Worsening of Migraine Associated with Hyperprolactinemia

A 45-year-old woman presented with worsening of migraine without aura. Laboratory test revealed hyperprolactinemia, but brain magnetic resonance imaging was normal. She had no known etiologies of hyperprolactinemia. Headache improved together with normalization of serum prolactin level after administration of bromocriptine. However, withdrawal of bromocriptine caused elevation of serum prolactin level and worsening of migraine headache. She repeated similar pattern of improvement and aggravation two times more. We suggest that hyperprolactinemia may cause aggravation of migraine headache.

Negative myoclonus associated with pregabalin / 영남의대학술지

Negative myoclonus (NM) is a jerky, shock-like involuntary movement caused by a sudden, brief interruption of muscle contraction. An 80-year-old man presented with multifocal NM and confusion. Two days before the onset of NM, he commenced the intake of pregabalin at a dose of 150 mg/day for neuropathic pain. His NM resolved completely and mental status improved gradually after the administration of lorazepam intravenously and the discontinuation of pregabalin. Our study suggests that pregabalin can cause NM even in patients without a history of seizures.

Negative myoclonus associated with pregabalin / 영남의대학술지

Negative myoclonus (NM) is a jerky, shock-like involuntary movement caused by a sudden, brief interruption of muscle contraction. An 80-year-old man presented with multifocal NM and confusion. Two days before the onset of NM, he commenced the intake of pregabalin at a dose of 150 mg/day for neuropathic pain. His NM resolved completely and mental status improved gradually after the administration of lorazepam intravenously and the discontinuation of pregabalin. Our study suggests that pregabalin can cause NM even in patients without a history of seizures.

Hyponatremia-induced Seizures in Schizophrenic Patient Treated with Olanzapine

Severe hyponatremia (serum sodium concentration <120 mEq/L) is a well-known etiology of acute symptomatic seizure. Severe hyponatremia may occur as a rare but clinically important adverse reaction of psychotrophic drugs. Among them, patients with psychogenic polydipsia have especially higher risk of severe hyponatremia. We present a schizophrenic patient with polydipsia who developed severe hyponatremia and symptomatic seizures while receiving olanzapine treatment.

Meralgia paresthetica affecting parturient women who underwent cesarean section: A case report / 대한마취과학회지

Meralgia paresthetica is commonly caused by a focal entrapment of lateral femoral cuteneous nerve while it passes the inguinal ligament. Common symptoms are paresthesias and numbness of the upper lateral thigh area. Pregnancy, tight cloths, obesity, position of surgery and the tumor in the retroperitoneal space could be causes of meralgia paresthetica. A 29-year-old female patient underwent an emergency cesarean section under spinal anesthesia without any problems. But two days after surgery, the patient complained numbness and paresthesia in anterolateral thigh area. Various neurological examinations and L-spine MRI images were all normal, but the symptoms persisted for a few days. Then, electromyogram and nerve conduction velocity test of the trunk and both legs were performed. Test results showed left lateral cutaneous nerve injury and meralgia paresthetica was diagnosed. Conservative treatment was implemented and the patient was free of symptoms after 1 month follow-up.

The effect of remifentanil for reducing myoclonus during induction of anesthesia with etomidate / 대한마취과학회지

BACKGROUND: Myoclonic movement is a common problem during induction of anesthesia with etomidate. We investigated the influences of pretreatment with remifentanil on etomidate induced myoclonus. METHODS: Ninety ASA class I patients were divided randomly into three groups. Group NS received normal saline 2 ml as placebo (n = 30), group R0.5 and group R1.0 were pretreated with remifentanil 0.5 microgram/kg (n = 30) or 1.0 microgram/kg (n = 30) 1 minute before induction with etomidate 0.3 mg/kg. Orotracheal intubation was performed after administration of rocuronium 0.5 mg/kg. We assessed the incidence, onset, duration and intensity of myoclonus. Mean arterial pressure (MAP), heart rate (HR) and bispectral index (BIS) were recorded during induction. RESULTS: Twenty five patients developed myoclonus in group NS (83.3%), 3 patients in group R0.5 developed myoclonus (10%), as did 5 patients in group R1.0 (16.7%). Moderate to severe myoclonus of grade 3 and 4 were found 66.7% of patients in group NS, whereas no patients in both remifentanil pretreated groups developed this grade of myoclonus. The duration of myoclonus was reduced significantly in the remifentanil groups: 93.8 +/- 59.5 sec in group NS, 49.3 +/- 34.9 sec in group R0.5, 36.0 +/- 27.0 sec in group R1.0 (P < 0.05). HR was decreased by pretreatment with remifentanil prior to induction, while MAP and HR were decreased after induction with etomidate (P < 0.05). BIS changes were not different among the three groups. The dose dependent differences between the two remifentanil doses were not noticed. CONCLUSIONS: Pretreatment with remifentanil significantly reduced the incidence, duration and intensity of etomidate induced myoclonus.

