Risk factors associated with repeated epidural blood patches using autologous blood

Background@#An epidural blood patch (EBP) is a procedure to treat intracranial hypotension that does not respond to conservative treatment. EBPs are commonly repeated when the symptoms persist. In this study, we used a large single-center retrospective cohort and evaluated the factors associated with repeated EBPs. @*Methods@#From January 2010 to December 2020, a total of 596 patients were treated with EBPs for intracranial hypotension. We evaluated the factors associated with repeated EBPs in the entire population, in patients with spontaneous intracranial hypotension (SIH), and in those with available myelographies. @*Results@#In a total of 596 patients, 125 (21.1%) patients required repeated EBPs, and 96/278 (34.5%) in SIH and 29/314 (9.2%) in iatrogenic population. In patients with SIH, international normalized ratio (INR) and cerebrospinal fluid (CSF) leakage on myelographies consistently exhibited significant associations (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.02–1.87; P = 0.043 and OR, 2.18; 95% CI, 1.28–3.69; P = 0.004). In patients with iatrogenic injury, INR and CSF leakage on myelogram did not show difference in repeated EBPs. @*Conclusions@#Repeated EBPs may be more frequently required in patients with SIH.Prolonged INR and CSF leakage were associated with repeated EBPs in patient with SIH. Further studies are needed to determine factors associated with repeated EBP requirements.

Hepatoid thymic carcinoma: a case report of a rare subtype of thymic carcinoma

Hepatoid thymic carcinoma is an extremely rare subtype of primary thymus tumor resembling “pure” hepatoid adenocarcinomas with hepatocyte paraffin 1 (Hep-Par-1) expression. A 53-year-old man presented with voice change and a neck mass. Multiple masses involving the thyroid, cervical and mediastinal lymph nodes, and lung were detected on computed tomography. Papillary thyroid carcinoma was confirmed by biopsy, and the patient underwent neoadjuvant chemoradiation therapy. However, the anterior mediastinal mass was enlarged after the treatment whereas the multiple masses in the thyroid and neck decreased in size. Microscopically, polygonal tumor cells formed solid sheets or trabeculae resembling hepatocytes and infiltrated remnant thymus. The tumor cells showed immunopositivity for cytokeratin 7, cytokeratin 19, and Hep-Par-1 and negativity for α-fetoprotein. Possibilities of germ cell tumor, squamous cell carcinoma, and metastasis of thyroid papillary carcinoma were excluded by immunohistochemistry. This report on the new subtype of thymic carcinoma is the third in English literature thus far.

Hepatoid thymic carcinoma: a case report of a rare subtype of thymic carcinoma

Hepatoid thymic carcinoma is an extremely rare subtype of primary thymus tumor resembling “pure” hepatoid adenocarcinomas with hepatocyte paraffin 1 (Hep-Par-1) expression. A 53-year-old man presented with voice change and a neck mass. Multiple masses involving the thyroid, cervical and mediastinal lymph nodes, and lung were detected on computed tomography. Papillary thyroid carcinoma was confirmed by biopsy, and the patient underwent neoadjuvant chemoradiation therapy. However, the anterior mediastinal mass was enlarged after the treatment whereas the multiple masses in the thyroid and neck decreased in size. Microscopically, polygonal tumor cells formed solid sheets or trabeculae resembling hepatocytes and infiltrated remnant thymus. The tumor cells showed immunopositivity for cytokeratin 7, cytokeratin 19, and Hep-Par-1 and negativity for α-fetoprotein. Possibilities of germ cell tumor, squamous cell carcinoma, and metastasis of thyroid papillary carcinoma were excluded by immunohistochemistry. This report on the new subtype of thymic carcinoma is the third in English literature thus far.

