Heezoo Kim

Multiple cardiac perforations and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty

Percutaneous vertebroplasty is a minimally invasive procedure in which polymethylmethacrylate polymer is used to treat painful diseased vertebral bodies. However, despite its minimally invasive nature and relative safety, cement leakage beyond involved vertebral bodies into the venous system can induce devastating cardiovascular complications. Here, the authors report a case of multiple cardiac perforations and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty.

Comparison of Surgical Pleth Index-guided Analgesia with Conventional Analgesia Practices in Children: A Randomized Controlled Trial.

Background:To compare surgical pleth index (SPI)-guided analgesia with conventional analgesia by evaluating intraoperative analgesic requirements, postoperative pain, and emergence agitation in children. Methods:This study was designed as a parallel, two-arm, double-blind, randomized controlled trial. Forty-five children undergoing elective adenotonsillectomy were randomly allocated to SPI-guided group (SPI-guided analgesia group, n = 21) or control group (conventional analgesia group, n = 24). Anesthesia was maintained with sevoflurane 2 to 3 vol% in 50% nitrous oxide and oxygen to achieve state entropy between 40 and 60. Intraoperative fentanyl 0.5 &mgr;g/kg was administered for the first event persisting 3 min and subsequent events persisting 5 min. An event was defined as an SPI over 50 (SPI-guided group) or a blood pressure or heart rate 20% above the baseline (control group). The primary outcome was intraoperative fentanyl requirement. Secondary outcomes included intraoperative sevoflurane consumption, postoperative emergence agitation and pain score, and postoperative rescue analgesic requirements. Results:Intraoperative fentanyl requirement was lower in SPI-guided group than in control group (0.43 ± 0.53 vs. 1.73 ± 0.59 &mgr;g/kg; P < 0.001). Intraoperative sevoflurane consumption was similar. The proportion of patients with high emergence agitation scores (4 to 5) was greater in SPI-guided group (61.9 vs. 25.0%; P = 0.01). The postoperative pain score and rescue fentanyl consumption were higher in SPI-guided group (7 [4.5; 9] vs. 3 [2; 6.75]; P = 0.002; 0.50 ± 0.34 vs. 0.29 ± 0.30 &mgr;g/kg; P = 0.04). Conclusions:As currently constructed, SPI does not appear to be valid in children. This may be due to both differences in blood vessel distensibility and baseline increased heart rates in children versus adults.

Antihistamine pretreatment to reduce incidence of withdrawal movement after rocuronium injection.

The purpose of this study was to determine the effectiveness of antihistamine therapy for withdrawal movements caused by rocuronium injection. One hundred seventy one ASA I-II adults undergoing elective surgery were randomly assigned to one of two groups. Patients in the control group (Group C) were premedicated with 2 mL normal saline, and those in the antihistamine group (Group A) were pre-medicated with 2 mL (45.5 mg) pheniramine maleate. After the administration of thiopental sodium 5 mg/kg, rocuronium 0.6 mg/kg was injected. Withdrawal movements were assessed using a four-grade scale. The administration of antihistamine reveals lower grade of withdrawal movement after rocuronium injection.

Comparison of the clinical effectiveness between the streamlined liner of pharyngeal airway (SLIPA) and the laryngeal mask airway by novice personnel

Background The aim of this study was to compare the streamlined liner of the pharynx airway (SLIPA) with the classic laryngeal mask airway when used by novice personnel. Methods There were 114 patients enrolled into this study who underwent general anesthesia were randomly allocated into one of 2 groups; LMA group (n = 57) or SLIPA group (n = 57). After insertion, insertion success rate, insertion time, and hemodynamic responses to insertion were accessed. After surgery, postoperative airway morbidity (sore throat, dysphonia, dysphagia) were evaluated. Results The SLIPA was successfully inserted in 96% of patients (55/57) and the LMA in 93% (53/57) (P = 0.408). First attempt success rates were 88% (44/57) and 77% (50/57) in the SLIPA and the LMA (P = 0.142). The successful insertion time in SLIPA group (33.4 ± 11.0 sec) was significantly shorter than that of LMA group (38.8 ± 16.6 sec) (P = 0.048) and the insertion time at the first attempt was also shorter in SLIPA group (31.0 ± 6.3 sec) than LMA group (34.7 ± 8.6 sec) (P = 0.013). There was no statistically significant difference between the two groups in hemodynamic responses and postoperative airway morbidity. Conclusions The SLIPA was similar to the LMA in insertion success rate, hemodynamic response, and postoperative airway morbidity by novice personnel. The insertion time at the first attempt and successful insertion time of the SLIPA were significantly shorter than those of the LMA. Therefore, the SLIPA could be a useful alternative to the LMA as primary SGA for novice personnel.

