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Despite advances in emergency transfer systems and trauma medicine, the incidence of preventable deaths due to massive hemorrhage remains high. Recent immunological research has elucidated key mechanisms underlying trauma-induced coagulopathy in the early stages of trauma, including sympathoadrenal stimulation, shedding of the glycocalyx, and endotheliopathy. Consequently, the condition progresses to fibrinogen depletion, hyperfibrinolysis, and platelet dysfunction. Coexisting factors such as uncorrected acidosis, hypothermia, excessive crystalloid administration, and a history of anticoagulant use exacerbate coagulopathy. This study introduces damage-control anesthetic management based on recent insights into damage-control resuscitation, emphasizing the importance of rapid transport, timely bleeding control, early administration of antifibrinolytics and fibrinogen concentrates, and maintenance of calcium levels and body temperature. Additionally, this study discusses brain-protective strategies for trauma patients with brain injuries and the utilization of cartridge-based viscoelastic assays for goal-directed coagulation management in trauma settings. This comprehensive approach may provide potential insights for anesthetic management in the fast-paced field of trauma medicine.
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Background@#Postoperative pain occurring after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is difficult to control because of extensive surgical injuries and long incisions. We assessed whether the addition of a four-quadrant transabdominal plane (4Q-TAP) block could help in analgesic control. @*Methods@#Seventy-two patients scheduled to undergo elective CRS with HIPEC and intravenous patient-controlled analgesia (IV PCA) were enrolled. The patients received 4Q-TAP blocks in a 10 ml mixture of 2% lidocaine and 0.75% ropivacaine per site (4Q-TAP group, n = 36) or normal saline (control group, n = 33). Oxycodone in the post-anesthesia care unit (PACU) and pethidine or tramadol in the ward were used as rescue analgesics. The primary outcome was less than 3 times of rescue analgesic administration (%) in the ward for 5 postoperative days. Secondary endpoints included oxycodone requirement in PACU, fentanyl doses of IV PCA, morphine milligram equivalent (MME) of total opioid use, hospital stay, and postoperative complications. @*Results@#During 5 postoperative days, there was no difference in pain scores and total rescue analgesic administration between two groups. However, the use of oxycodone in PACU (P = 0.011), fentanyl requirement in IV PCA (P = 0.029), and MME/kg of total opioid use (median, 2.35 vs. 3.21 mg/kg, P = 0.009) were significantly smaller in the 4Q-TAP group. Hospital stay and incidence of postoperative morbidity were similar in both groups. @*Conclusions@#The 4Q-TAP block enhanced multimodal analgesia and decreased opioid requirements in patients with CRS with HIPEC, but did not change postoperative recovery outcomes.
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Background@#Morbidly adherent placenta (MAP) may cause life-threatening postpartum hemorrhage (PPH) requiring massive transfusions. Furthermore, it could endanger the lives of both mother and baby. Despite various efforts, such as adjuvant endovascular embolization and hysterectomy, massive PPH due to MAP still occurs and is difficult to overcome. Case: Herein, we described the case of a 40-year-old woman with placenta previa totalis who experienced massive bleeding during a cesarean section. We used resuscitative endovascular balloon occlusion of the aorta (REBOA) and it improved the condition of the surgical field and the hemodynamic stability of the patient temporarily. The patient was successfully managed without further complications. @*Conclusions@#REBOA can be used as a rescue procedure for uncontrolled bleeding situations in patients with MAPs. Anesthesiologists should consider and recommend REBOA as another resuscitative therapeutic option in the case of massive PPH.
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We experienced a case of induction of general anesthesia without using neuromuscular blocking agents (NMBAs) in a 40-year-old woman with a history of anaphylaxis immediately after the administration of anesthetics lidocaine, propofol, and rocuronium to perform endoscopic sinus surgery 2 years before. The skin test showed a positive reaction to rocuronium and cis-atracurium. We induced general anesthesia without using NMBAs after inducing airway anesthesia with lidocaine (transtracheal injection and superior laryngeal nerve block). Deep general anesthesia was maintained with end-tidal 4 vol% sevoflurane. Hypotension was treated with phenylephrine infusion. The operation condition was excellent, and patient recovered without complications after surgery. Airway anesthesia with local anesthetics may be helpful when we cannot use NMBAs for any reason, including hypersensitivity to NMBA and surgery that needs neuromuscular monitoring.