Optimal precurarizing dose of rocuronium to decrease fasciculation and myalgia following succinylcholine administration / 대한마취과학회지

BACKGROUND: Succinylcholine commonly produces frequent adverse effects, including muscle fasciculation and myalgia. The current study identified the optimal dose of rocuronium to prevent succinylcholine-induced fasciculation and myalgia and evaluated the influence of rocuronium on the speed of onset produced by succinylcholine. METHODS: This randomized, double-blinded study was conducted in 100 patients randomly allocated into five groups of 20 patients each. Patients were randomized to receive 0.02, 0.03, 0.04, 0.05 and 0.06 mg/kg rocuronium as a precurarizing dose. Neuromuscular monitoring after each precurarizing dose was recorded from the adductor pollicis muscle using acceleromyography with train-of-four stimulation of the ulnar nerve. All patients received succinylcholine 1.5 mg/kg at 2 minutes after the precurarization, and were assessed the incidence and severity of fasciculations, while myalgia was assessed at 24 hours after surgery. RESULTS: The incidence and severity of visible muscle fasciculation was significantly less with increasing the amount of precurarizing dose of rocuronium (P < 0.001). Those of myalgia tend to decrease according to increasing the amount of precurarizing dose of rocuronium, but there was no significance (P = 0.072). The onset time of succinylcholine was significantly longer with increasing the amount of precurarizing dose of rocuronium (P < 0.001). CONCLUSIONS: Precurarization with 0.04 mg/kg rocuronium was the optimal dose considering the reduction in the incidence and severity of fasciculation and myalgia with acceptable onset time, and the safe and effective precurarization.

Acute pulmonary edema due to hypoxia during a difficult intubation in a rheumatoid arthritis patient / 대한마취과학회지

No abstract available.

The dose effect of ephedrine on the onset time and intubating conditions after cisatracurium administration / 대한마취과학회지

BACKGROUND: The aim of this randomized, double-blind, placebo-controlled study was to evaluate dose effects of ephedrine pretreatment on the onset time and intubating conditions after cisatracurium administration. METHODS: A total of 140 adult patients were randomized into 4 groups to receive either 30 microg/kg ephedrine (Group 30, n = 35), 70 microg/kg ephedrine (Group 70, n = 35), 110 microg/kg ephedrine (Group 110, n = 35), 3 ml normal saline (Group C, n = 35) as pretreatment given 30 s before anesthetic induction. Neuromuscular block was achieved with 0.15 mg/kg cisatracurium, evaluated accelomyographically with train-of-four stimulation. An anesthesiologist blinded to patient grouping assessed the intubating conditions 1.5 min after cisatracurium administration. RESULTS: An onset time of 70 s was obtained in the ephedrine groups (Group 30: 155.4 +/- 44.7 s, Group 70: 152.6 +/- 40.3 s, Group 110: 151.2 +/- 51.6 s) compared to Group C (224.6 +/- 56.9 s) after 0.15 mg/kg of cisatracurium (P 200/100 mmHg) 1 min after tracheal intubation with no patients in other groups. CONCLUSIONS: We conclude that pre-treatment with ephedrine 70 microg/kg improved intubating conditions 1.5 min after cisatracurium administration and facilitated the onset of neuromuscular block (70 s) without adverse hemodynamic effects.

Survey on understanding after anesthetic induction simulation training in medical students' anesthesiology practice / 대한마취과학회지

No abstract available.

Anesthetic considerations in patients with large obstructing vocal process granuloma / 대한마취과학회지

No abstract available.

The effect of hand dominance on neuromuscular monitoring at the adductor pollicis muscle / 대한마취과학회지

BACKGROUND: Neuromuscular blockade of the adductor pollicis muscle may be influenced by hand dominance resulting in conflicting results of several studies. The current study examined whether hand dominance could influence the measurements of neuromuscular blockade with acceleromyography at the adductor pollicis. METHODS: The acceleromyographic responses from 0.6 mg/kg of rocuronium were monitored supramaximally in both hands in 31 patients after induction of anesthesia. Onset, maximum effect, and offset of rocuronium were measured and compared in both hands. The train-of-four (TOF) ratios to 0.9 were recorded in all patients. RESULTS: In total, 27 patients were right-handed and 4 patients were left-handed. The mean supramaximal threshold or initial TOF ratio was not different between dominant and nondominant hands. No statistically significant differences were found between 716 paired TOF ratios in both hands. A correlation was seen between the dominant and nondominant hand (Nondominant = 0.931.Dominant + 1.714, R = 0.929). The analysis by the Bland-Altman plot showed an excellent agreement with a bias of 1.6% and limits of agreement of -21.2 to 24.5%. CONCLUSIONS: Dominant and nondominant hands can be used interchangeably for neuromuscular monitoring at the adductor pollicis.

