Kook Hyun Lee

The laryngeal mask airway in infants and children

Purpose: To compare the effectiveness of various laryngeal mask airway (LMA) sizes and their performance during positive pressure ventilation (PPV) in paralyzed pediatric patients.Methods: Pediatric patients (n=158),<30 kg, ASA 1 or 2 were studied. After paralysis, an LMA of the recommended size was inserted and connected to a volume ventilator. Fibreoptic bronchoscopy (FOB) was performed and graded: 1, larynx only seen; 2, larynx and epiglottis posterior surface seen; 3, larynx, and epiglottis tip or anterior surface seen—visual obstruction of epiglottis to larynx: <50%; 4, epiglottis down-folded, and its anterior surface seen—visual obstruction of epiglottis to larynx: >50%; 5, epiglottis down-folded and larynx not seen directly. Inspiratory and expiratory tidal volumes (VT), and airway pressure were measured by a pneumo-tachometer, and the fraction of leakage (FL) was calculated. In 79 cases, LMA was used for airway maintenance throughout surgery.Results: Successful LMA placement was achieved in 98% of cases: three failures were due to gastric insufflation. For LMA # 1, 1.5, 2, and 2.5, FOB grades [median (range)] were 3(1–5), 3(1–5), 1(1–5) and 1(1–3) respectively. In smaller LMAs, the cuff more frequently enclosed the epiglottis (P<.001). FL of LMA #1 was higher than those of LMA # 1.5 and LMA # 2.5 (P<.05), and FL of LMA # 2 was higher than that of LMA # 2.5 (P<.05). In the 79 patients, the number of patients experiencing complications decreased as LMA size increased (P<.05).Conclusion: Use of the LMA in smaller children results in more airway obstruction, higher ventilatory pressures, larger inspiratory leak, and more complications than in older children.RésuméObjectif: Comparer l’efficacité de masques laryngés (ML) de tailles différentes et leur performance pendant la ventilation à pression positive (VPP) chez des enfants curarisés.Méthode: On a étudié 158 patients pédiatriques, de moins de 30 kg et d’état physique ASA I ou II. Après la curarisation, un ML de taille appropriée a été inséré et raccordé à un ventilateur volumique. La fibroscopie bronchique (FB) réalisée a été graduée: 1, vision du larynx seulement; 2. vision du larynx et de de la surface postérieure de l’épiglotte; 3, vision du larynx, de la pointe et de la surface antérieure de l’épiglotte—vision du larynx obstruée par l’épiglotte: <50%; 4, épiglotte repliée vers le bas et vision de sa surface antérieure—vision du larynx obstruée par l’épiglotte: >50%; 5, épiglotte repliée vers le bas et vision indirecte du larynx. On a mesuré les volumes courants inspiratoire et expiratoire (VT) et la pression des voies aériennes avec un pneumotachomètre et on a calculé le pourcentage de fuite (PF). Dans 79 cas, le ML a été utilisé pour maintenir la perméabilité des voies aériennes tout au long de l’intervention.Résultats: La mise en place réussie du ML a été réalisée dans 98% des cas: trois échecs étaient liés à une insufflation gastrique. Les grades [médiane (intervalle)] de FB ont été, pour les ML 1, 1,5, 2 et 2,5 de 3(1–5), 3(1–5), 1(1–5) et 1(1–3) respectivement. Dans le cas des ML plus petits, le ballonnet couvrait fréquemment l’épiglotte (P<0,001). Le PF du ML 1 a été plus élevé que ceux des ML 1,5 et 2,5 (P<0,05); le PF du ML 2 a été plus élevé que celui du ML 2,5 (P<0,05). Parmi les 79 patients, plus la taille du ML était grande, moins nombreux étaient ceux qui présentaient des complications (P<0,05).Conclusion: L’utilisation du ML chez les jeunes enfants entraine davantage d’obstruction des voies aériennes, des pressions ventilatoires plus élevées, une fuite inspiratoire plus grande et plus de complications que chez les enfants plus agés.

