Factors associated with Taiwan anesthesiologists' intention to leave anesthesia practice.

BACKGROUND/PURPOSE: Anesthesiologists in Taiwan had the heaviest workload compared with other Taiwanese specialists. In a previous study, anesthesia-related mortality was >12 times the rate reported in the USA, UK, and Japan. Nine percent of Taiwanese anesthesiologists left their jobs to work as general practitioners in clinics. This study aims to assess the current working conditions of anesthesiologists in Taiwan and their satisfaction with their occupation, and to identify the factors associated with the intentions of anesthesiologists in Taiwan to leave anesthesia practice. METHODS: A self-reported questionnaire was completed by 474 attending anesthesiologists in Taiwan. The Chi-square test was used for categorical variables and the t test for continuous variables. Multivariate logistic regression was conducted to identify the factors significantly associated with the willingness of anesthesiologists to continue in anesthesiology. RESULTS: The sample anesthesiologists worked 59.9 hours/week, however a reasonable length of time to work is 49.6 hours/week. They simultaneously covered four operating rooms daily, but three rooms is considered reasonable. Surprisingly, 54.9% of them expressed their unwillingness to practice clinical anesthesia. Those anesthesiologists dissatisfied with their overall working conditions had a substantially increased odds ratio (6.96) of deterring continuing to practice in anesthesia. Furthermore, an inability to take care of the family and a low salary significantly decreased the willingness to practice in anesthesia (odds ratio: 0.42 and 0.38, respectively). CONCLUSION: Unfavorable working conditions were considered to lower the satisfaction of anesthesiologists in Taiwan. In particular, an inability to take care of the family and a low salary were major factors in deterring anesthesiologists in Taiwan from continuing in anesthesia.

A prospective evaluation of ultrasound-directed transparenchymal vascular control with linear cutting staplers in major hepatic resections.

BACKGROUND: We prospectively evaluated a novel ultrasound-directed technique of major hepatic resection using transparenchymal application of vascular staplers intending to minimize blood loss, operative time, and hepatic warm ischemia time. METHODS: Beginning in 1998 many major hepatic resections for hepatic tumors were performed with ultrasound-directed transparenchymal application of vascular linear cutting staplers. An endoscopic flexible neck vascular linear cutting stapler was used for control of the hepatic veins. RESULTS: From December 1998 to April 2003, 346 patients undergoing hepatic resection using this technique were identified from a prospective hepatobiliary tumor surgery database. Records were reviewed for blood loss, transfusion requirement, inflow occlusion (Pringle maneuver) time, overall operative time, and perioperative and postoperative complications. The average blood loss for all patients was 396 +/- 28.4 mL. The inflow occlusion time was 13.7 +/- .64 minutes with a total operative time of 140.7 +/- 3.7 minutes. Additional liver-related procedures were performed in 52% of the patients. The overall complication rate was 29.5% with a 90-day mortality rate of 1.4%. CONCLUSIONS: Ultrasound-directed transparenchymal application of vascular staplers to control inflow and outflow during major liver resection minimizes blood loss, warm ischemia time, and operative time compared to published reports of patients undergoing resection using other techniques.

Surgical management of hereditary pheochromocytoma.

BACKGROUND: Surgical treatment of hereditary pheochromocytoma remains controversial because of the need for lifelong corticosteroid therapy and the risk of Addisonian crisis associated with bilateral total adrenalectomy. We examined our large series of patients with hereditary pheochromocytoma to evaluate postsurgical outcomes, particularly in those who underwent cortical-sparing adrenalectomy. STUDY DESIGN: We retrospectively reviewed the outcomes of all patients with histopathologic diagnoses of hereditary pheochromocytoma treated at our institution from 1962 to 2003. Familial disease was initially determined by pedigree analysis, genetic testing, or both for multiple endocrine neoplasia (MEN) types 1, 2A, or 2B; von Hippel-Lindau disease (VHL); neurofibromatosis type 1 (NF-1); or familial paraganglioma syndrome (FP). RESULTS: Adrenal pheochromocytomas were present in 56 of 59 patients (95%): MEN2A (39), MEN2B (7), VHL (6), MEN1 (2), NF-1 (2). Paragangliomas (extraadrenal pheochromocytomas) were present in the remaining 3 of 59 patients (5%): FP (2) and NF-1 (1). Thirty-eight of 56 patients with pheochromocytomas had cumulative operations resulting in total or subtotal bilateral adrenalectomy. Acute adrenal insufficiency (Addisonian crisis) occurred in 4 of these 38 patients (11%). Cortical-sparing adrenalectomy was performed in 26 patients who underwent bilateral adrenal resection; 17 (65%) were corticosteroid independent at a median followup of 71 months. Recurrent pheochromocytoma developed in an adrenal remnant in 3 of 30 patients (10%) who underwent unilateral or bilateral cortical-sparing procedures. Metastatic disease did not develop in any patient with pheochromocytoma, but has occurred in two of three patients with paragangliomas. CONCLUSIONS: Our data suggest that a cortical-sparing adrenalectomy can successfully avoid the need for corticosteroid replacement in the majority of patients who undergo a bilateral adrenalectomy. Long-term followup should include monitoring of the remnant gland for recurrent pheochromocytoma with yearly biochemical screening studies.

