The objective of this study was to investigate the effect-site concentration (Ce) of remimazolam at loss of response (LOR) and recovery of response (ROR) in patients underwent general anesthesia using simulation. In addition, the relationships between patient’s factors and simulated Ce at LOR and ROR were examined. Methods: The medical records of 81 patients who underwent elective surgery under general anesthesia using remimazolam with simulation of Ce between August 4, 2021 and October 12, 2021, were retrospectively reviewed. Remimazolam was administered as an induction dose of 6 or 12 mg/kg/h until the patient became unresponsive, followed by 0.3–2 mg/kg/ h to maintain BIS values below 60. Simultaneously, simulations of manual infusion mode were performed using Asan Pump software and the Ce of remimazolam was simulated using the Schüttler model. Whenever infusion rate of remimazolam was manually changed, the simulated Ce was confirmed almost simultaneously. LOR and ROR, defined as unresponsive and eye-opening to verbal commands, respectively, were recorded in the Asan Pump program. Results: The median (1Q, 3Q) simulated Ce at LOR and ROR were 0.7 (0.5, 0.9) and 0.3 (0.2, 0.4) μg/ml, respectively. LOR was achieved in 1.9 min after remimazolam infusion with cumulative doses of 0.3 mg/kg. There was a significant relationship between age and simulated Ce at ROR (Ce at ROR = –0.0043 × age + 0.57, r = 0.30, P = 0.014). Conclusions: For optimal dosage adjustment, simulating Ce while administering remimazolam with a weight-based dose during anesthesia is helpful. Elderly patients may recover from anesthesia at lower Ce of remimazolam.

Reexpansion pulmonary edema is a rare but potentially lethal complication. We report a case of suspected reexpansion pulmonary edema that led to cardiac arrest. Case: A 16-year-old male patient underwent wedge resection due to right pneumothorax. The patient showed pink frothy sputum three hours following surgery, and a chest x-ray showed right unilateral pulmonary edema. Thirteen hours following surgery, the patient continuously showed pink frothy sputum and presented with severe hypoxemia, tachypnea, and tachycardia. After transferring to the intensive care unit (ICU), he developed ventricular tachycardia. Cardiopulmonary resuscitation was performed for 32 min. Chest X-ray showed diffuse bilateral pulmonary edema. Extracorporeal membrane oxygenation was performed. During the 65 days of ICU care, the patient became mentally alert. However, follow-up echocardiography revealed severe heart failure. Conclusions: Rexpansion pulmonary edema can rapidly progress to diffuse bilateral pulmonary edema. Therefore, careful observation is required for the patients who show signs of pulmonary edema after reexpansion.

With increasing use, the incidence of adverse events associated with sugammadex, a neuromuscular blockade reverser, is increasing. This study aimed to identify and analyze cases of adverse events caused by sugammadex reported in Korean population. Methods: Out of a total of 12 cases detected using various keywords in the Korean Journal of Anesthesia, Anesthesia and Pain Medicine (Seoul), KoreaMed, PubMed, EMBASE, Web of Science, and The Cochrane Library-CENTRAL from 2013 to December 2020, 10 cases directly associated with sugammadex were selected. Results: Adverse events included five cases of anaphylaxis, one case of cardiac arrest, one case of profound bradycardia, one case of negative pressure pulmonary edema, and two cases of incomplete recovery. Three patients had American Society of Anesthesiologists physical status ≥ 3, two had emergency surgery, and two had a history of allergic reaction. Neuromuscular monitoring was applied in nine cases. The average dose of sugammadex was 2.87 mg/kg, and there were six cases in which one full vial was used, regardless of the state of neuromuscular recovery. Sugammadex was administered immediately after surgery in two cases, at train of four (TOF) 0 in four cases, at TOF 3 in one case, and after evaluation of the clinical signs only with no neuromuscular monitoring in one case. Conclusions: Even with neuromuscular monitoring, an excessive dose of sugammadex was observed. Given that adverse events tend to occur within 10 min of administration, continuous monitoring is important even after administration.