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BACKGROUND: Endotracheal intubation can cause focal ischemia, damage or edema to the laryngeal mucosa, and may be followed by serious complications such as vocal cord paralysis, ulcers, and granulation tissue formation. Laryngeal granuloma is rare but also a significant late complication of endotracheal intubation, and anesthesiologists should be concerned about it.CASE: We experienced four cases of laryngeal granuloma that developed after two-jaw surgery January 2017–December 2018 in our hospital and would like to report these cases with brief review of literature.CONCLUSIONS: There are frequent movements on the head and neck in maxillofacial surgery and the nasotracheal intubation should be prolonged after bimaxillary osteotomy surgery because of post-operative airway problems. This may be why two-jaw surgery may have higher occurrence of laryngeal granuloma than others.
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Humanos , Edema , Tecido de Granulação , Granuloma Laríngeo , Cabeça , Intubação , Intubação Intratraqueal , Isquemia , Mucosa Laríngea , Pescoço , Osteotomia , Cirurgia Bucal , Úlcera , Paralisia das Pregas VocaisRESUMO
BACKGROUND: Endotracheal intubation often causes sore throat and coughing. The aim of this study was to decrease the incidence and severity of cough, sore throat, and hemodynamic changes after extubation by endotracheal administration of 1% lidocaine. METHODS: Sixty patients physical status American Society of Anesthesiologists classes I, II, and III who received a surgery under general anesthesia were randomly divided into two groups. L group was given 1% lidocaine 0.5 mg/kg by endotracheal administration. The other group, N group, received the same volume of normal saline. The number of cough, the severity of sore throat with numerical rating score (NRS), incidence of local anesthetic systemic toxic reaction, laryngospasm, and hoarseness were recorded. In addition, the number of coughs was divided into three levels by its severity, and it was converted into an indicator of cough score. RESULTS: L group had a significantly lower number of cough and sore throat NRS (P value < 0.05) than the N group, and also hoarseness did not occur. The changes in the hemodynamic parameters, before and after the emergence of anesthesia, were more stable in the L group than those in the N group, but not statistically significant. CONCLUSIONS: The results of this study suggest that endotracheal administration of 1% lidocaine is effective and safe method to reduce cough and sore throat caused by extubation.
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Humanos , Anestesia , Anestesia Geral , Tosse , Hemodinâmica , Rouquidão , Incidência , Intubação Intratraqueal , Laringismo , Lidocaína , Métodos , FaringiteRESUMO
BACKGROUND: The aim of this study was to estimate the optimal depth of nasotracheal tube placement. METHODS: We enrolled 110 patients scheduled to undergo oral and maxillofacial surgery, requiring nasotracheal intubation. After intubation, the depth of tube insertion was measured. The neck circumference and distances from nares to tragus, tragus to angle of the mandible, and angle of the mandible to sternal notch were measured. To estimate optimal tube depth, correlation and regression analyses were performed using clinical and anthropometric parameters. RESULTS: The mean tube depth was 28.9 ± 1.3 cm in men (n = 62), and 26.6 ± 1.5 cm in women (n = 48). Tube depth significantly correlated with height (r = 0.735, P < 0.001). Distances from nares to tragus, tragus to angle of the mandible, and angle of the mandible to sternal notch correlated with depth of the endotracheal tube (r = 0.363, r = 0.362, and r = 0.546, P < 0.05). The tube depth also correlated with the sum of these distances (r = 0.646, P < 0.001). We devised the following formula for estimating tube depth: 19.856 + 0.267 × sum of the three distances (R2 = 0.432, P < 0.001). CONCLUSION: The optimal tube depth for nasotracheally intubated adult patients correlated with height and sum of the distances from nares to tragus, tragus to angle of the mandible, and angle of the mandible to sternal notch. The proposed equation would be a useful guide to determine optimal nasotracheal tube placement.
