in sepsis. We previously proposed the modified CV SOFA score from data on blood pressure, norepinephrine equivalent dose, and lactate as gathered from emergency departments. In this study, we externally validated the modified CV SOFA score in multicenter intensive care unit (ICU) patients. @*Methods@#A multicenter retrospective observational study was conducted on ICU patients at six hospitals in Korea. We included adult patients with sepsis who were admitted to ICUs. We compared the prognostic performance of the modified CV/total SOFA score and the original CV/total SOFA score in predicting 28-day mortality. Discrimination and calibration were evaluated using the area under the receiver operating characteristic curve (AUROC) and the calibration curve, respectively. @*Results@#We analyzed 1,015 ICU patients with sepsis. In overall patients, the 28-day mortality rate was 31.2%. The predictive validity of the modified CV SOFA (AUROC, 0.712; 95% confidence interval [CI], 0.677–0.746; P < 0.001) was significantly higher than that of the original CV SOFA (AUROC, 0.644; 95% CI, 0.611–0.677). The predictive validity of modified total SOFA score for 28-day mortality was significantly higher than that of the original total SOFA (AUROC, 0.747 vs. 0.730; 95% CI, 0.715–0.779; P = 0.002). The calibration curve of the original CV SOFA for 28-day mortality showed poor calibration. In contrast, the calibration curve of the modified CV SOFA for 28-day mortality showed good calibration. @*Conclusion@#In patients with sepsis in the ICU, the modified SOFA score performed better than the original SOFA score in predicting 28-day mortality.

Effects of acute normovolemic hemodilution on healing of gastric anastomosis in rats

PURPOSE: Acute normovolemic hemodilution (ANH) is an autologous transfusion method, using blood collected during surgery, to reduce the need for allogeneic blood transfusion. ANH is controversial because it may lead to various complications. Among the possible complications, anastomotic leakage is one that would have a significant effect on the operation outcome. However, the relationship between ANH and anastomotic site healing requires additional research. Therefore, we conducted this prospective study of ANH, comparing it with standard intraoperative management, undergoing gastric anastomosis in rats. METHODS: Sixteen Sprague-Dawley rats were randomly assigned to three groups: group A, surgery with ANH; group N, surgery with standard intraoperative management; and group C, sham surgery with standard intraoperative management. ANH was performed in group A animals by, removing 5.8–6.6 mL of blood and replacing it with 3 times as much crystalloid. All rats were enthanized on postoperative day 6, and histopathologic analyses were performed. RESULTS: The mean hematocrit values, after hemodilution were 22.0% (range, 18.0%–29.0%), group A; 33.0% (29.0%–35.0%), group N; and 32.5% (29.0%–34.0%), group C. There were significant differences between groups A and N (P = 0.019, P = 0.009, P = 0.004, P = 0.039, and P = 0.027), and between groups N and C (P = 0.006, P = 0.027, P = 0.04, P = 0.008, and P = 0.009) with respect to inflammatory cell numbers, neovascularization, fibroblast numbers, edema and necrosis, respectively; there were no differences between groups A and N. CONCLUSION: In rat model, anastomotic complications did not increase in the ANH group, compared with the standard intraoperative management group.

Patient Blood Management: Anesthesiologist's Perspectives / 한양의대학술지

Preoperative anemia should be diagnosed and treated before surgery, because anemia is associated with increased postoperative mortality and morbidity. Even if iron deficiency is not detected, the possibility of functional iron deficiency should be considered. During surgery, patients should be managed to avoid hypothermia, acidosis, and hypocalcemia, while maintaining adequate blood pressure and preventing dilutional coagulopathy. It is currently recommended to start transfusion when hemoglobin is under 7–8 g/dL in patients without cardiac problems, using restrictive strategy rather than liberal, due to dangers of complications from transfusion. For those who refuse transfusion, or when transfusion is difficult due to multiple antibodies, or when attempting to reduce allogeneic transfusion, preoperative autologous blood donation (PAD), intraoperative acute normovolemic hemodilution (ANH), intraoperative blood salvage, or postoperative blood salvage can be used. For patients with trauma or massive bleeding, damage control resuscitation of permissive hypotension, restriction of crystalloid infusion, transfusion of blood product in a ratio similar to whole blood (1:1:1 of FFP, platelets, PRBC) must be actively carried out.

