Seon Woo Yoo

Fascia iliaca compartment block (FICB) reduces opioid consumption and pain scores after total hip arthroplasty (THA), and has recently been widely applied. We investigated whether FICB could also reduce postoperative bleeding. One hundred and fifteen consecutive patients who underwent elective THA under general anesthesia over 5 months were retrospectively analyzed. They were divided into 2 groups: the FICB group received an epinephrine-mixed FICB procedure and the control group did not receive any block. Using the hematocrit measured at 4 different time points (preoperative and 1, 24, and 48 hours after surgery), the estimated blood loss (EBL) was calculated for 3 different time periods (0–1, 1–24, 24–48 hours after surgery). EBL at 1 to 24 hours (226 vs 398 mL, P = .008) was significantly lower in the FICB group than in the control group. Additionally, the number of packed red cell (PRC) units transfused per patient over 48 hours was 0.38 units in the FICB group, which was significantly lower than the 0.70 units used in the control group (P = .040). Epinephrine-mixed FICB in THA has the potential to reduce postoperative bleeding in the first 24 hours after surgery as well as reduce PRC transfusion requirements.

Background: Postoperative quality of recovery (QoR) and patient satisfaction have gained increasing significance in medical services. This study aimed to compare these 2 parameters between 2 types of regional anesthetics (spinal anesthesia and combined sciatic-femoral nerve block) in orthopedic lower knee surgery. Methods: A total of 101 patients were classified into 2 groups (combined sciatic-femoral nerve block, group N; spinal anesthesia, group S) according to patient preference. In group N, sciatic and femoral nerve blocks were performed on the popliteal and groin regions, respectively, under ultrasound guidance. Spinal anesthesia was performed in group S. The primary outcomes were QoR and patient satisfaction. QoR was measured using the Korean translation of the QoR-15K. Patient satisfaction was assessed using an 11-point Likert scale (0–10) and a dichotomous question addressing anesthesia preferences for future surgeries. Results: The physical independence of the postoperative QoR-15K was significantly higher in group N than in group S (14.2 vs 12.0, P = .04). On the 11-point Likert scale, group N scored 8.8, and group S scored 7.8 (P = .001). In the dichotomous question, 93.8% of the group N and 52.8% of the group S answered that they would like to choose the same anesthesia method for the next surgery (P < .001). In addition, fewer participants in group N complained of backache than those in group S, and the time to first urination after anesthesia was shorter in group N than in group S (P = .004, <.001, respectively). Conclusion: Combined sciatic-femoral nerve block may provide better physical independence and satisfaction than spinal anesthesia in orthopedic below-knee surgeries.

Background: The reliability and validity of the anxiety subscale of the Hospital Anxiety and Depression Scale for Koreans (K-HADS-A) has not been studied in Korean surgical patients. This study aimed to validate the usefulness of K-HADS-A for measuring preoperative anxiety in Korean surgical patients. Additionally, the effect of preoperative anxiety on postoperative quality of recovery was evaluated.Methods: Preoperative anxiety in 126 inpatients with planned elective surgery was measured using the K-HADS-A. The postoperative quality of recovery was measured using the Korean version of the Quality of Recovery-15. The validity and reliability of the K-HADS-A were evaluated. The differences in quality of recovery on the first and seventh day postoperatively were then compared between the anxious and non-anxious groups.Results: There was a statistical correlation between the K-HADS-A and Anxiety Likert Scale. The goodness-of-fit indices of the structural equation model showed how well the data from the K-HADS-A match their concept. The Kaiser-Meyer-Olkin value was 0.848, and the P value of Bartlett’s test of sphericity was < 0.001. Cronbach’s alpha was high at 0.872. The K-HADS-A had an acceptable level of validity and reliability. Postoperative quality of recovery was significantly lower in the anxious group (postoperative day 1: t = 2.058, P = 0.042; postoperative day 7: t = 3.430, P = 0.002).Conclusions: The K-HADS-A is an acceptable tool for appropriately assessing preoperative anxiety in Korean surgical patients. Assessing preoperative anxiety is valuable, because preoperative anxiety affects the postoperative quality of mental and physical recovery.

