The Daily Life Functions of Elderly Peritrochanteric Fracture Patients after Surgical Treatment

PURPOSE: Although most peritrochanteric fractures in old age necessitates surgical treatment, daily life functions are still impaired after discharge. We assessed the types of peritrochanteric fracture, risk factors, and functional recovery in elderly patients who were over 65 years old. We also tried to determine factors for recovery to daily life. MATERIALS AND METHODS: From January 2006 to December 2007, among 61 patients who were over 65 years old with the possibility of 1 year follow-up, 50 patients were selected through interviews. After verifying age, sex, mode, types of fracture, and method, we analyzed daily living activities with a functional recovery index and estimated recovery of daily life functions after surgery, assuming a score increase if functional recovery was good. RESULTS: The mean age was 75.8 years, and females (31 patients, 62%) exceeded males. Slipping (27 patients, 54%) was the most common cause of fracture, and the intertrochanteric femur fracture was the most common fracture type (34, 68%). The average functional recovery index decreased 16.24% compared with the pre-operation value, having a tendency to decrease more in old age and female patients. Subtrochanteric femur fracture showed a 17.6% decrease in functional recovery index among the fracture types. CONCLUSION: In elderly patients over 65 years, the functional recovery index after peritrochanteric fracture decreased 16.24% on average compared with the preoperation state. The largest decrease was in basic life ability. The functional recovery index decreased more in old age, females, and subtrochanteric femur fracture, which indicates these factors influence functional recovery.

Application of single incision laparoscopic surgery for appendectomy in children / 대한외과학회지

PURPOSE: Recently, single incision laparoscopic surgery (SILS) has been popular in use with its progress studied for more minimally invasive surgery and cosmetic improvement. We investigated the feasibility and efficacy of SILS for appendectomy (SILS-A) in children and compare it with conventional laparoscopic appendectomy (C-LA). METHODS: We studied, retrospectively, adolescent patients who underwent C-LA or SILS-A. There were 25 patients in the C-LA group and 30 patients in the SILS-A group. The clinical outcomes were compared between the groups. RESULTS: The SILS-A procedures were performed successfully in adolescent patients . There were no significant difference between the C-LA and SILS-A group with respect to demographic data and post-operative outcomes. There was one complication (4%) in the C-LA group and two complications (6.6%) in the SILS-A group, but there was no significant difference. CONCLUSION: SILS-A was technically feasible and safe in children. Considering little postoperative scar and no difference in post-operative outcomes compared to C-LA, SILA could be applicable in adolescent patients. Larger studies and further technical implements will be necessary to assess the true benefit of this approach.

Application of Single Incision Laparoscopic Surgery for Appendectomies in Patients with Complicated Appendicitis

PURPOSE: Recently, single incision laparoscopic surgery (SILS) has been studied for its being less invasive surgery and having cosmetic improvement. We investigated the application of SILS for an appendectomy (SILS-A) in cases of complicated appendicitis and compare it with a conventional laparoscopic appendectomy (C-LA). METHODS: This study involved a total of 40 patients who underwent C-LA or SILS-A in patients with complicated appendicitis; 25 patients received a C-LA, and the other 15 patients received a SILS-A. The clinical outcomes and cosmetic results were compared between the groups. RESULTS: The SILS-A procedures were performed successfully in patients with complicated appendicitis, but 6 patients who underwent SILS-A needed an additional port for dissection and drainage. Clinical outcomes and postoperative complications were similar in both study groups. The SILS-A group showed significantly higher numbers of pain control than the C-LA group, and the one port SLLS-A group showed significantly better cosmetic result than the C-LA group. CONCLUSION: SILS-A is technically feasible and safe in patients with complicated appendicitis. However, SILS-A has more postoperative pain than C-LA, and more active pain control should be considered for patients undergoing SILS-A.

