Validity and reliability of head lift and tongue depressor test for diagnosis of the residual block

BACKGROUND: Head lift (HL) for 5 seconds and tongue depressor (TD) test have been used for diagnosis of the residual block after using the nondepolarizing muscle relaxants. We investigated validity and reliability of HL, TD, and both of them (HLTD). METHODS: Four-hundred-thirteen patients were enrolled in this study. Neuromuscular blockade was maintained with rocuronium and reversed with pyridostigmine and glycopyrrolate. TOF ratio was quantified by acceleromyograph in the recovery room. HL and TD test were performed in the patients who could respond to verbal command of the investigator. We analyzed the sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio, area under the cure (AUC) from ROC analysis and kappa statistics. RESULTS: Prevalences of residual block were 13%, 32% and 78% at 0.7, 0.9 and 1.0 of TOF ratio cutoff value, respectively. Specificity was good for HL (79.7-86.8%), TD (94.2-97.8%) and HLTD (77.8-85.7%), but sensitivity was not. Positive predictive value was higher in TD than HL and HLTD, and negative predictive value was similar among them. Positive and negative likelihood ratio was higher in TD than HL and HLTD. AUC had no difference among HL, TD and LTD. Kappa statistics were showed minimal or moderate relationship between clinical test and train of four responses. CONCLUSIONS: We concluded that HL, TD and HLTD were not good tools for diagnosis of the residual block in a view of validity and reliability.

Experience of a bloodless operation and care for Jehovah's Witnesses: Two cases report / 대한마취과학회지

We report two cases of Jehovah's Witness patients who had massive bleeding after surgery. The first case was a 37-year-old woman who underwent an emergency cesarean section; the other was a 48-year-old man with chronic anemia who underwent removal of a large mass. After the operation, their Hb levels were nearly 3.1 g/dl. They were treated with blood conserving methods, divided into 3 periods (pre, post and operative). Both patients completely recovered uneventfully and were discharged on the 19th and 21st postoperative day.

Experience of a bloodless operation and care for Jehovah's Witnesses: Two cases report / 대한마취과학회지

We report two cases of Jehovah's Witness patients who had massive bleeding after surgery. The first case was a 37-year-old woman who underwent an emergency cesarean section; the other was a 48-year-old man with chronic anemia who underwent removal of a large mass. After the operation, their Hb levels were nearly 3.1 g/dl. They were treated with blood conserving methods, divided into 3 periods (pre, post and operative). Both patients completely recovered uneventfully and were discharged on the 19th and 21st postoperative day.

Postoperative Residual Curarization in the Recovery Room after Vecuronium or Rocuronium Use

BACKGROUND: Postoperative residual curarization subsequent to the use of neuromuscular blocking drugs can cause respiratory problems. This study examined the incidence of postoperative residual curarization on the arrival of patients in the recovery room. METHODS: Two-hundred-fifty-nine patients were enrolled in the study. The neuromuscular blockade was maintained with vecuronium or rocuronium and all subjects were reversed with pyridostigmine. The train of four ratios (TR) was quantified by acceleromyography immediately upon their arrival in the recovery room. The residual curarization was defined as a TR of 0.9 (104.5 +/- 51.1 min) patients. The total dose of muscle relaxants corrected by the ED95 was significantly different between TR or = 0.9 patients. The total dose of vecuronium or rocuronium, and the dose of pyridostimine was similar in the TR or = 0.9 patients. CONCLUSIONS: Significant postoperative residual curarization waspresent in the majority of patients, even with the use of intermediate- acting neuromuscular blocking drugs. In addition, the time from the last dose of muscle relaxants to the TR assessment in the recovery room is a major factor that affects the residual curarization.

