Hae Keum Kil

Detection of Subclinical CO2 Embolism by Transesophageal Echocardiography During Laparoscopic Radical Prostatectomy

OBJECTIVES To document incidences of subclinical embolism in laparoscopic radical prostatectomy with continuous monitoring using transesophageal echocardiography (TEE). METHODS A total of 43 patients scheduled for elective robotic-assisted laparoscopic radical prostatectomy under general anesthesia were enrolled in this study. A 4-chamber view of 5.0-MHz multiplane TEE was continuously monitored to detect any intracardiac bubbles as an embolism. An independent TEE specialist reviewed the tapes for interpretation, and emboli were classified as 1 of 5 stages. Cardiorespiratory instability during gas emboli entry was defined as an appearance of cardiac arrhythmias, sudden decrease in mean arterial blood pressure >20 mm Hg, or an episode of pulse oximetric saturation <90%. RESULTS Gas embolisms were observed in 7 of 41 (17.1%) patients during transection of the deep dorsal venous complex. Of them, 1, 3, 1, and 2 showed stage I, II, III, and IV, respectively. However, there were no signs of cardiorespiratory instability associated with emboli. The 95% confidence interval for gas embolism was 0.204%-0.138%. No correlation was observed between episodes of gas embolism and blood gas variables or end-tidal CO(2) partial pressure. CONCLUSIONS Subclinical gas embolisms occur in 17.1% of laparoscopic radical prostatectomies. We should consider that this procedure has a potential for serious gas embolism, especially with the increasing popularity of laparoscopic prostatectomy using robot-assisted techniques.

Pulmonary edema after da Vinci-assisted laparoscopic radical prostatectomy: a case report.

A 63 year-old man developed sudden pulmonary edema after uneventful robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer despite normal preoperative laboratory findings and appropriate anesthetic management. The pulmonary edema was attributed to prolonged (4 hrs) pneumoperitoneum with concomitant high intraabdominal pressure (15-20 mmHg).

Incidence of venous gas embolism during robotic-assisted laparoscopic radical prostatectomy is lower than that during radical retropubic prostatectomy

BACKGROUND Robotic-assisted laparoscopic radical prostatectomy (RALRP) is gaining popularity as a less traumatic and minimally invasive alternative to open radical retropubic prostatectomy (RRP). The aim of this study was to evaluate the incidence and grade of venous gas embolism (VGE) during RALRP compared with those during RRP using transoesophageal echocardiography (TOE). METHODS Fifty-two patients undergoing RRP (n=26) or RALRP (n=26) were consecutively enrolled. TOE was continuously applied during surgery and VGE was graded by an independent researcher. RESULTS The total incidence of VGE (proportion, 95% CI) in the RRP group was higher than that in the RALRP group [20/25 (0.80, 0.60-0.92) and 10/26 (0.38, 0.22-0.58), respectively]. Most VGE in the RALRP group occurred during the transection of the deep dorsal venous complex. There was no difference in the incidence of severe VGE between the two groups. No patients with cardiorespiratory instabilities even with severe VGE were observed in this study. CONCLUSIONS In contrast to general belief, VGE occurred less frequently during RALRP. Although the VGE in this study did not cause any cardiorespiratory instability, close monitoring for possibly fatal VGE must be considered during both types of radical prostatectomy because those who undergo radical prostatectomy frequently have cardiopulmonary co-morbidities.

