Tae Soo Hahm

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.

A Correlation between Low Back Pain and Associated Factors: A Study Involving 772 Patients who Had Undergone General Physical Examination

Many factors are associated with the development of low back pain. Among them, exercise, obesity, smoking, age, educational level and stress are the most common. This study examined the association of these factors with low back pain. An additional aim was to determine a procedure for preventing low back pain. This study analyzed the responses to a questionnaire sent to 772 individuals who had undergone a medical examination at this hospital in 2003 and excluded the individuals who had shown symptoms or their test results indicated a particular disease. Assuming that there were no variables, individuals who exercised regularly 3-4 times per week would have a lower chance of having low back pain than those who did not exercise regularly. The analysis revealed that individuals with a college degree or higher education have a lower chance of experiencing low back pain than those with only a high school education or even college drop-outs. When the other variables were constant, age, extent of obesity (body mass index), smoking and level of stress were not found to affect the development of low back pain. The level of education was associated with the development of low back pain. However, regular exercise 3-4 times per week or more would be most effective in reducing the incidence and duration of low back pain.

Effects of epidural injection on spinal block during combined spinal and epidural anesthesia for cesarean delivery

Background and Objectives Epidural injection has been known to enhance spinal anesthesia in combined spinal and epidural (CSE) anesthesia. Saline and local anesthetics have been reported to have a volume effect, elevating sensory level when supplementing a volume into the epidural space. We evaluated the effects of epidural injection when using the CSE technique for cesarean delivery. Methods Sixty-six parturients were allocated randomly into group C (control, n = 21), S (saline, n = 21), or B (bupivacaine, n = 24): epidural injections of 10 mL saline and 0.25% bupivacaine were given in groups S and B, respectively, 10 minutes after they received 8 mg of 0.5% hyperbaric bupivacaine intrathecally, and no injection was given in group C. The sensory level at 10 minutes, the maximal level and the time to reach it, and degree of motor block and muscle relaxation were compared. We also investigated intraoperative side effects and postoperative findings in the postanesthesia care unit. Results Epidural injection raised the sensory level significantly in groups S and B, but the maximal height of sensory block and degree of muscle relaxation did not differ among the groups. Fewer patients complained of intraoperative pain in group B than in the other groups (P < .001). Conclusions We could not achieve satisfactory surgical analgesia with 8 mg of hyperbaric bupivacaine injected into the subarachnoid space using the needle-through-needle technique in cesarean deliveries. An epidural saline injection elevated the sensory level, which did not improve the spinal block, whereas an epidural injection of 10 mL of 0.25% bupivacaine enhanced the spinal block and sustained the block postoperatively.

Plasma levels of interleukin-6 and interleukin-10 are affected by ketorolac as an adjunct to patient-controlled morphine after abdominal hysterectomy.

Objective: Because morphine affects various immune functions, patient-controlled analgesia with morphine may further deteriorate the immune mechanisms after surgery. Therefore, the purpose of this study was to determine differences between morphine patient-controlled analgesia and a combination of morphine and ketorolac in interleukin-6 and interleukin-10 responses, and in analgesia and morphine-related side effects. Design: Prospective study. Patients: Twenty-two patients who underwent abdominal hysterectomy were classified randomly into two groups: (1) patient-controlled analgesia with morphine; and (2) patient-controlled analgesia with a combination of morphine and ketorolac. Blood samples to measure cytokines were collected at preoperatively, immediately postoperatively, and 2 hours, 4 hours, and 24 hours postoperatively. Outcome Measures: Plasma was separated and frozen until the analysis of cytokines using enzyme-linked immunosorbent assays. Postoperative pain was assessed using a visual analog score. Sedation was checked based on a protocol developed at the Samsung Medical Center. Results: In the two groups, interleukin-6 increased immediately postoperatively, and it remained consistent for 24 hours. Interleukin-10 concentrations peaked at 2 hours postoperatively and progressively decreased. Cytokine concentrations between the two groups were significantly different for interleukin-6 24 hours postoperatively (p = 0.026) and for interleukin-10 4 hours postoperatively (p = 0.045). Total analgesic use was not different, but morphine consumption was significantly different (p = 0.037 at 4 hours postoperatively, p = 0.015 at 24 hours postoperatively). Pain scores, sedation, and side effects were unaffected by the patient-controlled analgesia regimen. Conclusions: The authors conclude that supplementation using ketorolac plus administration of morphine modifies cytokine responses and may contribute to immune augmentations during postoperative periods.

Effects of Repeat Bolus Ethanol Injections on Cardiopulmonary Hemodynamic Changes during Embolotherapy of Arteriovenous Malformations of the Extremities