Adverse events associated with the intraoperative injection of isosulfan blue.

STUDY OBJECTIVE: To describe the adverse events associated with the intraoperative injection of isosulfan blue in a large group of patients having a wide range of surgical procedures, and to identify risk factors for these events. DESIGN: Retrospective chart review. SETTING: University-affiliated institution specializing in malignancies PATIENTS: 1835 patients representing a total of 1852 surgical procedures. MEASUREMENTS: Incidence, type, severity, onset time, duration, management, and the presence of potential risk factors for adverse events. Events were considered "major" if potentially life-threatening hypotension occurred. MAIN RESULTS: Adverse events occurred in 28 procedures (1.5%) and 14 of these adverse events (0.75%) were classified as major. The types of events were: skin reactions in 21 patients, hypotension in 14 patients, edema in 1 patients, and unspecified in 1 patient. The time of onset for adverse events was 42.2 +/- 53.9 minutes (median, 17.5; range, 1 to 180 min) after isosulfan blue injection, and was significantly longer for minor reactions compared with major events (p = 0.015). The longest adverse event lasted at least 21 hours. Treatment was successful with usual antiallergy/antianaphylaxis medications. Ten patients received diphenhydramine alone, and four patients received intravenous epinephrine infusions. Factors associated with a significantly increased incidence of adverse events were isosulfan blue injection in the vulvar area (p = 0.000038), and the chronic preoperative use of angiotensin-converting enzyme inhibitors or angiotensin receptor-blocking agents (p = 0.043). Trends toward an increased risk of an adverse event were noted with isosulfan blue injection in the breast area (p = 0.19), and having more than one surgical procedure with isosulfan blue (p = 0.14). CONCLUSIONS: Although the most frequent adverse event associated with injection of isosulfan blue was a skin reaction, potentially life-threatening hypotension occurred in 0.75% of all procedures. Anesthesiologists must be aware of the variable onset time and potentially prolonged duration of the adverse events. They should recognize the need for extra vigilance in patients with potential risk factors, and have the usual antiallergy/antianaphylaxis medications available for administration if necessary.

Treating AIDS-associated cerebral toxoplasmosis - pyrimethamine plus sulfadiazine compared with cotrimoxazole, and outcome with adjunctive glucocorticoids.

We conducted a retrospective study of AIDS-associated cerebral toxoplasmosis. Eighteen patients received pyrimethamine plus sulfadiazine and 25 co-trimoxazole, with comparable baseline characteristics. There were no differences in clinical outcomes, but co-trimoxazole was better tolerated (p = 0.066). There was also a trend towards more deaths among patients who received glucocorticoids.

Use of deep intravenous sedation with propofol and the laryngeal mask airway during transesophageal echocardiography.

OBJECTIVE: To describe the use of either deep intravenous sedation with propofol or light sedation with midazolam and topical anesthesia during transesophageal echocardiography (TEE) and to report the incidence of respiratory complications and their management. DESIGN: Retrospective study from March 2000 through August 2002. SETTING: Single institution, specialized cancer center. PARTICIPANTS: All patients undergoing TEE examination in the specified time period (n = 42). MAIN RESULTS: Eight patients received light sedation and 34 patients received deep intravenous sedation with propofol. An airway event occurred in one patient in the light sedation group and in six patients in the deep sedation group. The patient in the light sedation group was managed with the use of a face-mask and a manual resuscitation bag. All airway events in the deep sedation group were managed successfully using the laryngeal mask airway (LMA). CONCLUSION: Deep sedation with intravenous propofol can provide both excellent patient comfort and optimal conditions for TEE examination, particularly in patients who may require more lengthy procedures or in whom other techniques have failed. Although the incidence of respiratory depression was higher in patients receiving deep sedation with propofol than in patients who were lightly sedated (17.6% versus 12.5%, respectively), all six patients who had respiratory depression while under deep sedation with propofol were successfully ventilated using the LMA trade mark, without the need to remove the TEE probe and without terminating the examination prematurely. In contrast, in the one patient in the light sedation group who had respiratory depression, the TEE probe had to be removed to ventilate the patient via a face mask, and the procedure was cancelled.