The Use of Fresh Frozen Allogenic Bone Graft in the Impacted Tibial Plateau Fractures

PURPOSE: To assess the behaviour of fresh frozen cancellous allograft used for supporting the reconstructed articular surface in impacted tibial plateau fractures. MATERIALS AND METHODS: Between May 2004 and May 2008, 13 cases of impacted tibial plateau fracture were evaluated retrospectively. All fractures were treated with open reduction-internal fixation after restoration of the tibial plateau surface and insertion of fresh frozen cancellous allograft chips for subchondral support. Mean age was 46.6 (31~65) years. Average follow-up period was 36 (13~58) months. The radiological and clinical result for every patient was assessed according to the modified Rasmussen's system and Lysholm's knee score. RESULTS: According to last follow-up weight bearing A-P X-ray, the fresh frozen cancellous allograft incorporated soundly in all cases and no complications such as joint depression, fracture reduction loss, angular deformity, and malunion were found. The mean time to complete bone union was postoperative 10+/-0.7 weeks. The mean range of motion was 135 (115~145) degrees. The mean Rasmussen's radiological score at last follow up was 15.3 (10 cases: excellent, 3 cases: good). The mean Lysholm's knee score at last follow up was 88.2+/-4.3. CONCLUSION: We concluded that fresh frozen cancellous allograft in impacted tibial plateau fractures showed good results in terms of bone union and functional improvement and was considered to be a good structural supporter.

Role of Morphine in the Glutamate-Induced Oxidative Damage of C6 Glial Cells / 대한마취과학회지

BACKGROUND: Although many studies regarding several neurotransmitters and receptors have been conducted to define the mechanism involved in the development of dependence on opioids, definitive evidence has still not been presented. This study was designed to investigate the effect of morphine on glutamate-induced cytotoxicity of rat C6 glial cells. METHODS: The 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide (MTT) assay was used for cell viability. Morphology of nuclei was observed by fluorescent microscopy. Reduced glutathione (GSH) contents were measured in acid-soluble cell fractions. Generation of hydrogen peroxide (H2O2) was measured from the cultured supernatant of C6 glial cells using the scopoletin-horseradish peroxidase (HRP) assay. RESULTS: Glutamate induced the death of C6 glial cells in a time- and dose-dependent manner. Glutamate-induced cytotoxicity was protected by morphine and antioxidants, such as GSH and N-acetyl-L-cysteine (NAC). However, morphine antagonist, naloxone did not inhibit the protective effect of morphine on glutamate-induced cytotoxicity. In addition, the specific agonists, [D-Ala2, N-Me-Phe4, Gly5-ol]-Enkephalin acetate salt (DAMGO), [D-Pen2,5]-Enkephalin (DPDPE) and U69593 did not protect C6 glial cells from glutamate-induced cytotoxicity. Furthermore, morphine recovered the depletion of GSH by glutamate and inhibited the generation of H2O2 by glutamate in C6 glial cells. CONCLUSIONS: We suggest that morphine protects C6 glial cells from glutamate-induced cytotoxicity via the inhibition of GSH depletion and the generation of H2O2 by glutamate.

Morphine Protects Peroxynitrite-induced Cell Death in Primary Rat Neonatal Astrocytes / 대한마취과학회지

BACKGROUND: Astrocytes, representing a major non-neuronal cell population in the central nervous system (CNS), contain opioid receptors and are actively involved in several brain functions. This study is designed to evaluate the effects by which morphine contributes to cytotoxicity of nitric oxide (NO) species including NO and peroxynitrite (ONOO(-)) in primary astrocytes isolated from the cerebral cortexes of 1 - 2 day Sprague-Dawley rats. METHODS: The cultured cells were pretreated with morphine and exposed to 3-morpholinosydnonimine (SIN-1) which simultaneously generates NO and superoxide, thus possibly forming peroxynitrite. The cell damage was assessed by using an MTT (methylthizol-2-yl-2, 5-diphenyl, tetrazolium bromide) assay. Morphological nuclear changes of the cells after exposure to SIN-1 for 24 hours was evaluated by using 4', 6-diamidino-2-phenylindole (DAPI) staining. RESULTS: Morphine significantly protected primary rat astrocytes in a dose-dependent manner from the death mediated by sodium nitroprusside (SNP), a donor of nitric oxide, and SIN-1. Moreover, it was found that naloxone antagonized the protective effect of morphine on SIN-1-induced cell death, revealed as apoptosis by the occurrence of morphological nuclear changes characteristic of apoptosis. Morphine also inhibited the nuclear condensation of SIN-1-treated cells, however the action of morphine was antagonized by pretreatment of naloxone. The protective role of morphine on SIN-1-induced cytotoxicity was inhibited by DL-Buthionine-[S, R]-sulfoximine (BSO). Furthermore, the effects of morphine on SIN-1-induced cytotoxicity were blocked by pretreatment of Gi protein inhibitor, pertussis toxin, and phosphoinositide 3-kinase (PI3 kinase) inhibitors, Wortmannin and LY294002. CONCLUSIONS: These results suggest that morphine may protect primary rat astrocytes from NO species via the signaling cascades involving G-protein and PI3-kinase, and possibly regulates the anti-oxidant, glutathione (GSH).

