Necrotizing fasciitis likely mistaken for chronic low back pain: A case report

Necrotizing fasciitis is a significant factor of morbidity and mortality due to its sudden onset and rapid spread. It is accompanied by systemic toxicity and often fatal unless promptly recognized and aggressively treated. We reported a patient who presented symptoms confused with disc herniation and delayed initial diagnosis. The patient was treated for chronic low back pain. The origin of the pain was a foreign body-induced intra-abdominal infection that invaded the back muscles and eventually progressed to necrotizing fasciitis.

Estimation of the effect-site equilibration rate constant using the time-to-peak effect of muscle relaxants measured by train-of-four stimulation during general anesthesia induction / 대한마취과학회지

BACKGROUND: The concept of the effect-site concentration of anesthetic agents is important. The effect compartment model can be explained using the concepts of effect-site concentration and effect-site equilibration rate constant (k e0). This study confirms that the time-to-peak effect (tpe ) can be measured easily in clinical practice by applying a priming dose and train-of-four (TOF) during general anesthesia induction, and k e0 can be calculated from the tpe of the four muscle relaxants that are commonly used in general anesthesia. METHODS: Eighty patients who received general anesthesia were divided into the succinylcholine, rocuronium, atracurium, or vecuronium groups. Priming doses of muscle relaxants were administered. The effects of muscle relaxants were quantified by recording the twitch response of the adductor pollicis muscle after stimulating the ulnar nerve. The tpe was measured at the lowest TOF value. k e0 was calculated from the measured tpe . RESULTS: The k e0 values of the succinylcholine, rocuronium, atracurium, and vecuronium groups were 0.076 (0.030)/min, 0.228 (0.122)/min, 0.062 (0.011)/min, and 0.077 (0.019)/min, respectively. CONCLUSIONS: It is possible to estimate k e0 from the tpe of muscle relaxants using a priming dose and TOF during general anesthesia induction.

Endovascular Stenting for the Treatment of an Initially Asymptomatic Patient with Traumatic Carotid Artery Dissection / 대한구급학회지

No abstract available.

Evaluation of Respiratory Dynamics in an Asymmetric Lung Compliance Model / 대한구급학회지

BACKGROUND: Unilateral lung hyperinflation develops in lungs with asymmetric compliance, which can lead to vital instability. The aim of this study was to investigate the respiratory dynamics and the effect of airway diameter on the distribution of tidal volume during mechanical ventilation in a lung model with asymmetric compliance. METHODS: Three groups of lung models were designed to simulate lungs with a symmetric and asymmetric compliance. The lung model was composed of two test lungs, lung1 and lung2. The static compliance of lung1 in C15, C60, and C120 groups was manipulated to be 15, 60, and 120 ml/cmH₂O, respectively. Meanwhile, the static compliance of lung2 was fixed at 60 ml/cmH₂O. Respiratory variables were measured above (proximal measurement) and below (distal measurement) the model trachea. The lung model was mechanically ventilated, and the airway internal diameter (ID) was changed from 3 to 8 mm in 1-mm increments. RESULTS: The mean ± standard deviation ratio of volumes distributed to each lung (VL1/VL2) in airway ID 3, 4, 5, 6, 7, and 8 were in order, 0.10 ± 0.05, 0.11 ± 0.03, 0.12 ± 0.02, 0.12 ± 0.02, 0.12 ± 0.02, and 0.12 ± 0.02 in the C15 group; 1.05 ± 0.16, 1.01 ± 0.09, 1.00 ± 0.07, 0.97 ± 0.09, 0.96 ± 0.06, and 0.97 ± 0.08 in the C60 group; and 1.46 ± 0.18, 3.06 ± 0.41, 3.72 ± 0.37, 3.78 ± 0.47, 3.77 ± 0.45, and 3.78 ± 0.60 in the C120 group. The positive end-expiratory pressure (PEEP) of lung1 was significantly increased at airway ID 3 mm (1.65 cmH₂O) in the C15 group; at ID 3, 4, and 5 mm (2.21, 1.06, and 0.95 cmH₂O) in the C60 group; and ID 3, 4, and 5 mm (2.92, 1.84, and 1.41 cmH₂O) in the C120 group, compared to ID 8 mm (P < 0.05). CONCLUSIONS: In the C15 and C120 groups, the tidal volume was unevenly distributed to both lungs in a positive relationship with lung compliance. In the C120 group, the uneven distribution of tidal volume was improved when the airway ID was equal to or less than 4 mm, but a significant increase of PEEP was observed.

