Severe pulmonary edema occurred during endobronchial ultrasound under monitored anesthesia care - A case report.

BACKGROUND: Endobronchial ultrasound (EBUS) is widely used to diagnose lung cancer. Monitored anesthesia care (MAC) can enhance patient comfort and procedural conditions during EBUS. EBUS under MAC is usually safe but can lead to various complications. CASE: A 34-year-old male who had increased sputum for two months showed an enlarged paratracheal lymph node and planned for lymph node biopsy by EBUS. During EBUS under MAC, an unexpected oxygen saturation decline required intervention. After intubation, copious frothy fluid was suctioned from the bronchi, and oxygenation was recovered. A narrowed trachea and the EBUS bronchoscope might have resulted in upper airway obstruction, and suction performed under these conditions might have caused pulmonary edema. The patient received non-invasive ventilation and high-flow nasal cannula and recovered without complications. CONCLUSIONS: When there is an expected risk of upper airway obstruction during EBUS, careful preoperative evaluation and preparation are essential to prevent negative pressure pulmonary edema.

Anesthetic management of an elderly COVID-19 patient with pulmonary thromboembolism for hip surgery - A case report.

BACKGROUND: COVID-19 and delayed hip surgery are well-known risk factors for thromboembolism in elderly patients. CASE: We report the case of an 88-year-old female patient with COVID-19 and pulmonary thromboembolism (PTE) who underwent delayed hip surgery 21 days after the injury. Heparinization and inferior vena cava filters were used to treat and prevent PTE. Transesophageal echocardiography and extracorporeal membrane oxygenation (ECMO) sheaths were inserted as a precaution in case of emergencies during surgery; the procedure was performed without any specific event. CONCLUSIONS: COVID-19-infected patients suffering from a hip fracture have a high risk of thromboembolism, and therefore, require utmost attention for appropriate evaluation and prevention.

Catatonia associated with prolonged stupor after general anesthesia in a patient with multiple neuropsychiatric disorders -a case report.

BACKGROUND: Delayed emergence after general anesthesia may significantly affect a patient's condition. We present the case of a patient who experienced prolonged delayed recovery of consciousness, language, and motor response due to catatonia after eight hours of total elbow arthroplasty under general anesthesia. CASE: A 68-year-old woman with neuropsychiatric disorders and Parkinson's disease did not respond adequately during recovery after more than eight hours of general anesthesia. Following the operation, the patient was semi-comatose and appeared to have nonconvulsive status epilepticus upon awakening from anesthesia. However, subsequent examinations did not reveal any organic causes. The patient was subsequently diagnosed with catatonia, treated, and discharged following gradual improvement. CONCLUSIONS: Although rare, patients taking psychiatric drugs for an extended period may experience delayed emergence after prolonged general anesthesia without identifiable causes. Catatonia should be considered in the differential diagnoses of these patients.

Application of competency-based education in the Korean anesthesiology residency program and survey analysis.

BACKGROUND: Although competency-based education (CBE) is becoming a popular form of medical education, it has not been used to train residents. Recently, the Korean Society of Anesthesiologists completed a pilot implementation and evaluation of a CBE program.This study aims to outline the experience. METHODS: The chief training faculty from each hospital took a one-hour online course about CBE. Emails on the seven core competencies and their evaluation were sent ahead of a pilot core competency evaluation (CCE) to residents and faculty. The pilot CCE took place in late 2021, followed by a survey. RESULTS: A total of 68 out of 84 hospitals participated in the pilot CCE. The survey response rate was 55.9% (38/68) for chief training faculty, 10.2% (91/888) for training faculty, and 30.2% (206/683) for residents. More than half of the training faculty thought that CCE was necessary for the education of residents. Residents' and training faculty's responses about CCE were generally positive, although their understanding of CCE criteria was low. More than 80% of the hospitals had a defibrillator and cardiopulmonary resuscitation manikin while the rarest piece of equipment was an ultrasound vessel model. Only defibrillators were used in more than half of the hospitals. Thoughts about CCE were related to various factors, such as length of employment, location of hospitals, and the number of residents per grade. CONCLUSIONS: This study's results may be helpful in improving resident education quality to meet the expectations of both teaching faculty and residents while establishing CBE.

Quantitative Computed Tomography Parameters in Coronavirus Disease 2019 Patients and Prediction of Respiratory Outcomes Using a Decision Tree.

