The cardiovascular effects of midazolam co-induction to propofol for induction in aged patients / 대한마취과학회지

BACKGROUND: The aim of this study was to investigate whether a small dose of midazolam and lessening the propofol dosage could prevent cardiovascular change at tracheal intubation for induction in aged patients. METHODS: Eighty patients over 65 years (ASA physical status 1, 2) scheduled for elective surgery received general anesthesia with remifentanil and propofol or midazolam. Patients in group P (n = 40) were induced with 0.9% NaCl 0.03 ml/kg, propofol 1. 2 mg/kg and remifentanil. Patients in group MP (n = 40) were induced with midazolam 0.03 mg/kg, propofol 0.8 mg/kg and remifentanil. The time taken to reach loss of consciousness (LOC) and the value of bispectral index score (BIS) at LOC were recorded. After LOC, 0.8 mg/kg of rocuronium was given and tracheal intubation was performed. The mean blood pressure (MBP) and heart rate (HR) were recorded before induction as the base value, before intubation, immediately post-intubation and 3 minutes after intubation. RESULTS: Compared with the base values, MBP at before intubation and 3 minutes after intubation was significantly decreased in group P and group MP (P < 0.05). Compared with group P, the decrease of MBP was significantly less at before intubation, immediately after intubation and 3 minutes after intubation in group MP (P < 0.05). The time taken to reach LOC was significantly decreased in group MP compared with that in group P (P < 0.05). There were no significant differences of HR at any time between the two groups. CONCLUSIONS: Co-induction with midazolam and propofol could prevent a marked BP decrease at tracheal intubation for induction in aged patients.

The cardiovascular effects of midazolam co-induction to propofol for induction in aged patients / 대한마취과학회지

BACKGROUND: The aim of this study was to investigate whether a small dose of midazolam and lessening the propofol dosage could prevent cardiovascular change at tracheal intubation for induction in aged patients. METHODS: Eighty patients over 65 years (ASA physical status 1, 2) scheduled for elective surgery received general anesthesia with remifentanil and propofol or midazolam. Patients in group P (n = 40) were induced with 0.9% NaCl 0.03 ml/kg, propofol 1. 2 mg/kg and remifentanil. Patients in group MP (n = 40) were induced with midazolam 0.03 mg/kg, propofol 0.8 mg/kg and remifentanil. The time taken to reach loss of consciousness (LOC) and the value of bispectral index score (BIS) at LOC were recorded. After LOC, 0.8 mg/kg of rocuronium was given and tracheal intubation was performed. The mean blood pressure (MBP) and heart rate (HR) were recorded before induction as the base value, before intubation, immediately post-intubation and 3 minutes after intubation. RESULTS: Compared with the base values, MBP at before intubation and 3 minutes after intubation was significantly decreased in group P and group MP (P < 0.05). Compared with group P, the decrease of MBP was significantly less at before intubation, immediately after intubation and 3 minutes after intubation in group MP (P < 0.05). The time taken to reach LOC was significantly decreased in group MP compared with that in group P (P < 0.05). There were no significant differences of HR at any time between the two groups. CONCLUSIONS: Co-induction with midazolam and propofol could prevent a marked BP decrease at tracheal intubation for induction in aged patients.

The expression of survivin and its related genes in adipocyte-derived stem cell by demethylation / 대한마취과학회지

BACKGROUND: Survivin is thought to contribute to stem cell maintenance partly by a hypomethylation mechanism. This study attempted to elucidate the signal transduction pathway of adipocyte-derived stem cells (ASCs) by using a demethylating agent, 5-aza-2'-deoxycytidine (ADC), to analyze the survivin, MEK/ERK, c-Myc and p53 gene expression. METHODS: Demethylation in the ASCs was induced by 1 micrometer ADC treatment. RT-PCR for survivin mRNA was preformed, before and 24, 48 and 72 hours (hr) after ADC treatment. Western blotting analysis was performed for p53, survivin, unphosphorylated and phosphorylated (p)-MEK, and p-ERK. Immunohistochemistry for ERK and survivin was done to evaluate the localization of the proteins. RESULTS: ADC inhibited the population growth of the ASCs and it increased the number of apoptotic cells 24, 48, and 72 hr after treatment. ADC treatment slightly decreased the expression of survivin mRNA after 48 hr and its level was restored after 72 hr of treatment. Otherwise, the level of survivin protein gradually increased up to 48 hr and it was decreased at 72 hr. The levels of p-MEK and p53 were increased time-dependently. c-Myc and p-ERK were elevated after ADC treatment and their highest levels were seen 48 hr after treatment. The ADC treatment increased the nuclear expression of ERK and survivin in the ASCs. CONCLUSIONS: The overexpression of p-MEK/ERK, p53, and c-Myc increased the survivin protein expression of the demethylated ASCs. These results suggest that demethylation could alter the expression of survivin, and p53, c-Myc and the MAPK (MEK/ERK) pathway might play a role in survivin's regulation in ASCs.

