Anesthesia and pain medicine最新文献

Background: Submental intubation has been the recommended airway management procedure for maxillofacial surgery since proposed by Altemir in 1986. We adopted various submental intubation modifications based on modified intubation protocols and report on the effectiveness and problems of each modified method.

Case: Among a total of 13 submental intubation cases during the last five years, five representative methods are described. The proximal end of the endotracheal tube was protected by a nelaton catheter in case 1, by a suction connector in case 2, and by a dental needle cap in case 3. In case 4, a nasal speculum was used to expand a single route, and in case 5, a laparoscopic trocar was used to secure a single route.

Conclusions: Use of a laparoscopic trocar might be the most effective way to obtain a single submental route. However, considering cost, use of a nasal speculum is also an effective suboptimal solution.

Korea has a higher rate of cesarean sections under general anesthesia than in other countries. Neuraxial anesthesia is the gold standard for a cesarean section, but there are some cases in which general anesthesia is inevitable. Therefore, obstetric anesthesiologists should be familiar in performing general anesthesia for cesarean section. Rapid-sequence induction and intubation with cricoid pressure using thiopental-succinylcholine have been the standard for cesarean section under general anesthesia for a long time. Recently, with the introduction of new drugs (propofol, rocuronium, and sugammadex) and equipments (videolaryngoscopy and supraglottic airways), anesthesia methods have also gradually changed. Pursuing the safety of obstetric patients and anesthesiologists at the same time, this review will help update the knowledge or training in performing general anesthesia for cesarean section.

Background: During functional endoscopic sinus surgery (FESS), intranasal bleeding affects operative field visibility and increases the frequency of complications. Therefore, hypotensive anesthesia is a widely used technique to improve surgical outcomes. This study aimed to compare the efficacy of propofol and dexmedetomidine infusion for hypotensive anesthesia in patients undergoing FESS.

Methods: This prospective randomized trial was conducted in 80 adult patients who were scheduled for FESS under general anesthesia. Patients were randomly divided into two groups: group P (n = 40) received propofol infusion of 100-200 µg/kg/min and group D (n = 40) received dexmedetomidine infusion with a loading dose of 1 µg/kg over 10 min after induction, followed by maintenance infusion of 0.4-0.8 µg/kg/h. Intraoperative blood loss, quality of the surgical field (Fromme- Boezaart scale), hemodynamic control, and patient recovery were recorded. Statistical analysis was performed using Student's t-test, chi-square test, and Mann-Whitney U test.

Results: The mean arterial pressure and heart rate were significantly lower in group D throughout the surgery than in group P. Blood loss was significantly higher in group P (100.73 ± 18.12 ml) than in group D (85.70 ± 18.56 ml). The average number of patients with Fromme's score 1/2/3 was comparable between the groups. Intraoperatively, only one incidence of bradycardia and hypotension was observed in group D (2.5%) compared to group P.

Conclusions: Both dexmedetomidine and propofol are efficacious and safe drugs for facilitating controlled hypotension during FESS; however, dexmedetomidine provides better hemodynamic control and is associated with lesser blood loss without any significant adverse effects.

Background: This study aimed to evaluate the postoperative analgesic effect of magnesium sulfate during abdominal surgery.

Methods: This randomized double-blinded study involved 84 patients candidates for abdominal surgery into two same groups. In the magnesium group, at first 25 mg/kg/1 h magnesium sulfate; and then, 100 mg/kg/24 h was infused in the intensive care unit. The pain intensity (the primary outcome), was assessed using the numeric rating scale (NRS) every 3 h. If the NRS was > 3, morphine (as a secondary outcome) was used and evaluated. The results were analyzed using SPSS ver. 19 software, and statistical significance was set at P < 0.05.

Results: Demographic parameters were similar between the groups. The pain intensity were similar at first and then at the third hour in both groups (P = 0.393 and P = 0.172, respectively), but thereafter between 6 and 24 h, the pain severity was significantly lower in the magnesium group (4.4 ± 1.3 in the control and 3.34 ± 1 in the magnesium group at 6th hour and P = 0.001). In addition, morphine intake in the first 24 h in the two groups had a significant difference, with 13.2 ± 5.7 mg in control group and 8 ± 3.5 mg in magnesium group (P = 0.001).

