Background Although the use of volatile sedatives in the intensive care unit (ICU) is increasing in Europe, it remains infrequent in Asia. Therefore, there are no clinical guidelines available. This study investigates the proper initial concentration of sevoflurane, a volatile sedative that induces a Richmond agitation-sedation scale (RASS) score of –2 to –3, in patients who underwent head and neck surgery with tracheostomy. We also compared the amount of postoperative opioid consumption between volatile and intravenous (IV) sedation.
Methods We planned a prospective study to determine the proper initial sevoflurane concentration and a retrospective analysis to compare postoperative opioid consumption between volatile sedation and propofol sedation. Patients scheduled for head and neck surgery with tracheostomy and subsequent postoperative sedation in the ICU were enrolled.
Results In this prospective study, the effective dose 50 (ED50) of initial end-tidal sevoflurane concentration was 0.36% (95% confidence interval [CI], 0.20 to 0.60%), while the ED 95 was 0.69% (95% CI, 0.60 to 0.75%) based on isotonic regression methods. In this retrospective study, remifentanil consumption during postoperative sedation was significantly lower in the sevoflurane group (2.52±1.00 µg/kg/hr, P=0.001) than it was in the IV propofol group (3.66±1.30 µg/kg/hr).
Conclusions We determined the proper initial end-tidal concentration setting of sevoflurane for patients with tracheostomy who underwent head and neck surgery. Postoperative sedation with sevoflurane appears to be a valid and safe alternative to IV sedation with propofol.
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Background Postoperative admission to the surgical intensive care unit (S-ICU) is commonly planned to prevent and treat complications, unnecessary admission to the S-ICU increases medical costs and length of hospital stay. This study aimed evaluated outcome and the predictive factors for mortality in patients admitted to the S-ICU after abdominal surgery. Methods: The 168 patients admitted to the S-ICU immediately after abdominal surgery were reviewed retrospectively from January to December 2011. Results: The mortality rate of patients admitted to the S-ICU after abdominal surgery was 8.9% (15 of 168). Two preoperative factors (body mass index [BMI] < 18.5 kg/m2 [p < 0.001] and serum albumin < 3.0 g/dL [p = 0.018]), two operative factors (the need for transfusion [p = 0.008] or vasopressors [p = 0.013] during surgery), and three postoperative variables (mechanical ventilation immediately following surgery [p < 0.001], sequential organ failure assessment [p = 0.001] and SAPS II [p = 0.001] score) were associated with mortality in univariate analysis. After adjusting for age, gender, and SAPS II by a Cox regression, which revealed that BMI < 18.5 kg/m2 (p < 0.001, hazard ratio [HR] 9.690, 95% confidence interval [CI] 2.990-25.258) and the use of mechanical ventilation on admission to S-ICU (p < 0.001, HR 34.671, 95% CI 6.440-186.649) were independent prognostic factors. Conclusions: In patients in S-ICU after abdominal surgery, low BMI and postsurgical mechanical ventilation should be considered important predictors of mortality.
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Malignant cerebral infarction as postoperative complication after pulmonary resection occurs rarely, but can be rather serious. We report a case of 81-year-old man who suffered from malignant cerebral infarctions after pulmonary resection for lung cancer. He had a history of well-controlled hypertensions, but no evidences of arrhythmia, and neither stenosis nor atheroma in the carotid arteries and intracranial arteries. There were no specific events during his operation except that an inadvertent left carotid artery puncture occurred during the central line insertion. In intensive care unit (ICU), he had a delayed recovery of consciousness and dysarthria with right hemiplegia. Computed tomography revealed malignant middle cerebral infarctions due to the occlusion of left middle cerebral artery. It could be the thromboembolism due to pulmonary resections or carotid artery punctures in the patient without high risk factors.
