Si Ra Bang

Predictors of High Intraoperative Blood Loss Derived by Simple and Objective Method in Adult Living Donor Liver Transplantation

We conducted a risk factor analysis for high intraoperative blood loss (IBL) in 555 living donor liver transplantation (LDLT) cases with a simple and objective method of IBL estimation based on the concept of red cell mass (RCM): Lost RCM (mL) = patients estimated blood volume (mL) × (preoperative hematocrit in % - postoperative hematocrit in %) + (transfused leukocyte-depleted red blood cell in units × 213 × 70%) + (transfused Cell Saver blood in mL × 55%). Analysis of 33 preoperative variables revealed that Model for End-stage Liver Disease (MELD) score, albumin, the presence of ascites, and previous abdominal surgery were correlated with high IBL (lost RCM > 1000 mL) in multivariate logistical regression analysis. In conclusion, we found that MELD score, albumin, the presence of ascites, and previous abdominal surgery were significantly correlated with high IBL during adult LDLT.

Postoperative nausea and vomiting after endoscopic thyroidectomy: total intravenous vs. balanced anesthesia

Background Endoscopic thyroidectomy was recently introduced and has been rapidly accepted by surgeons and patients. The present study was conducted to estimate and compare the incidences of postoperative nausea and vomiting (PONV) after endoscopic thyroidectomy using two different anesthetic methods: sevoflurane based balanced anesthesia; total intravenous anesthesia (TIVA). Methods Ninety nine female patients that were scheduled to undergo elective endoscopic thyroidectomy under general anesthesia were enrolled. These patients were randomly allocated to receive sevoflurane based balanced anesthesia (BA group) or propofol-remifentanil anesthesia (TIVA group). PONV was evaluated using a 4-point Likert scale, and pain using a visual analogue scale (VAS; range 0 to 100) for 0-2, 2-6, and 6-24 hours postoperatively. At 24 hours postoperatively, overall patient satisfaction regarding PONV and pain were recorded. Results The incidence of PONV was 14.6% in the TIVA group and 51.3% in the BA group. The incidence of nausea at 0-2 and 2-6 hours postoperatively was lower in the TIVA group than in the BA group (4.2% vs. 35.9%, 6.3% vs. 23.1%, respectively), but no between-group difference was observed at 6-24 hours postoperatively (8.3% vs. 5.1%). Antiemetic usage at 0-2 and 2-6 hours was lower in the TIVA than the BA group (4.2% vs. 38.5%, 6.3% vs. 23.1%), but no between-group difference was observed for 6-24 hours (6.3% vs. 7.7%). There were no differences in pain or in patient satisfaction. Conclusions After endoscopic thyroidectomy, total intravenous anesthesia with propofol-remifentanil is associated with less PONV during the early postoperative period (0-6 hours) than sevoflurane based balanced anesthesia.

Antinociceptive Effects of Ginsenoside Rg3 in a Rat Model of Incisional Pain

Background: Ginsenoside Rg3 is an extract of total ginseng saponins, which accounts for 4.7% of all saponins. This study aimed to identify the mechanisms of the antinociceptive effects of ginsenoside Rg3. Methods: Rats were randomly divided into six groups, which were treated with vehicle or 0.5, 1, 1.5, 2, or 4 mg/kg of ginsenoside Rg3 intraperitoneally 2 h after a plantar incision was made. To evaluate the mechanisms of antinociceptive effects, the rats were intraperitoneally injected with naloxone 5 mg/kg, atropine 1 mg/kg, yohimbine 2 mg/kg, mecamylamine 1 mg/kg, prazosin 1 mg/kg, and dexmedetomidine 5 μg/kg. Hyperalgesia produced by the plantar incision was assessed using von Frey filaments 1 day before the incision (BI) and 2 h after the plantar incision (AP); this measurement was repeated at 15, 30, 45, 60, 80, 100 and 120 min, and 24 and 48 h after the injection of ginsenoside Rg3. Serum interleukin-1β (IL-1β) and interleukin-6 (IL-6) levels were measured 1 day before incision and 120 min, 24 h, and 48 h after the injection of ginsenoside Rg3 or vehicle. Results: The mechanical withdrawal threshold (MWT) significantly increased in the group that received ginsenoside Rg3. The dose-MWT response showed a curvilinear, bell-shaped relationship. The maximum MWT was found with the administration of ginsenoside Rg3 at 1.5 mg/kg; MWT decreased to 2 and 4 mg/kg. Yohimbine diminished the analgesic effect of ginsenoside Rg3. Prazosin and dexmedetomidine increased the analgesic effect of ginsenoside Rg3. IL-1β and IL-6 appeared significantly lower relative to control group. Conclusions: Ginsenoside Rg3 has an analgesic effect with a curvilinear dose-response relationship. Alpha 2 adrenergic receptor appeared to be related to the analgesic effect of ginsenoside Rg3. Also, the anti-inflammatory effect of ginsenoside Rg3 could be related to its analgesic effect.

