The Portland intensive insulin therapy effectively controls acute hyperglycemic change after graft reperfusion during liver transplantation. However, the time-consuming sophistication acts as a barrier leading to misinterpretation and decreasing compliance to the protocol; thus, we newly introduced an application software “Insulin protocol calculator” which automatically calculates therapeutic bolus/continuous insulin doses based on the Portland protocol. Methods: Of 144 patients who underwent liver transplantation, 74 patients were treated before the introduction of “Insulin protocol calculator” by using a paper manual, and 70 patients were treated by using the application. Compliance was defined as the proportion of patients treated with exact bolus/continuous insulin dose according to the Portland protocol. Results: Compliance was significantly greater in app group than in paper group regarding bolus dose (94.5% and 86.9%, P < 0.001), continuous dose (88.9% and 77.3%, P = 0.001), and both doses (86.6% and 73.8%, P < 0.001). Blood glucose concentration was significantly lower in app group at 3 h (125 ± 17 mg/dl vs. 136 ± 19 mg/dl, P = 0.014) and 4 h (135 ± 22 mg/dl vs. 115 ± 15 mg/dl, P = 0.029) after graft reperfusion. Acute hyperglycemic change during 30 min was more prominent in app group while hyperglycemia incidence was 71.4% vs. 54.1% (P = 0.031). However, hyperglycemia risk was comparable at 2 h (31.4% vs. 31.1%, P = 0.964), and even insignificantly lower in app group at 3 h (7.1% vs. 19.5%, P = 0.184). Conclusions: Compliance to the Portland protocol was significantly improved after introducing the application software; post-reperfusion hyperglycemia was better controlled. “Insulin protocol calculator” is cost-effective and time-saving with potential clinical benefits

BACKGROUND: The epidural injection technique is a commonly used intervention in the management of chronic spinal pain, which has the advantage of delivering various drugs, such as local anesthetics or steroids, in higher concentrations to the inflamed nerve root. A guidewire-reinforced epidural catheter was introduced through a Tuohy needle during the caudal epidural procedure, with a catheter threaded into the affected nerve roots and the spread-pattern of contrast agents observed under fluoroscopy. METHODS: Sixty-seven patients with low back pain, who showed evidence of a herniated nucleus pulposus on magnetic resonance imaging, were included. All patients received fluoroscopically guided caudal epidural injections, with the guidewire-reinforced epidural catheter introduced through a Tuohy needle and threaded either to the right or left side toward the target nerve roots. After confirming the catheter tip position at the affected nerve root, 2 ml increments of contrast agents (up to 6 ml) were injected, and their corresponding AP fluoroscopic views were obtained. Three radiologists reviewed all the radiographic findings and measured the proportion of the area of contrast spread at the side of target nerve roots. RESULTS: Greater proportion of the area of contrast spread was observed at the side of the target nerve roots (P < 0.0001). At each level of contrast injection (2- , 4- and 6 ml), more than 70% of the spread of contrast dye was observed at the side of the target nerve roots in 85%, 70%, and 55% of cases, respectively. CONCLUSIONS: The combination of a caudal epidural injection and use of a guidewire-reinforced epidural catheter significantly enhances the target specificity, as revealed by the selective spread of contrast dye at the side of target nerves.
Anesthetics, Local ; Catheters* ; Contrast Media ; Fluoroscopy ; Humans ; Injections, Epidural* ; Low Back Pain ; Magnetic Resonance Imaging ; Needles ; Sensitivity and Specificity ; Steroids

