A comparison of hemodynamic changes after endotracheal intubation by the Optiscope(TM) and the conventional laryngoscope / 대한마취과학회지

BACKGROUND: Optiscope(TM) is a newly developed video stylet device. This study evaluated and compared the hemodynamic changes observed after endotracheal intubation with video stylet and after conventional laryngoscopic endotracheal intubation. METHODS: Fifty-eight adult patients with American Society of Anesthesiologists (ASA) physical status class 1 or 2, undergoing general anesthesia, were randomized into two groups: one group of patients were intubated using video stylet (n = 29) and the other group were intubated using direct laryngoscope (n = 29). Systolic blood pressure (SBP), mean arterial pressure (MAP), diastolic blood pressure (DBP), heart rate (HR), POGO (percentage of glottic opening) score, time for intubation and degree of sore throat were recorded. RESULTS: There were no significant differences in the SBP, MAP, DBP, HR, and the sore throat incidence between the two groups. Optiscope(TM) produced better POGO scores, but time for intubation was longer than with conventional laryngoscope. CONCLUSIONS: Optiscope(TM), when compared with conventional laryngoscope for intubation, does not modify the hemodynamic response, but it provides a better view of the vocal cords.

A Comprehensive Model of Factors Affecting Adoption of Clinical Practice Guidelines in Korea

This study aims to investigate the factors related to the adoption of clinical practice guidelines in clinical settings in Korea; it also aims to determine how these factors differ depending on the specific situation of health care system and professional climate. The research sample comprised physicians who are board members of academic societies with experiences in development of clinical practice guidelines using a convenient sampling. We analyzed 324 physicians with pooling two-year sample of 2007 and 2008. From all the respondents, 48.8% stated that they followed Clinical Practice Guidelines, and 93.4% agreed with the content in the Clinical Practice Guidelines. With regard to the item on the self-efficacy of practicing guidelines, 90.3% of the respondents selected 'low level'. In the regression analysis, the factors associated with implementation were level of recognition, agreement and self-efficacy and positive attitude towards practice guidelines. Although the health care system in Korea differs from those in Western countries, our results revealed that the factors related to the adoption of practice guidelines were similar to the research results of Western countries. These results suggest that professionals' attitudes towards clinical practice guidelines are universal, and implementation strategies should be developed globally.

Cardiac arrest induced by tension pneumothorax during ventilating bronchoscopy: A case report / 대한마취과학회지

Tension pneumothorax during ventilating bronchoscopy for foreign body removal is a rare but life-threatening complication. The authors present a case of cardiac arrest caused by tension pneumothorax in a 9-month-old girl who underwent ventilating bronchoscopy for foreign body (peanut) removal. Tension pneumothorax was due to tracheobronchial lacerations caused by a bronchoscope. The patient was successfully resuscitated by cardiopulmonary resuscitation and chest tube insertion. The airway injury was effectively repaired by thoracotomy under extracorporeal membrane oxygenation.

Prolonged paradoxical air embolism during intraoperative intestinal endoscopy confirmed by transesophageal echocardiography: A case report- / 대한마취과학회지

Venous air embolism (VAE) during intestinal endoscopy is a rare complication. We report a case of cardiovascular collapse due to VAE confirmed by transesophageal echocardiography (TEE) during intraoperative intestinal endoscopy. TEE detected air bubbles in the left ventricle up to 1 hour after the event. When a patient deteriorates during endoscopic procedures, VAE and possible paradoxical air embolism (PAE) should be suspected. This case demonstrates that TEE can play an important role in diagnosing and managing an air embolism in anesthetized patients. In addition, this case demonstrates that PAEs may occur longer than expected after recovery from VAE-induced cardiovascular collapse.

2010 Conversion of the Journal of Korean Medical Science to Monthly Publication as an Open Access Journal

No abstract available.

Effect of active warming on shivering during spinal anesthesia / 대한마취과학회지

BACKGROUND: Hypothermia is considered one of the reasons for intraoperative shivering. The purpose of this study is to assess whether active warming can prevent hypothermia and shivering in young adults under spinal anesthesia. METHODS: Fifty male patients scheduled for an elective operation on lower extremity under spinal anesthesia were randomly assigned into the warming group (n = 25) and the control group (n = 25). The active warming was performed using a forced air-warming device, a warmed blanket and warmed fluid. Axillary and tympanic temperatures, shivering degree, thermal discomfort, and anesthetic level were checked every 10 minutes after intrathecal injection of local anesthetics. RESULTS: Patients' characteristics and anesthetic levels were comparable between the groups. Axillary and tympanic temperatures were maintained higher in the warming group than the control group 10 minutes and 20 minutes after intrathecal injection respectively. The lowest temperature in operating room was higher in the warming group (36.3 +/- 0.5degrees C) compared with the control group (35.7 +/- 0.5degrees C) (P < 0.05). Incidences of intraoperative shivering and thermal discomfort were lower in the warming group. CONCLUSIONS: We conclude that intraoperative active warming can prevent hypothermia and shivering during spinal anesthesia.