Optimal positive end-expiratory pressure during robot-assisted laparoscopic radical prostatectomy / 대한마취과학회지

BACKGROUND: Increased intra-abdominal pressure during laparoscopic surgery causes cephalad displacement of the diaphragm, resulting in the formation of atelectasis, which can be overcome by positive end-expiratory pressure (PEEP). The aim of this prospective study was to investigate the level of optimal PEEP to maintain adequate arterial oxygenation and hemodynamics during robot-assisted laparoscopic radical prostatectomy (RLRP). METHODS: One hundred patients undergoing RLRP were randomly allocated to one of five groups (n = 20) (0, 3, 5, 7 and 10 cmH2O of PEEP). Hemodynamic variables and respiratory parameters were measured at baseline with the patient in the supine position; at 30 min, 1, 2, 3 and 4 h during CO2 insufflation with the patient in the post-Trendelenburg position; and after deflation in the supine position with increasing PEEP. RESULTS: The PaO2 levels and alveolar-arterial difference in oxygen tension (AaDO2) were improved in patients with PEEPs compared with patients in whom PEEP was not used. The application of PEEP (10 cmH2O) resulted in higher PaO2 levels compared to those with lower PEEP levels, but excessive peak airway pressure (PAP) was sometimes observed. The application of a PEEP of 7 cmH2O resulted in similar PaO2 levels without causing excessive PAP. There was a significant difference in central venous pressure between the groups, but there were no significant differences in heart rate, mean arterial pressure or minute ventilation between the groups. CONCLUSIONS: A PEEP of 7 cmH2O is associated with the greater improvement of PaO2 and AaDO2 without causing excessive PAP during RLRP.

Fluoroscopic analysis of lumbar epidural contrast spread after retrograde interlaminar ventral epidural injection (RIVEI) / 대한마취과학회지

BACKGROUND: Retrograde interlaminar ventral epidural injection (RIVEI) may hypothetically be more effective if the catheter is placed at the ventrocaudal aspect of the exiting nerve. We tested that hypothesis by measuring ventral and dorsal epidural contrast flow during RIVEI. METHODS: To perform RIVEI, a 17 G Tuohy needle was inserted to access the epidural space. A 19 G epidural catheter was inserted and advanced through the needle, passing in a caudal direction to the lower aspect of the contralateral pedicle. Fluoroscopic images were recorded at 1.5 ml increments of contrast. Based on the images of contrast dispersal, the extent of contrast spreading was assessed in 82 patients. RESULTS: All 82 patients (100%) injected with 3.0 ml contrast medium demonstrated ventral epidural spreading. Mean spreading level from the catheter tip was 2.21 +/- 0.93 with 3.0 ml of contrast. Spreading to the superior aspect of the supra-adjacent intervertebral disc was observed in 67/82 (81.7%) of RIVEIs with 3.0 ml of contrast injected into the ventral epidural space. We found that 3.0 ml of contrast reached the inferior aspect of the infra-adjacent intervertebral disc in 95.1% (78/82) of RIVEIs performed. CONCLUSIONS: Our findings imply that a one-level RIVEI may be sufficient in situations where a two-level injection would currently be used.

Epidural contrast flow patterns of retrograde interlaminar ventral epidural injections stratified by the final catheter tip placement

