Factors Associated with Poor Satisfaction with Anesthesia in Patients Who Had Previous Surgery: A Retrospective Study.

BACKGROUND: As most studies investigating patient satisfaction with anesthesia have some bias, previous results may underrepresent the true level of dissatisfaction with anesthesia. OBJECTIVES: This study aimed to identify factors associated with patient satisfaction with anesthesia. METHODS: Data from patients aged ≥ 20 years who had previous surgery and were scheduled for additional surgery were obtained retrospectively through preoperative interviews conducted. Informed consent for anesthesia was obtained by an anesthesiologist prior to the additional surgery. The patients were assigned to one of four anesthesia satisfaction levels, then were categorized into two groups; a high satisfaction group and a low satisfaction group. After comparing parameters between the two groups, logistic regression analysis was performed to identify factors that were negatively associated with satisfaction with anesthesia. RESULTS: Of 478 patients interviewed subjects, 469 patients were analyzed. Five individuals were excluded because they were unable to provide informed consent, and four subjects were excluded because they were aged < 10 years at the time of their previous surgery. Age < 65 years, previous surgery for malignancy, female sex, estimated operation duration < 3 hours, and American Society of Anesthesiologists Physical Status score 1 or 2 were included in a logistic regression analysis. Age < 65 years, previous surgery for malignancy, and female sex were predictive of poor patient satisfaction with anesthesia. Reasons for poor satisfaction with anesthesia included postoperative shivering and chills, fear of surgery, ineffective spinal anesthesia, and postoperative surgery-related pain. Of the patients awaiting surgery for malignancy, 57.3% had previous surgery for malignancy. CONCLUSIONS: Age < 65 years, previous surgery for malignancy, and female sex were negatively associated with patient satisfaction with anesthesia. These factors should be considered when preparing patients for future procedures to improve postoperative patient satisfaction.

Factors Causing Post-Anesthetic High Respiratory Resistance in Patients Undergoing Transurethral Resection of Bladder Tumors.

BACKGROUND: In this study, we investigated the causes of high respiratory resistance that is observed after general anesthesia. We focused on respiratory resistance at 5 Hz (R5), which were measured preoperatively and postoperatively. METHODS: Our prospective observational study enrolled 68 patients who underwent transurethral resection of bladder tumors from April to October 2015. Respiratory impedance was measured the day before surgery and immediately after general anesthesia. Participants were divided into 2 groups: Group L (postoperative R5 values < 4.0 cmH2O/L/sec; n = 33) and Group H (postoperative R5 values ≥ 4.0 cmH2O/L/sec; n = 35). Patient background, preoperative R5 values, endotracheal tube or subglottic devices, anaesthetic period, desflurane or sevoflurane, and endotracheal suctioning were compared. RESULTS: Significant parameters were height, inhalation of desflurane, endotracheal suctioning, and preoperative R5 value. Logistic regression showed that endotracheal suctioning and a higher preoperative R5 level increased postoperative respiratory resistance (> 4 cmH2O/L/sec). CONCLUSIONS: The endotracheal suctioning at the end of anesthesia influenced respiratory resistance more than use of the endotracheal tube and desflurane.

Evaluation of ultrasound-guided posterior quadratus lumborum block for postoperative analgesia after laparoscopic gynecologic surgery.

STUDY OBJECTIVE: This study aimed to determine the efficacy of ultrasound-guided posterior quadratus lumborum block (QLB) in treating postoperative pain following laparoscopic gynecologic surgery. DESIGN: Prospective randomized controlled study. PATIENTS: Seventy adult patients scheduled for elective laparoscopic gynaecological surgery under general anesthesia. INTERVENTION: This randomized controlled study involved two groups of adult females who were scheduled to undergo laparoscopic gynecologic surgery under general anesthesia. Patients were randomly assigned to either the QLB group or Control group. In the QLB group, patients underwent posterior QLB with 20mL of 0.375% ropivacaine on each side. Patients were blinded to treatment. MEASUREMENTS: At 0, 1, 3, and 24 hours after anesthesia recovery, evaluator recorded the severity of postoperative pain in movement and at rest using a Numeric Rating Scale (NRS). We also evaluated the severity of nausea using NRS and number of additional analgesics. MAIN RESULTS: Immediately after recovery from anesthesia, the NRS score for pain in movement did not differ significantly between groups. NRS scores for pain both in movement and at rest were significantly higher in the Control group than in the QLB group at 1, 3, and 24h after recovery from anesthesia. CONCLUSION: Our results suggest that posterior QLB significantly reduces postoperative pain in movement and at rest following laparoscopic gynecologic surgery.

