Protective ventilation is a prevailing ventilatory strategy these days and is comprised of small tidal volume, limited inspiratory pressure, and application of positive end-expiratory pressure (PEEP). However, several retrospective studies recently suggested that tidal volume, inspiratory pressure, and PEEP are not related to patient outcomes, or only related when they influence the driving pressure. Therefore, this review introduces the concept of driving pressure and looks into the possibility of driving pressure-guided ventilation as a new ventilatory strategy, especially in thoracic surgery where postoperative pulmonary complications are common, and thus, lung protection is of utmost importance.

PURPOSE: This study was conducted to develop an empowering education program for Maternal-Fetal Intensive Care Unit (MFICU) nurses who provide intensive care to high-risk mother and fetus at hospitals, to test effects of the education program on nursing care confidence and nursing knowledge, and to examine program satisfaction. METHODS: This study comprised of 2 phases: program development and evaluation. First, we have followed a process of program development to develop and refine an empowering education program for MFICU nurses through collaborative works among clinical obstetrics and gynecology doctors and nurses and academic nursing professors. Second, the empowering education program was provided to 49 nurses and evaluated from July 5 to 6, 2019. Levels of MFICU nursing care confidence and knowledge were measured. RESULTS: The empowering education program included 18 hours of lectures, discussion, and Q & A, which continued for 2 days. This program significantly improved high-risk maternal-fetal nursing care confidence and knowledge of nurses. The program was well met with nurses' education need and goals, and found to be highly satisfactory. CONCLUSION: The empowering education program was observed to be effective in terms of improve nursing care confidence and knowledge of nurses in MFICU. It is proposed that this program should be open regularly for nurses to obtain and improve their clinical knowledge, confidence, and competency. Further study is needed to develop and run 2-levels of education such as basic and advanced levels based on nurses' clinical background and competency.
Critical Care ; Education ; Fetus ; Gynecology ; Humans ; Intensive Care Units ; Lectures ; Mothers ; Nursing ; Nursing Care ; Obstetrics ; Pregnancy, High-Risk ; Program Development

A patient with pulmonary alveolar proteinosis underwent whole lung lavage of the right lung. Lavage of the left lung was not immediately possible because of severe hypoxemia. Three days later, after correction of hypoxemia, we re-attempted the left lung lavage. However, the patient had severe hypoxemia (SpO₂< 80%) within a few minutes of performing right one lung ventilation (OLV). On bronchoscopic examination, proper tube location was confirmed. Bronchodilator nebulization and steroid injection were attempted with no effect. While searching for the cause of the hypoxemia, we found that the breath sound from the right lung had become very weak and distant compared with that from initial auscultation. Right pneumothorax was diagnosed on chest X-ray and a chest tube was inserted. After confirming pneumothorax resolution, we re-tried right OLV and were able to proceed with the left lung lavage without signs of aggravating air leak, loss of tidal volume, or severe hypoxemia.
Anoxia ; Auscultation ; Bronchoalveolar Lavage ; Chest Tubes ; Humans ; Lung ; One-Lung Ventilation ; Pneumothorax* ; Pulmonary Alveolar Proteinosis ; Therapeutic Irrigation* ; Thorax ; Tidal Volume

In this study, we analyzed the quantitative electroencephalograms (EEGs) of forty-eight subjects (18 with methamphetamine dependence and 30 non-methamphetamine users as controls). Immediately following data collection, all personally identifying information was replaced with random numbers to prevent bias and protect privacy. Statistical analysis was performed using SPSS version 20.0 for MS Windows. To investigate the general characteristics of the demographic background of the study subjects, frequency and technical analyses were conducted. Mann-Whitney U tests were performed to determine the difference in quantitative EEGs between methamphetamine users and non-methamphetamine users. Methamphetamine users demonstrated quantitative EEG abnormalities that were consistent with generalized encephalopathy.
Bias (Epidemiology) ; Brain Diseases ; Case-Control Studies* ; Data Collection ; Electroencephalography* ; Forensic Medicine ; Humans ; Methamphetamine* ; Privacy