The incidence of cough induced by remifentanil during anesthetic induction was decreased by graded escalation of the remifentanil concentration / 대한마취과학회지

BACKGROUND: It is well known that opioids induce coughing. Many drugs such as lidocaine and ketamine are used to effectively prevent the coughing induced by opioids and this has been revealed to be effective. In this study, we evaluated the preventive effect of a graded escalation of the remifentanil concentration using a target controlled infusion pump and we compared this with the effect of lidocaine. METHODS: One hundred fifty ASA I and II patients who were scheduled for elective surgery were randomly divided into 3 groups. The patients were pretreated with 2% lidocaine 1 mg/kg (Group L) or saline (Group S) and remifentanil infusion (an effect site concentration of 4.0 ng/ml) was followed 1 minute later by using a target controlled infusion pump. Group R was pretreated with saline and this was followed by remifentanil infusion (effect site concentration of 2.0 ng/ml at first and then it was reset to 4.0 ng/ml). We evaluated the incidence, severity and onset time of cough after remifentanil infusion. RESULTS: The incidence of coughing was significantly decreased in Group R (6 cases, 12%) and Group L (7 cases, 14%), as compared to that of Group S (17 cases, 34%) (P < 0.05), but there was no significant difference between Group R and Group L. The groups showed no significant difference in the severity and the onset time of coughing. CONCLUSIONS: This study demonstrated that administering graded escalation of the remifentanil concentration suppresses remifentanil-induced coughing as effectively as lidocaine 1 mg/kg pretreatment.

NMDA Receptor Activation Mediates Neuropathic Pain States Induced by Calcium Channel alpha2delta1 Subunit

BACKGROUND: Several studies have indicated that a nerve injury enhances the expression of the voltage-gated calcium channel alpha2delta1 subunit (Cavalpha2delta1) in sensory neurons and the dorsal spinal cord. This study examined whether NMDA receptor activation is essential for Cavalpha2delta1-mediated tactile allodynia in Cavalpha2delta1 overexpressing transgenic mice and L5/6 spinal nerve ligated rats (SNL). These two models show similar Cavalpha2delta1 upregulation and behavioral hypersensitivity, without and with the presence of other injury factors, respectively. METHODS: The transgenic (TG) mice were generated as described elsewhere (Feng et al., 2000). The left L5/6 spinal nerves in the Harlan Sprague Dawley rats were ligated tightly (SNL) to induce neuropathic pain, as described by Kim et al. (1992). Memantine 2 mg/kg (10 ul) was injected directly into the L5/6 spinal region followed by 10microl saline. Tactile allodynia was tested for any mechanical hypersensitivity. RESULTS: The tactile allodynia in the SNL rats could be reversed by an intrathecal injection of memantine 2 mg/kg at 1.5 hours. The tactile allodynia in the Cavalpha2delta1 over-expressing TG mice could be reversed by an intrathecal injection of memantine 2 mg/kg at 1.5, 2.0 and 2.5 hours. CONCLUSIONS: The behavioral hypersensitivity was similar in the TG mice and nerve injury pain model, supporting the hypothesis that elevated Cavalpha2delta1 mediates similar pathways that underlie the pain states in both models. The selective activation of spinal NMDA receptors plays a key role in mediating the pain states in both the nerve-injury rats and TG mice.

Reconstruction of Necrosis Following Total Knee Replacement Arthroplasty

In spite of proper maneuver of total knee replacement arthroplasty, some patients suffer from skin necrosis just above the implant. From Mar. 2000 to Jan. 2004, the authors performed reconstruction of knee skin defects after total knee replacement athroplasty. Total 6 cases of flap surgery were performed and patients ranged between 43-years-old to 82-years-old. Rectus femoris perforator based reversed adipofascial flaps were used in 2 cases, medial gastrocnemius muscular island flaps were used in 2 cases and sural artery based on adipofascial rotation flap was used in 1 case. One patient with extended necrosis underwent reconstruction with dual flaps of sural artery based adipofascial rotation flap and medial gastrocnemius muscular island flap. There were no distinctive complication needing additional procedure in all cases during the long term follow up. Reconstruction of necrosis following total knee replacement arthroplasty had several characteristics different from simple knee defect. The patients might have the history of long term steroid usages, excessive skin tension due to implants, underlying disease such as diabetes, rheumatoid disease, and etc. In addition, the early ambulation is mandatory in these patients of total knee replacement arthroplasty. With regards to these special considerations, a single stage and reliable operation must be needed. The authors introduce various reconstruction methods and algorithm that may aid easy decision making.