Effects of Morphine on Free Radical-induced Apoptosis of Human Neuroblastoma SH-SY5Y Cells / 대한마취과학회지

BACKGROUND: The effect of opioids on nitric oxide (NO)- and peroxynitrite-induced neuronal cell death is largely unknown. In the present study, we examined the effect of morphine on NO- and peroxynitrite-induced cell death using a human neuroblastoma SH-SY5Y cell line, which abundantly expresses micro, delta, kappa-opioid receptors. METHODS: The cultured cells were pretreated with morphine and exposed to 3-morpholinosydnonimine (SIN-1) that simultaneously generates NO and superoxide, thus possibly forming peroxynitrite. The cell damage was assessed by using MTT assay and crystal violet staining. Morphological nuclear changes and enzymatic evidences of apoptosis of the cells after exposure to SIN-1 for 24 hours were evaluated by using 4', 6-diamidino-2-phenylindole (DAPI) staining and the measurement of pro-apoptotic protease (caspase-3) activity, respectively. Levels of reduced glutathion (GSH) were measured by monochloronimane (MCB) assay. RESULTS: Pretreatment of SH-SY5Y with morphine significantly inhibited the apoptotic cell death. Morphine also inhibited SIN-1-induced caspase-3 (pro-apoptotic protease) activity in a dose-dependent manner. However, naloxone (20 microM) could not antagonize completely the effect of morphine in SIN- 1-induced cell death. Pre-administered GSH and N-acetylcysteine (NAC) have been found to protect SIN-induced apoptosis, and the neuroblastoma cells treated with morphine had significantly elevated the levels of GSH. CONCLUSIONS: The present study shows that morphine protects the human neuroblastoma cell line SH- SY5Y from peroxynitrite-induced apoptotic cell death through elevated GSH levels. The protective actionof morphine seems to be associated with inhibition of the apoptotic pathway. However, it is suggested that morphine protects the cells possibly via other unknown mechanisms in addition to the activation of opioid receptors.

Influence of Contrast Media on Alcoholic Sympathectomy / 대한마취과학회지

BACKGROUND: There have been unexpected cases of failed alcoholic sympathectomy, even though satisfactory effects had been obtained in test blocks with a mixture of contrast media and local anesthetics. It was plausible to suspect the contrast media as a cause of the failure of alcoholic sympathectomy. So, the purpose of this study was to evaluate whether the contrast media can hinder the action of alcohol in alcoholic sympathectomy or not. METHODS: In Sprague - Dawley rats (200 300g), thoracic paravertebral sympathetic chains were exposed and planned regimens were injected in these regions. The rats were divided randomly into seven groups, group C (control group), group D (administration of dye just after exposure), group D-A30 (administration of dye just after exposure, administration of alcohol 30 min. after dye), group A30 (administration of alcohol 30 min. after exposure), group D-A0 (administration of dye just after exposure, administration of alcohol just after dye), group D-A60 (administration of dye just after exposure, administration of alcohol 60 min. after dye) and group D-A90 (administration of dye just after exposure, administration of alcohol 90 min. after dye). Degrees of cytoplasmic contraction were evaluated in the ganglion cells of each member of the experimental groups. RESULTS: The contraction ratios of cytoplasms in group D-A30 and A30 were greater than that of group C and D. The contraction ratios of cytoplasm in group D-A60 and D-A90 were greater than those of group D-A0 and D-A30. CONCLUSIONS: According to our results, the contrast media seems to hinder the action of alcohol in alcoholic sympathectomy.