Association of body temperature and antipyretic treatments with mortality of critically ill patients with and without sepsis: multi-centered prospective observational study

IntroductionFever is frequently observed in critically ill patients. An independent association of fever with increased mortality has been observed in non-neurological critically ill patients with mixed febrile etiology. The association of fever and antipyretics with mortality, however, may be different between infective and non-infective illness.MethodsWe designed a prospective observational study to investigate the independent association of fever and the use of antipyretic treatments with mortality in critically ill patients with and without sepsis. We included 1,425 consecutive adult critically ill patients (without neurological injury) requiring > 48 hours intensive care admitted in 25 ICUs. We recorded four-hourly body temperature and all antipyretic treatments until ICU discharge or 28 days after ICU admission, whichever occurred first. For septic and non-septic patients, we separately assessed the association of maximum body temperature during ICU stay (MAXICU) and the use of antipyretic treatments with 28-day mortality.ResultsWe recorded body temperature 63,441 times. Antipyretic treatment was given 4,863 times to 737 patients (51.7%). We found that treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen independently increased 28-day mortality for septic patients (adjusted odds ratio: NSAIDs: 2.61, P = 0.028, acetaminophen: 2.05, P = 0.01), but not for non-septic patients (adjusted odds ratio: NSAIDs: 0.22, P = 0.15, acetaminophen: 0.58, P = 0.63). Application of physical cooling did not associate with mortality in either group. Relative to the reference range (MAXICU 36.5°C to 37.4°C), MAXICU ≥ 39.5°C increased risk of 28-day mortality in septic patients (adjusted odds ratio 8.14, P = 0.01), but not in non-septic patients (adjusted odds ratio 0.47, P = 0.11).ConclusionsIn non-septic patients, high fever (≥ 39.5°C) independently associated with mortality, without association of administration of NSAIDs or acetaminophen with mortality. In contrast, in septic patients, administration of NSAIDs or acetaminophen independently associated with 28-day mortality, without association of fever with mortality. These findings suggest that fever and antipyretics may have different biological or clinical or both implications for patients with and without sepsis.Trial registrationClinicalTrials.gov: NCT00940654

Torsade de pointes in liver transplantation recipient after induction of general anesthesia: a case report

Torsade de pointes (TdP) is an uncommon and specific form of polymorphic ventricular tachycardia, associated with a prolonged QT interval. Prolongation of the QT interval is the most widely recognized electrophysiological abnormality in patients with liver cirrhosis. We observed a case of TdP leading to cardiopulmonary resuscitation after the induction of general anesthesia, in a patient with liver cirrhosis scheduled for emergency cadaveric donor liver transplantation. The patient had mild QT prolongation on preoperative electrocardiography with a corrected QT (QTc) interval of 455 ms. Drugs used in the preoperative period can elongate cardiac repolarization. Sevoflurane and 5-hydroxytryptamine type 3 receptor antagonists such as palonsetron, used during general anesthesia may have triggered further QT prolongation, producing a fatal condition such as TdP. More caution and consideration in selecting drugs for anesthetic management are necessary for liver cirrhosis patients, especially in patients with preoperative QT prolongation.

Analysis of expert consultation referrals for anesthesia- related issues (December 2008-July 2010): KSA legislation committee report

Background Since 2009, database construction of anesthesia-related adverse events has been initiated through the legislation committee of the Korean Society of Anesthesiologists (KSA), based on expert consultation referrals provided by police departments, civil courts, and criminal courts. Methods This study was a retrospective descriptive analysis of expert consultation referrals on surgical anesthesia-related cases between December 2008 and July 2010. Results During the given period, 46 surgical anesthesia-related cases were referred to the KSA legislation committee for expert consultation. Because six cases were excluded due to insufficient data, 40 cases were included in the final analysis. Of 40 cases, 29 (72.5%) resulted in death. Respiratory events were most common in both surviving/disabled and dead patients (36.4 vs. 51.7%, respectively; P > 0.05). Overall, respiratory depression due to the drugs used for monitored anesthesia care (MAC) was the most common specific mechanism (25%), in which all but one case (profound brain damage) resulted in death. In all of these cases, surgeons or physicians provided MAC without the help of anesthesiologists. Conclusions Overall, the most common damaging mechanism was related to respiratory depression due to sedatives or anesthetics used for MAC. Almost all MAC injury cases are believed to be preventable with the use of additional or better monitoring and an effective response to initial physiological derangement. Thus, it is essential to establish practical MAC guidelines and adhere to these guidelines strictly to reduce the occurrence of severe anesthesia-related adverse outcomes.

