Risk factors for discontinuing intravenous patient-controlled analgesia after thoracic surgery.

PURPOSE: This study examined the risk factors of experiencing side effects from using intravenous patient-controlled analgesia (IV PCA) following lung and esophageal surgery. METHODS: Our study included adult patients who underwent lung or esophageal surgery and received IV PCA for postoperative acute pain control between 2020 and 2022. We collected information on side effects from IV PCA use, the decision to discontinue PCA, and the PCA regimen from the daily reports of the acute pain management team and verified the accuracy using electronic records from ward nurses. The primary outcome was the risk factor associated with discontinuing IV PCA due to its side effects. RESULTS: Out of the 1796 patients in our study, 1795 used PCA containing opioids; 196 patients stopped IV PCA due to unbearable side effects. Being female (adjusted odds ratio [aOR]: 2.65, 95% confidence interval [CI]: 1.70, 4.13) was linked to a higher chance of stopping PCA use. Having hypertension (aOR: 0.46, 95% CI: 0.26, 0.81) and being classified as the American Society of Anesthesiologists class 3 or higher (aOR: 0.48, 95% CI: 0.23, 0.86) were associated with a lower chance of discontinuing PCA use. CONCLUSION: Our study determined the risk factors to stop using IV PCA due to side effects following lung or esophageal surgery. These results emphasize the need for personalized pain management plans that take into account the patient's characteristics and the type of surgery performed.

Long-Term Particulate Matter Exposure and Mortality in Hospitalized Patients with COVID-19 in South Korea.

Rationale: Particulate matter (PM) exposure exacerbates health outcomes by causing lung damage. Objectives: To investigate whether prior exposure to particulate matter ⩽10 µm and ⩽2.5 µm in aerodynamic diameter (PM10 and PM2.5) was associated with clinical outcomes among patients with coronavirus disease (COVID-19). Methods: Data from the nationwide registration database of the National Health Insurance and Korea Disease Control and Prevention Agency in South Korea were used. The study included adult patients who were admitted to monitoring centers or hospitals between October 8, 2020 and December 31, 2021, after COVID-19 confirmation. AirKOREA database, which compiles air pollutant data from 642 stations in 162 cities and counties across South Korea, was used to extract data on PM levels. Average values of monthly exposure to PM10 and PM2.5 from the year previous to hospital admission because of COVID-19 to the date of confirmation of COVID-19 were calculated and used to define PM exposures of patients with COVID-19. Results: In total, 322,289 patients with COVID-19 were included, and 4,633 (1.4%) died during hospitalization. After adjusting for covariates, a 1-µg/m3 increase in PM10 and PM2.5 exposure was associated with 4% (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.03-1.05; P < 0.001) and 6% (OR, 1.06; 95% CI, 1.04-1.07; P < 0.001) increase in the risk of in-hospital mortality, respectively. In addition, a 1-µg/m3 increase in PM10 and PM2.5 was associated with 5% (OR, 1.05; 95% CI, 1.04-1.07; P < 0.001) and 8% (OR, 1.08; 95% CI, 1.06-1.10; P < 0.001) increase in the risks of requiring intensive care unit (ICU) admission and mechanical ventilation, respectively. Conclusions: PM10 and PM2.5 exposure was associated with increased in-hospital mortality and the need for ICU admission and mechanical ventilation among patients with COVID-19 in South Korea.

The association of perioperative blood transfusion with survival outcomes after major cancer surgery: a population-based cohort study in South Korea.

PURPOSE: The correlation between perioperative blood transfusions and the prognosis after major cancer surgery remains controversial. We investigated the association between perioperative blood transfusion and survival outcomes following major cancer surgeries and analyzed trends in perioperative blood transfusions. METHODS: Data for this population-based cohort study were obtained from the National Health Insurance Service of South Korea. Adult patients who underwent major cancer surgery between January 1, 2016, and December 31, 2020, were included. The primary endpoint was 90-day mortality. RESULTS: The final analysis included 253,016 patients, of which 55,094 (21.8%) received perioperative blood transfusions. In the multivariable logistic regression model, select factors, including neoadjuvant/adjuvant chemotherapy, an increased preoperative Charlson Comorbidity Index, moderate or severe liver disease, liver cancer surgery, and small bowel cancer surgery, were associated with an increased likelihood of blood transfusion. In the multivariable Cox regression model, patients who received blood transfusion had a significantly higher risk of 90-day mortality (hazard ratio: 5.68; 95% confidence interval: 5.37, 6.00; P < 0.001) than those who did not. CONCLUSION: We identified potential risk factors for perioperative blood transfusions. Blood transfusion is associated with an increased 90-day mortality risk after major cancer surgery.

