Update of sedation in view of Joint Commission International standards

Although the practice of sedation has markedly increased and expanded beyond the operating room with the development of new diagnostic and minimally invasive surgical procedures, there is no guideline for hospitals to set up a sedation policy in Korea. The Joint Commission International (JCI), which is a division of Joint Commission of United States, has urged Korean hospitals to develop guidelines for sedation. Because JCI defines the sedation standards as a minimum, there is much for Korean medical association and physicians in charge of sedation to do in order to improve the safety of sedated patients and set up an economical and efficient sedation system. There are three main requirements to meet JCI standards. Aqualified individual responsible for sedation should complete a formal training program supervised by an anesthesiologist or experienced practitioner, and adequate facilities and monitoring systems must be available to safely care for patients throughout sedation. Secondly, a documentation process around sedation, including informed consent, pre-operative assessment, the parameters obser-ved during sedation, and discharge criteria, should be organized according to the sedation policy, which in turn should be determined by an institutional sedation committee. Lastly, JCI requires continuous quality improvement activity, which can improve the efficiency of the sedation process and the safety of sedation care. Multi-departmental joint discussion may be necessary to advance the practice of sedation and avoid conflicts among departments. This review aims to highlight the starting points of adiscussionon local standards for sedation.ope

The Antinociceptive Properties of the Corydalis yanhusuo Extract

Corydalis yanhusuo. W.T. extracts (YHS) are widely used for the treatment of pain and inflammation. There are a few studies that assessed the effects of YHS in pain assays; however, none of these studies has systematically compared its activities in the different pain animal modes namely: acute, inflammatory and chronic pain. Furthermore, little is known about the mechanism of YHS activity in these assays. The aim of this study was to systematically evaluate the antinociceptive properties of YHS by testing it in four standardized pain assays and to investigate its mechanism. YHS antinociceptive properties were analyzed in the tail flick, the formalin paw licking, the von Frey filament and the hot box assays after spinal nerve ligation, which monitors acute nociceptive, persistent inflammatory and chronic neuropathic pain, respectively. YHS pharmacological profile was determined by screening it against a battery of G-protein coupled receptors and its mechanism of action was studied using knock-out mice. Our study shows that YHS, at a non-sedative dose, increases the tail flick latency in the tail flick assay without resulting in development of tolerance. YHS also decreases paw licking time in the formalin assay. Further, YHS increases paw withdraw threshold and latency in the von Frey filament and the hot box assays, respectively. In vitro, YHS exhibits prominent dopamine receptor antagonistic properties. In dopamine D2 receptor knockout mice, its antinociceptive effects are attenuated in acute and neuropathic pain but not inflammatory pain assays. Our results therefore indicate that YHS effectively attenuates acute, inflammatory and neuropathic pain, without causing tolerance. The effects on acute and neuropathic pain, but not inflammatory pain, are at least partially mediated through dopamine D2 receptor antagonism. Since YHS is a dietary supplement commercially available in the United States, our data suggest that it might be a candidate for alternative pain treatment.ope

Anesthetic Management of Endovascular Stent Graft Placement for Thoracic Aortic Diseases

Endovascular aortic repair is a new alternative to conventional surgical repair of aortic pathology. It is a less invasive technique and gives less hemodynamic stress to the patients who may have concomitant systemic diseases, compared with open aortic reconstruction. We report 2 cases of patients with thoracic aortic diseases, who underwent endovascular stent graft placement under general anesthesia. We also include a review of the literature about anesthetic management of endovascular aortic repair and present our opinions about the need to choose a suitable anesthetic technique for each patient, the method to recognize and handle the possible complications and hemodynamic changes to which we have to pay attention during procedures.ope

Hemodynamic effect of full flexion of the hips and knees in the supine position: a comparison with straight leg raising.