Learning curve of skilled anesthesiologists for endotracheal intubation using Optiscope™

BACKGROUND: Optiscope™ is a semi-rigid fiberscope for endotracheal intubation. A camera attached to the distal end of the stylet shows the laryngeal view through an adjustable LCD-monitor attached at the handle. The aim of this study was to evaluate the learning curve of skilled anesthesiologists in the use of Optiscope™. METHODS: Eighty-patients with normal airways were randomly assigned to four anesthesiologists, who did not have previous experience of intubation with Optiscope™. After induction of general anesthesia, the four investigators performed 20 intubations each, using the Optiscope™. Time to intubation (TTI), number of intubation attempts, and reasons of prolonged TTI were evaluated. RESULTS: The success rate of intubation was 98.8%. The TTI was significantly faster in 16th–20th patients (35.0 s, interquartile range 27.3–41.4) than in the first 10 patients (54.1 s, interquartile range 31.2–75.5) (P = 0.006). All patients after the 16th intubation were intubated at the first attempt. Frequent problems encountered were difficulty in getting the stylet tip under the epiglottis, and mucous secretion obscuring the laryngeal anatomy. CONCLUSIONS: Optiscope™ is an effective device for endotracheal intubation. About 15 intubations in patients with normal airways provided clinically adequate experience to the skilled anesthesiologists. Additional maneuver of airway opening such as jaw thrust and sufficient removal of oral secretion, are suggested to reduce TTI.

Learning curve of skilled anesthesiologists for endotracheal intubation using Optiscope™

BACKGROUND: Optiscope™ is a semi-rigid fiberscope for endotracheal intubation. A camera attached to the distal end of the stylet shows the laryngeal view through an adjustable LCD-monitor attached at the handle. The aim of this study was to evaluate the learning curve of skilled anesthesiologists in the use of Optiscope™. METHODS: Eighty-patients with normal airways were randomly assigned to four anesthesiologists, who did not have previous experience of intubation with Optiscope™. After induction of general anesthesia, the four investigators performed 20 intubations each, using the Optiscope™. Time to intubation (TTI), number of intubation attempts, and reasons of prolonged TTI were evaluated. RESULTS: The success rate of intubation was 98.8%. The TTI was significantly faster in 16th–20th patients (35.0 s, interquartile range 27.3–41.4) than in the first 10 patients (54.1 s, interquartile range 31.2–75.5) (P = 0.006). All patients after the 16th intubation were intubated at the first attempt. Frequent problems encountered were difficulty in getting the stylet tip under the epiglottis, and mucous secretion obscuring the laryngeal anatomy. CONCLUSIONS: Optiscope™ is an effective device for endotracheal intubation. About 15 intubations in patients with normal airways provided clinically adequate experience to the skilled anesthesiologists. Additional maneuver of airway opening such as jaw thrust and sufficient removal of oral secretion, are suggested to reduce TTI.

Endovascular Stenting for the Treatment of an Initially Asymptomatic Patient with Traumatic Carotid Artery Dissection / 대한중환자의학회지

No abstract available.

Beneficial effects of the addition of intrathecal fentanyl to bupivacaine for spinal anesthesia in cesarean section

BACKGROUND: The addition of fentanyl or epinephrine to bupivacaine enhances the quality of intraoperative spinal anesthesia during cesarean section. This study aimed to evaluate the beneficial effects of adding fentanyl or epinephrine to bupivacaine in spinal anesthesia solutions used for patients undergoing cesarean section. METHODS: This retrospective study included 391 patients who underwent cesarean section under spinal anesthesia between March 2009 and February 2014. Parturients were categorized into group N (no addition; n = 103), group E (addition of epinephrine; n = 196), and group F (addition of fentanyl; n = 92). Perioperative hemodynamic changes, complications, sensory recovery times, Apgar scores, and cord blood pH were analyzed. RESULTS: Nausea and vomiting occurred more frequently in group E than in the other two groups (P < 0.001 and P = 0.027, respectively). The mean sensory recovery times to T10 level showed statistically significant intergroup differences (P < 0.001). Group F showed the highest 1-min and 5-min Apgar scores, with statistically significant differences amongst the three groups (P = 0.007 and P < 0.001, respectively). However, the blood gas analysis variables of the cord blood did not show significant differences. CONCLUSIONS: Addition of fentanyl to bupivacaine was related to a longer sensory recovery time than did the addition of nothing or epinephrine. Moreover, it had been associated with beneficial effects such as a reduction in complications following spinal anesthesia.

