Driving pressure guided ventilation / 대한마취과학회지

Protective ventilation is a prevailing ventilatory strategy these days and is comprised of small tidal volume, limited inspiratory pressure, and application of positive end-expiratory pressure (PEEP). However, several retrospective studies recently suggested that tidal volume, inspiratory pressure, and PEEP are not related to patient outcomes, or only related when they influence the driving pressure. Therefore, this review introduces the concept of driving pressure and looks into the possibility of driving pressure-guided ventilation as a new ventilatory strategy, especially in thoracic surgery where postoperative pulmonary complications are common, and thus, lung protection is of utmost importance.

Whole-lung lavage complicated with pneumothorax: a case report / 대한마취과학회지

A patient with pulmonary alveolar proteinosis underwent whole lung lavage of the right lung. Lavage of the left lung was not immediately possible because of severe hypoxemia. Three days later, after correction of hypoxemia, we re-attempted the left lung lavage. However, the patient had severe hypoxemia (SpO₂< 80%) within a few minutes of performing right one lung ventilation (OLV). On bronchoscopic examination, proper tube location was confirmed. Bronchodilator nebulization and steroid injection were attempted with no effect. While searching for the cause of the hypoxemia, we found that the breath sound from the right lung had become very weak and distant compared with that from initial auscultation. Right pneumothorax was diagnosed on chest X-ray and a chest tube was inserted. After confirming pneumothorax resolution, we re-tried right OLV and were able to proceed with the left lung lavage without signs of aggravating air leak, loss of tidal volume, or severe hypoxemia.

Management of cardiac arrest in a parturient with Eisenmenger's syndrome and complete atrioventricular block during Cesarean section: a case report / 대한마취과학회지

A 26-year-old parturient with Eisenmenger's syndrome and complete atrioventricular block was presented for emergency Cesarean section due to preterm labor. Ventricular tachycardia (VT), which progressed to ventricular fibrillation (VF), started immediately after the incision. Cardiopulmonary resuscitation with electric shocks was given by anesthesiologists while the obstetrician delivered the baby between the shocks. A cardiac surgeon was ready for extracorporeal membrane oxygenation institution in case of emergency but spontaneous circulation of the patient returned after the 3rd shock and the delivery of the baby. The newborn's Apgar score was 4 at 1 minute and 8 at 5 minutes. An implantable cardioverter-defibrillator was inserted before the discharge because the patient had recurrent episodes of VT and VF postoperatively.

Clinical benefits of preemptive thoracic epidural analgesia with hydromorphone and bupivacaine in open thoracotomy lung surgery

BACKGROUND: Preemptive analgesia is known to decrease the sensitization of the central nervous system and reduce subsequent amplification of nociceptive stimuli. We investigated whether preemptive thoracic epidural analgesia (TEA) demonstrated intraoperative and postoperative short and long term clinical advantages. METHODS: Thirty patients scheduled for open thoracotomy were randomly allocated to one of two groups to receive continuous TEA (0.15% bupivacaine and 8 microg/ml hydromorphone) either before surgical incision (preemptive group) or at the end of the operation (nonpreemptive group). Incidence of hypotension during surgery was recorded. Numerical rating scales (NRS) and the incidence of side effects such as nausea, pruritus, sedation, hypotension, and respiratory depression were recorded at 2, 6, 24, and 48 hours postoperatively. Pulmonary function test (PFT) was performed before, 24 and 48 hours after the operation. Persistence of pain control was investigated at 6 months postoperatively. RESULTS: The NRS score, side effects, and PFT changes were comparable between the two groups. TEA and intravenous rescue morphine consumed at 2, 6, 24, and 48 hours postoperatively were not different between the two groups. During surgery, the incidence of hypotension was significantly higher in the preemptive group (P = 0.027). At 6-month follow up, two patients in the nonpreemptive group complained of persistent pain at wound and none in the preemptive group. CONCLUSIONS: Preemptive TEA with hydromorphone and bupivacaine during surgery may cause unnecessary intraoperative hypotension without a prominent advantage in reducing acute or chronic pain or enhancing pulmonary function after thoracotomy. The advantageous concept of preemptive TEA may be dubious and may not provide perioperative clinical benefits.

