Jung-Man Lee

Efficacy of butylscopolamine for the treatment of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study

BACKGROUND Catheter-related bladder discomfort (CRBD) secondary to intraoperative catheterization of urinary bladder is one of the most distressing symptoms during recovery from anaesthesia. Butylscopolamine, a peripheral antimuscarinic agent, is effective for relieving the pain, which is because of smooth muscle contraction. The aim of this study was to assess the efficacy and safety profiles of butylscopolamine in treating CRBD after urological surgeries. METHODS Adult male patients undergoing urological surgery requiring urinary bladder catheterization intraoperatively were enrolled. Induction and maintenance of anaesthesia were standardized. Patients were randomized into two groups after complaining of CRBD in the post-anaesthesia care unit. The control group (n=29) received normal saline and the butylscopolamine group (n=28) was administered butylscopolamine 20 mg i.v. The severity of CRBD, postoperative pain, and adverse effects were assessed at baseline, 20 min, 1, 2, and 6 h after administration of the study drug. RESULTS The severity of CRBD observed in the butylscopolamine group was significantly lower than that of the control group at 1, 2, and 6 h after administration of the study drug [59 (12), 50 (16), 40 (21) in the control group vs 41 (22), 32 (25), 23 (18) in the butylscopolamine group, P<0.01]. Rescue analgesics were required less in the butylscopolamine group than in the control group (P=0.001). Adverse events were comparable between the two groups. CONCLUSION Butylscopolamine 20 mg administered i.v. after complaining CRBD during recovery reduced both the severity of CRBD and the need for rescue analgesics without adverse effects in patients undergoing urologic surgeries.

The head-down tilt position decreases vasopressor requirement during hypotension following induction of anaesthesia in patients undergoing elective coronary artery bypass graft and valvular heart surgeries.

Background and objective Previous studies have failed to demonstrate that the head-down tilt position confers benefits in hypovolaemic hypotensive patients. The aim of this study was to evaluate the haemodynamic effect and vasopressor use by this position in hypotensive patients after the induction of general anaesthesia. Methods This prospective randomised study involved 98 patients scheduled for elective cardiac surgery and 40 patients (40.1%) developed hypotension after anaesthesia induction. Upon occurrence of hypotension, patients were randomly allocated to the supine (n = 19) or head-down tilt (n = 21) groups (15° head-down tilt position). Blood pressure, heart rate, cardiac index and stroke volume index were recorded at 1-min interval for 10 min from the occurrence of hypotension. Vasopressors were administered to treat hypotension in both groups. Results No haemodynamic difference was observed between the supine and head-down tilt groups except for SBP changes from baseline at 1 min (−3.98 ± 6.31 vs. 1.84 ± 8.25%, P = 0.004) and 2 min (1.51 ± 14.34 vs. 9.37 ± 10.57%, P = 0.032). The number of vasopressor administrations and percentage of the patients requiring vasopressors in the supine group were greater than that in the head-down tilt group [median 1 (range 1–5) vs. median 0 (range 0–2), P = 0.002, 19/19 (100%) vs. 10/21 (47.6%), P < 0.001]. Conclusion The head-down tilt position in hypotensive patients following anaesthesia induction reduced vasopressor requirement by almost one third. Minimal haemodynamic effect may be caused by different vasopressor administrations. This result suggests that the head-down tilt position may enable more stable anaesthesia induction in patients undergoing elective coronary artery bypass graft or valvular heart surgeries.

Intravenous palonosetron increases the incidence of QTc prolongation during sevoflurane general anesthesia for laparotomy

Background Palonosetron is a recently introduced 5-hydroxytryptamine-3 (5-HT3) receptor antagonist useful for postoperative nausea and vomiting prophylaxis. However, 5-HT3 receptor antagonists increase the corrected QT (QTc) interval in patients who undergo general anesthesia. This retrospective study was performed to evaluate whether palonosetron would induce a QTc prolongation in patients undergoing general anesthesia with sevoflurane. Methods We reviewed a database of 81 patients who underwent general anesthesia with sevoflurane. We divided the records into palonosetron (n = 41) and control (n = 40) groups according to the use of intraoperative palonosetron, and analyzed the electrocardiographic data before anesthesia and 30, 60, 90, and 120 min after skin incision. Changes in the QTc interval from baseline, mean blood pressure, heart rate, body temperature, and sevoflurane concentrations at each time point were compared between the two groups. Results The QTc intervals at skin incision, and 30, 60, 90, and 120 min after the skin incision during general anesthesia were significantly longer than those at baseline in the two groups (P < 0.001). The changes in the QTc intervals were not different between the two groups (P = 0.41). However, six patients in the palonosetron group showed a QTc interval > 500 ms 30 min after skin incision, whereas no patient did in the control group (P = 0.01). No significant differences were observed between the two groups in mean blood pressure, body temperature, heart rate, or sevoflurane concentrations. Conclusions Palonosetron may induce QTc prolongation during the early general anesthesia period with sevoflurane.

