Implantable drug delivery systems with morphine in fibromyalgia: A case report

The fibromyalgia syndrome (FMS) could be approached by various treatments modalities including education, aerobic exercise, cognitive behavioral therapy, tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, pregabalin, and so on. If other treatments fail, opioids including morphine should be considered. In this case report, we describe the case of a 44-year-old woman who was diagnosed with FMS three years ago, and suffered from severe intractable pain, side effects from other drugs, and opioid tolerance. Administration of morphine via an implantable drug delivery system resulted in significant improvement in the patient's pain intensity, fibromyalgia impact questionnaire score, and sleep disturbance. Our case demonstrates that an implantable drug delivery system with morphine can be a potential treatment option for refractory fibromyalgia patients.

Long-term Results of Stellate Ganglion Block in Patients with Olfactory Dysfunction

BACKGROUND: Olfactory dysfunction, including anosmia and hyposmia is difficult to treat. Although the mechanism is not well known, stellate ganglion block (SGB) is used to treat olfactory dysfunction. There are no prior studies on the long-term effects of SGB on olfactory dysfunction. The purpose of this study was to evaluate the continuity of therapeutic effects and patient satisfaction with SGB treatment. METHODS: This was a follow-up study carried out via a telephonic survey. The olfactory function of the patient was evaluated using a visual analog scale (VAS). We checked VAS three times: VAS-I (pre-treatment VAS), VAS-A (post-treatment VAS), and VAS-C (VAS at follow up telephone survey). We divided the subjects into 2 groups according to their responsiveness to SGB: the responsive (R group) and the unresponsive groups (UR group). Patient satisfaction was evaluated using a Likert scale. RESULTS: Out of the 40 subjects, 37 responded to the telephone survey. In the UR group, there was difference in the olfactory function. However, in the R group, there were significant VAS differences; VAS-I was 9.6 +/- 0.7, VAS-A was 5.1 +/- 4.2, and VAS-C was 2.7 +/- 2.7 (P < 0.05). On the Likert scale, patient satisfaction was as follows: grade 1, 17 patients (45.9%); grade 2, 6 patients (16.2%); grade 3, 6 patients (16.2%); and grade 4, 8 patients (21.6%). CONCLUSIONS: SGB is a safe, long-lasting, and effective therapeutic modality for olfactory dysfunction treatment.

Amnesia and Pain Relief after Cardiopulmonary Resuscitation in a Cancer Pain Patient: A Case Report

The mechanism of chronic pain is very complicated. Memory, pain, and opioid dependence appear to share common mechanism, including synaptic plasticity, and anatomical structures. A 48-yr-old woman with severe pain caused by bone metastasis of breast cancer received epidural block. After local anesthetics were injected, she had a seizure and then went into cardiac arrest. Following cardiopulmonary resuscitation, her cardiac rhythm returned to normal, but her memory had disappeared. Also, her excruciating pain and opioid dependence had disappeared. This complication, although uncommon, gives us a lot to think about a role of memory for chronic pain and opioid dependence.

Post-traumatic Back Pain Revealed as Tuberculous Spondylitis: A Case Report

Tuberculous spondylitis is a very rare disease, but it can result in bone destruction, kyphotic deformity, spinal instability, and neurologic complications unless early diagnosis and proper management are done. Because the most common symptom of tuberculous spondylitis is back pain, it can often be misdiagnosed. Atypical tuberculous spondylitis can be presented as a metastatic cancer or a primary vertebral tumor. We must make a differential diagnosis through adequate biopsy. A 30-year-old man visited our clinic due to back and chest pain after a recent traffic accident. About 1 year ago, he had successfully recovered from tuberculous pleurisy after taking anti-tuberculosis medication. We performed epidural and intercostal blocks but the pain was not relieved. For the further evaluation, several imaging and laboratory tests were done. Finally, we confirmed tuberculous spondylitis diagnosis with the biopsy results.