Lung transplantation in a patient with massive pneumomediastinum following 66 days of awake extracorporeal membrane oxygenation support: A case report

In a 54-year-old man with interstitial lung disease associated with dermatomyositis, acute exacerbation of the disease had occurred and massive pneumothorax, pneumomediastinum and extensive subcutaneous emphysema were developed while waiting for lung transplantation. He was supported by awake extracorporeal membrane oxygenation (ECMO) for 66 days and bridged to lung transplantation, but mechanical ventilation was not done during ECMO period and induction period to avoid tension pneumothorax and cardiac tamponade. Notable points of this report are that the days of ECMO support were long, the type was awake ECMO, and positive pressure ventilation was not done during whole pretransplant period including anesthesia induction. The transplantation was done successfully and the patient was discharged 25 days after lung transplantation.

Respiratory insufficiency and dynamic hyperinflation after rigid bronchoscopy in a patient with relapsing polychondritis: a case report / 대한마취과학회지

Relapsing polychondritis (RP) is an uncommon disease that is characterized by inflammation and destruction of cartilaginous structures. When tracheobronchial tree is involved, respiratory obstructive symptoms can occur. A 35-year-old man, with a previous diagnosis of RP, was scheduled for rigid bronchoscopy to relieve dyspnea, caused by subglottic stenosis. After laser splitting of the subglottic web, the spontaneous respiration of the patient was insufficient, and hypercarbia developed progressively even with assisted ventilation. After 20 minutes of aggressive hyperventilation to reduce end-tidal CO2 level, sudden extreme tachycardia and hypotension developed. Ventilation rate was reduced and prolonged expiration time was allowed to alleviate a near-tampon status from dynamic hyperinflation. After the hemodynamic status was stabilized, the patient was transferred to the ICU for mechanical ventilation. He received ICU care for 30 days, and now, he was on supportive care on a ward, considering Y stent insertion to prevent luminal collapse from tracheobronchomalacia.

Effects of a Self-discovery Program for Ego resilience, Self-esteem, Stress and Depression in Elementary School Students / 정신간호학회지

PURPOSE: This study was done to identify the effects of a Self-discovery Program for elementary school students. The study consisted of two phases: Developing the program and evaluating its effectiveness. METHODS: Forty six students who were in elementary school in B city participated in a survey, which was carried out from May 25 to July 15, 2010. To test the effects of the Self-discovery Program, the participants were divided into two groups, an experimental group (n=23) and a control group (n=23). The research design used in this study was a non-equivalent control group pretest-posttest research design. Data were analyzed by using chi2-test, t-test and ANCOVA with the SPSS/WIN 14.0 program. RESULTS: Significant differences were found in scores for self-esteem (t=2.60, p=.006), stress (F=18.65, p<.001) and depression (F=23.88, p<.001) between the experimental group and the control group. CONCLUSION: The results indicate that Self-discovery Program should be used with children to help them and to improve their mental health.

Risk score for postoperative complications in thoracic surgery / 대한마취과학회지

BACKGROUND: Risk scoring system for thoracic surgery patients have not been widely used, as of recently. We tried to forge a risk scoring system that predicts the risk of postoperative complications in patients undergoing major thoracic surgery. We used a prolonged ICU stay as a representative of postoperative complications and tested various possible risk factors for its relation. METHODS: Data from all patients who underwent major lung and esophageal cancer surgeries, between 2005 and 2007 in our hospital, were collected retrospectively (n = 858). Multiple logistic regression analysis was performed with various possible risk factors to build the risk scoring system for prolonged ICU stay (> 3 days). RESULTS: A total of 9% of patients exhibited more than 3 days of ICU stay. Age, operation name, preoperative lung injury, no epidural analgesia, and predicted post operative forced expiratory volume in 1 second (ppoFEV1) were the risk factors for prolonged ICU stay, by multivariable analysis (P < 0.05). Risk score, p was derived from the formula: logit(p/[1-p]) = -5.39 + 0.06 x age + 1.12 x operation name(2) + 1.52 x operation name(3) + 1.32 x operation name(4) + 1.56 x operation name(5) + 1.30 x preoperative lung injury + 0.72 x no epidural analgesia - 0.02 x ppoFEV1 [Age in years, operation name(2): pneumonectomy, operation name(3): esophageal cancer operation, operation name(4): completion pneumonectomy, operation name(5): extended operation, preoperative lung injury(+), epidural analgesia(-), ppoFEV1 in %]. CONCLUSIONS: Age, operation name, preoperative lung injury, epidural analgesia, and ppoFEV1 can predict postoperative morbidity in thoracic surgery patients.