Comparative study on the osseointegration of implants in dog mandibles according to the implant surface treatment

OBJECTIVES: This study compared the impact of implant surface treatment on the stability and osseointegration of implants in dog mandibles. MATERIALS AND METHODS: Six adult dogs received a total of 48 implants that were prepared using four different surface treatments; resorbable blast media (RBM), hydroxyapatite (HA), hydrothermal-treated HA, and sand blasting and acid etching (SLA). Implants were installed, and dogs were separated into 2- and 4-week groups. Implant stability was evaluated via Periotest M, Osstell Mentor, and removal torque analyzers. A histomorphometric analysis was also performed. RESULTS: The stability evaluation showed that all groups generally had satisfactory values. The histomorphometric evaluation via a light microscope revealed that the HA surface implant group had the highest ratio of new bone formation on the entire fixture. The hydrothermal-treated HA surface implant group showed a high ratio of bone-to-implant contact in the upper half of the implant area. CONCLUSION: The hydrothermal-treated HA implant improved the bone-to-implant contact ratio on the upper fixture, which increased the implant stability.

Successful transfusion-free pancreatectomy in Jehovah's Witness patients

BACKGROUNDS/AIMS: Although perioperative therapies have improved greatly, pancreatectomies still often need blood transfusions. However, the morbidity from blood transfusions, the poor prognosis of blood transfused patients, high cost, and decreasing supply of blood products is accelerating transfusion-free (TF) surgery in the patients who have pacreatectomies. The aim of this study was to assess the feasibility of TF pancreatectomies for patients who are Jehovah's Witness. METHODS: We investigated the possibility of TF pancreatectomies for the Jehovah's Witness patients undergoing pancreatectomies between January 2007 and Februay 2014. There were 4 cases of Whipple's operation, 4 of pylorus-preserving pancreaticoduodenectomy, 2 of radical antegrade modular pancreatosplenectomy and 1 of laparoscopic distal pancreatectomy. All were performed by one surgeon. RESULTS: Most of the TF pancreatecomies patients received perioperative blood augmentation and intraoperative acute normovolemic hemodilution (ANH). They received no blood transfusions at any time during their hospitalization, and pre- and intra-operative data and outcomes were acceptably favorable. CONCLUSIONS: To the best of our knowledge, this report is the first successful consecutive pancreatectomy program for Jehovah's Witness not involving blood transfusion. TF pancreatectomy can be performed successfully in selected Jehovah's Witness. Postoperative prognosis and outcomes should be confirmed in follow up studies.

Comparison of Morphine and Remifentanil on the Duration of Weaning from Mechanical Ventilation / 대한중환자의학회지

No abstract available.

Comparison of Morphine and Remifentanil on the Duration of Weaning from Mechanical Ventilation / 대한구급학회지

No abstract available.

Tachycardia-bradycardia syndrome in a patient with atrial fibrillation: a case report / 대한마취과학회지

An 83-year-old woman was scheduled for a second transurethral resection of a bladder tumor. The preoperative electrocardiogram evaluation revealed atrial fibrillation with a slow ventricular response (ventricular rate: 59 /min). After intravenous injection of 1% lidocaine 40 mg and propofol 60 mg, the ventricular rate increased to 113 beats/min and then fell rapidly to 27 beats/min. Blood pressure was 70/40 mmHg. Later an atrial fibrillation rhythm, with a ventricular rate of 100-130 beats/min, was observed together with a sinus pause and sinus rhythm with a ventricular rate of 40-50 beats/min. An external pacemaker was applied and set at 60 mA, 40 counts. After the patient regained consciousness, she presented an alert mental state and had no chest symptoms. She was discharged 2 weeks later without complications after insertion of a permanent pacemaker.

Comparison of Morphine and Remifentanil on the Duration of Weaning from Mechanical Ventilation / 대한중환자의학회지

BACKGROUND: A randomized, multicenter, open-label, parallel group study was performed to compare the effects of remifentanil and morphine as analgesic drugs on the duration of weaning time from mechanical ventilation (MV). METHODS: A total of 96 patients with MV in 6 medical and surgical intensive care units were randomly assigned to either, remifentanil (0.1-0.2 mcg/kg/min, n = 49) or morphine (0.8-35 mg/hr, n = 47) from the weaning start. The weaning time was defined as the total ventilation time minus the sum of controlled mode duration. RESULTS: Compared with the morphine group, the remifentanil-based analgesic group showed a tendency of shorter weaning time (mean 143.9 hr, 89.7 hr, respectively: p = 0.069). Secondary outcomes such as total ventilation time, successful weaning rate at the 7th of MV day was similar in both groups. There was also no difference in the mortality rate at the 7th and 28th hospital day. Kaplan-Meyer curve for weaning was not different between the two groups. CONCLUSIONS: Remifentanil usage during the weaning phase tended to decrease weaning time compared with morphine usage.

