Validity and reliability of the Korean version of the Quality of Recovery-15 questionnaire.

BACKGROUND: The quality of recovery-40 questionnaire (QoR-40) has been widely used to assess quality of recovery after surgery, but it is too lengthy for clinical use. The short form of QoR-40, QoR-15, has been validated in many languages; however, an official Korean version of the QoR-15 (QoR-15K) has not yet been established. This study aimed to develop and validate QoR-15K. METHODS: Based on the previously-validated Korean QoR-40, we selected 15 items; the QoR-15K was patterned on the original QoR-15. We analyzed 210 subjects who had been scheduled for elective surgery under general anesthesia. The patients completed the questionnaire before surgery and on postoperative days one and two. The validity, reliability, and responsiveness of the QoR-15K were evaluated. RESULTS: We obtained excellent convergent validity on visual analog scale for recovery (ρ = 0.882, P < 0.001). The duration of anesthesia, post-anesthesia care unit, and overall hospital stay with the QoR-15K showed a significant negative correlation (ρ = -0.183, -0.151, and -0.185, respectively). Cronbach's α was 0.909. Cohen's effect size and standardized response mean were 0.819 and 0.721. The recruitment and completion rate were 92.9% and 100%, respectively. We based the above calculations on the results obtained on the first day following surgery. CONCLUSIONS: The validity and reliability of the QoR-15K are comparable to those of the English version. The QoR-15K would be a good instrument to assess the quality of recovery in Korean patients after surgery.

High-dose intraoperative remifentanil infusion increases early postoperative analgesic consumption: a prospective, randomized, double-blind controlled study.

PURPOSE: The purpose of this study was to determine whether intraoperative infusion of remifentanil induces acute tolerance to opioids, and compare the postoperative pain and opioid consumption by the effect site concentrations of remifentanil. METHODS: One hundred and ninety-eight patients undergoing gastrectomy were randomly assigned to maintain target effect site concentrations of remifentanil at 0 (Group 1, n = 39), 2 (Group 2, n = 40), 4 (Group 3, n = 39), 8 (Group 4, n = 40), or 12 ng/ml (Group 5, n = 40) during operation. Postoperative pain intensities and fentanyl requirement were recorded at postoperative 2, 6, 24, and 48 h. RESULTS: Fentanyl requirement for postoperative 2 h was significantly greater in Group 5 compared to Group 1 (376 ± 116 vs. 283 ± 129 µg, P = 0.03). However, there were no differences in fentanyl requirements among the groups after postoperative 2 h. Also, total fentanyl consumption for 48 h was similar in all groups (Group 1; 3106 ± 629, Group 2; 2970 ± 705, Group 3; 3017 ± 555, Group 4; 3151 ± 606, and Group 5; 2984 ± 443 µg, P = 0.717). Pain scores at rest and during deep breathing were comparable in all groups at the time of each examination. CONCLUSION: Intraoperative infusion of remifentanil with 12 ng/ml of effect site concentration in patients undergoing gastrectomy increases early postoperative fentanyl requirement. Acute opioid tolerance would be developed by higher concentration of remifentanil than dosage of common anesthetic practice.

Validity and reliability of the Korean version of the Quality of Recovery-40 questionnaire.