Trend of Intensive Care Unit Admission in Neurology-Neurosurgery Adult Patients in South Korea : A Nationwide Population-Based Cohort Study.

OBJECTIVE: We aimed to examine trends in critically ill neurology-neurosurgery (NNS) patients who were admitted to the intensive care unit (ICU) in South Korea and identify risk factors for in-hospital mortality after ICU admission in NNS patients. METHODS: This nationwide population-based retrospective cohort study enrolled adult NNS adult patients admitted to the ICU from 2010 to 2019 extracted from the National Health Insurance Service in South Korea. The critically ill NNS patients were defined as those whose main admission departments were neurology or neurosurgery at ICU admission. The number of ICU admission, age, and total cost for hospitalization from 2010 to 2019 in critically ill NNS patients were examined as trend information. Moreover, multivariable logistic regression modeling was used to identify risk factors for in-hospital mortality among critically ill NNS patients. RESULTS: We included 845474 ICU admission cases for 679376 critically ill NNS patients in South Korea between January 1, 2010 to December 31, 2019. The total number of ICU admissions among NNS patients was 79522 in 2010, which increased to 91502 in 2019. The mean age rose from 62.8 years (standard deviation [SD], 15.6) in 2010 to 66.6 years (SD, 15.2) in 2019, and the average total cost for hospitalization per each patient consistently increased from 6206.1 USD (SD, 5218.5) in 2010 to 10745.4 USD (SD, 10917.4) in 2019. In-hospital mortality occurred in 75455 patients (8.9%). Risk factors strongly associated with increased in-hospital mortality were the usage of mechanical ventilator (adjusted odds ratio [aOR], 19.83; 95% confidence interval [CI], 19.42-20.26; p<0.001), extracorporeal membrane oxygenation (aOR, 3.49; 95% CI, 2.42-5.02; p<0.001), and continuous renal replacement therapy (aOR, 6.47; 95% CI, 6.02-6.96; p<0.001). In addition, direct admission to ICU from the emergency room (aOR, 1.38; 95% CI, 1.36-1.41; p<0.001) and brain cancer as the main diagnosis (aOR, 1.30; 95% CI, 1.22-1.39; p<0.001) are also potential risk factors for increased in-hospital mortality. CONCLUSION: In South Korea, the number of ICU admissions increased among critically ill NNS patients from 2010 to 2019. The average age and total costs for hospitalization also increased. Some potential risk factors are found to increase in-hospital mortality among critically ill NNS patients.

Joblessness, decreased income, and disability in intensive care unit survivors of nontraumatic intracranial hemorrhage in South Korea.

OBJECTIVES: To examine the proportions of unemployment, decreased household income, and newly acquired disability, and their impact on long-term mortality after intensive care unit (ICU) admission due to nontraumatic intracranial hemorrhage (IH). MATERIALS AND METHODS: This nationwide population-based retrospective cohort study enrolled adult patients admitted to the ICU because of nontraumatic IH between 2010 and 2018 in South Korea. Patients who were alive ≥365 days after ICU admission were defined as nontraumatic IH survivors. RESULTS: In total, 104,086 nontraumatic IH survivors were included in the final analysis. Among them, 7,225 (6.9 %) experienced job loss, 25,709 (24.7 %) experienced decreased household income, and 20,938 (20.1 %) had newly acquired disabilities, of whom 14,188 (13.6 %) had newly acquired brain disabilities. Male sex, increased duration of intensive care unit stay, comorbid status, hospital admission through the emergency room, nontraumatic intracerebral hemorrhage, receipt of surgery, mechanical ventilatory support, and increased total cost of hospitalization were associated with job loss, decreased household income, and newly acquired disabilities. However, these changes were not significantly associated with 2-year all-cause mortality (adjusted hazard ratio: 1.00, 95 % confidence interval: 0.95, 1.06; P = 0.997). CONCLUSIONS: Many nontraumatic IH survivors experienced unemployment, decreased household income, and newly acquired disability one year after ICU admission in South Korea. Some factors were potential risk factors for these changes, but the changes were not associated with 2-year all-cause mortality.

