Regional analgesia techniques for video-assisted thoracic surgery: a frequentist network meta-analysis / 대한마취과학회지

Background@#Various regional analgesia techniques are used to reduce postoperative pain in patients undergoing video-assisted thoracic surgery (VATS). This study aimed to determine the relative efficacy of regional analgesic interventions for VATS using a network meta-analysis (NMA). @*Methods@#We searched the Medline, EMBASE, Cochrane Controlled Trial Register, Web of Science, and Google Scholar databases to identify all randomized controlled trials (RCTs) that compared the analgesic effects of the following interventions: control, thoracic paravertebral block (TPVB), erector spinae plane block (ESPB), serratus plane block (SPB), and intercostal nerve block (INB). The primary outcome was opioid consumption during the first 24-h postoperative period. Pain scores were also collected during three different postoperative periods: the early (0–6 h), middle (6–18 h), and late (18–24 h) periods. @*Results@#A total of 21 RCTs (1391 patients) were included. TPVB showed the greatest effect on opioid consumption compared with the control (mean difference [MD] = −13.2 mg; 95% CI [−16.2, −10.1]). In terms of pain scores in the early period, ESPB had the greatest effect compared to control (MD = −1.6; 95% CI [−2.3, −0.9]). In the middle and late periods, pain scores showed that TPVB, ESPB and INB had superior analgesic effects compared to controls, while SPB did not. @*Conclusions@#TPVB had the best analgesic efficacy following VATS, though the analgesic efficacy of ESPBs was comparable. However, further studies are needed to determine the optimal regional analgesia technique to improve postoperative pain control following VATS.

Can chronic postsurgical pain be prevented by using regional block? / 대한마취과학회지

No abstract available.

Appropriate angle and depth in thoracic transforaminal epidural block in Koreans

BACKGROUND: Selective transforaminal epidural block has come to the for as a targetspecific modality in the treatment and diagnosis of spinal pain. Thoracic transforaminal epidural block (TTFEB) has the associated risk of pneumothorax. This article describes a retrospective study conducted using computed tomography (CT) imaging to investigate the TTFEB angle and depth appropriate to minimize the risk of pneumothorax in Koreans. METHODS: The subjects of the present study were 100 randomly selected patients between 50 and 70 years of age found be free of thoracic disease according to chest CT performed in the present hospital. On the chest CT, the superior, middle, and inferior thoracic vertebrae were observed at the T2, T7, and T11 levels, respectively. RESULTS: The average distance and the needle insertion angle from the skin point at which the needle may be inserted without piercing the lung to the intervertebral foramen were 117.8 ± 12.1 mm and 58.1 ± 6.1° at the T2 level, 85.6 ± 10.0 mm and 61.7 ± 4.3° at the T7 level, and 94.3 ± 8.7 mm and 64.4 ± 7.0° at the T11 level, respectively. CONCLUSIONS: The needle insertion at the point further than 40 mm, on the upper, middle thorax, if the needle pass from the inner vertebral body to lamina, it could be safer. However, on the lower thorax, needle could pierce the lung though the needle start from the inner vertebral body. Thus, it can be safer if the needle pass toward the exterior margin of lamina.

Effect of dexmedetomidine on endotracheal intubating conditions during endotracheal intubation without neuromuscular blocker following propofol/remifentanil

BACKGROUND: In the present study, we investigated the effect of dexmedetomidine on the intubating conditions and hemodynamic changes during endotracheal intubation following anesthetic induction performed using propofol and remifentanil without a neuromuscular blocking agent. METHODS: We selected 70 adult patients aged 20 to 65 years scheduled to undergo general anesthesia. Induction was performed using 2 mg/kg of propofol and 1.5 µg/kg of remifentanil. The patients were divided into two groups, a dexmedetomidine group (Group D) and a control group (Group C). Group D received an infusion of dexmedetomidine 1 µg/kg for 10 minutes before induction, and Group C received the same volume of normal saline infused in the same manner. Intubating conditions were evaluated and blood pressure and heart rate were recorded at various time points to assess hemodynamic stability. RESULTS: Intubating conditions were evaluated as excellent for 34 patients and good for 1 patient in Group D, and excellent for 4 patients, good for 20 patients, poor for 4 patients, and bad for 7 patients in Group C (P < 0.001). The heart rate was significantly lower in Group D than in Group C at all measurement times. The mean arterial blood pressure was significantly lower in Group C than in Group D at 10 minutes after dexmedetomidine administration (P = 0.049), after the induction of anesthesia (P < 0.001), immediately after endotracheal intubation (P = 0.008), and 3 minutes after endotracheal intubation (P < 0.001). CONCLUSIONS: Dexmedetomidine 1 µg/kg improved the intubating conditions and stabilized hemodynamic changes following anesthetic induction performed using propofol 2 mg/kg and remifentanil 1.5 µg/kg without a neuromuscular blocking agent.

