Kyung Han Kim

Predictors of difficult intubation defined by the intubation difficulty scale (IDS): predictive value of 7 airway assessment factors

Background The intubation difficulty scale (IDS) has been used as a validated difficulty score to define difficult intubation (DI). The purpose of this study is to identify airway assessment factors and total airway score (TAS) for predicting DI defined by the IDS. Methods There were 305 ASA physical status 1-2 patients, aged 19-70 years, who underwent elective surgery with endotracheal intubation. During the pre-anesthetic visit, we evaluated patients by 7 preoperative airway assessment factors, including the following: Mallampati classification, thyromental distance, head & neck movement, body mass index (BMI), buck teeth, inter-incisor gap, and upper lip bite test (ULBT). After endotracheal intubation, patients were divided into 2 groups based on their IDS score estimated with 7 variables: normal (IDS < 5) and DI (IDS ≥ 5) groups. The incidence of TAS (> 6) and high score of each airway assessment factor was compared in two groups: odds ratio, confidence interval (CI) of 95%, with a significant P value ≤ 0.05. Results The odds ratio of TAS (> 6), ULBT (class III), head & neck movement (< 90°), inter-incisor gap (< 4 cm), BMI (≥ 25 kg/m2) and Mallampati classification (≥ class III) were respectively 13.57 (95% CI = 2.99-61.54, P < 0.05), 12.48 (95% CI = 2.50-62.21, P < 0.05), 3.11 (95% CI = 0.87-11.13), 2.32 (95% CI = 0.75-7.19), 2.22 (95% CI = 0.81-6.06), and 1.22 (95% CI = 0.38-3.89). Conclusions We suggest that TAS (> 6) and ULBT (class III) are the most useful factors predicting DI.

The cardiovascular effects of midazolam co-induction to propofol for induction in aged patients.

Background The aim of this study was to investigate whether a small dose of midazolam and lessening the propofol dosage could prevent cardiovascular change at tracheal intubation for induction in aged patients. Methods Eighty patients over 65 years (ASA physical status 1, 2) scheduled for elective surgery received general anesthesia with remifentanil and propofol or midazolam. Patients in group P (n = 40) were induced with 0.9% NaCl 0.03 ml/kg, propofol 1. 2 mg/kg and remifentanil. Patients in group MP (n = 40) were induced with midazolam 0.03 mg/kg, propofol 0.8 mg/kg and remifentanil. The time taken to reach loss of consciousness (LOC) and the value of bispectral index score (BIS) at LOC were recorded. After LOC, 0.8 mg/kg of rocuronium was given and tracheal intubation was performed. The mean blood pressure (MBP) and heart rate (HR) were recorded before induction as the base value, before intubation, immediately post-intubation and 3 minutes after intubation. Results Compared with the base values, MBP at before intubation and 3 minutes after intubation was significantly decreased in group P and group MP (P < 0.05). Compared with group P, the decrease of MBP was significantly less at before intubation, immediately after intubation and 3 minutes after intubation in group MP (P < 0.05). The time taken to reach LOC was significantly decreased in group MP compared with that in group P (P < 0.05). There were no significant differences of HR at any time between the two groups. Conclusions Co-induction with midazolam and propofol could prevent a marked BP decrease at tracheal intubation for induction in aged patients.

G protein-coupled receptor, family C, group 5 (GPRC5B) downregulation in spinal cord neurons is involved in neuropathic pain

Background G protein-coupled receptor, family C, group 5 (GPRC5B), a retinoic acid-inducible orphan G-protein-coupled receptor (GPCR), is a member of the group C metabotropic glutamate receptor family proteins presumably related in non-canonical Wnt signaling. In this study, we investigated altered GPRC5B expression in the dorsal horn of the spinal cord after spinal nerve injury and its involvement in the development of neuropathic pain. Methods After induction of anesthesia by intraperitoneal injection of pentobarbital (35 mg /kg), the left L5 spinal nerve at the level of 2 mm distal to the L5 DRG was tightly ligated with silk and cut just distal to the ligature. Seven days after nerve injury, animals were perfused with 4% paraformaldehyde, and the spinal cords were extracted and post-fixed at 4℃ overnight. To identify the expression of GPRC5B and analyze the involvement of GPRC5B in neuropathic pain, immunofluorescence was performed using several markers for neurons and glial cells in spinal cord tissue. Results After L5 spinal nerve ligation (SNL), the expression of GPRC5B was decreased in the ipsilateral part, as compared to the contralateral part, of the spinal dorsal horn. SNL induced the downregulation of GPRC5B in NeuN-positive neurons in the spinal dorsal horn. However, CNPase-positive oligodendrocytes, OX42-positive microglia, and GFAP-positive astrocytes were not immunolabeled with GPRC5B antibody in the spinal dorsal horn. Conclusions These results imply that L5 SNL-induced GPRC5B downregulation may affect microglial activation in the spinal dorsal horn and be involved in neuropathic pain.

