Standard versus Rotation Technique for Insertion of Supraglottic Airway Devices: Systematic Review and Meta-Analysis

PURPOSE: Supraglottic airway devices have been widely utilized as an alternative to tracheal intubation in various clinical situations. The rotation technique has been proposed to improve the insertion success rate of supraglottic airways. However, the clinical efficacy of this technique remains uncertain as previous results have been inconsistent, depending on the variable evaluated. MATERIALS AND METHODS: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials in April 2015 for randomized controlled trials that compared the rotation and standard techniques for inserting supraglottic airways. RESULTS: Thirteen randomized controlled trials (1505 patients, 753 with the rotation technique) were included. The success rate at the first attempt was significantly higher with the rotation technique than with the standard technique [relative risk (RR): 1.13; 95% confidence interval (CI): 1.05 to 1.23; p=0.002]. The rotation technique provided significantly higher overall success rates (RR: 1.06; 95% CI: 1.04 to 1.09; p<0.001). Device insertion was completed faster with the rotation technique (mean difference: -4.6 seconds; 95% CI: -7.37 to -1.74; p=0.002). The incidence of blood staining on the removed device (RR: 0.36; 95% CI: 0.27 to 0.47; p<0.001) was significantly lower with the rotation technique. CONCLUSION: The rotation technique provided higher first-attempt and overall success rates, faster insertion, and a lower incidence of blood on the removed device, reflecting less mucosal trauma. Thus, it may be considered as an alternative to the standard technique when predicting or encountering difficulty in inserting supraglottic airways.

Randomized Comparison of Actual and Ideal Body Weight for Size Selection of the Laryngeal Mask Airway Classic in Overweight Patients

Size selection of the laryngeal mask airway (LMA) Classic based on actual body weight remains a common practice. However, ideal body weight might allow for a better size selection in obese patients. The purpose of our study was to compare the utility of ideal body weight and actual body weight when choosing the appropriate size of the LMA Classic by a randomized clinical trial. One hundred patients with age 20 to 70 yr, body mass index > or =25 kg/m2, and the difference between LMA sizes based on actual weight and ideal weight were allocated to insert the LMA Classic using either actual body weight or ideal body weight in a weight-based formula for size selection. After insertion of the device, several variables including insertion parameters, sealing function, fiberoptic imaging, and complications were investigated. The insertion success rate at the first attempt was lower in the actual weight group (82%) than in the ideal weight group (96%), even it did not show significant difference. The ideal weight group had significantly shorter insertion time and easier placement. However, fiberoptic views were significantly better in the actual weight group. Intraoperative complications, sore throat in the recovery room, and dysphonia at postoperative 24 hr occurred significantly less often in the ideal weight group than in the actual weight group. It is suggested that the ideal body weight may be beneficial to the size selection of the LMA Classic in overweight patients (Clinical Trial Registry, NCT 01843270).

Thrombus entrapped by patent foramen ovale in a patient with pulmonary embolism: a case report / 대한마취과학회지

Thrombus-in-transit appears to increase the risk of mortality compared to pulmonary embolism alone and can require alteration in therapeutic plan. We present the case of a biatrial thromboembolus caught in transit across a patent foramen ovale diagnosed by intraoperative transesophageal echocardiogram in a 69-year-old female with acute pulmonary embolism and subsequent acute cerebral infarction. We suggest that echocardiography should be performed in a patient with suspected pulmonary thromboembolism to evaluate right heart function and diagnose emboli in transit.

Effects of steep head-down position on pulse pressure variation

BACKGROUND: The effects of head-down position on dynamic hemodynamic variables remain without full understanding. We evaluated the effects of steep head-down position on the pulse pressure variation (PPV). METHODS: Forty patients were positioned at 30degrees head-down position after anesthesia induction. We measured the heart rate (HR), arterial blood pressure (BP) and PPV before and 2 minutes after the position change. RESULTS: PPV and HR decreased (9.3 +/- 3.2% to 4.6 +/- 1.8%, 67.2 +/- 11.4 to 62.4 +/- 7.8, respectively) after steep head-down position, whereas the BP increased. Baseline PPV was related with decreases of PPV (r2 = -0.83, P < 0.0001). An 8% PPV threshold discriminated the patients with more than 5% decreases of absolute PPV value. The area under the receiver operating characteristic curve was 0.98 (95% CI = 0.88 to 1.00, P < 0001). CONCLUSIONS: Steep head-down position caused decreases in PPV. Higher PPV at the supine position decreased more after the position change. Further investigations are required to assess the significance, the duration and the relationship with fluid responsiveness of this change.

