Pharmacokinetics describes the processes of absorption, distribution, and elimination of drugs and pharmacodynamics describes the effect of drugs on the body. Sedation can be performed by various classes of drugs each with its own mechanism of action and using varying routes of administration: oral, rectal, or parenteral. The course of sedation over time is a reflection of the relationship between pharmacokinetics and pharmacodynamics. The safety and efficacy of sedation is mainly dependant on understanding pharmacologic principles. This review will focus on the general concepts of the pharmacokinetics and pharmacodynamics of drugs used for sedation.
Absorption

As various diagnostic and treatment technologies evolve, the performance of diagnostic and therapeutic procedures on pediatric patients outside operating rooms is rapidly becoming more common. Procedural sedation and analgesia refers to the use of sedatives and analgesics to provide anxiolysis, analgesia, and immobilization during the procedure. There is a need for a common guideline that may be used by different health professionals, including anesthesiologists, pediatricians, emergency medicine physicians, dentists, radiologists, and others that are involved in these settings. Furthermore, during the entire process an anesthesiologist should be responsible for the training of those involved. Procedural sedation and analgesia is a branch of clinical medicine that includes informed consent, fasting before sedation, patient evaluation, medication administration, patient monitoring, recovery and discharge, and cardiopulmonary resuscitation. Complications associated with procedural sedation and analgesia may occur due to a drug overdose or side effects, inadequate patient monitoring, physician's errors, and/or insufficient recovery. Although the most common complications are airway obstruction or respiratory depression, these may be prevented by careful patient monitoring and appropriate emergency response. Further progress in procedural sedation and analgesia will require research, an assessment of newer sedatives, and improvements in the reporting system for adverse events.
Airway Obstruction ; Analgesia ; Analgesics ; Cardiopulmonary Resuscitation ; Child ; Clinical Medicine ; Conscious Sedation ; Deep Sedation ; Dentists ; Drug Overdose ; Emergencies ; Emergency Medicine ; Fasting ; Health Occupations ; Humans ; Hypnotics and Sedatives ; Immobilization ; Informed Consent ; Monitoring, Physiologic ; Operating Rooms ; Respiratory Insufficiency

The demand for sedation outside of the operating room for diagnostic or therapeutic procedures has recently been dramatically increasing. The Joint Commission International (JCI) is pressing domestic hospitals trying to obtain JCI certification to accept its sedation policies. This article aimed to investigate recent trends in sedation and suggest desirable directions for safe and high-quality sedation. The most active areas in research are procedural sedation, sedation in the intensive care unit (ICU), and pediatric sedation. Patient safety and performance of procedures without complications are the most important goals during sedation. According to the JCI regulation, noninvasive blood pressure, electrocardiography, pulse oximetry and capnography are the basic requirements, and sedation personnel should be separate from those who perform the procedure. Careful preprocedural assessment and tight intra-procedural monitoring for airway obstruction are critical in procedural sedation. Many merits of dexmedetomidine in procedural sedation have been reported despite its hemodynamic risks. Daily intermittent interruption is the main trend in ICU sedation providing better outcomes for mechanically ventilated patients. Analgosedation in the ICU is initial analgesia starting with remifentanil and later adding sedatives if required. Individual readjustment of the dosage using a sedation scoring system is a key requirement for successful results in ICU sedation. Ketofol, mixture of ketamine and propofol, has recently become popular for painful pediatric procedures. Pediatric sedation (especially for those < or = 3 years) with computed tomography or magnetic resonance imaging examination has a greater risk of hypoxia, but pediatric sedation experts are lacking. In conclusion, there is an urgent need for the nationwide establishment of standard sedation regulation, and securing or training sedation specialists.
Airway Obstruction ; Ambulatory Surgical Procedures ; Analgesia ; Anoxia ; Blood Pressure ; Capnography ; Certification ; Dexmedetomidine ; Electrocardiography ; Hemodynamics ; Humans ; Hypnotics and Sedatives ; Intensive Care Units ; Joints ; Ketamine ; Magnetic Resonance Imaging ; Operating Rooms ; Oximetry ; Patient Safety ; Piperidines ; Propofol ; Specialization

No abstract available.