Post-radiation Piriformis Syndrome in a Cervical Cancer Patient: A Case Report

The piriformis syndrome is a condition allegedly attributable to compression of the sciatic nerve by the piriformis muscle. Recently, magnetic resonance neurography and electrophysiologic study have helped to diagnose piriformis syndrome. High dose radiotherapy could induce acute and delayed muscle damage. We had experienced piriformis syndrome with fatty atrophy of piriformis muscle after radiotherapy for recurrent cervical cancer.

Experience of Epidural Steroids in Transverse Myelitis : A case report

Transverse myelitis is a focal inflammatory disorder of the spinal cord characterized by motor, sensory, and autonomic dysfunction. A 41-year-old man with transverse myelitis and no pre-existing neurologic disease presented with hypesthesia, numbness, weakness in the both lower extremities, back pain, decreased libido, constipation, and dysuria. A MRI test showed intramedullary high signal intensity between T4 and T8 on a T2-weighted image. After high-dose intravenous methylprednisolone and oral prednisolone therapy, he showed facial swelling and acneiform eruption. Therefore, we injected 40 mg methylprednisolone via an epidural route. A 7-dose serial treatment improved most symptoms. A follow up MRI showed radiological improvement. We report a case of transverse myelitis treated by epidural steroids.

The Effect of Thalidomide on Entero-Behcet's Disease

Behcet's disease is a chronic relapsing vasculitis characterized by recurrent aphthous oral and genital ulcers with uveitis. Multiple organs can be involved. Entero-Behcet's disease is often uncontrollable, relapsing, and can cause acute intestinal bleeding, fistula formation, or perforation. Corticosteroids, immunosuppressors, and colchicines are used to treat Entero-Behcet's disease with varying degree of success. Thalidomide may also be feasible. We present a 29-year-old male Entero-Behcet's patient suffering from abdominal pain, diarrhea, and back pain. He did not respond to prior treatments, but responded to thalidomide.

Relapsing Polychondritis with Subglottic Stenosis Diagnosed after Tonsillectomy: A case report / 대한마취과학회지

Relapsing polychondritis (RP) is a rare autoimmune connective tissue disease of unclear pathogenesis and may present with the multisystem involvements and varied presentations, courses and responses to the therapy. The respiratory complaints or history such as dyspnea or snoring deserve to be in consideration, especially in the cases of no specific causes and must be ruled out the rare autoimmune airway diseases such as relapsing polychondritis, Wegener's granulomatosis, rhinoscleroma, or amyloidosis resulting in serious airway obstruction without adequate management. In this report we described a case of 15-year-old young male with the delayed diagnosis of relapsing polychondritis with intractable subglottic stenosis during the course of the management for several months despite of tonsillectomy for the relief of the airway obstruction.

The Efficacy of Stellate Ganglion Block in Sensorineural Anosmia Patients Unresponsive to Steroid Therapy / 대한통증학회지

BACKGROUND: Anosmia can be frustrating for both the patient and physician, with no clear treatment. We prospectively investigated the effects of stellate ganglion block (SGB) in anosmic patients who were unresponsive to conventional steroid therapy. METHODS: Thirteen patients with anosmia were treated with SGB. To evaluate the improvement in olfactory function, we evaluated both changes in subjective symptoms and the butanol threshold test. The number of SGB required for improvement in olfactory function was counted. RESULTS: Seven patients (54%) showed improvement of olfactory function with SGB. The average number of SGB for the first response was 7.4 +/- 5.9 times. CONCLUSIONS: These results suggest that SGB may be a good treatment modality for patients with anosmia unresponsive to steroid therapy.