BACKGROUND: The Quality of Recovery-40 (QoR-40) is a widely-used, self-rated, and self-completed questionnaire for postoperative patients. The questionnaire is intended to elicit information from each patient regarding the quality of recovery during the postoperative period. It is noteworthy, however, that an official Korean version of the QoR-40 (QoR-40K) has not been established. The purpose of this study was to develop the QoR-40K by translation and cultural adaptation process and to evaluate the validity and reliability of the QoR-40K. METHODS: After pre-authorization from the original author of the QoR-40, the translation procedure was established and carried out based upon Beaton's recommendation to create a QoR-40K model comparable to the original English QoR-40. Two hundred surgical patients were enrolled, and each completed the questionnaire during the preoperative period, on the third day, and 1 month after surgery. The QoR-40K was compared with the visual analogue scale (VAS) and another health-related questionnaire, the Short-form Health Survery-36 (SF-36). The method of validation for QoR-40K included test-retest reliability, internal consistency, and level of responsiveness. RESULTS: Spearman's correlation coefficient for test-retest reliability was 0.895 (P < 0.001), and Cronbach's alpha of the global QoR-40K on the third day after surgery was 0.956. A positive correlation was obtained between the QoR-40K and the mental component summary of SF-36 (ρ = 0.474, P < 0.001), and a negative correlation was observed between QoR-40K and VAS (ρ = -0.341, P < 0.001). The standardized responsive mean of the total QoR-40K was 0.71. CONCLUSIONS: The QoR-40K was found to be as acceptable and reliable as the original English QoR-40 for Korean patients after surgery, despite the apparent differences in the respective patients' cultural backgrounds.

Comparing the Rates of Dopamine Hemodynamic Effect Onset after Infusion through Peripheral Veins in Three Regions.

BACKGROUND: Dopamine is an inotropic agent that is often selected for continuous infusion. For hemodynamic stability, the rate of infusion is controlled in the range of 5-15 µg/kg/min. This study aimed to compare the time intervals from the administration of dopamine to the onset of its hemodynamic effects when dopamine was administered through three different peripheral veins (the cephalic vein [CV], the great saphenous vein [GSV], and the external jugular vein [EJV]). METHODS: Patients in group 1, group 2, and group 3 received dopamine infusions in the CV, GSV, and EJV, respectively. A noninvasive continuous cardiac output monitor (NICCOMO™, Medis, Ilmenau, Germany) was used to assess cardiac output (CO) and systemic vascular resistance (SVR). Six minutes after intubation, baseline heart rate (HR), systolic blood pressure (BP), diastolic BP, mean arterial pressure (MAP), CO, and SVR values were recorded and dopamine infusion was initiated at a dose of 10 µg/kg/min. Hemodynamic changes at 0, 4, 8, 12, and 15 minutes postinfusion were recorded. RESULTS: No statistically significant differences were observed among the three groups with respect to the rate of hemodynamic change. In all groups, systolic BP, diastolic BP, MAP, and SVR tended to increase after decreasing for the first 4 minutes; in contrast, HR and CO decreased until 8 minutes, after which they tended to reach a plateau. CONCLUSIONS: For patients under general anesthesia receiving dopamine at 10 µg/kg/min, there were no clinical differences in the effect of dopamine administered through three different peripheral veins.

The changes of endotracheal tube cuff pressure by the position changes from supine to prone and the flexion and extension of head.

BACKGROUND: The proper cuff pressure is important to prevent complications related to the endotracheal tube (ETT). We evaluated the change in ETT cuff pressure by changing the position from supine to prone without head movement. METHODS: Fifty-five patients were enrolled and scheduled for lumbar spine surgery. Neutral angle, which was the angle on the mandibular angle between the neck midline and mandibular inferior border, was measured. The initial neutral pressure of the ETT cuff was measured, and the cuff pressure was subsequently adjusted to 26 cmH2O. Flexed or extended angles and cuff pressure were measured in both supine and prone positions, when the patient's head was flexed or extended. Initial neutral pressure in prone was compared with adjusted neutral pressure (26 cmH2O) in supine. Flexed and extended pressure were compared with adjusted neutral pressure in supine or prone, respectively. RESULTS: There were no differences between supine and prone position for neutral, flexed, and extended angles. The initial neutral pressure increased after changing position from supine to prone (26.0 vs. 31.5 ± 5.9 cmH2O, P < 0.001). Flexed and extended pressure in supine were increased to 38.7 ± 6.7 (P < 0.001) and 26.7 ± 4.7 cmH2O (not statistically significant) than the adjusted neutral pressure. Flexed and extended pressure in prone were increased to 40.5 ± 8.8 (P < 0.001) and 29.9 ± 8.7 cmH2O (P = 0.002) than the adjusted neutral pressure. CONCLUSIONS: The position change from supine to prone without head movement can cause a change in ETT cuff pressure.

