Hong-Seuk Yang

The supraglottic airway I-gel in comparison with ProSeal laryngeal mask airway and classic laryngeal mask airway in anaesthetized patients.

Background and objective The I-gel is a new single-use supraglottic airway device without an inflatable cuff. This study was designed to investigate the usefulness of the I-gel compared with the classic laryngeal mask airway (cLMA) and ProSeal laryngeal mask airway (pLMA) in anaesthetized, paralysed patients. Methods The American Society of Anesthesiologists physical status I–II patients (n = 167) scheduled for orthopaedic surgery were included in this prospective study. General anaesthesia was achieved with intravenous infusion of propofol, remifentanil and rocuronium. The patients were randomly assigned to I-gel, pLMA and cLMA groups (64, 53 and 50 patients, respectively). Properly sized I-gel (No. 3-4) or LMA (No. 4-5) was inserted. We assessed haemodynamic data, airway leak pressure, leak volume, success rates and postoperative complications. Results There were no differences in the demographic data and haemodynamic data immediately after insertion of devices among the three groups. The airway leak pressures of the I-gel group (27.1 ± 6.4 cmH2O) and pLMA group (29.8 ± 5.7 cmH2O) were significantly higher than that of the cLMA group (24.7 ± 6.2 cmH2O). The success rates for first attempt of insertion were similar among the three groups (P = 0.670). There were no differences in the incidence of adverse events except for the larger incidence of sore throat in the cLMA group. Conclusion I-gel may have a similar airway sealing to that of pLMA, higher than that of cLMA, and is not associated with adverse events. The I-gel might be an effective alternative as a supraglottic airway device.

Warming of Intravenous Fluids Prevents Hypothermia During Off-Pump Coronary Artery Bypass Graft Surgery

OBJECTIVE Even mild perioperative hypothermia (34 degrees -36 degrees C) can cause numerous adverse outcomes, including morbid cardiac events, coagulopathy with increased blood loss, and a decreased resistance to surgical wound infection. The purpose of this study was to evaluate the effect of fluid warming on preventing hypothermia during off-pump coronary artery bypass (OPCAB) surgery. DESIGN A prospective randomized clinical study. SETTING A tertiary care university hospital. PARTICIPANTS Forty patients undergoing OPCAB procedures. INTERVENTIONS Patients were randomized into control (n = 20) and Hotline (n = 20) groups. In the Hotline group, all intravenous fluids were warmed to 41 degrees C by using 2 Hotline (SIMS Inc, Rockland, MD) systems. All patients (control and Hotline groups) were managed with standardized institutional practice by using a combination of increased ambient operating room temperature (to 25 degrees C) and the use of a warmed water mattress (38 degrees C). MEASUREMENTS AND MAIN RESULTS Temperatures were recorded every hour after the induction of anesthesia at the pulmonary artery, nasopharynx, rectum, and bladder. In the Hotline group, temperatures were maintained or increased. In the control group, temperatures gradually decreased. There were no significant differences between the 2 groups in hemodynamic parameters, serum catecholamine concentrations, duration of intensive care unit stay, or duration of ward stay. CONCLUSIONS The results show that the warming of intravenous fluids by using the Hotline system prevents decreases in systemic temperatures during OPCAB surgery.

