Tae Hun An

Effects of lidocaine, ketamine, and remifentanil on withdrawal response of rocuronium

Background Rocuronium has been well known to produce withdrawal response in 50-80% patients when administered intravenously. Several drugs are administered prior injection of rocuronium to prevent the withdrawal response. We compared the preventive effect of lidocaine, ketamine, and remifentanil on the withdrawal response of rocuronium. Methods A total of 120 patients undergoing various elective surgeries were enrolled. Patients were allocated into 4 groups according to the pretreatment drugs (Group N, normal saline; Groups L, lidocaine 40 mg; Group K, ketamine 0.5 mg/kg; Group R, remifentanil 1 µg/kg). Patients received drugs prepared by dilution to 3 ml volume before injection of rocuronium. Withdrawal responses after injection of rocuronium were graded on a 4-point scale. Hemodynamic changes were observed before and after administration of pretreatment drugs and after endotracheal intubation. Results Incidence of withdrawal response was significantly lower in group L (20%), group K (30%), and group R (0%), than group N (87%). Severe withdrawal response was observed in 5 of the 30 patients (17%) in group L, and in 9 of the 30 patients (30%) in group K. There was no severe withdrawal response in group R. Mean blood pressure and heart rate were significantly decreased in group R compared to other groups. Conclusions It seems that remifentanil (1 µg/kg intravenously) was the strongest and most effective in prevention of withdrawal response after rocuronium injection among the 3 drugs.

Analysis of expert consultation referrals for anesthesia- related issues (December 2008-July 2010): KSA legislation committee report

Background Since 2009, database construction of anesthesia-related adverse events has been initiated through the legislation committee of the Korean Society of Anesthesiologists (KSA), based on expert consultation referrals provided by police departments, civil courts, and criminal courts. Methods This study was a retrospective descriptive analysis of expert consultation referrals on surgical anesthesia-related cases between December 2008 and July 2010. Results During the given period, 46 surgical anesthesia-related cases were referred to the KSA legislation committee for expert consultation. Because six cases were excluded due to insufficient data, 40 cases were included in the final analysis. Of 40 cases, 29 (72.5%) resulted in death. Respiratory events were most common in both surviving/disabled and dead patients (36.4 vs. 51.7%, respectively; P > 0.05). Overall, respiratory depression due to the drugs used for monitored anesthesia care (MAC) was the most common specific mechanism (25%), in which all but one case (profound brain damage) resulted in death. In all of these cases, surgeons or physicians provided MAC without the help of anesthesiologists. Conclusions Overall, the most common damaging mechanism was related to respiratory depression due to sedatives or anesthetics used for MAC. Almost all MAC injury cases are believed to be preventable with the use of additional or better monitoring and an effective response to initial physiological derangement. Thus, it is essential to establish practical MAC guidelines and adhere to these guidelines strictly to reduce the occurrence of severe anesthesia-related adverse outcomes.

Pneumonia due to aspiration of povidine iodine after induction of general anesthesia -A case report-.

Aspiration pneumonia is usually caused by aspiration of gastric contents during anesthesia. It causes severe pulmonary complications. Povidone iodine was used widely as an oral antiseptic. Although povidone iodine is thought to be a safe and effective antiseptic, severe complications from its aspiration may occur. We present a case of pneumonia secondary to aspiration of povidone iodine in a 16 year old female patient who underwent orofacial surgery. Aspiration pneumonia must be treated immediately. Mechanical ventilation with PEEP and periodical bronchial toilet with fiberoptic bronchoscopy were carried in the operating room and ICU. Bronchodilators, antibiotics, steroids and diuretics were also used to treat pneumonia. The patient was treated successfully without any complication.

Effect on thermoregulatory responses in patients undergoing a tympanoplasty in accordance to the anesthetic techniques during PEEP: a comparison between inhalation anesthesia with desflurane and TIVA

Background It has been known that positive end-expiratory pressure (PEEP) increases the vasoconstriction threshold by baroreceptor unloading. We compared the effect on the thermoregulatory responses according to anesthetic techniques between an inhalation anesthesia with desflurane and a total intravenous anesthesia (TIVA) with propofol and reminfentanil when PEEP was applied in patients undergoing tympanoplasty. Methods Forty-six patients with a scheduled tympanoplasty were enrolled and the patients were divided in two study groups. Desflurane was used as an inhalation anesthetic in group 1 (n = 22), while TIVA with propofol and remifentanil was used in group 2 (n = 24). PEEP was applied by 5 cmH2O in both groups and an ambient temperature was maintained at 22-24℃ during surgery. The core temperature and the difference of skin temperature between forearm and fingertip were monitored for about 180 minutes before and after the induction of general anesthesia. Results The final core temperature was significantly higher in group 2 (35.4 ± 0.7℃) than in group 1 (34.9 ± 0.5℃). Peripheral thermoregulatory vasoconstriction was found in 5 subjects (23%) in group 1 and in 21 subjects (88%) in group 2. The time taken for reaching the thermoregulatory vasoconstriction threshold was 151.4 ± 19.7 minutes in group 1 and 88.9 ± 14.4 minutes in group 2. Conclusions When PEEP will be applied, anesthesia with TIVA may have more advantages in core temperature preservation than an inhalation anesthesia with desflurane.

