Seong-Soo Choi

Prognostic implications of preoperative E/e' ratio in patients with off-pump coronary artery surgery.

Background: The ratio of early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/e′) correlates with left ventricular (LV) filling pressure. In particular, an E/e′ ratio more than 15 is an excellent predictor of increased LV filling pressure. The authors evaluated the prognostic implications of preoperative estimated LV filling pressure, assessed by E/e′ ratio, in patients undergoing off-pump coronary artery bypass graft surgery. Methods: This observational study investigated 1,048 consecutive adults undergoing elective off-pump coronary artery bypass graft surgery. The primary outcome was occurrence of major adverse cardiac events (MACE), defined as a composite of death, myocardial infarction, malignant ventricular arrhythmia, cardiac dysfunction, or need for new revascularization. Logistic regression and survival analyses were performed. Results: An E/e′ ratio more than 15 was independently associated with 30-day MACE (odds ratio 2.4, 95% CI 1.4–3.9, P = 0.001) and 1-yr MACE (hazard ratio 2.1, 95% CI 1.4–3.1, P = 0.001), irrespective of underlying LV ejection fraction. MACE free 1-yr survival rate was significantly decreased in patients with E/e′ >15, irrespective of underlying LV ejection fraction. Conclusions: Increased LV filling pressure, assessed by E/e′ ratio, is an independent predictor of 30-day and 1-yr MACE in patients who undergo elective off-pump coronary artery bypass graft surgery. These findings indicate that measurements of E/e′ may assist in preoperative risk stratification of these patients.

Treatment of chronic lumbosacral radicular pain using adjuvant pulsed radiofrequency: a randomized controlled study.

OBJECTIVES The objective of this study was to determine the effects of combining pulsed radiofrequency (PRF) treatment and transforaminal epidural injection (TFEI) to treat patients with chronic refractory lumbar radicular pain caused by lumbar spinal stenosis. STUDY DESIGN Randomized control trial. SETTINGS Interventional pain management practice. METHOD Sixty-two patients were assigned to the study groups (PRF group = 31; control group = 31). Under fluoroscopic guidance, the RF needle was positioned close to the lumbar dorsal root ganglion. The PRF group received 3 cycles of PRF treatment, and sensory stimulation without RF lesioning was applied to the control group. After PRF or sham lesioning, a local anesthetic with steroid was injected. The primary outcome of a successful response was defined as: 1) ≥50% or 4-point pain reduction in the numerical rating scale (NRS) without an increase in the Oswestry disability index (ODI) or medication quantification scale (MQS), or mean score <4 in the global perceived effect (GPE) scale; or 2) ≥30% or 2-point pain reduction in NRS with a simultaneous decrease in ODI, MQS, or ≥6 points in the GPE scale. RESULT The number of patients with successful treatment results was higher in the PRF group at 2 months (P = 0.032) and 3 months (P = 0.018). No significant differences were observed in terms of the secondary outcome variables between the 2 groups. CONCLUSION The TFEI provided significant short-term pain relief and PRF can be applied in conjunction with TFEI to achieve higher treatment efficacy compared with TFEI alone.

Factors associated with blood transfusion in donor hepatectomy: results from 2344 donors at a large single center.

Background The safety of healthy living donors undergoing hepatic resection for living-donor liver transplantation is of paramount concern. Although blood transfusions have been associated with morbidity and mortality after hepatectomy, there is limited information about the risk factors associated with blood transfusion in living liver donors. Methods We retrospectively analyzed 2344 donors who underwent a hepatectomy for living-donor liver transplantation. Logistic regression analysis was performed to determine blood transfusion predictors in living-donor hepatectomy. Results Of these donors, 48 (2.0%) and 97 (4.1%) were transfused with packed red blood cell (PRBC) and fresh-frozen plasma (FFP), respectively. The amount of PRBC and FFP administered to donors transfused with blood products were 1.9±0.8 and 3.7±2.5 units, respectively. In multivariate logistic regression analysis, a low preoperative hemoglobin level was found to be an independent predictor of PRBC transfusion in donor hepatectomy (odds ratio=0.585; 95% confidence interval=0.451–0.758; P<0.001). A high graft-to-donor weight ratio predicted an FFP transfusion in donor hepatectomy (odds ratio=2.997; 95% confidence interval=1.226–7.327; P=0.016). Conclusions These results indicate that, in donor hepatectomy, the preoperative hemoglobin value and graft-to-donor weight ratio can provide useful information on the probability of PRBC and FFP transfusion, respectively.