Successful Treatment of Occipital Radiating Headache Using Pulsed Radiofrequency Therapy

Rheumatoid arthritis (RA) is a chronic inflammatory disease involving multiple joints. The cervical spine is often affected, and cases involving atlantoaxial joint can lead to instability. Anterior atlantoaxial subluxation in RA patients can lead to posterior neck pain or occipital headache because of compression of the C2 ganglion or nerve. Here, we report the successful treatment of a RA patient with occipital radiating headache using pulsed radiofrequency therapy at the C2 dorsal root ganglion.

Comparison of etomidate and propofol on intubating conditions and the onset time associated with cisatracurium administration / 대한마취과학회지

BACKGROUND: This study compared intubating conditions and the onset time associated with administration of cisatracurium, a nondepolarizing neuromuscular blocker with a relatively slow onset, according to prior injection of one of two intravenous anesthetic agents: propofol or etomidate. METHODS: Forty-six female patients, undergoing general anesthesia and endotracheal intubation for elective surgery, were randomized to two groups; group P were administered propofol (2 mg/kg) prior to cisatracurium (0.2 mg/kg); group E were administered etomidate (0.3 mg/kg) prior to cisatracurium (0.2 mg/kg). We measured intubating conditions and the onset time according to the types of intravenous anesthetic administered. Measurements of heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were taken immediately prior to induction; immediately and 1 min after IV anesthetic administration; and immediately and 1, 2, 3, 4, 5, 7, and 15 min after endotracheal intubation. RESULTS: Intubating conditions were superior in group E compared with group P (P = 0.009). The average onset time of cisatracurium was more rapid in group E (155.74 +/- 32.92 s vs. 185.26 +/- 38.57 s in group P; P = 0.008). There were no group differences in SBP, DBP, and HR following intravenous anesthetic drug injection and endotracheal intubation. However, SBP and DBP were substantially higher in group E after endotracheal intubation. CONCLUSIONS: Etomidate improves intubating conditions and provide a more rapid onset time of cisatracurium during anesthetic induction compared to propofol.

Anesthesia and sedation outside of the operating room / 대한마취과학회지

Due to rapid evolution and technological advancements, medical personnel now require special training outside of their safe zones. Anesthesiologists face challenges in practicing in locations beyond the operating room. New locations, inadequate monitoring devices, poor assisting staff, unfamiliarity of procedures, insufficient knowledge of basic standards, and lack of experience compromise the quality of patient care. Therefore, anesthesiologists must recognize possible risk factors during anesthesia in nonoperating rooms and familiarize themselves with standards to improve safe practice. This review article emphasizes the need for standardizing hospitals and facilities requiring nonoperating room anesthesia, and encourages anesthesiologists to take the lead in applying these practice guidelines to improve patient outcomes and reduce adverse events.