BACKGROUND Robotic radical prostatectomy is performed in elderly patients and requires extreme changes in the patient's position and is often associated with a long surgery time. This study reviewed the pulmonary complications occurring after a robotic radical prostatectomy and analyzed the potential risk factors. METHODS The medical records of all patients who had undergone robotic radical prostatectomy at our institution were reviewed. Among the 80 total patients, 58 were capable of spontaneous respiration at the end of surgery (Group I), whereas 22 patients required assisted ventilation (Group II). A comparison between the two groups was made in terms of the demographic characteristics, coexisting diseases, anesthesia and operation time, amount of intraoperative blood loss and transfused blood products. RESULTS The mean age of the patients was 67.2 +/- 7.3 years. The mean operation time was 384.1 +/- 203.4 min (range, 195-1,180 min). The anesthesia and operation time, amount of intraoperative blood loss and number of transfused patients were all significantly higher in Group II.
Univariate analysis revealed age, body mass index, intraoperative blood loss and transfusion, anesthesia and operation time to be related to postoperative respiratory insufficiency. Multivariate analysis revealed intraoperative transfusion and operation time to be predictive risk factors. CONCLUSIONS Prolonged laparoscopic surgery in a steep Trendelenburg position has a high likelihood of postoperative respiratory insufficiency, with the intraoperative transfusion and a longer operation time being possible contributing factors.
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BACKGROUND The present study was designed to examine the purpose of intensive care unit (ICU) admission and the prevalence of disease in postoperative patients admitted to general surgical-medical ICU. METHODS Between 1 January 2007 and 31 December 2007, 646 cases of 612 patients admitted to a general postoperative patients admitted to general surgical-medical ICU were examined. The patients were classified into two groups, ICU treatment and ICU monitoring groups according to Knaus' suggestion which defines the kinds of treatment done exclusively in ICU. Patients' demographics, preoperative American Society of Anesthesiologists physical status classification (ASA) grade, prevalence of disease and emergent operation rate were analyzed. RESULTS 255 patients (39.5%) were included in the ICU treatment group and 391 cases (60.5%) in the ICU monitoring group. The prevalence of respiratory, gastrointestinal, and central nervous diseases was higher significantly in the ICU treatment group. In addition, the average of ASA grade and the duration of operation were higher significantly in the ICU treatment group. CONCLUSION Admission rate only for monitoring was higher than one for intensive treatment. An alternative strategy should be considered to care for postoperative patients who need just close monitoring.
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Retrospective investigation of anesthetic management and outcome in patients with deep neck infections Tae Kwane Kim, Hye Jin Yoon, Yuri Ko, Yuna Choi, Ui Jin Park, Jun Rho Yoon Anesthesia and Pain Medicine.2019; 14(3): 347. CrossRef
BACKGROUND Calculation of the base excess (BE) and the anion gap (AG) is commonly used to identify the presence and to analyze the cause of metabolic acidosis in critically ill patients. However, the calculation of BE assumes normal water content, electrolytes, and albumin, changes in these values will change the calculated BE. Calculation of the AG does not control for changes in albumin and cannot distinguish plasma concentration changes of negatively charged protein (albumin) from that of other anions. Based on Stewart's physicochemical principles, Gilfix et al developed equations to calculate the BE caused by unmeasured anions (BEua) taking into account changes in free water, chloride, albumin, and PCO2 that theoretically should reflect metabolic changes better than the less complete biochemical measurements. This study was designed to evaluate the influence of BEua and other variables on the length of postoperative hospital stay. METHODS: The data from 100 consecutive patients were collected prospectively in patients who underwent intra-abdominal operations under general anesthesia and admitted to the adult intensive care unit. All samples were routine samples taken from arterial lines postoperatively and analyzed for arterial blood gas, plasma electrolytes, inorganic phosphates and albumin concentrations. BEua was calculated from the equations developed by Gilfix et al. We also calculated AGNa, K (Na++K+-Cl--HCO3-) and AGNa (Na+-Cl--HCO3-). Correlations between the length of postoperative hospital stay and these variables were studied using linear regression analysis. RESULTS BEua and BE were significantly correlated with the length of ICU stay (r=0.295, p<0.01 and r=0.249, p<0.05).