Postoperative nausea and vomiting after endoscopic thyroidectomy: total intravenous vs. balanced anesthesia / 대한마취과학회지

BACKGROUND: Endoscopic thyroidectomy was recently introduced and has been rapidly accepted by surgeons and patients. The present study was conducted to estimate and compare the incidences of postoperative nausea and vomiting (PONV) after endoscopic thyroidectomy using two different anesthetic methods: sevoflurane based balanced anesthesia; total intravenous anesthesia (TIVA). METHODS: Ninety nine female patients that were scheduled to undergo elective endoscopic thyroidectomy under general anesthesia were enrolled. These patients were randomly allocated to receive sevoflurane based balanced anesthesia (BA group) or propofol-remifentanil anesthesia (TIVA group). PONV was evaluated using a 4-point Likert scale, and pain using a visual analogue scale (VAS; range 0 to 100) for 0-2, 2-6, and 6-24 hours postoperatively. At 24 hours postoperatively, overall patient satisfaction regarding PONV and pain were recorded. RESULTS: The incidence of PONV was 14.6% in the TIVA group and 51.3% in the BA group. The incidence of nausea at 0-2 and 2-6 hours postoperatively was lower in the TIVA group than in the BA group (4.2% vs. 35.9%, 6.3% vs. 23.1%, respectively), but no between-group difference was observed at 6-24 hours postoperatively (8.3% vs. 5.1%). Antiemetic usage at 0-2 and 2-6 hours was lower in the TIVA than the BA group (4.2% vs. 38.5%, 6.3% vs. 23.1%), but no between-group difference was observed for 6-24 hours (6.3% vs. 7.7%). There were no differences in pain or in patient satisfaction. CONCLUSIONS: After endoscopic thyroidectomy, total intravenous anesthesia with propofol-remifentanil is associated with less PONV during the early postoperative period (0-6 hours) than sevoflurane based balanced anesthesia.

Does a single dose of intravenous nicardipine or nimodipine affect the bispectral index following rapid sequence intubation? / 대한마취과학회지

BACKGROUND: Theoretically, L-type calcium channel blockers could modulate anesthetic effects. Nicardipine does not affect the bispectral index (BIS), but nimodipine, which can penetrate the blood-brain barrier, has not been studied. The aim of this study was to evaluate whether a single dose of intravenous nicardipine or nimodipine could affect BIS following rapid sequence intubation. METHODS: This study was done in a double-blind, randomized fashion. Anesthesia was induced with fentanyl 2 microgram/kg, thiopental sodium 5 mg/kg, and 100% oxygen. After loss of consciousness, patients received rocuronium 1.0 mg/kg and either a bolus of 20 microgram/kg nicardipine, nimodipine, or a comparable volume of normal saline (n = 20). Intubation was performed 1 min after study drug administration. BIS, mean blood pressure (MBP), and heart rate (HR) were measured before anesthetic induction, after loss of consciousness, before intubation, during intubation, and 1, 2 and 5 min after intubation. RESULTS: BIS dropped rapidly after induction but increased to 60 before intubation in all groups irrespective of study drug. In nimodipine, the increase in BIS during intubation was not significant compared to pre-intubation, in contrast to the other two groups, but there was no difference in BIS during intubation. HR significantly increased, but MBP just rose to pre-induction values after intubation in nicardipine and nimodipine groups. BIS, MBP, and HR following intubation increased in control group. CONCLUSIONS: A single dose of intravenous nicardipine or nimodipine could attenuate blood pressure increases but not affect BIS increases in rapid sequence intubation.