Background: Chest computed tomography (CT) scans play an important role in the diagnosis of coronavirus disease 2019 (COVID-19). This study aimed to describe the quantitative CT parameters in COVID-19 patients according to disease severity and build decision trees for predicting respiratory outcomes using the quantitative CT parameters. Methods: Patients hospitalized for COVID-19 were classified based on the level of disease severity: (1) no pneumonia or hypoxia, (2) pneumonia without hypoxia, (3) hypoxia without respiratory failure, and (4) respiratory failure. High attenuation area (HAA) was defined as the quantified percentage of imaged lung volume with attenuation values between -600 and -250 Hounsfield units (HU). Decision tree models were built with clinical variables and initial laboratory values (model 1) and including quantitative CT parameters in addition to them (model 2). Results: A total of 387 patients were analyzed. The mean age was 57.8 years, and 50.3% were women. HAA increased as the severity of respiratory outcome increased. HAA showed a moderate correlation with lactate dehydrogenases (LDH) and C-reactive protein (CRP). In the decision tree of model 1, the CRP, fibrinogen, LDH, and gene Ct value were chosen as classifiers whereas LDH, HAA, fibrinogen, vaccination status, and neutrophil (%) were chosen in model 2. For predicting respiratory failure, the decision tree built with quantitative CT parameters showed a greater accuracy than the model without CT parameters. Conclusions: The decision tree could provide higher accuracy for predicting respiratory failure when quantitative CT parameters were considered in addition to clinical characteristics, PCR Ct value, and blood biomarkers.

Prophylactic use of donut-shaped cushion to reduce sacral pressure injuries during open heart surgery.

Background: Pressure injuries are likely to develop in the operating room due to the high temperature and humidity underneath the patients. This study was designed to reduce sacral pressure injuries using donut-shaped cushions on patients undergoing open heart surgery in a supine position for more than three hours. Materials and Methods: Patients undergoing open heart surgery for more than three hours were randomly allocated. Depending on the allocation, either the donut-shaped cushion (donut group) or hydrophilic foam dressing (control group) was applied before draping. Patients were evaluated for the development of pressure injuries, National Pressure Ulcer Advisory Panel (NPUAP) stage, and injury size immediately after surgery, 48 hours, and seven days after surgery. Results: Forty-five patients were enrolled in this study. Twenty-two were assigned to the donut group and 23 were assigned to the control group. Three patients developed pressure injuries of NPUAP stage I or higher. All injuries occurred in the control group, but there was no statistically significant difference (P = 0.083). Conclusions: Patients who underwent cardiac surgery for more than three hours and used a donut-shaped cushion did not develop pressure injuries, although no statistical difference was noted. Specific preventative measures in the operating room may play a crucial role in preventing pressure injuries, and further research should be pursued.

Two cases of late-onset cardiovascular toxicities after a single injection of local anesthetics during supraclavicular brachial plexus block - A report of two cases.

BACKGROUND: Local anesthetics systemic toxicity (LAST) is a grave complication of regional anesthesia that usually occurs immediately after local anesthetics injection. Here, we report on rare late-onset toxicity cases after supraclavicular brachial plexus blocks. CASE: Two patients underwent surgery for radius fractures. We used lidocaine 100 mg and ropivacaine 150 mg for blocking and infused dexmedetomidine for intraoperative sedation. The 63-year-old male patient's blood pressure dropped to 87/60 mmHg after 3 h 15 min after blocking. Ventricular fibrillation occurred 10 min later. After five defibrillations, electrocardiography showed ventricular tachycardia that was normalized through one cardioversion. The 54-year-old female patient's heart rate decreased to 35 beats/min 2 h 30 min after blocking. Her vital signs returned to normal after administering atropine, ephedrine, epinephrine, and lipid emulsion. CONCLUSIONS: Physicians should remember that LAST may occur long after local anesthetic injection and be aware of factors that may adversely affect the course of LAST.

Successful anesthetic management of a giant lower lip hemangioma patient using high flow nasal cannula -a case report.

BACKGROUND: Giant lip hemangioma is a rare disease that may cause difficulty in preoxygenation and ventilation when using face masks and intubation during general anesthesia induction. CASE: A laparoscopic cholecystectomy was planned for a 77-year-old woman. The patient had a giant lower lip hemangioma that was 12 x 5 x 5 cm, which made preoxygenation and ventilation through a face mask impossible and put her at risk of hemangioma rupture. We preoxygenated her through a high-flow nasal cannula (HFNC). Following propofol and succinylcholine administration, we intubated the patient with a video laryngoscope without desaturation, hemangioma rupture, or CO2 retention. CONCLUSIONS: HFNC is a useful tool when difficult intubation is expected in patients who have problems using conventional face masks.

Epidural analgesia versus intravenous analgesia after minimally invasive repair of pectus excavatum in pediatric patients: a systematic review and meta-analysis.