Measurements of the length and diameter of main bronchi on three-dimensional images in Asian adult patients in comparison with the height of patients.

OBJECTIVE: To measure the length and diameter of the main bronchus using the three-dimensional reconstruction images from the spiral chest computerized tomography scans in Asian adult patients, and to evaluate the relationship between the height of patients and the length and diameter of main bronchi. DESIGN: Prospective observational study. SETTING: Academic, tertiary care hospital. PARTICIPANTS: Two hundred Asian adults undergoing a chest spiral computerized tomography scan. INTERVENTION: No intervention. MEASUREMENTS AND MAIN RESULTS: The authors measured the anteroposterior and transverse diameters of the mid-portion of the right main bronchus and 2 cm below the carina of the left main bronchus. In addition, the length of both main bronchi was also measured. The length of the left main bronchus was about 3-4 times greater than its right counterpart. The main bronchus of women was oval-shape, with a large anteroposterior diameter, but the main bronchus of men was round-shape. There was no significant correlation between the measurements of main bronchi and the height of patients. CONCLUSIONS: The results showed that there is no direct relationship between the length and diameter of main bronchi and the height of patients. The height is not the criterion for choosing DLT size. Therefore, the authors proposed that 3-D images be used to determine the size of the main bronchi. The diameter of main bronchus using the 3-D images can be used to determine the optimal size of the DLT in a clinical setting, although further studies are needed.

Anesthetic management of a pregnant woman undergoing laparoscopic surgery for pheochromocytoma -A case report-.

Pheochromocytoma is a rare catecholamine producing tumor. Anesthetic management for the resection of pheochromocytoma is hard and challenging issue to anesthesiologist, because of its potentially lethal cardiovascular complications. It becomes more complicated when the patient is pregnant. Clinicians must keep the safety of both mother and fetus in mind. The timing of surgery for pheochromocytoma in pregnancy is very important for the maternal and fetal safety and depends on the gestational age when diagnosis is made, clinical response to medical treatment, the surgical accessibility of the tumor, and the presence of fetal distress. We report anesthetic experience of a laparoscopic resection for pheochromocytoma in 25th week gestational woman.

Effect of ketorolac on the prevention of emergence agitation in children after sevoflurane anesthesia.

BACKGROUND: The purpose of this study was to evaluate the effects of ketorolac on the incidence and severity of emergence agitation in children recovering from sevoflurane anesthesia. METHODS: Eighty-five children aged 3 to 7 years were randomly assigned to the control group or the ketorolac group (1 mg/kg ketorolac). The children were evaluated by the Pediatric Anesthesia Emergence Delirium Scale and a four-point agitation scale. RESULTS: The median agitation scores did not differ significantly between the two groups. The overall incidence of emergence agitation was similar in the two groups (41% in the control group vs. 32% in the ketorolac group, P = 0.526). The number of children who received rescue drugs for treatment of emergence agitation was not significantly different between the two groups. CONCLUSIONS: The administration of 1 mg/kg of ketorolac is not effective in decreasing the incidence and severity of emergence agitation in children aged 3 to 7 years after sevoflurane anesthesia.

Reliability of assessment of nasal flow rate for nostril selection during nasotracheal intubation.

STUDY OBJECTIVE: To evaluate the reliability of assessments of nasal flow rate for improved nostril selection for nasotracheal intubation. DESIGN: Prospective, randomized, double-blinded study. SETTING: Operating room of a university-affiliated hospital. PATIENTS: 118 ASA physical status 1 and 2 patients, aged 18-65 years, scheduled for elective maxillofacial and oral surgery requiring nasotracheal intubation. INTERVENTIONS: Patients were randomized to the left or right nostril groups. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV(1)) through the mouth and each nostril were measured before anesthesia induction. MEASUREMENTS: The relationship between the rate of airflow through the selected nostril and frequency of epistaxis and navigability of the nasotracheal tube were evaluated. MAIN RESULTS: There were no significant differences in the frequency of epistaxis and degree of navigability of the tracheal tube between the left and right nostril groups. In both nostril groups, patients who suffered epistaxis showed significantly less FEV(1) and FEV(1)/FVC values than did patients without epistaxis (P < 0.05). In addition, in both groups patients who passed the tube easily showed significantly higher FEV(1) and FEV(1)/FVC values than did patients who passed the tube with resistance or failed tube passage (P < 0.05). CONCLUSION: Measurement of nasal flow rate is a useful clinical method for choosing a nostril for nasotracheal intubation.