Interscalene brachial plexus block: depth and angle from the skin insertion point to the brachial plexus and to C6-7 intervertebral foramen / 대한마취과학회지

BACKGROUND: The angle and depth from the insertion point to the brachial plexus (BP) and C6-7 intervertebral foramen (IF) was examined to prevent critical complications of an interscalene brachial plexus block (ISBPB), such as an epidural or subdural injection of local anesthetics and spinal cord injury. METHODS: Thirty patients (female = 12, male = 18), aged 20-64 years, undergoing shoulder or upper limb surgery were examined. ISBPB was performed at the interscalene groove intersecting the extended transverse line from the cricoid cartilage. A needle was then advanced towards the C6 transverse process (TP) and C6-7 IF under the C-arm fluoroscopic guidance. The depth and angle of the needle path intersecting the sagittal plane from the skin insertion point to BP, transverse process (TP) and IF were measured. RESULTS: The mean depth of the needle from the insertion point to BP, TP and IF were 2.6 +/- 0.3 cm, 3.2 +/- 0.4 cm, 3.7 +/- 0.3 cm in the female patients, and 2.7 +/- 0.3 cm, 3.6 +/- 0.5 cm, 4.1 +/- 0.3 cm in the male patients. The mean angle of the needle path at the same point was 56.0 +/- 7.2o (range, 42.0-65.0degrees), 54.2 +/- 5.8degrees, 53.7 +/- 4.4degrees in the female patients, and 59.3 +/-8.3degrees (45.0-75.0degrees), 54.0 +/- 6.3degrees, 54.9 +/- 4.2degrees in male patients. There were significant differences in the depth from the skin to the TP and IF between males and females. CONCLUSIONS: These findings are expected to provide a guideline for more accurate needle placement and successful block during ISBPB.

Interscalene brachial plexus block: depth and angle from the skin insertion point to the brachial plexus and to C6-7 intervertebral foramen / 대한마취과학회지

BACKGROUND: The angle and depth from the insertion point to the brachial plexus (BP) and C6-7 intervertebral foramen (IF) was examined to prevent critical complications of an interscalene brachial plexus block (ISBPB), such as an epidural or subdural injection of local anesthetics and spinal cord injury. METHODS: Thirty patients (female = 12, male = 18), aged 20-64 years, undergoing shoulder or upper limb surgery were examined. ISBPB was performed at the interscalene groove intersecting the extended transverse line from the cricoid cartilage. A needle was then advanced towards the C6 transverse process (TP) and C6-7 IF under the C-arm fluoroscopic guidance. The depth and angle of the needle path intersecting the sagittal plane from the skin insertion point to BP, transverse process (TP) and IF were measured. RESULTS: The mean depth of the needle from the insertion point to BP, TP and IF were 2.6 +/- 0.3 cm, 3.2 +/- 0.4 cm, 3.7 +/- 0.3 cm in the female patients, and 2.7 +/- 0.3 cm, 3.6 +/- 0.5 cm, 4.1 +/- 0.3 cm in the male patients. The mean angle of the needle path at the same point was 56.0 +/- 7.2o (range, 42.0-65.0degrees), 54.2 +/- 5.8degrees, 53.7 +/- 4.4degrees in the female patients, and 59.3 +/-8.3degrees (45.0-75.0degrees), 54.0 +/- 6.3degrees, 54.9 +/- 4.2degrees in male patients. There were significant differences in the depth from the skin to the TP and IF between males and females. CONCLUSIONS: These findings are expected to provide a guideline for more accurate needle placement and successful block during ISBPB.