Background: This study aimed to investigate the association between e-cigarette (EC) use and development of acute severe pneumonia in the Korean population using a national database. Methods: We conducted a retrospective analysis using linkage of data between the Korean National Health and Nutrition Examination Survey (KNHANES) and the National Health Insurance Service (NHIS) administrative claims database. The primary endpoint of this study was development of severe pneumonia requiring hospital admission according to EC use during the study period. The secondary endpoints were in-hospital mortality, intensive care unit (ICU) admission, ventilator care, and days of hospital stay. Results: The final analysis included 28,950 individuals, of which 578 (2.0%) were EC users.EC users were younger and more often male than non-EC users. The EC users showed higher level of education and household income and had fewer comorbidities. Severe pneumonia was noted in 37 of 28,372 non-EC users (0.13%), but there were no occurrences of severe pneumonia in EC users. The incidence of pneumonia occurrence was not different between the two groups (P = 1.000). Conclusions Since e-cigarette or vaping use-associated lung injury (EVALI) is most likely included in acute severe pneumonia occurring within 3 months of EC use, it is considered that there might be no EVALI patients in Korea during the investigation period. A large-scale, prospective study is necessary to evaluate the association between EC use and acute lung injury.

BACKGROUND: Cortical suspensory femoral fixation is commonly performed for graft fixation to the femur in anterior cruciate ligament (ACL) reconstruction using hamstring tendons. The purpose of this study was to compare graft healing in the femoral tunnel, implant-related failure, and clinical results between fixed- and adjustable-length loop devices in outside-in ACL reconstruction. METHODS: A total of 109 patients who underwent ACL reconstruction using the outside-in technique from December 2010 to July 2014 were included. For femoral graft fixation, a fixed-length loop device was used in 48 patients (fixed-loop group) and an adjustable-length loop device was used in 61 patients (adjustable-loop group). For evaluation of graft healing in the femoral tunnel, magnetic resonance imaging was performed at postoperative 6 months and the signal-to-noise ratios (SNRs) of the tendon graft and tendon-bone interface in the femoral bone tunnel were evaluated. The presence of synovial fluid was evaluated to determine loop lengthening at the femoral tunnel exit. Clinical results assessed using International Knee Documentation Committee score, Tegner-Lysholm Knee Scoring scale, and knee instability tests were compared between groups. RESULTS: The SNRs of the tendon graft and tendon-bone interface were not statistically different between groups. The presence of synovial fluid at the femoral exit showed no statistical difference between groups. Clinical results were not significantly different between groups. CONCLUSIONS: The adjustable-length loop device provided comparable graft healing, implant-related failure, and clinical results with the fixed-length loop device, allowing adaptation of the graft to the different tunnel lengths. Therefore, it could be effectively used with an adjustment according to the femoral tunnel length.
Anterior Cruciate Ligament Reconstruction* ; Anterior Cruciate Ligament* ; Femur ; Humans ; Knee ; Magnetic Resonance Imaging* ; Signal-To-Noise Ratio ; Synovial Fluid ; Tendons ; Transplants

Tumor necrosis factor-alpha (TNF-alpha) is a key component of the host defense against mycobacterial infection. Mycobacterium gordonae (M. gordonae) is one of the least virulent mycobacteria, and is generally considered non-pathogenic if detected from a clinical specimen. Here, we report a rare case of pulmonary M. gordonae infection in a patient with ulcerative colitis who had been treated with infliximab, a TNF-alpha antagonist. M. gordonae infection was treated successfully with clarithromycin, rifampin, and ethambutol. We believe this to be the first report of M. gordonae pulmonary disease associated with TNF-alpha antagonist treatment.
Clarithromycin ; Colitis, Ulcerative* ; Ethambutol ; Gordonia Bacterium ; Humans ; Lung Diseases* ; Mycobacterium* ; Nontuberculous Mycobacteria* ; Rifampin ; Tumor Necrosis Factor-alpha ; Ulcer* ; Infliximab

PURPOSE: We evaluated the clinical and radiological outcomes of double-bundle anterior cruciate ligament (ACL) reconstruction using an outside-in technique with a follow-up of two- to six-years, especially in terms of the sports activity level and radiological degeneration. MATERIALS AND METHODS: Sixty-seven patients who were available for a minimum two-year follow-up after double-bundle ACL reconstruction using an outside-in technique were retrospectively evaluated. The mean follow-up period was 43.7 months. The knee function and stability were evaluated before the operation, one year after the operation (short-term follow-up), and more than two years after the operation (last follow-up). RESULTS: Regarding the knee function, the Lysholm score, International Knee Documentation Committee (IKDC) evaluation, and hop test showed significant improvement. Regarding the stability, the Lachman test, pivot shift test, KT-2000 arthrometer data, and anterior drawer radiographs using Telos showed significant improvement. Regarding the sports activity level, the patients who returned to pre-injury level activity was 68.7% according to the Tegner activity score and 76.1% according to the Cincinnati sports activity scale score. The incidence of aggravated degeneration or development of greater than IKDC grade A degeneration after surgery was 10.4%. CONCLUSIONS: Double-bundle ACL reconstruction using an outside-in technique showed favorable clinical and radiological outcomes with respect to the knee function and stability, joint degeneraion, and, especially, return to pre-injury sports activity.
Anterior Cruciate Ligament ; Anterior Cruciate Ligament Reconstruction ; Follow-Up Studies ; Humans ; Humulus ; Incidence ; Joints ; Knee ; Retrospective Studies ; Sports

