Young Chul Yoo

Maintaining Optimal Surgical Conditions With Low Insufflation Pressures is Possible With Deep Neuromuscular Blockade During Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-Blind, Parallel-Group Clinical Trial.

AbstractCarbon dioxide (CO2) absorption and increased intra-abdominal pressure can adversely affect perioperative physiology and postoperative recovery. Deep muscle relaxation is known to improve the surgical conditions during laparoscopic surgery. We aimed to compare the effects of deep and moderate neuromuscular block in laparoscopic colorectal surgery, including intra-abdominal pressure.In this prospective, double-blind, parallel-group trial, 72 adult patients undergoing laparoscopic colorectal surgery were randomized using an online randomization generator to achieve either moderate (1–2 train-of-four response, n = 36) or deep (1–2 post-tetanic count, n = 36) neuromuscular block by receiving a continuous infusion of rocuronium. Adjusted intra-abdominal pressure, which was titrated by a surgeon with maintaining the operative field during pneumoperitoneum, was recorded at 5-minute intervals. Perioperative hemodynamic parameters and postoperative outcomes were assessed.Six patients from the deep and 5 from the moderate neuromuscular block group were excluded, leaving 61 for analysis. The average adjusted IAP was lower in the deep compared to the moderate neuromuscular block group (9.3 vs 12 mm Hg, P < 0.001). The postoperative pain scores (P < 0.001) and incidence of postoperative shoulder tip pain were lower, whereas gas passing time (P = 0.002) and sips of water time (P = 0.005) were shorter in the deep neuromuscular block than in the moderate neuromuscular block group.Deep neuromuscular blocking showed several benefits compared to conventional moderate neuromuscular block, including a greater intra-abdominal pressure lowering effect, whereas surgical conditions are maintained, less severe postoperative pain and faster bowel function recovery.

Combination of pregabalin and dexamethasone for postoperative pain and functional outcome in patients undergoing lumbar spinal surgery: A randomized placebo-controlled trial

Objectives:In this randomized-controlled study, we investigated the effects of combined administration of pregabalin and dexamethasone on postoperative pain and analgesic requirements, and functional outcome in patients who underwent lumbar spinal surgery. Methods:One hundred eight patients were randomized to group C (placebo+placebo), group P (pregabalin+placebo), or group PD (pregabalin+dexamethasone). According to their allocated group, patients received placebo or pregabalin 150 mg every 12 hours starting 1 hour before anesthetic induction for a total of 8 doses. Dexamethasone 16 mg or normal saline was injected before the induction of anesthesia. The pain intensity, analgesic requirements, and side effects were assessed in the postoperative period: postanesthesia care unit, 12, 24, 48, and 72 hours. Pain intensity and daily activity performance were also assessed 1, 3, and 6 months after surgery. Results:Compared with group C, the pain scores were lower in group PD at 24 hours after surgery (P=0.011). The frequency of additional rescue analgesic administration was significantly lower in group PD until 48 hours after surgery (P<0.05) and in group P at 24 to 48 hours (P=0.005) relative to group C. Back pain intensity at work was lower (P=0.048) and daily activity performance was better (P=0.006) in group PD compared with group C at 1 month after surgery. Conclusions:Combined administration of pregabalin and dexamethasone conferred analgesic benefits superior to those of pregabalin alone. This regimen also helped facilitate return to normal daily activity after surgery.

The uncalibrated pulse contour cardiac output during off-pump coronary bypass surgery: performance in patients with a low cardiac output status and a reduced left ventricular function