PURPOSE This study was designed to investigate the effects of repeat bolus absolute ethanol injections on cardiopulmonary hemodynamic changes during ethanol embolotherapy of inoperable congenital arteriovenous (AV) malformations in the extremities. MATERIALS AND METHODS Thirty adult patients (14 male, 16 female; age range, 22-51 years) who underwent ethanol embolotherapy of extremity AV malformations were enrolled in the study. A pulmonary artery catheter was used to measure hemodynamic profiles at baseline (T(baseline)), immediately before (T(pre)) and after (T(post)) a bolus injection of absolute ethanol, at the time of the maximum mean pulmonary arterial pressure (PAP) value during a session (T(highest)), 10 minutes after the final injection (T(final)), and after restoration of spontaneous breathing (T(resp)). RESULTS The systolic, mean, and diastolic PAP (P < .01, P < .01, and P < .01, respectively) and the systemic vascular resistance index (P < .05) and pulmonary vascular resistance index (PVRI; P < .05) of T(highest) and T(resp) were significantly higher than values for T(final). The volume of a single bolus injection of absolute ethanol from 0.023 to 0.175 mL/kg of body weight showed that the systolic PAP (P = .02), pulmonary capillary wedge pressure (P = .02), and PVRI (P < .01) significantly increased in accordance with the increased single volume of absolute ethanol. A significant increase of the right ventricular end-diastolic volume index and right ventricular end-systolic volume index were observed at a dose of more than 0.14 mL/kg of body weight for a single bolus injection of absolute ethanol. CONCLUSIONS During ethanol embolotherapy of extremity AV malformations, significant hemodynamic changes can arise during a bolus injection of absolute ethanol. Cardiopulmonary hemodynamic profiles should be monitored closely after a bolus injection of more than 0.14 mL/kg of body weight of absolute ethanol.

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.

Differences of perioperative liver function, transfusion, and complications according to the type of hepatectomy in living donors

Numerous living donor hepatectomy are being performed safely. However, donors are still exposed to various complications including hepatic failure. We examined the donors potential risk and morbidity depending on the type of hepatectomy: left lateral segmentectomy (group LLS, n = 30), left lobectomy (group LL, n = 15), and right lobectomy (group RL, n = 128). The charts and computerized hospital data of 173 donors from March 2000 to September 2003 were retrospectively reviewed. We analyzed liver function tests (LFT), RBC transfusion, and complications. Although the graft weight was greatest, and surgical and anesthetic times were longest in the group RL, there were no significant differences in postoperative hospital stay, RBC transfusion, and major complications among the groups. However, minor complications were significantly higher in group RL than group LLS. Postoperative prothrombin time and total bilirubin were significantly higher in the group RL than the other groups (P < 0.05). Living donor hepatectomy is relatively safe, and it is evidenced by rapid recovery of LFT and low occurrence of major complications. However, noticeable depression of LFT and frequent minor complications occur after hepatectomy, especially RL.

The Effects of Prehydration on the Properties of Cerebrospinal Fluid and the Spread of Isobaric Spinal Anesthetic Drug

BACKGROUND: In a two-part clinical study, we investigated the effect of the administration of fluids “prehydration” on the physical properties of cerebrospinal fluid (CSF) and intrathecal spread of local anesthetics. METHODS: First, in the clinical spinal anesthesia study, 68 patients were allocated randomly into the prehydration or nonprehydration groups. One group was prehydrated with 10 mL/kg of lactated Ringers solution, and spinal anesthesia was performed with 12 mg of 0.5% isobaric tetracaine in all patients at the lumbar level. The arterial blood pressure, heart rate, and sensory block level were assessed. Second, in a magnetic resonance image study, 24 male volunteers were enrolled. CSF motion variables were measured after infusion of 10 mL/kg of lactated Ringers solution to examine the net flow and volume displacement of the CSF at the L2–3 disk level. RESULTS: In the clinical study, there were no significant differences in arterial blood pressure, heart rate, and median peak sensory block level between the two groups, but the median time to reach peak sensory block level (26.4 ± 15.7 vs 16.5 ± 9.2 min, P < 0.05) was longer in group P. In posthydration magnetic resonance images, the CSF regurgitant fraction (caudal flow) was significantly increased after hydration, but the stroke volume, absolute stroke volume, mean flux, stroke distance, and mean velocity in the cranial direction were significantly decreased. CONCLUSIONS: Rapid crystalloid prehydration can affect CSF flow in the lumbar region, reducing cephalic spread of 0.5% isobaric tetracaine and delaying the time to reach the peak sensory level.

Effect of Cryoanalgesia Combined with Intravenous Continuous Analgesia in Thoracotomy Patients

Fifty patients undergoing thoracotomy was studied to compare the effects of cryoanalgesia combined with intravenous continuous analgesia (IVCA). Patients were randomized into two groups: IVCA group and IVCA-cryo group. Subjective pain intensity was assessed on a visual analogue scale at rest (VAS-R) and during movement (VAS-M). Analgesic requirements were evaluated over the 7 days following surgery. Forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV1) were measured before operation, on the 2nd and 7th postoperative days (POD). We interviewed patients by telephone to evaluate the prevalence of post-thoracotomy pain at the 1st, 3rd, and 6th months postoperatively. No significant differences were observed between the two groups with respect to postoperative pain, analgesic requirements, side effects, respiratory complications, or prevalence of post-thoracotomy pain. However, a significant increase in FVC and FEV1 was observed on the 7th POD in IVCAc-ryo group. The incidence of the post-thoracotomy pain at the 1st, 3rd, and 6th months postoperatively was 68, 60, and 44% in IVCA group, and 88, 68, and 28% in IVCA-cryo group, respectively. Our study showed that cryoanalgesia combined with IVCA effectively restore respiratory function on 7th POD, but that it was not effective at reducing the incidence of post-thoracotomy pain.

Prolonged inspiratory time produces better gas exchange in patients undergoing laparoscopic surgery: A randomised trial

Laparoscopic surgery performed with a patient in the Trendelenburg position is known to have adverse effects on pulmonary gas exchange and respiratory mechanics. We supposed that prolonged inspiratory time can improve gas exchange at lower airway pressure.