Prepuncture Ultrasound-Measured Distance: An Accurate Reflection of Epidural Depth in Infants and Small Children

Background and Objectives: Epidural cannulation is technically difficult in children who have small anatomic structures. Ultrasound information regarding the distance of skin-to-ligament flavum may be useful, leading to an increase in success rate without dural puncture. This study was performed to assess whether ultrasound-measured, skin-to-ligament flavum distance would reflect the needle depth during epidural puncture in infants and children. Methods: The study compromised 180 children, aged 2 to 84 months, undergoing urologic surgery. After induction of anesthesia, ultrasound images of the longitudinal median and transverse views were acquired from L4-L5 in lateral decubitus position. Measured distance of skin-to-ligament flavum in each view was compared with the perpendicular skin-to-epidural depth, which was obtained from needle depth and angle by use of a trigonometric ratio equation. Additionally, we evaluated the ultrasound visibility of the ligament flavum and dura mater, number of puncture attempts, and complications. Results: The correlation coefficient between measured distance and perpendicular epidural depth was slightly higher in longitudinal median view (R2 = 0.848) than in transverse view (R2 = 0.788). The visibility of ligament flavum and dura mater was “good” in 91 and 170 of 180 patients, respectively, and “sufficient” in the remaining subjects. The epidural space was located on first puncture attempt in 179 of 180 cases (99.4%). No incidents of dural puncture or bloody tap occurred. Conclusions: Ultrasound, particularly in the longitudinal median view, provides accurate information on the distance of skin-to-ligament flavum in infants and children. With reference to the measured distance, epidural puncture can be performed with minimal risk of dural puncture (upper limit of 95% CI = 1.67%).

Hepatic resection by the cavitron ultrasonic surgical Aspirator® increases the incidence and severity of venous air embolism

The Cavitron Ultrasonic Surgical Aspirator (CUSA®) is an innovative tool for resecting hepatic parenchyma, which reduces intraoperative blood loss and perioperative morbidity. We designed this study to compare the incidence and severity of venous air embolism (VAE) detected via transesophageal echocardiography (TEE) during hepatic resection by using either the clamp-crushing method or the CUSA® method. Fifty patients scheduled for hepatic resection were randomly assigned to receive hepatic resection by the clamp-crushing method (CC group) or by CUSA® (CUSA® group). After the induction of anesthesia, the TEE probe was inserted into the patient’s esophagus. An independent anesthesiologist graded VAE shown in the 4-chamber view of TEE. All patients in the CUSA® group showed VAE during hepatic resection and 44% of the patients had air embolism filling more than half the right heart diameter. In CC group, 68% of the patients showed VAE, which filled less than half the right heart diameter. There were no significant differences in hemodynamics and end-tidal CO2 partial pressure between the two groups. In conclusion, hepatic resection by CUSA® increases the incidence and severity of VAE.

A Comparison of High Volume/Low Concentration and Low Volume/High Concentration Ropivacaine in Caudal Analgesia for Pediatric Orchiopexy

BACKGROUND: It is unclear whether the volume or concentration of local anesthetic influences its spread and quality of caudal analgesia when the total drug dose is fixed. METHODS: We performed this study in a prospective, randomized, observer-blind manner. Children aged 1–5 yr received a constant dose of 2.25 mg/kg of ropivacaine prepared as either 1.0 mL/kg of 0.225% (low volume/high concentration [LVHC], n = 37) or 1.5 mL/kg of 0.15% solution (high volume/low concentration [HVLC], n = 36). Both solutions contained radiopaque dye. RESULTS: The median spread levels with ranges in the HVLC group (confirmed by fluoroscopic examination) were significantly higher (T6, T3-11) than in the LVHC group (T11, T8-L2). There were no significant differences in recovery times, postoperative pain scores, or side effects between the two groups. After discharge, fewer children in the HVLC group required rescue oral acetaminophen compared with the LVHC group (50.0% vs 75.7%). First oral acetaminophen time was found to be significantly longer with HVLC patients than LVHC patients (363.0 min vs 554.5 min). CONCLUSIONS: We confirmed (with fluoroscopy) that a caudal block with 1 mL/kg ropivacaine spreads to T11 and to T6 with 1.5 mL/kg. If the total dose is fixed, caudal analgesia with a larger volume of diluted ropivacaine (0.15%) provides better quality and longer duration after discharge than a smaller volume of more concentrated ropivacaine (0.225%) in children undergoing day-case orchiopexy. The spread level of ropivacaine correlated significantly with the first oral acetaminophen time after discharge.