Forty six patients (23 in-family and 23 out-family child sexual offenders) diagnosed with pedophilia participated in this study. For each patient, computerized objective data, obtained from the doctors, nurses, psychologists, and prosecutors involved, and the hospital information system, were collected. Immediately after the authors collected data that included any personal identifying information, it was replaced by random numbers to prevent bias and to protect privacy. Statistical analysis was performed using SPSS version 20.0 for MS Windows. Comparative items on demographic characteristics were evaluated by a paired t test and chi-square test. Out-family child sexual offenders were younger, assaulted younger victims, and possessed a higher sexual recidivism rate than in-family sexual offenders did (P<0.05). The four scales of Minnesota Multiphasic Personality Inventory showed a significant difference between in-family and out-family child sexual offenders. There was no statistically significant difference in the victim's gender and the incidence of comorbid psychiatric disease between in-family and out-family child sexual offenders.
Bias (Epidemiology) ; Child* ; Criminals* ; Forensic Medicine ; Hospital Information Systems ; Humans ; Incidence ; MMPI* ; Pedophilia* ; Privacy ; Psychology ; Sex Offenses ; Weights and Measures

BACKGROUND: Preemptive analgesia is known to decrease the sensitization of the central nervous system and reduce subsequent amplification of nociceptive stimuli. We investigated whether preemptive thoracic epidural analgesia (TEA) demonstrated intraoperative and postoperative short and long term clinical advantages. METHODS: Thirty patients scheduled for open thoracotomy were randomly allocated to one of two groups to receive continuous TEA (0.15% bupivacaine and 8 microg/ml hydromorphone) either before surgical incision (preemptive group) or at the end of the operation (nonpreemptive group). Incidence of hypotension during surgery was recorded. Numerical rating scales (NRS) and the incidence of side effects such as nausea, pruritus, sedation, hypotension, and respiratory depression were recorded at 2, 6, 24, and 48 hours postoperatively. Pulmonary function test (PFT) was performed before, 24 and 48 hours after the operation. Persistence of pain control was investigated at 6 months postoperatively. RESULTS: The NRS score, side effects, and PFT changes were comparable between the two groups. TEA and intravenous rescue morphine consumed at 2, 6, 24, and 48 hours postoperatively were not different between the two groups. During surgery, the incidence of hypotension was significantly higher in the preemptive group (P = 0.027). At 6-month follow up, two patients in the nonpreemptive group complained of persistent pain at wound and none in the preemptive group. CONCLUSIONS: Preemptive TEA with hydromorphone and bupivacaine during surgery may cause unnecessary intraoperative hypotension without a prominent advantage in reducing acute or chronic pain or enhancing pulmonary function after thoracotomy. The advantageous concept of preemptive TEA may be dubious and may not provide perioperative clinical benefits.
Analgesia ; Analgesia, Epidural* ; Bupivacaine* ; Central Nervous System ; Chronic Pain ; Follow-Up Studies ; Humans ; Hydromorphone* ; Hypotension ; Incidence ; Lung* ; Morphine ; Nausea ; Pruritus ; Respiratory Function Tests ; Respiratory Insufficiency ; Tea ; Thoracotomy* ; Weights and Measures ; Wounds and Injuries

In a 54-year-old man with interstitial lung disease associated with dermatomyositis, acute exacerbation of the disease had occurred and massive pneumothorax, pneumomediastinum and extensive subcutaneous emphysema were developed while waiting for lung transplantation. He was supported by awake extracorporeal membrane oxygenation (ECMO) for 66 days and bridged to lung transplantation, but mechanical ventilation was not done during ECMO period and induction period to avoid tension pneumothorax and cardiac tamponade. Notable points of this report are that the days of ECMO support were long, the type was awake ECMO, and positive pressure ventilation was not done during whole pretransplant period including anesthesia induction. The transplantation was done successfully and the patient was discharged 25 days after lung transplantation.
Anesthesia ; Cardiac Tamponade ; Dermatomyositis ; Extracorporeal Membrane Oxygenation* ; Humans ; Lung Diseases, Interstitial ; Lung Transplantation* ; Mediastinal Emphysema* ; Middle Aged ; Pneumothorax ; Positive-Pressure Respiration ; Respiration, Artificial ; Subcutaneous Emphysema

Relapsing polychondritis (RP) is an uncommon disease that is characterized by inflammation and destruction of cartilaginous structures. When tracheobronchial tree is involved, respiratory obstructive symptoms can occur. A 35-year-old man, with a previous diagnosis of RP, was scheduled for rigid bronchoscopy to relieve dyspnea, caused by subglottic stenosis. After laser splitting of the subglottic web, the spontaneous respiration of the patient was insufficient, and hypercarbia developed progressively even with assisted ventilation. After 20 minutes of aggressive hyperventilation to reduce end-tidal CO2 level, sudden extreme tachycardia and hypotension developed. Ventilation rate was reduced and prolonged expiration time was allowed to alleviate a near-tampon status from dynamic hyperinflation. After the hemodynamic status was stabilized, the patient was transferred to the ICU for mechanical ventilation. He received ICU care for 30 days, and now, he was on supportive care on a ward, considering Y stent insertion to prevent luminal collapse from tracheobronchomalacia.
Adult ; Bronchoscopy* ; Constriction, Pathologic ; Diagnosis ; Dyspnea ; Hemodynamics ; Humans ; Hyperventilation ; Hypotension ; Inflammation ; Laryngostenosis ; Phenobarbital ; Polychondritis, Relapsing* ; Respiration ; Respiration, Artificial ; Respiratory Insufficiency* ; Stents ; Tachycardia ; Tracheobronchomalacia ; Ventilation