Neither AGNa, K nor AGNa was correlated with the length of ICU stay. Significant correlation was observed between the length of postoperative hospital stay and BEua (r=0.316, p<0.01), BE (r=0.288, p<0.01), AGNa, K (r=0.284, p<0.01), and AGNa (r=0.263, p<0.05). CONCLUSIONS: In this study BEua was significantly correlated with the length of ICU stay and postoperative hospital stay compared with other variables.
This finding suggests that BEua may be used as a more reliable predictor of outcome in ICU patients.
BACKGROUND The objects of this study were to determine the effects of foot reflexo massage on the postoperative pain of the subtotal gastrectomy patients according to quasi-experimental research design, and to provide demonstrative data for using the foot reflexo massage as an intervention for pain nursing. METHODS: The foot reflexo massages were performed on 34 subtotal gastrectomy patients after informed consent was obtained. They were divided into two groups, i.e. control group (n=17) and experimental group (n=17). After 6 hours and 12 hours from the subtotal gastrectomy, the massage was carried out on each foot for 10 minutes twice. Visual analogue scale (VAS) was employed as the measurement tools of pain, and the degree of postoperative pain was measured through frequency of prn (pro re nata) analgesia in chart review. RESULTS: The experimental group with foot reflexo massage 6 hours after the operation have significantly less score of postoperative pain than the control group (5.76+/-0.83, 4.35+/-1.0, p=.000). The experimental group with foot reflexo massage 12 hours after the operation have significantly less score of postoperative pain than the control group (5.12+/-0.53, 3.00+/-1.17, p=.000). The experimental group with foot reflexo massage have significantly less frequency of prn analgesics than the control group from six hours to twelve hours after the operation (p=.004). CONCLUSIONS: It is considered foot reflexo massage is effective for reducing postoperative pain of subtotal gastrectomy patients, as well as useful for an immediate nursing intervention.
Postoperative delirium in the intensive care unit is a serious problem that has recently attracted much attention.
We present a 73-year-old female patient who was admitted by multiple fractures induced by an accident. We started general anesthesia for the operation of open reduction and internal fixation. After the discontinuation of general anesthesia, the patient was transported to the intensive care unit. The symptoms of delirium were developed and controlled with medications including haloperidols, benzodiazepines, and vitamins. The patient was recovered three weeks after the management and received two other operations, but delirium did not be developed again. She was discharged from the hospital without complications.
Shin Hwang, Dong Lak Choi, Cheol Soo Ahn, Dong Eun Park, Sun Hyung Joo, Jang Yong Jeon, Kyeong Mo Kim, Yang Won Nah, Kwang Min Park, Young Joo Lee, Sung Gyu Lee
Many liver recipients have required intensive care, which is individualized and customized to each recipient.
Prerequisites qualifying this care are wide comprehension of characteristics of end-stage liver disease and mechanisms of surgical procedures and immunologic knowledge. We present our principles of intensive care and experience from more than 300 cases of liver transplantation. There are roughly two types of liver transplantation, cadaveric and living-donor. These two types are different in their postoperative courses as following; severity of preservation injury, graft-size matching and morphologic liver regeneration and risk of vascular and biliary complications.
Intensive care for liver recipients should be directed toward preventive and protective care along reasonable prediction of its clinical course. We described our experience about following subjects: management of hepatorenal syndrome, fulminant hepatic failure, acute renal failure, pneumonia, disturbance of consciousness, prophylaxis of viral hepatitis B, tumor recurrence, use of antibiotics, induction of liver function recovery, maintenance of vital signs, electrolyte balance, diet and infection control, nutritional support. The most important factor is the state of transplanted liver graft in determination of posttransplant course. If the graft functions well, many problems will be solved spontaneously.
If not, intensive care will be required. Most of operative complications are related to the surgery itself, so that comprehension to surgical procedures to each recipient should be preceded for early detection and proper management. To achieve a favorable posttransplant course, all factors including maintenance of vital signs, elimination of obstacles to hepatic recovery, appropriate immunosuppression and solution of surgical complications should be met altogether. Of course, every member of liver transplantation team should pay durable attention and dedication to each liver recipient.