Expiratory Valve Malfunction Detected Immediately after Endotracheal Intubation: A case report / 대한마취과학회지

The malfunction of an expiratory unidirectional valve (EV) can cause rebreath of expired gas, barotraumas, or ventilatory failure during the general anesthesia. The following is a report on a case of ventilatoryfailure caused by an EV that failed to open during the induction of anesthesia. A 57-year-old man was scheduled for the biopsy of a vocal cord polyp. After intubation, we could not detect the evidence of ventilation through the endotracheal tube. Suspecting the esophageal intubation, we administered extubation. The patient was still having difficulty in ventilating even after a retrial of intubation. Then we discovered the EV was failing to open properly with ventilation and thus not able to function properly. The common cause of ventilatory failure immediately after intubation is malposition of an endotracheal tube, like esophageal intubation, and equipment failure also has reported. Accordingly, we should remember possible causes of ventilatory failure after intubations and routine conscientious inspection of the ventilator.

Anesthetic Management of Myotonic Dystrophy: A case report / 대한마취과학회지

Myotonic dystrophy is a muscle disorder characterized by progressive muscle wasting and weakness associated with myotonia. It is a systemic disease transmitted in an autosomal dominant pattern. Myotonia may be precipitated by hypothermia, shivering, and mechanical or electrical stimulation. Furthermore, sensitivity to sedative, anesthetic and neuromusclular blocking agents may result in intraoperative and early postoperative cardiovascular and respiratory complications, as well as prolonged recovery from anesthesia. Therefore, a patient with myotonic dystrophy is at high risk for complications from anesthetic management. We report the successful anesthetic management of such a patient undergoing a total abdominal hysterectomy, in which we used an epidural technique for intraoperative anesthesia and postoperative analgesia.

Effect of Rilmenidine and Clonidine Premedication on the Cardiovascular Action of Phenylephrine and Nitroprusside in Rats / 대한마취과학회지

BACKGROUND: Patients premedicated with clonidine often present with hypotension and bradycardia. The hypotensive patient premedicated with clonidine should be given a vasopressor to treat hypotension. In these patients, an augmented vasopressor response would be shown. Rilmenidine as an allied drug of clonidine is an antihypertensive agent with selectivity for the imidazoline receptor that acts centrally by reducing sympathetic overactivity. This study was designed to evaluate the effect of clonidine and rilmenidine on changes in mean blood pressure and baroreflex sensitivity following phenylephrine and nitroprusside administration. METHODS: Sixty Sprague-Dawley rats were assigned randomly into one of three groups, control group (n = 20), clonidine group (n = 20) or rilmenidine group (n = 20). Saline (control group), clonidine 30ng/kg (clonidine group) or rilmenidine 300ng/kg (rilmenidine group) were intraperitoneally injected respectively. Following the injection, a phenylephrine and nitroprusside test were performed. RESULTS: The percent change in mean blood perssure from the baseline values in the control group, clonidine group and rilmenidine group were 35 +/- 18%, 54 +/- 17% and 62 +/- 38%, respectively. There was no difference between the baroreflex sensitivity in the pressure (phenylephrine) test (0.94 +/- 0.43, vs 1.05 +/- 0.62, vs 1.13 +/- 0.59 msec/mmHg). In contrast, the slopes of the depressor (nitroprusside) test were decreased in rats receiving clonidine and rilmenidine (0.51 +/- 0.34, vs 0.12 +/- 0.08, vs 0.18 +/- 0.09 msec/mmHg, P < 0.05). CONCLUSIONS: It is concluded that the rilmenidine and clonidine groups showed a more augmented pressure response to vasopressors than the control group. Therefore, the decreased dosage of vasopressors is recommended to treat hypotension in rilmenidine premedicated patients.