Effects of balanced anesthesia with sevoflurane-remifentanil and total intravenous anesthesia with propofol-remifentanil on postoperative stress responses in patients with stomach cancer

BACKGROUND: The effects of anesthetics on postoperative stress response remains not fully understood. We evaluated the effects of sevoflurane-remifentanil balanced anesthesia and propofol-remifentanil total intravenous anesthesia (TIVA) on postoperative interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-alpha), cortisol, and laboratory test values for patients with stomach cancer. METHODS: Forty patients were randomly assigned to sevoflurane-remifentanil group (group S) and propofol-remifentanil group (group P). Anesthesia was maintained with balanced anesthesia (group S) or TIVA (group P). We measured the IL-6, TNF-alpha, cortisol and performed laboratory tests before (T1) and after surgery (T2). RESULTS: Concentration of IL-6 and cortisol increased (group S: 1.89 +/- 1.69 pg/ml to 47.11 +/- 44.37 pg/ml, 10.68 +/- 4.89 pg/ml to 14.93 +/- 6.79 pg/ml, group P: 1.74 +/- 1.60 pg/ml to 61.58 +/- 48.65 pg/ml, 9.96 +/- 4.40 pg/ml to 14.27 +/- 7.43 pg/ml, respectively) postoperatively in both groups, but there were not different between group S and group P. There were no differences of TNF-alpha between T1 and T2 in both groups. Changes of other laboratory values were indifferent between groups. CONCLUSIONS: The effects of sevoflurane-remifentanil balanced anesthesia and propofol-remifentanil TIVA on postoperative stress responses in patients with stomach cancer were not different. Further investigations are required to assess the effects of anesthetics on other stress response profiles and such significances.

Conversion of orotracheal to nasotracheal intubation using a fiberoptic bronchoscope in a patient with intraoral hematoma / 대한마취과학회지

No abstract available.

Stress-induced cardiomyopathy after negative pressure pulmonary edema during emergence from anesthesia: A case report / 대한마취과학회지

Stress-induced cardiomyopathy (SICM) presenting as an acute myocardial dysfunction is characterized by transient left ventricular wall motion abnormality, which has been known to be associated with excessive catecholamine production caused due to various types of stress. Sympathetic hyperactivity is common during the perioperative period, and reports of SICM occurring during this period have actually increased. We present a case of SICM following negative pressure pulmonary edema due to upper airway obstruction during emergence from anesthesia. Excessive catecholamine release in response to respiratory difficulty could have been the underlying inciting factor.

Facial paralysis after spine surgery : A case report

diopathic facial nerve paralysis after surgery is not common but has clinical significance. We report a case of facial nerve paralysis in the immediate postanesthetic period after cervical spine surgery. A 41-year-old man with cervical herniated disc was scheduled for cervical laminectomy. After uneventful surgery, he suffered from left facial numbness and weakness. Imaging study and audiogram couldn't reveal any anatomic abnormality except Thornwaldt cyst. Conservative treatment with steroids and antivirals resolved his symptoms until 16th day after surgery.

Unilateral pulmonary edema during an operation in patient with undiagnosed pheochromocytoma: A case report / 대한마취과학회지

Pheochromocytoma is a rare tumor, but it can cause severe hemodynamic disturbances during anesthesia, and particularly in patients whose pheochromocytoma was not diagnosed preoperatively. We report here on a case of unilateral pulmonary edema during laparoscopic adrenalectomy, and this edema was due to pheochromocytoma that was not diagnosed preoperatively.