High-intensity Focused Ultrasound Treatment (HIFU) for the Advanced Pancreatic Cancer

PURPOSE: We wanted to evaluate the levels of effect and safety of high-intensity focused ultrasound ablation (HIFU) for treating patients with advanced pancreatic cancer. MATERIALS AND METHODS: Nineteen sessions of HIFU, with the patients under general anesthesia, were performed in 18 patients with advanced pancreatic cancer. The change of the gray-scale of the target lesion was analyzed during HIFU, and MRI was performed before and after HIFU. We assessed the extent of coagulative necrosis, the change of pain and the complications after HIFU. The change of tumor size and the survival of patients were also evaluated. RESULTS: The average size of tumor was 4 cm in diameter. Eighty nine percent of the target tumors showed increased echogenicity. On MRI, necrosis of the entire target tumor occurred in 79% of the patients. After treatment, effective pain relief was noted in 89% of the patients. There were no major complications. No size increase of the treated tumor was noted during 24 weeks of follow-up for 10 patients. Six patients among 12 patients who were available for follow-up are still alive and they are receiving chemotherapy. Six patients expired due to other disease or progression of metastasis. CONCLUSION: HIFU is a safe method without any major complications, and it is effective for inducing tumor necrosis and achieving pain control for patients with advanced pancreatic cancer.

Positive Effects of Local Anesthetic Nerve Blocks for a Patient with Newly Developed Left Side Spasmodic Torticollis after Surgical Intervention of Right Side Spasmodic Torticollis: A case report / 대한통증학회지

We report here on a case of right side spasmodic torticollis (ST) that was refractory to botulinum toxin type A injection and medication.The patient finally underwent a selective ramisectomy with ipsilateral sternocleidomastoid muscle (SCM) resection, but the remaining symptoms slowly aggravated, and a contralateral left side SCM spasm began.As conservative therapy for reducing the spasmodic symptoms, accessory nerve block, upper cervical plexus block and stellate ganglion block were performed twice in a week.After 6 months, the spasmodic symptoms significantly decreased. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) decreased by more than 70%.After one year of serial intermittent local anesthetic blockade therapy, the patient became almost free from the original ST symptoms (TWSTRS = 1).Serial local anesthetic interventions for the ST patient may have a beneficial role on the pathological peripherocentral neural activity of the ST patient and can modulate motor-sensory integration in the patient.

Clinical Course of Hypoxic-ischemic Coma after Cardiopulmonary Resuscitation in Korea

PURPOSE: This study analyzed the survival and the recovery of consciousness in hypoxic-ischemic coma at different time points till 30 days after cardiopulmonary resuscitation (CPR). METHODS: A survival analysis was done using Kaplan-Meier estimates, and 30-day outcomes were calculated for all unconscious patients at 24 h, 72 h, 5 days, 7 days, and 14 days after CPR. The patient's characteristics and outcomes were compared with those for published patient series. RESULTS: After 30 days, 32.4% of 74 patients were alive and conscious, 16.2% were still unconscious, and 51.4% had died. The proportions of patients who regained conscious were 32.4% of those unconscious within 6 h post CPR, 34.7% of those still unconscious after 72 h, and 21.1% of those still unconscious after 2 weeks. The proportion surviving increased from 16.2% of patients who were unconscious initially to 63.1% of those still unconscious after 2 weeks. CONCLUSION: The outcomes of hypoxic-ischemic coma vary with the duration of unconsciousness after CPR.

The Effect of Blood Transfusion on the Tissue Perfusion and Lung Injury during Cardiopulmonary Bypass / 대한구급학회지