Rationale: Operative hysteroscopy intravascular absorption syndrome (OHIAS) results from systemic absorption of hypotonic solution during hysteroscopy, which may induce severe hyponatremia within hours. Depending on the serum sodium (Na⁺) level, this can be life-threatening and requires prompt and careful remedial treatment. Patient concerns and diagnoses: A 53-year-old woman underwent hysteroscopic myomectomy for submucosal leiomyoma. Approximately 3 hours postoperatively, the serum Na⁺ level decreased to 82 mM/L, accompanied by pulmonary edema and lactic acidosis. The patient was strongly suspicious of OHIAS. Interventions and outcomes: A rapid correction was made using 3% NaCl to prevent brain edema as an initial response. After the serum Na⁺ level reached 120 mM/L, gradual correction was performed considering osmotic demyelination syndrome, and desmopressin was administered to prevent overcorrection caused by excessive water diuresis. Serum Na⁺ level normalized in 4 days and the patient recovered without any specific sequelae. Lessons: The detection of OHIAS may be delayed under general anesthesia, and prior vigilance is important if the operation time is prolonged. In severe hyponatremia with an apparently rapid onset, such as OHIAS, a two-step correction process may be safe and useful: rapid correction followed by more gradual correction.

Background: The molecular adsorbent recirculating system (MARS) is a hepatic replacement system that supports excretory liver function in patients with liver failure. However, since MARS has been employed in our hospital, bleeding complications have occurred in many patients during or after MARS. The objective of this study was to determine how MARS affects coagulopathy and identify specific factors associated with bleeding complications.Methods: We retrospectively analyzed data from 17 patients undergoing a total of 41 MARS sessions. Complete blood count, coagulation profiles, and blood chemistry values were compared before and after MARS. To identify pre-MARS factors associated with increased bleeding after MARS, we divided patients into bleeder and non-bleeder groups and compared their pre-MARS laboratory values.Results: MARS significantly reduced bilirubin and creatinine levels. MARS also increased prothrombin time and reduced platelet and fibrinogen, thus negatively impacting coagulation. Pre-MARS hemoglobin was significantly lower in the bleeder group than in the non-bleeder group (P=0.015). When comparing the upper and lower 33% of MARS sessions based on the hemoglobin reduction rate, hemoglobin reduction was significantly greater in MARS sessions involving patients with low pre-MARS international normalized ratio of prothrombin time (PT-INR) and factor V (P=0.038 and P=0.023, respectively).Conclusions: MARS could appears to alter coagulation-related factors such as factor V and increase the risk of bleeding complications particularly in patient with low hemoglobin. However, individual differences among patients were large, and various factors, such as low hemoglobin, PT-INR, and factor V levels, appear to be involved.

Seon Woo Yoo, Min-Jong Ki, A Ram Doo, Cheol Jong Woo, Ye Sull Kim, and Ji-Seon Son. Korean J Pain 2021;34:339-45. https://doi.org/10.3344/kjp.2021.34.3.339

Background: The molecular adsorbent recirculating system (MARS) is an artificial liver support system that supports excretory liver function in patients with liver failure and is used as bridge therapy for patients waiting for liver transplantation. However, MARS may increase the tendency for bleeding. The objective of this study was to determine how MARS affects coagulopathy and identify specific factors associated with bleeding complications. Methods: We retrospectively analyzed data from 15 patients undergoing a total of 36 MARS sessions. Complete blood count, coagulation profiles, and blood chemistry values were compared before and after MARS. To identify pre-MARS factors associated with increased bleeding after MARS, we divided patients into bleeder and non-bleeder groups and compared their pre-MARS laboratory values. Results: MARS significantly reduced bilirubin and creatinine levels. MARS also increased prothrombin time and activated partial thromboplastin time and reduced fibrinogen, thus negatively impacting coagulation. Seven patients had bleeding complications and were classified into the bleeder group. Pre MARS hemoglobin was significantly lower in the bleeder group (8.3 mg/dl) than in the non bleeder group (10.0 mg/dl, P=0.014). When comparing the upper and lower 25 % of MARS sessions based on the hemoglobin reduction rate, hemoglobin reduction was significantly greater in MARS sessions involving patients with low pre MARS hemoglobin and factor V (P=0.008 and P=0.032, respectively). Conclusions: MARS appears to alter coagulation related factors and increase the risk of bleeding complications. However, individual differences among patients were large, and various factors, such as low hemoglobin and factor V levels, appear to be involved.