Evaluation of Respiratory Dynamics in an Asymmetric Lung Compliance Model / 대한중환자의학회지

BACKGROUND: Unilateral lung hyperinflation develops in lungs with asymmetric compliance, which can lead to vital instability. The aim of this study was to investigate the respiratory dynamics and the effect of airway diameter on the distribution of tidal volume during mechanical ventilation in a lung model with asymmetric compliance. METHODS: Three groups of lung models were designed to simulate lungs with a symmetric and asymmetric compliance. The lung model was composed of two test lungs, lung1 and lung2. The static compliance of lung1 in C15, C60, and C120 groups was manipulated to be 15, 60, and 120 ml/cmH₂O, respectively. Meanwhile, the static compliance of lung2 was fixed at 60 ml/cmH₂O. Respiratory variables were measured above (proximal measurement) and below (distal measurement) the model trachea. The lung model was mechanically ventilated, and the airway internal diameter (ID) was changed from 3 to 8 mm in 1-mm increments. RESULTS: The mean ± standard deviation ratio of volumes distributed to each lung (VL1/VL2) in airway ID 3, 4, 5, 6, 7, and 8 were in order, 0.10 ± 0.05, 0.11 ± 0.03, 0.12 ± 0.02, 0.12 ± 0.02, 0.12 ± 0.02, and 0.12 ± 0.02 in the C15 group; 1.05 ± 0.16, 1.01 ± 0.09, 1.00 ± 0.07, 0.97 ± 0.09, 0.96 ± 0.06, and 0.97 ± 0.08 in the C60 group; and 1.46 ± 0.18, 3.06 ± 0.41, 3.72 ± 0.37, 3.78 ± 0.47, 3.77 ± 0.45, and 3.78 ± 0.60 in the C120 group. The positive end-expiratory pressure (PEEP) of lung1 was significantly increased at airway ID 3 mm (1.65 cmH₂O) in the C15 group; at ID 3, 4, and 5 mm (2.21, 1.06, and 0.95 cmH₂O) in the C60 group; and ID 3, 4, and 5 mm (2.92, 1.84, and 1.41 cmH₂O) in the C120 group, compared to ID 8 mm (P < 0.05). CONCLUSIONS: In the C15 and C120 groups, the tidal volume was unevenly distributed to both lungs in a positive relationship with lung compliance. In the C120 group, the uneven distribution of tidal volume was improved when the airway ID was equal to or less than 4 mm, but a significant increase of PEEP was observed.

How to design intravenous anesthetic dose regimens based on pharmacokinetics and pharmacodynamics principles

Pharmacokinetics is the study of the rate and degree of drug transport to various tissues in the human body. Pharmacokinetic parameters summarize drug kinetics and ideally predict a clinical situation. A single kinetic profile may be summarized by peak concentration, peak time, half-life and area under the curve. Dosage regimens are designed to confer the maximum desired effects for the required time period with minimal toxicity. Target-controlled infusions use pharmacokinetic models to titrate intravenous anesthetic administration to achieve a desired drug concentration. Context-sensitive half time is used to predict the clinical time course, rather than terminal half-life. It is important that anesthesiologists understand the basic pharmacological principles and apply them in their daily clinical practice. This review discusses the ways in which anesthesiologists can design a patient-specific dosage regimen of intravenous anesthetics by utilizing basic concepts of pharmacokinetics and pharmacodynamics using pharmacokinetic simulations.

Airway management in a patient with Reinke's edema: A case report

Reinke's edema begins with a chronic diffuse edema on the surface of the lamina propria of the vocal folds. It frequently occurs in women, smokers, professional voice users, and in patients with gastroesophageal reflux disease. Herein, we report the case of a patient who experienced ventilation difficulties during general anesthesia using positive pressure mask ventilation.

Epidural anesthesia for a lumbar discectomy in a patient with paramyotonia congenita: A case report

Paramyotonia congenita is a rare hereditary skeletal muscle disease characterized by exercise- or cold-induced myotonia. Anesthesiologists should make any efforts to prevent perioperative myotonic attack and muscle weakness in patients with this kind of disorder. Specifically, the administration of depolarizing muscle relaxants should be avoided and serum potassium level as well as body temperature should be carefully managed. The present report describes our experiences with successful epidural anesthesia in a patient with paramyotonia congenita who underwent a lumbar discectomy.