BACKGROUND: The blood components of priming solution for cardiopulmonary bypass (CPB) may have opposite roles for tissue perfusion, which are the activation of inflammatory reaction and the improvement of oxygen carrying capacity. This study is aimed to investigate the effect of blood transfusion of priming solution on inflammatory response and tissue perfusion. METHODS: Twenty mongrel dogs randomly allocated and received hypothermic CPB with blood- containing (H group, n=10), or non-hemic (NH group, n=10) priming solution. Gastric intramucosal CO2 concentration (PrCO2), intramucosal pH (pHi), interleukin-8 (IL-8), blood gas and hemodynamic parameters were measured at 1) before CPB, 2) 1 hour during CPB, 3) the end of CPB, 4) 2 hours after CPB, 5) 4 hours after CPB. The ratio of wet to dried lung weight was measured. Statistical verification was performed using repeated measures ANOVA and unpaired t-test. RESULTS: PrCO2 increased and pHi decreased during the study without significant difference between the groups. IL-8 increased in both groups and IL-8 of H group increased higher than that of NH group during the study. The difference between PaCO2 and end-tidal CO2 of NH group was higher than that of H group at 4 hours after CPB. The ratio of wet to dried lung weight was not significantly different between the groups. CONCLUSIONS: We conclude that the allogenic blood in priming solution aggravates the CPB- induced inflammatory reaction, however, the CPB-induced impairment of gastric mucosal perfusion and the pulmonary edema are not significantly affected, compared to non-hemic solution.

Prediction of Poor Outcome in Comatose Survivors after Cardiopulmonary Resuscitation with Somatosensory Evoked Potentials and Proton Magnetic Resonance Spectroscopy

PURPOSE: The study was conducted to examine the usefulness of somatosensory evoked potentials (SEP) and proton magnetic resonance spectroscopy (1H-MRS) in predicting poor outcomes for comatose survivors after cardiopulmonary resuscitation. METHODS: We investigated 36 patients who were comatose after cardiac arrest. Among them, 35 had short latency SEP, and 27 had 1H-MRS. Both tests were performed in 26 patients. To estimate the cerebral outcome, we used the cerebral performance category (CPC) to classify the outcomes for our patients as good (CPC 1-2) or poor (CPC 3-5). RESULTS: Of the 36 patients, 11(31%) presented with good outcomes (CPC 1-2). A bilaterally absent N20 peak (n=35) predicted poor outcomes with a sensitivity of 54.2% and a specificity of 100%. A lactate-positive resonance (n=27) predicted poor outcomes with a sensitivity of 78.9% and a specificity of 100%. Using a combination of a bilaterally absent N20 peak and a lactate-positive resonance (n=26) predicted poor outcomes with a sensitivity of 94.4% and a specificity of 100%. CONCLUSION: The combination of a bilaterally absent N20 peak and a lactate-positive resonance is better than either alone in predicting poor outcomes in patients who are comatose after cardiac arrest.

Effect of Epidural Ketamine Combined with Bupivacaine and Meperidine on Postoperative Pain and Analgesic Consumption after Cesarean Section / 대한마취과학회지

BACKGROUND: Ketamine is a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist with analgesic properties. This study was undertaken to evaluate the potential utility of epidural ketamine combined with meperidine and bupivacaine for postoperative patient-controlled epidural analgesia (PCEA) after cesarean section. METHODS: Forty-five patients received epidural catheterization in the L3-4 intervetebral space and underwent cesarean section under epidural anesthesia. In the recovery room, these patients were randomly allocated to 3 groups; group I (control; n = 15) received 1 mg/ml bupivacaine and 1 mg/ml meperidine, group II (n = 15) received 1 mg/ml bupivacaine and 1 mg/ml meperidine with 0.25 mg/ml ketamine, group III (n = 14) received 1 mg/ml bupivacaine and 1 mg/ml meperidine with 0.75 mg/ml ketamine using a PCEA device for postoperative pain control. The analgesic effects and PCEA consumption were assessed at 6, and 24 hours after surgery. Side effects were also evaluated. RESULTS: There were no statistically significant differences in the visual analogue scale for pain, the consumption of the analgesics and side effects among the groups. CONCLUSIONS: Epidural ketamine combined with bupivacaine and meperidine did not improve postoperative analgesia, nor did it reduce consumption of the analgesics and side effects.