Measuring depth of anesthesia with EEG and ECG in children / 대한마취과학회지

BACKGROUND: Heart rate is tightly controlled by brain. If activity of brain and electroencephalograph (EEG) are changed by anesthetics, electrocardiograph (ECG) might be changed. We investigated whether there is a correlation between EEG and ECG, ECG could replace EEG as a monitor for depth of anesthesia. METHODS: We recruited 50 patients, aged 2-8 years. Inspired and expired end-tidal sevoflurane concentrations were held constant at 1.0 or 2.5 vol%, after which ECG and EEG were obtained for 15 minutes. Total power (TP), low-frequency power (LFP), high-frequency power (HFP), approximate entropy (ApEn), and Hurst exponent (H) were calculated from the ECG. The relationship between EEG and ECG indices at the two sevoflurane concentrations was measured by Pearson's correlation coefficient. RESULTS: As anesthesia deepened, ApEn, H of ECG and beta wave decreased and those of delta and theta increased in 4 channels. In FP2, changes of beta and theta wave were negatively correlated with ApEn and H of ECG (P < 0.05), and changes of delta wave was positively correlated with ApEn (P < 0.05) and H (P < 0.01). In F8, changes of beta and theta wave were negatively correlated with ApEn (P < 0.05) and only theta wave was negatively correlated with H (P < 0.05). In C4, change of delta wave was positively correlated with ApEn (P < 0.001) and H (P < 0.05). CONCLUSIONS: EEG and ECG indices are correlated during sevoflurane anesthesia in children, and ECG-derived indices could possibly be used to monitor depth of anesthesia.

Effects of ATP and LTC4 on hypoxic pulmonary vasoconstriction in isolated rat lungs / 대한마취과학회지

BACKGROUND: Hypoxic pulmonary vasoconstriction (HPV) is unique to pulmonary circulation but the mechanism remains elusive. Red blood cells (RBCs) are known to augment HPV and to release more ATP as oxygen content falls. Leukotrienes constrict smooth muscle and could be important for the regulation of the pulmonary circulation. Hence we hypothesized that ATP and leukotrienes are mediators of HPV produced during acute alveolar hypoxia. METHODS: In forty Sprague-Dawley rats, lungs were isolated and perfused. We administered ATP (10 micrometer) to the ATP group (n = 8), the ATP antagonist, suramin (100 micrometer) to the suramin group (n = 8), leukotriene C4 (LTC4, 5 microgram) to the LTC4 group (n = 8), the LTC4 antagonist, LY171883 (20 micrometer) to the LY171883 group (n = 8), and LTC4 (5 microgram) + ATP (10 micrometer) to the LTC4 + ATP group (n = 8) during normoxic ventilation. HPV responses were induced by three hypoxic challenges for 5 minutes separated by 5 minutes of ventilation with a normoxic gas mixture. Baseline pulmonary artery pressure change after exposure to each drug and hypoxic pressor response between a period 21% normoxic gas ventilation and that of 3% hypoxic gas ventilation were measured. RESULTS: ATP and LTC4 + ATP increased baseline pulmonary artery pressures but LTC4 did not alter it. ATP did not affect hypoxic pressor response. Suramin, LY171883 and LTC4 + ATP inhibited the pressor response to hypoxia. LTC4 increased hypoxic pressor response. CONCLUSIONS: In isolated rat lungs, HPV may be mediated by ATP and LTC4 appears more likely to be a modulator than a mediator of HPV.

