A Study on the Usefulness of Postmortem Diabetes Mellitus-Related Tests / 대한법의학회지

Diabetes mellitus (DM) is a group of metabolic disorders, that have become a major cause of death worldwide. This study aimed to determine the usefulness of diabetes-related laboratory tests for diagnosis of postmortem DM. From March to August 2018, among the autopsy cases investigated by the National Forensic Service, heart blood and vitreous humor samples from 253 cases that had not been decomposed were collected, and the data from 208 cases except 45 cases that were incapable of testing were analyzed for statistical significance and compared with the causes of death on autopsy reports. The levels of C-peptide, insulin, acetoacetate, β-hydroxybutyrate (β-HA), total ketone, and HbA1c were measured in the heart blood, and the levels of glucose, blood urea nitrogen, creatinine, and potassium were measured in the vitreous humor. The levels of glucose in the vitreous humor and HbA1c, β-HA, and total ketone in the heart blood were significantly correlated. C-peptide and insulin levels were lower than normal levels in most cases (C-peptide 92.3%, P=0.480, insulin 97.6%, P=0.589), and were not useful measures indicating diabetic complications. In the group with DM history, the average levels of HbA1c from the heart blood and glucose from the vitreous humor were higher than in those with no or unknown history of DM, indicating their usefulness as diagnostic tools. The results of this study suggest a postmortem DM diagnosis model.Therefore, postmortem DM-related tests can help diagnose the cause of death in forensic medicine.

Effect of fermented soybean products intake on the overall immune safety and function in mice

Various functional activities have been reported for the fermented soybean products doenjang (DJ) and cheonggukjang (CGJ), although no systemic investigations of their immune functions have been conducted to date. We examined the effects of an experimental diet of DJ, CGJ, or a mixture of unfermented raw material for 4 weeks on overall immunity and immune safety in mice. No significant alterations were observed in peripheral or splenic immune cells among groups. Enhanced splenic natural killer cell activity was observed in the DJ and CGJ groups compared with the plain diet group. T helper type-1 (Th1)-mediated immune responses were enhanced in the DJ and CGJ groups with an upregulated production ratio of IFN-γ vs. IL-4 and IgG2a vs. IgG1 in stimulated splenic T and B cells, respectively. Resistance to Listeria monocytogenes infection was observed in the DJ and CGJ groups. Overall, the results of this study suggest that DJ and CGJ intake consolidates humoral and cellular immunity to Th1 responses.

Current clinical application of dexmedetomidine for sedation and anesthesia

Many sedatives are used clinically and include benzodiazepines, barbiturates, antihistamines, propofol, and alpha-2-agonist. Benzodiazepines activate GABA neuronal receptors in the brain and present sedating, hypnotic, anxiolytic, amnestic, and anticonvulsant effects, but low analgesic effects. Propofol induce sedative, anxiolytic, and amnestic effects but no analgesic effects. However, risks such as cardiopulmonary instability and hypotension must be considered during administration. Dexmedetomidine is a high selective alpha-2 agonist and has many advantages as a sedative. Patients under dexmedetomidine sedation awaken easily and are more likely to be cooperative. Risk of respiratory depression and cardiopulmonary instability is low as well. Additionally, dexmedetomidine decreases amount of analgesic needed during and after surgery, presenting analgesic effects. Dexmedetomidine also decreases risk of delirium. However, bradycardia may occur and biphasic effects on blood pressure may be observed during beginning of administration. Because of lengthy symptom onset and offset time, physicians should carefully control administration at the beginning and end of dexmedetomidine administration. The purpose of this review is to evaluate the efficacy and availability of dexmedetomidine in various clinical fields including sedation for critically ill patients, regional anesthesia, monitored anesthesia care for some invasive procedures, stabilization of heart in cardiac surgery or endoscopic procedures.