Risk factors for discontinuation of intravenous patient-controlled analgesia after general surgery: a retrospective cohort study.

Identifying patients at risk for developing side effects secondary to intravenous patient-controlled analgesia (IV PCA) and making the necessary adjustments in pain management are crucial. We investigated the risk factors of discontinuing IV PCA due to side effects following general surgery; adult patients who received IV PCA after general surgery (2020-2022) were included. Data on postoperative pain intensity, PCA pain relief, side effects, continuity of PCA use, and PCA pump settings were collected from the records of the acute pain management team. The primary outcome was identifying the risk factors associated with PCA discontinuation due to side effects. Of the 8745 patients included, 94.95% used opioid-containing PCA, and 5.05% used non-steroidal anti-inflammatory drug (NSAID)-only PCA; 600 patients discontinued PCA due to side effects. Female sex (adjusted odds ratio [aOR] 3.31, 95% confidence interval [CI] 2.74-4.01), hepato-pancreatic-biliary surgery (aOR 1.43, 95% CI 1.06-1.94) and background infusion of PCA (aOR 1.42, 95% CI 1.04, 1.94) were associated with an increased likelihood of PCA discontinuation. Preoperative opioid use (aOR 0.49, 95% CI 0.28-0.85) was linked with a decreased likelihood of PCA discontinuation. These findings highlight the importance of individualized pain management, considering patient characteristics and surgical procedures.

Intensivist coverage and critically ill COVID-19 patient outcomes: a population-based cohort study.

BACKGROUND: Trained intensivist staffing improves survival outcomes in critically ill patients at intensive care units. However, the impact on outcomes of critically ill patients with coronavirus disease 2019 has not yet been evaluated. We aimed to investigate whether trained intensivists affect outcomes among critically ill coronavirus disease 2019 patients in South Korean intensive care units. METHODS: Using a nationwide registration database in South Korea, we included adult patients admitted to the intensive care unit from October 8, 2020, to December 31, 2021, with a main diagnosis of coronavirus disease 2019. Critically ill patients admitted to intensive care units that employed trained intensivists were included in the intensivist group, whereas all other critically ill patients were assigned to the non-intensivist group. RESULTS: A total of 13,103 critically ill patients were included, with 2653 (20.2%) patients in the intensivist group and 10,450 (79.8%) patients in the non-intensivist group. In the covariate-adjusted multivariable logistic regression model, the intensivist group exhibited 28% lower in-hospital mortality than that of the non-intensivist group (odds ratio: 0.72; 95% confidence interval: 0.62, 0.83; P < 0.001). CONCLUSIONS: Trained intensivist coverage was associated with lower in-hospital mortality among critically ill coronavirus disease 2019 patients who required intensive care unit admission in South Korea.

Role of Unfolded Protein Response and Endoplasmic Reticulum-Associated Degradation by Repeated Exposure to Inhalation Anesthetics in Caenorhabditis elegans.

Background: When an imbalance occurs between the demand and capacity for protein folding, unfolded proteins accumulate in the endoplasmic reticulum (ER) lumen and activate the unfolded protein response (UPR). In addition, unfolded proteins are cleared from the ER lumen for ubiquitination and subsequent cytosolic proteasomal degradation, which is termed as the ER-associated degradation (ERAD) pathway. This study focused on changes in the UPR and ERAD pathways induced by the repeated inhalation anesthetic exposure in Caenorhabditis elegans. Methods: Depending on repeated isoflurane exposure, C. elegans was classified into the control or isoflurane group. To evaluate the expression of a specific gene, RNA was extracted from adult worms in each group and real-time polymerase chain reaction was performed. Ubiquitinated protein levels were measured using western blotting, and behavioral changes were evaluated by chemotaxis assay using various mutant strains. Results: Isoflurane upregulated the expression of ire-1 and pek-1 whereas the expression of atf-6 was unaffected. The expression of both sel-1 and sel-11 was decreased by isoflurane exposure, possibly indicating the inhibition of retro-translocation. The expression of cdc-48.1 and cdc-48.2 was decreased and higher ubiquitinated protein levels were observed in the isoflurane group than in the control, suggesting that deubiquitination and degradation of misfolded proteins were interrupted. The chemotaxis indices of ire-1, pek-1, sel-1, and sel-11 mutants decreased significantly compared to N2, and they were not suppressed further even after the repeated isoflurane exposure. Conclusion: Repeated isoflurane exposure caused significant ER stress in C. elegans. Following the increase in UPR, the ERAD pathway was disrupted by repeated isoflurane exposure and ubiquitinated proteins was accumulated subsequently. UPR and ERAD pathways are potential modifiable neuroprotection targets against anesthesia-induced neurotoxicity.