Repeated cardiac arrests caused by transfusion-related hyperkalemia and massive bleeding : A case report

Transfusion-related hyperkalemic cardiac arrest (TRHCA) is a serious complication of administration of packed red blood cell (P-RBC). We present a case of repeated TRHCAs in a 13 month-old girl, who was undergoing intra-abdominal huge mass excision. There were three consecutive TRHCAs during the operation. The first (11.7 mM of K+) and the second (9.5 mM of K+) cardiac arrests were successfully resuscitated. However, the last cardiac arrest (8.9 mM of K+) was failed to be recovered with conventional treatment. Risk factors of TRHCA such as hypocalcemia, hypoxemia, acidosis, hyperglycemia, hyperlactatemia, and low cardiac out state were combined. The transfused P-RBCs were all irradiated. In this situation, processing of P-RBC using an autotransfusion device before the transfusion should be considered to prevent hyperkalemia in addition to conventional treatment of TRHCA.

Anesthetic management of children with Beckwith-Wiedemann syndrome : Two cases report / 대한마취과학회지

Beckwith-Wiedemann syndrome consists of various abnormalities, including macroglossia, visceromegaly, omphalocele, and neonatal hypoglycemia. These abnormalities frequently require operative correction and careful anesthetic management. Principal problems associated with anesthetic management in this syndrome are congenital heart disease, hypoglycemia, and difficult airway combined with macroglossia. We report two cases of general anesthetic management in children with Beckwith-Wiedemann syndrome.

Hemothorax due to injuries of subclavian artery and first intercostal artery after subclavian venous catheterization in a pediatric patient : A case report / 대한마취과학회지

Central venous catheterization is useful to evaluate intravascular volume status, while it has a chance of severe complications such as tension pneumothorax, cardiac tamponade, and so on. Now, we report a case of hemothorax after trying subclavian venous catheterization over again in a 2-year-old patient undergoing encephalo-duro-arterio-synangiosis, that required surgical intervention at the end. Though arterial puncture and massive hemothorax is a possible complication of subclavian venous catheterization, the injury of first intercostal artery might be due to inappropriate introducer needle accidentally. In conclusion, both routine chest image confirmation and close observation of expert might be important to prevent iatrogenic complication by anesthetic maneuvers.

Optimal clinical dose of rocuronium bromide for laryngeal mask airway insertion during sevoflurane anesthesia in children / 대한마취과학회지

BACKGROUND: The median effective dose, ED(50), of rocuronium bromide for inserting the laryngeal mask airway (LMA) in children was not known. The purpose of this study was to determine the clinical ED(50) (cED(50): median value of rocuronium dose of 6 set of crossing success and failure by Dixon's up-and-down method) of rocuronium to insert a LMA in pediatric patients. METHODS: Children aged 2 to 12 years (n = 21) and scheduled for urologic, orthopedic, plastic or ophthalmic surgery lasting less than 2 hr under general anesthesia were enrolled in this study. After applying a standard cardiorespiratory monitor, all patients received thiopental sodium 5 mg/kg for induction of anesthesia. Insertion of LMA was attempted 90 seconds after administration of rocuronium and manual ventilation with 8 vol% of sevoflurane. We recorded the movement of patients, blood pressure and heart rate. The initial dose of rocuronium was 0.3 mg/kg, and in accordance with Dixon's up-and-down method, the rocuronium concentration for consecutive patients in each patient was varied with increments or decrements of 0.05 mg/kg based on the result of previous patient. RESULTS: The cED(50) of rocuronium required to insert a LMA was 0.09 mg/kg with 8 vol% sevoflurane. With isotonic regression, cED95 of rocuronium was 0.13 mg/kg (95% confidence intervals 0.096-0.14 mg/kg). CONCLUSIONS: This study demonstrated that the cED(50) and cED(95) of rocuronium were 0.09 mg/kg and 0.13 mg/kg in children respectively. It provides satisfactory conditions for LMA insertion in anesthetized children and decreases the excessive hemodynamic change.

Internal Jugular Vein Thrombosis Detected during Ultrasound-guided Cannulation in Children: A case report / 대한마취과학회지

Ultrasound-guided catheterization of the central vein is a precise, safe, and easy compared with the conventional landmark method. We incidentally detected thrombosis in the right internal jugular vein (IJV) during the ultrasound-guided cannulation (on) in a 22-month-old male patient. Cardiac operations had been performed 5 times previously and the right IJV was cannulated lastly 2 months ago. The thrombosis occluded right IJV near totally, so we cannulated the left IJV instead using the ultrasound. This case demonstrates that ultrasound-guided central vein catheterization approach is helpful not only in precise puncture but also in selection of appropriate vessel.