Current clinical application of dexmedetomidine for sedation and anesthesia

Many sedatives are used clinically and include benzodiazepines, barbiturates, antihistamines, propofol, and alpha-2-agonist. Benzodiazepines activate GABA neuronal receptors in the brain and present sedating, hypnotic, anxiolytic, amnestic, and anticonvulsant effects, but low analgesic effects. Propofol induce sedative, anxiolytic, and amnestic effects but no analgesic effects. However, risks such as cardiopulmonary instability and hypotension must be considered during administration. Dexmedetomidine is a high selective alpha-2 agonist and has many advantages as a sedative. Patients under dexmedetomidine sedation awaken easily and are more likely to be cooperative. Risk of respiratory depression and cardiopulmonary instability is low as well. Additionally, dexmedetomidine decreases amount of analgesic needed during and after surgery, presenting analgesic effects. Dexmedetomidine also decreases risk of delirium. However, bradycardia may occur and biphasic effects on blood pressure may be observed during beginning of administration. Because of lengthy symptom onset and offset time, physicians should carefully control administration at the beginning and end of dexmedetomidine administration. The purpose of this review is to evaluate the efficacy and availability of dexmedetomidine in various clinical fields including sedation for critically ill patients, regional anesthesia, monitored anesthesia care for some invasive procedures, stabilization of heart in cardiac surgery or endoscopic procedures.

Predicting the optimal minimal cuff volume of the laryngeal mask airway from physical examination parameters

BACKGROUND: Head and neck anatomy affects the laryngeal mask airway (LMA) cuff volume. The purpose of this study was to identify physical parameters that can be standardized to predict LMA cuff volume and measure the optimal and minimal LMA cuff volume in adults. METHODS: The predictors of volume or pressure of the LMA cuff were investigated in 167 patients. Manufacturers recommend a maximal cuff pressure (MCP) (i.e., 40 ml for size 5, 30 ml for size 4), an optimal cuff volume (OCV) at a cuff pressure of 60 cmH2O, and a minimal cuff volume (MCV) just before audible air leakage. The physical parameters measured included height, weight, body mass index, modified Mallampati classification (MMP), neck circumference, neck length, and thyro-mental distance. Data were analyzed by stepwise multilinear analysis. RESULTS: The regression equations (REs) were as follows: OCV (1.2 + [0.1 × height] + [0.5 × neck length]); MCV for men (−35.7 + [0.25 × height] + [0.7 × neck length] − [4.1 × MMP]); and MCV for women (−42.5 + [0.27 × height] + [0.75 × neck length] − [2.5 × MMP]). The mean values were as follows: MCP > 200 cmH2O, minimal cuff pressure < 20 cmH2O, OCV of 24.7 ml for men and 15.9 ml for women, and MCV of 12.1 ml for men and 7.1 ml for women. CONCLUSIONS: LMA cuff volume is estimated from the patient's height, neck length, and MMP. The RE for calculating the MCV shows a high correlation with height, neck length, and MMP.

Predicting the optimal minimal cuff volume of the laryngeal mask airway from physical examination parameters

BACKGROUND: Head and neck anatomy affects the laryngeal mask airway (LMA) cuff volume. The purpose of this study was to identify physical parameters that can be standardized to predict LMA cuff volume and measure the optimal and minimal LMA cuff volume in adults. METHODS: The predictors of volume or pressure of the LMA cuff were investigated in 167 patients. Manufacturers recommend a maximal cuff pressure (MCP) (i.e., 40 ml for size 5, 30 ml for size 4), an optimal cuff volume (OCV) at a cuff pressure of 60 cmH2O, and a minimal cuff volume (MCV) just before audible air leakage. The physical parameters measured included height, weight, body mass index, modified Mallampati classification (MMP), neck circumference, neck length, and thyro-mental distance. Data were analyzed by stepwise multilinear analysis. RESULTS: The regression equations (REs) were as follows: OCV (1.2 + [0.1 × height] + [0.5 × neck length]); MCV for men (−35.7 + [0.25 × height] + [0.7 × neck length] − [4.1 × MMP]); and MCV for women (−42.5 + [0.27 × height] + [0.75 × neck length] − [2.5 × MMP]). The mean values were as follows: MCP > 200 cmH2O, minimal cuff pressure < 20 cmH2O, OCV of 24.7 ml for men and 15.9 ml for women, and MCV of 12.1 ml for men and 7.1 ml for women. CONCLUSIONS: LMA cuff volume is estimated from the patient's height, neck length, and MMP. The RE for calculating the MCV shows a high correlation with height, neck length, and MMP.

