Mi-Young Kwon

Clinical factors affecting the pain on injection of propofol

Background Pain on propofol injection is a well-known adverse effect. We evaluated the clinical factors that affect the pain on injection of propofol to develop a strategy to prevent or reduce pain. Methods We conducted a prospective, observational study of 207 adult patients (ASA I-II), and the patients were classified according to gender, age, the body mass index (BMI), the IV site and the side of the IV site. During the 10 seconds after propofol injection, pain intensity was measured on an 11-point numerical rating scale (0 = no pain and 10 = worst possible pain). Pain in excess of 3 on the numerical scale was regarded as moderate to severe pain. Results The subgroups of gender (female: 55.6% vs. male: 25.0%; P < 0.01) and the IV site (dorsum of hand: 61.2% vs. wrist: 40.0% vs. antecubital fossa: 22.5%; P < 0.01) had significantly different frequencies for the incidence of pain on injection on the univariate and multivariate analyses. For the subgroup of females, the incidence of pain was statistically different according to the age group (20-40 yr: 71.0% vs. 41-60: 54.8% vs. 61-80: 38.5%; P = 0.014). Conclusions Our results showed that the younger age patients, the patients with a peripheral IV site and female patients are more sensitive to pain on the injection of propofol.

Effect of ulinastatin on perioperative organ function and systemic inflammatory reaction during cardiac surgery: a randomized double-blinded study.

Background This study evaluated the efficacy of ulinastatin for attenuating organ injury and the release of proinflammatory cytokines due to cardiopulmonary bypass (CPB) during cardiac surgery. Methods Patients undergoing valvular heart surgery employing CPB were assigned to receive either ulinastatin (group U, n = 13) or a placebo (group C, n = 11) before the commencement of CPB. Hemodynamic data, parameters of major organ injury and function, and proinflammatory cytokines were measured after the induction of anesthesia (T1), after CPB (T2), at the end of anesthesia (T3), and at 24 hours after surgery (POD). Results The demographic data, CPB duration, and perioperative transfusions were not different between the groups. PaO2/FiO2 in group U was significantly higher than that in group C at T3 (3.8 ± 0.8 vs. 2.8 ± 0.7, P = 0.005) and at POD (4.0 ± 0.7 vs. 2.8 ± 0.7, P < 0.001). Creatine kinase-MB at POD in group U was significantly lower than that in group C (17.7 ± 8.3 vs. 33.7 ± 22.1, P = 0.03), whereas troponin I at POD was not different between the groups. Creatinine clearance and the extubation time were not different between the groups at POD. The dopamine infusion rate during the post-CPB period in group U was significantly lower than that in group C (1.6 ± 1.6 vs. 5.5 ± 3.3 µg/kg/min, P = 0.003). The interleukin-6 and tumor necrosis factor-α concentrations at T1, T2, and T3 as well as the incidences of postoperative cardiac, pulmonary and kidney injuries were not different between the groups. Conclusions Ulinastatin pretreatment resulted in an improved oxygenation profile and reduced inotropic support, probably by attenuating the degree of cardiopulmonary injury; however, it did not reduce the levels of proinflammatory cytokines.

Spectral entropy for assessing the depth of propofol sedation

Background For patients in the intensive care unit (ICU) or under monitored anesthetic care (MAC), the precise monitoring of sedation depth facilitates the optimization of dosage and prevents adverse complications from underor over-sedation. For this purpose, conventional subjective sedation scales, such as the Observers Assessment of Alertness/Sedation (OAA/S) or the Ramsay scale, have been widely utilized. Current procedures frequently disturb the patients comfort and compromise the already well-established sedation. Therefore, reliable objective sedation scales that do not cause disturbances would be beneficial. We aimed to determine whether spectral entropy can be used as a sedation monitor as well as determine its ability to discriminate all levels of propofol-induced sedation during gradual increments of propofol dosage. Methods In 25 healthy volunteers undergoing general anesthesia, the values of response entropy (RE) and state entropy (SE) corresponding to each OAA/S (5 to 1) were determined. The scores were then analyzed during each 0.5 mcg/ml- incremental increase of a propofol dose. Results We observed a reduction of both RE and SE values that correlated with the OAA/S (correlation coefficient of 0.819 in RE-OAA/S and 0.753 in SE-OAA/S). The RE and SE values corresponding to awake (OAA/S score 5), light sedation (OAA/S 3-4) and deep sedation (OAA/S 1-2) displayed differences (P < 0.05). Conclusions The results indicate that spectral entropy can be utilized as a reliable objective monitor to determine the depth of propofol-induced sedation.