Conclusions: In this study, intravenous magnesium sulfate after abdominal surgeries for 24 h resolved the pain intensity after six hours and reduced morphine dosage.

Background: The Portland intensive insulin therapy effectively controls acute hyperglycemic change after graft reperfusion during liver transplantation. However, the time-consuming sophistication acts as a barrier leading to misinterpretation and decreasing compliance to the protocol; thus, we newly introduced an application software "Insulin protocol calculator" which automatically calculates therapeutic bolus/continuous insulin doses based on the Portland protocol.

Methods: Of 144 patients who underwent liver transplantation, 74 patients were treated before the introduction of "Insulin protocol calculator" by using a paper manual, and 70 patients were treated by using the application. Compliance was defined as the proportion of patients treated with exact bolus/continuous insulin dose according to the Portland protocol.

Results: Compliance was significantly greater in app group than in paper group regarding bolus dose (94.5% and 86.9%, P < 0.001), continuous dose (88.9% and 77.3%, P = 0.001), and both doses (86.6% and 73.8%, P < 0.001). Blood glucose concentration was significantly lower in app group at 3 h (125 ± 17 mg/dl vs. 136 ± 19 mg/dl, P = 0.014) and 4 h (135 ± 22 mg/dl vs. 115 ± 15 mg/dl, P = 0.029) after graft reperfusion. Acute hyperglycemic change during 30 min was more prominent in app group while hyperglycemia incidence was 71.4% vs. 54.1% (P = 0.031). However, hyperglycemia risk was comparable at 2 h (31.4% vs. 31.1%, P = 0.964), and even insignificantly lower in app group at 3 h (7.1% vs. 19.5%, P = 0.184).

Conclusions: Compliance to the Portland protocol was significantly improved after introducing the application software; post-reperfusion hyperglycemia was better controlled. "Insulin protocol calculator" is cost-effective and time-saving with potential clinical benefits.

Background: Pulmonary hypertension in pregnancy is rare and leads to high maternal morbidity and mortality.

Case: A 27-year-old parturient woman with a 31-week gestational age underwent cesarean delivery under combined spinal-epidural anesthesia. She had systemic lupus erythematosus associated with severe pulmonary arterial hypertension. The operation was done in the cardiac theatre along with meticulous invasive monitoring. Insertion of femoral artery and femoral vein catheters for veno-arterial extracorporeal membrane oxygenation was done before delivery as preparation for the potential emergency of a life-threatening form of decompensated cardiac failure. During the delivery, the patient suddenly developed increased pulmonary arterial pressure. This was controlled by the continuous infusion of intravenous milrinone.

Conclusions: We report the successful management of this patient in the perioperative period. For cases such as that reported here, we recommend multidisciplinary team collaboration coupled with invasive cardiovascular monitoring and scrupulous anesthetic management.

Background: Post-reperfusion syndrome (PRS) results in sudden hemodynamic instability following graft reperfusion. Although PRS is known to influence outcomes following liver transplantation, little is known regarding the effects of anesthetics on PRS. This study investigated the association between the type of anesthetic agent and PRS in liver transplantation.

Methods: This single-center retrospective cohort study included patients who underwent liver transplantation between June 2016 and December 2019. Patients were divided into sevoflurane and propofol groups according to the anesthetic agent used. Stabilized inverse probability of treatment weighting (IPTW) analysis was performed to investigate the association between PRS identified based on blood pressure recordings and the type of anesthesia. Associations between the anesthetic agent and the duration of hypotension as well as early postoperative outcomes were also investigated.

Results: Data were analyzed for 398 patients, 304 (76.4%) and 94 (23.6%) of whom were anesthetized with propofol and sevoflurane, respectively. PRS developed in 40.7% of the 398 patients. Following stabilized IPTW analysis, the association with PRS was lower in the sevoflurane group than in the propofol group (odds ratio, 0.47; P = 0.018). However, there was no association between the type of anesthetic used and early postoperative outcomes.

Conclusions: The association of PRS was lower in the sevoflurane group than in the propofol group. However, there was no association between the type of anesthetic and the early postoperative outcomes. Further studies are required to determine the optimal anesthetic for liver transplantation.