Postoperative respiratory difficulty due to asymptomatic anterior cervical osteophyte after brain tumor surgery: a case report / 대한마취과학회지

Anterior cervical osteophytes are commonly found in elderly patients, but rarely produce symptoms. When symptoms occur, they can range from mild symptoms of dysphagia, dysphonia, and foreign body sensation to severe symptoms of airway obstruction due to compression of the pharynx or larynx. We report the case of a 59-year-old man who underwent brain tumor surgery, and developed post-operative respiratory difficulty due to progressive pharyngo-laryngeal edema, requiring urgent endotracheal intubation, secondary to the presence of a previously asymptomatic anterior cervical osteophyte. It is paramount to recognize that asymptomatic anterior cervical osteophytes are a potential cause of life-threatening post-operative respiratory complications that can rapidly progress to life-threatening airway obstruction after surgeries in the prone position, especially in elderly patients.

Easy airway management using the i-gel(TM) supraglottic airway in a patient with Treacher Collins syndrome / 대한마취과학회지

No abstract available.

Preanesthetic dexmedetomidine 1 microg/kg single infusion is a simple, easy, and economic adjuvant for general anesthesia / 대한마취과학회지

BACKGROUND: Dexmedetomidine is an alpha2-adrenoreceptor agonist with sedative, analgesic and anxiolytic effects, and it has more selective alpha2-adrenergic effect than clonidine. We evaluate the effect of preansethetic dexmedetomidine 1 microg/kg single infusion on sedation, hemodynamics, anesthetic consumption, and recovery profiles during anesthesia. METHODS: Forty-two female patients with American Society of Anesthesiologists physical status I or II undergoing gynecologic surgery with anticipated operation time of 2 h, were randomly assigned to receive dexmedetomidine 1 microg/kg (Dex group) or saline (control group) iv over 10 min before anesthetic induction. After tracheal intubation with propofol 2 mg/kg, cisatracurium 0.15 mg/kg iv, anesthesia was maintained with sevoflurane, O2 50%, N2O 50% around a BIS value of 40. RESULTS: After study drug infusion, BIS of Dex group was lower than that of control group (93.9 +/- 3.1 vs 51.5 +/- 5.2, P < 0.05). Mean arterial pressure (MAP) and heart rate (HR) after intubation were increased in control group, but did not change in Dex group. During maintenance, there was no difference in MAP between groups, but HR of Dex group was lower compared to that of control group. End-tidal concentration (2.0 +/- 0.5 vol% vs 1.4 +/- 0.3 vol%, P < 0.05) and total cumulative consumption of sevoflurane (34.6 +/- 3.8 ml vs 26.5 +/- 5.3 ml, P < 0.05) were lower in Dex group than in control group. Recovery profiles, modified Aldrete score, postoperative nausea vomiting, and visual analogue pain score were not significantly different between groups. CONCLUSIONS: Preanesthetic dexmetomidine 1 microg/kg single infusion is a simple, easy, and economic general anesthetic adjuvant that maintains stable hemodynamics and decrease anesthetic consumption without the change of recovery profiles.

Interruption of fresh gas supply without alarm signs by the partial disconnection of fresh gas outlet during general anesthesia: A case report

We report our experience of unexpected low expiratory concentration of sevoflurane 0.8 vol%, low inspired fraction of oxygen 31%, and high value of bispctral index (BIS) 62 with sevoflurlane vaporizer setting 2.0 vol% and the inspired fraction of oxygen 50% during general anesthesia of a 56-year-old man undergoing elective laparoscopic hemicolectomy. The anesthesia machine (Cato edition, Drager, Lubeck, Germany) with a piston-based, electronically controlled ventilator was used for anesthesia. We checked thoroughly all the possible causes of the discrepancy of anesthetic gas concentration, and then detected the partial disconnection of fresh gas outlet. But there were no alarm signs of anesthetic monitor with adequate ventilator function. This malfunction of anesthetic gas supply without alarm signs may lead to hypoxia and awareness of patients. The intraoperative monitoring of anesthetic gas analyzer and BIS may be essential to detect the malfunction of anesthesia machine.

