Risk factors for postoperative delirium in elderly patients after spinal fusion surgery

Background@#Postoperative delirium (POD) has an incidence rate of 9% to 41%. It is directly linked to decreasing cognitive function, increasing length of hospitalization and cost, as well as other complications and mortality. We aimed to assess the risk factors for POD among elderly patients by analyzing data from those who underwent spinal surgery. @*Methods@#This study included 446 patients aged 65 years or older who underwent spinal surgery at our institution between March 2013 and May 2018. Data were collected retrospectively from the patients’ electronic medical records, and logistic regression was used to identify the risk factors associated with POD. The diagnosis of POD was based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and was made through consultation with a psychiatrist during postoperative hospitalization and before discharge. @*Results@#Seventy-eight (78/446, 17.4%) patients were diagnosed with POD. The most relevant risk factor for POD was preoperative cognitive dysfunction (odds ratio [OR], 4.37; 95% confidence interval [CI], 1.60 to 11.93; P = 0.004), followed by emergency surgery (OR, 2.70; 95% CI, 1.27 to 5.74; P = 0.01), age (OR, 1.19; 95% CI, 1.13 to 1.26; P < 0.001), and anesthesia time (OR, 1.01; 95% CI 1.00 to 1.01; P = 0.002). @*Conclusions@#Preoperative cognitive dysfunction, emergency surgery, age, and anesthesia time were factors that affected POD occurrence after spinal surgery. Patients with such associated factors may be at a higher risk for POD when undergoing spinal surgery, and hence, careful management may be necessary for these patients.

Risk factors of 30-day mortality following endovascular thoracic and abdominal aortic repair with general anesthesia

BACKGROUND: Recently, endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR), have been used for treatment of thoracic and abdominal aortic aneurysms. The purpose of this study was to analyze the outcome and predictors for 30-day mortality and complications, in patients that underwent EVAR and/or TEVAR under general anesthesia. METHODS: In this study, 151 cases of EVAR and/or TEVAR under general anesthesia in 140 patients during 2009–2017 were studied. The primary outcome was 30-day mortality after surgery. Multivariate logistic regression analysis was used, to clarify risk for postoperative 30-day mortality. RESULTS: Postoperative 30-day mortality rate was 9.9% in the study population (10.3% in EVAR, and 9.3% in TEVAR, respectively). Seventy-two cases (47.7%) experienced postoperative complications within 30 days. Elderly older than age 76.5 (odds ratio [ORs] = 48.89, 95% confidential interval [95% CI] 1.40–1,710.25, P = 0.032), technically expertness (OR = 0.01, 95% CI 0.00–0.40, P = 0.013), severity of systemic complications (OR = 23.24, 95% CI, 2.27–238.24, P = 0.008), and severity of local-vascular complications (OR = 31.87, 95% CI, 1.29–784.66, P = 0.034) were significantly associated with 30-day mortality. CONCLUSIONS: This study revealed that elderly, technically expertness, and severity of systemic and local-vascular complications were associated with 30-day mortality of EVAR and TEVAR in aortic aneurysm.

Effect of intravenous tranexamic acid on perioperative bleeding and transfusion in spine surgery: systematic review and meta-analysis of randomized controlled trials

BACKGROUND: This study aimed to systematically review the literature investigating the effect of intravenous (IV) tranexamic acid (TXA) on the perioperative blood loss and amount of transfused blood in patients who underwent spine surgery under general anesthesia. METHODS: MEDLINE, EMBASE, and CENTRAL databases were searched for studies published up to June 2017. Randomized controlled trials comparing the intervention of tranexamic acid use with a placebo in corrective spine fusion surgery were included. Outcome measures included intraoperative and postoperative blood loss and perioperative blood transfusion volume. We also conducted subgroup analyses according to the dose of administration of intervention drug. RESULTS: In total, 12 studies involving 875 patients were included in the final analysis. Blood loss decreased in patients treated with perioperative IV TXA by a mean volume of 189.58 ml intraoperatively (95% confidence interval [CI]: 135.82 to 243.34 ml, P < 0.001; I² = 74%), 121.04 ml postoperatively (95% CI: 84.92 to 157.17 ml, P < 0.001; I² = 0%), and 285.97 ml in total (95% CI: 190.70 to 381.23 ml, P < 0.001; I² = 0%). Perioperative transfusion volume also decreased by 162.10 ml in patients who received IV TXA (95% CI: 31.77 to 292.44 ml, P = 0.010; I² = 47%). CONCLUSIONS: Blood loss was reduced in patients who were administered TXA during spine surgery. Additionally, the perioperative volume of blood transfusion decreased in patients who received TXA. Further research is required to confirm the optimal dosage and timing of TXA usage.