Correlation between BIS and layered behavior of heart rate in children under general anesthesia

BACKGROUND: The bispectral index (BIS) is based on changes in the electroencephalogram, and is commonly used to monitor depth of anesthesia. The central nervous system (CNS) controls heart rate variability (HRV). The purpose of this study was to examine the relationship between heart rate variability and changes in BIS. METHODS: We recruited 33 patients, aged 2-12 years. On arrival at the operating room, electrocardiograph (ECG), SpO2, noninvasive blood pressure, and BIS were monitored. After induction and intubation, patients were ventilated with sevoflurane in 35% oxygen in air. At a tidal volume of 7 ml/kg, the respiratory rate was adjusted to maintain an end-tidal CO2 of 35-40 mmHg. Inspired and expired end-tidal sevoflurane concentrations were held constant at 1.0 or 2.5 vol% for more than 10 minutes, after which ECG and BIS data were obtained for 15 minutes. Low-frequency power (LFP), highfrequency power (HFP), approximate entropy (ApEn), maximum layered behavior indices (MaxLI), and mean layered behavior indices (MeanLI) were calculated from the ECG. The relationship between mean BIS and variability indices at the two sevoflurane concentrations was measured by Pearson's correlation coefficient. RESULTS: MaxLI and MeanLI were positively correlated to BIS; whereas LFP, HFP, and ApEn were not. CONCLUSIONS: BIS and ECG indices are correlated during sevoflurane anesthesia in children, and thus ECG-derived indices could be used to monitor depth of anesthesia.

The Effect of Intraoperative Autotransfusion using a Continuous Autotransfusion System (CATS(R)) on for Homologous Transfusion in Children / 대한마취과학회지

BACKGROUND: Until recently, it was not easy to conduct intraoperative autotransfusion in children due to technical limitations, however, due to advanced technology this is now possible. This study was conducted to determine if the intraoperative use of the continuous autotransfusion system (CATS(R)) can reduce homologous transfusion during pediatric orthopaedic surgery. METHODS: Fifty-five children scheduled for elective orthopaedic surgery were reviewed and divided into two groups according to the availability of the CATS(R). The control group (n = 29) had surgery without the cell saver, whereas the CATS(R) group (n = 26) had surgery with the cell saver. The amounts of perioperative homologous transfusion were then compared between the two groups. RESULTS: The amount of homologous blood transfusion required during the operation was significantly less in the CATS(R) group 5 +/- 10 (ml/kg) than in the control group 15 +/- 13 (ml/kg) (P < 0.01). There was no difference in the amount of homologous blood transfusion required after operation between the groups. CONCLUSIONS: CATS(R) can reduce the need for intraoperative homologous transfusion during pediatric orthopaedic surgery.

Anesthetic management for a patient with aberrant right subclavian artery: A case report / 대한마취과학회지

Aberrant right subclavian artery (ARSA) is a congenital anomaly that usually does not produce symptoms. However, patients with symptoms may require surgical intervention. Surgical procedures consist of division of ARSA from the descending aorta and reimplantation to the right common carotid artery or ascending aorta. Specific anesthetic management includes invasive monitoring of blood pressure in both radial arteries, monitoring of adequate cerebral perfusion, and ventilatory strategy to facilitate surgical exposure. Although many reports are available regarding its surgical treatment, there are few reports, to the author's best knowledge, that describe anesthetic management for its surgical correction. This case report will focus on important aspects of the anesthetic management of patients with ARSA.

Comparison of emergence agitation between sevoflurane, desflurane, and propofol with bispectral index monitoring in pediatric anesthesia / 대한마취과학회지

BACKGROUND: Sevoflurane, desflurane, and propofol are widely used in pediatric anesthesia because of their rapid recovery. However, emergence agitation is more reported with sevoflurane or desflurane than with propofol. Our clinical experience indicates emergence agitation with propofol is also frequent. We tested the hypothesis that depth of anesthesia could lead to frequent emergence agitation with propofol. METHODS: Sixty children, ASA 1, aged 3-12 years, undergoing general anesthesia for adenotonsillectomy were randomized to receive maintenance anesthesia with sevoflurane, desflurane, or propofol. The bispectral index was monitored and maintained within 40-65. Time to extubation, duration of postanesthetic care units stay, bispectral index just before stopping the anesthetic agent, anesthetic time, early and late postoperative Pediatric Anesthesia Emergence Delirium Scale (PAEDS), and Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) were compared among the 3 groups. Data were analyzed using ANOVA (demographic data, measured time interval, BIS) and Kruskal-Wallis test (PAEDS and CHEOPS). The Spearman correlation coefficient was used to confirm the correlation between the two scales. RESULTS: Although desflurane resulted in the fastest extubation, other scales were not statistically different. PAEDS and CHEOPS for sevoflurane showed a positive correlation in the early recovery period, but desflurane and propofol did not. CONCLUSIONS: With the same depth of anesthesia, emergence agitation among desflurane, sevoflurane, and propofol was not different in children.