External Validation of the Acute Physiology and Chronic Health Evaluation II in Korean Intensive Care Units

Purpose This study was designed to validate the usefulness of the Acute Physiology and Chronic Health Evaluation (APACHE) II for predicting hospital mortality of critically ill Korean patients. Materials and Methods We analyzed data on 826 patients who had been admitted to nine intensive care units and were included in the Fever and Antipyretics in Critical Illness Evaluation study cohort. Results Among the patients enrolled, 62% (512/826) were medical and 38% (314/826) were surgical patients. The median APACHE II score was 17 (11 to 23 interquartile range), and the hospital mortality rate was 19.5%. Age, underlying diseases, medical patients, mechanical ventilation, and renal replacement therapy were independently associated with hospital mortality. The calibration of APACHE II was poor (H=57.54, p<0.0001; C=55.99, p<0.0001), and the discrimination was modest [area under the receiver operating characteristic (aROC)=0.729]. Calibration was poor for both medical and surgical patients (H=63.56, p<0.0001; C=73.83, p<0.0001, and H=33.92, p<0.0001; C=33.34, p=0.0001, respectively), while discrimination was poor for medical patients (aROC=0.651) and modest for surgical patients (aROC=0.704). At the predicted risk of 50%, APACHE II had a sensitivity of 36.6% and a specificity of 87.4% for hospital mortality. Conclusion For Koreans, the APACHE II exhibits poor calibration and modest discrimination for hospital mortality. Therefore, a new model is needed to accurately predict mortality in critically ill Korean patients.

Lower intra-abdominal pressure has no cardiopulmonary benefits during laparoscopic colorectal surgery: a double-blind, randomized controlled trial

BackgroundHigher intra-abdominal pressure may impair cardiopulmonary functions during laparoscopic surgery. While 12–15xa0mmHg is generally recommended as a standard pressure, the benefits of lower intra-abdominal pressure are unclear. We thus studied whether the low intra-abdominal pressure compared with the standard pressure improves cardiopulmonary dynamics during laparoscopic surgery.MethodsPatients were randomized according to the intra-abdominal pressure and neuromuscular blocking levels during laparoscopic colorectal surgery: low pressure (8xa0mmHg) with deep-block (post-tetanic count 1–2), standard pressure (12xa0mmHg) with deep-block, and standard pressure with moderate-block (train-of-four count 1–2) groups. During the laparoscopic procedure, we recorded cardiopulmonary variables including cardiac index, pulmonary compliance, and surgical conditions. We also assessed postoperative pain intensity and recovery time of bowel movement. The primary outcome was the cardiac index 30xa0min after onset of laparoscopy.ResultsPatients were included in the low pressure with deep-block (nu2009=u200944), standard pressure with deep-block (nu2009=u200944), and standard pressure with moderate-block (nu2009=u200943) groups. The mean (SD) of cardiac index 30xa0min after laparoscopy was 2.7 (0.7), 2.7 (0.9), and 2.6 (1.0) Lxa0min−1xa0m−2 in each group (Pu2009=u20090.715). The pulmonary compliance was higher but the surgical condition was poorer in the low intra-abdominal pressure than the standard pressure (both Pu2009<u20090.001). Other variables were comparable between groups.ConclusionWe observed few cardiopulmonary benefits but poor surgical conditions in the low intra-abdominal pressure during laparoscopy. Considering cardiopulmonary dynamics and surgical conditions, the standard intra-abdominal pressure may be preferable to the low pressure for laparoscopic surgery.