The effect of pre-anesthetic administration of dexmedetomidine on the consumption of opioids in postoperative gynecologic patients

BACKGROUND: This study was designed to assess whether pre-anesthetic administration of dexmedetomidine reduces the postoperative consumption of opioids, in patients receiving patient-controlled fentanyl after gynecological laparotomy. METHODS: This was a prospective, randomized, double-blind, controlled study. Ten minutes before induction of anesthesia, 36 patients scheduled for elective gynecological laparotomy were assigned to receive either normal saline (group N) or dexmedetomidine 1 µg/kg (group D). A patient-controlled analgesia (PCA) device was used to administer fentanyl for the postoperative 24 h period. Cumulative fentanyl consumption and pain score were assessed at postoperative 30 min, 6 h and 24 h. Patient's satisfaction for pain control and other side effects (nausea, sedation score) were recorded for all corresponding time points. RESULTS: There was no significant difference between the groups in cumulative fentanyl consumption (Group N: 11.1 ± 3.2 µg/kg, Group D: 10.3 ± 2.9 µg/kg, P value: 0.706). The incidence of side-effects did not differ between the groups. Both groups showed similar blood pressure after anesthesia induction. However, 10 min after anesthesia induction, the heart rates in group D were significantly lower than group N (P = 0.0002). CONCLUSIONS: In patients undergoing gynecological laparotomy, the pre-anesthetic administration of single loading dose dexmedetomidine (1 µg/kg) given 10 min before anesthesia induction did not reduce the PCA consumption of postoperative fentanyl or the pain score.

Anesthetic management with extracorporeal membrane oxygenation in a patient with acute airway obstruction after inhalation burn injury: A case report

A 36-year-old woman was admitted to the intensive care unit because of an inhalation burn injury. Five days after admission, she developed dyspnea and hypercarbia. Therefore, fiberoptic bronchoscopy was performed through the endotracheal tube, which revealed foreign bodies in the tube. Tracheostomy was performed to remove, albeit incompletely, the foreign bodies (endotracheal debris). As sudden movement of the patient or airway reaction could cause the foreign bodies to move deeper into the bronchus during manipulation of the rigid bronchoscope, general anesthesia was induced and maintained by using total intravenous anesthesia with extracorporeal membrane oxygenation (ECMO). The foreign bodies were successfully removed without any other complications. This case showed that sloughed endobronchial debris after an inhalation burn injury caused acute airway obstruction. In such cases, alternative ventilation methods such as tracheostomy and ECMO may have to be applied, which can support a surgeon to focus on the procedure regardless of prolonged procedural time.

The efficacy of warming blanket on reducing intraoperative hypothermia in patients undergoing transurethral resection of bladder tumor under general anesthesia