Paradoxical carbon dioxide embolism during laparoscopic cholecystectomy as a cause of cardiac arrest and neurologic sequelae: a case report

An 81-year-old male patient was scheduled for a laparoscopic cholecystectomy due to acute cholecystitis. About 50 minutes into the operation, the arterial blood pressure suddenly decreased and ventricular fibrillation appeared on the electrocardiography. The patient received cardiopulmonary resuscitation and recovered a normal vital sign. We suspected a carbon dioxide embolism as the middle hepatic vein had been injured during the surgery. We performed a transesophageal echocardiography and were able to confirm the presence of multiple gas bubbles in all of the cardiac chambers. After the operation, the patient presented a stable hemodynamic state, but showed weaknesses in the left arm and leg. There were no acute lesions except for a chronic cerebral cortical atrophy and chronic microvascular encephalopathy on the postoperative brain-computed tomography, 3D angiography and magnetic resonance image. Fortunately, three days after the operation, the patients hemiparesis had entirely subsided and he was discharged without any neurologic sequelae.

Difference of the hemodynamic changes induced by tracheal intubation using remifentanil between smokers and nonsmokers

Background It was well-known that smoking affects the cardiovascular system, and remifentanil can suppress the sympathetic stimulations induced by tracheal intubation. The purpose of this study was to investigate whether there was any difference in the hemodynamic changes induced by tracheal intubation with using remifentanil between smokers and nonsmokers. Methods Eighty patients were enrolled: male smokers (MS), male nonsmokers (MN), female smokers (FS) and female nonsmokers (FN). Anesthesia was induced with diluted remifentanil (20 µg/ml) at a rate of 10 µg/kg/hr using an infusion pump, and 2 min later, midazolam 0.05 mg/kg and propofol 0.8 mg/kg were injected for achieving unconsciousness. Rocuronium 1 mg/kg was used for muscle relaxation, and tracheal intubation was performed 2 min after rocuronium injection. After tracheal intubation, the remifentanil was decreased to 2 µg/kg/hr. The mean arterial pressure (MAP) and heart rate (HR) were checked before induction, on unconsciousness, just before intubation, just after intubation and 1, 2 and 3 minutes after intubation, and these values were compared between the groups. Results In men, the MAP and HR just after intubation and at 1, 2 and 3 minutes after intubation in Group MS were significantly higher than those of Group MN (P < 0.05). For the women, the HR in both groups (the FS and FN groups) were increased just after intubation and 1, 2 and 3 minutes after intubation compared with that at the baseline, respectively, but there was no difference between the two groups. Conclusions There was a difference of the hemodynamic changes induced by tracheal intubation with using remifentanil between the male smokers and nonsmokers, but not in women.

Changes of Serum Na+ , K+ Levels and Platelet Count after Massive Blood Transfusion

Currently, the incidence of massive transfusions during operation has been increasing because the more complicated and invasive operations than before can be done due to enhanced technololgy in both anesthesia and surgery. In spite of marked improvement in immunology and transfusion technique, massive transfusions are associated with several problems usually not seen in normal transfusion practice. In order to evaluate the effect of massive transfusion on the serum sodium, potassium levels and platelet count in the blood during general anesthesia, we have retrospectively examined these values before and after massive transfusion in 62 patients who received at least one blood volume at Kosin Medical Center from January 1985 through May 1989. Statistical significance was assessed by using Students t-test. The results obtained were summarized as follows; 1) The average volume of transfusion was 5432 ml (13.4 units). 2) The total number of massive transfusions was 62 (0.47%), excluding cases with renal failure or open heart surgery, out of 13,213 anesthetic patients 3) The hightest incidence of age distribution was from 50 to 59 years. 4) There were 2 fatalities (3.2%) that seemed to be due primarily to the transfused blood itself. 5) The decrease in the serum sodium concentration after transfusion was not statistically significant (p>0.05). 6) There was a statistically significant decrease in serum potassium concentration after transfusion (p 0.05) after massive transfusion between the shock and non-shock groups. Since massive transfusion can be associated with the decrease in the serum potassium and platelet count, these patients blood levels should be monitored during and after maseive transfusion for proper management.