Comparison of respiratory mechanics between sevoflurane and propofol-remifentanil anesthesia for laparoscopic colectomy

Background The creation of pneumoperitoneum and Trendelenburg positioning during laparoscopic surgery are associated with respiratory changes. We aimed to compare respiratory mechanics while using intravenous propofol and remifentanil vs. sevoflurane during laparoscopic colectomy. Methods Sixty patients undergoing laparoscopic colectomy were randomly allocated to one of the two groups: group PR (propofol-remifentanil group; n = 30), and group S (sevoflurane group; n = 30). Peak inspiratory pressure (PIP), dynamic lung compliance (Cdyn), and respiratory resistance (Rrs) values at five different time points: 5 minutes after induction of anesthesia (supine position, T1), 3 minutes after pneumoperitoneum (lithotomy position, T2), 3 minutes after pneumoperitoneum while in the lithotomy-Trendelenburg position (T3), 30 minutes after pneumoperitoneum (T4), and 3 minutes after deflation of pneumoperitoneum (T5). Results In both groups, there were significant increases in PIP and Rrs while Cdyn decreased at times T2, T3, and T4 compared to T1 (P < 0.001). The Rrs of group PR for T2, T3, and T4 were significantly higher than those measured in group S for the corresponding time points (P < 0.05). Conclusions Respiratory mechanics can be adversely affected during laparoscopic colectomy. Respiratory resistance was significantly higher during propofol-remifentanil anesthesia than sevoflurane anesthesia.

Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis

Air-Q® (air-Q) is a supraglottic airway device which can be used as a guidance of intubation in pediatric as well as in adult patients. We evaluated the efficacy and safety of air-Q compared to other airway devices during general anesthesia in pediatric patients by conducting a systematic review and meta-analysis. A total of 10 studies including 789 patients were included in the final analysis. Compared with other supraglottic airway devices, air-Q showed no evidence for a difference in leakage pressure and insertion time. The ease of insertion was significantly lower than other supraglottic airway devices. The success rate of intubation was significantly lower than other airway devices. However, fiberoptic view was better through the air-Q than other supraglottic airway devices. Therefore, air-Q could be a safe substitute for other airway devices and may provide better fiberoptic bronchoscopic view.

Neonatal anesthesia: how we manage our most vulnerable patients

Neonates undergoing surgery are at higher risk than older children for anesthesia-related adverse events. During the perioperative period, the maintenance of optimal hemodynamics in these patients is challenging and requires a thorough understanding of neonatal physiology and pharmacology. Data from animals and human cohort studies have shown relation of the currently used anesthetics may associate with neurotoxic brain injury that lead to later neurodevelopmental impairment in the developing brain. In this review, the unique neonatal physiologic and pharmacologic features and anesthesia-related neurotoxicity will be discussed.

Comparison of analgesic effects of programmed intermittent epidural bolus and continuous epidural infusion after total knee arthroplasty

After total knee arthroplasty (TKA), patients suffer pain; therefore, many analgesic techniques have been invented. Epidural analgesia is widely used and can be delivered by continuous epidural infusion (CEI), patient controlled epidural analgesia (PCEA), or intermittent epidural bolus (IEB). However, CEI is associated with greater incidence of motor block with higher concentrations of anesthetics, and inadequate analgesia is sometimes observed with diluted solutions [1]. One study suggested that uniform diffusion of anesthetics in epidural space is better obtained by administration of bolus [2], however, additional work is needed on nurses or patients.

Cardiac Tamponade Following Ultrasonography-Guided Trigger Point Injection

Abstract Background: Trigger point injection [TPI] is generally considered a safe and easy procedure. Findings: We describe a case of cardiac tamponade after ultrasonography [US]-guided TPI in a thin patient. The symptoms progressively appeared directly after the injection, and the patient experienced cardiogenic shock 3 h later. Cardiac tamponade was diagnosed with difficulty when US was performed near the injection site, and then pericardiocentesis was performed immediately. Conclusions: When US-guided TPI is performed near the neck and chest, the authors suggest that the entire shaft and tip of the needle be identified to prevent any critical complications during an US-guided procedure.

Successful use of caudal anesthesia and light sevoflurane mask ventilation for inguinal hernia repair in an infant with multiple large intrapulmonary cysts.