BACKGROUND: The aim of the study is to evaluate the relevant spreading for contrasts in the ventral and dorsal epidural space during retrograde interlaminar ventral epidural injections (RIVEIs) with the catheter tip placed ventral or dorsal to the spinal nerve. METHODS: For RIVEIs, a 17G Tuohy needle was inserted in retrograde fashion. Catheter containing a removable stylet was inserted and advanced via the needle and passed to the lower aspect of contralateral pedicles in 75 patients. Fluoroscopic images were recorded at 1.5 ml increments of contrast. Using the fluoroscopy, the contrast spreading pattern and whether the contrast spread to the specific anatomic landmarks (superior aspect of the supra-adjacent intervertebral disc [SIVD] and inferior aspect of the infra-adjacent intervertebral disc [IIVD]) were evaluated. Whether the catheter was placed ventral or dorsal to the spinal nerve was assessed with the computed tomography axial and sagittal views. RESULTS: There were no significant differences in the mean levels of epidural contrast spreading extents between ventral and dorsal catheter placements. Ventral or dorsal catheter tip placements demonstrated ventral concurrent flows over to the SIVD and IIVD over 80% of subjects with 3.0 ml of contrast. CONCLUSIONS: During RIVEIs, the catheter tip placed ventral to the spinal nerve did not show superiority with regards to epidural spreading extent as compared with dorsal catheter placement. One-level instead of a two-level injection may be considered for the two-level central pathology.

Antiemetic efficacy of capsicum plaster on acupuncture points in patients undergoing thyroid operation / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) occurs in up to 63-84% of patients after thyroid surgery. This study aims to assess the effects of using a capsicum plaster to reduce PONV after thyroid surgery at either the Chinese acupuncture point (acupoint) Pericardium 6 (P6) or Korean hand acupuncture point K-D2. METHODS: One-hundred eighty-four patients who underwent thyroid surgery were randomized in four groups (n = 46 each): control group = inactive tape at P6 acupoints and on both shoulders as a nonacupoint; P6 group = capsicum plaster at P6 points and inactive tape on both shoulders; K-D2 group = capsicum plaster at K-D2 acupoints and inactive tape on both shoulders; Sham group = capsicum plaster on both shoulders and inactive tape at P6 acupoints. The capsicum plaster was applied before the induction of anesthesia and removed at 8 hr after surgery. RESULTS: The incidence and severity of nausea and vomiting and the need for rescue antiemetics were decreased in the patients in the P6 and K-D2 groups compared to the patients in the control and sham groups (P < 0.001). The patients in the P6 and K-D2 groups also reported that they were more satisfied (P < 0.05). CONCLUSIONS: We conclude that the capsicum plaster at the P6 and K-D2 acupoint was a promising antiemetic method for the patients undergoing thyroid surgery.

Antioxidant effect of muscle relaxants (vecuronium, rocuronium) on the rabbit abdominal aortic endothelial damage induced by reactive oxygen species / 대한마취과학회지

BACKGROUND: Muscle relaxants induce vascular smooth muscle relaxation by inducing synthesis of the prostaglandins that influence vasomotor tone. However, the effects of muscle relaxants on endothelial cells and tissues following injury by reactive oxygen species (ROS) are unclear. We tested the effects of the muscle relaxants vecuronium and rocuronium on impaired acetylcholine (ACh)-induced relaxation following induction of ROS in rabbit aorta in vitro. METHODS: Isolated rabbit abdominal aortic ring segments were pretreated with vecuronium or rocuronium at 10(-4), 3 x 10(-4), 10(-3) or 3 x 10(-3) M, with or without inhibitors of Cu/Zn superoxide dismutase (diethyldithiocarbamate; DETCA, 0.8 mM) or catalase (3-amino-1,2,4-triazole; 3AT, 50 mM). All groups of aortic rings were then exposed to ROS generated by electrolysis in the organ bath medium (Krebs-Henseleit solution). The effects of vecuronium and rocuronium on ROS-induced impairment of relaxation induced by ACh (10(-6) M) were assessed. RESULTS: Aortic rings treated with vecuronium or rocuronium at 10(-4), 3 x 10(-4), 10(-3) or 3 x 10(-3) M preserved the capacity for ACh-induced endothelial relaxation following ROS exposure in a dose-dependent manner. Pretreatment with DETCA partially inhibited the protective effects of vecuronium and rocuronium on ACh-induced relaxation (P < 0.001), but pretreatment with 3AT had no effect. CONCLUSIONS: Muscle relaxants protected the endothelium in isolated rabbit abdominal aorta from free-radical injury in a dose-dependent manner. These results suggest that vecuronium and rocuronium may act as superoxide anion scavengers.