The Effect of Intraoperative Magnesium Sulphate Infusion on Emergence Agitation after Ambulatory Ophthalmic Surgery in Children.

This study investigated whether intraoperative infusion of magnesium sulphate reduces the incidence of emergence agitation (EA) in paediatric patients who undergo ambulatory ophthalmic surgery using the Paediatric Anaesthesia Emergence Delirium (PAED) scale. Ninety-two paediatric patients who were scheduled for elective ophthalmic surgery were randomly allocated to two groups: control or magnesium. In the magnesium group, patients received an initial intravenous loading dose of 30 mg/kg of 10% solution of magnesium sulphate over 10 min and then a continuous infusion of 10 mg/kg×h during the surgery. In the control group, an equal volume of 0.9% isotonic saline was administered in the same way as in the magnesium group. The PAED scale was assessed at 15-min intervals until the PAED score reached below 10 at the postanaesthetic care unit. EA was defined as a PAED score of 10 or higher. Of the 86 patients recruited, 44 and 42 were allocated to the control and magnesium groups, respectively. The incidence of EA was 77.3% in the control group and 57.1% in the magnesium group (odds ratio, 0.392; 95% confidence interval, 0.154 to 0.997; p = 0.046). The intraoperative infusion of magnesium sulphate significantly reduced the incidence of EA.

Pre-operative chronic opioid or glucocorticoid use and mortality after noncardiac surgery: A retrospective cohort study.

BACKGROUND: The chronic use of opioids and glucocorticoids is associated with serious side effects. Moreover, both medications are related to poor long-term postoperative outcomes. OBJECTIVE: The study aimed to investigate the association between pre-operative chronic opioid and glucocorticoid use and 90-day mortality after noncardiac surgery. DESIGN: Retrospective, population-based cohort study. SETTING: Single tertiary academic hospital. PATIENTS: The study enrolled adult (≥18 years of age) patients admitted to Seoul National University Bundang Hospital, between January 2012 and December 2018 for planned, elective, noncardiac surgery. MAIN OUTCOME MEASURES: The study compared the 90-day mortality for patients using opioids or glucocorticoids chronically (≥3 months) prior to surgery and for opioid-naïve and glucocorticoid-naïve patients. RESULTS: A total of 112 606 patients were included in the study. Among them, 107 843 (95.9%) were opioid-naïve and glucocorticoid-naïve patients; 3373 (3.0%), 1199 (1.1%) and 191 patients (0.2%) were chronic users of opioids, glucocorticoids or both, respectively. In the multivariable model, compared with opioid-naïve and glucocorticoid-naïve patients, the odds of dying within 90 days were significantly higher for chronic users of opioids [3.56-fold; 95% confidence intervals (CIs) 2.36 to 5.38; P < 0.001], glucocorticoids (4.17-fold; 95% CI 3.28 to 5.29; P < 0.001) and combined opioids and glucocorticoids (7.66-fold; 95% CI 3.91 to 15.01; P < 0.001). CONCLUSION: Chronic pre-operative use of opioids and glucocorticoids, together or individually, were associated with increased 90-day mortalities after noncardiac surgery, compared with opioid-naïve and glucocorticoid-naïve patients. Our results suggest that chronic pre-operative use of opioids and glucocorticoids should be managed carefully.

Association of Immediate Postoperative Temperature in the Surgical Intensive Care Unit with 1-Year Mortality: Retrospective Analysis Using Digital Axillary Thermometers.