Consumption of medical services has been expanding since the health insurance system was established in the Republic of Korea. However, physicians do not seem to be satisfied with the current state of medical practice. One of the main reasons for this dissatisfaction seems to be related to underpayment of costs. The monopolistic insurance agency has kept reimbursements for appropriate medical services below cost. The public also seems to have less trust in doctors than in the past because of repeated scandales in the news media such as doctors' accepting inappropriate rebates from the pharmaceutical industry. Patients are vulnerable to illness and depend on their doctors' decision making and advising. Plus family members and taxpayers must share in caring and the financial burden that patients face. Therefore, society has high ethical standards for physicians. The medical society also has been responding to these practices. To meet society's expectations, doctors should not abandon self-regulation through the medical society. Furthermore, because the identity of a professional healthcare provider is based on the trust and endorsement of society, physicians should attempt to maintain appropriate care for patients' best interests. The public should support physicians' appropriate medical practice via reasonable reimbursement of medical costs. Through self-support and self-regulation to maintain appropriate medical practice for patients, physicians can enhance public trust. In turn, public trust in doctors will address this country's distorted medical services and restore the eroded reputation of physicians as healthcare professionals.
Cytochrome P-450 CYP1A1 ; Decision Making ; Delivery of Health Care ; Drug Industry ; Ethics, Medical ; Health Personnel ; Humans ; Insurance ; Insurance, Health ; Republic of Korea ; Societies, Medical

The administration of adequate fluid to the severely dehydrated patients takes precedence over all other treatment regardless of the underlying disease. Although the understanding of pathogenesis and the appropriate management of water, electrolytes, and acid-base disturbance are emphasized in medical education, many physicians are not very confident in treating the patients with those disturbances. The first thing that should be remembered in fluid therapy is how much of water and sodium is required to the patients-in other words, how much water with what concentration of sodium should be given to the patients. Water deficit can be estimated by assessing the severity of dehydration, while the sodium deficit from the types of dehydration, that is, the plasma sodium concentration of the patients. This review will summarize the principles of how to choose and give the adequate fluid according to the severity and the types of dehydration.
Child* ; Dehydration ; Education, Medical ; Electrolytes ; Fluid Therapy* ; Humans ; Plasma ; Sodium ; Water

There are three groups of patients with constipating symptoms; those with obstructed defecation, slow transit constipation, or both. The treatment of obstructed defecation (pelvic outlet obstruction) is often challenging because the underlying disorders are diverse with a wide range of and clinical symptoms. The underlying anatomical and pathophysiological changes in patients with obstructed defecation are complex and often poorly understood. As a consequence, many medical, surgical, and behavioral approaches have been described, with no single panacea. For successful outcomes, preoperative physiologic testing is mandatory to differentiate between obstructed defecation caused by pelvic outlet obstruction and slow transit constipation. Obstructed defecatory disorders can distress patients both socially and psychologically and greatly impair their quality of life. For the great majority of patients, dietary adjustment with an increased fiber and liquid supplement can resolve the symptoms. The surgical approach depends upon the etiology, severity of symptoms, and operative risks. In a small group of patients with a rectocele or a third degree sigmoidocele, surgical intervention yields a high success rate. Division or resection of the puborectalis muscle is not recommended. In patients with a mixed pattern of slow transit colon and pelvic outlet obstruction, surgical intervention alone is often not successful; these patients can experience better outcomes by conservative treatment of pelvic outlet obstruction, followed by a colectomy. Stapled transanal rectal resection has recently become a recommended surgical procedure for obstructed defecation syndrome. One problem when using a transanal stapling device for rectal surgery is the potential damage to the structures located in front of the anterior rectal wall. The laparoscopic approach can shorten the hospital stay with good outcomes and is well tolerated in elderly patients with rectal prolapse. Despite the progress in modern surgery, the choice of the surgical procedure of pelvic outlet obstruction is still controversial. Preoperative counseling of all patients undergoing surgery is of extreme importance, in particular to explain the evolving nature of pelvic floor dysfunction and the possible need for further reconstructive surgery. To identify patients who will benefit from surgery for obstructed defecation, a careful selection of candidate patients remains the crucial issue in the diagnostic assessment. Surgical intervention should be limited only to the patients with identifiable, surgically correctable causes of outlet obstruction. This review gives an overview of surgical treatment options in patients with obstructed defecation.
Aged ; Colectomy ; Colon ; Constipation ; Counseling ; Defecation* ; Humans ; Length of Stay ; Pelvic Floor ; Quality of Life ; Rectal Prolapse ; Rectocele