Anesthetic management of a patient with Mounier-Kuhn syndrome undergoing off-pump coronary artery bypass graft surgery -A case report-

Mounier-Kuhn-syndrome patients have markedly dilated trachea and main bronchi due to an atrophy or absence of elastic fibers and thinning of smooth muscle layers in the tracheobronchial tree. Although this syndrome is rare, airway management is challenging and general anesthesia may produce fatal results. However, only a few cases have been reported and this condition is not widely known among anesthesiologists. We present the case of a tracheobronchomegaly patient undergoing an emergency off-pump coronary artery bypass. Although the trachea was markedly dilated with numerous tracheal diverticuli, there was an undilated 2 cm portion below the vocal cords found on the preoperative CT. Under a preparation of extracorporeal membrane oxygenation, we intubated and placed the balloon of an endotracheal tube (I.D. 9 mm) at this portion, and maintained ventilation during the operation. This case showed that a precise preoperative evaluation and anesthetic plan is essential for successful anesthetic management.

Assisted head extension minimizes the frequency of dental contact with laryngoscopic blade during tracheal intubation.

OBJECTIVES We hypothesized that the assisted maintenance of head extension would reduce the frequency of direct contact between the laryngoscope blade and the maxillary incisors during tracheal intubation. METHODS Sixty-eight patients undergoing elective surgical procedures under general anesthesia were enrolled in this prospective, randomized, controlled crossover study. A single experienced anesthesiologist performed the simulated tracheal intubations with a classic Macintosh laryngoscope. After reaching the sniffing position during direct laryngoscopy, tracheal intubations with and without maintaining the head extension (by an assistant) were simulated twice in each patient in random order. The occurrence of dental contact with the laryngoscope blade was recorded during the simulated tracheal intubation. The distance between the laryngoscopic blade and maxillary central incisors was assessed using a digital caliper. The angle of head extension and the glottic view were also evaluated. RESULTS The frequency of dental contact was lower with the assisted head extension than without it (25/68 [37%] vs 67/68 [99%], P < .001). The blade-to-tooth distance was longer with assistance than without it (1.8 ± 1.9 [0-8] mm vs 0.0 ± 0.1 [0-1] mm, P < .001). The angle of head extension was greater with assistance than without it (26.6° ± 5.8° [6.0°-37.4°] vs 19.9° ± 5.4° [3.4°-31.8°], P < .001). No significant difference was observed between 2 simulated tracheal intubations with regard to the glottic views. CONCLUSION The assisted maintenance of head extension during the simulation of tracheal intubation reduced the frequency of dental contact with the laryngoscopic blade without compromising the laryngoscopic views. The results of this study suggest that assisted head extension during tracheal intubation may reduce the possibility of unexpected dental injury.

Preoperative Aspirin Resistance does not Increase Myocardial Injury during Off-pump Coronary Artery Bypass Surgery

We performed a prospective cohort trial on 220 patients undergoing elective off-pump coronary artery bypass surgery and taking aspirin to evaluate the effect of aspirin resistance on myocardial injury. The patients were divided into aspirin responders and aspirin non-responders by the value of the aspirin reaction units obtained preoperatively using the VerifyNow™ Aspirin Assay. The serum levels of troponin I were measured before surgery and 1, 6, 24, 48 and 72 hr after surgery. In-hospital major adverse cardiac and cerebrovascular events, graft occlusion, the postoperative blood loss and reexploration for bleeding were recorded. Of the 220 patients, 181 aspirin responders (82.3%) and 39 aspirin non-responders (17.7%) were defined. There were no significant differences in troponin I levels (ng/mL) between aspirin responders and aspirin non-responders: preoperative (0.04 ± 0.08 vs 0.03 ± 0.06; P = 0.56), postoperative 1 hr (0.72 ± 0.87 vs 0.86 ± 1.10; P = 0.54), 6 hr (2.92 ± 8.76 vs 1.50 ± 2.40; P = 0.94), 24 hr (4.16 ± 13.44 vs 1.25 ± 1.95; P = 0.52), 48 hr (2.15 ± 7.06 vs 0.65 ± 0.95; P = 0.64) and 72 hr (1.20 ± 4.63 vs 0.38 ± 0.56; P = 0.47). Moreover, no significant differences were observed with regard to in-hospital outcomes. In conclusion, preoperative aspirin resistance does not increase myocardial injury in patients undergoing off-pump coronary artery bypass surgery. Postoperative dual antiplatelet therapy might have protected aspirin resistant patients.