The Effect of Acute Hypervolemic Hemodilution on Blood Loss and Mononuclear Cell Counts during Bone Marrow Harvesting / 대한마취과학회지

BACKGROUND: Hypervolemic hemodilution (HHD) seems to be a good alternative to acute normovolemic hemodilution to reduce transfusion requirements because it requires less time and effort. In a prospective study in healthy donors, we studied the effects of HHD on blood loss and mononuclear cell counts of aspirated bone marrow which were transplanted. METHODS: After induction of anesthesia and positioning to prone, donors of the HHD group (n = 25) were administered 7.5 ml/kg of pentastarch and the same amount of Hartmann's solution prior to aspiration, but those of the control group (n = 25) were administered only 2 ml/kg/h of Hartmann's solution. Bone marrow was aspirated at the iliac spine and blood loss was replaced with pentastarch and Hartmann's solution for both groups. Hemoglobins and hematocrits were counted after induction, after hemodilution and the end of aspiration. Hemoglobins and mononuclear cell counts of aspirated bone marrow were also counted. RESULTS: HHD decreased hemoglobin from 13.2 +/- 1.1 g/dl to 10.7 +/- 1.0 g/dl significantly (P < 0.01). Even though hemoglobins of both groups at the end of aspiration were not different (9.3 +/- 2.3 g/dl at control vs 9.5 +/- 1.1 g/dl at HHD), calculated blood loss based on body weight through aspirated bone marrow was less in the HHD group (18.0 +/- 1.8% at control vs 16.3 2.0% at HHD, P < 0.05). There was no difference in counted mononuclear cell counts between the two groups (1.8 +/- 0.7 x 10(7)/ml at control vs 1.8 +/- 0.7 x 10(7)/ml at HHD). CONCLUSIONS: During bone marrow harvesting in healthy donors, HHD reduced blood loss through aspirated bone marrow, but does not affect transplanted bone marrow mononuclear cell counts.

L2-3 versus T12-L1 Administration of Meperidine and Bupivacaine Using Patient-Controlled Epidural Analgesia after Obstetric and Gynecologic Surgery / 대한마취과학회지

BACKGROUND: A combined administration of epidural opioid and local anesthetic using patient- controlled epidural analgesia (PCEA) produces effective postoperative analgesia, but often causes profound motor and sensory blockade. The purpose of this study is to investigate the effect the location of the catheter insertion site has on total dose requirements and troublesome side effects including motor and sensory blockade after surgery. METHODS: 140 patients who had undergone obstetric and gynecologic surgery were randomly assigned to receive either L2-3 (Group L2-3) or T12-L1 (Group T12-L1) epidural catheter. All patients received meperidine and bupivacaine by PCEA. Patients were assessed with respect to total dose requirements, visual analogue scores and side effects. RESULTS: Total dose requirements, motor and sensory blocks were significantly lower in group T12-L1 compared with group L2-3. There were no significant differences in VAS, pruritus, nausea/vomiting, or patient's satisfaction. CONCLUSIONS: When the epidural placement level is closer to the dermatomes of the surgical incision in lower abdominal surgery, the total dose requirements can be reduced, and motor blocks that interfere with early ambulation and sensory block can also be reduced.

Anesthetic Management during Laparoscopic Splenectomy in a Third Trimester Pregnant Patient with Idiopathic Thrombocytopenic Purpura / 대한마취과학회지