BACKGROUND: Postoperative body temperature is closely associated with prognosis although there is limited research regarding this association at Postoperative intensive care unit (ICU) admission. Furthermore, no studies have used digital axillary thermometers to measure Postoperative body temperature. This study investigated the association between mortality and Postoperative temperature measured using a digital axillary thermometer within 10 minutes after ICU admission. METHODS: This retrospective observational study evaluated data from adult patients admitted to an ICU after elective or emergency surgery. The primary outcome was 1-year mortality after ICU admission. Multivariable logistic regression analysis with restricted cubic splines was used to evaluate the association between temperature and outcomes. RESULTS: We evaluated data from 5,868 patients admitted between January 1, 2013 and May 31, 2016, including 5,311 patients (90.5%) who underwent noncardiovascular surgery and 557 patients (9.5%) who underwent cardiovascular surgery. Deviation from the median temperature (36.6℃) was associated with increases in 1-year mortality (≤ 36.6℃: linear coefficient, -0.531; P<0.001 and ≥36.6℃: spline coefficient, 0.756; P<0.001). Similar statistically significant results were observed in the noncardiovascular surgery group, but not in the cardiovascular surgery group. CONCLUSIONS: An increase or decrease in body temperature (vs. 36.6℃) measured using digital axillary thermometers within 10 minutes of Postoperative ICU admission was associated with increased 1-year mortality. However, no significant association was observed after cardiovascular surgery. These results suggest that Postoperative temperature is associated with longterm mortality in patients admitted to the surgical ICU in the Postoperative period.

Anesthetic management for a patient with bronchobiliary fistula after pancreaticoduodenectomy: A case report.

RATIONALE: Perioperative management of patients with bronchobiliary fistula (BBF) is an anesthetic challenge because they typically exhibit poor lung function preoperatively, require meticulous lung isolation intraoperatively and need postoperative respiratory support. PATIENT CONCERNS: A 44-year-old man with a past surgical history of pancreaticoduodenectomy presented fluctuating fever, jaundice, dyspnea and yellowish sputum. Despite intravenous antibiotic treatment and repeated percutaneous drainage, patient showed gradual deterioration with hypoxemia, and uncontrolled pneumonia. DIAGNOSES: The patient was diagnosed with BBF based on the clinical manifestation such as biloptysis with pneumonia, and imaging studies. INTERVENTIONS: Resection of the fistula and bilobectomy was performed under general anesthesia. Avoidance of positive pressure ventilation before lung isolation and precise lung isolation are essential for patients with BBF to protect the unaffected lung. Therefore, rapid sequence induction was performed. Left-sided double-lumen tube was inserted for lung isolation and position of the tube was confirmed by visualization with fiberoptic bronchoscopy. Bile-stained secretion was repeatedly suctioned in trachea and both bronchi during surgery. OUTCOMES: In spite of decrease in SpO2 with institution of one-lung ventilation, the patient's oxygenation was gradually improved as surgery progressed without hemodynamic instability. At the end of surgery, the double-lumen tube was replaced with a single-lumen endotracheal tube for postoperative mechanical ventilation. LESSONS: Absolute lung isolation using double-lumen tube for one-lung ventilation and bronchial toilet during surgery and replacement of single-lumen tube for postoperative respiratory support at the end of surgery are effective to improve oxygenation in patients with BBF.

Chronic hyperglycemia with elevated glycated hemoglobin level and its association with postoperative acute kidney injury after a major laparoscopic abdominal surgery in diabetes patients.

