Spontaneous, Fulminant Gas Gangrene Caused by Klebsiella Pneumoniae: An Unrecognized Small Air Bubbles in the Left Femoral, External and Common Iliac Vein, and Inferior Vena Cava: A case report / 대한마취과학회지

Fulminant gas gangrene is a rare condition, usually associated with contaminated traumatic injuries. It carries a high rate of mortality and morbidity. Also, a number of studies have implicated non-traumatic gas gangrene, associated mostly with underlying diseases that cause immunodeficiency. We report a non-traumatic fatal case of Klebsiella pneumoniae gas gangrene with small air bubbles in the left external and common iliac vein, and inferior vena cava in a previously healthy male. We would like to recommend you do not use nitrous oxide in case of gas gangrene, because it can aggravate pulmonary air embolism.

A Comparison of the Use of Several Concentrations of Bupivacaine with Epidural Volume Extension during Combined Spinal-epidural Anesthesia in Total Knee Replacement / 대한마취과학회지

BACKGROUND: Currently, combined spinal-epidural anesthesia (CSE) is frequently administered, especially in obstetrics and orthopedic surgery. The aim of this study is to determine the appropriate concentration of bupivacaine to use with epidural volume extension that is suitable for total knee replacement during CSE. METHODS: Eighty patients (ASA physical status I and II) scheduled for totalknee replacement were randomly allocated to four groups of 20 patients each: All patients intrathecally received 2 ml of 0.5% hyperbaric bupivacaine. After fixation of spinal anesthesia, the groups received the following treatments. Group S patients received a 10 ml administration of normal saline for 15 min followed by a continuous 10 ml/hr epidural infusion. Group B1 patients received a 10 ml administration of 0.125% bupivacaine for 15 min followed by a continuous 10 ml/hr epidural infusion. Group B2 patients received a 10 ml administration of 0.25% bupivacaine for 15 min followed by a continuous 10 ml/hr epidural infusion. Group B3 patients received a 10 ml administration of 0.5% bupivacaine for 15 min followed by a continuous 10 ml/hr epidural infusion. RESULTS: The incidence of intraoperative movement in group S and group B1 patients were significantly greater than the incidence for group B2 and B3 patients. The incidence of intraoperative pain in group S patients was significantly greater than for patients in any of the other groups. CONCLUSIONS: We conclude that it is necessary to administer more than a 0.25% concentration of epidural bupivacaine load and provide continuous administration after a spinal block during total knee replacement.

Rocuronium-induced Neuromuscular Block after Long Pretreatment of Magnesium Sulfate in Rabbits / 대한마취과학회지

BACKGROUND: Magnesium sulfate (MgSO4) has been used in the treatment of pre-eclampsia, hypertension and arrhythmia. This study was been conducted to evaluate the potency and time course of rocuronium-induced neuromuscular block after prolonged pretreatment with MgSO4 in rabbits. METHODS: Forty rabbits were randomly assigned to two groups; the control group: normal saline 0.1 ml/kg sq for 6 weeks; and the study group: 50% MgSO4 60 mg/kg sq for 6 weeks. The dose-response relationships of rocuronium were studied during thiopental anesthesia in twenty rabbits. Each group received rocuronium 40, 60 and 80microgram/kg rocuronium, respectively, and the time course of rocuronium, at 0.6 mg/kg, evaluated in the twenty rabbits in each group. RESULTS: The mean serum magnesium concentration were 2.3-2.6 and 3.3-3.9 mEq/L in the control and study groups, respectively (P < 0.001). The calculated ED50s for rocuronium were 52.7 and 61.2microgram/kg in the control and study groups, respectively (P < 0.05). The times after rocuronium administration until the 95% twitch recovery were 49.3 and 34.8 min in the control and study groups, respectively (P < 0.05). CONCLUSIONS: Rocuronium, following prolonged MgSO4 pretreatment had a decreased effect and short duration of action compared with the control, for which increased doses of nondepolarizing muscle relaxants would be required to obtain a similar effect.

