Suxamethonium induces a prompt increase in the bispectral index

Upon inducting general anesthesia in the operating room, we have observed a prompt increase in the bispectral index (BIS) after the intravenous injection of suxamethonium. We hypothesized that the cause of this BIS increase is muscle hyperactivity owing to fasciculation. However, no reports have been published regarding this abrupt increase in the BIS upon the induction of general anesthesia by suxamethonium. To investigate the degree of change in the BIS in patients receiving anesthesia with suxamethonium, we performed a prospective observational study of 63 participants who underwent closed reduction for nasal bone fracture. Anesthesia was induced by the total intravenous administration of anesthetics and 1.5 mg kg of suxamethonium was injected intravenously upon achieving BIS between 45 and 55. Intubation was performed after fasciculation. Electromyograms and BIS values were recorded from the induction of suxamethonium until 15 minutes after intubation. The mean BIS values were 95.4, 48.5, and 69.3 before induction, before the intravenous injection of suxamethonium, and immediately after fasciculation, respectively. The BIS value immediately after fasciculation (69.3 ± 10.6) was significantly higher than the cutoff BIS value of 60 (P < .001). Although fasciculation after the intravenous injection of suxamethonium resulted in the prompt increase of the BIS to values over 60, none of the participants was awake during surgery. In conclusion, the administration of suxamethonium resulted in the postfasciculation increase of the BIS to an average value of 69.3 without affecting the patient's state of consciousness.ope

The prophylactic effect of acupressure (P6) on the postoperative nausea and vomiting in patients underwent thyroidectomy

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common problem in patients recovering from anesthesia and surgery. P6 point is the acupressure point for prevention of postoperative nausea and vomiting. We evaluated the efficacy of acupressure at the P6 point in 94 patients undergoing thyroidectomy in a randomized, prospective and placebo-controlled study. METHODS: Ninety-four female patients, aged 18 to 60, scheduled for elective thyroidectomy, were randomized to have either placebo band or acupressure band (Sea-Band(R) UK Ltd., Leicestershire, England, UK) applied to the P6 point of both hands before induction of anesthesia. The acupressure bands removed 24 h later. Postoperative nausea and vomiting was evaluated 1, 6 and 24 h following surgery. In addition, the need for rescue antiemetic medication during 24 h was registered. RESULTS: The incidence of postoperative nausea was lower in acupressure group at 0-1 h (16.7% vs. 39.1%; P = 0.015) and at 6-24 h (0% vs. 15.2%; P = 0.05). The need for rescue antiemetic medication was also lower at 0-1 h (4.2% vs. 23.9%; P = 0.006), at 1-6 h (6.2% vs. 20.9%; P = 0.039) and at 6-24 h (0% vs. 13%; P = 0.012). CONCLUSIONS: In patients undergoing thyroidectomy, nausea and need of rescue antiemetic medication were reduced by acupressure at the P6 pointope

Postherpetic Neuralgia Mimiking Renal Colic: Zoster Sine herpete with Segmental Thoracic Motor Paresis

We describe a case of zoster sine herpete with a motor paresis mimicking a urolithiasis. A 54 year-old woman admitted for her flank pain in an emergency room. The computer tomography (CT) scans and her symptoms were similar to those caused by renal colic. A urology surgeon operated on her for a urolithiasis. However, her flank pain did not improve. She felt the allodynia and burning pain in the left T10-12 dermatomes. She also complained abdominal wall bulging in same lesion. She had no history of skin eruption and no scar of herpes zoster. The abdominal CT scan did not find any pathologic findings. Electromyelography showed denervation potential on some abdominal muscles. Serologic studies indicated that varicella-zoster virus IgG titers were positive. We concluded that this condition was zoster sine herpete. Fortunately, the patient responded well to our empirical therapy, which included gabapentin and epidural steroid injections.ope

Implementation of the Head of Bed (HOB) Elevation Protocol on Clinical and Nutritional Outcomes in Critically Ill Patients with Mechanical Ventilator Support