Interruption of fresh gas supply without alarm signs by the partial disconnection of fresh gas outlet during general anesthesia: A case report

We report our experience of unexpected low expiratory concentration of sevoflurane 0.8 vol%, low inspired fraction of oxygen 31%, and high value of bispctral index (BIS) 62 with sevoflurlane vaporizer setting 2.0 vol% and the inspired fraction of oxygen 50% during general anesthesia of a 56-year-old man undergoing elective laparoscopic hemicolectomy. The anesthesia machine (Cato edition, Drager, Lubeck, Germany) with a piston-based, electronically controlled ventilator was used for anesthesia. We checked thoroughly all the possible causes of the discrepancy of anesthetic gas concentration, and then detected the partial disconnection of fresh gas outlet. But there were no alarm signs of anesthetic monitor with adequate ventilator function. This malfunction of anesthetic gas supply without alarm signs may lead to hypoxia and awareness of patients. The intraoperative monitoring of anesthetic gas analyzer and BIS may be essential to detect the malfunction of anesthesia machine.

Association of Hyperlactatemia and IL-6 Hypercytokinemia after Cardiopulmonary Bypass: A Preliminary Report / 대한구급학회지

BACKGROUND: In cardiac surgery with cardiopulmonary bypass (CPB), hyperlactatemia (HL) is common and is associated with postoperative morbidity and mortality. At present, the cause of HL during CPB is proposed to be tissue hypoxia. Tissue perfusion and oxygen delivery can be impaired to varying degrees during CPB. Although surgery involving CPB apparatus is associated with increased pro-inflammatory mediators, such as TNF-alpha and IL-6, tissue hypoxia that occurs during CPB may be an additionally potent stimulus to inflammation. We hypothesized that hypoxic patients during CPB that experience elevated serum lactate levels, may be related to higher serum cytokine level after CPB than normoxic patients during CPB with normal serum lactate levels. METHODS: Levels of TNF-alpha and IL-6 were measured by ELISA in a) Time 1; before initiation of CPB, b) Time 2; 30 min after aortic de-clamping, c) Time 3; 24 hrs after aortic de-clamping. Levels of lactate was measured at a) Time A; before initiation of CPB, b) Time B; 30 min after aortic de-clamping. Postoperative ICU stay, intubation time and oxygen index were evaluated as postoperative morbidity scale. RESULTS: There were no statistical differences between HL (n = 43, lactate > or =3 mMol/L at time B) and normal lactate group (NL) (n = 63, lactate <3 mMol/L at time B) in demographic data, preoperative left ventricular ejection fraction, CPB time, and aortic cross-clamp time. Level of IL-6 in HL at time 3 was higher than that of NL. The ICU stay and intubation time were longer in HL. The oxygen index on 1st postoperative day was lower in HL. CONCLUSIONS: Our results suggest that hyperlactatemia after weaning from CPB may be related to IL-6 hypercytokinemia, and therefore related to postoperative morbidity.

Pleural effusion after microtia reconstructive surgery: A case report / 대한마취과학회지

Microtia reconstructive surgery is usually a multi-stage repair procedure that involves the use of cartilage and skin grafts. Complications can arise at both ear reconstruction sites and cartilage donor sites. In particular, pneumothorax, atelectasis, chest scars, and chest deformities are known to be associated with the harvesting of costal cartilage. However, delayed pleural effusion can also develop. Our patient complained of a cough and chest pain at 5 days postoperatively, and pleural effusion was detected by chest radiography. However, thoracentesis was not performed and the effusion resolved spontaneously and completely.

Feasibility of ultrasound-guided posterior approach for interscalene catheter placement during arthroscopic shoulder surgery / 대한마취과학회지