Background We compared the continuous cardiac index measured by the FloTrac/Vigileo™ system (FCI) to that measured by a pulmonary artery catheter (CCI) with emphasis on the accuracy of the FCI in patients with a decreased left ventricular ejection fraction (LVEF) and a low cardiac output status during off-pump coronary bypass surgery (OPCAB). We also assessed the influence of several factors affecting the pulse contour, such as the mean arterial pressure (MAP), the systemic vascular resistance index (SVRI) and the use of norepinephrine. Methods Fifty patients who were undergoing OPCAB (30 patients with a LVEF ≥ 40%, 20 patients with a LVEF < 40%) were enrolled. The FCI and CCI were measured and we performed a Bland-Altman analysis. Subgroup analyses were done according to the LVEF (< 40%), the CCI (≤ 2.4 L/min/m), the MAP (60-80 mmHg), the SVRI (1,600-2,600 dyne/s/cm5/m2) and the use of norepinephrine. Results The FCI was reliable at all the time points of measurement with an overall bias and limit of agreement of -0.07 and 0.67 L/min/m2, respectively, resulting in a percentage error of 26.9%. The percentage errors in the patients with a decreased LVEF and in a low cardiac output status were 28.2% and 22.3%, respectively. However, the percentage error in the 91 data pairs outside the normal range of the SVRI was 40.2%. Conclusions The cardiac output measured by the FloTrac/Vigileo™ system was reliable even in patients with a decreased LVEF and in a low cardiac output status during OPCAB. Acceptable agreement was also noted during the period of heart displacement and grafting of the obtuse marginalis branch.

Assessing the stability and safety of procedure during endoscopic submucosal dissection according to sedation methods: a randomized trial.

Background Although endoscopic submucosal dissection (ESD) is routinely performed under sedation, the difference in ESD performance according to sedation method is not well known. This study attempted to prospectively assess and compare the satisfaction of the endoscopists and patient stability during ESD between two sedation methods. Methods One hundred and fifty-four adult patients scheduled for ESD were sedated by either the IMIE (intermittent midazolam/propofol injection by endoscopist) or CPIA (continuous propofol infusion by anesthesiologist) method. The primary endpoint of this study was to compare the level of satisfaction of the endoscopists between the two groups. The secondary endpoints included level of satisfaction of the patients, patient’s pain scores, events interfering with the procedure, incidence of unintended deep sedation, hemodynamic and respiratory events, and ESD outcomes and complications. Results Level of satisfaction of the endoscopists was significantly higher in the CPIA Group compared to the IMIE group (IMIE vs. CPIA; high satisfaction score; 63.2% vs. 87.2%, P=0.001). The incidence of unintended deep sedation was significantly higher in the IMIE Group compared to the CPIA Group (IMIE vs. CPIA; 17.1% vs. 5.1%, P=0.018) as well as the number of patients showing spontaneous movement or those requiring physical restraint (IMIE vs. CPIA; spontaneous movement; 60.5% vs. 42.3%, P=0.024, physical restraint; 27.6% vs. 10.3%, P=0.006, respectively). In contrast, level of satisfaction of the patients were found to be significantly higher in the IMIE Group (IMIE vs. CPIA; high satisfaction score; 85.5% vs. 67.9%, P=0.027). Pain scores of the patients, hemodynamic and respiratory events, and ESD outcomes and complications were not different between the two groups. Conclusion Continuous propofol and remifentanil infusion by an anesthesiologist during ESD can increase the satisfaction levels of the endoscopists by providing a more stable state of sedation. Trial Registration ClinicalTrials.gov NCT01806753

Room for Quality Improvement in Endoscopist-Directed Sedation: Results from the First Nationwide Survey in Korea

Background/Aims This study sought to characterize the current sedation practices of Korean endoscopists in real-world settings. Methods All active members of the Korean Society of Gastrointestinal Endoscopy were invited to complete an anonymous 35-item questionnaire. Results The overall response rate was 22.7% (1,332/5,860). Propofol-based sedation was the dominant method used in both elective esophagogastroduodenoscopy (55.6%) and colonoscopy (52.6%). The mean satisfaction score for propofol-based sedation was significantly higher than that for standard sedation in both examinations (all p<0.001). The use of propofol was supervised exclusively by endoscopists (98.6%). Endoscopists practicing in nonacademic settings, gastroenterologists, or endoscopists with <10 years of endoscopic practice were more likely to use propofol than were their counterparts (all p<0.001). In total, 27.3% of all respondents performed sedation practices without having undergone sedation training, and 27.4% did so without any formal sedation protocols. The choice of propofol as the dominant sedation method was the only significant predictor of endoscopist experience with serious sedation-related adverse events (odds ratio, 1.854; 95% confidence interval, 1.414 to 2.432). Conclusions Endoscopist-directed propofol administration is the predominant sedation method used in Korea. This survey strongly suggests that there is much room for quality improvement regarding sedation training and patient vigilance in endoscopist-directed sedation.