Protease-Activated Receptor-2 Is Associated with Terminal Differentiation of Epidermis and Eccrine Sweat Glands

BACKGROUND: Protease-activated receptor 2 (PAR-2) participates in various biological activities, including the regulation of epidermal barrier homeostasis, inflammation, pain perception, and melanosome transfer in the skin. OBJECTIVE: To evaluate the basic physiological role of PAR-2 in skin. METHODS: We investigated PAR-2 expression in human epidermis, skin tumors, and cultured epidermal cells using western blot and immunohistochemical analysis. Additionally, we examined the effect of the PAR-2 agonist, SLIGRL-NH2, on cultured keratinocytes. RESULTS: Strong PAR-2 immunoreactivity was observed in the granular layer of normal human skin and the acrosyringium of the eccrine sweat glands. In contrast, weak PAR-2 immunoreactivity was seen in the granular layer of callused skin and in the duct and gland cells of the eccrine sweat glands. Interestingly, PAR-2 immunoreactivity was very weak or absent in the tumor cells of squamous cell carcinoma (SCC) and syringoma. PAR-2 was detected in primary keratinocytes and SV-40T-transformed human epidermal keratinocytes (SV-HEKs), an immortalized keratinocyte cell line, but not in SCC12 cells. SV-HEKs that were fully differentiated following calcium treatment displayed higher PAR-2 expression than undifferentiated SV-HEKs. Treatment of cultured SV-HEKs with PAR-2 agonist increased loricrin and filaggrin expression, a terminal differentiation marker. CONCLUSION: Our data suggest that PAR-2 is associated with terminal differentiation of epidermis and eccrine sweat glands.

Analysis of Anesthesia-related Medical Disputes in the 2009-2014 Period Using the Korean Society of Anesthesiologists Database

Using the Korean Society of Anesthesiologists database of anesthesia-related medical disputes (July 2009-June 2014), causative mechanisms and injury patterns were analyzed. In total, 105 cases were analyzed. Most patients were aged < 60 yr (82.9%) and were classified as American Society of Anesthesiologists physical status < or = II (90.5%). In 42.9% of all cases, the injuries were determined to be 'avoidable' if the appropriate standard of care had been applied. Sedation was the sec most common type of anesthesia (37.1% of all cases), following by general anesthesia. Most sedation cases (27/39, 69.2%) showed a common lack of vigilance: no pre-procedural testing (82.1%), absence of anesthesia record (89.7%), and non-use of intra-procedural monitoring (15.4%). Most sedation (92.3%) was provided simultaneously by the non-anesthesiologists who performed the procedures. After the resulting injuries were grouped into four categories (temporary, permanent/minor, permanent/major, and death), their causative mechanisms were analyzed in cases with permanent injuries (n=20) and death (n=82). A 'respiratory events' was the leading causative mechanism (56/102, 54.9%). Of these, the most common specific mechanism was hypoxia secondary to airway obstruction or respiratory depression (n=31). The sec most common damaging event was a 'cardiovascular events' (26/102, 25.5%), in which myocardial infarction was the most common specific mechanism (n=12). Our database analysis demonstrated several typical injury profiles (a lack of vigilance in seemingly safe procedures or sedation, non-compliance with the airway management guidelines, and the prevalence of myocardial infarction) and can be helpful to improve patient safety.

Analysis of Anesthesia-related Medical Disputes in the 2009-2014 Period Using the Korean Society of Anesthesiologists Database

Using the Korean Society of Anesthesiologists database of anesthesia-related medical disputes (July 2009-June 2014), causative mechanisms and injury patterns were analyzed. In total, 105 cases were analyzed. Most patients were aged < 60 yr (82.9%) and were classified as American Society of Anesthesiologists physical status < or = II (90.5%). In 42.9% of all cases, the injuries were determined to be 'avoidable' if the appropriate standard of care had been applied. Sedation was the sec most common type of anesthesia (37.1% of all cases), following by general anesthesia. Most sedation cases (27/39, 69.2%) showed a common lack of vigilance: no pre-procedural testing (82.1%), absence of anesthesia record (89.7%), and non-use of intra-procedural monitoring (15.4%). Most sedation (92.3%) was provided simultaneously by the non-anesthesiologists who performed the procedures. After the resulting injuries were grouped into four categories (temporary, permanent/minor, permanent/major, and death), their causative mechanisms were analyzed in cases with permanent injuries (n=20) and death (n=82). A 'respiratory events' was the leading causative mechanism (56/102, 54.9%). Of these, the most common specific mechanism was hypoxia secondary to airway obstruction or respiratory depression (n=31). The sec most common damaging event was a 'cardiovascular events' (26/102, 25.5%), in which myocardial infarction was the most common specific mechanism (n=12). Our database analysis demonstrated several typical injury profiles (a lack of vigilance in seemingly safe procedures or sedation, non-compliance with the airway management guidelines, and the prevalence of myocardial infarction) and can be helpful to improve patient safety.