Comparison of intubation times using a manikin with an immobilized cervical spine: Macintosh laryngoscope vs. GlideScope vs. fiberoptic bronchoscope

Objective Airway management in patients with suspected cervical spine injury is classified as a “difficult airway.” The best device for managing difficult airways is not known. Therefore, we conducted an intubation study simulating patients with cervical spine injury using three devices: a conventional Macintosh laryngoscope, a video laryngoscope (GlideScope), and a fiberoptic bronchoscope (MAF-TM). Success rates, intubation time, and complication rates were compared. Methods Nine physician experts in airway management participated in this study. Cervical immobilization was used to simulate a difficult airway. Each participant performed intubation using airway devices in a randomly chosen order. We measured the time to vocal cord visualization, time to endotracheal tube insertion, and total tracheal intubation time. Success rates and dental injury rates were compared between devices. Results Total tracheal intubation time using the Macintosh laryngoscope, GlideScope, and fiberoptic bronchoscope was 13.3 (range, 11.1 to 20.1), 14.9 (range, 12.7 to 22.3), and 19.4 seconds (range, 14.1 to 32.5), respectively. Total tracheal intubation time differed significantly among the devices (P=0.009). Success rates for the Macintosh laryngoscope, GlideScope, and fiberoptic bronchoscope were 98%, 96%, and 100%, respectively, and dental injury rates were 5%, 19%, and 0%, respectively. Conclusion The fiberoptic bronchoscope required longer intubation times than the other devices. However, this device had the best success rate with the least incidence of dental injury.

The effects of the Trendelenburg position and intrathoracic pressure on the subclavian cross-sectional area and distance from the subclavian vein to pleura in anesthetized patients.

BACKGROUND:The effects of maneuvers to increase intrathoracic pressure and of Trendelenburg position on the cross-sectional area (CSA) of the subclavian vein (SCV) and the relationship between the SCV and adjacent structures have not been investigated. METHODS:In ultrasonography-guided SCV catheterization (N = 30), the CSA of the SCV and the distance between the SCV and pleura (DSCV-pleura) were determined during 10-second airway opening, and 10-second positive inspiratory hold with 20 cm H2O in the supine position (S-0, and S-20) and the 10° Trendelenburg position (T-0, and T-20). In addition to a statistical significance of P < 0.05, CSA and DSCV-pleura differences of ≥15% were defined as clinically relevant changes. RESULTS:CSA (mean [95% confidence interval]) in S-20, T-0, and T-20 (1.02 [0.95–1.14] cm2, 1.04 [0.95–1.15] cm2, and 1.14 [1.04–1.24] cm2, respectively) was significantly larger than a CSA in S-0 (0.93 [0.86–1.00] cm2, all P < 0.001). However, only the increase of CSA in T-20 vs S-0 (0.21 cm2, 23.2%) was clinically meaningful (≥15%). The number of patients who showed CSA increase ≥15% was more in S-0 to T-20 (57%) compared with those in S-0 to S-20 (23%) and S-0 to T-0 (27%). DSCV-pleura measurements (mean) in S-20 and T-20 (0.61 and 0.60 cm) were significantly shorter than those in S-0 (0.70 cm, all P < 0.001), but the reductions of DSCV-pleura were not clinically meaningful (≥15%). CONCLUSIONS:The combined application of inspiratory hold and Trendelenburg position provided a greater and more relevant degree of CSA increase without compromising DSCV-pleura, which may facilitate SCV catheterization. Further investigations are needed to determine whether these results affect the success rate of catheterization and the risk of procedural injury.

Placing a Saline Bag Underneath the Heart Enhances Transgastric Transesophageal Echocardiographic Imaging During Cardiac Displacement for Off-Pump Coronary Artery Bypass Surgery