Many factors are associated with the development of low back pain. Among them, exercise, obesity, smoking, age, educational level and stress are the most common. This study examined the association of these factors with low back pain. An additional aim was to determine a procedure for preventing low back pain. This study analyzed the responses to a questionnaire sent to 772 individuals who had undergone a medical examination at this hospital in 2003 and excluded the individuals who had shown symptoms or their test results indicated a particular disease. Assuming that there were no variables, individuals who exercised regularly 3-4 times per week would have a lower chance of having low back pain than those who did not exercise regularly. The analysis revealed that individuals with a college degree or higher education have a lower chance of experiencing low back pain than those with only a high school education or even college drop-outs. When the other variables were constant, age, extent of obesity (body mass index), smoking and level of stress were not found to affect the development of low back pain. The level of education was associated with the development of low back pain. However, regular exercise 3-4 times per week or more would be most effective in reducing the incidence and duration of low back pain.
Stress, Psychological/epidemiology ; Statistics ; Smoking/epidemiology ; Sex Distribution ; Risk Factors ; Risk Assessment/*methods ; Prognosis ; Physical Examination/*statistics & numerical data ; Obesity/epidemiology ; Middle Aged ; Male ; Low Back Pain/diagnosis/*epidemiology/prevention & control ; Korea/epidemiology ; Humans ; Female ; *Exercise ; Educational Status ; Comorbidity ; Aged, 80 and over ; Aged ; Age Distribution ; Adult ; Adolescent

BACKGROUND: Even though the effect of prehydration on the spinal anesthesia-induced hypotension has not yet been concluded, prehydration prior to spinal anesthesia is recommended in order to reduce the incidence and severity of hypotension. We investigated the effects of prehydration on hemodynamic change during spinal anesthesia with isobaric 0.5% tetracaine. METHODS: We prospectively performed this study on 96 patients who underwent elective transurethral surgery from October 2002 to January 2004. Patients were randomly allocated to receive either no prehydration or 10 ml/kg crystalloids administered over 10 15 min prior to spinal anesthesia. We compared dermatomal spreads of spinal anesthesia, hemodynamic parameters (blood pressure, heart rate), incidences of hypotension and bradycardia between two groups. RESULTS: Hemodynamic parameters, incidences of hypotension and bradycardia showed no statistically significant differences during spinal anesthesia between two groups. There were statistically significant differences in the dermatomal spread of sensory levels between two groups from 5 to 90 min after spinal anesthesia. Sensory block levels in prehydration group were statistically lower than no prehydration group. CONCLUSION: We hypothesized that prehydration can be one of factors that influence on dermatomal spread of local anesthetics in isobaric spinal anesthesia. The difference of dermatomal spread between two groups may be caused by brain blood barrier (BBB)-freely passing crystalloids, which may influence on the volume and density of cerebrospinal fluids. To verify this phenomenon found in our study, further investigation is still warranted.
Anesthesia, Spinal* ; Anesthetics, Local ; Blood-Brain Barrier ; Bradycardia ; Cerebrospinal Fluid ; Heart ; Hemodynamics ; Humans ; Hypotension ; Incidence ; Prospective Studies ; Tetracaine

BACKGORUND: Venovenous bypass (VVB) in liver transplantation has been used to decrease the acute hemodynamic and metabolic changes during anhepatic periods. But, the use of VVB in patients undergoing liver transplantation is still under debate concerning its relative risks and benefits. Therefore, the aim of this study was to examine the influences of VVB on the coagulation status and the amount of transfusion in living-related liver transplantation. METHODS: We conducted this retrospective study on 39 patients who underwent orthotopic living-related liver transplantation using the piggyback technique from March 2001 to April 2002. While 19 patients did not receive venovenous bypass, 20 patients received. We compared the two groups in terms of coagulation-related parameters (prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen and thromboelastograph), the amount of transfusion during intraoperative and post-operative 1day. We also compared the incidences of post-reperfusion syndrome in the two groups. RESULTS: The group that underwent living-related liver transplantation with VVB required more packed red blood cell (p-RBC) transfusion than the other group without VVB from post-reperfusion untill the end of operation (P<0.05). This difference in the amount of p-RBC transfusion may be due to the blood remained in the VVB circuit at the termination of VVB. However, the two groups were similar in terms of coagulation-related parameters, the amount of other blood components, such as fresh frozen plasma, platelet concentrates, cryoprecipitate, total amount of transfusion during the 24 hours post- operatively, and the incidence of post-reperfusion syndrome. CONCLUSiONS: We conclude that the using of venovenous bypass in living-related liver transplantation did not influence coagulation status and the amount of transfusion perioperatively.
Blood Platelets ; Erythrocytes ; Fibrinogen ; Hemodynamics ; Humans ; Incidence ; Liver Transplantation* ; Liver* ; Partial Thromboplastin Time ; Plasma ; Platelet Count ; Retrospective Studies ; Risk Assessment