Changes in Ionized and Total Magnesium Concentration during Spinal Surgery / 대한마취과학회지

BACKGROUND: The incidence of postoperative hypomagnesemia in patients undergoing spinal surgery has been reported to be 70%. Ionized magnesium is considered to be the biologically active form, but until the early 1990s, only the total magnesium concentration could be measured. Currently, the ionized magnesium concentration as well as total magnesium concentration can be assessed due in part to the development of a selective electrode. The aim of this study was to more fully characterize the changes in the total and ionized magnesium concentrations in patients undergoing elective spinal fusion surgery. METHODS: The total and ionized magnesium, creatinine, albumin, urinary magnesium concentration, hematocrit, total amount of fluid administration, transfusion, blood loss, and urine output were evaluated both preoperatively and postoperatively in each patient. RESULTS: The total and ionized magnesium concentrations decreased from 0.783 mM/L and 0.529 mM/L preoperatively to 0.717 mM/L and 0.511 mM/L during the postoperative period, respectively. CONCLUSIONS: The incidence of total hypomagnesemia during spinal surgery was 15% but the incidence of ionized hypomagnesemia was only 3%.

Obstruction of an Endotracheal Tube with Change of the Head Position in a Trachea Deviated Patient : A case report / 대한마취과학회지

Various causes of endotracheal tube obstruction during general anesthesia exist. Herein, the case of a 77-year old male patient, with tracheal deviation, who was intubated with an endotracheal tube in the emergency room, without a Murphy eye, is reported. He was transferred to the operating room for the removal of a subdural hematoma. The endotracheal tube suddenly became obstructed during flexion of neck for the craniotomy procedure. The distal bevel of the endotracheal tube, without Murphy eye, was discovered to have come into contact with the tracheal wall, with the airway being obstructed during the fiberoptic bronchoscopy. Shortly after extubation of the obstructed tube, an armored tube, with a Murphy eye, was reintubated, after which the respiration pattern immediately returned to normal.

Traumatic Tricuspid Regurgitation Following Cardiac Massage

We report a 66-yr-old male patient who developed tricuspid regurgitation secondary to internal cardiac massage. After uneventful off-pump coronary artery bypass surgery, the subject experienced cardiac arrest in the intensive care unit. External cardiac massage was initiated and internal cardiac massage was performed eventually. A transesophageal echocardiography revealed avulsion of the anterior papillary muscle and chordae to the anterior leaflet after successful cardiopulmonary resuscitation. Emergency repair of the papillary muscle was performed under cardiopulmonary bypass.

Airway Management by Extended Endotracheal Tube for a Patient with Tracheal Stenosis during Laryngeal Microscopic Surgery: A case report / 대한마취과학회지

A small sized tube can be used for a patient with tracheal stenosis. However, an ordinary endotracheal tube may be not long enough to pass over stenotic lesion of trachea in adult patient for nasotracheal intubation, when stenotic lesion is located distally. We experienced a patient with severe tracheal stenotic lesion 5 cm above the carina and 3.1 cm length of stenotic lesion scheduled for laryngeal microscopic surgery. The two 4.0 mm tubes-connected tube using modified connector was designed and prepared. We performed fiberoptic-guided awake nasotracheal intubation using the extended endotracheal tube and the patient was successfully managed without complications until the surgery was completed.

Efficacy of Sufentanil during Laryngeal Microscopic Surgery / 대한마취과학회지

BACKGROUND: Various anesthetic agents have been used in laryngeal microscopic surgery, because the airway is shared with the surgeon, there is a short operation duration and intense cardiovascular stimulation occurs during the surgery. Sufentanil is superior than other anesthetic agents in blocking the cardiovascular response to the airway stimulation and a short duration of effects. METHODS: Thirty patients undergoing elective laryngeal microscopic surgery were randomized to receive sufentanil 0.125 microgram/kg (group 1, n = 10), sufentanil 0.25 microgram/kg (group 2, n = 10) or sufentanil 0.5 microgram/kg (group 3, n = 10). The bispectral index score, blood pressure, heart rate, recovery time from general anesthesia, the need for additional analgesics and naloxone and the postoperative complications associated with sufentanil were measured. RESULTS: The bispectral index, blood pressure and heart rate were similar in the three groups. Only four patients in group 3 required naloxone (P < 0.05). Three patients in group 1, one in group 2 and 0 in group 3 required an additional dose of sufentanil. Postoperative sore throat was detected in 6 patients in the immediate postoperative period and in 8 patients 6 hours after the end of anesthesia in group 1 (P < 0.05). CONCLUSIONS: Sufentanil is an effective analgesic for attenuating the cardiovascular responses of airway stimulation in laryngeal microscopic surgery. In addition, sufentanil 0.25 microgram/kg is an appropriate dose for the rapid recovery and attenuation of the cardiovascular response in laryngeal microscopic surgery.