Comparison of Poloxamer-407 to Soybean Oil as an Emulsifying Agent for Propofol: Histamine Release and Plasma Lipid Levels / 대한마취과학회지

BACKGROUND: To reduce side effects (hyperlipidemia, pain on injection, etc.) of the present formation of propofol, many attempts to change the emulsifying agent for propofol have been tried. This study was designed to examine the poloxamer-407 as an emulsifying agent for propofol compared to soybean oil regarding histamine release and plasma lipid levels. METHODS: Twelve Beagle dogs weighing 12 - 16 kg were randomly assigned to one of two groups according to the formulation of propofol. Group 1 received Diprivan propofol 1% (AstraZeneca Co. UK), and group 2 received poloxamer-407 formulated propofol by a continuous intravenous infusion at 30 mg/kg/h for 3 hours. Three, 6, 9 and 12 hours after discontinuing the propofol infusion, venous blood samples from the cranial tibial vein were analysed by an ELISA kit for the histamine level. Also, blood lipid levels were checked 3 hours after the infusion and blood propofol concentration were checked every hour during the infusion. RESULTS: Group 2 showed significantly less histamine release than group 1 at 3, 6 and 9 hours after the infusion (P < 0.05). In the plasma lipid study, there was no difference in high-density lipoprotein (HDL) between the two groups, but triglyceride and cholesterol were significantly higher in group 2 (P < 0.05). There was no difference in propofol concentrations between the two groups. CONCLUSIONS: Poloxamer-407 as an emulsifying agent for propofol showed no advantage compared to a present formulation regarding hyperlipidemia, and even decreased the histamine level.

Aspiration Pneumonia in Esophageal Achalasia Patient during Anesthesia for Cesarian Section / 대한마취과학회지

Achalasia is a motility disorder of the esophagus characterized by aperistalsis, incomplete lower esophageal sphincter (LES) relaxation, and increased LES tension. Obstruction at the esophageal hiatus results in dilatation of the thoracic esophagus, which can cause coughing and dyspnea by compression of the trachea and main-stem bronchi, and predisposes the patient to regurgitation and pulmonary aspiration of stagnant esophageal contents. We report a case of slight aspiration pneumonia during anesthesia in a pregnant woman who had achalasia of the esophagus. Epidural anesthesia was performed for a cesarian section uneventfully. She had a regurgitation of the gastroesophageal contents after a thiopental 225 mg IV because she wanted to sleep due to anxiety. We performed endotracheal intubation with Sellick's maneuver immediately followed by suction. We regret not to have recognized that she had achalasia of the esophagus. Therefore, we did not remove the esophageal contents with a nasogastric tube. The result was that she had slight aspiration pneumonia.

What is the Minimum Effective Dose of Propofol in Relieving Epidural Morphine Induced Pruritus? / 대한마취과학회지

BACKGROUND: Mu-receptor antagonists are considered effective for the treatment of epidural morphine induced pruritus (EMIP). However, they have been associated in certain cases with a concomitant reduction in analgesia. It is noteworthy that propofol has been shown to produce marked spinal depression, in particular of the dorsal and ventral horn. Recently it was reported that subhypnotic doses of propofol were efficient in relieving EMIP. This study was designed to investigate an effective minimum dose of propofol. METHODS: After obtaining informed consent from patients and with IRB approval, 155 patients having cesarean section received an epidural morphine 3 mg bolus, and 4 mg/day with continuous infusion for 2 days via a Baxter infusor(R). Patients who had pruritus with scratching were allocated randomly to one of the three groups. Patients received 10 mg propofol intravenously in group I (n = 25), 20 mg in group II (n = 25) and 30 mg in group III (n = 25). Pruritus and the level of sedation were assessed 5 minutes later using 5 points pruritus rating scale (PRS) and 4 points sedation rating scale (SRS). Statistical analysis was performed using chi-square test, one-way ANOVA and paired t-test. P or = 3). The success rate was significantly greater in the group II (76%) and group III (80%) than in the group I (48%) (P < 0.05). Seven patients had an increase in sedation in the group III versus none in the group I and group II (P < 0.05). The beneficial effect of treatment was longer than 60 minutes in 100% of patients in group I, II and III. CONCLUSION: These results suggest that 20 mg propofol and 30 mg propofol intravenously are equally effective in treating EMIP than 10 mg propofol. However the level of sedation is significantly less in 20 mg propofol group than 30 mg propofol group.