BACKGROUND: Perioperative hypothermia, defined as a core temperature under 36℃, increases the risk of cardiac complication, bleeding and infection. This study aimed to compare the hypothermia-preventing effects of a warming blanket (Ready-heat®) and one-layer cotton blanket in patients undergoing transurethral resection of the bladder (TURBT) under general anesthesia. METHODS: Patients undergoing TURBT under general anesthesia were allocated to the warming blanket (N = 23) or one-layer cotton blanket (N = 23) groups. Ten minutes before induction of anesthesia, warming blanket or one-layer cotton blanket was applied according to the assigned group. Tympanic temperature was measured just before induction of anesthesia. Esophageal temperature and tympanic temperature were measured from 20 min after induction of anesthesia at 10-min intervals. Tympanic temperature was measured at 10-min intervals over a 30-min period in the post-anesthesia care unit (PACU). In addition, the incidence and intensity of shivering and thermal comfort were also measured. RESULTS: The core temperature during general anesthesia showed no significant intergroup difference. The warming blanket group showed a lower incidence of hypothermia at 1 h after induction of anesthesia. Tympanic temperature, the incidence and intensity of shivering, and thermal comfort in the PACU showed no significant intergroup differences. CONCLUSIONS: Application of the warming blanket or one-layer cotton blanket for 10 min before induction of anesthesia showed no hypothermia-preventing effects. However, at one hour after induction of anesthesia, warming blanket application reduced the incidence of hypothermia to a greater degree than one-layer cotton blanket.

Risk factors associated with outcomes of hip fracture surgery in elderly patients / 대한마취과학회지

BACKGROUND: Hip fracture surgery on elderly patients is associated with a high incidence of morbidity and mortality. The aim of this study is to identify the risk factors related to the postoperative mortality and complications following hip fracture surgery on elderly patients. METHODS: In this retrospective study, the medical records of elderly patients (aged 65 years or older) who underwent hip fracture surgery from January 2011 to June 2014 were reviewed. A total of 464 patients were involved. Demographic data of the patients, American Society of Anesthesiologists physical status, preoperative comorbidities, type and duration of anesthesia and type of surgery were collected. Factors related to postoperative mortality and complications; as well as to intensive care unit admission were analyzed using logistic regression. RESULTS: The incidence of postoperative mortality, cardiovascular complications, respiratory complications and intensive care unit (ICU) admission were 1.7, 4.7, 19.6 and 7.1%, respectively. Postoperative mortality was associated with preoperative respiratory comorbidities, postoperative cardiovascular complications (P < 0.05). Postoperative cardiovascular complications were related to frequent intraoperative hypotension (P <0.05). Postoperative respiratory complications were related to age, preoperative renal failure, neurological comorbidities, and bedridden state (P < 0.05). ICU admission was associated with the time from injury to operation, preoperative neurological comorbidities and frequent intraoperative hypotension (P < 0.05). CONCLUSIONS: Adequate treatment of respiratory comorbidities and prevention of cardiovascular complications might be the critical factors in reducing postoperative mortality in elderly patients undergoing hip fracture surgery.

The effect of long-term oral dantrolene on the neuromuscular action of rocuronium: a case report / 대한마취과학회지

Oral dantrolene causes a dose-dependent depression of skeletal muscle contractility. A 52-year-old man treated with oral dantrolene for spasticity after spinal cord injury was scheduled to undergo irrigation and drainage of a thigh abscess under general anesthesia. He had taken 50 mg oral dantrolene per day for 3 years. Under standard neuromuscular monitoring, anesthesia was performed with propofol, rocuronium, and sevoflurane. A bolus dose of ED95 (0.3 mg/kg) of rocuronium could not depress T1 up to 95%. An additional dose of rocuronium depressed T1 completely and decreased the train-of-four (TOF) count to zero. There was no apparent prolongation of the neuromuscular blocking action of rocuronium. The TOF ratio was recovered to more than 0.9 within 40 minutes after the last dose of rocuronium. A small dose of oral dantrolene does not prolong the duration of action and recovery of rocuronium.

Comparison of two types of combined spinal-epidural sets in terms of catheter positioning: reinforced catheter vs. non-reinforced catheter