Breakage of a thoracic epidural catheter during its removal: A case report / 대한마취과학회지

The breakage of an epidural catheter is a rare complication during the removal of a thoracic epidural catheter. There are many causes to breakage of an epidural catheter, such as the characteristics of the catheter itself, patient's factors (anatomy, position during insertion and removal of the catheter, and the BMI), and the difficulty of the procedure. Surgical removal is considered if there is a possibility that the retained catheter might cause neurological problems. We experienced a breakage of an epidural catheter during its removal, which led to surgical intervention. To prevent the catheter breakage during its removal, the catheter should be withdrawn without excessive tension. In addition, an understanding of the patient's anatomy is essential.

Comparison of the effectiveness of lidocaine and salbutamol on coughing provoked by intravenous remifentanil during anesthesia induction / 대한마취과학회지

BACKGROUND: Coughing is a side effect of opioids that is rarely studied. Here, we evaluated the incidence of remifentanil induced coughing during anesthesia induction in an attempt to identify its risk factors and to examine the preventive effects of lidocaine and salbutamol. METHODS: A total of 237 patients scheduled to undergo general anesthesia were allocated randomly into three groups. Group C received no medication, while Group L received 2% lidocaine at 0.5 mg/kg intravenously 1 minute prior to remifentanil infusion and Group S inhaled one metered aerosol puff of salbutamol 15 minutes prior to entering the operating room. Remifentanil was infused at 5 ng/ml by target controlled infusion and coughing was measured for five minutes and graded as none, mild, moderate, or severe based on the number of coughs. RESULTS: The incidences of coughing were 30.4%, 25.3%, and 35.4% in Groups C, L, and S, respectively. The incidences, onset times, and severity of coughing did not differ significantly among groups. In addition, multivariate analysis showed that non-smoking and a lower body weight were risk factors of remifentanil-induced coughing (odds ratio, 8.13; P = 0.024, 1.11, and 0.004, respectively). CONCLUSIONS: The incidence of remifentanil-induced coughing was 30%. A total of 0.5 mg/kg lidocaine and 1 metered aerosol puff of salbutamol did not prevent coughing. Non-smoking and low body weight were found to be risk factors of remifentanil-induced coughing.

Is Intravenous Patient Controlled Analgesia Enough for Pain Control in Patients Who Underwent Thoracoscopy?

This prospective randomized study was conducted to evaluate the efficacy of two common analgesic techniques, thoracic epidural patient-controlled analgesia (Epidural PCA), and intravenous patient-controlled analgesia (IV PCA), in patients undergoing lobectomy by the video-assisted thoracic surgical (VATS) approach. Fifty-two patients scheduled for VATS lobectomy were randomly allocated into two groups: an Epidural PCA group receiving an epidural infusion of ropivacaine 0.2%+fentanyl 5 microg/mL combination at a rate of 4 mL/hr, and an IV PCA group receiving an intravenous infusion of ketorolac 0.2 mg/kg+fentanyl 15 microg/mL combination at a rate of 1 mL/hr. Pain scores were then recorded using the visual analogue scale at rest and during motion (VAS-R and VAS-M, 0-10) for five days following surgery. In addition, we measured the daily morphine consumption, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), satisfaction score, and the incidence of side effects. Thirty-seven patients out of 52 completed the study (18 in the Epidural PCA group, 19 in the IV PCA group). There were no differences in the pain scores, analgesic requirements, pulmonary function, satisfaction score, and the incidence of side effects between groups. This indicates that IV PCA and Epidural PCA are equally effective to control the postoperative pain after VATS lobectomy, which suggests that IV PCA may be used instead of Epidural PCA.

Ex utero intrapartum treatment (EXIT) for fetal intubation with giant neck mass: A case report / 대한마취과학회지

Large fetal neck masses can cause life threatening airway obstructions after delivery. The ex utero intrapartum treatment (EXIT) can be used to obtain a fetal airway while feto-maternal circulation is preserved. The relationship of neck mass to airway structures can be defined prenatally with ultrasound and magnetic resonance imaging (MRI). We present a successful EXIT case in which prenatally a large fetal neck mass was diagnosed on ultrasound and MRI at 35 weeks of gestation in 30 year-old paturient.