Comparison of Verapamil and Esmolol for Controlling the Blood Pressure and Heart Rate to Tracheal Intubation According to the Different Anesthetic Induction Agents / 대한마취과학회지

BACKGROUND: Antihypertensive agents such as verapamil and esmolol are well known for their effects of hemodynamic stabilization on tracheal intubation. But hemodynamic discrepancies in these agents may result from different techniques of anesthetic induction. The aim of the present study was to compare and evaluate their efficacy in controlling hemodynamic responses to tracheal intubation under the different anesthetic induction agents. METHODS: Seventy-two patients, ASA physical status I or II, were randomly assigned to one of six groups (n = 12 each): a Thiopental-Saline (T-S) group and a Propofol-Saline (P-S) group in saline 10 ml; a Thiopental-Verapamil (T-V) group and a Propofol-Verapamil (P-V) group in verapamil 0.1 mg/kg; a Thiopental-Esmolol (T-E) group and a Propofol-Esmolol (P-E) group in esmolol 1 mg/kg according to the induction agents, thiopental or propofol. Anesthesia was induced with thiopental 5 mg/kg or propofol 2 mg/kg intravenous, respectively. Next, saline, verapamil and esmolol were administered as a bolus, and were immediately followed by succinylcholine 1.5 mg/kg. Tracheal intubation was carried out 60 s and 90 s after the intravenous injections of verapamil and esmolol, respectively. Systolic and diastolic blood pressure and heart rate were measured before induction and every minute for 5 minutes after tracheal intubation. RESULTS: There was a significant attenuation in systolic and diastolic arterial pressure after tracheal intubation in the verapamil groups compared to the esmolol groups. Heart rates were significantly lower in the esmolol groups than in the verapamil groups after tracheal intubation. CONCLUSIONS: Verapamil 0.1 mg/kg and esmolol 1 mg/kg attenuated increases in blood pressure and heart rate after tracheal intubation. The different anesthetic induction agents did not influence the hemodynamic effects of verapamil and esmolol on tracheal intubation.

Comparison of Verapamil and Esmolol for Controlling the Blood Pressure and Heart Rate to Tracheal Intubation According to the Different Anesthetic Induction Agents / 대한마취과학회지

BACKGROUND: Antihypertensive agents such as verapamil and esmolol are well known for their effects of hemodynamic stabilization on tracheal intubation. But hemodynamic discrepancies in these agents may result from different techniques of anesthetic induction. The aim of the present study was to compare and evaluate their efficacy in controlling hemodynamic responses to tracheal intubation under the different anesthetic induction agents. METHODS: Seventy-two patients, ASA physical status I or II, were randomly assigned to one of six groups (n = 12 each): a Thiopental-Saline (T-S) group and a Propofol-Saline (P-S) group in saline 10 ml; a Thiopental-Verapamil (T-V) group and a Propofol-Verapamil (P-V) group in verapamil 0.1 mg/kg; a Thiopental-Esmolol (T-E) group and a Propofol-Esmolol (P-E) group in esmolol 1 mg/kg according to the induction agents, thiopental or propofol. Anesthesia was induced with thiopental 5 mg/kg or propofol 2 mg/kg intravenous, respectively. Next, saline, verapamil and esmolol were administered as a bolus, and were immediately followed by succinylcholine 1.5 mg/kg. Tracheal intubation was carried out 60 s and 90 s after the intravenous injections of verapamil and esmolol, respectively. Systolic and diastolic blood pressure and heart rate were measured before induction and every minute for 5 minutes after tracheal intubation. RESULTS: There was a significant attenuation in systolic and diastolic arterial pressure after tracheal intubation in the verapamil groups compared to the esmolol groups. Heart rates were significantly lower in the esmolol groups than in the verapamil groups after tracheal intubation. CONCLUSIONS: Verapamil 0.1 mg/kg and esmolol 1 mg/kg attenuated increases in blood pressure and heart rate after tracheal intubation. The different anesthetic induction agents did not influence the hemodynamic effects of verapamil and esmolol on tracheal intubation.

