Soo Joo Choi

Neck circumference to thyromental distance ratio: a new predictor of difficult intubation in obese patients

BACKGROUND This study was performed to assess whether intubation is more difficult in obese patients and to assess the ability of a new index: the ratio of the neck circumference to thyromental distance (NC/TM), to predict difficult intubation in obese patients. METHODS The incidence of difficult tracheal intubation in 123 obese (BMI≥27.5 kg m(-2)) and 125 non-obese patients was compared. Difficult intubation was determined using the intubation difficulty scale (IDS≥5). The NC/TM ratio was calculated and its ability to predict difficult intubation in obese patients was compared with that of established predictors including high BMI, the Mallampati score, the Wilson score, NC, width of mouth opening, sternomental distance, TM, and a previous history of difficult intubation. RESULTS Difficult intubation was more frequent in obese patients than in non-obese patients (13.8% vs 4.8%; P=0.016). Multivariate analysis revealed that the Mallampati score, the Wilson score, and NC/TM independently predicted difficult intubation in obese patients. Among these three indices, NC/TM showed the highest sensitivity and a negative predictive value, and largest area under the curve on an ROC curve. CONCLUSIONS Difficult intubation was more common in obese patients and the NC/TM was a better method for predicting difficult intubation than other established indices.

The changes in coagulation profile and epidural catheter safety for living liver donors: A report on 6 years of our experience

The use of epidural catheters has been a subject of active debate in living liver donors because of the possible postoperative coagulation derangement and the subsequent risk of epidural hematoma. The aim of this study was to evaluate the safety of epidural catheters in relation to the changes in coagulation profile based on a review of previously published literature and the results of our 360 donors. In both the literature and in our cases, platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) in cases of heparin administration showed significant changes (P < 0.05), especially after right lobectomy. Platelet count reached its nadir on postoperative day (POD) 2–3, while PT and aPTT reached their peaks on POD 1–2 and at the end of the operation, respectively. In our donors, the ranges of platelet count, PT, and aPTT for the first 3 PODs were 54–359 ×10/μL, 0.99–2.38 international normalized ratio (INR), and 25.9–300 seconds, respectively, and of note, 5 donors (1.4%) had a platelet count of <80 × 10/μL and 9 donors (2.5%) had a PT of >2.0 INR. Epidural catheterizations were performed in 242 donors, and the catheters were removed on POD 3–4 in 177 donors (73.1%). Mean (range) of platelet count, PT, and aPTT on the day of catheter removal were 168.4 ± 42.9 (82–307) × 10/μL, 1.33 ± 0.18 (0.99–1.93) INR, and 40.9 ± 4.8 (32.0–70.6) seconds, respectively. No epidural hematoma was observed in this study. In conclusion, the discreet use of epidural catheters in live liver donors, in spite of postoperative coagulation derangements, appears to be safe regardless of the type of hepatectomy performed. Liver Transpl 13:62–70, 2007.

Effects of Gender on White Blood Cell Populations and Neutrophil-Lymphocyte Ratio Following Gastrectomy in Patients with Stomach Cancer

Alterations of absolute number or percentage of circulating white blood cell (WBC) subsets are associated with psychological and physical stress. Gender effects on the changes of circulating WBC subsets following surgical treatment have not been determined. Therefore, the current study aimed to determine whether circulating neutrophils, lymphocytes and monocytes, and neutrophil-lymphocyte ratio (N/L) are different following major surgery according to the gender. We studied 409 male patients and 212 female patients who underwent total or subtotal gastrectomy due to stomach cancer, from 1 January to 31 December in 2005. The WBC count and percentage of its subsets were obtained from database and N/L was directly calculated from the full blood count preoperatively, immediate postoperatively, and postoperative day 1, 3, 5 in a retrospective manner. Compared to preoperative values, neutrophilia, lymphopenia, monocytopenia, and increased N/L were associated with gastrectomy in all patients. In the comparison study between genders, there were significantly increased proportion of neutrophils, decreased lymphocytes and monocytes, and higher N/L in female patients than in male patients after gastrectomy. These findings indicate that female patients showed more immune-compromised response to gastrectomy than male patients.