Intrathecal Administration of Mesenchymal Stem Cells Reduces the Reactive Oxygen Species and Pain Behavior in Neuropathic Rats

BACKGROUND: Neuropathic pain induced by spinal or peripheral nerve injury is very resistant to common pain killers, nerve block, and other pain management approaches. Recently, several studies using stem cells suggested a new way to control the neuropatic pain. In this study, we used the spinal nerve L5 ligation (SNL) model to investigate whether intrathecal rat mesenchymal stem cells (rMSCs) were able to decrease pain behavior, as well as the relationship between rMSCs and reactive oxygen species (ROS). METHODS: Neuropathic pain of the left hind paw was induced by unilateral SNL in Sprague-Dawley rats (n = 10 in each group). Mechanical sensitivity was assessed using Von Frey filaments at 3, 7, 10, 12, 14, 17, and 24 days post-ligation. rMSCs (10 microl, 1 x 105) or phosphate buffer saline (PBS, 10 microl) was injected intrathecally at 7 days post-ligation. Dihydroethidium (DHE), an oxidative fluorescent dye, was used to detect ROS at 24 days post-ligation. RESULTS: Tight ligation of the L5 spinal nerve induced allodynia in the left hind paw after 3 days post-ligation. ROS expression was increased significantly (P < 0.05) in spinal dorsal horn of L5. Intrathecal rMSCs significantly (P < 0.01) alleviated the allodynia at 10 days after intrathecal injection (17 days post-ligation). Intrathecal rMSCs administration significantly (P < 0.05) reduced ROS expression in the spinal dorsal horn. CONCLUSIONS: These results suggest that rMSCs may modulate neuropathic pain generation through ROS expression after spinal nerve ligation.

Glomus Tumor Causing Anterior Thigh Pain: A Case Report

Glomus tumors are a rare, benign neoplasm and 75% exist in the subungual region. Extradigital glomus tumors are much more difficult to diagnose because of their atypical location and symptoms. Furthermore, if their symptoms are similar to neuropathic pain, the patient can suffer from misdirected treatment due to misdiagnosis. It is essential to perform careful evaluation of the lesion itself in order to reduce misdiagnosis. Ultrasonography is a useful, non-invasive method that can be easily performed in the pain clinic for local evaluation and diagnosis. We report a case of misdiagnosed glomus tumor in the thigh which was properly diagnosed after ultrasonography.

Percutaneous vertebroplasty for painful spinal metastasis: a good option for better quality of life / 대한마취과학회지

No abstract available.

Efficacy of the oral neurokinin-1 receptor antagonist aprepitant administered with ondansetron for the prevention of postoperative nausea and vomiting / 대한마취과학회지

BACKGROUND: 5-HT3 receptor antagonist, dexamethasone and droperidol were used for the prevention of postoperative nausea and vomiting (PONV). Recently, neurokinin-1 (NK1) antagonist has been used for PONV. We evaluated the effect of oral aprepitant premedication in addition to ondansetron. METHODS: A total 90 patients scheduled for elective rhinolaryngological surgery were allocated to three groups (Control, Ap80, Ap125), each of 30 at random. Ondansetron 4 mg was injected intravenously to all patients just before the end of surgery. On the morning of surgery, 80 mg and 125 mg aprepitant were additionally administered into the Ap80 group and Ap125 group, respectively. The rhodes index of nausea, vomiting and retching (RINVR) was checked at 6 hr and 24 hr after surgery. RESULTS: Twelve patients who used steroids unexpectedly were excluded. Finally 78 patients (control : Ap80 : Ap125 = 24 : 28 : 26) were enrolled. Overall PONV occurrence rate of Ap125 group (1/26, 3.9%) was lower (P = 0.015) than the control group (7/24, 29.2%) at 6 hr after surgery. The nausea distress score of Ap125 group (0.04 +/- 0.20) was lower (P = 0.032) than the control group (0.67 +/- 1.24) at 6 hr after surgery. No evident side effect of aprepitant was observed. CONCLUSIONS: Oral aprepitant 125 mg can be used as combination therapy for the prevention of PONV.