BACKGORUND: To choose optimal potassium free solutions in chronic renal failure patients, we studied the effects of 0.45% or 0.9% saline solutions on the serum sodium concentrations of patients undergoing kidney transplantation surgery. METHODS: Sixty two patients, ASA physical status iii iV, undergoing kidney transplantation surgery, were allocated to receive either 0.45% saline (n = 26) or 0.9% saline solutions (n = 36). The patients received 2 L of 0.45% or 0.9% saline solutions with a CVP of 10 mmHg prior to a renal vein anastomosis. Serum sodium and potassium concentrations were measured before (Na0, K0) and after the administration of 2 L of 0.45% or 0.9% saline solutions (Na2, K2), respectively. RESULTS: Serum sodium concentrations decreased after the administration of 0.45% saline solutions, and after administrating 2 L of 0.9% saline, the serum sodium concentrations increased in patients with baseline serum sodium concentrations lower than 136 mEq/L. When we administered 0.9% saline, which had a sodium concentration lower than the serum sodium concentration, the serum sodium concentration measured after 2 L of 0.9% saline infusion proportionally decreased in patients with baseline serum sodium concentration greater than 136 mEq/L (P<0.001). CONCLUSiONS: For ideal fluid selection in chronic renal failure patients, this study suggests a 0.45% saline solution for chronic renal failure patients with a baseline serum sodium concentration below the normal range and a 0.9% saline solution for patients with a baseline sodium concentration within the normal range.
Humans ; Kidney Failure, Chronic* ; Kidney Transplantation ; Potassium ; Reference Values ; Renal Veins ; Sodium Chloride ; Sodium*

BACKGROUND: Respiratory complications have been the main cause of death after a resection of esophageal cancer. This retrospective study was conducted to investigate the effect of thoracic epidural analgesia on respiratory complications after a resection of esophageal cancer. METHODS: This study enrolled two groups of patients undergoing an esophageal resection during a 7-year period. The first group (control group) was comprised of 105 patients in whom thoracic epidural analgesia was not used. The second group (epidural group) was comprised of 121 patients in whom thoracic epidural analgesia was done routinely. The latter group received an initial bolus of 0.1% bupivacaine 10 ml with 2 mg of morphine at the end of surgery and an infusion of 2 ml/hr of the solution comprised of 0.1% bupivacaine with 0.2 mg/ml morphine for 3 days. The incidence of respiratory complications and the duration of ventilator care and ICU stay were investigated by reviewing of charts. RESULTS: There were no significant differences in the incidence of respiratory complications and the duration of ventilator care and ICU stay in both groups. CONCLUSIONS: The results of this study suggest that the routine use of thoracic epidural analgesia did not reduce the incidence of respiratory complications after resection of esophageal cancer.
Analgesia, Epidural* ; Bupivacaine ; Cause of Death ; Esophageal Neoplasms* ; Humans ; Incidence ; Morphine ; Retrospective Studies ; Ventilators, Mechanical