Cystic lung diseases of infants include congenital cystic adenoid malformation, pulmonary sequestration, bronchogenic cyst, and bronchial atresia. The progressions of cystic lung disease vary from spontaneous regression to severe respiratory difficulty [1]. Infants with cystic lung disease can suffer variable degrees of respiratory symptoms which can result in recurrent infection and pulmonary hypoplasia [2]. Therefore, perioperative management of patients with cystic lung disease can be a challenge for anesthesiologists. We report our experience with a 2-month-old female patient with multiple large intrapulmonary cysts. The 2-month-old-female patient was scheduled for surgery for a right-side inguinal hernia. The baby was born prematurely at 36 weeks, weighing 3.4 kg. She was admitted to the neonatal intensive care unit for 4 days right after birth. She was asymptomatic at birth and doing well after discharge. The patient was diagnosed with inguinal hernia and scheduled for surgery. In the preoperative evaluation, chest X-rays showed a unilocular air-containing cystic lesion of 4.8 × 3.3 cm in size occupying the left upper lung region (Fig. 1A). She was checked via a computed tomography (CT) scan. The CT scan revealed a large air-containing cyst in left upper lung and several small cysts in right upper lobe, right middle lobe, and both lower lobes (Fig. 1B). Fig. 1 Preoperative infantogram. An unilocular air-containg cystic lesion (4.8 × 3.3 cm) in left upper lung (A). CT scan represented large air-containing cyst in the left upper lung and several small cysts in multiple lobes (B). In the operating room, she was monitored through pulse oximetry, non-invasive arterial pressure and electrocardiographic monitoring. She received 1 mg/kg ketamine intravenously. The patient was placed in the right lateral position. After local anesthesia with 1% lidocaine, we used 0.25% bupivacaine 1 ml/kg for the caudal block with 22-gauge angiocatheter using an ultrasound machine (Philips CX50, Philips ultrasound, Bothell, WA, USA). She turned into the supine position right after the injection. After 10 minutes, we confirmed motor block of the lower extremities. There was no lower extremity movement during the operation. Blood pressure and heart rate were maintained within baseline values. During the operation, we used spontaneous breathing light sevoflurane for sedation via a face mask. The total operation time was 20 minutes. She was transferred to the postanesthetic care unit with intact self-respiration. She was discharged the next day uneventfully. A caudal block is a commonly performed technique during anesthesia of pediatric patients. It is known to be used as the sole form of anesthesia instead of as general anesthesia for high-risk neonate patients. Our institution usually performs general anesthesia in infants for inguinal hernia repair. However, in this case, we considered the use of regional anesthesia to avoid unintentional complications. A variety of congenital cystic lung lesions may appear in the neonatal period. The development of prenatal care has made frequent the detection of congenital cystic lung disease via fetal ultrasonography [1]. The cystic lesion in her CT scan represented large air-containing cyst in the left upper lung and several small cysts in multiple lobes. There are few reports of the anesthetic management of cases of inguinal hernia repair in infants with multiple intrapulmonary cysts. Our anesthetic concern was to prevent barotraumas due to positive pressure ventilation. Large cystic lesions can induce tension pneumothorax and can further cause cardiovascular collapse. Therefore we decided to utilize regional anesthesia with spontaneous mask ventilation. Another concern was the risk of postoperative apnea. Before reaching the postconceptional age of 60 weeks, ex-premature infants are at risk of postoperative apnea [3]. Our patients postconceptional age was 44 weeks so the risk of apnea still remained. There are several anesthtetic techniques to avoid postoperative apnea including caudal or spinal anesthesia. Caudal anesthesia has considerably easier technical requirements and for that reason is performed widely. It is known to a safe and effective procedure for pediatric patients undergoing subumbilical surgery. However, there remain some problems such as the presence of pain and the possibility of an inadequate anesthetic level. Geze et al. [4] reported a successful case of caudal anesthesia during inguinal hernia repair of a low-birth-weight neonate while awake. However, we used ketamine during caudal block for relief in patients with stressful conditions. During the operation, we established light sevoflurane mask ventilation and maintained self-respiration without any adverse events. The epidural space of infants is different from that of adults due to increased vascularity, less fat, and a smaller absorptive surface for local anesthetics [5]. So, we used ultrasonography to ensure safety and accuracy of the regional block. It provided the advantage of detecting sacral anatomy and of visualing the spread of local anesthetics. Therefore, the side effects of a caudal block, such as an inadvertent vascular or dural injection, can be minimized. The combination of sevoflurane and caudal anesthesia may prevent movement and pain during surgery in accordance with a stable hemodynamic condition. In conclusion, the anesthesic care of infants with cystic lesions can be challenging for anesthesiologists. We report a successful single-shot caudal block under light sevoflurane sedation. It can be used effectively for performing a procedure on a high-risk infant.

Dexmedetomidine and remifentanil in the perioperative management of an adolescent undergoing resection of pheochromocytoma -A case report-

A 15-year-old adolescent with unilateral multiple adrenal pheochromocytoma had an episode of subcortical intracerebral hemorrhage and seizure 6 weeks before the surgery. He was pretreated with terazosin, losartan, atenolol and levetiracetam for 2 weeks. Dexmedetomidine was started in the preoperative waiting area, and a combination of dexmedetomidine and remifentanil was continuously infused for most of anesthetic time. To control blood pressure, bolus injection of remifentanil and low-dose infusion of sodium nitroprusside, nicardipine, and esmolol were administered during three adrenergic crises. There was minimal post-resection hypotension, and his trachea was extubated safely 20 min after the surgery. He was discharged without noticeable complication. His catecholamine levels showed the steadily decreasing pattern during the operation in this case. Though a combination of dexmedetomidine and remifentanil may not prevent the hemodynamic instability impeccably during the tumor manipulation, this combination seems to be the way of interrupting release of catecholamines and minimizing hemodynamic fluctuations.