The average length of menstrual cycle is 28 days, and duration of flow is 4 days, and an average blood loss is 35cc. Abnormal uterine bleeding is defined as bleeding at abnormal or unexpected times or by an excessive flow at the time of expected menses. Any bleeding should be considered abnormal in premenarchal girls and in postmenopausal women. The etiology of abnormal uterine bleeding encompasses a wide range of disorders that can be secondary to pregnancy-related disorders, anatomic changes of the female genital tract, infection, endocrinologic disorders, malignancies, and systemic illnesses. Dysfunctional uterine bleeding (anovulatory or ovulatory) is diagnosed by exclusion of these causes. An appropriate workup is guided by age-related differential diagnoses for abnormal bleeding. Modern diagnostic tools can readily reveal the underlying pathology and allow timely intervention. Most abnormal genital tract bleeding occurs in the form of uterine bleeding, which is one of the most common gynecologic problems that health care providers encounter with, accounting for approximately 19% of office visits and 25% of gynecologic operations. The author will review the categories of abnormal uterine bleeding and the diagnostic tools needed to establish the correct diagnosis and treatment strategy.
Anovulation ; Diagnosis ; Diagnosis, Differential ; Female ; Health Personnel ; Hemorrhage ; Humans ; Menorrhagia ; Menstrual Cycle ; Metrorrhagia ; Office Visits ; Pathology ; Uterine Hemorrhage*

Although anemia of chronic disease (ACD) is the most prevalent form of anemia next to iron deficiency anemia, its significance has been overridden by the dominant manifestation of the underlying diseases, i.e. chronic inflammation, infection, organ failure, or malignancy. As the treatment of ACD is being recognized to be important for the restoration of life quality, clinicians should be aware of how to detect, how to discriminate, and how to treat the disease. The key pathophysiology of ACD lies on the trapping of iron in the reticuloendothelial system by pro-inflammatory cytokines. The best treatment of ACD is the treatment of underlying disease per se, which is unfeasible in a substantial portion of the cases. Blood transfusion is occasionally harmful without altering the natural course of underlying disease. The benefit of erythropoietin (EPO) was already established in chronic renal disease. EPO has emerged as an important palliative measure for anemia in a variety of cancers. Augmented supplement of EPO may overcome the blunted response to physiologic EPO in anemia secondary to chronic infection or inflammation. Functional or absolute iron deficiency in ACD is manageable using EPO in conjunction with parenteral iron supplement. The iron deficiency in ACD can be identified by low ferritin value (<30 ug/L) or a high ratio of soluble transferrin receptor/log ferritin (>2). Further studies are required for the elucidation of molecular pathogenesis, more accurate diagnosis and new treatment to mobilize trapped iron into active erythropoiesis. The judicious use of therapeutic options currently available can result in palliation of ACD in a majority of the patients, and every single clinician should be fully aware of the principles behind the palliative measures.
Anemia* ; Anemia, Iron-Deficiency ; Blood Transfusion ; Chronic Disease* ; Cytokines ; Diagnosis ; Erythropoiesis ; Erythropoietin ; Ferritins ; Humans ; Inflammation ; Iron ; Mononuclear Phagocyte System ; Quality of Life ; Renal Insufficiency, Chronic ; Transferrin

The hereditary hemolytic anemia (HHA) can be classified into three types according to the pathogenesis: RBC membrane defects, hemoglobinopathies, and RBC enzymopathies. Clinical characteristics of these three types of HHA are presented briefly in this paper. In Korea, HHA due to RBC membrane defect such as hereditary spherocytosis had been relatively well recognized, while HHA due to hemoglobinopathies and RBC enzymopathies had been considered rare. However, with the recent development of molecular testing, beta thalassemia, G6PD and pyruvate kinase deficiency have been reported with identification of disease-causing mutations. If a patient with microcytic hypochromic anemia shows unproportionally low MCV or MCH or refractory to iron therapy, hemoglobin electrophoresis and gene study for thalassemia or other unstable hemoglobinopathies are needed. It should be noted that the recent population migration to Korea from the regions where hemoglobinopathies or enzymopathies are prevalent warrants considering a broad spectrum of etiologies for the diagnosis of HHA.
Anemia, Hemolytic, Congenital* ; Anemia, Hypochromic ; beta-Thalassemia ; Diagnosis ; Electrophoresis ; Hemoglobinopathies ; Humans ; Iron ; Korea ; Membranes ; Pyruvate Kinase ; Thalassemia