BACKGROUND: Postoperative pain control after the minimally invasive repair of pectus excavatum (MIRPE) is essential, but there is a controversy about a better analgesic method between epidural and intravenous (IV) analgesia. This systematic review and meta-analysis aimed to compare the effect of epidural versus IV analgesia following MIRPE. METHODS: We searched PubMed, MEDLINE, EMBASE, Cochrane Central Register, and ClinicalTrials.gov for randomized controlled trials (RCTs) dated up to 31st May 2021. The primary outcome was the area under the curve (AUC) of the weighted mean visual analog scale (VAS) after MIRPE. The secondary outcomes were postoperative nausea, operation time, total operating room time, and postoperative length of hospital stay. RESULTS: Four RCTs involving 243 patients were finally included in this meta-analysis. The AUC of the weighted mean VAS was 343.62 in the epidural group and 375.24 in the IV group. The epidural group showed lower VAS than the IV group at 12 to 48 h after the surgery. Postoperative nausea, operation time and length of hospital stay was not different between two groups. The epidural group had a significantly longer total operating room time due to epidural catheter insertion time. CONCLUSIONS: Epidural analgesia after the MIRPE had a better analgesic effect than IV analgesia. However, IV analgesia may also be a viable option, and physicians should wisely choose analgesic modalities after MIRPE.

Peroneal nerve palsy after compression stockings application.

Peroneal nerve palsy can be caused by various etiology. We report unilateral peroneal nerve palsy after compression stockings application. A 64-year-old man underwent off-pump coronary bypass graft. Surgeon did not use saphenous vein for the bypass graft. Sedation was stopped after 3 h postoperative. After 16 h, for prophylaxis of deep vein thrombosis, knee-high elastic stocking was applied. After 1 h, he took off right stocking because of numbness but left stocking was kept. After 24 h postoperative, (8 h after stocking application) patient complained suddenly left foot drop. Manual muscle test revealed 0/5 of ankle dorsiflexion, ankle eversion, and toe extension. Sensory was decreased to 70% in lower half of anterolateral aspect of tibia, foot dorsum, and toes. Foot drop and sensory abnormality decreased in 3 weeks. Cardiac surgery patients already have many risk factors for peripheral neuropathy. Clinicians should be careful when applying stockings on those patients.

Anticholinergic premedication-induced fever in paediatric ambulatory ketamine anaesthesia.

OBJECTIVE: A randomized, double-blind, prospective study to evaluate the effect of anticholinergic drugs on thermoregulation in paediatric patients undergoing ambulatory anaesthesia with ketamine. METHODS: Patients were randomized to receive either 0.005 mg/kg glycopyrrolate or the equivalent volume of normal saline (placebo) at 30 min before ketamine anaesthesia. Body temperature was measured tympanically at baseline and at 0, 30, 60 and 90 min postoperatively. The quantity of saliva prodiced during surgery and incidence of fever were recorded. RESULTS: Body temperature was significantly higher in the glycopyrrolate group (n = 42) than the placebo group (n = 42) at 30, 60 and 90 min after surgery, and higher than baseline at 0, 30, 60 and 90 min after surgery. In the placebo group, body temperature was significantly higher than baseline at 0 and 30 min after surgery. Saliva secretion was significantly lower in the glycopyrrolate group than the placebo group. CONCLUSION: Routine premedication with adjunctive anticholinergics should not be considered in paediatric patients receiving ketamine sedation due to the increased risk of fever.Trial registration number, Clinicaltrials.gov: NCT02430272.

Increasing the area and varying the dosage of Botulinum toxin a injections for effective treatment of hemifacial spasm.

CONCLUSION: Wider-area botulinum toxin (BT) injection with the dosage depending on specific pathology is a promising approach for the treatment of hemifacial spasm (HFS), resulting in effective and long-lasting control of HFS with fewer side-effects. OBJECTIVE: The aim of this study was to develop a BT injection strategy that minimizes complications by considering the causes, duration, and electrophysiologic features of the disease, as well as the patient's age. METHODS: From July 2011 to July 2015, 26 patients were included in the strategy. The mean age was 61.8 ± 14.6. In the case of essential HFS, 2 units/injection site was the standard dosage. If a patient was aged over 60 and had a reduced electromyogram (EMG) amplitude, the dosage was reduced by 0.5 units/site. In the case of post-paralytic and tumor-induced HFS, 1.5 units/site was the standard dosage. All cases were managed by alternating injections of Botox and Dysport with no physical therapy. RESULTS: Most HFS patients treated with the injection strategy had complete remission of HFS within 1 week. The average number of BT injection sites was 22.6 ± 6.7. The mean total BT dosage on the affected side was 28.6 ± 4.9 units. The mean duration of BT efficacy was 28.6 ± 7.7 weeks.

Postpartum spinal subdural hematoma: irrelevant epidural blood patch: a case report.

