Sedation for gastrointestinal endoscopy with the application of target-controlled infusion.

BACKGROUND/AIMS: A majority of esophagogastroduodenoscopy (EGD) and colonoscopy procedures are performed under sedation, with the intravenous administration of a hypnotic agent combined with an opioid analgesic agent. The goal of our study was to establish the quality and plausibility of target-controlled infusion (TCI) as a sedation mechanism for upper and lower gastrointestinal (GI) endoscopies. MATERIALS AND METHODS: A randomized, single-blinded, controlled clinical trial was arranged in a local community hospital. In total, 100 adult outpatients scheduled for upper and lower GI endoscopies were included and randomly allocated to a control group (n=50) and a TCI group (n=50). The sedation quality was assessed using the simplified quality of an anesthesia scoring system. Categorical parameters were compared using Pearson's chi-square test. Continuous parameters that were normally distributed were further compared using Student's t-test, and the others were compared using the Mann-Whitney test. RESULTS: The significantly lower anesthesia quality score in the TCI group (12.2 vs. 12.7) indicated that the anesthesia quality was better in this group. CONCLUSION: This study showed that sedation using TCI for GI endoscopy provided safe and effective sedation and was associated with a better sedation quality. We believe that TCI can be used to provide routine sedation for patients receiving GI endoscopy.

Risk stratification for predicting 30-day mortality of intracerebral hemorrhage.

OBJECTIVE: The aim of this study was to develop a grading scale for predicting the 30-day mortality of spontaneous intracerebral hemorrhage (ICH) using initial evaluation data. DESIGN: Univariate and multivariate logistic regression models were used to identify independent risk factors and to construct a grading scale for predicting the outcome of ICH. SETTING: The Taichung Veterans General Hospital in Taichung, Taiwan. PARTICIPANTS: Two hundred and ninety-three patients were diagnosed with spontaneous ICH between 1 January 2006 and 31 December 2007. INTERVENTION: Development of the simplified ICH score (sICH score) for predicting the 30-day mortality of ICH. MAIN OUTCOME MEASURES: The discrimination of the prediction model was determined by measuring the accuracy, sensitivity, specificity and the area under the receiver operating characteristic curves (AUC). RESULTS: The accuracy of the sICH score was 80.5%, the sensitivity was 82.5% and the specificity was 80.2%. The AUCs are as follows: sICH score, 0.89 (0.84-0.94); ICH score, 0.74 (0.65-0.83) and ICH-GS, 0.74 (0.65-0.83). CONCLUSIONS: The sICH score showed best discrimination among tested models. Also, it was easier for physicians without special training in neurology or radiology to use this scale. With statistical power and ease of use, the sICH score is a very suitable model for risk stratification of spontaneous ICH.

Perioperative thrombotic occlusion of left external iliac artery during anterior lumbar interbody fusion.

We report a case of thrombotic occlusion of left external iliac artery during the procedure of anterior lumbar interbody fusion. The diagnosis was confirmed by computed tomography angiography. The patient also developed severe rhabdomyolysis postoperatively. In spite of receiving emergent thromboendarterectomy, the patient expired on postoperative day 3. This report attempts to remind spinal surgeons and anesthesiologists of this rare but potentially fatal complication, and discuss the possible mechanism, management, and prevention.

Are P values and statistical assessments in poster abstracts presented at annual meetings of Taiwan Society of Anesthesiologists relative to the characteristics of hospitals?

BACKGROUND: Many anesthesiologists in medical centers (MC) or in anesthesiologist-training hospitals (ATH) are accustomed to present their research data in the form of poster abstracts at the annual meetings of Taiwan Society of Anesthesiologists (TSA) to represent their academic gainings in a designated period of time. However, an orphaned P value without mentioning the related specified statistical test has frequently been found in these articles. The difference in presentation of statistical test after P value between MC/ATH and non-MC/non-ATH in recent three TSA consecutive annual meetings was explored in this article. METHODS: We collected the proceedings handbooks of TSA annual meetings in a period spanning 3 yrs (2003 to 2005) and analyzed the hospital characteristic of first institute-byliner in the poster abstract. Data were analyzed with Fisher's exact test and statistical significance was assumed if P < 0.05. RESULTS: Included were 101 poster abstracts with byliners of 20 hospitals. Only 2 of the 20 hospitals were accredited as non-ATH and 4 as non-MC. There were 64 (63%) abstracts without specified statistical test after P value and no significant difference was found among each category. (P = 0.47 in ATH vs. non-ATH and P = 0.07 in MC vs. non-MC). CONCLUSIONS: The basic concept of P value with specified statistical test was not applicable comprehensively in poster abstracts of the annual conferences. Based on our wishful intention, we suggest that the anesthesia administrators and senior anesthesiologists at ATH or MC, and the members of the committee responsible for running academic affairs in TSA, should pay attention to this prodigy and work together to improve our basic statistics in poster presentation.

Prediction for major adverse outcomes in cardiac surgery: comparison of three prediction models.