BACKGROUND: Straight raising of the legs in the supine position or Trendelenburg positioning has been used to treat hypotension or shock, but the advantages of these positions are not clear and under debate. We performed a crossover study to evaluate the circulatory effect of full flexion of the hips and knees in the supine position (exaggerated lithotomy), and compare it with straight leg raising. METHODS: This study was a prospective randomized crossover study from the tertiary care unit at our university hospital. Twenty-two patients scheduled for off-pump coronary artery bypass surgery were enrolled. Induction and maintenance of anesthesia were standardized. Exaggerated lithotomy position or straight leg raising were randomly selected in the supine position. Hemodynamic variables were measured in the following sequence: 10 min after induction, 1, 5, and 10 min following the designated position, and 1 and 5 min after returning to the supine position. Ten min later, the other position was applied to measure the same hemodynamic variables. RESULTS: During the exaggerated lithotomy position, cerebral and coronary perfusion pressure increased significantly (P < 0.01) without a change in cardiac output. During straight leg raising, cardiac output increased at 5 min (P < 0.05) and cerebral and coronary perfusion pressures did not increase except for cerebral perfusion pressure at 1 min. However, the difference between the two groups at each time point in terms of cerebral perfusion pressure was clinically insignificant. CONCLUSIONS: Full flexion of the hips and knees in the supine position did not increase cardiac output but may be more beneficial than straight leg raising in terms of coronary perfusion pressure.ope

Effect of various anesthetic induction agents on blood magnesium and calcium concentration.

BACKGROUND: Decrease in blood magnesium and calcium concentration is associated with an increase in the incidence of arrhythmia, especially during the induction period. Therefore, it is important to evaluate the effects of propofol, pentothal sodium, and sevoflurane on calcium and magnesium concentration. METHODS: Thirty-six premedicated, ASA grade I patients were selected and randomly allocated into 3 groups. Six percent sevoflurane inhalation (sevo group), propofol 1.5 mg/kg (propofol group), and 5 mg/kg of pentothal sodium (pento group) were administered for anesthetic induction and anesthetic maintenance was done with end-tidal sevoflurane concentration at 3.5%. Blood sampling was performed during the pre-induction period (pre-induction), just before tracheal intubation (pre-intubation), and 2 min after intubation (post-intubation). pH corrected ionized magnesium and calcium were calculated and analyzed simultaneously. RESULTS: Both total calcium and magnesium concentrations decreased significantly in all groups during the pre-intubation and post-intubation periods compared with the pre-induction period. Ionized calcium only decreased significantly during pre-intubation and post-intubation in the pento group, and did not change throughout the study period in the sevo and propofol groups. Ionized magnesium did not change throughout the study period in any of the groups. pH corrected ionized calcium decreased significantly only at post-intubation in the pento group. CONCLUSIONS: All anesthetic induction agents administered in this study can be used safely in terms of magnesium-associated arrhythmia. However, ionized calcium concentration decreased in the pento group, but all values were within normal limits. This finding indicated that it is safe to use propofol, pentothal sodium, and sevoflurane for anesthetic inductionope

Spinal anesthesia is associated with lower recurrence rates after resection of non-muscle invasive bladder cancer

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Relationship between PaO2/FiO2 and number of regions with B-line on transthoracic lung ultrasound: a prospective, observational study

Background: Aeration of the lungs must be monitored during general anesthesia because of the possibility of postsurgical pulmonary complications. The aim of this study was to compare PaO2/FiO2 and the number of regions with B-line on transthoracic lung ultrasonography (TLU) between the postinduction and postsurgical periods. Methods: Twenty-six adult patients undergoing major abdominal surgery were enrolled. Arterial blood gas analysis and TLU were performed 30 min after the induction of anesthesia (postinduction) and after skin closure (postsurgical period) while patients were under mechanical ventilation. TLU was performed in 12 regions (anterior, lateral, and posterior in the upper and lower regions of both lungs). The number of regions with Bline was counted. Results: Compared with postinduction values, the number of regions with B-line on TLU was increased in the postsurgical period (0.3 ± 0.5 to 1.3 ± 1.2, P < 0.001); however, PaO2/FiO2 did not significantly differ (421.3 ± 95.8 to 425.2 ± 86.0, P = 0.765). The change in PaO2/FiO2 (postinduction-postsurgical period) was significantly higher in Group B than in Group A (P = 0.028). Conclusions: Although the number of regions with B-line on TLU was increased in the postsurgical period, lung oxygenation did not differ, based on the main assessment in this study. In contrast, patients with an increased number of regions with B-line tended to show a reduction in PaO2/FiO2 during the postsurgical period. Further study seems necessary to establish the number of regions with B-line on TLU as a tool for evaluation of perioperative oxygenation.ope