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Adulto , Feminino , Humanos , Masculino , Intubação , Mandíbula , Pescoço , Cirurgia BucalRESUMO
No abstract available.
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Bloqueio do Plexo Braquial , Plexo Braquial , Mepivacaína , Mioclonia , Extremidade SuperiorRESUMO
An elevated serum concentration of uric acid may be associated with an increased risk of acute kidney injury (AKI). The aim of this study was to investigate the impact of preoperative uric acid concentration on the risk of AKI after coronary artery bypass surgery (CABG). Perioperative data were evaluated from patients who underwent CABG. AKI was defined by the AKI Network criteria based on serum creatinine changes within the first 48 hr after CABG. Multivariate logistic regression was utilized to evaluate the association between preoperative uric acid and postoperative AKI. We evaluated changes in C statistic, the net reclassification improvement, and the integrated discrimination improvement to determine whether the addition of preoperative uric acid improved prediction of AKI. Of the 2,185 patients, 787 (36.0%) developed AKI. Preoperative uric acid was significantly associated with postoperative AKI (odds ratio, 1.18; 95% confidence interval, 1.10-1.26; P<0.001). Adding uric acid levels improved the C statistic and had significant impact on risk reclassification and integrated discrimination for AKI. Preoperative uric acid is related to postoperative AKI and improves the predictive ability of AKI. This finding suggests that preoperative measurement of uric acid may help stratify risks for AKI in in patients undergoing CABG.
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Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Injúria Renal Aguda/etiologia , Ponte de Artéria Coronária/efeitos adversos , Creatinina/sangue , Hiperuricemia/sangue , Testes de Função Renal , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Período Pré-Operatório , Estudos Retrospectivos , Ácido Úrico/sangueRESUMO
A 47-year-old man was referred to the operating room to treat a dentigenous cyst of the mandibular bone. Initial assessment of the airway was considered normal. However, after the induction of anesthesia, we could not intubate the patient due to severe distortion of the glottis. Fiberoptic bronchoscopy and video laryngoscopy were not effective. Intubation using a retrograde wire technique was successful. After the conclusion of surgery, the patient recovered without any complications. Subsequent magnetic resonance imaging of the patient's neck showed a 6 × 4 × 8.6 cm heterogeneous T2 hyperintense, T1 isointense well-enhancing mass in the prestyloid parapharyngeal space. The patient was scheduled for excision of the mass. We planned awake intubation with fiberoptic bronchoscopy. The procedure was successful and the patient recovered without complications. Anesthetic induction can decrease the muscle tone of the airway and increase airway distortion. Therefore, careful airway assessment is necessary.
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Humanos , Pessoa de Meia-Idade , Manuseio das Vias Aéreas , Anestesia , Broncoscopia , Glote , Intubação , Laringoscopia , Imageamento por Ressonância Magnética , Pescoço , Salas CirúrgicasRESUMO
A 47-year-old man was referred to the operating room to treat a dentigenous cyst of the mandibular bone. Initial assessment of the airway was considered normal. However, after the induction of anesthesia, we could not intubate the patient due to severe distortion of the glottis. Fiberoptic bronchoscopy and video laryngoscopy were not effective. Intubation using a retrograde wire technique was successful. After the conclusion of surgery, the patient recovered without any complications. Subsequent magnetic resonance imaging of the patient's neck showed a 6 × 4 × 8.6 cm heterogeneous T2 hyperintense, T1 isointense well-enhancing mass in the prestyloid parapharyngeal space. The patient was scheduled for excision of the mass. We planned awake intubation with fiberoptic bronchoscopy. The procedure was successful and the patient recovered without complications. Anesthetic induction can decrease the muscle tone of the airway and increase airway distortion. Therefore, careful airway assessment is necessary.