BACKGROUND: The purpose of this study is to examine the usefulness of a combined spinal-epidural set with reinforced catheter (CombiSpeed(R), Ace Medical, Seoul, Korea) as compared with the non-reinforced catheter (PORTEX(R), Smiths medical, Brisbane, Australia) in terms of catheter positioning and clinical aspects of anesthesia. METHODS: One hundred and two patients scheduled for regional anesthesia were enrolled in this study. They were allocated randomly either into group A (CombiSpeed(R)) or group P (PORTEX(R)). Vital signs and the levels of sensory and motor block were measured every 5 minutes. Ease of insertion and the removal of the catheter were assessed, so was the incidence of venous cannulation and paresthesia during epidural catheter insertions. After the placement of epidural catheter, we checked the location of catheter by radiography and measured in a clockwise angle from the midline to catheter tip (angle X). In laboratory, tensile strength of the two products was measured by using tonometry. RESULTS: There were no significant differences between groups in intra-operative vital sign, block level and ease of catheter insertion and removal. No difference was observed in angle X between the groups (group A: 93.6 +/- 129.5degrees, group P: 124.5 +/- 127.7degrees, P = 0.22). There were no complications such as paresthesia or venous cannulation during catheter insertion. The tensile strength was higher in group A (group A: 1.70 +/- 0.05 kg, group P: 1.30 +/- 0.03 kg, P < 0.05). CONCLUSIONS: CombiSpeed(R) is as useful as PORTEX(R) in terms of ease for catheter placement, positioning of catheter tip and clinical aspects of anesthesia.

Sedation with Dexmedetomidine during Tracheostomy in Severe Tracheal Stenotic Patients / 대한구급학회지

In patients with severely compromised airways, a tracheostomy is usually performed under local anesthesia. Dexmedetomidine can be a better choice of sedative for such patients because it causes minimal respiratory depression. We report two cases of patients with severe stenosis of the airways who underwent sedation with dexmedetomidine during tracheostomy under local anesthesia. In the first case, recurrent laryngeal cancer caused laryngeal stenosis, and the narrowest laryngeal width was less than 3 mm. In the second case, the tracheostomy opening site was narrowed to a diameter of 3.4 mm in a patient with a history of total laryngectomy. For both patients, sedation was induced by dexmedetomidine infusion and the tracheostomy was performed successfully under local anesthesia without any events. Dexmedetomidine seems to be an effective and safe sedative for tracheostomies in patients with critical airways. The management and implications of sedation with dexmedetomidine in the patients with severe stenotic airways are discussed.

General anesthesia versus monitored anesthetic care with dexmedetomidine for closed reduction of nasal bone fracture / 대한마취과학회지

BACKGROUND: Reduction of nasal bone fracture can be performed under general or local anesthesia. The aim of this study was to compare general anesthesia (GA) and monitored anesthetic care (MAC) with dexmedetomidine based on intraoperative vital signs, comfort of patients, surgeons and nurses and the adverse effects after closed reduction of nasal bone fractures. METHODS: Sixty patients with American Society of Anesthesiologists physical status I or II were divided into a GA group (n = 30) or MAC group (n = 30). Standard monitorings were applied. In the GA group, general anesthesia was carried out with propofol-sevoflurane-N2O. In the MAC group, dexmedetomidine and local anesthetics were administered for sedation and analgesia. Intraoperative vital signs, postoperative pain scores by visual analog scale and postoperative nausea and vomiting (PONV) were compared between the groups. RESULTS: Intraoperatively, systolic blood pressures were significantly higher, and heart rates were lower in the MAC group compared to the GA group. There were no differences between the groups in the patient, nurse and surgeon's satisfaction, postoperative pain scores and incidence of PONV. CONCLUSIONS: MAC with dexmedetomidine resulted in comparable satisfaction in the patients, nurses and surgeons compared to general anesthesia. The incidence of postoperative adverse effects and severity of postoperative pain were also similar between the two groups. Therefore, both anesthetic techniques can be used during the reduction of nasal bone fractures based on a patient%s preference and medical condition.

Erratum: Comparison of two types of combined spinal-epidural sets in terms of catheter positioning: reinforced catheter vs. non-reinforced catheter

We found an error in our published article.