Effect of hydroxyethyl starch on blood glucose levels

Background Hydroxyethyl starch (HES), a commonly used resuscitation fluid, has the property to induce hyperglycemia as it contains large ethyl starch, which can be metabolized to produce glucose. We evaluated the effect of 6% HES-130 on the blood glucose levels in non-diabetic patients undergoing surgery under spinal anesthesia. Methods Patients scheduled to undergo elective lower limb surgery were enrolled. Fifty-eight patients were divided into two groups according to the type of the main intravascular fluid used before spinal anesthesia (Group LR: lactated Ringers solution, n = 30 vs. Group HES: 6% hydroxyethyl starch 130/0.4, n = 28). Blood glucose levels were measured at the following time points: 0 (baseline), 20 min (T1), 1 h (T2), 2 h (T3), 4 h (T4), and 6 h (T6). Results Mean blood glucose levels at T5 in the LR group and T4, T5 in the HES group, increased significantly compared to baseline. There were no significant changes in the serial differences of mean blood glucose levels from baseline between the two groups. Conclusions Administration of 6% HES-130 increased blood glucose levels within the physiologic limits, but the degree of glucose increase was not greater than that caused by administration of lactated Ringers solution. In conclusion, we did not find evidence that 6% HES-130 induces hyperglycemia in non-diabetic patients.

The effects of intrathecal fentanyl for spinal anesthesia in lower extremity surgery

BACKGROUND Intrathecal opioids in combination with bupivacaine has been shown to provide adequate sensory blockade and early recovery from spinal anesthesia. This study was investigated the added effects of intrathecal fentanyl 10 microgram to bupivacaine for spinal anesthesia. METHODS Sixty patients undergoing lower extremity surgery were into three groups. Group I received bupivacaine 10 mg (0.5%), gruop II received bupivacaine 5 mg with normal saline 1 ml, and group III received bupivacaine 5 mg with fentanyl 10 microg and normal saline 0.8 ml. RESULTS There was no significant difference between group I and group III in the peak level and duration of sensory block. But the intensity of motor blockade was decreased in group III compared with group I and side effects of spinal anesthesia with local anesthetics was decreased in group III compared with group I. In Group II, 7 patients were complained the pain during surgery. CONCLUSIONS Intrathecal fentanyl 10 microgram with bupivacaine 5 mg on spinal blockade provide reliable anesthesia for lower extremity surgery.

Thermoregulatory responses of sevoflurane, desflurane, and isoflurane during gynecologic laparoscopic surgery

BACKGROUND Core temperature decreases rapidly after the induction of general anesthesia, because the heat is redistributed to peripheral tissues. Thermoregulatory responses of volatile anesthetics have been tested, but their effects have not been directly compared. Therefore, we evaluated the thermoregulatory responses to sevoflurane, desflurane, and isoflurane. METHODS Sixty healthy patients scheduled for laparoscopic myomectomy or radical hysterectomy were allocated into three groups; Group S (sevoflurane, n = 20), Group D (desflurane, n = 20), and Group I (isoflurane, n = 20). Anesthesia was maintained with 1 minimum alveolar concentration (MAC) of sevoflurane, desflurane, and isoflurane in a 50/50 mixture of N2O/O2. Patients were maintained in a normovolemic and normocapnic state. The core temperature and forearm minus fingertip skin-temperature gradient (an index of peripheral vasoconstriction) were monitored after the induction of general anesthesia. RESULTS Each of the seven patients given sevoflurane, desflurane, and isoflurane vasoconstricted at a core temperature of 35.3 +/- 0.5degrees C, 33.6 +/- 0.4degrees C, and 35.2 +/- 0.4degrees C, respectively. The vasoconstriction threshold was the lowest in patients anesthetized with desflurane. The core temperature gradient (Ti-Tf) was significantly higher in patients that were anesthetized with desflurane than in those that were anesthetized with sevoflurane or isoflurane. The core temperature of desflurane was significantly lower than that of sevoflurane or isoflurane 15 minutes after the induction of anesthesia until 180 minutes of anesthesia. CONCLUSIONS These results indicate that the core temperature is maintained at a higher level in patients that have been anesthetized with sevoflurane or isoflurane than in those that have been anesthetized with desflurane.