BACKGOUND: Postoperative complications in the geriatric patients undergoing radical neck dissection are generally considered to be more severe than young patients. The incidence of carotid sinus hypersensitivity in elderly patients is also considered to be higher than the young. The comparison between old (above 65 years) and young (below 65 years) aged groups about intraoperative carotid sinus hypersensitivity and postoperative complication is necessary for safe anesthesia. METHODS Sixty five adult patients, of either sex, regardless of age, given radical neck dissection from January 1990 to January 1998, were investigated for the incidence of intraoperative carotid sinus hypersensitivity and postoperative hypertension by way of retrospective chart review. The authors also examined the postoperative complications such as high fever, pulmonary, cardiac and renal complications, cerebrovascular diseases and neurologic injuries. RESULTS The incidence of intraoperative carotid sinus hypersensitivity were 28% in elderly patients (n=25), 10% in young patients (n=40) but there was no statistical significance. The incidence of postoperative hypertension were 79.1% in patients with hypertension history, 34.1% in patients without hypertension history and there was statistical significance between the two groups (P=0.001).
The incidence of postoperative pulmonary complication were 44% in elderly patients, 20% in young patients, and there was also statistical significance between the two groups (P=0.038). There was no statistical significance in the incidence of postoperative high fever above 38.5degrees C between the two groups (p=0.059). CONCLUSION After the radical neck dissection, the geriatric patients had a greater incidence of postoperative pulmonary complications than young patients and the most relating factor to postoperative hypertension was previous history of hypertension. Therefore optimal preoperative preparations for the hypertensive patients and the prevention and immediate treatment of the postoperative pulmonary complications in geriatric patients are very important during the radical neck dissection.
Because the emergence from anesthesia may be delayed in the patient with the cerebral palsy, extubation must be delayed until consciousness is recovered completely. Postoperative pulmonary edema has several causes and one of them, upper airway obstruction is rare. We had experienced pulmonary edema due to upper airway obstruction after neck mass excision in the patient with cerebral palsy, who was 21-year-old, 50 kg, male and normal preoperative laboratory data. There was no significant change in blood volume during operation for 1 hour. After operation, the patient breathed spontaneously and the endotracheal tube was extubated in the operating room. When the patient was transfered to the recovery room, he had cyanosis, intercostal and substernal retraction, and the pulse oximeter showed very low oxygen saturation. We supplied oxygen to the patient and reintubated him, and recognized the pinkish frothy sputum by suction of the endotracheal tube. On the portable chest X-ray film of the patient at the moment, hazy increased density on both lung fields indicating pulmonary edema, but the heart size was not increased. By routine treatment for pulmonary edema, the symtoms and signs of the patient were improved. He had stayed for 1 day in the SICU and then transfered to the general ward.
Introduction: Anesthesia deaths are rare, while deaths due to surgical or other risk factors are more frequent. The goal of this analysis is to evaluate risk factors associated with postoperative mortality. METHODS We have analyzed 34,200 surgical patients between 1990 and 1996 through records of anesthesia. The following informations were recorded; age of patients, physical status, site of operation, time of death, primary cause of death. RESULTS The results are as follows; 1) Of 34,200 surgical patients, 119 died in the hospital. 2) The postoperative mortality rose progressively with age and was highest above 70 years. 3) Within 48 hours, the mortality was 36.1% of total deaths, declined progressively thereafter. The patients who had head operations exceeded 45% of deaths during this period. Eight days after the operation the mortality rate was 34.2% of total deaths and the patients who had an elective operation of the abdomen were 60.8%. 4) 34.2% patients of the total deaths had brain damages. Of these, 79.5% showed physical status V and had an emergency head operation and 47.5% were 50~60 years of age. 17.5% and 13.2% of deaths were due to sepsis and respiratory insufficiency and 48.6% of these two categories were physical status II, III and had an elective operation and 55.5% were above 60 years. CONCLUSION The postoperative mortality was highest in the patients who had an emergency head operation and primary cause of death was brain damage. The patients of above 60 years, had a physical status II, III, had an elective abdominal operation were succeptable to sepsis and respiratory insufficieny.