Short Term Outcomes and Prognostic Factors Based on Radiofrequency Thermocoagulation on Lumbar Medial Branches

Background Lumbar zygapophysial joints are a common source of chronic lower back pain and radiofrequency thermocoagulation (RF) of the medial branches (MB) has been shown to be effective at providing substantial pain relief for chronic low back pain. Therefore, we carried out this study to determine the short term outcomes and prognostic factors of RF on the MB of patients with lumbar facet syndrome. Methods We performed RF in fourteen patients who showed greater than 80% pain relief up to three times after a diagnostic MB block was conducted using 0.3 ml of 0.5% bupivacaine. Using 10 cm curved electrodes with 10-mm active tip, a 60 second, 80℃ lesion was made after electrical stimulation at 50 Hz for sensory and 2 Hz for motor nerve testing. The degree of pain relief was then assessed after 2 weeks, and again after 3 months using a visual analog scale (VAS) and a four point Likert scale. The outcome was regarded as 'success' if at least a 50% reduction in the VAS was observed. Possible prognostic factors between the two groups were also evaluated. Results The success rate was 71.4% (10/14) after three months of follow-up. However, there were transient complications, such as neuritis like syndrome, in 4 patients. In addition, short symptom duration and low minimal voltage (< 0.4 V) for sensory stimulation were shown to be the relevant prognostic factors for a successful outcome. Conclusions RF may be an alternative to repeated MB block or intraarticular injection for palliation of lumbar facet syndrome. For better outcomes, early diagnosis and strict patient selection should be coupled with efforts to avoid anatomically incorrect RF.ope

Comparison of meperidine and nefopam for prevention of shivering during spinal anesthesia

BACKGROUND: Shivering is a frequent event during spinal anesthesia and meperidine is a well-known effective drug for prevention and treatment of shivering. Nefopam is a non-opiate analgesic and also known to have an anti-shivering effect. We compared nefopam with meperidine for efficacy of prevention of shivering during spinal anesthesia. METHODS: Sixty five patients, American Society of Anesthesiologists physical status I or II, aged 20-65 years, scheduled for elective orthopedic surgery under spinal anesthesia were investigated. Patients were randomly divided into two groups, meperidine (Group M, n = 33) and nefopam (Group N, n = 32) groups. Group M and N received meperidine 0.4 mg/kg or nefopam 0.15 mg/kg, respectively, in 100 ml of isotonic saline intravenously. All drugs were infused for 15 minutes by a blinded investigator before spinal anesthesia. Blood pressures, heart rates, body temperatures and side effects were checked before and at 15, 30, and 60 minutes after spinal anesthesia. RESULTS: The incidences and scores of shivering were similar between the two groups. The mean arterial pressures in Group N were maintained higher than in Group M at 15, 30, and 60 minutes after spinal anesthesia. The injection pain was checked in Group N only and its incidence was 15.6%. CONCLUSIONS: We conclude that nefopam can be a good substitute for meperidine for prevention of shivering during spinal anesthesia with more stable hemodynamics, if injection pain is effectively controlled.ope

Analysis and Expression of Cloning of rpoB Gene of Drug-Resistant Mycobacterium tuberculosis

Using DNA sequencing method, we analyzed mutations of rpoB (RNA polymerase beta subunit) rifampin-resistant Mycobaterium tuberculosis strains which were identified by conventional test at Masan National Hospital and The Korean Institute of Tuberculosis. Though it has been reported different mutations of rpoB region of rifampin-resistant M. tuberculosis strains in the south of Korea, it is not confirmed whether these mutations of rpoB region actually express rifampin resistance through experiment. We confirmed experimentally these mutations of rpoB region of M. tuberculosis strains induced rifampin-resistance through ampified rpoB by polymerase chain reaction (PCR) and cloning of mutant rpoB into rifampin sensitive-M. tuberculosis strain.ope