Mega Acer Kit® is more effective for warming the intravenous fluid than Ranger™ and ThermoSens® at 440 ml/h of infusion rate: an experimental performance study

Background Few studies have investigated the effectiveness of intravenous fluid warmers at low and moderate flow rates below 1,000 ml/h. In this study, we compared the effectiveness of three different fluid warmers at a low flow rate (440 ml/h). Methods We experimentally investigated the fluid warming performances of Mega Acer Kit® (Group M, n = 10), Ranger™ (Group R, n = 10), and ThermoSens® (Group T, n = 10) at 440 ml/h for 60 min. All devices were set at a warming temperature of 41℃ with preheating for 10 min. Intravenous fluids were then delivered through them. The fluid temperature (primary endpoint) was measured at 76 cm from the device after infusion for 60 min. The expected decrease in mean body temperature (secondary endpoint) after 5 h infusion for a 70 kg patient (ΔMBT5) was also calculated. Results The fluid temperature (mean [95% CI]) at 76 cm from the device, 60 minutes after the infusion was higher in group M (36.01 [35.73–36.29]℃), compared to groups T (29.81 [29.38–30.24]℃) and R (29.12 [28.52–29.72]℃) (P < 0.001). The ΔMBT5 (mean [95% CI]) was significantly smaller in group M (−0.04 [−0.04 to −0.03]℃) than that in groups T (−0.27 [−0.28 to −0.29]℃; P < 0.001) and R (−0.30 [−0.32 to −0.27]℃; P < 0.001). However, none of the fluid warmers provided a constant normothermic temperature above 36.5℃. Conclusions Mega Acer Kit® was more effective in warming the intravenous fluid with the smallest expected change in the mean body temperature, compared to Ranger™ and ThermoSens®, at a flow rate of 440 ml/h.

A comparison of the clinical duration and recovery characteristics of cisatracurium after priming using rocuronium or cisatracurium: preliminary study.

Background The priming technique can speed up the onset of cisatracurium during intubation. However, there have been no reports on the effect of the priming technique on duration or recovery profile of cisatracurium. Therefore, we attempted to determine whether or not a priming technique with rocuronium or cisatracurium can affect clinical duration or recovery profiles of cisatracurium. Methods A total of 36 patients, ASA I and II, who were scheduled to undergo elective surgery, were enrolled. The patients were randomized into three groups and administered different drugs for the priming technique. Patients in group 1 received normal saline (control group). Patients in group 2 received rocuronium (0.06 mg/kg), and those in group 3 received cisatracurium (0.01 mg/kg) as a priming agent. Three minutes after injection of drugs, intubation doses of cisatracurium were administered (Group 1, 0.15 mg/kg; Groups 2 and 3, 0.14 mg/kg). Anesthesia was induced and maintained with propofol and remifentanil. Onset time, clinical duration, recovery index, recovery time, and total recovery time were measured by train of four monitoring. Results Onset time in the group 2 was significantly shorter than that of group 1 or 3 (P < 0.05). However, no significant differences in clinical duration, recovery index, recovery time, and total recovery time were observed among the three groups. Conclusions Priming with rocuronium for 3 minutes resulted in significantly accelerated onset of cisatracurium. However, it did not affect the clinical duration and recovery profiles of cisatracurium.

Is 0.6 mg/kg of succinylcholine adequate for tracheal intubation in Korean?

BACKGROUND The usual dose of succinylcholine for tracheal intubation is 1.0 mg/kg. If the patient is not ventilated by face mask after administration of the succinylcholine (1.0 mg/kg), the patient may experience significant hemoglobin desaturation. The purpose of the present study was to evaluate an appropriate dose of succinylcholine for tracheal intubation in Korean. METHODS Sixty patients scheduled for elective surgery were randomly divided into three groups; group I (succinylcholine 0.3 mg/kg, n = 20), group II (succinylcholine 0.6 mg/kg, n = 20), group III (succinylcholine 1.0 mg/kg, n = 20). All patients were not premedicated. After loss of consciousness, the patients received succinylcholine 0.3, 0.6, 1.0 mg/kg, respectively. The contraction responses of the adductor pollices muscle were monitored by using TOF. Tracheal intubation was accomplished as the height of T1 was inhibited maximally. Then, intubation scores were recorded. The recovery times from neuromuscular blockade in groups II and III were also measured. RESULTS The acceptable conditions for tracheal intubation were 30%, 100%, and 100%, respectively in groups I, II, and III. The onset time was 80.4 +/- 15.5 sec, 69.6 +/- 13.1 sec, and 56.1 +/- 9.3 sec, respectively. The recovery time (T1 = 90%) was 446.0 +/- 86.2 sec, 694.0 +/- 84.7 sec, respectively in groups II and III. The onset time was the fastest in group III. But the recovery time in group III was slower than in group II. CONCLUSIONS We concluded that 0.6 mg/kg of succinylcholine is an appropriate dose for tracheal intubation in Korean except for rapid sequence intubation.