BACKGROUND: Prolonged extracorporeal circulation entails tremendous threats of red cell lysis, severe bleeding problems due to platelet injury and activation, and endothelial damages by sequestered leukocytes. In consideration of these problems, a new centrifugal pump was developed and tested clinically to evaluate its effectiveness. METHODS: We compared the effects of a centrifugal pump with those of a roller pump on hematological responses during cardiopulmonary bypass (CPB) in 20 coronary artery bypass surgery patients. The patients were divided into two groups of 10 each. The studied parameters included WBC counts, platelet counts, plasma Hb and D-dimer. Blood samples were taken after sternotomy, at 60 min, 120 min and 180 min after CPB start, and at 2 hr after CPB stop. RESULTS: No differences between the groups were found in bypass time, aortic cross clamp time, extracorporeal circulation flow and hematocrit. The centrifugal pump group demonstrated less platelet depletion (p<0.05), hemolysis (plasma Hb, p<0.05) and fibrinolysis (D-dimer, p<0.05). These differences were CPB time dependent and became statistically significant after 120 min bypass. CONCLUSION: We conclude that roller pump still can be safely used for standard cardiac procedures with bypass time less than 120 minutes and the centrifugal pump has significant potential to be safely applied to CPB for long ypass time in order to avoid postperfusion syndrome.
Blood Platelets ; Cardiopulmonary Bypass* ; Coronary Artery Bypass ; Extracorporeal Circulation ; Fibrinolysis ; Hematocrit ; Hemolysis ; Hemorrhage ; Humans ; Leukocytes ; Plasma ; Platelet Count ; Sternotomy

BACKGROUND: An increase in total body water and the systemic inflammatory response occurs during cardiopulmonary bypass (CPB) which has resulted in the release of inflammatory mediators, including tumor necrosis factor-alpha (TNFalpha), interleukin-1beta, interleukin-6,and interleukin-8. These substances were suggested to be responsible for postoperative organ dysfunction and morbidity. Conventional ultrafiltration (cUF) and modified ultrafiltration (mUF) were used in cardiac operations to reduce volume overload and total body water. The purpose of this study was to estimate the value of these techniques in removing inflammatory mediators during CPB. METHODS: Serial plasma samples were taken before CPB,after 1 hour of CPB, just before cUF, after cUF, after mUF and 24 hrs after bypass. Cytokines were detected using highly specific double-ligand enzyme-linked immunosorbent assays. The data were analyzed using the repeated measurement ANOVA. RESULTS: TNFalpha, interleukin-1beta, interleukin-6, and interleukin-8 were increased during CPB and peaked just before cUF. After cUF, all four cytokines had been significantly decreased. After mUF,interleukin-6 and interleukin-8 had significantly been decreased, but TNFalpha and interleukin-1beta did not change significantly. After 24 hours of CPB , TNFalpha and interleukin-8 returned to preCPB values, but interleukin-1beta and interleukin-6 did not. CONCLUSIONS: We conclude that ultrafiltration has the potential to remove cytokines from the circulation. The ultrafiltration technique may be a useful technique in the management of patients undergoing bypass, particularly in patients at high risk of accumulating fluids and inflammatory reactions.
Body Water ; Cardiopulmonary Bypass* ; Coronary Vessels* ; Cytokines* ; Enzyme-Linked Immunosorbent Assay ; Humans ; Interleukin-1beta ; Interleukin-6 ; Interleukin-8 ; Plasma ; Tumor Necrosis Factor-alpha ; Ultrafiltration*

A 75-year-old male patient with a left intertrochanteric fracture underwent emergency total hip arthroplasty under spinal anesthesia. He had an operation for laryngeal cancer about 10 years ago. Bronchiectasis and atelectasis were noticed in his preoperative roentgenogram. He underwent spinal anesthesia with 13 mg of 0.5% isobaric tetracaine. The level of spinal anesthesia was T7. The SpO2 (oxygen saturation of pulse oxymeter) decreased to 55% at 1 hour after start of operation. Breath sounds on the right lung were diminished. Tracheal intubation was performed for endotracheal suction. A large amount of yellowish secretion was aspirated through suction catheter. The SpO2 returned to 98%. We report a case of severe hypoxemia due to inability of expectoration in patient with bronchiectasis who underwent spinal anesthesia.
Aged ; Anesthesia, Spinal* ; Anoxia* ; Arthroplasty, Replacement, Hip ; Bronchi* ; Bronchiectasis* ; Catheters ; Emergencies ; Humans ; Intubation ; Laryngeal Neoplasms ; Lung ; Male ; Pulmonary Atelectasis ; Suction ; Tetracaine