Massive Diffuse Alveolar Hemorrhage Caused by the Aspiration of Gastric Contents during Induction of Anesthesia in Patients with Adhesive Ileus: A Case Report / 대한구급학회지

Aspiration pneumonitis is best defined as an acute lung injury, following the aspiration of regurgitated gastric contents. Major cause of pulmonary aspiration, during anesthesia, is gastric contents. Pulmonary aspiration can present symptoms of wheezing, coughing, dyspnea, cyanosis, pulmonary edema, hypotension, and hypoxemia, which may progress rapidly to severe acute respiratory distress syndrome (ARDS). However, there was no report of massive alveolar hemorrhage associated with aspiration pneumonitis. A 63-year-old man, who had undergone a total gastrectomy and received adjuvant chemotherapy, four months ago, was scheduled for adhesiolysis of the small bowel. The patient occurred aspiration of gastric contents, during induction of anesthesia, and subsequently, hypoxia developed during surgery. The patient moved to an intensive care unit (ICU), without extubation. Mechanical ventilation with PEEP was performed in an ICU. However, the patient died by ARDS and massive alveolar hemorrhage.

Comparison of the Pentax AWS and the Glidescope with the Macintosh laryngoscope for tracheal intubation in patients with Mallampati classification I or II

BACKGROUND: The Pentax AWS and the Glidescope are new intubating devices.They were designed to provide a view of the glottis without alignment of the oral, pharyngeal and tracheal axis. The purpose of this study was to evaluate the effectiveness of the Pentax AWS and the Glidescope in comparison with the Macintosh laryngoscope, when performing tracheal intubation in patients with mallampati classification I or II. METHODS: Ninety patients presenting for surgery requiring tracheal intubation, and who were deemed easy for tracheal intubation of mallampati classification I or II were randomly assigned to undergo intubation using a Macintosh (Group M, n = 30), Pentax AWS (Group P, n = 30) or Glidescope (Group G, n = 30). Time to complete tracheal intubation and number of attempts until successful intubation were recorded. Noninvasive blood pressure and heart rate recorded before induction (PI), just before intubation (PT), 1 min and 5 min after intubation. Patients were assessed for postoperative sore throat at 6-12 h after surgery. RESULTS: Time to secure the airway with the Macintosh 13.0 (min 7, max 23.0) s was lesser than with the Pentax AWS 20.4 (8, 51.2) s and Glidescope 22.1 (10, 42.0) s. There were no significant differences in the rate of successful intubations and sore throat among the groups. There were significant increases in both mean arterial pressure and heart rate 1 min after intubation in all groups compare with PI. CONCLUSIONS: The Pentax AWS and the Glidescope had no specific advantage over the Macintosh laryngoscope for the patients with normal airway.

Electrical stimulation of the epiradicular space using a catheter with a removable stylet

BACKGROUND: Electrical stimulation can be used to verify the location of epidural catheters. Although epiradicular localization of a catheter is important for patients with radiating pain in the lower extremities due to spinal stenosis or disc herniation, no prospective study results pertaining to the stimulation threshold within the epiradicular space have been reported. Therefore, we set out to investigate the threshold current for motor response in the epiradicular space by the use of a catheter containing a removable stylet. In addition, this study examines the reliability of such epiradicular stimulation. METHODS: In 105 patients undergoing a retrograde interlaminar ventral epidural injection, a lumbar epiradicular catheter was inserted. Loss of resistance was used to identify the epidural space. Afterward, the TheraCath was advanced into the epiradicular space and connected to a nerve stimulator. A nerve stimulator delivered progressively, increasing electrical current until an appropriate muscle contraction was observed. Contrast media was then injected and epiradicular dispersal was assessed. RESULTS: Epiradicular stimulation yielded a mean threshold of 0.56 +/- 0.50 mA (range: 0.06 to 2.84). When compared with epiradicular dispersal as a gold standard, the sensitivity, specificity, positive predictive value, and negative predictive value of epiradicular stimulation with the TheraCath were 90%, 56%, 96% and 33%, respectively. CONCLUSIONS: The threshold current of an insulated needle required to elicit a motor response in the epiradicular space was evaluated. We conclude that the epiradicular stimulation test is useful for confirming catheter placement. Nonetheless, further studies are required before implementing its routine use in clinical settings.