BACKGROUND/PURPOSE: Recent advances in medical treatment have altered the profile of patients referred for cardiac surgery. The proportion of high risk patients has increased dramatically. Numerous multifactorial risk scores have been developed to predict outcomes after cardiac surgery. However, these additive risk models were all developed outside of Asia and have never been validated in Taiwan. We applied the Parsonnet score, Tu score and logistic regression to a population in Taiwan who received cardiac surgery to predict the mortality, morbidity and likelihood of prolonged stay in the intensive care unit (ICU). METHODS: This retrospective study included 622 adult patients who received cardiac surgery during a 2-year period at Taichung Veterans General Hospital. The patients were randomly divided into a reference set (n = 423) and a validation set (n = 199). The Parsonnet score and Tu score were calibrated separately with the reference set to determine mortality, morbidity and likelihood of prolonged ICU stay. We developed a separate logistic regression model for each of the three outcomes by using the reference set. The validation set was used to test these models. RESULTS: The area under the receiver operating characteristic (ROC) curve (AUC) of the Parsonnet score, Tu score and logistic regression for predicting in-hospital mortality were 0.843, 0.714 and 0.867, respectively. The AUC of the Parsonnet score, Tu score and logistic regression for predicting major morbidity were 0.784, 0.736 and 0.808, respectively. The AUC of the Parsonnet score, Tu score and logistic regression for predicting likelihood of prolonged ICU stay were 0.701, 0.689 and 0.764, respectively. CONCLUSION: The Parsonnet score performed as well as the logistic regression models in predicting major adverse outcomes. The Parsonnet score appears to be a very suitable model for clinicians to use in risk stratification of cardiac surgery.

Risk factors affecting adverse outcomes of cardiac surgery in patients aged 70 years and older.

BACKGROUND: The elderly segment of the population in Taiwan is increasing rapidly. According to the latest information from the Directorate-General of Budget, Accounting and Statistics, Executive Yuan, Taiwan, 1,553,367 civilians of the total population of 22,879,510 (6.8%) are seventy years old and older in 2007. The proportion of high-risk patients has increased dramatically owing to a greater number of elderly patients and increased number of average patients with heart diseases presenting for cardiac surgery. We analyzed the preoperative risk factors for in-hospital mortality, morbidity and the likelihood of prolonged intensive care unit (ICU) stay in elderly patients after cardiac surgery. METHODS: We retrospectively studied 952 adult patients who received cardiac surgery during a three-year period (from August 1, 2004 to December 31, 2006) at Taichung Veterans General Hospital. Patients were divided into a control group and a study group. The study group (n=395) exclusively consisted of patients aged seventy or over while the rest of the patients under study served as reference group (n=557). Continuous variables were compared using Student's t test, and categorical variables were compared using Pearson chi-square test. Variables associated with in-hospital mortality, major morbidity and prolonged ICU stay in univariate analysis with P < 0.05 were entered into multivariate analysis using logistic regression with a stepwise forward selection procedure to determine independent variables and identify variables associated with major adverse outcomes. RESULTS: Fifty-six (14.2%) patients died during their hospitalization in the study group and 46 (8.3%) in the reference group. Major mortality in the study group was 58.0% versus 39.7% in the reference group. The patients of the study group spent more days in the ICU than did patients of the reference group (8.7 +/- 12.0 versus 6.1 +/- 10.0 days, P < 0.05). In addition, 114 (28.9%) patients of the study group and 85 (15.3%) of the reference group spent more than 7 days in the ICU. Using multiple logistic regression analysis, risk factors affecting in-hospital mortality in the study group include impairment of renal function, reoperation, congestive heart failure (CHF), catastrophic event. Impaired renal function, complexity of surgical procedure, CHF, chronic obstructive pulmonary disease (COPD) and catastrophic state were significant factors affecting morbidity in the study group. CHF, COPD and catastrophic event contributed to prolonged ICU stay in the study group. CONCLUSIONS: The perioperative risk of cardiac surgery increases in older patient groups, and some risk factors have different influences on mortality, morbidity and ICU stay. Risk assessment in older cardiosurgical patients with convenient risk factors helps the clinicians to apply rational and cost-effective treatment strategies into practice.

Metastatic hepatocellular carcinoma of the right atrium causing right ventricular outflow tract obstruction during induction of anesthesia--a case report.

Metastatic hepatocellular carcinoma (HCC) to the right atrium occurs rarely and may lead to lethal perioperative complications. A 61-year-old female who was about to undergo operation for resection of a right intraatrial tumor thought possibly to be metastatic hepatocellular carcinoma met with sudden protrusion of the tumor from the right atrial wall that sank into the right ventricle during induction of anesthesia. Right ventricular outflow tract obstruction developed and was quickly diagnosed by transesophageal echocardiography. Emergent cardiopulmonary bypass was rushed on the spot and the surgery was completed smoothly. Here we discuss the possible causes of the event and we recommend that special attention should be paid to the anesthetic techniques and proper precaution should be taken in the face of such a risky surgery.