A comparison of direct laryngoscopic views in different head and neck positions in edentulous patients

OBJECTIVE Proper head and neck positioning is an important factor for successful direct laryngoscopy, and the optimum position in edentulous patients is unclear. We compared direct laryngoscopic views in simple head extension, sniffing, and elevated sniffing positions in edentulous patients. METHODS Eighteen adult edentulous patients scheduled for elective surgery were included in the study. After induction of anesthesia, the laryngeal view was assessed under direct laryngoscopy using the percentage of glottic opening (POGO) score in 3 different head and neck positions in a randomized order: simple head extension without a pillow, sniffing position with a pillow of 7 cm, and elevated sniffing position with a pillow of 10 cm. After assessment of the laryngeal views, tracheal intubation was performed. RESULTS A significant difference was observed in the laryngeal views assessed at the 3 head positions (P= .001). The POGO scores (mean [SD]) in the sniffing position (78.9% [19.7%]) and elevated sniffing position (72.6% [20.8%]) were significantly improved compared to that with simple head extension (53.8% [25.9%]) (P= .001, respectively). The sniffing position provided the best laryngeal view. The mean POGO scores were higher in the sniffing position than the elevated sniffing position, but no significant difference was observed between these 2 positions (P= .268). CONCLUSIONS The sniffing and elevated sniffing positions provide better laryngeal views during direct laryngoscopy compared to simple head extension in edentulous patients.

Left ventricular outflow tract obstruction with systolic anterior motion of the mitral valve in patient with pericardial effusion caused by ascending aortic dissection -A case report-.

Left ventricular outflow tract (LVOT) obstruction with systolic anterior motion (SAM) of mitral valve is not only limited to patients with hypertrophic cardiomyopathy. A diagnosis of LVOT obstruction with SAM is important because conventional inotropic support may potentially aggravate hemodynamic deterioration. We present a case of LVOT obstruction with SAM in a patient who underwent an emergent surgery for ascending aortic dissection with pericardial effusion. The patient showed refractory hypotension after standard pharmacologic interventions during induction of anesthesia. Transesophageal echocardiography (TEE) revealed LVOT obstruction with SAM and it was managed appropriately under the guidance of TEE. Intraoperative TEE can play an important role in diagnosis and management of LVOT obstruction with SAM caused by pericardial effusion.

Effect of the Macintosh curved blade size on direct laryngoscopic view in edentulous patients

Objective: In the present study, we compared the laryngoscopic view depending on the size of the Macintosh curved blade in edentulous patients. Methods: Thirty‐five edentulous adult patients scheduled for elective surgery were included in the study. After induction of anesthesia, two direct laryngoscopies were performed alternately using a standard‐sized Macintosh curved blade (No. 4 for men and No. 3 for women) and smaller‐sized Macintosh curved blade (No. 3 for men and No. 2 for women). During direct laryngoscopy with each blade, two digital photographs of the lateral view were taken when the blade tip was placed in the valleculae; the laryngoscope was lifted to achieve the best laryngeal view. Then, the best laryngeal views were assessed using the percentage of glottic opening (POGO) score. On the photographs of the lateral view of direct laryngoscopy, the angles between the line extending along the laryngoscopic handle and the horizontal line were measured. Results: The POGO score was improved with the smaller‐sized blade compared with the standard‐sized blade (87.3% [11.8%] vs. 71.3% [20.0%], P < 0.001, respectively). The angles between the laryngoscopic handle and the horizontal line were greater with the smaller‐sized blade compared to the standard‐sized blade when the blade tip was placed on the valleculae and when the laryngoscope was lifted to achieve the best laryngeal view (both P < 0.001). Conclusions: Compared to a standard‐sized Macintosh blade, a smaller‐sized Macintosh curved blade improved the laryngeal exposure in edentulous patients.

A Randomized Controlled Trial Comparing the Utility of Lighted Stylet and GlideScope for Double-Lumen Endobronchial Intubation

OBJECTIVE To compare GlideScope and lighted stylet for double-lumen endobronchial tube (DLT) intubation in terms of intubation time, success rate of first attempt at intubation, difficulty in DLT advancement toward the glottis, and postoperative sore throat and hoarseness. DESIGN A prospective, randomized study. SETTING Medical center governed by a university hostpial. PARTICIPANTS Sixty-two adult patients undergoing thoracic surgery using DLT intubation. INTERVENTION After the induction of anesthesia, DLT intubation was performed using GlideScope (n = 32) or lighted stylet (n = 32). MEASUREMENTS AND MAIN RESULTS Number of intubation attempts, difficulty of DLT advancement toward the glottis, time taken for DLT intubation, and the incidence and severity of postoperative sore throat and hoarseness at 1 and 24 hours after surgery were evaluated. Time taken for DLT intubation was shorter in the lighted stylet group compared with the GlideScope group (30 [28-32] s v 45 [38-53] s, median [interquartile range], respectively; p < 0.001). DLT advancement toward the glottis was easier in the lighted stylet group than in the GlideScope group (p = 0.016). The success rate of DLT intubation in the first attempt (96.9% v 90.6% for lighted stylet and GlideScope, respectively), and the incidence and severity of postoperative sore throat and hoarseness were not different between the two groups. CONCLUSIONS The use of lighted stylet allowed easier advancement of the DLT toward the glottis in the oropharyngeal space and reduced time for achieving DLT intubation compared with GlideScope.