Thoracoscopic Bleb Resection Using Two-Lung Ventilation Anesthesia With Low Tidal Volume for Primary Spontaneous Pneumothorax

BACKGROUND We performed thoracoscopic surgery for pneumothorax using two-lung ventilation with low tidal volume and evaluated the feasibility and safety of this procedure. METHODS Forty-six patients (mean age, 23.6 +/- 10.47 years) each with a primary spontaneous pneumothorax underwent wedge resection with chemical and mechanical pleurodesis. Two-lung ventilation anesthesia was performed with a single-lumen endotracheal tube, and the tidal volume was reduced to 4 mL/kg; the respiratory rate was increased to 24 cycles/min. Airway pressure, end-tidal CO(2), and the results of blood gas analysis were obtained right after endotracheal intubation and during the operation, and were compared. RESULTS The tidal volume was 496.2 +/- 94.33 mL at anesthesia induction, which decreased to 243.9 +/- 34.43 mL during the two-lung ventilation. In 5 patients, the tidal volume was additionally decreased by 32.5 +/- 12.58 mL (p = 0.014) to obtain an optimal working field. The differences between the airway pressure, pH, partial pressure of carbon dioxide, and partial pressure of oxygen were significant between the two measurement times. However, all of the values of the arterial blood gas analysis were within normal range. The oxygen saturation (99.9% +/- 0.69% versus 99.8 +/- 0.72%; p = 0.160) and end-tidal CO(2) (33.2 +/- 3.74 mm Hg versus 34.1 +/- 4.19 mm Hg; p = 0.157) were not significantly different. The time from intubation before the incision was 17.1 +/- 4.18 minutes, the operation time was 31.9 +/- 14.48 minutes, and the total anesthesia time was 65.8 +/- 15.02 minutes. CONCLUSIONS Thoracoscopic surgery for primary spontaneous pneumothorax using two-lung ventilation with low tidal volume was technically feasible.

Sugammadex for reversal of rocuronium-induced neuromuscular blockade in pediatric patients: A systematic review and meta-analysis.

Background:Previous studies have shown that sugammadex, a modified &ggr;-cyclodextrin, is a well-tolerated agent for the reversal of neuromuscular blockade (NMB) induced by a steroidal neuromuscular blocking drug in adult patients. However, its use has not been reviewed in pediatric patients. The aim of this meta-analysis was to evaluate the efficacy and safety of sugammadex in the reversal of rocuronium-induced NMB during surgery under general anesthesia in pediatric patients. Methods:A literature search was performed using the Pubmed, EMBASE: Drugs and pharmacology, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. Analysis was conducted using RevMan 5.3. Data collected from different trials were pooled; the weighted mean difference or the pooled risk ratio and the corresponding 95% confidence interval (CI) were used for analysis, and heterogeneity (I2) assessment was performed. Results:Six randomized controlled trials comparing 253 pediatric patients (age range, 2–18 years) were included in the final analysis. The mean time taken to reach a train-of-four ratio of ≥0.9 was significantly shorter in the sugammadex groups (2 and 4 mg/kg) than in the control group (neostigmine or placebo), although the heterogeneity was high. The weighted mean differences of the 2 and 4 mg/kg sugammadex groups were −7.15 (95% CI: −10.77 to −3.54; I2 = 96%; P = 0.0001) and −17.32 (95% CI: −29.31 to −5.32; I2 = 98%; P = 0.005), respectively. The extubation time in the sugammadex group was shorter than that in the control group; the weighted mean difference of the sugammadex group was −6.00 (95% CI: −11.46 to −0.53; I2 = 99%; P = 0.03). There was no significant difference between the groups in terms of the incidence of postanesthetic adverse events; the pooled risk ratio was 0.67 (95% CI: 0.27–1.71; I2 = 59%; P = 0.41). Conclusion:We suggest that sugammadex is fast and effective in reversing rocuronium-induced NMB in pediatric patients. Although there was no evidence of a higher incidence of adverse events with sugammadex compared to that with neostigmine or placebo, much more data regarding the safety of sugammadex in pediatric patients may be still required.

The analgesic effect of nefopam combined with low dose remifentanil in patients undergoing middle ear surgery under desflurane anesthesia: a randomized controlled trial

Background We investigated the effects of the combined administration of nefopam, a N-methyl-D-aspartate receptor antagonist and low dose remifentanil, on early postoperative pain and analgesic requirement. Methods Fifty patients scheduled to undergo mastoidectomy and tympanoplasty were randomized to be given either nefopam 40 mg mixed with normal saline 100 ml (Group N) or an equal amount of normal saline (Group C) before anesthesia induction. Anesthesia was maintained with 5-6 vol% desflurane and remifentanil 0.05-0.15 µg/kg/min during the surgery. Postoperative pain was controlled by titration of ketorolac in the postanesthesia care unit (PACU) and ward. We evaluated the intraoperative remifentanil dose, recovery profiles, ketorolac demand in the PACU and ward, numeric rating scale (NRS) for pain at time intervals of every 10 min for 1 h in the PACU, 6, 12, 18 and 24 h in a ward, as well as the time to first analgesic requirement in the PACU and ward. Results Ketorolac demand and NRS in the PACU were significantly lower in Group N than Group C (P = 0.002, P = 0.005, respectively). The time to first analgesic requirement in the PACU in Group N were significantly longer than Group C (P = 0.046). There were no significant differences in intraoperative remifentanil dose, ketorolac demand, NRS, and the time to first analgesic requirement in the ward between the groups. Conclusions Nefopam administration combined with low dose remifentanil infusion reduces pain and analgesic consumption during the immediate postoperative period in patients undergoing middle ear surgery under desflurane anesthesia.