[A Difficult Airway after Anesthetic Induction in a Patient with Masticatory Muscle Tendon-Aponeurosis Hyperplasia].

We present a case of masticatory muscle tendon- aponeurosis hyperplasia in a patient who underwent general anesthesia for gynecologic surgery. The patient's square-shaped mandible was noticed during preoperative assessment by an anesthesiologist. Further investigation revealed masticatory muscle tendon- aponeurosis hyperplasia. Anesthetic induction agents were administered, and facemask ventilation was initi- ated easily. As the anesthesiologist had predicted, the patient's mouth opening was reduced after administration of muscle relaxants, and keeping her mouth open was more difficult than when she was conscious. Nasotracheal intubation was performed successfully using a bronchoscope. Patients with muscle tendon- aponeurosis hyperplasia do not generally have associated pain, and do not know that they have a limited mouth opening. They are therefore sometimes unaware that they have the condition. Anesthesiologists need to predict that airway intubation will be difficult when the patient has a limited mouth opening associated with a square-shaped mandible.

[Cesarean Section under General Anesthesia in a Pregnant Woman with Fibromyalgia].

We report a case of a 34-year-old pregnant woman with fibromyalgia (FM) who underwent cesarean sec- tion under general anesthesia. The patient was taking duloxetine and pregabalin for FM, as well as several anti-depressants due to severe depression. To avoid the exacerbation of FM by spinal anesthesia, we decided to perform cesarean section under general anesthesia. After a crash induction with propofol and rocuronium, tracheal intubation was performed using the Pentax- AWS Airwayscopeo. The procedure was completed uneventfully. Postoperatively, the patient received an ultrasound-guided transverse abdominal plane block and a continuous intravenous fentanyl infusion to relieve pain. No FM exacerbation was noted.

LMA-ProSeal insertion by novice doctors as affected by a 90° bend created by an intubating stylet: a randomized clinical trial.

STUDY OBJECTIVE: This study aimed to test the hypothesis that insertion of the supraglottic device LMA-ProSeal (ProSeal) by novice doctors in anesthetized patients can be improved by using an intubating stylet to create a 90° bend and that better sealing pressure is achieved. DESIGN: Randomized clinical trial. SETTING: Operating room. PATIENTS: Seventy adult patients scheduled for elective surgery under general anesthesia using ProSeal with American Society of Anesthesiologists physical status 1 to 3. INTERVENTIONS: ProSeal were inserted with the 90° bend created by the intubating stylet (90D group, 35 patients) or not (ie, conventional insertion; C group, 35 patients). MEASUREMENTS: The number of attempts to successful insertion, sealing pressure, subjective difficulty of insertion by novice doctors, and postoperative pharyngeal pain or hoarseness were compared between groups. MAIN RESULTS: The total number of insertion attempts for the 90D and control groups were 1 (24 and 8, respectively), 2 (8 and 13), 3 (3 and 9), and failure (0 and 5), respectively, showing significant differences between groups (P<.001). Sealing pressure was significantly higher in the 90D group than in the C group (90D group, 23.3±3.7cm H2O; C group, 19.5±2.6cm H2O; P<.001), and the subjective difficulty of insertion was significantly lower in the 90D group (90D group, 27.3±17.6mm; C group, 55.4±22.8mm; P<.001). The incidence of postoperative pharyngeal pain and hoarseness did not differ significantly between groups. CONCLUSIONS: Our results suggest that creating a 90° bend using an intubating stylet facilitates ProSeal insertion by novice doctors, as reflected by higher successful insertion rates, higher sealing pressure, and lower subjective difficulty of insertion in anesthetized patients.

Perioperative evaluation of respiratory impedance using the forced oscillation technique: a prospective observational study.