Effect of lidocaine (40 mg) mixed to prevent injection pain of propofol on the intubating conditions and onset time of rocuronium / 대한마취과학회지

BACKGROUND: To analyze how lidocaine 40 mg mixed prevents injection pain of propofol affects the onset time of rocuronium, tracheal intubating conditions and intubation related hemodynamic changes. METHODS: This study consisted of 70 patients with an American Society of Anesthesiologists (ASA) physical status class 1 or 2 for general anesthesia. All the patients were randomly allocated into two groups: propofol 2 mg/kg plus normal saline 2 ml (Group C) and propofol 2 mg/kg plus 2% lidocaine 40 mg (Group L). Each group was administrated intravenously during induction and the patient was intubated 1 minute after an injection of 0.6 mg/kg of rocuronium. The time at disappearance of the first twitch and intubation scores were recorded. Also, blood pressure and heart rate were measured at the baseline, after intravenous injection of propofol, before intubation, and at 0, 1, 2, 3 and 5 minutes after intubation. RESULTS: There were no significant differences between group C and L (P > 0.05). CONCLUSIONS: 40 mg of lidocaine mixed with propofol to prevent injection pain did not affect the onset time of rocuronium, intubating conditions and intubation related hemodynamic changes.

Clinical Experiences on the Effect of Scrambler Therapy for Patients with Postherpetic Neuralgia

Postherpetic neuralgia (PHN) is a debilitating complication of herpes zoster, especially in elderly and comorbid patients. Unfortunately, the currently available treatments have shown limited efficacy and some adverse events that are poorly tolerated in elderly patients. Scrambler Therapy, proposed as an alternative treatment for chronic neuropathic pain recently, is a noninvasive approach to relieve pain by changing pain perception at the brain level. Here, we report our clinical experiences on the effect of Scrambler Therapy for three patients with PHN refractory to conventional treatment.

Antinociceptive drug interaction between intrathecal vitamin E and gabapentin in the rat formalin test / 대한마취과학회지

BACKGROUND: Gabapentin is thought to exert an effect through the voltage-dependent calcium channel. Vitamin E is a widely known antioxidant which neutralizes the harmful effect of ROS which is considered to play a prominent role in various painful conditions. This study was therefore conducted to assess the antinociceptive effects of gabapentin and vitamin E and the interaction of these drugs in the modulation of pain in rats subjected to a formalin test. METHODS: Sprague-Dawley rats with a lumbar intrathecal catheter were tested for their paw flinches by 5% formalin injection after intrathecal injection of gabapentin or vitamin E. After obtaining dose-response curves for each drug, the effect of the combination was tested by the total dose fraction value and isobolographic analysis. RESULTS: When a single drug was injected intrathecally, significant dose-dependent decreases in flinches were shown only in the late phase. ED50 values of intrathecal gabapentin and vitamin E in the late phase were 75.3 +/- 9.58 microg, and 17.56 +/- 1.65 mg/kg respectively. The combination of gabapentin and vitamin E produced dose-dependent decreases in the number of flinches in both phases induced by the formalin test. The ED50 value of the combination was lower than the theoretical additive values in the late phase, but did not show a significant difference with the theoretical additive value. CONCLUSIONS: Gabapentin and vitamin E (by itself) have no antinociceptive effect in the early phase; however their combination has shown an antinociceptive effect. In addition, they show additive effects in the late phase of the formalin test.

