Risk factors associated with hypotensive bradycardic events during open shoulder surgery in the beach chair position.

BACKGROUND: Shoulder surgery in the beach chair position frequently causes hypotensive bradycardic events (HBEs), which are potentially associated with an increased risk of cerebral hypoperfusion. Here, we aimed to investigate the incidence and characteristics of symptomatic HBEs that require pharmacological interventions, and to identify specific risk factors associated with symptomatic HBEs. METHODS: We retrospectively examined the records of all patients aged ≥ 18 years who underwent shoulder arthrotomy in the beach chair position between January 2011 and December 2018 at Samsung Medical Center. For patients who experienced HBEs while in the beach chair position, the minimum heart rate and systolic blood pressure were noted, as was the total dose of ephedrine or atropine. RESULTS: Symptomatic HBEs occurred in 61.0% of all cases (256/420). Two patients with symptomatic HBEs experienced postoperative neurological complications. Multivariable logistic regression analysis showed that preoperative interscalene brachial plexus block (ISB) and advanced age were risk factors associated with symptomatic HBEs (odds ratio [OR]: 3.240, 95% CI: 2.003, 5.242, P < 0.001; OR: 1.060 for each 1-year increase, 95% CI: 1.044, 1.076, P < 0.001, respectively). Receiver operating curve analysis revealed that a threshold of 62 years of age had a moderate degree of accuracy for predicting symptomatic HBEs (area under curve: 0.764, 95% CI: 0.720, 0.804, P < 0.001). CONCLUSIONS: Considering the increasing risk of neurocognitive complications with aging, proactive hemodynamic management is needed, especially for elderly patients undergoing shoulder surgery in the beach chair position using ISB.

Comparison of Pulmonary Gas Exchange During Kidney Transplantation: Second-Generation Laryngeal Mask Airway vs Endotracheal Tube.

INTRODUCTION: We evaluated whether second-generation laryngeal mask airway (LMA) could provide an adequate pulmonary gas exchange during prolonged abdominal surgery compared to endotracheal tube (ETT) using propensity score matching. METHODS: Of the 257 recipients who underwent living donor kidney transplantation (LDKT), the LMA group and ETT group were matched: 87 of 101 recipients who inserted second-generation LMA were matched with 87 of 156 recipients who inserted ETT. Arterial partial pressure of carbon dioxide (PaCO2) and ratio of arterial partial pressure of oxygen to fractional inspired oxygen (PFR) and intraoperative ventilator parameters were compared between the 2 groups. In addition, we compared incidences of postoperative pulmonary and nonpulmonary complications including hoarseness, vocal cord palsy, nausea, vomiting, arrhythmia, and delirium between the 2 groups. RESULTS: Median anesthesia time was 357 minutes. PaCO2 and PFR were comparable between the 2 groups and did not show group and time interaction. Ventilator parameters during surgery were comparable, and incidences of both postoperative pulmonary and nonpulmonary complications were also comparable between the 2 groups. CONCLUSION: Second-generation LMA could provide an adequate pulmonary gas exchange compared with ETT during LDKT. In terms of pulmonary gas exchange, second-generation LMA could be considered as a suitable alternative to ETT during prolonged abdominal surgery.

Improvement of laryngoscopic view by hand-assisted elevation and caudad traction of the shoulder during tracheal intubation in pediatric patients.

Pediatric patients have large heads and relatively small bodies, making it difficult to perform intubation even in the sniffing position. Therefore, this study was planned on the assumption that hand-assisted elevation and caudad traction of the shoulder (HA-ECTS) would compensate for the laryngoscopic view. In this observational study, 45 pediatric patients aged 0-36 months with an ASA physical status of I-III and scheduled for elective surgery under general anesthesia were enrolled. HA-ECTS was defined as hand-assisted personalized traction in the upper and caudad directions with both hands under the lower cervical area. The POGO (percentage of glottis opening) score, MO (mouth opening), and LHS (laryngoscopic handling score) were compared before and after HA-ECTS. The median [range] POGO score was 30[10-50]% and 60[15-80]% before and after HA-ECTS, respectively (median difference, 20; 95% confidence interval [CI] 10 to 25%; P = 0.002). MO was 1.0[0.8-1.9] cm and 1.8[1.3-2.0] cm before and after HA-ECTS, respectively (median difference, 0.45 cm; 95% CI 0.25 to 0.60; P < 0.001). The ease of laryngoscopic handling was improved after HA-ECTS(P < 0.001). The application of HA-ECTS to pediatric patients younger than 3 years improved POGO score, MO, and LHS and could prove to be an assistive technique for tracheal intubation.

Trends in medical disputes involving anesthesia during July 2009-June 2018: an analysis of the Korean Society of Anesthesiologists database.

BACKGROUND: To identify trends in injuries and substandard care associated with anesthesia, we analyzed the Korean Society of Anesthesiologists database for anesthesia-related case files from July 2009 to June 2018. METHODS: Case characteristics, injuries, and outcomes were compared between the first part (July 2009-June 2014, n = 105) and the second part (July 2014-June 2018, n = 92) of the analyzed time period. RESULTS: Overall, 132 cases resulted in death. The proportion of fatal cases for sedation was similar to general anesthesia (66.2% vs. 76.3%). The proportion of cases with permanent injury or death decreased significantly in the second part of the period compared with the first part (76.1% vs. 93.3%, P = 0.002). With a growing trend in the proportion of sedation cases, a similar number of sedation and general anesthesia cases were referred during the overall period (77 and 76 cases, respectively). Propofol-based regimens remained the dominant sedation method (89.7% in the first part vs. 78.9% in the second part). The most common adverse event in cases of permanent injury or death was identified as being respiratory in origin (98/182, 53.8%). Permanent injuries or deaths were related to local anesthetic systemic toxicity (LAST) and beach-chair positioning for shoulder surgery, in 8 and 5 cases, respectively. CONCLUSIONS: Despite the decreasing trend in injury severity with time, several characteristic injury profiles were identified: lack of vigilance in propofol-based sedation, neurological injuries related to the beach-chair position, and LAST occurring during tumescent anesthesia or brachial plexus block.

Clinical effect of the proximity of epidural blood patch injection to the leakage site in spontaneous intracranial hypotension.

BACKGROUND: Epidural blood patch (EBP) has been shown to be an effective treatment option for spontaneous intracranial hypotension (SIH). We investigated whether response to the EBP was related to the distance of the injection site from the leakage site in patients with SIH. METHODS: We reviewed patients with SIH who underwent EBP at a single hospital. Patients were assigned to group R (response after EBP) or group N (no response after EBP). We then analyzed the demographics, clinical characteristics, leakage site, leakage length, EBP injection level and distance from leakage site, and injected EBP volume. RESULTS: Sixty-two patients were included in the analysis. The overall response rate to EBP was 59.7% (37 patients). The leakage length and injection distance from the leakage site did not differ between the two groups. Age, gender, body mass index, leakage site, and EBP volume did not differ significantly between the two groups. CONCLUSION: The clinical effect of EBP in SIH was not affected by leakage length or injection distance to leakage site. Further large studies must be conducted to investigate the efficacy of targeted EBP for SIH.