Non-neurologic complications following surgery for scoliosis

Background The purpose of this study was to determine the prevalence of non-neurologic complications following surgery for scoliosis and to identify factors that can increase this risk. Methods The demographic data, medical and surgical histories, and prevalence of non-neurologic complications were reviewed in a retrospective cohort of 602 patients, who had undergone corrective surgery for scoliosis between January 2001 and June 2011. Results There were 450 patients under 20 years old (U20) and 152 of patients above 20 years old (A20) enrolled in this study. Forty-nine patients in U20 (10.9%) and 18 patients in A20 (11.8%) had post-operative complications. Respiratory complications were most common in U20 (4%) and gastrointestinal complications were most common in A20 (7%). There was no significant difference between the 2 groups in the prevalence of complications. Logistic regression revealed that factors that correlated with an increased odds for complications were Cobb angle (P = 0.001/P = 0.013, respectively), length of operation time (P = 0.003/P = 0.006, respectively), duration of anesthesia (P < 0.001/P = 0.005, respectively) and transfusion (P = 0.003/P = 0.015, respectively) in U20 and A20. Also, comorbidities (P = 0.021) in U20, and decreased body mass index (P = 0.030), pre-operative forced vital capacity (P = 0.001), forced expired volume in 1s (P = 0.001), increased numbers of vertebrae fused (P = 0.004), blood loss (P = 0.001) in A20 were associated with increased odds for complications. Conclusions There was no difference in the prevalence of complication in scoliosis patients by age. The prevalence of complication was dependent on Cobb angle, length of operation time, duration of anesthesia and transfusion of PRBC. Deterioration of preoperative pulmonary function significantly increased risk of post-operative complications in adult patients.

Early postoperative albumin level following total knee arthroplasty is associated with acute kidney injury: A retrospective analysis of 1309 consecutive patients based on kidney disease improving global outcomes criteria.

Abstract Hypoalbuminemia has been reported to be an independent risk factor for acute kidney injury (AKI). However, little is known about the relationship between the albumin level and the incidence of AKI in patients undergoing total knee arthroplasty (TKA). The aim of our study was to assess incidence and risk factors for AKI and to evaluate the relationship between albumin level and AKI following TKA. The study included a retrospective review of medical records of 1309 consecutive patients who underwent TKA between January 2008 and December 2014. The patients were divided into 2 groups according to the lowest serum albumin level within 2 postoperative days (POD2_alb level < 3.0 g/dL vs ≥3.0 g/dL). Multivariate logistic regression analysis was used to assess risk factors for AKI. A comparison of incidence of AKI, hospital stay, and overall mortality in the 2 groups was performed using propensity score analysis. Of 1309 patients, 57 (4.4%) developed AKI based on Kidney Disease Improving Global Outcomes criteria. Factors associated with AKI included age (odds ratio [OR] 1.05; 95% confidence interval [CI] 1.01–1.09; P = 0.030), diabetes (OR 3.12; 95% CI 1.65–5.89; P < 0.001), uric acid (OR 1.51; 95% CI 1.26–1.82; P < 0.001), beta blocker use (OR 2.65; 95% CI 1.48–4.73; P = 0.001), diuretics (OR 16.42; 95% CI 3.08–87.68; P = 0.001), and POD2_alb level < 3.0 g/dL (OR 1.92; 95% CI 1.09–3.37; P = 0.023). After propensity score analysis, POD2_alb level<3.0 g/dL was associated with AKI occurrence (OR 1.82; 95% CI 1.03–3.24, P = 0.041) and longer hospital stay (P = 0.001). In this study, we demonstrated that POD2_alb level<3.0 g/dL was an independent risk factor for AKI and lengthened hospital stay in patients undergoing TKA.

A randomised controlled trial comparing continuous supraclavicular and interscalene brachial plexus blockade for open rotator cuff surgery

Continuous interscalene block is an approved modality for postoperative pain control, but it may cause hemidiaphragmatic paresis. In this study we aimed to determine whether continuous supraclavicular block would provide postoperative analgesia comparable to that of continuous interscalene block and reduce the incidence of hemidiaphragmatic paresis. Patients scheduled for open rotator cuff repair were randomly allocated to receive continuous interscalene (n = 38) or supraclavicular block (n = 37). Both participants and assessing clinicians were blinded to the group allocation. The primary endpoint was the mean pain intensity 24 h after the surgery. Postoperative mean (SD) pain scores at 24 h were similar in the supraclavicular and interscalene groups (2.57 (1.71) vs 2.84 (1.75) respectively; p = 0.478). The incidence of complete or partial hemidiaphragmatic paresis was lower in the supraclavicular group at 1 h after admission to the postanaesthetic care unit and 24 h after the surgery [25 (68%) vs 38 (100%); p = 0.001 and 14 (38%) vs 27 (71%) respectively; p = 0.008]. Continuous supraclavicular block provided comparable analgesia compared with interscalene block with a reduced incidence of complete or partial hemidiaphragmatic paresis for 24 h following surgery.