BACKGROUND: Risk scoring system for thoracic surgery patients have not been widely used, as of recently. We tried to forge a risk scoring system that predicts the risk of postoperative complications in patients undergoing major thoracic surgery. We used a prolonged ICU stay as a representative of postoperative complications and tested various possible risk factors for its relation. METHODS: Data from all patients who underwent major lung and esophageal cancer surgeries, between 2005 and 2007 in our hospital, were collected retrospectively (n = 858). Multiple logistic regression analysis was performed with various possible risk factors to build the risk scoring system for prolonged ICU stay (> 3 days). RESULTS: A total of 9% of patients exhibited more than 3 days of ICU stay. Age, operation name, preoperative lung injury, no epidural analgesia, and predicted post operative forced expiratory volume in 1 second (ppoFEV1) were the risk factors for prolonged ICU stay, by multivariable analysis (P < 0.05). Risk score, p was derived from the formula: logit(p/[1-p]) = -5.39 + 0.06 x age + 1.12 x operation name(2) + 1.52 x operation name(3) + 1.32 x operation name(4) + 1.56 x operation name(5) + 1.30 x preoperative lung injury + 0.72 x no epidural analgesia - 0.02 x ppoFEV1 [Age in years, operation name(2): pneumonectomy, operation name(3): esophageal cancer operation, operation name(4): completion pneumonectomy, operation name(5): extended operation, preoperative lung injury(+), epidural analgesia(-), ppoFEV1 in %]. CONCLUSIONS: Age, operation name, preoperative lung injury, epidural analgesia, and ppoFEV1 can predict postoperative morbidity in thoracic surgery patients.
Analgesia, Epidural ; Esophageal Neoplasms ; Forced Expiratory Volume ; Humans ; Logistic Models ; Lung ; Lung Injury ; Pneumonectomy ; Postoperative Complications ; Retrospective Studies ; Risk Factors ; Thoracic Surgery

BACKGROUND: Endoscopic thyroidectomy was recently introduced and has been rapidly accepted by surgeons and patients. The present study was conducted to estimate and compare the incidences of postoperative nausea and vomiting (PONV) after endoscopic thyroidectomy using two different anesthetic methods: sevoflurane based balanced anesthesia; total intravenous anesthesia (TIVA). METHODS: Ninety nine female patients that were scheduled to undergo elective endoscopic thyroidectomy under general anesthesia were enrolled. These patients were randomly allocated to receive sevoflurane based balanced anesthesia (BA group) or propofol-remifentanil anesthesia (TIVA group). PONV was evaluated using a 4-point Likert scale, and pain using a visual analogue scale (VAS; range 0 to 100) for 0-2, 2-6, and 6-24 hours postoperatively. At 24 hours postoperatively, overall patient satisfaction regarding PONV and pain were recorded. RESULTS: The incidence of PONV was 14.6% in the TIVA group and 51.3% in the BA group. The incidence of nausea at 0-2 and 2-6 hours postoperatively was lower in the TIVA group than in the BA group (4.2% vs. 35.9%, 6.3% vs. 23.1%, respectively), but no between-group difference was observed at 6-24 hours postoperatively (8.3% vs. 5.1%). Antiemetic usage at 0-2 and 2-6 hours was lower in the TIVA than the BA group (4.2% vs. 38.5%, 6.3% vs. 23.1%), but no between-group difference was observed for 6-24 hours (6.3% vs. 7.7%). There were no differences in pain or in patient satisfaction. CONCLUSIONS: After endoscopic thyroidectomy, total intravenous anesthesia with propofol-remifentanil is associated with less PONV during the early postoperative period (0-6 hours) than sevoflurane based balanced anesthesia.
Anesthesia ; Anesthesia, General ; Anesthesia, Intravenous ; Balanced Anesthesia ; Female ; Humans ; Incidence ; Methyl Ethers ; Nausea ; Patient Satisfaction ; Postoperative Nausea and Vomiting ; Postoperative Period ; Thyroidectomy