Comparison of the incidence of emergence agitation and emergence times between desflurane and sevoflurane anesthesia in children: A systematic review and meta-analysis

Background:The differences in the incidence and severity of emergence agitation (EA) and emergence times between desflurane and sevoflurane anesthesia have not been as clearly elucidated in children as in adults. Methods:The design of the study is a systematic review with meta-analysis of randomized controlled trials. The study methodology is based on the Cochrane Review Methods. A comprehensive literature search was conducted to identify clinical trials comparing the incidence or severity of EA and emergence times in children anesthetized with desflurane or sevoflurane. Two reviewers independently assessed each study according to predefined inclusion criteria and extracted data from each study using a prespecified data extraction form. The data from each study were combined using a fixed effect or random effect model to calculate the pooled risk ratio (RR) or standardized mean difference (SMD) and 95% confidence interval (CI). Funnel plots were used to assess publication bias. Subgroup and sensitivity analyses were performed. Results:Fourteen studies met the inclusion criteria. Among the 1196 patients in these 14 studies, 588 received desflurane anesthesia and 608 received sevoflurane anesthesia. The incidence of EA was comparable between the 2 groups (pooled RR = 1.21; 95% CI: 0.96–1.53; I2 = 26%), and so was the severity of EA (EA score) between the 2 groups (SMD = 0.12; 95% CI: −0.02 to 0.27; I2 = 0%). Extubation and awakening times were shorter in the desflurane group than in the sevoflurane group; the weighted mean differences were −2.21 (95% CI: −3.62 to −0.81; I2 = 93%) and −2.74 (95% CI: −3.80 to −1.69; I2 = 85%), respectively. No publication bias was found in the funnel plot. The subgroup analysis based on the type of EA scale showed a higher incidence of EA in the desflurane group than in the sevoflurane group in studies using 3-, 4-, or 5-point EA scales; the pooled RR was 1.38 (95% CI: 1.10–1.73; I2 = 37%). Conclusion:The incidence and severity of EA were comparable between desflurane and sevoflurane anesthesia in children; however, emergence times, including extubation and awakening times, were shorter in desflurane anesthesia.

A simple and secure technique for tracheal T-tube insertion

We describe a simple and secure technique for the insertion of a long Montgomery type T-tube in patients with tracheal stenosis. An endotracheal tube is placed into the lumen of the T-tube and by maintaining the airway during insertion, the technique has been found to be safe and it can prevent the kind of tracheal damage occurring with blind techniques.

Comparison of relative oxycodone consumption in surgical pleth index-guided analgesia versus conventional analgesia during sevoflurane anesthesia: A randomized controlled trial.

Background:The surgical pleth index (SPI) is proposed for titration of analgesic drugs during general anesthesia. Several reports have investigated the effect of SPI on the consumption of opioids including remifentanil, fentanyl, and sufentanil during anesthesia, but there are no reports about oxycodone. We aimed to investigate intravenous oxycodone consumption between SPI-guided analgesia and conventional analgesia practices during sevoflurane anesthesia in patients undergoing thyroidectomy. Methods:Forty-five patients undergoing elective thyroidectomy were randomly assigned to an SPI group (SPI-guided analgesia group, n = 23) or a control group (conventional analgesia group, n = 22). Anesthesia was maintained with sevoflurane to achieve bispectral index values between 40 and 60. In the SPI group, oxycodone 1 mg was administered intravenously at SPI values over 50; in the control group, oxycodone 1 mg was administered intravenously at the occurrence of tachycardia or hypertension event. Intraoperative oxycodone consumption and extubation time were recorded. The number of hemodynamic and somatic movement events was recorded, as were postoperative pain and recovery scores. Results:Patients’ characteristics were comparable between the groups. Intraoperative oxycodone consumption in the SPI group was significantly lower than the control group (3.5 ± 2.4 vs 5.1 ± 2.4 mg; P = 0.012). Extubation time was significantly shorter in the SPI group (10.6 ± 3.5 vs 13.4 ± 4.6 min; P = 0.026). Hemodynamic and somatic movement events during anesthesia were comparable between the groups, as were numeric rating scales for pain and modified Aldrete scores at postanesthesia care unit. Conclusions:SPI-guided analgesia reduces intravenous oxycodone consumption and extubation time compared with conventional analgesia based on clinical parameters during sevoflurane anesthesia in patients undergoing thyroidectomy.