Use of hyaluronidase as an adjuvant to ropivacaine to reduce axillary brachial plexus block onset time: a prospective, randomised controlled study

When considering brachial plexus block as a practical alternative to general anaesthesia for upper limb surgery, the time to achieve complete sensory block is a clinically important variable. In this prospective randomised double‐blind controlled trial, we investigated the hypothesis that addition of hyaluronidase to ropivacaine may reduce the time to achieve complete sensory block after axillary brachial plexus block. The patients were randomly assigned into a hyaluronidase group (n = 24) and a control group (n = 24). The hyaluronidase group received ropivacaine 0.5% with 100 IU.ml−1 of hyaluronidase, and the control group received ropivacaine alone. The primary endpoint was the time to achieve complete sensory block. The hyaluronidase group demonstrated significantly shorter mean (SD) sensory block onset time (13.8 (6.0) min) compared with the control group (22.5 (6.3) min, p < 0.0001). Addition of hyaluronidase to ropivacaine resulted in a reduction in the time needed to achieve complete sensory block.

A comparison of supraglottic airway i-gel™ vs. classic laryngeal mask airway in small children.

Background i-gel™ is a new single-use supraglottic airway device without an inflatable cuff. This study was designed to compare the usefulness of i-gel™ versus a classic laryngeal mask airway (cLMA) in small children. Methods Sixty-three children (age range : 4-72 months) were randomly assigned to an i-gel™ or cLMA group. We evaluated hemodynamic data, airway sealing ability, the success rate of insertion, and adverse events including an inadvertent sliding out during ventilation. Results Demographic data and hemodynamic data obtained immediately after the insertion of these devices did not differ between the two groups. The success rates for insertion on the first attempt were 77 and 84% for i-gel™ and cLMA, respectively (P = 0.54), and the overall success rates were 87 and 100% respectively (P = 0.14). There were no significant differences in terms of airway leak pressure. The inserted i-gel™ inadvertently slid out in 8 of 31 patients but only one sliding out case occurred in the cLMA group (P = 0.02). There were no differences between the groups in terms of other side effects (e.g., coughing, bleeding) associated with the use of i-gel™ and cLMA (P = 0.75 and 0.49, respectively). Conclusions Oropharyngeal leak pressure and insertion success rate of i-gel™ are similar to those of cLMA. However, i-gel™ is prone to inadvertent sliding out of the mouth in small children. Therefore, it is recommended that the i-gel™ should be secured more tightly to avoid displacement of the device.

Anesthetic care for electroconvulsive therapy during pregnancy -A case report-

Electroconvulsive therapy (ECT) is recommended for patients with psychotic disorders that do not respond to medication. Usually, many psychotropic medications have teratogenic effects on the fetus. ECT seems to be a relatively safe and effective treatment during pregnancy. We report here on a 33-year-old primigravida patient in her third trimester receiving ECT.

Effects of sugammadex on the coronary circulation: direct effects on coronary vessels or hypersensitivity (Kounis syndrome)?