BACKGROUND: Intravascular fluid shifts, mechanical ventilation and inhalational anesthetic drugs may contribute to intraoperative lung injury. This prospective observational study measured the changes in respiratory impedance resulting from inhalational anesthesia and mechanical ventilation in adults undergoing transurethral resection of bladder tumors. The components of respiratory impedance (resistance and reactance) were measured using the forced oscillation technique (FOT). METHODS: Respiratory resistance at 5 Hz (R5) and 20 Hz (R20), respiratory reactance at 5 Hz (X5), resonant frequency (Fres) and area of low reactance (ALX) were measured before and immediately after surgery in 30 adults. In addition, preoperative vital capacity (VC), forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1.0) were evaluated using spirometry. All patients were intubated with an endotracheal tube and were mechanically ventilated, with anesthesia maintained with sevoflurane. Pre- and postoperative FOT measurements were compared using Wilcoxon paired rank tests, and the relationships between FOT measurements and preoperative spirometry findings were determined by Spearman's rank correlation analysis. RESULTS: Twenty-six patients were included in the final analysis: postoperative FOT could not be performed in four because of postoperative restlessness or nausea. The mean duration of surgery was 47 min. All components of respiratory resistance deteriorated significantly over the course of surgery, with median increases in R5, R20, and R5-R20 of 1.67 cmH2O/L/s (p < 0.0001), 1.28 cmH2O/L/s (p < 0.0001) and 0.46 cmH2O/L/s (p = 0.0004), respectively. The components of respiratory reactance also deteriorated significantly, with X5 decreasing 1.7 cmH2O/L/s (p < 0.0001), Fres increasing 5.57 Hz (p < 0.0001) and ALX increasing 10.51 cmH2O/L/s (p < 0.0001). There were statistically significant and directly proportional relationships between pre- and postoperative X5 and %VC, %FEV1.0 and %FVC, with inverse relationships between pre- and postoperative Fres and ALX. CONCLUSIONS: All components measured by FOT deteriorated significantly after a relatively short period of general anesthesia and mechanical ventilation. All components of resistance increased. Of the reactance components, X5 decreased and Fres and ALX increased. Pre- and postoperative respiratory reactance correlated with parameters measured by spirometry. TRIAL REGISTRATION: JMA-IIA00136 .

[Anesthetic Management of Video-assisted Left Upper Lobectomy in a Patient with Ischemic Heart Disease Using an Intraaortic Balloon Pump].

We report the successful anesthetic management of video-assisted left upper lobectomy in a patient with ischemic heart disease using an intra-aortic balloon pump (IABP). An 81-year-old man with severe ischemic heart disease was scheduled for partial lobectomy for suspected lung cancer under general anesthesia. Although he had severe ischemic heart disease, coronary intervention such as percutaneous cardiac intervention or coronary artery bypass grafting was impossible due to severe coronary stenosis. IABP was instituted through the femoral artery before inducing anesthesia. Tracheal intubation was performed with the McGRATH MAC videolaryngoscope to minimize stress. Surgery was performed uneventfully and the patient was transferred to the intensive care unit under sedation. IABP was removed three hours postoperatively. After confirming no ischemic or vital sign changes, he was extubated the next day. No complications resulting from the IABP were observed.

[The Effects of Tracheal Suction on Respiratory Impedance].

BACKGROUND: Tracheal suctioning is performed just before extubation to remove sputum from the trachea. Although it is an invasive procedure, its adverse effect on the airway has not been investigated because this is difficult to achieve using conventional tests or monitoring. We performed a study using the forced oscillation technique to investigate whether tracheal suctioning affects respiratory impedance (consisting of respiratory resistance and respiratory reactance). METHODS: This prospective observational study was conducted in 43 patients undergoing transurethral resection of bladder tumors under general anesthesia. Respiratory impedance (R5, R20, and X5) was measured the day before surgery and just after surgery. R5 and R20 are representative values of respiratory resistance, while X5 is representative of respiratory reactance. Participants were divided into two groups: those with or without tracheal suctioning. RESULTS: There were no significant differences in patient backgrounds or preoperative respiratory impedance parameters. In the suctioning group, post- operative R5 and R20 were significantly higher than in the non-suctioning group (P=0.002 and 0.063, respec- tively). There was no significant difference in postop- erative X5 between the two groups. CONCLUSIONS: Tracheal suctioning caused an increase in respiratory resistance in this cohort of patients, sug- gesting that unnecessary suctioning should be avoided during surgery.

[A Case of Severe Bradycardia Associated with Bladder Perforation during Spinal Anesthesia].

Here we report a case of severe bradycardia associated with bladder perforation during transurethral resection of the bladder. The patient was diagnosed with bladder cancer eight months ago and underwent transurethral resection of the bladder tumor. After balloon-occluded arterial infusion chemotherapy, she was scheduled for a bladder biopsy under spinal anesthesia. Spinal anesthesia was induced with 2.5 ml of 0.5% bupivacaine hydrochloride at L3-4, and sensory loss (T9) was confirmed. The operation started uneventfully 20 minutes after bupivacaine administration. However, ten minutes into the operation, bladder perforation occurred and was followed by severe bradycardia (20-30 beats x min(-1)). While preparing for transcutaneous pacing, bradycardia improved with intravenous atropine and ephedrine. The level of spinal anesthesia remained unchanged. General anesthesia was induced with propofol, rocuronium and fentanyl. The patient was extubated uneventfully after the operation and was discharged 14 days later.