Antinociceptive Effects of Intraperitoneal and Intrathecal Vitamin E in the Rat Formalin Test

BACKGROUND: Vitamin E is widely known to be one of the reactive oxygen species (ROS) scavengers and a drug that can easily be obtained, and it has been shown to attenuate the pain responses induced by various causes in animal pain models. Thus, this experiment was conducted to assess the antinociceptive effects of vitamin E by comparing intraperitoneal and intrathecal injections in rats subjected to the formalin test. METHODS: After the intraperitoneal and intrathecal injections of vitamin E were carried out, respectively (IP: 500 mg/kg, 1 g/kg, and 2 g/kg, IT: 3 mg/kg, 10 mg/kg, and 30 mg/kg), the formalin test was perfumed. As soon as 5% formalin was injected into left hind paw, the number of flinches induced by pain was measured at 5-minute intervals for 1 hour. RESULTS: Formalin injected into the left hind paw induced biphasic nociceptive behavior in all animals. Intraperitoneal injection of vitamin E diminished the nociceptive behavior in a dose-dependent manner during the early and late phase. Intrathecal vitamin E diminished nociceptive behavior dose dependently during the late phase but showed no significant difference in the early phase. CONCLUSIONS: Vitamin E attenuated acute nociception when it was injected systemically, while both systemic and intrathecal injection produced analgesia in a rat model of formalin-induced hyperalgesia.

Ultrasonographic Measurement of the Ligamentum Flavum Depth; Is It a Reliable Method to Distinguish True and False Loss of Resistance?

BACKGROUND: Previous studies have shown that if performed without radiographic guidance, the loss of resistance (LOR) technique can result in inaccurate needle placement in up to 30% of lumbar epidural blocks. To date, no study has shown the efficacy of measuring the depth of the posterior complex (ligamentum flavum, epidural space, and posterior dura) ultrasonographically to distinguish true and false LOR. METHODS: 40 cervical epidural blocks were performed using the LOR technique and confirmed by epidurograms. Transverse ultrasound images of the C6/7 area were taken before each cervical epidural block, and the distances from the skin to the posterior complex, transverse process, and supraspinous ligament were measured on each ultrasound view. The number of LOR attempts was counted, and the depth of each LOR was measured with a standard ruler. Correlation of false and true positive LOR depth with ultrasonographically measured depth was also statistically analyzed. RESULTS: 76.5% of all cases (26 out of 34) showed false positive LOR. Concordance correlation coefficients between the measured distances on ultrasound (skin to ligamentum flavum) and actual needle depth were 0.8285 on true LOR. Depth of the true positive LOR correlated with height and weight, with a mean of 5.64 +/- 1.06 cm, while the mean depth of the false positive LOR was 4.08 +/- 1.00 cm. CONCLUSIONS: Ultrasonographic measurement of the ligamentum flavum depth (or posterior complex) preceding cervical epidural block is beneficial in excluding false LOR and increasing success rates of cervical epidural blocks.

Antinociceptive effect of phenyl N-tert-butylnitrone, a free radical scavenger, on the rat formalin test / 대한마취과학회지

BACKGROUND: Reactive oxygen species (ROS) such as superoxide radicals, hydrogen peroxide, nitric oxide, and nitroperoxide, cause oxidative stress which interferes with normal cell functioning, resulting in cell damage. It is reported to be associated with chronic pain, especially neuropathic pain, and inflammatory pain. ROS is also closely related to central sensitization. Therefore, this study was designed to explore the effects of Phenyl N-tert-butylnitrone (PBN), an ROS scavenger, in acute, continuous, and increasing pain caused by central sensitization. METHODS: Male Sprague-Dawley rats were divided into 2 groups, an intraperitoneal group (IP) and an intrathecal group (IT), and once again divided into an experimental group and a control group. The experimental group was injected with Phenyl N-tert-butylnitrone (PBN), a free radical scavenger, either intraperitoneally or intrathecally. After inducing pain by injecting formalin into the hind paw, pain behaviors were measured. Lumbar enlargement immmunohistochemistry was performed to assess nitrotyrosine, an oxidative stress marker, to identify the degree of protein nitration. RESULTS: Both experimental groups of IP and IT showed statistically significant decreases in the number of flinches compared to the control group in phase 1 and 2. Immunohistochemical evaluation in the control group revealed an increase in nitrated proteins in the gray matter of the lumbar spinal cord, but a significant decrease in nitrated proteins in the gray matter of lumbar spinal cord of the experimental group. CONCLUSIONS: Intraperitoneal and intrathecal administration of PBN decreases analgesic behaviors, allowing us to believe that ROS is mainly responsible for acute pain and central sensitization.