Comparison of Morphine and Remifentanil on the Duration of Weaning from Mechanical Ventilation / 대한구급학회지

BACKGROUND: A randomized, multicenter, open-label, parallel group study was performed to compare the effects of remifentanil and morphine as analgesic drugs on the duration of weaning time from mechanical ventilation (MV). METHODS: A total of 96 patients with MV in 6 medical and surgical intensive care units were randomly assigned to either, remifentanil (0.1-0.2 mcg/kg/min, n = 49) or morphine (0.8-35 mg/hr, n = 47) from the weaning start. The weaning time was defined as the total ventilation time minus the sum of controlled mode duration. RESULTS: Compared with the morphine group, the remifentanil-based analgesic group showed a tendency of shorter weaning time (mean 143.9 hr, 89.7 hr, respectively: p = 0.069). Secondary outcomes such as total ventilation time, successful weaning rate at the 7th of MV day was similar in both groups. There was also no difference in the mortality rate at the 7th and 28th hospital day. Kaplan-Meyer curve for weaning was not different between the two groups. CONCLUSIONS: Remifentanil usage during the weaning phase tended to decrease weaning time compared with morphine usage.

Antioxidant effect of muscle relaxants (vecuronium, rocuronium) on the rabbit abdominal aortic endothelial damage induced by reactive oxygen species / 대한마취과학회지

BACKGROUND: Muscle relaxants induce vascular smooth muscle relaxation by inducing synthesis of the prostaglandins that influence vasomotor tone. However, the effects of muscle relaxants on endothelial cells and tissues following injury by reactive oxygen species (ROS) are unclear. We tested the effects of the muscle relaxants vecuronium and rocuronium on impaired acetylcholine (ACh)-induced relaxation following induction of ROS in rabbit aorta in vitro. METHODS: Isolated rabbit abdominal aortic ring segments were pretreated with vecuronium or rocuronium at 10(-4), 3 x 10(-4), 10(-3) or 3 x 10(-3) M, with or without inhibitors of Cu/Zn superoxide dismutase (diethyldithiocarbamate; DETCA, 0.8 mM) or catalase (3-amino-1,2,4-triazole; 3AT, 50 mM). All groups of aortic rings were then exposed to ROS generated by electrolysis in the organ bath medium (Krebs-Henseleit solution). The effects of vecuronium and rocuronium on ROS-induced impairment of relaxation induced by ACh (10(-6) M) were assessed. RESULTS: Aortic rings treated with vecuronium or rocuronium at 10(-4), 3 x 10(-4), 10(-3) or 3 x 10(-3) M preserved the capacity for ACh-induced endothelial relaxation following ROS exposure in a dose-dependent manner. Pretreatment with DETCA partially inhibited the protective effects of vecuronium and rocuronium on ACh-induced relaxation (P < 0.001), but pretreatment with 3AT had no effect. CONCLUSIONS: Muscle relaxants protected the endothelium in isolated rabbit abdominal aorta from free-radical injury in a dose-dependent manner. These results suggest that vecuronium and rocuronium may act as superoxide anion scavengers.

Survey on understanding after anesthetic induction simulation training in medical students' anesthesiology practice / 대한마취과학회지

No abstract available.

Prognosis and evaluation of tooth damage caused by implant fixtures

Damage to adjacent teeth is one of the various complications that may occur during implant placement and is often the result of improper direction during fixture placement or excessive depth of placement. In general, if detrimental symptoms, such as reaction to percussion in damaged teeth, mobility, and pulp necrosis, are not present, osseointegration should be observed at follow-up. In three cases, the possibility of root damage due to an implant fixture placed too close to each adjacent tooth was perceived on radiographs. However, in all of these cases, there were no clinical symptoms or radiographic changes present in the tooth, and the implants did not exhibit decreased stability or peri-implantitis. Therefore, we can carefully predict that the implant fixture close to the adjacent tooth did not invade the cementum of the root, and therefore did not produce the suspected pulpal damage or periradicular symptoms. In this study, we considered both the implant status as well as the adjacent tooth.