Lymphangiomyomatosis discovered by massive hemoptysis during general anesthesia -A case report-.

Lymphangiomyomatosis (LAM) is a rare lung disease that is characterized by the progressive proliferation of atypical smooth muscle-like cells, which leads to severe respiratory impairment and death. Dyspnea, cough, recurrent pneumothorax, and hemoptysis are the most common clinical symptoms of LAM. We report a 29-year-old female patient with massive hemoptysis during laparoscopic gynecologic surgery under general anesthesia, who was diagnosed with pulmonary LAM.

The preanesthetic interview by anesthesiology residents: analysis of time and content.

BACKGROUND: A preanesthetic visit can increase a patient's satisfaction. However, it is uncertain whether a preanesthetic visit by an anesthesiology resident can achieve the goal. We studied the time distribution for content of preanesthetic interviews (PI) and evaluated the patient's satisfaction with the PI. METHODS: We recorded the PI duration of 200 patients by a voice recorder. The degrees of patient satisfaction with the PI and the changes of anxiety level after the PI were quantified by a questionnaire. We analyzed the time distribution for content of the PI and the correlation between patient characteristics and PI duration or a patient's satisfaction. RESULTS: The total PI duration was 184 (134-286) sec (median, 25-75%), and the time distributions for content of the PI were 8 (5-10) of greeting, 45 (23-70) of history taking, 15 (10-20) of physical examination, 50 (25-98) for obtainingan informed consent, 20 (10-30) of explanation for anesthetic planning, 15 (5-28) for explanation of patient controlled analgesia, and 10 (0-4) sec for questions and answers. Age, ASA physical status, and educational level were correlated with PI duration (P < 0.001). The patient's level of satisfaction was "very satisfied" in 39%, "satisfied" in 50%, and "moderate" in 11% of interviews. The anxiety level was "decreased" in 50%, "increased" in 8%, and "not changed" in 42% of patients. CONCLUSIONS: Although the duration of a PI given by residents was a relatively short, 89% of patients of were satisfied with the interview. The PI took a longer time to complete in patients of older age, higher ASA physical status, or lower educational levels.

The effects of incremental continuous positive airway pressure on arterial oxygenation and pulmonary shunt during one-lung ventilation.

BACKGROUND: Although one lung ventilation (OLV) is frequently used for facilitating thoracic surgical procedures, arterial hypoxemia can occur while using one lung anesthesia. Continuous positive airway pressure (CPAP) in 5 or 10 cmH(2)O to the non-ventilating lung is commonly recommended to prevent hypoxemia. We evaluated the effects of incremental CPAP to the non-ventilating lung on arterial oxygenation and pulmonary shunt without obstruction of the surgical field during OLV. METHODS: Twenty patients that were scheduled for one lung anesthesia were included in this study. Systemic and pulmonary hemodynamic data and blood gas analysis was recorded every fifteen minutes according to the patient's positions and CPAP levels. CPAP was applied from 0 cmH(2)O by 3 cmH(2)O increments until a surgeon notifies that the surgical field was obstructed by the expanded lung. Following that, pulmonary shunt fraction (Q(S)/Q(T)) was calculated. RESULTS: There were no significant differences of Q(S)/Q(T) between supine and lateral positions with two lung ventilation (TLV). OLV significantly decreased arterial oxygen partial pressure (PaO(2)) and increased Q(S)/Q(T) compared to TLV. PaO(2) and Q(S)/Q(T) significantly improved at 6 and 9 cmH(2)O of CPAP compared to 0 cmH(2)O. However, there were no significant differences of PaO(2) and Q(S)/Q(T) between 6 and 9 cmH(2)O CPAP. In 18 patients (90%), surgical fields were obstructed at 9 cmH(2)O CPAP. CONCLUSIONS: This study suggests that 6 cmH(2)O CPAP effectively improved arterial oxygenation without interference of the surgical field during OLV when CPAP was applied from 0 cmH(2)O in 3 cmH(2)O increments.