Change in serum sodium level predicts clinical manifestations of transurethral resection syndrome: a retrospective review.

BACKGROUND: Patients undergoing transurethral resection (TUR) of the prostate are at risk of TUR syndrome, generally defined as having cardiovascular and/or neurological manifestations, along with serum sodium concentrations less than or equal to 125 mmol/l. As these symptoms can also occur in patients with serum sodium greater than 125 mmol/l, this study aimed to investigate the relationship between serum sodium concentrations and neurological manifestations of TUR syndrome. METHODS: Data on patients who underwent TUR of the prostate under local anesthesia over an 8-year period were retrospectively reviewed. Based on their cardiovascular and neurological manifestations, patients were divided into two groups: a symptomatic and an asymptomatic group. Logistic regression analysis was used to detect the risk factors for being symptomatic. Receiver operator characteristic (ROC) curve analysis was used to determine the optimal cutoff value of estimated change in serum sodium level that could predict the development of clinical manifestation of TUR syndrome. RESULTS: Of the 229 patients, 60 showed symptoms. Serum sodium level correlated with neurological score (Spearman's correlation coefficient > 0.5). Logistic regression detected that the risk factors for being symptomatic were serum sodium level variables, operation time longer than or equal 90 min, and presence of continuous drainage from the bladder. ROC curve analysis showed that a change in serum sodium level of 7.4 mmol/l was the optimal cutoff value, with a sensitivity of 0.72, a specificity of 0.87, and an area under the curve (AUC) of 0.87. ROC curve analysis also showed that a 7.0% change in serum sodium level was optimal for this parameter, with a sensitivity of 0.70, a specificity of 0.89, and an AUC of 0.87. CONCLUSIONS: Changes in serum sodium concentration of > 7 mmol/l and of > 7% could predict the development of cardiovascular and neurological manifestations, which were assumed to be symptoms of TUR syndrome.

[Successful double-lumen endotracheal tube exchange with a soft-tipped extra firm exchange catheter in a patient with severe subcutaneous emphysema].

We report a case of successful double-lumen endotracheal tube exchange with a soft-tipped extra firm exchange catheter in a patient with severe subcutaneous emphysema. A 70-year-old man underwent right lower lobectomy for primary lung cancer under general anesthesia. He developed pneumothorax on postoperative day (POD) 14, which led to subcutaneous emphysema. An emergent operation was performed on POD20 to close the pulmonary fistula under general anesthesia with a single-lumen endotracheal tube and bronchial blocker. Subcutaneous emphysema became worse and pharyngeal emphysema was also suspected; re-operation to close the pulmonary or bronchial fistula was planned. We decided to place a double-lumen tube to precisely detect the fistula. Under the guide of a Pentax-AWS Airwayscope, the single-lumen endotracheal tube was exchanged uneventfully to a 35 Fr double-lumen endotracheal tube with a 110 cm soft-tipped extra firm exchange catheter. The fistula was detected by a leak test and the operation was performed uneventfully, leading to improvement of subcutaneous emphysema.

[Successful tracheal intubation through the air-Q intubating laryngeal airway in a patient with severe pharyngeal edema].

A 68-year-old man was diagnosed with severe pharyngeal edema after neck lymph node dissection for cancer of the external ear canal. He was scheduled for an emergency tracheotomy, but preoperative fiberoptic laryngoscopy revealed airway and glottic obstruction due to severe pharyngeal edema. As difficult mask ventilation and tracheal intubation were anticipated, intubation under spontaneous ventilation was performed to avoid a "can't ventilate, can't intubate" situation. The first attempt to intubate the patient using the Pentax-AWS Airwayscope with a thin Intlock resulted in failure due to hindered visualization of the glottis. Therefore, a size 3.5 air-Q intubating laryngeal airway was inserted using a bronchofiberscope to perform tracheal intubation through a laryngeal mask. Successful tracheal intubation was achieved while maintaining spontaneous ventilation. The air-Q intubating laryngeal airway can be useful in the setting of anticipated difficult mask ventilation and tracheal intubation, as in the case of severe pharyngeal edema.