BACKGROUND: Continuous interscalene block has been known to improve postoperative analgesia after arthroscopic shoulder surgery. This was a prospective study investigating the ultrasound-guided posterior approach for placement of an interscalene catheter, clinical efficacy and complications after placement of the catheter. METHODS: Forty-two patients undergoing elective arthroscopic shoulder surgery were included in this study and an interscalene catheter was inserted under the guidance of ultrasound with posterior approach. With the inplane approach, the 17 G Tuohy needle was advanced until the tip was placed between the C5 and C6 nerve roots. After a bolus injection of 20 ml of 0.2% ropivacaine, a catheter was threaded and secured. A continuous infusion of ropivacaine 0.2% 4 ml/hr with patient-controlled 5 ml boluses every hour was used over 2 days. Difficulties in placement of the catheter, clinical efficacy of analgesia and complications were recorded. All patients were monitored for 48 hours and examined by the surgeon for complications within 2 weeks of hospital discharge. RESULTS: Easy placement of the catheter was achieved in 100% of the patients and the success rate of catheter placement during the 48 hr period was 92.9%. Postoperative analgesia was effective in 88.1% of the patients in the post anesthetic care unit. The major complications included nausea (7.1%), vomiting (4.8%), dyspnea (4.8%) and unintended vascular punctures (2.4%). Other complications such as neurologic deficits and local infection around the puncture site did not occur. CONCLUSIONS: The ultrasound-guided interscalene block with a posterior approach is associated with a success high rate in placement of the interscalene catheter and a low rate of complications. However, the small sample size limits us to draw definite conclusions. Therefore, a well-designed randomized controlled trial is required to confirm our preliminary study.

Differential Expression of Matrix Metalloproteinases and Tissue Inhibitors of Metalloproteinases in Thioacetamide-Induced Chronic Liver Injury

Hepatic fibrogenesis, a complex process that involves a marked accumulation of extracellular matrix components, activation of cells capable of producing matrix materials, cytokine release, and tissue remodeling, is regulated by matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs). The MMP-TIMP balance can regulate liver fibrogenesis. The aim of this study was to evaluate the expression patterns of MMPs and TIMPs during thioacetamide (TAA)-induced liver fibrogenesis. Chronic liver injury was induced with TAA (200 mg/kg i.p.) for 4 or 7 weeks in male Sprague-Dawley rats. Hepatic injury and fibrosis were assessed by hematoxylin-eosin (H&E) staining, and collagen deposition was confirmed by Sirius Red staining. The level of hepatic injury was quantified by serological analysis. The transcriptional and translational levels of alpha-smooth muscle actin (alpha-SMA), MMPs, and TIMPs in the liver were measured by Western blotting, RT-PCR, and immunohistochemistry. MMP, TIMP, and alpha-SMA were observed along fibrotic septa and portal spaces around the lobules. TAA treatment increased transcription of both MMPs and TIMPs, but only TIMPs showed increased translation. The dominant expression of TIMPs may regulate the function of MMPs to maintain liver fibrosis induced by TAA.

Posterior auricular pain caused by the trigger points in the sternocleidomastoid muscle aggravated by psychological factors: A case report / 대한마취과학회지

Psychological factors play a significant role in the pain mechanism, and psychological approaches may be useful complements to traditional medical and surgical treatments in pain management. The authors report a case of recurrent severe posterior auricular pain caused by trigger points in the right sternocleidomastoid muscle and influenced by stressful psychological situations (e.g., family affairs, job loss) in a 50-year-old man.

Effects of the knockdown of hypoxia inducible factor-1alpha expression by adenovirus-mediated shRNA on angiogenesis and tumor growth in hepatocellular carcinoma cell lines / 대한간학회지

BACKGROUND/AIMS: Hypoxia-inducible factor-1alpha (HIF-1alpha) is a central transcriptional factor involved in the cellular responses related to various aspects of cancer biology, including proliferation, survival, and angiogenesis, and the metabolism of the extracellular matrix in hypoxia. This study evaluated whether adenovirus-mediated small hairpin RNA (shRNA) against HIF-1alpha (shHIF-1alpha) inhibits cell proliferation and angiogenesis in hepatocellular carcinoma (HCC) cell lines. METHODS: Knockdown of HIF-1alpha expression was constructed by adenovirus-mediated RNA interference tools, and HCC cell lines infected with shHIF-1alpha coding virus were cultured under a hypoxia condition (1% O2) for 24 hours. Following infection, the expression levels of HIF-1alpha, angiogenesis factors, and matrix metalloproteinase (MMP) were examined using Western blotting. Cell proliferation and angiogenesis were measured by a cell proliferation assay (MTT assay) and an angiogenesis-related assay (invasion and tube-formation assay), respectively. RESULTS: Adenovirus mediated inhibition of HIF-1alpha induced suppression of tumor growth in HCC cell lines. It also down-regulated the expression of angiogenesis factor and MMP proteins. Angiogenesis as well as mobility of vascular cells to tumor was suppressed by adenovirus-mediated shHIF-1alpha-infected groups in human umbilical vein endothelial cells (HUVECs). CONCLUSIONS: These data suggest that adenovirus-mediated inhibition of HIF-1alpha inhibits the invasion, tube formation, and cell growth in HUVECs and HCC cells.