The Effect of Fentayl and Midazolam on the Incidence of Emergence Agitation in Children Following Sevoflurane Anesthesia for Tonsillectomy / 대한마취과학회지

BACKGROUND: It is well known that sevoflurane anesthesia is associated with emergence agitation (EA) in children, and that fentanyl may reduce its incidence. However, in case of midazolam, there have been conflicting reports. Therefore, we measured the effect of midazolam on EA after sevoflurane anesthesia and compared it with that of fentanyl. METHODS: Sixty pediatric patients receiving sevoflurane anesthesia for tonsillectomy was assigned to 3 groups. Saline 0.1 ml/kg (group P), midazolam 0.1 mg/kg (group M), or fentanyl 1 microgram/kg (group F) was administered intravenously 10 minutes before the end of surgery. The incidences of over-sedation (OS) and EA were checked three times at the postanesthesia care unit. RESULTS: Group M had a tendency to show a high incidence of OS, but its incidence of EA was not different from the other groups. In group F, OS and EA were less frequent than in groups P and M. CONCLUSIONS: After sevoflurane anesthesia for tonsillectomy, fentanyl effectively prevented EA, but midazolam elicited OS and was ineffective at preventing EA.

Evaluation of Presynaptic Action of Depolarizing Neuromuscular Blocking Agents with Single Twitch Response in Vitro / 대한마취과학회지

BACKGROUND: This study was performed to evaluate the presynaptic effects of depolarizing neuromuscular blocking drugs by using slow and fast frequencies of indirect stimulation on partial twitch depression in vitro. METHODS: A rat phrenic nerve hemidiaphragm was dissected and was mounted in an organ bath containing an oxygenated Krebs solution. The phrenic nerve was stimulated supramaximally and the twitch response (0.1 Hz) was stabilized for at least 30 minutes. T200/T1 ratio (twitch height of the 200th stimuli divided by that of the first stimuli) at frequencies of 0.2, 0.5, 1.0, and 2.0 Hz using a drug concentration which provided approximately 20% twitch depression at 0.1 Hz was calculated. To compare T200/T1 ratios with TOF ratios, a 2.0 Hz TOF response was measured immediately after the 200th stimuli at either frequency of stimulation. RESULTS: T200/T1 ratios produced by succinylcholine (SCC) and decamethonium (C10) were located between alpha-bungarotoxin (ABX) and hexamethonium (C6), however, significant differences among the four drugs were found at 2.0 Hz. The propensity for a decrease in T200/T1 ratios at 2.0 Hz might differ from this study: C6 > C10 > SCC > ABX. T200/T1 ratios at 2.0 Hz were not different from TOF ratios. CONCLUSIONS: It is concluded that small doses of C10 have a greater presynaptic activity than that of SCC, when the observed effects in this study were compared with the result of ABX acting predominantly at postsynaptic receptors and C6 acting predominantly at presynaptic receptors.

Comparison of Arterial and End-Tidal CO2 Tension by Position and Time Changes during Hip Replacement Arthroplasty in Elderly Patients / 대한마취과학회지

BACKGROUND: Hip replacement arthroplasty (HRA) is highly traumatic and performed in a lateral position for several hours and dead-space ventilation may increase. So, the difference between arterial and end-tidal PCO2 was investigated depending on the changes in the patient's posture during HRA in elderly patients. METHODS: Forty-three patients scheduled for a HRA were divided into two groups; Adult Group (n = 21, A-Group) and Elderly Group (n = 22, E-Group). Mean arterial pressure (MAP), heart rate (HR), PaO2, PaCO2, and end-tidal carbon dioxide tension (P(ET)CO2) were simultaneously measured at 10 min after anesthesia in a supine position (S[10]), at 30 min intervals from 30 min (L[30]) to 180 min (L[180]) in a lateral position and at 10 min in a supine position after the end of surgery (ES[10]) in both groups. The PaCO2-P(ET)CO2 gradient (P[a-ET]CO2) and dead space ventilation (Vd/ Vt) were calculated. RESULTS: At S(10), P(a-ET)CO2 in the A- and E-Groups was 7.0 +/- 5.0 and 7.2 +/- 3.3 mmHg respectively. From L(30) to ES(10), the P(a-ET)CO2 and the ratio of Vd/Vt in both groups increased significantly and progressively (P < 0.05 vs the control value) and the slope in the E-Group rose two times as compared to that in the A-Group. The correlation coefficient between P(a)CO2 and P(ET)CO2 was very significant from S(10) to L(90) and ES(10) in the A-Group, and from S(10) to L (60) in the E-Group (P < 0.01). CONCLUSIONS: For maintaining adequate ventilation of the elderly patient during HRA, PaCO2 should be measured intermittently along with the position changes after anesthesia in addition to the constant monitoring of PETCO2.