Effects and Related Factors of Endotracheal Intubation on Voice Change Following General Anesthesia / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Reliable studies about the impact of short-term intubation, particularly as part of general anesthesia, are scarce. That scarcity led to the following research objectives. First of all, we tried to find out how often and why voice change last more than 72 hours after intubation conducted for general anesthesia. SUBJECTS AND METHOD: The study enrolled 80 patients who were due to undergo general anesthesia at the Seoul Paik Hospital from Aug. 2009 to May 2010. The patients were examined through stroboscopic examination and voice analysis before surgery. Three days after the surgery, the same tests were performed again to single out patients whose results were abnormal; thus a proportion could be calculated. The other objective was to determine the factors involved with voice change. This was done according to the Mallampati classification, using the images from laryngoscopy and compiling records of cuff pressure, cuff volume, tube size, duration of intubations, and the number of intubation trials. RESULTS: 7.5% of the patients suffered from voice change longer than 3 days. Three factors, namely, cuff pressure, duration of anesthesia and patient age demonstrated statistically significant relationships among them. CONCLUSION: The results indicate that there is a need for patients scheduled to face general anesthesia to receive sufficient explanation about the possible postoperative voice change that could last longer than 3 days. Furthermore, surgeons and anesthesiologists need to cooperate closely by taking the patient age, duration of anesthesia and cuff pressure into account in order to limit postoperative voice change to the minimum extent.

A Case of Primary Aldosteronism due to Remnant Adenoma after Adrenalectomy in Pregnant Woman / 대한신장학회지

Primary aldosteronism is present in approximately 1 percent of hypertensive patients, and is rarely associated with pregnancy. We report a case of unilateral aldosterone producing adenoma in a pregnant woman. A 29-year-old woman was referred to with hypertension and proteinuria at 14 weeks' gestation. She had known that she had unilateral aldosterone producing adenoma for 18 months and refused medical or surgical treatment. She was prescribed antihypertensive medication and preformed laparoscopic adrenalectomy in left adrenal gland at 22 weeks' gestation. After adrenalectomy, her blood pressure was normal. At 29 weeks' gestation, she complained headache, and her blood pressure was 200/100 mmHg with pitting edema. We thought preeclampsia and performed cesarean section. After the baby was delivered, she had uncontrolled hypertension, hypokalemia with persistent proteinuria. We checked plasma renin activitity, aldoterone and abdminopelvic computed tomography. We found remnant left adrenal adenoma and perfomed laparoscopic operation. After reoperation, her blood pressure was normal and no proteinuria.

Pneumothorax in a post-anesthetic care unit after right thyroidectomy with left neck dissection: A case report / 대한마취과학회지

A 46-year-old woman underwent a right thyroidectomy with left neck dissection under general anesthesia. The operation was performed successfully for over the course of 3 hours 30 minutes. After extubation, the patient was transferred to post-anesthetic care unit (PACU). After 10 minutes, dyspnea, chest discomfort, desaturation was suddenly occurred. Intubation was performed in PACU. The emergency chest X-ray revealed a right pneumothorax, and the patient was treated by chest tube insertion. The patient was improved and was discharged uneventfully from hospital 8 days later.

A Case of Lupus-Like Syndrome after Kidney Transplantation / 대한이식학회지

Systemic erythematous lupus is a systemic inflammatory autoimmune disease that develops from drug, viral, or chemical irritants. We report a case of lupus-like syndrome after kidney transplantation with an unknown cause. A 55-year-old woman was admitted with severe myalgia, fever, and arthralgia 2 days previously. She had received a kidney transplantation 8 years ago, because an acute kidney injury had progressed to chronic kidney disease. After transplantation, she had no problems. We performed blood, urine, and sputum cultures but could found no microorganisms. We suspected a connective tissue disease, such as adult Still's disease, and performed autoantibody testing. As a result, antinuclear antibody was positive, and we diagnosed her with lupus-like syndrome due to an unknown cause. We increased the prednisolone dose and her symptoms improved.