Experience of hemostasis in tracheal bleeding very close to the carina by the bronchial blocker: a case report

Massive hemoptysis is respiratory compromise which should be managed as a life-threatening condition. In our case, the bronchial blocker played a role in hemostasis of tracheal bleeding very close to the carina and prevented further spillage into the contralateral lung. Right-sided one-lung isolation in an 87-year-old female, who received cardiopulmonary resuscitation due to myocardial infarction, was requested due to hemoptysis. Right-sided bronchial bleeding was suspected on auscultation, but esophageal and tracheal bleeding due to violent intubation with a stylet was also considered. We attempted one-lung isolation with the bronchial blocker. The bronchial blocker was inadvertently advanced to the left mainstem bronchus, but the inflated balloon of the bronchial blocker compressed the site of bleeding, which was within 1 cm proximal and left posterior to the carina. Tracheal bleeding stopped, and we confirmed that hemostasis was achieved with the balloon of the bronchial blocker using a fiberoptic bronchoscope.

The effects of an insulin-glucose-potassium (IGK) pretreatment on the bupivacaine cardiotoxicity.

Background The purpose of this study is to evaluate the effect of an IGK pretreatment on the cardiotoxicity of bupivacaine. Methods Twenty-one anesthetized mongrel dogs were randomly divided into the following three groups: the control group (CG, n = 7), the treatment group (TG, n = 7) and the pretreatment group (PTG, n = 7). For the 30 min of pretreatment period, CG and TG received normal saline, while PTG received an IV bolus of insulin 2 U/kg, followed by an IGK infusion (2 U/kg/hr of insulin, 0.5-1.5 g/kg/hr of glucose, 1-2 mEq/kg/hr of KCl). The bupivacaine infusion was started at the rate of 0.5 mg/kg/min in all groups after the pretreatment period. CG received normal saline only. In TG, insulin (2 U/kg) was injected simultaneously with bupivacaine infusion, followed by the IGK infusion as with PTG. The hemodynamic variables and the time duration to reach the mean arterial pressure (MAP) of 60 mmHg were compared. Results The bupivacaine infusion decreased the cardiac index, MAP, and heart rate in all three groups. Although insulin concentration was higher in TG than in PTG during bupivacaine infusion, the hemodynamic variables in PTG decreased at the slowest rate. The time taken to reach MAP of 60 mmHg in PTG, TG, and CG was 51.4 ± 8.5, 36.4 ± 9.6, and 27.1 ± 8.7 min, respectively (P < 0.05). Conclusions IGK delays the bupivacaine-induced cardiac depression. However, a pretreatment with IGK is more effective in delaying the bupivacaine-induced hypotension than simultaneous administration, regardless of insulin concentration.

Erratum to: Insulin/glucose infusion successfully resuscitates bupivacaine-induced sudden-onset circulatory collapse in dogs

In the article entitled: ‘‘Insulin/glucose infusion successfully resuscitates bupivacaine-induced suddenonset circulatory collapse in dogs’’ published in the May 2013 issue, Can J Anesth 2013; 60: 471-8, the name, degree and affiliation of the sixth author is incorrect and should read: Jong Min Kim, DVM, Clinical Research Institute, Seoul National University Hospital, Seoul, South Korea. The publisher apologizes most sincerely for this error.

Insulin Facilitates the Recovery of Myocardial Contractility and Conduction during Cardiac Compression in Rabbits with Bupivacaine-Induced Cardiovascular Collapse

Bupivacaine inhibits cardiac conduction and contractility. Insulin enhances cardiac repolarization and myocardial contractility. We hypothesizes that insulin therapy would be effective in resuscitating bupivacaine-induced cardiac toxicity in rabbits. Twelve rabbits were tracheally intubated and midline sternotomy was performed under general anesthesia. Cardiovascular collapse (CVC) was induced by an IV bolus injection of bupivacaine 10u2009mg/kg. The rabbits were treated with either saline (control) or insulin injection, administered as a 2u2009U/kg bolus. Internal cardiac massage was performed until the return of spontaneous circulation (ROSC) and the time to the return of sinus rhythm (ROSR) was also noted in both groups. Arterial blood pressure, and electrocardiography were continuously monitored for 30u2009min and plasma bupivacaine concentrations at every 5u2009min. The ROSC, ROSR and normalization of QRS duration were attained faster in the insulin-treated group than in the control group. At the ROSC, there was a significant difference in bupivacaine concentration between two groups. Insulin facilitates the return of myocardial contractility and conduction from bupivacaine-induced CVC in rabbits. However, recovery of cardiac conduction is dependent mainly on the change of plasma bupivacaine concentrations.