The effects of desflurane and propofol‐remifentanil on postoperative hepatic and renal functions after right hepatectomy in liver donors

Various volatile anesthetics have been used in hepatectomy in living donors, and their effects on major organs have been extensively evaluated. However, the impact of total intravenous anesthesia (TIVA) on postoperative liver and renal functions after large liver resections has been less extensively investigated than that of volatile agents. The aim of this study was to compare the postoperative hepatic and renal functions between volatile anesthesia with desflurane and TIVA with propofol‐remifentanil in living donors undergoing right hepatectomy. Seventy adult patients were randomly allocated into 2 groups: the desflurane group (n = 35) and TIVA group (n = 35). Aspartate aminotransferase, alanine aminotransferase, prothrombin time (PT), albumin, total bilirubin (TB), blood urea nitrogen (BUN), creatinine (Cr), BUN/Cr ratio, estimated glomerular filtration rate (GFR), platelet count, and hemoglobin levels were analyzed in the preoperative period, immediately after the operation, and on the first, second, third, fifth, seventh, and thirtieth postoperative days (PODs). Most of the liver function test results were not significantly different between the 2 groups. However, PT (international normalized ratio) and TB were significantly greater on POD 5 in the TIVA group. Among the renal function tests, Cr was significantly higher and estimated GFR was significantly lower on POD 1 in the TIVA group. The platelet counts and hemoglobin levels were similar between the 2 groups. In conclusion, the results of our study suggest that living related donors for liver transplant may have a better outcome following anesthesia with desflurane. However, further testing will be necessary to prove this hypothesis. Liver Transpl 14:1150–1158, 2008.

Incidence of severe ventricular arrhythmias during pulmonary artery catheterization in liver allograft recipients

Liver allograft recipients may develop a hyperdynamic circulation and cardiac electrophysiologic abnormalities. The incidence of severe ventricular arrhythmias in liver allograft recipients during pulmonary artery (PA) catheterization was determined. One hundred five liver allograft recipients were studied prospectively; 5 of the patients with preexisting valvular heart disease, ischemic heart disease, or arrhythmias were excluded. Severe ventricular arrhythmia, defined as 3 or more consecutive ventricular premature beats occurring at a rate of >100 per minute, was observed in 37.0% of the patients during insertion of the catheter and in 25.0% of the patients during removal of the catheter. Two patients developed ventricular tachycardia, and 2 developed ventricular fibrillation; the arrhythmias in these 4 patients did not respond to appropriate pharmacological treatment but resolved promptly after removal of the PA catheter. The catheter transit time from the right ventricle to the pulmonary capillary wedge position was longer in patients with severe ventricular arrhythmia than in those without this arrhythmia (91.6 ± 103.6 s versus 53.3 ± 18.4 s, P < 0.05). In conclusion, patients undergoing liver transplantation have a high risk of developing a ventricular arrhythmia during PA catheterization. Liver Transpl 13:1451–1454. 2007.

Intrathecal morphine combined with intravenous patient‐controlled analgesia is an effective and safe method for immediate postoperative pain control in live liver donors

The healthy condition of living donors makes their tolerance to pain particularly low, and clinicians are often challenged to come up with an analgesic technique that is effective yet ensures donor safety. This study compared, in donor right hepatectomy, the efficacy and safety of preoperative intrathecal morphine (ITM) combined with intravenous patient‐controlled analgesia (IV‐PCA) with IV‐PCA alone. Forty adult patients were randomly allocated into 2 groups: ITM+IV‐PCA group (n = 20) and IV‐PCA‐only group (n = 20). Patients in the ITM+IV‐PCA group received morphine sulfate (400 μg). The visual analog scale (VAS) at rest and when coughing and supplementary meperidine and IV‐PCA (fentanyl) consumption were assessed at 2, 4, 6, 8, 10, 12, 18, 24, 30, 36, 42, 48 56, 64, and 72 hours after surgery. Also, side effects such as sedation, dizziness, nausea, vomiting, pruritus, and respiratory depression were evaluated. The ITM+IV‐PCA group showed significantly less pain at rest and when coughing for up to 30 hours and 24 hours, respectively. Cumulative postoperative consumption of meperidine and IV‐PCA (fentanyl) were significantly less in the ITM+IV‐PCA group. The incidence of side effects were comparable between the 2 groups except for pruritus; its incidence was significantly higher in the ITM+IV‐PCA group during the first 24 hours, but no treatment was required due to its mild severity. The results of our study suggest that preoperative ITM combined with IV‐PCA may be considered as an effective and safe pain management regimen in living liver donors who have characteristics of low tolerance to pain and postoperative coagulation derangement. Liver Transpl 15:381–389, 2009.