The effect of ambient pressure oxygen apply via T-piece in thoracoscopic surgery or thoracotomy

BACKGROUND: This prospective, randomized study was to investigate whether ambient pressure oxygen administration via T-piece can be used to reduce arterial desaturation during one-lung ventilation. It can be more beneficial for thoracoscopic surgery, where partial inflation of the non-ventilated lung by continuous positive airway pressure can make the operation itself difficult, delayed, or impossible. METHODS: Patients undergoing thoracotomy (Thoracotomy group, n = 50) or video-assisted thoracoscopic surgery (VATS) (VATS group, n = 50) were enrolled into this study. Each group was further divided into two groups: control group (n = 25), and ambient pressure group (n = 25), respectively. Fifteen minutes after two-lung ventilation (TLV1) PaO2, peak inspiratory pressure, plateau pressure, and tidal volume were measured. Then, in control group, one-lung ventilation was started as usual method while in ambient pressure group, the lumen of the non-ventilated lung was connected to a T-piece with 10 L/min flow rate of oxygen. Same measurements were repeated at 15 minutes and 1 hour after one-lung ventilation (OLV1, OLV2), and 15 minutes after resuming two-lung ventilation (TLV2). Fluid input, urine output, estimated blood loss, operation side/time, and one-lung ventilation time were recorded after operation. RESULTS: In thoracotomy group, there were no significant differences in PaO2 between control group and ambient pressure group. However, in VATS group, PaO2 at OLV1 and OLV2 were significantly higher in ambient pressure group than in control group. CONCLUSIONS: In patients undergoing VATS, application of ambient pressure oxygen to the non-ventilated lung during one-lung ventilation was effective in increasing PaO2.

Left Main Stem Bronchus Compression Occurred in Primary Pulmonary Hypertension Patient: A case report / 대한마취과학회지

Eleven year-old boy was scheduled for right encephalo-duro arterial synangiosis (EDAS). He received left EDAS 4 months ago, and there was no problem during the perioperative period. Mild cardiomegaly was suspected in his preoperative chest PA. After intubaton, we couldn't hear the breathing sound of left chest, and the saturation went down to 95%. There was large opaque hemithorax on emergency chest AP, and on the fiberoptic bronchoscopic examination, left main stem bronchus (LMSB) was observed slit-like appearance. Echocardiography revealed severely dilated right atrium and ventricle. In his chest CT, the LMSB was nearly obliterated. The patient was diagnosed as primary pulmonary hypertension, and received full sedation, controlled ventilation, and NO gas. However, the blood pressure of this patient was not maintained in spite of using high-dose inotropics. He expired two days later and this case warns that suspected mild cardiomegaly might hide more ominous sign of primary pulmonary hypertension.

The Incidence Rate and Risk Factors of Pressure-induced Skin Breakdown during Operation / 대한마취과학회지

BACKGROUND: Pressure-induced skin breakdown is not only a painful inconvenience to the patient, but it is also associated with a prolonged hospital stay. This study examined the incidence of pressure-induced skin breakdown in attempt to identify the associated risk factors during elective surgery. METHODS: Data were collected from 808 subjects who underwent orthopedic, thoracic, neuro- or plastic surgery over a six-month period. The data included age, gender, weight, height, body mass index, ASA status, surgical position, operation time, estimated blood loss, preoperative hemoglobin concentration, serum albumin, co-morbidity, and intraoperative hypotension. The patient's skin was inspected closely within 24 hours after surgery. The sites and severity of skin breakdown were assessed. RESULTS: Of the 808 patients in this study, 192 patients (23.8%) developed skin breakdown during surgery. The incidence of blisters, abrasion, or blister and abrasion was 6.1%. The patient's weight, operation time, estimated blood loss, malignancy, and intraoperative hypotension were significantly related to the development of skin breakdown (P < 0.05). The incidence of pressure-induced skin breakdown was highest in the prone position (P = 0.000). Age, gender, body mass index, hypertension, diabetes, preoperative hemoglobin and albumin level were not found to be risk factors of skin breakdown. CONCLUSIONS: The early identification of a patient at risk is a first step in a scientifically based approach for preventing the development of pressure sores. Although intervention will not always prevent the development of pressure sores, a medical team must recognize the risk factors associated with skin breakdown and carry out careful intervention during the perioperative period.