Continuous Noninvasive Hemoglobin Measurement Is Useful in Patients Undergoing Double-Jaw Surgery

PURPOSE Continuous measurement of hemoglobin by pulse CO-oximetry (SpHb; Masimo Radical 7 device, Masimo Corp, Irvine, CA) may be helpful during double-jaw surgery when massive hemorrhage is anticipated. Given the possible influence of low blood pressure on the detection of hemoglobin levels, the agreement of the SpHb was evaluated in patients undergoing orthognathic surgery when using hypotensive anesthesia. MATERIALS AND METHODS Patients who underwent elective Le Fort I osteotomy and bilateral sagittal split ramus osteotomy (BSSO) were enrolled in this observational prospective cohort study. SpHb was compared with time-matched arterial total hemoglobin (tHb) before incision, at Le Fort I osteotomy, at BSSO, and at skin closure. The correlation between simultaneous SpHb and tHb measurement pairs was evaluated. Agreement was assessed by a comparison of SpHb with tHb using the intraclass correlation coefficient (ICC) and the Bland-Altman plot. RESULTS The average age of 51 patients was 23 ± 5 years and 32 patients were male. The correlations of SpHb and tHb measurements were 0.72, 0.85, 0.89, and 0.78 before incision, at Le Fort I osteotomy, at BSSO, and at closure, respectively. Bland-Altman analysis for SpHb and tHb showed respective bias values of 0.12, 0.07, -0.09, and -0.90 g/dL. ICC values between SpHb and tHb were 0.82, 0.90, 0.91, and 0.87, respectively. CONCLUSIONS Continuous monitoring of hemoglobin may help to determine the appropriate time to perform an invasive measurement of hemoglobin in patients who undergo double-jaw surgery.

Fluid management in living donor hepatectomy: Recent issues and perspectives

The importance of the safety of healthy living liver donors is widely recognized during donor hepatectomy which is associated with blood loss, transfusion, and subsequent post-operative morbidity. Although the low central venous pressure (CVP) technique can still be effective, it may not be advantageous concerning the safety of healthy donors undergoing hepatectomy. Emerging evidence suggests that stroke volume variation (SVV), a simple and useful index for fluid responsiveness and preload status in various clinical situations, can be applied as a guide for fluid management to reduce blood loss during living donor hepatectomy. Synthetic colloid solutions are also associated with serious adverse events such as the use of renal replacement therapy and transfusion in critically ill or septic patients. However, it is uncertain whether the intra-operative use of colloid solution is associated with similarly adverse effects in patients undergoing living donor hepatectomy. In this review article we discuss the recent issues regarding the low CVP technique and the high SVV method, i.e., maintaining 10%-20% of SVV, for fluid management in order to reduce blood loss during living donor hepatectomy. In addition, we briefly discuss the effects of intra-operative colloid or crystalloid administration for surgical rather than septic or critically ill patients.

Incidence and Risk Factors of Acute Kidney Injury after Radical Cystectomy: Importance of Preoperative Serum Uric Acid Level.

Background: Acute kidney injury (AKI) is a common complication after surgery and increases costs, morbidity, and mortality of hospitalized patients. While radical cystectomy associates significantly with an increased risk of serious complications, including AKI, risk factors of AKI after radical cystectomy has not been reported. This study was performed to determine the incidence and independent predictors of AKI after radical cystectomy. Methods: All consecutive patients who underwent radical cystectomy in 2001-2013 in a single tertiary-care center were identified. Their demographics, laboratory values, and intraoperative data were recorded. Postoperative AKI was defined and staged according to the Acute Kidney Injury Network criteria on the basis of postoperative changes in creatinine levels. Independent predictors of AKI were identified by univariate and multivariate logistic regression analyses. Results: Of the 238 patients who met the eligibility criteria, 91 (38.2%) developed AKI. Univariate logistic regression analyses showed that male gender, high serum uric acid level, and long operation time associated with the development of AKI. On multivariate logistic regression analysis, preoperative serum uric acid concentration (odds ratio [OR] = 1.251; 95% confidence interval [CI] = 1.048-1.493; P = 0.013) and operation time (OR = 1.005; 95% CI = 1.002-1.008; P = 0.003) remained as independent predictors of AKI after radical cystectomy. Conclusions: AKI after radical cystectomy was a relatively common complication. Its independent risk factors were high preoperative serum uric acid concentration and long operation time. These observations can help to prevent AKI after radical cystectomy.

Differential Postoperative Effects of Volatile Anesthesia and Intraoperative Remifentanil Infusion in 7511 Thyroidectomy Patients: A Propensity Score Matching Analysis.