Anesthetic management during a laparoscopic splenectomy in a third trimester pregnant patient with idiopathic thrombocytopenic purpura (ITP) is critical because of the possibility of massive intra- and postoperative bleeding either maternal, fetal, or both. Laparoscopic surgery may be beneficial in pregnant patients compared to open laparotomy, but the safety of laparoscopic operations in pregnant women is under investigation. Pregnancy, especially in the third trimester, has been considered a contraindication of a laparoscopic procedure because the effect of CO2 pneumoperitoneum on the fetus and uterine blood flow is unclear. However, the benefits of laparoscopic surgery such as less stress response and a shorter hospital stay are postulated. The careful anesthetic management and close hemodynamic monitoring of patient and fetus will be helpful in making laparoscopic surgery safer in pregnant patients. We report on the anesthetic management during a laparoscopic splenectomy in a third trimester pregnant patient with ITP. We monitored the intestinal mucosal CO2 using Tonocap because we considered it could sensitively represent the uterine perfusion and intestinal CO2 status, and we also monitored the noninvasive cardiac output by using NICO . Although the arterial and intestinal mucosal CO2 tension, PrCO2 and CO2 gap increased gradually during the operation, hypercapnia was not remarkable. Tonocap represented the earliest changes which made us control intraabdominal gas inflation pressure by detecting fluctuations of CO2 gap and pHi even though other respiratory and monitored hemodynamic parameterswere quite stable during the procedure in this case. The patient was maintained well postoperatively and discharged with an improved condition. She had preterm labor at 36 weeks and 4 days of eventful gestation, but safely delivered a healthy baby by a normal spontaneous method.

Effect of Cervical Sympathectomy on Ischemic Brain Damage Induced by Focal Cerebral Infarction in Rats / 대한마취과학회지

BACKGROUND: Recently Umeyama et al. reported that cerebral blood flow is definitely increased on the ipsilateral side after the blockade of stellate ganglion. Considering that the most obvious solution to the problem of poor cerebral blood flow is to augment the flow, cervical sympathectomy may reduce the volume and extent of the brain damage by increasing the cerebral blood flow. We studied the effects of cervical sympathectomy on ischemic brain damage in a middle cerebral artery occlusion model in rats. METHOD: The experimental animals were divided into three groups. In the sham-operated control group (n=7), middle cerebral artery was occluded without cervical sympathectomy. In the experimental group I (n=7), cervical sympathectomy was performed 5 minutes before middle cerebral artery occlusion. In the experimental group II (n=7), cervical sympathectomy was performed 5 minutes after middle cerebral artery occlusion. The neurological grade of each experimental animal was evaluated at 24 hours post occlusion and then the animals were sacrificed. The brain was cut into coronal sections. The volume of infarct was computed and the edema volume was calculated. RESULTS: 1. There were no differences in the physiological variables in all groups. 2. Cervical sympathectomy, compared with the controls, significantly reduced the volume of infarct (P<0.05). 3. There was no significant difference in ischemic brain edema between each group. 4. The neurologic deficit was less severe in sympathectomized groups compared with the control group (P<0.05). And neurological grades were significantly correlated with the volume of infarction (P<0.05). CONCLUSION: These results suggest that cervical sympathectomy may improve the neurologocal deficit and reduce the infarct volume measured 24 hours following induction of focal cerebral infarction.

Midazolam Compared with Thiopental as an Induction Agent / 대한마취과학회지

This study was performed to evaluate the induction time, hemodynamic responses and local venous complications after intravenous induction with midazolam, comparing with those after intravenous induction with thiopental. Sixty adult surgical patients received either 5 mg/kg thiopental sodium(group I) or 0.2 mg/kg midazolam hydrochloride(group II) as an induction agent. The results were as follows. 1) The induction time(loss of palpebral reflex) of the group II(68.2+/-21.5 sec) was significantly longer than those of group I(29.6+/-8.3 sec) 2) The magnitude of rises in the systolic blood pressure, 1 and 2 minute after intravenous administration of induction agent, of group II were significantly smaller than those of group I. 3) The magnitude of rises in the diastolic blood pressure, 2 minute after intravenous administration of induction agent,of group II were significantly smaller than those of group L 4) The magnitude of rises in the pulse rate, 1 and 2 minute after intravenous administration of induction agent, of group II was not significantly differ from those of group I. 5) In three patients of the group I complained of pain during injection, but no patients of the group II complained of pain. There was no significant difference in the incidence of the postoperative local venous complication.