Reexpansion Pulmonary Edema Occurred after Evacuating the Hepatic Hydrothorax in a Liver Transplant Patient: A case report / 대한마취과학회지

A hepatic hydrothorax is a pleural effusion that develops in patients with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. It is a complication of end-stage liver disease, and a liver transplant is the treatment of choice. In our case, a reexpansion pulmonary edema occurred after evacuating 4,250 ml of ascites and aspirating 3,600 ml of the pleural effusion within 15 minutes aimed at visually improving the surgical field in a 46-year-old male patient receiving a liver transplant. 1 hour 30 minutes after aspirating the pleural effusion, the level of oxygen saturation decreased from 100% to 95%, and serosanguinous fluid spilled over from the endotracheal tube. We inserted a double lumen endotracheal tube to both separate and protect the unaffected left lung, and applied CPAP 10 cmH2O at the affected right lung. The reexpansion pulmonary edema was successfully treated using this supportive management.

Hemodynamic Responses to Rapid Sequence Endotracheal Intubation Using Propofol and Rocuronium at Three Different Doses of Remifentanil Infusion / 대한마취과학회지

BACKGROUND: This study compared the effect of the three different infusion doses of remifentanil on the hemodynamic response to rapid sequence anesthesia induction and tracheal intubation. METHODS: In this prospective, randomized double-blind study, 60 ASA I or II patients without any airway abnormalities, who were scheduled to undergo elective surgery requiring endotracheal intubation, were allocated to receive remifentanil 0.25, 0.5, or 1.0 microgram/kg/min. Anesthesia was induced with a remifentanil infusion and propofol 2.0 mg/kg. Rocuronium 1.0 mg/kg was given after a loss of consciousness and endotracheal intubation was performed 1 min after the rocuronium injection. The remifentanil infusion was stopped immediately before intubation. The noninvasive blood pressure (BP) and heart rate (HR) were recorded before induction (baseline), immediately before intubation, and at 1 min intervals until 5 min after intubation. RESULTS: The HR and BP measured immediately before intubation decreased significantly in the three doses. The HR was similar in the three doses, and the BP was significantly different only between the 0.25 and 1.0 microgram/kg/min doses (P < 0.05). The hemodynamic response to endotracheal intubation was very well blunted in 0.5 and 1.0 microgram/kg/min, but not in 0.25 microgram/kg/min. The HR and BP increased significantly 1 min after intubation in the 0.25 microgram/kg/min (P < 0.05). There were no significant differences between the 0.5 and 1.0 microgram/kg/min doses until 5 min after intubation. CONCLUSIONS: Remifentanil 0.5 microgram/kg/min infusion without a bolus provides excellent hemodynamic stability for a rapid sequence endotracheal intubation using propofol and rocuronium. There are no advantages in using remifentanil doses higher than 0.5 microgram/kg/min.

Effective Acupoint of Electroacupuncture on Ankle-sprained Pain in Rats / 대한마취과학회지

BACKGROUND: The stimulation and selection of an effective acupoint is important for producing effective analgesia in electraoacupuncture. This study examined the effect of electroacupuncture to different acupoints and investigated the effective acupoint for ankle-sprained pain in rats. METHODS: A Sprain was produced by manually overextending the lateral ligament of the right ankle in rats. Electrical stimulation was delivered individually to five acupoints: bilateral Yangno (SI6s), contralateral Zusanli (ST36), Hapko (LI4) and Sanyinjiao (SP6). The level of pain evoked by ankle sprain was measured by the stepping force of the sprained paw during walking at pre-sprain and 24 hrs after the sprain. The effect of electroacupuncture was evaluated by the % full recovery of the stepping force at 1, 2, 4 hr after terminating electroacupuncture. RESULTS: Electrical stimulation to SI6 and ST36 among the five acupoints produced a significant increase in the % full recovery of the stepping force of the ankle-sprained paw during walking. CONCLUSIONS: The effective acupoints for electroacupuncture on ankle-sprained pain in rats is SI6 and ST36. These points are relatively specific to ankle-sprain. It is important to select the appropriate acupoint for effective electroacupuncture-induced analgesia.