Finding the 'Ideal' Regimen for Fentanyl-Based Intravenous Patient-Controlled Analgesia: How to Give and What to Mix?

Purpose This analysis was done to investigate the optimal regimen for fentanyl-based intravenous patient-controlled analgesia (IV-PCA) by finding a safe and effective background infusion rate and assessing the effect of adding adjuvant drugs to the PCA regimen. Materials and Methods Background infusion rate of fentanyl, type of adjuvant analgesic and/or antiemetic that was added to the IV-PCA, and patients that required rescue analgesics and/or antiemetics were retrospectively reviewed in 1827 patients who underwent laparoscopic abdominal surgery at a single tertiary hospital. Results Upon multivariate analysis, lower background infusion rates, younger age, and IV-PCA without adjuvant analgesics were identified as independent risk factors of rescue analgesic administration. Higher background infusion rates, female gender, and IV-PCA without additional 5HT3 receptor blockers were identified as risk factors of rescue antiemetics administration. A background infusion rate of 0.38 µg/kg/hr [area under the curve (AUC) 0.638] or lower required rescue analgesics in general, whereas, addition of adjuvant analgesics decreased the rate to 0.37 µg/kg/hr (AUC 0.712) or lower. A background infusion rate of 0.36 µg/kg/hr (AUC 0.638) or higher was found to require rescue antiemetics in general, whereas, mixing antiemetics with IV-PCA increased the rate to 0.37 µg/kg/hr (AUC 0.651) or higher. Conclusion Background infusion rates of fentanyl between 0.12 and 0.67 µg/kg/hr may safely be used without any serious side effects for IV-PCA. In order to approach the most reasonable background infusion rate for effective analgesia without increasing postoperative nausea and vomiting, adding an adjuvant analgesic and an antiemetic should always be considered.

Effect of Intraoperative Dexmedetomidine Infusion on Postoperative Bowel Movements in Patients Undergoing Laparoscopic Gastrectomy: A Prospective, Randomized, Placebo-Controlled Study

AbstractSympathetic hyperactivation is one of the causes of postoperative ileus, which occurs frequently after abdominal surgery and adversely influences the patients prognosis. We aimed to investigate whether dexmedetomidine (DEX) could attenuate postoperative ileus in patients undergoing laparoscopic gastrectomy.Ninety-two patients were randomized to the control (n = 46) or DEX group (n = 46). DEX was administered at a loading dose of 0.5 &mgr;g/kg for 10 minutes, followed by an infusion rate of 0.4 &mgr;g/kg/h from insufflation of the pneumoperitoneum to the end of surgery. The primary goal was to compare postoperative bowel movements by evaluating the time to first flatus. The balance of the autonomic nervous system, duration of postoperative hospital stay, and pain scores were assessed.The time to first flatus was shorter in the DEX group compared with the control group (67.2 ± 16.8 hours vs 79.9 ± 15.9 hours, P < 0.001). The low-frequency/high-frequency power ratio during pneumoperitoneum increased in the control group, compared with baseline values and the DEX group. The length of postoperative hospital stay was shorter in the DEX group compared with the control group (5.4 ± 0.7 days vs 5.8 ± 1.1 days, P = 0.04). Patients in the DEX group had lower pain scores and required fewer analgesics at 1 hour postoperatively.DEX facilitated bowel movements and reduced the length of hospital stay in patients undergoing laparoscopic gastrectomy. This may be attributed to the sympatholytic and opioid-sparing effects of DEX.