AbstractAlthough remifentanil is used widely by many clinicians during general anesthesia, there are recent evidences of opioid-induced hyperalgesia as an adverse effect. This study aimed to determine if intraoperative remifentanil infusion caused increased pain during the postoperative period in patients who underwent a thyroidectomy.A total of 7511 patients aged ≥ 20 years, who underwent thyroidectomy between January 2009 and December 2013 at the Asan Medical Center were retrospectively analyzed. Enrolled patients were divided into 2 groups: group N (no intraoperative remifentanil and only volatile maintenance anesthesia) and group R (intraoperative remifentanil infusion including total intravenous anesthesia and balanced anesthesia). Following propensity score matching analysis, 2582 patients were included in each group. Pain scores based on numeric rating scales (NRS) were compared between the 2 groups at the postoperative anesthetic care unit and at the ward until 3 days postoperation. Incidences of postoperative complications, such as nausea, itching, and shivering were also compared.The estimated NRS pain score on the day of surgery was 5.08 (95% confidence interval [CI] 4.97–5.19) in group N patients and 6.73 (95% CI 6.65–6.80) in group R patients (P < 0.001). There were no statistically significant differences in NRS scores on postoperative days 1, 2, and 3 between the 2 groups. Postoperative nausea was less frequent in group R (31.4%) than in group N (53.5%) (P < 0.001). However, the incidence of itching was higher in group R (4.3%) than in group N (0.7%) (P < 0.001).Continuous infusion of remifentanil during general anesthesia can cause higher intensity of postoperative pain and more frequent itching than general anesthesia without remifentanil infusion immediately after thyroidectomy. Considering the advantages and disadvantages of continuous remifentanil infusion, volatile anesthesia without opioid may be a good choice for minor surgeries, such as thyroidectomy.

Risk factors for intraoperative massive transfusion in pediatric liver transplantation: a multivariate analysis.

Background: Pediatric liver transplantation (LT) is strongly associated with increased intraoperative blood transfusion requirement and postoperative morbidity and mortality. In the present study, we aimed to assess the risk factors associated with massive transfusion in pediatric LT, and examined the effect of massive transfusion on the postoperative outcomes. Methods: We enrolled pediatric patients who underwent LT between December 1994 and June 2015. Massive transfusion was defined as the administration of red blood cells ≥100% of the total blood volume during LT. The cases of pediatric LT were assigned to the massive transfusion or no-massive transfusion (administration of red blood cells <100% of the total blood volume during LT) group. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with massive transfusion in pediatric LT. Kaplan-Meier survival analysis, with the log rank test, was used to compare graft and patient survival within 6 months after pediatric LT between the 2 groups. Results: The total number of LT was 112 (45.0%) and 137 (55.0%) in the no-massive transfusion and massive transfusion groups, respectively. Multivariate logistic regression analysis indicated that high white blood cell (WBC) count, low platelet count, and cadaveric donors were significant predictive factors of massive transfusion during pediatric LT. The graft failure rate within 6 months in the massive transfusion group tended to be higher than that in the no-massive transfusion group (6.6% vs. 1.8%, P = 0.068). However, the patient mortality rate within 6 months did not differ significantly between the massive transfusion and no-massive transfusion groups (7.3% vs. 7.1%, P = 0.964). Conclusion: Massive transfusion during pediatric LT is significantly associated with a high WBC count, low platelet count, and cadaveric donor. This finding can provide a better understanding of perioperative blood transfusion management in pediatric LT recipients.

Comparative Effects of Dexmedetomidine and Propofol on US-Guided Radiofrequency Ablation of Hepatic Neoplasm Under Monitored Anesthesia Care: A Randomized Controlled Study.

AbstractPercutaneous radiofrequency ablation (RFA) is a useful and safe procedure for treating hepatic neoplasm. However, liver RFA causes severe pain, which thereby increases the demand for monitored anesthesia care (MAC). Here, we compared the efficacy and safety of propofol and dexmedetomidine, which are commonly administered during MAC when performing RFA to assess hepatic neoplasm.In this randomized controlled trial, 40 patients were randomly allocated to 2 groups for elective RFA. Patients received either dexmedetomidine (group D) or propofol (group P). Both groups received the continuous infusion of remifentanil for pain control. The primary outcomes were opioid consumption and differences in partial pressure of arterial carbon dioxide (PaCO2) between pre- and postprocedure RFA. In addition, hemodynamic parameters, patient satisfaction, and interventional radiologist satisfaction were determined.There were significant differences in opioid consumption (50.1 ± 16.8 ng/kg/min [group D] vs 71.2 ± 18.7 ng/kg/min [group P]; P = 0.001) and delta PaCO2 (10.4 ± 6.4 mm Hg vs 17.2 ± 9.2 mm Hg, respectively; P = 0.016). Moreover, respiratory rates were significantly different between groups during RFA (P < 0.001). However, blood pressure and heart rate did not significantly change during RFA. Neither patient nor interventional radiologist satisfaction was significantly different between groups.Dexmedetomidine provides better respiratory stability and reduces opioid consumption in comparison with propofol when administered under MAC when performing RFA for hepatic neoplasm.

A case report: Clinical application of celiac plexus block in bile duct interventional procedures.

AbstractAlthough percutaneous transhepatic biliary drainage (PTBD) and tract dilatation (TD) are very painful procedures, almost all of those procedures have been conducted under local anesthesia and opioid injection due to the lack of manpower and time. Celiac plexus block (CPB) is an interventional technique used for diagnostic and therapeutic purposes in the treatment of abdominovisceral pain. CPB decreases the side effects of opioid medications and enhances analgesia from medications. We present the case of a patient who underwent PTBD and TD under CPB in order to reduce procedure-related abdominal pain.CPB can be a useful alternative technique for pain management during and after biliary interventional procedures, although CPB-induced complications must always be kept in mind.