Effect of Preoperative Volume Loading with New Hydroxyethyl Starch (6% HES 130/0.4) in Patients undergoing Off-Pump Coronary Artery Bypass Graft Surgery / 대한마취과학회지

BACKGROUND: It is important to maintain adequate intravascular volume during off-pump coronary artery bypass surgery (OPCAB) to prevent hypotension. The aim of this study was to assess the effect of acute volume loading with new colloid solution, 6% hydroxyethyl starch (HES) 130/0.4 on hemodynamics and coagulation in patients undergoing OPCAB. METHODS: With the IRB approval, forty patients undergoing OPCAB were allocated to two groups receiving 10 ml/kg of Plasma solution A (Control group, n = 21) or HES 130/0.4 (HES group, n = 19) for 30 min before pericardiotomy. We measured hemodynamic variables and coagulation parameters at 10 min after anesthesia induction (T1), 10 min after fluid loading (T2), 10 min after Y-graft formation (T3), and after sternum closure. Amount of infused fluid, blood loss, tranfusion and urine output were recorded intraoperatively and for 16 hr after surgery. Thromboelastography and electrolytes were also measured. RESULTS: Both groups were similar in demographic data and fluid/blood volume during and after surgery. Cardiac index and right ventricular ejection fraction were maintained throughout the surgery in HES group but were decreased in Control group. The ratio of arterial oxygen partial pressure to inhaled oxygen fraction was increased in HES group after surgery. Thromboelastography and other parameters didn't demonstrate significant differences between the groups. CONCLUSIONS: Acute HES loading before pericardiotomy could prevent the decrease of cardiac index and right ventricular ejection fraction in OPCAB patients. Additionally, it showed desirable effects on oxygenation without adverse effects on coagulation.

The CobraPLA(TM) During Anesthesia with Controlled Ventilation: A Clinical Trial of Efficacy

The CobraPLA(TM) (CPLA) is a relatively new supraglottic airway device that has not been sufficiently investigated. Here, we performed a prospective observational study to evaluate the efficacy of the CPLA during controlled ventilation. In 50 anesthetized and paralyzed patients undergoing elective surgery a CPLA was inserted and inflated to an intracuff pressure of 60 cm H2O. The success rate of insertion upon the first attempt was 82% (41/50), with a mean insertion time of 16.3 +/- 4.5 seconds. The adequacy of ventilation was assessed by observing the end tidal CO2 waveform, movement of the chest wall, peak airway pressure (13.5 cm H2O), and leak fraction (4%). We documented the airway sealing pressure (22.5 cm H2O) and noted that the the site of gas leaks at that pressure were either at the neck (52%), the abdomen (46%), or both (2%). In 44 (88%) patients, the vocal cords were visible in the fiberoptic view through the CPLA. There was no gastric insufflation during the anesthesia. Respiratory and hemodynamic parameters remained stable during CPLA insertion. Postoperative blood staining of CPLA was minimal, occurring in 22% (11/50) of patients. Mild and moderate throat soreness was reported in 44% (22/50) and 4% (2/50) of patients, respectively. Lastly, mild dysphonia was observed in 6% (3/50) of patients and mild dysphagia in 10% (5/50) of patients. Our results indicated that the CPLA is both easy to place and allows adequate ventilation during controlled ventilation.