Effects of systemic lidocaine versus magnesium administration on postoperative functional recovery and chronic pain in patients undergoing breast cancer surgery: A prospective, randomized, double-blind, comparative clinical trial

Introduction We aimed to compare the effects of intraoperative lidocaine and magnesium on postoperative functional recovery and chronic pain after mastectomy due to breast cancer. Systemic lidocaine and magnesium reduce pain hypersensitivity to surgical stimuli; however, their effects after mastectomy have not been evaluated clearly. Methods In this prospective, double-blind, clinical trial, 126 female patients undergoing mastectomy were randomly assigned to lidocaine (L), magnesium (M), and control (C) groups. Lidocaine and magnesium were administered at 2 mg/kg and 20 mg/kg for 15 minutes immediately after induction, followed by infusions of 2 mg/kg/h and 20 mg/kg/h, respectively. The control group received the same volume of saline. Patient characteristics, perioperative parameters, and postoperative recovery profiles, including the Quality of Recovery 40 (QoR-40) survey, pain scales, length of hospital stay, and the short-form McGill pain questionnaire (SF-MPQ) at postoperative 1 month and 3 months were evaluated. Results The global QoR-40 scores on postoperative day 1 were significantly higher in group L than in group C (P = 0.003). Moreover, in sub-scores of the QoR-40 dimensions, emotional state and pain scores were significantly higher in group L than those in groups M and C (P = 0.027 and 0.023, respectively). At postoperative 3 months, SF-MPQ and SF-MPQ-sensitive scores were significantly lower in group L than in group C (P = 0.046 and 0.036, respectively). Conclusions Intraoperative infusion of lidocaine improved the quality of recovery and attenuated the intensity of chronic pain in patients undergoing breast cancer surgery.

Conventional versus Analgesia-Oriented Combination Sedation on Recovery Profiles and Satisfaction after ERCP: A Randomized Trial

Background The importance of providing effective analgesia during sedation for complex endoscopic procedures has been widely recognized. However, repeated administration of opioids in order to achieve sufficient analgesia may carry the risk of delayed recovery after propofol based sedation. This study was done to compare recovery profiles and the satisfaction of the endoscopists and patients between conventional balanced propofol sedation and analgesia-oriented combination sedation for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Methods Two hundred and two adult patients scheduled for ERCP were sedated by either the Conventional (initial bolus of meperidine with propofol infusion) or Combination (repeated bolus doses of fentanyl with propofol infusion) method. Recovery profiles, satisfaction levels of the endoscopists and patients, drug requirements and complications were compared between groups. Results Patients of the Combination Group required significantly less propofol compared to the Conventional Group (135.0 ± 68.8 mg vs. 165.3 ± 81.7 mg, P = 0.005). Modified Aldrete scores were not different between groups throughout the recovery period, and recovery times were also comparable between groups. Satisfaction scores were not different between the two groups in both the endoscopists and patients (P = 0.868 and 0.890, respectively). Conclusions Considering the significant reduction in propofol dose, the non-inferiority of recovery profiles and satisfaction scores of the endoscopists and patients, analgesia oriented combination sedation may be a more safe yet effective sedative method compared to conventional balanced propofol sedation during ERCP.

Does the type of anesthesia really affect the recurrence-free survival after breast cancer surgery?

Background Although previous studies have suggested that propofol inhibits cancer recurrence and metastasis, the association between anesthetic agents and the recurrence of breast cancer has not been clearly investigated. We compared total intravenous anesthesia and balanced anesthesia with volatile agents to investigate the differences in their effects on recurrence-free survival and overall survival after breast cancer surgery. Materials and Methods The electronic medical records of 2,729 patients who underwent breast cancer surgery between November 2005 and December 2010 were retrospectively reviewed to analyze the factors associated with recurrence-free survival after surgery. Cox proportional hazards models were used to identify the risk factors for cancer recurrence and overall mortality after breast cancer surgery. Results Data from 2,645 patients were finally analyzed. The recurrence-free survival rate in this study was 91.2%. Tumor-node-metastasis staging exhibited the strongest association with breast cancer recurrence. However, we were unable to identify significant differences between the preventive effects of total intravenous anesthesia and those of volatile agents on postoperative breast cancer recurrence using Cox regression analyses and propensity score matching. Furthermore, the survival probability with regard to postoperative recurrence and mortality showed no significant differences among anesthetic agents. Conclusions Our findings suggest that the effects of total intravenous anesthesia are comparable with those of volatile agents with regard to postoperative recurrence-free survival and overall survival in patients with breast cancer.