Is Early Spinal Cord Stimulation in Patients with Complex Regional Pain Syndrome Necessary?: A case report / 대한통증학회지

Complex regional pain syndrome (CRPS) is clinically characterized by pain, abnormal regulation of blood flow and sweating, edema of skin and subcutaneous tissues, sensory and motor disturbances, and trophic changes of the skin. A 21-year-old man was suffering from pain and swelling in his right hand and forearm. His arm had been in splints for 3 weeks following an extension injury of the right fingers and wrist, with the pain having developed 2 weeks after the splinting. He was treated with various nerve blocks including continuous epidural infusion, thoracic sympathetic block and peripheral nerve blocks, and squeezing his edematous region under general anesthesia as well as intravenous lidocaine and ketamine infusions. However, all of the performed treatments had no effect on the patient's pain or hand swelling. As a next line therapy, spinal cord stimulation should be considered because of intractable severe pain and swelling to almost all other modalities of therapy. We therefore performed an early intervention of spinal cord stimulation for the patient with refractory CRPS type I 5 months after the onset of pain and have got an excellent result.

What is an Optimal Dosage of Alfentanil for Minimizing the Hemodynamic Change to Endotracheal Intubation during Anesthesia Induction with Propofol Target-Controlled Infusion? / 대한마취과학회지

BACKGROUND: Laryngoscopy and tracheal intubation are associated with hemodynamic pressor responses, which can have adverse effects. During anesthesia induction with propofol target-controlled infusion (TCI), we aimed to determine the most appropriate dosage of alfentanil required for intubation, using a steady effect-site concentration of propofol and with the use of vecuronium. METHODS: Eighty ASA class 1 or 2 patients presenting for elective surgery were allocated at random to one of four groups. Anesthesia was induced in all patients with TCI of propofol target concentration 8 microgram /ml, followed by vecuronium (0.12 mg/kg). This was reduced to 5microgram/ml when the effect-site concentration had been 4microgram/ml. After the effect-site concentrations had reached to 5microgram/ml, control group received normal saline, group 1 received alfentanil 10microgram/kg, group 2 received alfentanil 20microgram/kg, and group 3 received alfentanil 30microgram/kg. Laryngoscopy and intubation were performed 90 s later. Heart rate was monitored continuously. Systolic blood pressure, diastolic blood pressure and mean arterial pressure were measured at pre-induction, post-induction (pre-intubation) and post-intubation, respectively. Complications such as hypotention and bradycardia were recorded until 5 minutes had elapsed after tracheal intubation. RESULTS: Control group showed significant increases associated with tracheal intubation in all hemodynamic variables (P < 0.05). Post-intubation values decreased significantly from pre-induction values in groups 1, 2 and 3 (P < 0.05). In groups 2 and 3, hypotension and bradycardia occurred (zero in group 1) but there were no significant differences in their incidences between the three groups. CONCLUSIONS: We suggest that alfentanil 10microgram/kg constitutes the optimal dosage to obtund the hemodynamic responses to tracheal intubation, using propofol TCI (5microgram/ml) and vecuronium for induction of anesthesia.

The Effect of Nickel and Manganese on Store-Operated Channels in Canine Pulmonary Arterial Smooth Muscle Cells / 대한마취과학회지

BACKGROUND: Pulmonary vasoconstriction greatly contributes to the elevated pulmonary vascular resistance in patients with pulmonary hypertension. A rise in cytosolic Ca2+ concentration ([Ca2+]cyt) in pulmonary arterial smooth muscle cells (PASMCs) is a major trigger for pulmonary vasoconstriction. Presently, little is known about the nature of the store-operated channels (SOCs) in PASMCs, even though store depletion-mediated capacitative Ca2+ entry (CCE) is a critical mechanism for refilling the empty sarcoplasmic reticulum (SR) with Ca2+, and for maintaining a sustained increase in [Ca2+]cyt. The goal of this in vitro study was to investigate the effects of nickel and manganese on store-operated channels in canine PASMCs. METHODS: Isolated PASMCs were obtained from an enzymatically treated canine pulmonary artery. Currents were recorded at room temperature using the dialyzed whole cell recording technique. The protocol used to deplete the intracellular Ca2+ stores and to monitor the development of the store-operated Ca2+ currents, involved voltage-clamping cells at 0 mV to inactivate any voltage-dependent calcium currents. Crrents were recorded in response to a 200 ms voltage step from 120 to 40 mV in 20 mV increments every 15 seconds. RESULTS: Simultaneous depletion of intracellular Ca2+ leads to a voltage-independent and linear store-operated Ca2+ current (ISOC) reversal near 0 mV. Nickel and manganese inhibit ISOC. CONCLUSIONS: In canine PASMCs, the depletion of intracellular Ca2+ stores leads to the activation of ISOC, which is inhibited by nickel and manganese. These metals are non-specific inhibitors of non-selective cation channels. Our results indicate that Ni2+- and Mn2+-sensitive pathways may mediate Ca2+ entry, or that a class of non-selective cation channels may contribute to CCE in canine PASMCs.