OBJECTIVEnThe authors hypothesized that placing a saline bag (saline-filled surgical glove) underneath a displaced heart would improve ultrasound transmission for transgastric (TG) imaging and transesophageal echocardiography (TEE) to visualize left ventricular regional wall motion (LV-RWM) during cardiac displacement for off-pump coronary artery bypass (OPCAB) surgery.nnnDESIGNnProspective observational study.nnnSETTINGnTertiary University Hospital.nnnPARTICIPANTSnAdult patients undergoing OPCAB surgery.nnnINTERVENTIONSnIntraoperative TEE examinationnnnMEASUREMENT AND MAIN RESULTSnFor off-line analyses of LV-readable segments, mid-esophageal (ME, 4-chamber, 2-chamber, and long-axis) and TG (basal- and mid-short-axis) TEE views were recorded under 3 different intraoperative conditions in 13 cases of OPCAB surgery: Before cardiac displacement (Tcontrol), after cardiac displacement (Tdisplaced), and after placing the saline bag underneath the displaced heart (Tsaline-bag). There were more LV-readable segments in the 17-segment model using integrated ME and TG views(ME + TG views) at Tsaline-bag and Tcontrol (mean[95% confidence interval], 17[17-17] and 17[17-17]) than using ME+TG at Tdisplaced (15[15-16], P = 0.002 and P<0.001, respectively). Using ME + TG views provided more LV-readable segments in the 17-segment model than using ME views at Tsaline-bag (vs. 16[14-16], P < 0.001), but not at Tdisplaced (vs. 15[14-15]). Incidences of inadequate RWM monitoring (LV-readable segments<14/17 using ME + TG views) at Tsaline-bag and Tcontrol (all 0/13) were less frequent than at Tdisplaced (3/13, all P = 0.038). There were more LV-readable segments in TG basal- and mid-short-axis views at Tsaline-bag (median [range], 6[5-6] and 5[5-6]) than at Tdisplaced (0[0-2] and 0[0-1], all P < 0.05).nnnCONCLUSIONSnPlacing a saline bag underneath the displaced heart enhances the ability of TEE to visualize global LV-RWM by improving TG TEE imaging during OPCAB surgery.

A case of life-threatening post-operative diffuse alveolar hemorrhage in patient with recent chemotherapy -A case report-

A 53-year-old woman who had undergone total gastrectomy and received adjuvant chemotherapy two months ago underwent adhesiolysis of the small bowel. She presented with sudden desaturation and dyspnea of unknown etiology at postanesthetic care unit. Following ET intubation, the endotracheal tube suction revealed massive hemoptysis. Bilateral lung infiltrated on her chest radiograph and bronchofibroscopic examination disclosed a diffuse hemorrhage on both lung fields without bleeding focus. These findings were consistent with diffuse alveolar hemorrhage (DAH) syndrome. As per our knowledge and search, this is the first reported case of DAH that occurred during the recovery period immediately after general anesthesia. DAH is known to have a high mortality rate and an early detection followed by adequate treatment is essential.

The development of tension pneumothorax during mask ventilation under general anesthetic induction

Elevated peak inspiratory pressure (PIP) can cause pulmonary barotrauma during general anesthetic induction [1]. However, in patients who have bulla, tension pneumothorax can occur even if PIP is not highly elevated. We report a case of tension pneumothorax which occurred during anesthetic induction. The patient was a 67-year-old male scheduled for video-assisted thoracoscopic (VATS) bullectomy. He weighed 45 kg and was 163 cm tall. He was diagnosed with the human immunodeficiency virus (HIV) prior to pneumocystis pneumonia. His medical history included atrial fibrillation and chronic obstructive pulmonary disease (COPD). Physical examination revealed crackles and coarse lung sounds in both fields. Preoperative arterial blood gas analysis in room air showed a hydrogen ion concentration (pH) of 7.50, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mmHg, a partial pressure of arterial oxygen (PaO2) of 71 mmHg, and an arterial oxygen saturation (SaO2) of 96%. Radiologic findings showed a sizeable cyst which had recently developed in the right lower lobe (Fig. 1). Pulmonary function test presented severe obstructive pattern possibly combined with restriction: predicted percentage of Forced expiration value after 1 second (FEV1) was 28%, predicted percentage of forced vital capacity (FVC) was 75%, and FEV1/FVC ratio was 28%. He arrived at the operating room without premedication. The vital signs prior to anesthetic induction were as followes: a blood pressure of 110–115/55–60 mmHg, an atrial fibrillation rhythm with a heart rate about 90 beats/min, and a peripheral oxygen saturation (SpO2) of 94% in room air. The left radial artery was cannulated with a 20-gauge catheter for continuous monitoring of systemic blood pressure. After preoxygenation, we administered 2% propofol with the Master target-controlled infusion (Orchestra Ⓡ Base Primea; Fresenius-MCM GmbH, Germany) after administration of lidocaine (40 mg). After confirming loss of consciousness, we administered rocuronium (0.5 mg/kg), and remifentanil TCI was started. Assisted and controlled ventilation using mask and reservoir bag with O2 6 L/min was applied. Airway pressure release valve was set in 20 cmH2O and PIP was maintained below 20 cmH2O during ventilation.