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Humanos , Pessoa de Meia-Idade , Manuseio das Vias Aéreas , Anestesia , Broncoscopia , Glote , Intubação , Laringoscopia , Imageamento por Ressonância Magnética , Pescoço , Salas CirúrgicasRESUMO
BACKGROUND: Identifying early markers of septic complications can aid in the diagnosis and therapeutic management of hospitalized patients. In this study, the utility of procalcitonin (PCT) vs. C-reactive protein (CRP) as early markers of sepsis was compared. METHODS: A series of 2,697 consecutive blood samples was collected from hospitalized patients and serum PCT and CRP levels were measured. Patients were categorized by PCT level as follows: 10 ng/ml. Diagnostic utility was analyzed by receiver operating characteristic (ROC) curves. RESULTS: Mean CRP levels varied among the five PCT categories at 0.31 ± 2.87, 5.65 ± 6.26, 13.78 ± 8.01, 12.15 ± 10.16, and 17.77 ± 10.59, respectively (P < 0.05). PCT and CRP differed between positive and negative blood culture groups (PCT: 15.9 vs. 4.78 mg/dl; CRP: 11.5 ng/ml vs. 9.57 ng/ml; P < 0.05). The areas under the ROC curves (PCT, 95% confidence interval [CI]: 0.743, range: 0.698-0.789 at a threshold of 0.5 ng/ml; CRP, 95% CI: 0.540, range: 0.478-0.602 at a threshold of 8 mg/l) differed for PCT and CRP (P < 0.05). CONCLUSIONS: Therefore, PCT is a reliable marker for sepsis diagnosis and is more relevant than CRP in patients with a positive blood culture. These findings can be useful for the treatment of critically ill sepsis patients.
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Humanos , Proteína C-Reativa , Estado Terminal , Diagnóstico , Curva ROC , SepseRESUMO
BACKGROUND: Identifying early markers of septic complications can aid in the diagnosis and therapeutic management of hospitalized patients. In this study, the utility of procalcitonin (PCT) vs. C-reactive protein (CRP) as early markers of sepsis was compared. METHODS: A series of 2,697 consecutive blood samples was collected from hospitalized patients and serum PCT and CRP levels were measured. Patients were categorized by PCT level as follows: 10 ng/ml. Diagnostic utility was analyzed by receiver operating characteristic (ROC) curves. RESULTS: Mean CRP levels varied among the five PCT categories at 0.31 ± 2.87, 5.65 ± 6.26, 13.78 ± 8.01, 12.15 ± 10.16, and 17.77 ± 10.59, respectively (P < 0.05). PCT and CRP differed between positive and negative blood culture groups (PCT: 15.9 vs. 4.78 mg/dl; CRP: 11.5 ng/ml vs. 9.57 ng/ml; P < 0.05). The areas under the ROC curves (PCT, 95% confidence interval [CI]: 0.743, range: 0.698-0.789 at a threshold of 0.5 ng/ml; CRP, 95% CI: 0.540, range: 0.478-0.602 at a threshold of 8 mg/l) differed for PCT and CRP (P < 0.05). CONCLUSIONS: Therefore, PCT is a reliable marker for sepsis diagnosis and is more relevant than CRP in patients with a positive blood culture. These findings can be useful for the treatment of critically ill sepsis patients.