Paroxysmal atrial fibrillation developed during incomplete epidural anesthesia: A case report / 대한마취과학회지

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia, and occurs in organic heart disease such as rheumatic, atherosclerotic and hypertensive heart disease. In recent studies, the sympathetic and parasympathetic nervous systems have been shown to have important roles in initiating paroxysmal AF. We report here a patient who developed paroxysmal AF that might be a result of an imbalance of the sympathetic-parasympathetic systems due to epidural anesthesia, and that was potentiated by pain with inadequate analgesia. A 69-year-old woman was scheduled for operation of a right-sided ankle fracture. Twenty minutes after epidural drug injection, paroxysmal AF occurred. Even after intravenous administration of esmolol and digoxin, AF continued. After transfer to the intensive care unit, her heart rate gradually decreased and AF disappeared. During perioperative anesthetic management, the proper preoperative prevention and intraoperative treatment are needed in AF high-risk patients.

Effect of remifentanil or esmolol on bispectral index and entropy to tracheal intubation during propofol anesthesia

BACKGROUND: The bispectral index (BIS) and entropy (response entropy, state entropy; RE, SE) have been used to monitor the anesthetic depth, and the difference between RE and SE (RE-SE difference) may represent the nociceptive stimuli during general anesthesia. This study was designed to determine whether BIS or entropy (RE, SE, and RE-SE difference) represent the response to tracheal intubation with iv bolus of remifentanil or esmolol forstable hemodynamic control during propofol anesthesia. METHODS: Eighty-nine patients were randomly divided into three groups (the control, esmolol, and remifentanil groups). Patient received propofol by target controlled infusion with air 2 L/min and O2 2 L/min. After the maintenance with target effect site concentration of propofol 5 microgram/ml for 5 min, patients received normal saline or esmolol 1.0 mg/kg or remifentanil 1.0 microgram/kg iv bolus according to group. And rocuronium 0.6 mg/kg iv bolus was administered and tracheal intubation was done. We measured mean arterial pressure (MAP), heart rate (HR), BIS, and entropy (RE, SE, RE-SE difference) during tracheal intubation. RESULTS: Changes in MAP or HR after tracheal intubation were greater in the control and esmolol groups than those in the remifentanil group. Although BIS, RE, and SE did not increase after intubation in all groups, but RE-SE difference significantly increased at 1 min after tracheal intubation in the control and esmolol group, but was unchanged in the remifentanil group. CONCLUSIONS: Among BIS, RE, SE and RE-SE difference, RE-SE difference is the good indicator for estimate of nociception during tracheal intubation.

Anatomical Consideration of the Anterior and Lateral Cutaneous Nerves in the Scalp

To better understand the anatomic location of scalp nerves involved in various neurosurgical procedures, including awake surgery and neuropathic pain control, a total of 30 anterolateral scalp cutaneous nerves were examined in Korean adult cadavers. The dissection was performed from the distal to the proximal aspects of the nerve. Considering the external bony landmarks, each reference point was defined for all measurements. The supraorbital nerve arose from the supraorbital notch or supraorbital foramen 29 mm lateral to the midline (range, 25-33 mm) and 5 mm below the supraorbital upper margin (range, 4-6 mm). The supratrochlear nerve exited from the orbital rim 16 mm lateral to the midline (range, 12-21 mm) and 7 mm below the supraorbital upper margin (range, 6-9 mm). The zygomaticotemporal nerve pierced the deep temporalis fascia 10 mm posterior to the frontozygomatic suture (range, 7-13 mm) and 22 mm above the upper margin of the zygomatic arch (range, 15-27 mm). In addition, three types of zygomaticotemporal nerve branches were found. Considering the superficial temporal artery, the auriculotemporal nerve was mostly located superficial or posterior to the artery (80%). There were no significant differences between the right and left sides or based on gender (P>0.05). These data can be applied to many neurosurgical diagnostic or therapeutic procedures related to anterolateral scalp cutaneous nerve.