Vocal cord paralysis is one of the most serious complications, which, in most situations, is preventable, associated with tracheal intubation. Unilateral vocal cord paralysis following tracheal intubation usually causes hoarseness. Postoperative vocal cord paralysis may be due to mechanical or neurogenic factors. The patient complained of hoarseness one day after operation and coughing on swallowing water ten days after operation. The vocal cords were examined with a fiberoptic nasopharyngolaryngoscopy and the right vocal cord was fixed in the paramedian position. We present a case of unilateral vocal cord paralysis following endotracheal intubation in a 71-year-old male patient with descending colon carcinoma and left renal cell carcinoma.
Aged ; Carcinoma, Renal Cell ; Colon, Descending ; Cough ; Deglutition ; Hoarseness ; Humans ; Intubation ; Intubation, Intratracheal ; Male ; Vocal Cord Paralysis ; Vocal Cords ; Water

BACKGROUND: Malignant hyperthermia (MH) has a high mortality rate and a family history. Then, caffeine and halothane contracture test (CHCT), generally used to detect MH susceptibility, is needed for early detection. The aim of this survey is to collect the opinion about establishment of the center for CHCT in Korea. METHODS: A people who were anesthesiologists working in the training hospital of Korea participated the survey between January and March 2011. Usual anesthetic drug during general anesthesia including volatile agents, opioids, muscle relaxants, incidence, diagnoses and treatments of MH, and opinion about establishment of the center for CHCT, were investigated. RESULTS: A total of 105 people who were anesthesiologists working in Korea were registered, they answered that 33 anesthesiologists (32%) met MH patient, and MH occurred once in a decade. If there is a diagnostic method such as CHCT in Korea, 89 anesthesiologists (89%) will recommend the test for the patients and their family. CONCLUSIONS: Many anesthesiologists want to recommend the CHCT for patients and their family. But, in Korea, it is impossible because there is no laboratory available for CHCT. Now, we considered carefully to establish the laboratory available for CHCT.
Analgesics, Opioid ; Anesthesia, General ; Caffeine ; Contracture ; Halothane ; Humans ; Incidence ; Korea ; Malignant Hyperthermia ; Muscles ; Surveys and Questionnaires

BACKGROUND/AIMS: Deterioration of renal function in cirrhotic patients with spontaneous bacterial peritonitis (SBP) is a predictor for in-hospital mortality; however, the clinical significance of renal dysfunction during bacterial infection other than SBP is unknown. The aim of this study was to investigate the prevalence and clinical significance of renal dysfunction due to bacterial infections other than SBP in patients with liver cirrhosis. METHODS: Retrospective data from inpatients with bacterial infections other than SBP were analyzed. RESULTS: Eighty patients were recruited for the analysis. The types of infections included that of urinary tract (37.5%), pneumonia (23.8%), biliary tract (20%), cellulitis (12.5%), and bacteremia of unknown origin (6.3%). Renal dysfunction developed in 29 patients (36.3%), of which 11 patients had irreversible renal dysfunction. The initial MELD score, neutrophil count, albumin, and blood pressure were significant risk factors in the univariate analysis, whereas only the MELD score was an independent risk factor for the development of renal dysfunction (p<0.001) after multivariate analysis. CONCLUSIONS: The prevalence of renal dysfunction during bacterial infection other than SBP in patients with liver cirrhosis was 36.3%, and its development was related to the severity of the liver disease. Occurrence of irreversible renal dysfunction seemed to affect the prognosis of these patients.
Bacteremia ; Bacterial Infections ; Biliary Tract ; Blood Pressure ; Cellulitis ; Humans ; Incidence ; Inpatients ; Liver Cirrhosis ; Liver Diseases ; Multivariate Analysis ; Neutrophils ; Peritonitis ; Pneumonia ; Prevalence ; Prognosis ; Retrospective Studies ; Risk Factors ; Urinary Tract