Introduction: guidelines and advisory development.

Since 1992, the American Society of Anesthesiologists has produced 12 evidence-based practice guidelines, 2 practice advisories, and 3 guideline updates. These documents have assisted anesthesiologists and practitioners in many other specialties. Their brevity, practicality, and ease of use, coupled with a thorough and systematic evaluation of the evidence have been instrumental in bringing together the science and practice of medicine. The application of formal evidence-collection processes for literature and opinion and efficient analytic evaluations combine with the experience and practical knowledge of clinicians to produce widespread application of the guidelines. The evidence-based process developed by the ASA has been found to be adaptable to a wide variety of issues relating to clinical practice. The goal is to systematically collect and evaluate evidence from multiple sources and apply it ina comprehensive manner to the guideline recommendations. The ASA guideline and advisory development process is continuing to evolve in response to changes in medical technology, research, and practice. By providing synthesized evidence from multiple sources and robust clinical recommendations the ASA offers the practice of anesthesiology, an invaluable bridge between science and clinical practice.

Epidural and intrathecal analgesia is effective in treating refractory cancer pain.

The use of neuraxial (intrathecal and epidural) analgesia has been suggested in treatment guidelines put forth for the treatment of refractory cancer pain. We review the literature and present our algorithm for using neuraxial analgesia. We also present our outcomes using this algorithm over a 28-month period. We used neuraxial analgesia in 87 of 4,107 patients, approximately 2% of those seen for pain consultation. Evaluation of those patients at an 8-week follow-up revealed improved pain control. After institution of neuraxial analgesia, there was a significant reduction in the proportion of patients with severe pain (defined as a "pain worst" score in the severe range of 7-10), from 86% to 17%, noted to be highly statistically significant. At follow-up, numerical pain scores decreased significantly from 7.9 +/- 1.6 to 4.1 +/- 2.3. No difference was noted between the intrathecal and epidural groups. Oral opioid intake after instituting neuraxial analgesia revealed a significant decrease from 588 mg/day oral morphine equivalents to 294 mg/day. At follow-up, self-reported drowsiness and mental clouding (0-10) also significantly decreased from 6.2 +/- 3.0 and 5.4 +/- 3.4 to 3.2 +/- 3.0 and 3.1 +/- 3.0, respectively. This retrospective review shows promising efficacy of neuraxial analgesia in the context of failing medical management.

Is extended hepatectomy for hepatobiliary malignancy justified?

BACKGROUND: Extended hepatectomy may be required to provide the best chance for cure of hepatobiliary malignancies. However, the procedure may be associated with significant morbidity and mortality. METHODS: We analyzed the outcome of 127 consecutive patients who underwent extended hepatectomy (resection of > or = 5 liver segments) for hepatobiliary malignancies. RESULTS: The patients underwent extended hepatectomy for colorectal metastases (n = 86; 67.7%), hepatocellular carcinoma (n =12; 9.4%), cholangiocarcinoma (n =14; 11.0%), and other malignant diseases (n =15; 11.5%). Thirty-two left and ninety-five right extended hepatectomies were performed. Eight patients also underwent caudate lobe resection, and 40 patients underwent a synchronous intraabdominal procedure. Twenty patients underwent radiofrequency ablation, and 31 underwent preoperative portal vein embolization. The median blood loss was 300 mL for right hepatectomy and 600 mL for left hepatectomy (P = 0.02). Thirty-six patients (28.3%) received a blood transfusion. The overall complication rate was 30.7% (n = 39), and the operative mortality rate was 0.8% (n = 1). Significant liver insufficiency (total bilirubin level > 10 mg/dL or international normalized ratio > 2) occurred in 6 patients (4.7%). Multivariate analysis showed that a synchronous intraabdominal procedure was the only factor associated with an increased risk of morbidity (hazard ratio [HR], 4.9; P = 0.02). The median survival was 41.9 months. The overall 5-year survival rate was 25.5%. CONCLUSIONS: Extended hepatectomy can be performed with a near-zero operative mortality rate and is associated with long-term survival in a subset of patients with malignant hepatobiliary disease. Combining extended hepatectomy with another intraabdominal procedure increases the risk of postoperative morbidity.