The change of anterior atlanto-dense interval in atlantoaxial instability patients: preoperative vs postoperative

BACKGROUND: Atlantoaxial subluxation (AAS) is a frequent manifestation of rheumatoid arthritis (RA). The instability of the cervical spine caused by AAS is potentially fatal condition under intubation for surgery. Anterior atlanto-dens interval (AADI) is a mirror of the risk for neural injury. We evaluated the change of AADI in atlantoaxial instability patients, before and after surgery. METHODS: The present study included 56 patients who underwent surgical procedures by AAS. Lateral radiographs were checked at preoperative, postoperative, 1 month later and 6 month later. AADI was measured using picture archiving communication system (PACS) system in each lateral radiograph. RESULTS: The value of AADI is 8.40 +/- 2.29 mm in preoperative period, 2.72 +/- 0.53 mm in postoperative, 2.68 +/- 0.53 mm in 1 month, and 2.70 +/- 0.51 mm in 6 months later. After cervical fusion, AADI immediately decreased 5.68 +/- 2.24 mm. There were significant decreased in postoperative, 1 month and 6 months, when compared with preoperative AADI. CONCLUSIONS: After the cervical fusion of AAS, the neurological and radiological stability was achieved by decrement of AADI. We concluded that the cervical fusion of AAS provide more safety during endotracheal intubation by decreased AADI.

Hemodynamic parameters during robotic radical prostatectomy in elderly patients with increased cardiac risk

BACKGROUND: We studied the hemodynamic changes associated with steep Trendelenburg position and prolonged pneumoperitoneum during robot-assisted laparoscopic prostatectomy in elderly patients with cardiac diseases. METHODS: Hemodynamic variables were measured at baseline supine position, at 30 min, 1, 2, 3 and 4 h during CO2 insufflation in post-Trendelenburg position, and after deflation in the supine position. RESULTS: In comparison with normal subjects, the cardiac index and systemic vascular resistance index of patients with cardiac diseases were significantly affected by the Trendelenburg position and pneumoperitoneum (P < 0.001). However, other variables of heart rate, mean arterial pressure and central venous pressure were not differed between the groups. CONCLUSIONS: We conclude that attention should be paid to maintain adequate hemodynamic status during prolonged pneumoperitoneum in the Trendelenburg position, and which is unfeasible in patients with severe heart failure and unstable angina.

Minimum current requirement for confirming the localization of an epiradicular catheter placement / 대한마취과학회지

BACKGROUND: Based on the necessity to confirm the epiradicular catheter misplacement, epiradicular threshold current for the confirmation of catheter tip localization is required. METHODS: Thirty-four adult patients with low extremity radiating pain were to receive epiradicular catheterization at the lumbosacral level. The epidural space was accessed percutaneously in cranial to caudal direction. A metal coil-reinforced epidural catheter was inserted and advanced caudolaterally toward the target neural foramen until the catheter tip was located below the bisection of pedicle. The electrical stimulation was performed after catheter placement in epidural and epiradicular space. Using the constant current nerve stimulator, the stimulating current was increased from 0 to 5 mA (pulse width of 0.3 ms; frequency of 2 Hz) until adequate motor contraction was evident. The threshold current for motor response with epidural space (EDmA) and epiradicular space (ERmA) placement were recorded upon electrical stimulation. In addition, the threshold charge for motor response with epidural (EDnC) and epiradicular (ERnC) placement were recorded. RESULTS: Of 34 catheters intentionally placed in the epiradicular space, ERmA was 0.53 +/- 0.48 mA. The ERnC was significantly lower than EDnC (P < 0.05). The EDmA and ERmA were below 1 mA in 3 patients and above 1 mA in 4 patients, respectively. CONCLUSIONS: We conclude that, threshold current for motor response seems to be lower for epiradicular compared with epidural placement, although we were not able to directly investigate the epidural threshold current. The threshold current of epiradicular space overlap that in the epidural space.