Total Spinal Anesthesia as a Complication of Epidural Nerve Block: A case report / 대한마취과학회지

Epidural nerve block is the most widely practiced procedure in the pain clinic. Accidental dural puncture during epidural nerve block also has been associated with postdural puncture headache and total spinal anesthesia. Especially, total spinal anesthesia is the most serious complication of epidural nerve block and can lead to a life threatening conditions. We have experienced two cases in whom total spinal anesthesia occurred during epidural nerve block for neck and lower back pain control. Immediately after epidural nerve block, the patients became unresponsive and apneic with loss of muscle tone in all extremity. We performed resuscitations and about 3 hours later the patients recovered completely without any complication.

The Suitable Time for the Removal of Laryngeal Mask Airway / 대한마취과학회지

BACKGROUND: There were several studies for the incidence of gastroesophageal reflux associated with the laryngeal mask airway (LMA), but the results of those studies were much different from one another. This conflicting results may be due to the time of the removal of LMA, which has been usually after the arousal (when the patient can open the mouth on command). So, the authors investigated the incidence of the gastroesophageal reflux and the regurgitation of gastric contents above the upper esophageal sphincter associated with the difference of the time of the removal of LMA. METHODS: Sixty three patients scheduled for elective orthopedic surgery with a standardized general anesthetic technique were allocated randomly to Group A (n=34, LMA was removed when the rejection signs such as struggle, restlessness, swallowing and cough came out.) or Group B (n=29, LMA was removed after arousal). For the detection of reflux and regurgitation episodes during anesthesia, a pH monitoring probe was positioned in the lower esophagus and a methylene blue (50 mg) gelatine capsule was swallowed just before induction. At the end of anesthesia, the episodes of reflux and regurgitation of gastric contents were analyzed according to the pharyngeal blue staining or pH< or = 4. RESULTS: The incidence of reflux (pH< or = 4) from the time of the rejection signs to the removal of LMA and the total incidence of reflux in Group B were significantly higher than that of Group A. No patient in both group showed pharyngeal staining of methylene blue. There was no clinical evidence of aspiration of gastric contents in either group. CONCLUSION: Maintenance of LMA until the patient can open the mouth on command seems to increase the incidence of the gastroesophageal reflux.

The Risk of Aspiration in Laryngeal Mask Airway: Laryngeal Mask Airway vs Endotracheal Tube

BACKGROUND: There were several studies for the incidence of gastroesophageal reflux associated with the laryngeal mask airway(LMA), but the results of those studies were much different much different from one another. The aim of this study was to compare the incidence of gastroesophageal reflux and regurgitation of gastric contents between the LMA and the endotracheal tube(ETT). METHOD: Ninety patients scheduled for elective orthopedic surgery with a standardized general anesthetic technique were randomly allocated to receive either a LMA(n-49) or a ETT(n=41) for airway management. The esophageal manometry was carried out for the exclusion of esophageal motility disorders and the 24-hour ambulatory pH metry was done from one day before the operation. A methylene blue(50mg) capsule was swallowed just before the induction and the simultaneous recordings of pH were maintained during anesthesia. At the end of anesthesia, the episodes of regurgitation of gastric contents above hypopharynx were analyzed by the pharyngeal blue staining and the pH metric data were analyzed for the detection of gastroesophageal relux episodes during anesthesia. RESULTS: There was no significant difference in the incidence of gastroesophageal relux(pH< or =4) between two groups; only two patients in LMA and three patients in ETT had reflux episodes during the removal or arousal phase. There was no episode of the pharyngeal blue staining in both group. All of the gastroesophageal reflux patients in both group developed a cough or straining during those phases. There was no clinical evidence of aspiration of gastric contents in both group. CONCLUSION: In comparison with ETT, use of LMA does not appear to increase the incidence of gastroesophageal reflux and regurgitation above hypophryngeal level in positive pressure ventilating patients during long surgical procedures. Therefore, the risk of aspiration in LMA will not be much more than ETT.