Death on the General Wards after Discharge from ICU / 대한마취과학회지

BACKGROUND: Intensive care units (ICUs) provide a service for patients with potentially recoverable disease who might potentially benefit from closer observation and treatment. However, a number of patients who are successfully discharged from ICU subsequently die during their hospital admission. The aim of this study was to identify the incidence and characteristics of these deaths in general wards after discharge from ICUs. METHODS: Patients who were admitted to our ICU were classified in the following manner; Group 1, patients who survived to hospital discharge; Group 2, patients who died in the ICU; Group 3, patients who died in general wards after discharge from the ICU. Data was collected and patients age, sex, main diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE) II scores on the admission, and number of days in the ICU were compared. RESULTS: 1498 consecutive patients were admitted to the general ICU, and 1339 patients were discharged alive from hospital, 114 patients died in the ICU and 45 patients died during their post ICU hospital stay. 28% of the deaths after intensive care occurred in general wards before discharge from hospital. Among those patients who died in general wards, 7 (15.5%) were expected to survive. 29 (64%) had been withdrawn from sustained therapy before discharge from the ICU. CONCLUSIONS: Although some deaths following ICU discharge were inevitable, others were unexpected, and may have been preventable.

Clinical Characteristics of the Patients Who Died Despite of Low APACHE II Score after Intensive Care / 대한마취과학회지

BACKGROUND: The acute physiology and chronic health evaluation (APACHE) II score is considered to be a precise predictor of mortality and a useful basic research tool. A lower APACHE II score means a better prognosis of patients, which means that these relatively low risk patients are more likely to benefit from the improved patient management than the higher predicted mortality admissions. Therefore, these patients are obvious targets for intensive care and for decreasing the level of intensive care unit (ICU) mortality. METHODS: This study reviewed the medical records of 729 patients, whose APACHE II scores on the ICU admission day were 10 or less, from June 1, 2001 to May 31, 2002 in University Hospital. The data of the patient's age, gender, disease category, first admission or readmission, APACHE II score, length of stay at the ICU and the hospital were reviewed. RESULTS: The average mortality rate of the patients who had an APACHE II score of 10 or less was 4.1%. The mortality of the cancer patients (8%) was significantly higher than the other disease groups. The mortality of the readmitted patients was significantly higher than the mortality of the patients who were admitted to the ICU for the first time. CONCLUSIONS: Among the patients in the ICU with a low APACHE II score, the mortality of cancer patients was high. The mortality of the readmitted patients was significantly higher than in those on the first admission.

During Inhalation Anesthesia with Sevoflurane Using LMA, Spontaneous Breathing is Feasible / 대한마취과학회지

BACKGROUND: Sevoflurane is used as an anesthetic agent is now commonly. Several studies have reported on the use of sevoflurane in spontaneous breathing patients. However none of these studies focused on spontaneous breathing under sevoflurane anesthesia with a laryngeal mask airway (LMA). The purpose of the present study was to assess the feasibility of spontaneous breathing during inhalation anesthesia using sevoflurane with an LMA. METHODS: We studied 50 patients undergoing elective upper/lower extremity surgery in which muscle relaxation was not required. All patients received thiopental sodium 5.5 mg/kg after glycopyrrolate 0.004 mg/kg premedication. They were allowed to breathe spontaneously after the insertion of an LMA under sevoflurane anesthesia. Ventilation was measured before induction and ventilatory variables of 3-4% sevoflurane were measured during spontaneous ventilation. Arterial blood gas analysis was also performed in both phases. RESULTS: During spontaneous breathing under sevoflurane anesthesia with LMA, tidal volume (TV) significantly reduced and respiration rate (RR) increased versus resting ventilation (P < 0.05). But, minute volume (MV) was not significantly different. PaCO2, HCO3-, total CO2, BE were all significantly increased (P < 0.05). CONCLUSIONS: It was concluded that spontaneous breathing can be maintained during clinical depth sevoflurane inhalation anesthesia in patients without a cardiopulmonary abnormality.

Epinephrine-induced Metabolic Acidosis during Orthognatic Surgery: A case report / 대한마취과학회지

Epinephrine has a variety of clinical uses one is its use as a topical hemostatic agent on bleeding surfaces, such as in the mouth. We report a temporal association between the administration of topical epinephrine and the development of metabolic acidosis during general anesthesia. A 21 year-old patient, with facial asymmetry, had undergone orthognatic surgery. During the operation, serial blood gas analysis revealed the onset of a metabolic acidosis following the local infiltration (0.036 mg) and topical application of a high dose of epinephrine-Bosmin(R) (1:1,000 epinephrine). The metabolic acidosis resolved within 5 hours.