BACKGROUND: Although head of bed (HOB) elevation is an important strategy to prevent ventilator associated pneumonia (VAP), some observational studies have reported that the application of the semi-recumbent position was lower in patients receiving mechanical ventilator support. We performed this study to assess the effect of implementation of the HOB elevation protocol in the intensive care unit (ICU) on clinical and nutritional outcomes. METHODS: We developed a HOB elevation protocol including a flow chart to determine whether the HOB of newly admitted patients to ICU could be elevated. We measured the level of HOB elevation in patients with mechanical ventilator twice a day and 2 days a week for 5 weeks before and after the implementation of the protocol, respectively. Hemodynamic, respiratory and nutritional data were also collected, resulting in 251 observations from 35 patients and 467 observations from 66 patients before and after implementation. RESULTS: After implementing the protocol, the level of HOB elevation (16.7 +/- 9.9 vs. 23.6 +/-1 2.9, p 30degrees increased significantly (34 vs. 151, p 100 ml) occurred less frequently after implementing the protocol (50% vs. 17%, p = 0.001) CONCLUSIONS: Implementation of the protocol for HOB elevation could improve the level of HOB elevation, oxygenation parameter and enteral nutrition deliveryope

Undiagnosed light chain systemic amyloidosis: does it matter to anesthesiologists? -a case report-

Light chain systemic amyloidosis is rare but may accompany laryngeal or pulmonary involvement, which may increase the risk in airway management. We present a case of a patient planned for resection of cervical epidural mass. The patient had face and neck ecchymoses and purpuras with an unknown cause. Mask ventilation and intubation were successful, but the operation was cancelled to evaluate bleeding from facial skin lesions. A diagnosis of light chain systemic amyloidosis prompted evaluation of involvement of other organs and treatment. This case shows the importance of preoperative evaluation and careful airway management in patients with systemic amyloidosis.ope

Effects of APACHE II Score and Initial Nutritional Status on Prognosis of the Critically Ill Patients

Background: Malnutrition is common in hospitalized patients, especially in critically ill patients and affects their mortality and morbidity. However, the correlation between malnutrition and poor outcome is not fully understood. Our hypothesis is that the nutritional effect on the patient’s prognosis would differ depending on the severity of the disease. Methods: 3,758 patients admitted to the intensive care unit (ICU) were observed retrospectively. Patients were divided into well, moderate and severe groups, according to their nutritional status as assessed by their serum albumin level and total lymphocyte count (TLC). The severity of the disease was assessed by the Acute Physiologic and Chronic Health Evaluation (APACHE II score). All patients were followed clinically until discharge or death and ICU days, hospital days, ventilator days, and mortality rates were recorded. Results: Depending on the definition used, the prevalence of hospital malnutrition is reported to be 68.3%. Hospital days, ICU days, as well as ventilator days of moderate and severe groups were longer than the well group. In patients exhibiting mild severity of disease, moderate and severe malnutrition groups have 3－5 times the mortality rate than the well group. Conclusions: Malnutrition affects the prognosis of patients who have an APACHE II score ranging from 4－29 points. Active nutritional support may be more effective for patients with a disease of mild severity.ope

The effects of 6% Hydroxyethyl Starch (HES) 130/0.4 and 6% HES 200/0.5 on tissue oxygenation and postoperative bleeding in patients undergoing off-pump coronary artery bypass surgery

Background : Hydroxyethyl starch (HES) effectively restores plasma volume and thereby enhances microcirculation and tissue oxygenation at the expense of coagulation impairment. These effects are related to molecular weight, substitution and C2:C6 ratio. But, most of the studies regarding coagulation impairment in cardiac surgeries were performed in patients undergoing cardiopulmonary bypass which significantly causes coagulation derangements. Therefore, we have evaluated the effects of 2 different HES solutions on tissue oxygenation and postoperative bleeding in patients undergoing off-pump coronary artery bypass surgery (OPCAB). Methods : Forty four patients were prospectively enrolled. After the induction of anesthesia, either HES 130/0.4 (V group) or 200/0.5 (H group) were infused for fluid therapy to maintain predetermined urine output, cardiac index and filling pressure up to 16 h after the surgery. Tissue oxygenation profiles and respiratory parameters were recorded after induction of anesthesia, completion of distal anastomosis and sternum closure, upon admission at intensive care unit, and 4 h thereafter. The amounts of chest tube drainage, transfusion and fluid balance were measured up to 16 h after the surgery. Results : Patients' demographic data were similar between the groups. Tissue oxygenation profiles, respiratory parameters, hemodynamics, and time to extubate were not different between the groups. However, chest tube drainage and transfusion requirements were significantly less in the V group. Conclusions : In OPCAB, 6% HES 130/0.4 causes less postoperative bleeding and transfusion requirement and has a comparable efficacy on hemodynamic stability, pulmonary function and tissue oxygenation when compared to 6% HES 200/0.5.ope