Antioxidant effects of methylprednisolone and hydrocortisone on the impairment of endothelium dependent relaxation induced by reactive oxygen species in rabbit abdominal aorta / 대한마취과학회지

BACKGROUND: The reperfusion following ischemia produces reactive oxygen species (ROS). We studied the influences of methylprednisolone (MPD) and hydrocortisone (CRT) on ROS effects using the endothelium of rabbit abdominal aorta. METHODS: Isolated rabbit aortic rings were suspended in an organ bath filled with Krebs-Henseleit (K-H) solution. After precontraction with norepinephrine, changes in arterial tension were recorded following the cumulative administration of acetylcholine (ACh). The percentages of ACh-induced relaxation of aortic rings before and after exposure to ROS, generated by electrolysis of K-H solution, were used as the control and experimental values, respectively. The aortic rings were pretreated with MPD or CRT at the same concentrations, and the effects of these agents were compared with the effects of ROS scavenger inhibitors: superoxide dismutase inhibitor, diethylthiocarbamate (DETCA), and the catalase inhibitor, 3-amino-1,2,4-triazole (3AT). RESULTS: Both MPD and CRT maintained endothelium-dependent relaxation induced by ACh in a dose-related manner in spite of ROS attack. The restored ACh-induced relaxation of MPD and CRT group was not attenuated by pretreatment of 3AT and DETCA. CONCLUSIONS: MPD and CRT preserve the endothelium-dependent vasorelaxation against the attack of ROS, in a dose-related manner. Endothelial protection mechanisms of MPD and CRT may be not associated with hydrogen peroxide and superoxide scavenging.

Anesthetic considerations in patients with large obstructing vocal process granuloma / 대한마취과학회지

No abstract available.

A Comparative Study of Intermaxillary Fixation and Manual Reduction at Open Reduction and Internal Fixation of Mandibular Fractures

Comparison of the Pentax AWS and the Glidescope with the Macintosh laryngoscope for tracheal intubation in patients with Mallampati classification I or II

BACKGROUND: The Pentax AWS and the Glidescope are new intubating devices.They were designed to provide a view of the glottis without alignment of the oral, pharyngeal and tracheal axis. The purpose of this study was to evaluate the effectiveness of the Pentax AWS and the Glidescope in comparison with the Macintosh laryngoscope, when performing tracheal intubation in patients with mallampati classification I or II. METHODS: Ninety patients presenting for surgery requiring tracheal intubation, and who were deemed easy for tracheal intubation of mallampati classification I or II were randomly assigned to undergo intubation using a Macintosh (Group M, n = 30), Pentax AWS (Group P, n = 30) or Glidescope (Group G, n = 30). Time to complete tracheal intubation and number of attempts until successful intubation were recorded. Noninvasive blood pressure and heart rate recorded before induction (PI), just before intubation (PT), 1 min and 5 min after intubation. Patients were assessed for postoperative sore throat at 6-12 h after surgery. RESULTS: Time to secure the airway with the Macintosh 13.0 (min 7, max 23.0) s was lesser than with the Pentax AWS 20.4 (8, 51.2) s and Glidescope 22.1 (10, 42.0) s. There were no significant differences in the rate of successful intubations and sore throat among the groups. There were significant increases in both mean arterial pressure and heart rate 1 min after intubation in all groups compare with PI. CONCLUSIONS: The Pentax AWS and the Glidescope had no specific advantage over the Macintosh laryngoscope for the patients with normal airway.

Clinical Evaluation of Mandibular Condyle Fractures

Experimental Study of Osseointegration and Stability of Intentionally Exposed Hydroxyapatite Coating Implants

A Case of Acute Lung Injury after Transfusion during Cesarean Section: A Case Report / 대한구급학회지

Transfusion-related acute lung injury (TRALI) is a serious complication following the transfusion of blood products. TRALI is under-diagnosed and under-reported because of a lack of awareness. TRALI occurs within 6 hours of transfusion in the majority of cases and its presentation is similar to other forms of acute lung injury. We report on the case of a 34-year-old pregnant woman who suffered from TRALI after transfusion during Cesarean section.