Difference in Core temperature in response to propofol-remifentanil anesthesia and sevoflurane-remifentanil anesthesia / 대한마취과학회지

BACKGROUND: Hypothermia following the induction of anesthesia is caused by core to peripheral redistribution of body heat. It has been reported that propofol causes more severe hypothermia than sevoflurane by inhibiting thermoregulatory vasoconstriction during surgical procedures. Therefore, we evaluated the induction and maintenance of anesthesia with intravenous propofol to determine if it causes more core hypothermia than inhaled sevoflurane. METHODS: Forty-five patients who underwent hysterectomy were divided into two groups randomly, a propofol-remifentanil (PR) anesthesia group and a sevoflurane-remifentanil (SR) anesthesia group. Each group was subjected to anesthetic induction with either 1.5 mg/kg propofol or inhalation of 5% sevoflurane, respectively. Anesthesia in the former group was maintained with propofol while it was maintained with sevoflurane in the latter group. Specifically, 6-10 mg/kg/hr propofol, 3 L/min medical air, 2 L/min O2, and 0.25 mg/kg/hr remifentanil were used in the PR group for maintenance, while 1.5 vol% sevoflurane, 3 L/min medical air, 2 L/min O2 and 0.25 mg/kg/hr remifentanil were used for maintenance in the SR group. We measured the core temperature 8 times, prior to induction and 10, 20, 30, 45, 60, 75 and 90 minutes after induction. RESULTS: Core temperatures decreased in both the PR and SR group during surgical operation, but there was no significant difference between the two groups. CONCLUSIONS: Anesthesia induced and maintained by propofol did not cause a greater degree of hypothermia than sevoflurane.

Transfusion Free Kidney Transplantation in Jehovah's Witness Patients / 대한이식학회지

Transfusion free surgery is of increasing interest as more patients are refusing a blood transfusion because of religious belief, infection or fear of a blood-transmitted disease such as AIDS. Patients of the Jehovah's Witness faith generally do not accept transfusions of blood or blood products but some will accept cadaveric organs for transplantation. Recently, it is possible to perform 'bloodless' autologous or reduced-intensity allogeneic transplants in properly selected patients. The success of these procedures depends on the transplantation technique and on meticulous attention to blood conservation and supportive care. In our center, nine Jehovah's Witness received a kidney transplantations and transfusion free surgery. All the patients received erythropoietin injection and iron supplement before kidney transplantation. They were not serious bleeding in surgery and graft dysfunction after surgery. All the recipients are alive and have well functioning grafts. Elective living donor kidney transplantation allows implementation of a transfusion free strategy. We think that various methods replaced blood transfusion reduced risk of postoperative anemia and unnecessary transfusion.

Accidental epidural injection of ephedrine: A case report / 대한마취과학회지

We report a case of accidental epidural ephedrine injection. A 29-year-old male with left femoral artery occlusion was scheduled for thromboembolectomy. The operation was performed under epidural anesthesia. During the operation, ephedrine (30 mg/6 ml) was accidentally injected through epidural catheter instead of ropivacaine (45 mg/6 ml). Following the incident, we injected normal saline (10 ml) in the epidural space to dilute the solution. The patient had no complaint but blood pressure rose to 165/115 mmHg transiently. We observed the patient closely in recovery room and no further complication was found. In previous reports, various attempts have been tried to manage such incidents, but no definitive treatment for accidental injection is known. We present this case to remind the importance of confirming the drug everytime before injection.

A Case of Invasive Aspergillosis in Transplanted Kidney and Perirenal Area / 대한이식학회지

Recently, the incidence of fungal infection increases because of immunosuppressive therapy and chemotherapy. In immunosuppressed transplant recipients, Aspergillus can be a dangerous pathogen, capable of inducing fulminant clinical disease. Invasive fungal infections are life-threatening complications in solid-organ transplantation. Although the rate of fungal infections in transplant recipients is lower than that of other infections, the mortality rate is higher. A 34 year-old male was admitted to our hospital with fever and gross hematuria. He had received renal transplantation 2 years ago and had been transferred the other hospital 1 month ago. Initial laboratory data evaluation showed a pancytopenia and azotemia. We thought that pancytopenia was caused by immunosuppressive agents and infection. The patient was treated with antibiotics but fever was not subsided. After 4 days, he complained of transplant site pain and tenderness to percussion. A percutaneous renal biopsy was performed. Microscopic examination showed invasive aspergillosis in transplanted kidney and perirenal area. We removed the transplanted kidney and perirenal tissue, and prescribed antifungal agents for 3 months.