Intraoral Reconstruction with Buccinator Myomucosal Flap

Since the buccinator myomucosal flap was first described, it has been modified, with the study of anatomical model. Therefore, buccinator myomucosal flap can be elevated in various direction according to defect with its sufficient arc of rotation. With the buccinator myomucosal flap, intraoral reconstruction was performed in 3 patients. Two adult patients were suffered from complete cleft palete. Partial tongue reconstruction was performed in another patient following partial glossectomy due to tongue cancer. Satisfied results were obtained in all three patients. In these cases, the author designed flaps in island patterns. It would be more helpful to close donor site primarily and obtaining free rotation arc. The pedicle was located in retromolar trigone, flap detachment was not needed. Considering the disadvantages of other reconstruction methods, such as contracture, hair growth and poor oral hygiene caused by skin graft or conventional free flap, the buccinator myomucosal flap would be another good option for intraoral reconstruction with "like tissue".

Two Cases of Rotor Syndrome in Brothers

No abstract available.

The Clinical Consideration for the Acute Subdural Hematoma

Acute subdural hematoma is commonly occurred by severe or minor head injury, which is encountered to neurosurgeons and needed the emergency operation. But the mortality rate of the acute subdural hematoma is still very high(60-90%) in spite of the recently advanced neuroradiology. Neurosurgery and anesthesiology the authors had managed 50 cases of acute subdural hematomas, confirmed surgically, during 24 months from march 1971 to march 1973 and observed clinically. Followings are the results. 1. The male sex was predominantly high in incidence, 6 to 1. the age incidence was high in the 3 rd decade to 5 th decade which is in vigorous social activity. 2. The most common mode of the head injury was the traffic accident in 35 of 50 cases. 15 cases were from other injuries. 3. The level of consciousness of the acute subdural hematoma was various from drowsy consciousness to coma. The lucid interval was developed in 18% of those. 44 cases showed papillary change. 39(88.6%) of these were ipsilateral mydriasis. In 23 of 50 cases had motor disturbance and 78.2% of 23 cases showed contralateral hemiplegia or hemiparesis. The papillary change and hemiplegia were valuable to know the side of hematoma. 4. One of the best diagnostic procedure for the acute subdural hematoma was the angiography. The authors performed the carotid angiography before surgery in all cases. The avascular zone of the angiographic finding was crescentic form in 71.4% of all and the most common site was the parietotemporal region, but rare in the posterior fossa in one case. 5. The mortality rate was 46%. the high mortality was observed in the condition of the old age, persistant coma after surgery, bilateral mydriatic fixed pupil, concomitant profound brain damage and brain swelling. 3 cases of non survival which were in the persistant coma after surgery were died of the complication of severe decubital ulcer, septicemia, pneumonia and cachexia. 6. In 27 survival cases, the hemiplegia, oculomotor palsy, organic dementia and epilepsy were observed as sequelae, which were progressively recovered. 9 of 27 cases were completely recovered to normal social life. But the epilepsy and organic dementia were falt to be the worst sequelae remaining the problem.

The Clinical Observation on the Acute Epidural Hematoma

Acute epidural hematoma is the one which neurosurgeons encounter commonly in severe head injuries and needs emergency operation. But the fact that the mortality of it is still very high(20-50%), is disheartening to all neurosurgeons. In my country, the acute epidural hematoma has been recognized and treated since the 1950th by neurosurgeons. Nevertheless, the report of the collected acute epidural hematoma is rarely seen. The reason is felt that the illness is quite common around us but the mortality is so high to make the report be delayed. The authors have treated 60 cases of surgically confirmed acute epidural hematoma during 24 months from April 1969 to March 1971 and have observed clinically. Following are the results: 1) Sex incidence showed male(50), female(10), and age incidence ranged 2 years of age to 60 yrs. But it was most common in 2nd decade to 4th decade. 2) Most common mode of injury was traffic accident(33 cases) and there were 15 cases of falling down accident and 12 cases of direct batting over the head by blunt materials. 3) There were lucid interval in 13 cases. Most common papillary change was ipsilateral mydriasis(23 cases). Bilateral mydriasis were in 4 cases & other showed miotic or normal pupils. Bilateral positive Babinski's sign were noted in 22 cases and there were 14 cases of unilateral Babinski's sign. 4) Site of hematoma;Most common site of the hematoma was temporoparietal region but there were 8 cases of confined frontal pole and 3 cases of posterior fossa region. In 42 cases of 60, the site of hematoma was confirmed by carotid angiography & on the rest, direct surgery was performed without carotid angiography. 5) Mortality; 47 cases of 60, have survived. The age, level of consciousness, other intracranial associated injuries, time of operation, bilateral positive Babinski's sign, volume of hematoma were felt to be the influencing factors to mortality. In 5 cases of 13 which expired, have died 4 weeks after surgery and the causes of death were pulmonary edema, pneumonia, septicemia, tracheal bleeding & renal shut down. In survivals, hemiplegia, hydrocephalus, oculomotor nerve palsy and mental confusion were observed which improved gradually except 4 cases, & 43 cases of 60 which have survived could remain to return to his usual daily activity.