The authors evaluated a case of cardiac arrest after sugammadex administration in a 76-year-old man with no notable medical history who was scheduled for robot-assisted radical prostatectomy. The cardiac arrest was followed by bigeminy-type ventricular premature contraction immediately after the sugammadex administration. Cardiac resuscitation was done successfully, and the patient was discharged uneventfully on postoperative day 8. The patient had taken several tests for the evaluation of possible coronary circulation abnormality with an impression of direct effects of sugammadex on the coronary circulation. However, the authors did not further evaluate the patient for hypersensitivity or anaphylaxis other than skin tests, which were done 4 weeks after the event. In my opinion, I think that this case may be a sugammadex hypersensitivity event, similar to Kounis syndrome, rather than acute coronary syndrome, as the authors had described [2]. According to their report, the reasons for the diagnosis were as follows; first, fatal arrhythmia occurred immediately after sugammadex injection within 5 min; second, the typical skin lesion of hypersensitivity was not observed.; third, the patient had a history of variant angina with infrequent chest pain.; fourth, a positive finding of coronary circulation was obtained after recovery.; and, fifth, sugammadex is not known to have any direct cardiac effects that may induce any significant hemodynamic instability or prolong the QT interval [3]. Sugammadex is now widely used in clinical practice for the selective reversal of aminosteroidal non-depolarizing neuromuscular blockers, such as rocuronium. However, sugammadex is reported to have several complications, including a hypersensitivity reaction [4]. Although several years had passed since its approval in Europe and Korea, Sugammadex was approved only in 2016 by the U.S. Food and Drug Administration owing to concerns about hypersensitivity. Tsur and Kalansky [4] described that awareness must be raised about the possibility of drug-induced hypersensitivity during the critical 5-min period immediately after the administration of sugammadex, and it was explicitly reported that most patients who developed hypersensitivity after sugammadex injection had no previous exposure to sugammadex. I understand that many kinds and grades of drug-induced hypersensitivity reaction may possibly occur during anesthetic care, and indeed sugammadex can be one of them. Kounis syndrome is defined as the concurrence of acute coronary syndromes with conditions associated with mast cell and platelet activation, which involves inflammatory cells in the setting of allergic reactions or hypersensitivity, and anaphylactic or anaphylactoid insults. It is known to affect persons of any age or medical condition. Moreover, although hypersensitivity reactions are normally combined with specific skin lesions, Kounis hypersensitivity-associated coronary syndrome is not accompanied by skin lesions such as skin rash, redness, erythematous wheal, or urticaria [4,5]. A definite diagnosis of Kounis syndrome, like in this case, needs to be established. Considering the patient’s history, the impression of this case seems to correspond to hypersensitivity coronary syndrome or Kounis syndrome, not a direct effect on coronary circulation [5]. The preceding hypersensitivities may have affected the myocardium and coronary arteries, respectively; the first is type II, which is an inflammatory disease affecting the myocardium and the cardiac conduction system manifesting as a complication of drug therapy, and the second is type III, which is the concurrence of acute coronary syndromes associated with mast cell activation that may involve interrelated and interacting inflammatory cells. In this patient, immediate allergic screening with measurement of mast cell mediators such as histamine, tryptase, chymase, and arachidonic acid metabolites might have given further information that could have helped rule out contemporary coronary mast cell activation.

Effects of Presynaptic Muscarinic Receptor Blockade on Neuromuscular Transmission as Assessed by the Train-of-Four and the Tetanic Fade Response to Rocuronium

This study investigated the effect of muscarinic M1 and M2 receptor antagonists on the rocuronium‐induced train of four (TOF) fade and tetanic fade, respectively. Ex‐vivo phrenic nerves and diaphragms were obtained from adult Sprague‐Dawley rats and stabilized in Krebs buffer; the nerve‐stimulated muscle TOF fade was observed at 20 s intervals. For the TOF study, phrenic nerves and diaphragms were incubated with pirenzepine (an M1 blocker) at concentrations of 0 nmol L−1 (control), 10 nmol L−1 (PZP10), or 100 nmol L−1 (PZP100). Rocuronium was then administered incrementally until the first twitch tension had depressed by >95% during TOF stimulation. The mean TOF ratios were compared when the first twitch tensions were depressed by 40%‐50%. For the tetanic fade study, 50 Hz/5 s tetani was applied initially, 30 min after the administration of a loading dose of rocuronium and methoctramine (an M2 receptor blocker, loaded at 0 μmol L−1 [control], 1 μmol L−1 [MET1], or 10 μmol L−1 [MET10]). The EC95 of rocuronium was significantly lower in the PZP10 group than in the control group. In the PZP10 group, the TOF ratios at 50% and first twitch tension depression were significantly lower than those in the control group (P=.02). During tetanic stimulation, the tetanic fade was significantly enhanced in the MET10 group compared to the other groups. This study shows that antagonists of muscarinic M1 and M2 receptors affect the rocuronium‐induced neuromuscular block as demonstrated by the reduced EC95 and TOF ratios (M1 antagonist, pirenzepine) or the enhanced 50‐Hz tetanic fade (M2 antagonist, methoctramine).