Determination of the optimal angle for needle insertion during caudal block in children using ultrasound imaging

Using ultrasound imaging, the optimal angle for needle insertion during caudal epidural injection in children was estimated. After general anaesthesia, ultrasonography was performed at the sacral hiatus in 130 children aged 2–84 months positioned in the lateral position. The median [range] values for the intercornual, caudal space depth and the distance from skin to the posterior sacral bony surface were 17.0 [9.6–24] mm, 3.5 [1–8] mm and 21.0 [10–39] mm, respectively. The optimal angle showed no significant correlation with age, weight, height or body surface area. The median [range] calculated optimal angle for the needle was 21.0 [10–38]°. We conclude that the needle should be inserted at about 20° to the skin to avoid puncture of the bone and potential intra‐osseous injection.

Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia

BACKGROUND Psychological factors are thought to drive inter-patient variations in anaesthetic and analgesic requirements. This cross-sectional study investigated whether preoperative psychological factors can predict anaesthetic requirements and postoperative pain. METHODS Before total thyroidectomy, 100 consecutive women completed the Spielbergers State-Trait Anxiety Inventory (STAI) and the pain sensitivity questionnaire (PSQ). Target-controlled propofol was administered for induction of anaesthesia, and sevoflurane-oxygen-air was given to maintain equal depths of anaesthesia, as determined by bispectral index (BIS) monitoring. RESULTS Patients with higher anxiety scores (state and trait) required greater amounts of propofol to reach light (BIS=85) and moderate (BIS=75) levels of sedation, but only trait anxiety was significantly associated with propofol requirements in reaching a deep level of sedation (BIS=65). The MAC-hour of sevoflurane was significantly correlated only with PSQ scores. The postoperative pain intensity was significantly correlated with both STAI and PSQ. CONCLUSIONS Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia. Anaesthetic and analgesic doses could be modified based on the patients preoperative anxiety and pain sensitivity.

Effect of dexamethasone in combination with caudal analgesia on postoperative pain control in day-case paediatric orchiopexy

BACKGROUND Dexamethasone has a powerful anti-inflammatory action and has demonstrated reduced morbidity after surgery. The aim of this study was to examine the effects of a single i.v. dose of dexamethasone in combination with caudal block on postoperative analgesia in children. METHODS Seventy-seven children (aged 1-5 yr) undergoing day-case orchiopexy were included in this prospective, randomized, double-blinded study at a single university hospital. After inhalation induction of general anaesthesia, children received either dexamethasone 0.5 mg kg(-1) (maximum 10 mg) (n=39) or the same volume of saline (n=38) i.v. A caudal anaesthetic block was then performed using 1.5 ml kg(-1) of ropivacaine 0.15% in all patients. After surgery, rescue analgesic consumption, pain scores, and adverse effects were evaluated for 24 h. RESULTS Significantly, fewer patients in the dexamethasone group required fentanyl for rescue analgesia (7.9% vs 38.5%) in the post-anaesthetic care unit or acetaminophen (23.7% vs 64.1%) after discharge compared with the control group. The time to first administration of oral acetaminophen was significantly longer in the dexamethasone group (646 vs 430 min). Postoperative pain scores were lower in the dexamethasone group and the incidence of adverse effects was similar in both groups. CONCLUSIONS Intravenous dexamethasone 0.5 mg kg(-1) in combination with a caudal block augmented the intensity and duration of postoperative analgesia without adverse effects in children undergoing day-case paediatric orchiopexy. TRIAL REGISTRATION ClinicalTrials.gov. The number of registration: NCT01041378.

Topical glycopyrrolate for patients with facial hyperhidrosis.

Background  Facial hyperhidrosis may negatively impact the quality of life. Although various conservative modalities have been suggested, the condition is not often treated successfully.