Tracheal rupture after endotracheal intubation - A report of three cases -.

Tracheal rupture is a rare but serious complication that occurs after endotracheal intubation. It usually presents as a linear lesion in the membranous wall of the trachea, and is more prevalent in women and patients older than 50 years. The clinical manifestations of tracheal injury include subcutaneous emphysema and respiratory distress. We report the cases of three female patients of old age presenting tracheal rupture after endotracheal intubation. Two cases received surgical repair without complication and one recovered uneventfully after conservative management. We presume that the tracheal injuries were caused by over-inflation of cuff and sudden movement of the tube by positional change. Therefore, we recommend cuff pressure monitoring during general anesthesia and minimized movement of the head and neck at positional change.

Desflurane-induced hemodynamic changes in patients with diabetic cardiovascular autonomic neuropathy.

BACKGROUND: Diabetic cardiovascular autonomic neuropathy (CAN) causes perioperative cardiovascular instability. A rapid increase in the desflurane concentration induces tachycardia and hypertension (HTN). This study examined the effects of the cardiovascular response to desflurane on patients with diabetic CAN. METHODS: Forty diabetes mellitus (DM) patients with CAN were divided two groups: one with HTN (DM+HTN group, n = 17) and one without HTN (DM group, n = 23). The control group (n = 20) was composed of healthy patients without DM or HTN. In each group, the concentration of desflurane inspired was increased abruptly to 12.0 vol% 2 minutes after a thiopental injection. The target was to produce an end-tidal concentration of desflurane of 10.0 vol%, which was maintained until the end of the study by adjusting the vaporizer dial setting. The heart rate (HR), mean arterial pressure (MAP), and cardiac index (CI) were measured. RESULTS: The HR, MAP and CI increased significantly in all three groups when compared with the baseline (P<0.05). Additionally, the HR and MAP showed did not differ among the three groups at any of sampling times. However, the CI of the DM group and the DM+HTN group differed when compared with the control group at 90 and 120 seconds after intubation (P<0.05). CONCLUSIONS: In diabetic patients with CAN, the hemodynamic responses to a rapid increase in desflurane concentration are similar to those in non-diabetic patients before endotracheal intubation. However, after endotracheal intubation, increments in CI are blunted in diabetic patients with CAN.

Calculation of ionization balance and electrical conductivity in nonideal aluminum plasma.

A practical approach has been implemented to calculate the ionization balance and electrical conductivity of warm dense aluminum plasma with the Coulomb coupling effect taken into account. The correction term for ionization potential is formulated with a number of basic dimensionless parameters that characterize nonideal plasma and incorporated with the fitted formulas of excess free energy given by Tanaka, Mitake, and Ichimaru [Phys. Rev. A 32, 1896 (1985)] and Chabrier and Potekhin [Phys. Rev. E 58, 4941 (1998)] to determine the ionization balance in an equilibrium state. The calculated degree of ionization of aluminum plasma exhibits a sudden increase near the solid density approximately 1 g/cm(3) at temperatures of a few eV, which effectively demonstrates the pressure-induced ionization. The electrical conductivity is evaluated in a partially ionized plasma regime based on a linear mixture rule that takes into account both the electron-ion and electron-neutral collisions and then the computed results are compared with available data from recent experiments. It is shown that the calculation well reproduces the overall trend of measured electrical conductivity of nonideal aluminum plasma accounting for the metal-insulator transition.