The effects of desflurane and sevoflurane on hepatic and renal functions after right hepatectomy in living donors

We compared postoperative hepatic and renal functions between the two inhalational anesthetics, desflurane and sevoflurane in living donors undergoing right hepatectomy. Seventy‐four adult donors were randomly allocated into Des group (n = 37) and sevo group (n = 37). Before the induction of anesthesia, morphine sulfate 400 μg was injected intrathecally. Anesthesia was maintained with one minimum alveolar concentration (MAC) of deflurane or sevoflurane plus continuous intravenous remifentanil. Liver and renal function tests were performed and analysed at preoperative period, immediately after operation, and on 1st, 2nd, 3rd, 5th, 7th, and 30th postoperative days (PODs). Aspartate aminotransferase (AST) showed significant elevations from the day of surgery to POD 3 and alanine aminotransferase (ALT) was significantly elevated on POD 1 and POD 3 in the sevo group. Albumin level was significantly lower on POD 2 in the sevo group. Creatinine was significantly higher on POD 3 and POD 30 and estimated glomerular filtration ratio was significantly lower on POD 3 and POD 30 in the sevo group. No patient developed hepatic or renal failures. The results of our study showed better postoperative hepatic and renal function test with desflurane than sevoflurane at equivalent dose of 1 MAC in living donors undergoing right hepatectomy, but further study is required to evaluate clinical importance.

Effect of intraoperative lidocaine on anesthetic consumption, and bowel function, pain intensity, analgesic consumption and hospital stay after breast surgery

Background Perioperative lidocaine infusion improves postoperative outcomes, mostly after abdominal and urologic surgeries. Knowledge of the effect of lidocaine on peripheral surgeries is limited. Presently, we investigated whether intraoperative lidocaine infusion reduced anesthetic consumption, duration of ileus, pain intensity, analgesic consumption and hospital stay after breast plastic surgeries. Methods Sixty female patients, aged 20-60 years, enrolled in this prospective study were randomly and equally divided to two groups. One group (n = 30) received a 1.5 mg/kg bolus of lidocaine approximately 30 min before incision followed by continuous infusion of lidocaine (1.5 mg/kg/h) until skin closure (lidocaine group). The other group (n = 30) was untreated (control group). Balanced inhalation (sevoflurane) anesthesia and multimodal postoperative analgesia were standardized. End tidal sevoflurane concentration during surgery, time to the first flatus and defecation, visual analog pain scale (0-10), analgesic consumption and associated side effects at 24, 48, and 72 h after surgery, hospital stay, and patients general satisfaction were assessed. Results Compared to the control group, intraoperative lidocaine infusion reduced by 5% the amount of sevoflurane required at similar bispectral index (P = 0.014). However, there were no significant effects of lidocaine regarding the return of bowel function, postoperative pain intensity, analgesic sparing and side effects at all time points, hospital stay, and level of patients satisfaction for pain control. Conclusions Low dose intraoperative lidocaine infusion offered no beneficial effects on return of bowel function, opioid sparing, pain intensity and hospital stay after various breast plastic surgeries.

Comparison of tracheal intubation with the Airway Scope or Clarus Video System in patients with cervical collars

Tracheal intubations with the Airway Scope or the Clarus Video System, a new rigid fibrescope, were compared in 140 patients whose necks were immobilised by cervical collars. The time for intubation, success rate, number of attempts and number of optimisation manoeuvres were assessed. Mean (SD) intubation time was longer with the Airway Scope (30.4 (16.5) s) than with the Clarus Video System (18.9 (15.2) s; p = 0.003) and the median (IQR [range]) number of optimisation manoeuvres was also marginally different; 0 (0–1 [0–2]) with the Airway Scope, 0 (0–0 [0–2]) with the Clarus Video System; p = 0.004. The tracheas of 67 (95.7%) and 66 (94.3%) patients were successfully intubated with the Airway Scope and the Clarus Video System, respectively (p = 1.0). The number of attempts, vital signs and complications were not different between devices. The Clarus Video System was comparable to the Airway Scope in the success rate for tracheal intubation, but provided faster and easier intubations than the Airway Scope in patients with cervical collars.

Comparison of the prophylactic anti-emetic efficacy of ramosetron and ondansetron in patients at high-risk for postoperative nausea and vomiting after total knee replacement.

We compared the prophylactic anti‐emetic efficacy of ramosetron, a newly developed 5‐HT3 antagonist, and ondansetron in patients at high‐risk for postoperative nausea and vomiting after total knee replacement. Eighty‐four patients with three risk factors for postoperative nausea and vomiting (female, non‐smoking and use of postoperative opioid use (ropivacaine and hydromorphone patient controlled epidural analgesia)) undergoing unilateral total knee replacement were randomly allocated to ramosetron 0.3 mg (n = 42) or ondansetron 4 mg (n = 42) groups. A complete response (no postoperative nausea and vomiting and no rescue anti‐emetic) and the incidence of postoperative nausea and vomiting were assessed for 48 h after surgery at 0–2 h, 2–6 h, 6–24 h, and 24–48 h. More patients in the ramosetron group had a complete response between 2 and 48 h. The incidence of nausea between 2 and 24 h and the severity of nausea between 2 and 48 h were also less in the ramosetron group. Ramosetron was more effective than ondansetron in preventing postoperative nausea and vomiting in patients at high risk undergoing unilateral total knee replacement.