We report a healthy patient with postpartum headache and neck stiffness which were diagnosed as symptoms of pseudoaneurysm of vertebral artery. She had received a Cesarean section under the spinal anesthesia, and complaint of headache and neck stiffness. Epidural blood patches were done twice, but symptoms persisted. Eight days later, she experienced sensory disturbance and emergent laminectomy was done. When persistent postpartum headache occurs after epidural blood patch, more precise differential diagnosis should be made and considering other possible pathologies.

Meta-Analysis of Sodium Bicarbonate Therapy for Prevention of Cardiac Surgery-Associated Acute Kidney Injury.

OBJECTIVE: The aim of this study was to determine whether or not perioperative administration of sodium bicarbonate had a preventive effect on cardiac surgery-associated acute kidney injury (CSA-AKI) as shown in randomized controlled trials. DESIGN: The authors conducted a systematic review and meta-analysis using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and KoreaMed. SETTING: The authors searched MEDLINE, EMBASE, CENTRAL, and KoreaMed without language and date restrictions. They used both MeSH and free-text terms to identify relevant studies. Electronic searches were undertaken on July 31, 2014. PARTICIPANTS: Five randomized controlled studies included in this review. MEASUREMENTS AND MAIN RESULTS: There were no differences in the development of CSA-AKI among patients in the sodium bicarbonate group compared with those in the control group (5 trials, 1,092 patients; n = 233 of 547 in sodium bicarbonate (SB) group versus 225 of 545 in control group (SC); risk ratio (RR), 0.95; 95% confidence interval (CI), 0.74-1.22. Also, there were no statistical differences in in-hospital mortality (3 trials, 573 patients; n = 21 of 288 in SB versus 14 of 285 in SC; RR, 1.44; 95% CI, 0.76-2.72), need for renal replacement therapy (4 trials, 1,000 patients; n = 21 of 503 in SB versus 23 of 497 in SC; RR, 0.90; 95% CI, 0.50-1.60), length of stay in the intensive care unit (ICU) (hours) (4 trials, n = 969 patients, weighted men difference (WMD), 2.17; 95% CI, -1.15-5.49), and length of ventilation (hours) (4 trials, 969 patients; WMD, 0.34; 95% CI,-0.80-1.48). CONCLUSIONS: Perioperative administration of sodium bicarbonate did not reduce the rate of CSA-AKI in randomized controlled trials. Therefore, use of perioperative administration of sodium bicarbonate for the prevention of CSA-AKI is questionable.

Suspected coronary ostium calcification identified as a protruding stent by epiaortic echography.

A 76-year-old male patient was admitted for mitral valvuloplasty. He had suffered a myocardial infarction 7 months earlier, and two stents had been inserted in the left main coronary artery and left circumflex artery. Intraoperative transesophageal echocardiography revealed a 10 × 8 mm echogenic mass at the ostium of the left main coronary artery. We initially suspected severe atheromatous calcification at the coronary ostium, which might require aortotomy and removal, but we decided to perform an epiaortic ultrasonographic scan first to obtain better images and reevaluate. Epiaortic scanning with a linear sonographic probe identified the mass as a protruding coronary stent.

Left atrial wall dissection after mitral valve replacement.

Left atrial dissection does occur, though rarely, after mitral valve surgery. A 68-year-old Korean female presented with moderate mitral stenosis, mild mitral regurgitation, moderate tricuspid regurgitation and mild aortic regurgitation. She was scheduled for mitral valve replacement and tricuspid annuloplasty. We experienced a left atrial dissection after weaning from cardiopulmonary bypass and decided not to repair it. The patient recovered uneventfully. We suggest that a specific type of left atrial dissection can be treated conservatively.

Comparison of cardiac output derived from FloTrac™/Vigileo™ and impedance cardiography during major abdominal surgery.

OBJECTIVES: Impedance cardiography (ICG) is a noninvasive technique that provides reasonably accurate measurements of cardiac output, but the usefulness of ICG in patients undergoing open abdominal surgery has not been validated. METHODS: Cardiac output was measured while patients underwent open gastrectomy using an ICG monitor (niccomo™; ICG-CO); the results were compared with those measured using a FloTrac™/Vigileo™ monitor (Flo-CO), which measures cardiac output by analysing the arterial waveform. Data collection commenced at the beginning of anaesthetic induction and continued until the patient was awake. Data were compared using the Bland-Altman analysis, and the clinical significance of the difference between the two methods was evaluated by calculating the percentage error (%). RESULTS: Eleven patients were monitored during surgery. The bias of the Flo-CO and ICG-CO values was -0.45 l/min. The upper and lower limits of agreement were 0.96 l/min and -1.85 l/min, respectively. The percentage error was 28.5%. Electrocautery induced interference that transiently impaired the performance of the ICG monitor. CONCLUSIONS: ICG provided useful information in evaluating the cardiac output of patients during abdominal surgery.