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Humanos , Proteína C-Reativa , Estado Terminal , Diagnóstico , Curva ROC , SepseRESUMO
BACKGROUND: The early detection of coagulopathy helps guide decisions regarding optimal transfusion management during cardiac surgery. This study aimed to determine whether rotational thromboelastometry (ROTEM) analysis during cardiopulmonary bypass (CPB) could predict thrombocytopenia and hypofibrinogenemia after CPB. METHODS: We analyzed 138 cardiac surgical patients for whom ROTEM tests and conventional laboratory tests were performed simultaneously both during and after CPB. An extrinsically activated ROTEM test (EXTEM), a fibrin-specific ROTEM test (FIBTEM) and PLTEM calculated by subtracting FIBTEM from EXTEM were evaluated. Correlations between clot amplitude at 10 min (A10), maximal clot firmness, platelet count, and fibrinogen concentrations at each time point were calculated. A receiver operating characteristic analysis with area under the curve (AUC) was used to assess the thresholds of EXTEM, PLTEM and FIBTEM parameters during CPB and for predicting thrombocytopenia and hypofibrinogenemia after weaning of CPB. RESULTS: The A10 on EXTEM, PLTEM, and FIBTEM during CPB showed a good correlation with platelet counts (r = 0.622 on EXTEM and r = 0.637 on PLTEM; P < 0.0001 for each value) and fibrinogen levels (r = 0.780; P < 0.0001) after CPB. A10 on a FIBTEM threshold of 8 mm during the CPB predicted a fibrinogen concentration < 150 mg/dl (AUC = 0.853) after CPB. Additionally, the threshold level of A10 on EXTEM during CPB for predicting platelet counts < 100,000 /microl after CPB was 42 mm (AUC = 0.768). CONCLUSIONS: EXTEM, PLTEM, and FIBTEM parameters during CPB may be useful for predicting thrombocytopenia and hypofibrinogenemia after weaning of CPB.
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Humanos , Ponte Cardiopulmonar , Fibrinogênio , Contagem de Plaquetas , Curva ROC , Cirurgia Torácica , Tromboelastografia , Trombocitopenia , DesmameRESUMO
BACKGROUND: Coughing during emergence from general anesthesia may be detrimental in children. We compared the effect of a small dose of propofol or ketamine administered at the end of sevoflurane anesthesia on the incidence or severity of coughing in children undergoing a minimal invasive operation. METHODS: One hundred and eighteen children aged between 3 and 15 years, American Society of Anesthesiologists (ASA) status I, were enrolled in this randomized double blind study. Anesthesia was induced with propofol or ketamine and maintained with sevoflurane in N2O/O2. Each group received propofol 0.25 mg/kg or ketamine 0.25 mg/kg and the control group received saline 0.1 ml/kg. The decision to perform tracheal extubation was based on specified criteria, including the resumption of spontaneous respiration. During emergence from anesthesia and extubation, coughing was observed and graded at predefined times. RESULTS: The incidence of emergence without coughing was higher in the propofol group than in the ketamine and control group (19%, 11% and 6%, respectively), whereas the incidence of severe coughing was higher in the control group than in propofol and ketamine group (17.14%, 10.0% and 6.98%, respectively). CONCLUSIONS: The addition of propofol 0.25 mg/kg decreased the incidence of coughing after sevoflurane general anesthesia in children undergoing non-painful procedures.
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Idoso , Criança , Humanos , Extubação , Anestesia , Anestesia Geral , Tosse , Método Duplo-Cego , Incidência , Ketamina , Laringismo , Éteres Metílicos , Propofol , RespiraçãoRESUMO
BACKGROUND: Inadequate tube cuff inflation during tracheal intubation can cause complications. Laparoscopic surgery requiring Trendelenburg positioning and maintaining pneumoperitoneum can also result in complications. The focus of our study was to compare the connection between postoperative sore throat and pressure changes associated with methods involving cuff inflation. METHODS: Sixty gynecologic patients undergoing laparoscopic surgery were subjected to the study. The patients were divided into two groups, P and M. Endotracheal tube cuffs were inflated with the pilot balloon palpation technique in group P, while cuffs in group M were inflated with the minimally occlusive volume technique. Cuff pressures were measured with a portable manometer after intubation and before reversing muscle relaxation. Anesthesia was maintained with sevoflurane and N2O. Postoperative sore throat and voice changes were recorded from the PACU until one day after surgery. RESULTS: Initial and final cuff pressure in group P was significantly higher than group M (P < 0.05). Frequency of sore throat and voice change both in the PACU and one day after surgery were higher in group P. Sore throat in group P in the PACU showed higher frequency of grade 2 and 3 than group M. CONCLUSIONS: Minimally occlusive volume technique caused less of an increase in cuff pressure than the pilot balloon palpation technique, resulting in less complications such as sore throat. Therefore, this technique is helpful in reducing postoperative sore throat and complications during laparoscopic surgery. However, it is noted that these assumptive methods are less accurate than direct measurement with a manometer.