A Preliminary Study on the Circadian Rhythm of Autonomic Nervous System in Patients Admitted to Intensive Care Unit, Using the Heart Rate Variability

Objectives : A normal circadian rhythm of autonomic nervous system function stands for the daily change of sympathetic and parasympathetic modulation, which can be measured by heart rate variability (HRV). Generally, patients in the intensive care unit (ICU) are prone to sleep-wake cycle dysregulation, therefore, it may have an influence on the circadian rhythm of autonomic nervous system. This study was designed to interpret possible dysregulation of autonomic nervous system in ICU patients by using HRV. Methods : HRV was assessed every 3 hours in 21 ICU patients during a 7-minute period. The statistical differences of HRV features between the morning (AM 6 : 00-PM 12 : 00), and the afternoon (PM 12 : 00-PM 18 : 00) periods were evaluated in time domain and frequency domain. Results : Patients showed significantly increased normalized power of low frequencey (nLF), absolute power of low frequencey (LF)/absolute power of high frequencey (HF) in the afternoon period as compared to the morning period. However, normalized power of high frequency (nHF) was significantly decreased in the afternoon period. There was no statistically significant difference between the morning period and the afternoon period in the time domain analysis. Conclusions : The increased sympathetic tone in the afternoon period supports possible dysregulation in the circadian rhythm of autonomic nervous system in ICU patients. Future studies can help to interpret the association between autonomic dysregulation and negative outcomes of ICU patients.ope

Impact of Delirium on Clinical Outcomes in Intensive Care Unit Patients : An Observational Study in a Korean General Hospital

Objectives : The purpose of this study is to evaluate the impact of delirium on clinical outcomes in intensive care unit (ICU) patients in a Korean general hospital. Methods : All patients admitted to ICU from March 1, 2013 to October 31, 2013 were assessed by Confusion Assessment Method adapted for use in the ICU for delirium daily, and consistently comatose patients were excluded for analysis. Differences in clinical outcomes (mortality, length of hospital stay, length of ICU stay) were analyzed between delirious patients and non-delirious patients. Subsequently, the impact of delirium on clinical outcomes was analyzed with adjusting for covariates including surgery, age, emergent admission, presence of surgery, and severity of illness. Results : The analysis included 129 delirious patients and 469 non-delirious patients. As primary outcome, mortality, length of stay (hospital day, ICU-stay) were significantly high in the delirious group. The association remained the same after adjusting for the covariates. Conclusion : The results correspond with those of previous research studies conducted in foreign ICU. Based on this observation that delirium also has an impact on clinical outcomes in Korean ICU, integrative and in-depth investigation on ICU delirium will be needed.ope

Reference values of neutrophil-lymphocyte ratio, lymphocyte-monocyte ratio, platelet-lymphocyte ratio, and mean platelet volume in healthy adults in South Korea

There is a growing interest in research aimed at better understanding the disease status or predicting the prognosis of patients with simple blood tests associated with systemic inflammation. The neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), and mean platelet volume (MPV) can be used as factors to determine the prognosis of patients in various clinical situations. However, reference values for these attributes based on large, healthy populations have yet to be determined.From January 2014 to December 2016, data from routine blood analyses were collected from healthy patients in the checkup center of a tertiary hospital in Seoul, South Korea. Retrospective data review was then performed on an electronic medical record system. Data were treated anonymously as only age, sex, body mass index, medical history including cancer diagnosis, medications, and smoking status were considered. After the initial screen, we had a collection of 12,160 samples from patients without any medical history, including cancer treatment. This patient pool consisted of 6268 (51.5%, median age 47 years) and 5892 (48.5%, median age 46 years) male and female patients, respectively. The mean NLR across all ages was 1.65 (0.79), and the values for men and women were 1.63 (0.76) and 1.66 (0.82), respectively. The mean LMR, PLR, and MPV were 5.31 (1.68), 132.40 (43.68), and 10.02 (0.79), respectively. This study provides preliminary reference data on LMR, PLR, and MPV from different age and sex groups in South Korea. The results suggest that different cutoff values should be applied to the various patient populations.ope