BACKGROUND: The relationship between preoperative hyperglycemia and postoperative acute kidney injury (AKI) occurrence in non-cardiac surgery including laparoscopic surgery remains unclear. This study aimed to assess the relationship between preoperative chronic hyperglycemia and postoperative AKI occurrence after a major laparoscopic abdominal surgery. METHODS: We retrospectively reviewed medical records of diabetic patients (≥ 20 years old) who underwent elective major laparoscopic abdominal surgery procedures between 2010 and 2016. Patients were divided into two groups based on a cut-off value of hemoglobin A1c (HbA1c) at 6%. Serum creatinine value was used for the diagnosis of AKI, and all assessments and diagnoses of postoperative AKI were performed on 0-3 postoperative days (POD) using the criteria of Kidney Disease: Improving Global Outcomes. RESULTS: In all, 1885 patients were included in the final analysis, and patients were divided into the following groups: < 6.0% group with 1257 patients (66.7%), and ≥ 6.0% group with 628 patients (33.3%). Sixty-nine patients (3.7%) were diagnosed with postoperative AKI within 3 POD. Multivariable logistic regression analysis showed no significant difference in the incidence rate of postoperative AKI between the HbA1c ≥ 6.0% group and the < 6.0% group (odds ratio 1.10, 95% confidence interval 0.57-2.15; P = 0.770). In addition, there was no significant interaction between preoperative HbA1c group and exposure to acute hyperglycemia (serum glucose > 200 mg/dL) for incidence of AKI on POD 0-3 (P = 0.181). CONCLUSIONS: In diabetic patients, preoperative chronic hyperglycemia is not associated with postoperative AKI occurrence within 3 POD after a major laparoscopic abdominal surgery.

Anesthetic management of the first forearm transplantation in Korea.

Vascularized composite allotransplantation for the forearm is a complex surgical procedure, requiring multidisciplinary collaboration. It is important to provide optimal blood flow to the grafts, effective immunosuppression, and early rehabilitation for graft survival and good functional outcomes. As ischemia-reperfusion injury and substantial but unquantifiable blood loss are inevitable in this type of surgery, anesthetic management should focus on providing adequate hemodynamic management with proper monitoring, and anesthetic and analgesic strategies to prevent vasoconstriction in the graft. In this paper, we describe the anesthetic management of the first forearm transplantation performed in Korea.

Assessment of phytotoxicity of ZnO NPs on a medicinal plant, Fagopyrum esculentum.

Fagopyrum esculentum commonly named as buckwheat plant is pseudocereal food crops and healthy herbs but is not known as a bioindicator of environmental condition. In the present study, the effects of ZnO nanoparticles (NPs) and microparticles (MPs) on plant growth, bioaccumulation, and antioxidative enzyme activity in buckwheat were estimated under hydroponic culture. The significant biomass reduction at concentrations of 10-2,000 mg/L was 7.7-26.4 % for the ZnO NP and 11.4-23.5 % for the ZnO MP treatment, (p < 0.05). ZnO NPs were observed in root cells and root cell surface by scanning electron microscopy and transmission electron microscopy analysis. Zn bioaccumulation in plant increased with increasing treatment concentrations. The upward translocation (translocation factor <0.2) of Zn in plant was higher with the ZnO NP treatment than that with the ZnO MP treatment. Additionally, reactive oxygen species generation by ZnO NPs was estimated as the reduced glutathione level and catalase activity, which would be a predictive biomarker of nanotoxicity. The results are the first study to evaluate the phytotoxicity of ZnO NPs to medicinal plant. F. esculentum can be as a good indicator of plant species in NP-polluted environment.

Effects of soil-plant interactive system on response to exposure to ZnO nanoparticles.

The ecotoxicological effects of nanomaterials on animal, plant, and soil microorganisms have been widely investigated; however, the nanotoxic effects of plant-soil interactive systems are still largely unknown. In the present study, the effects of ZnO nanoparticles (NPs) on the soil-plant interactive system were estimated. The growth of plant seedlings in the presence of different concentrations of ZnO NPs within microcosm soil (M) and natural soil (NS) was compared. Changes in dehydrogenase activity (DHA) and soil bacterial community diversity were estimated based on the microcosm with plants (M+P) and microcosm without plants (M-P) in different concentrations of ZnO NPs treatment. The shoot growth of M+P and NS+P was significantly inhibited by 24% and 31.5% relative to the control at a ZnO NPs concentration of 1,000 mg/kg. The DHA levels decreased following increased ZnO NPs concentration. Specifically, these levels were significantly reduced from 100 mg/kg in M-P and only 1,000 mg/kg in M+P. Different clustering groups of M+P and M-P were observed in the principal component analysis (PCA). Therefore, the M-P's soil bacterial population may have more toxic effects at a high dose of ZnO NPs than M+P's. The plant and activation of soil bacteria in the M+P may have a less toxic interactive effect on each of the soil bacterial populations and plant growth by the ZnO NPs attachment or absorption of plant roots surface. The soil-plant interactive system might help decrease the toxic effects of ZnO NPs on the rhizobacteria population.