Effects of propofol and nalbuphine on emergence agitation after sevoflurane anesthesia in children for strabismus surgery / 대한마취과학회지

BACKGROUND: Emergence agitation in children is frequently associated with sevoflurane general anesthesia. We measured the effects of propofol and nalbuphine on emergence agitation after sevoflurane anesthesia in children for strabismus surgery. METHODS: Ninety pediatric patients receiving sevoflurane anesthesia for elective strabismus surgery were enrolled. They were randomized to receive either saline (Group S), propofol 1 mg/kg (Group P), or nalbuphine 0.1 mg/kg (Group N) at the end of surgery. We evaluated the incidence of emergence agitation and recovery in the postanesthesia care unit. RESULTS: The time to recovery was similar between the three study groups. The incidence of agitation was significantly lower in Group N compared with Group S, but the incidence of agitation between Group S and Group P was not different. CONCLUSIONS: Nalbuphine 0.1 mg/kg at the end of strabismus surgery under sevoflurane anesthesia effectively reduced emergence agitation in children without delaying recovery, but propofol did not.

Effects of propofol and nalbuphine on emergence agitation after sevoflurane anesthesia in children for strabismus surgery / 대한마취과학회지

BACKGROUND: Emergence agitation in children is frequently associated with sevoflurane general anesthesia. We measured the effects of propofol and nalbuphine on emergence agitation after sevoflurane anesthesia in children for strabismus surgery. METHODS: Ninety pediatric patients receiving sevoflurane anesthesia for elective strabismus surgery were enrolled. They were randomized to receive either saline (Group S), propofol 1 mg/kg (Group P), or nalbuphine 0.1 mg/kg (Group N) at the end of surgery. We evaluated the incidence of emergence agitation and recovery in the postanesthesia care unit. RESULTS: The time to recovery was similar between the three study groups. The incidence of agitation was significantly lower in Group N compared with Group S, but the incidence of agitation between Group S and Group P was not different. CONCLUSIONS: Nalbuphine 0.1 mg/kg at the end of strabismus surgery under sevoflurane anesthesia effectively reduced emergence agitation in children without delaying recovery, but propofol did not.

Effects of Protein Kinase C on Hypoxic Pulmonary Vasoconstriction in Isolated Rat Lungs / 대한마취과학회지

BACKGROUND: Protein kinase C represents an important component of a signal transduction pathway that regulates vascular smooth muscle contraction. This study was performed with an inhibitor and activators of protein kinase C to determine their effects on hypoxic pulmonary vasoconstriction (HPV) in isolated rat lung model. METHODS: Isolated lungs from Sprague-Dawley rats were ventilated with a normoxic gas (21%O2-5%CO2-balanced N2) and a hypoxic gas (3%O2-5%CO2-balanced N2) alternatively, and then perfused with constant pulmonary blood flow. Baseline hypoxic pressor responses (delta PAP) were measured as the difference of pulmonary artery pressure between normoxic ventilation and hypoxic ventilation. After baseline delta PAP had obtained, rats were randomly divided into a chelerythrine group, an phorbol 12, 13-dibutyrate (PDBu) group, and a farnesylthiotriazole (FTT) group. The different concentrations of each drug were added into the perfusate sequentially. delta PAP in the different concentrations of each drug were calculated as a percentage of the delta PAP in each concentration of drug to the baseline delta PAP in the absence of drug (%delta PAP). RESULTS: The %delta PAP of chelerythrine were 83.7 +/- 19.2%, 71.5 +/- 24.1% and 68.4 +/- 28.3% at 0.1, 1, and 10micrometer, respectively (P < 0.05). The %delta PAP of PDBu were 111.3 +/- 10.1%, 144.4 +/- 37.8% and 168.4 +/- 89.1% at 20, 100, and 300 nM, respectively (P < 0.05). The %delta PAP of FTT were 80.1 +/- 25.1%, 61.0 +/- 17.2% and 30.1 +/- 18.4% at 1, 10, and 30micrometer, respectively (P < 0.05). CONCLUSIONS: The results of this study suggest that regulator of protein kinase C influence HPV.