A Comparison between Discrimination Indices and Item-Response Theory Using the Rasch Model in a Clinical Course Written Examination of a Medical School / 한국의학교육

PURPOSE: The reliability of test is determined by each items' characteristics. Item analysis is achieved by classical test theory and item response theory. The purpose of the study was to compare the discrimination indices with item response theory using the Rasch model. METHODS: Thirty-one 4th-year medical school students participated in the clinical course written examination, which included 22 A-type items and 3 R-type items. Point biserial correlation coefficient (C(pbs)) was compared to method of extreme group (D), biserial correlation coefficient (C(bs)), item-total correlation coefficient (C(it)), and corrected item-total correlation coeffcient (C(cit)). Rasch model was applied to estimate item difficulty and examinee's ability and to calculate item fit statistics using joint maximum likelihood. RESULTS: Explanatory power (r2) of Cpbs is decreased in the following order: C(cit) (1.00), C(it) (0.99), C(bs) (0.94), and D (0.45). The ranges of difficulty logit and standard error and ability logit and standard error were -0.82 to 0.80 and 0.37 to 0.76, -3.69 to 3.19 and 0.45 to 1.03, respectively. Item 9 and 23 have outfit > or =1.3. Student 1, 5, 7, 18, 26, 30, and 32 have fit > or =1.3. CONCLUSION: C(pbs), C(cit), and C(it) are good discrimination parameters. Rasch model can estimate item difficulty parameter and examinee's ability parameter with standard error. The fit statistics can identify bad items and unpredictable examinee's responses.

Generalized tonic-clonic seizure following spinal anesthesia for Cesarean section with bupivacaine: A case report

Regional anesthesia for Cesarean section is a popular anesthetic method and a subarachnoid injection of local anesthetics provides rapid onset and a reliable block. Furthermore, it maintains airway reflexes and consciousness of the parturient and is associated with less neonatal depression. Complications related with spinal anesthesia are most often postdural puncture headache, back pain, hematoma, abscess, paresthesia or motor weakness and very rarely, myoclonus. Generalized seizures as a complication following epidural anesthesia with bupivacaine has been reported, but rarely following spinal anesthesia. We present a case of a parturient who was well antenatally, but presented with generalized tonic-clonic seizures following delivery. Although the possible etiologic factors of these transient seizures after spinal anesthesia are difficult to clarify, we emphasize that careful airway monitoring after regional anesthesia is important.

Effects of upper airway obstruction on respiratory mechanics in a variable compliance model

BACKGROUND: Upper airway obstruction is caused by an intrinsic or extrinsic neck mass and vocal cord paralysis. A recognized hazard of prolonged endotracheal intubation is progressive airway occlusion resulting from deposition of secretions. If the obstruction persists, it may be life threatening condition. However, early diagnosis of partial airway obstruction is very difficult because patients are asymptomatic and do not have lesions with abnormal radiological characteristics. METHODS: In the test lung model, lung compliances were set to normal (25 ml/cmH2O; [control, C25 group]) and to levels seen in chronic obstructive pulmonary disease (40 ml/cmH2O; [C40 group]), and acute respiratory distress syndrome (20 ml/cmH2O; [C20 group] and 15 ml/cmH2O; [C15 group]). A ventilator (Drager Fabius GS, Germany) was attached to a test lung, and a series of endotracheal tubes (ETTs) ranging in size from 7.5 to 2.5 mm in inner diameter (ID) of the connector were used to simulate progressive occlusion. During the lung compliance and the connector size were changed, we measured some respiratory mechanics. RESULTS: Progressive ETT occlusion induced an increase in the peak inspiratory pressure. In the C40 group, the inspiratory pause pressure spontaneously increased on repeated ventilation. Auto- positive end-expiratory pressure (Auto-PEEP) was observed under the condition of high compliance and occlusion. Dynamic compliance decreased at an ID of 5.5 mm in all groups. Respiratory resistance was inversely proportional to the ID of the connector. CONCLUSIONS: The dynamic compliance and resistance were significantly changed. However the change of static compliance had little effect on respiratory mechanics.

A case of back pain caused by Salmonella spondylitis: A case report / 대한마취과학회지

Salmonella spondylitis is a rare illness, and it generally occurs in patients who have already had sickle cell anemia, and it is even rarer in patients who are without sickle cell anemia. A 61-year-old male patient was hospitalized for the evaluation of his renal function and then treatment was started for his back pain. His back pain had developed about 2 months previously without any specific trauma. Only a bulging disc was detected on the initial lumbar MRI. Regarding his fever, it was diagnosed as possible atypical pneumonia, scrub typhus, etc., and multiple antibiotic therapy was administered. At the time of transfer, the leucocytes and hs-CRP were normal and the ESR was elevated. A diagnostic epidural block was performed for his back pain, but his symptoms were not improved. Lumbar MRI was performed again and it showed findings of infective spondylitis. Salmonella D was identified on the abscess culture and so he was diagnosed as suffering from Salmonella spondylitis. After antibiotic treatment, his back pain was improved and the patient was able to walk.

Is It Useful and Safe to Maintain the Sitting Position During Only One Minute before Position Change to the Jack-knife Position?

BACKGROUND: Conventional spinal saddle block is performed with the patient in a sitting position, keeping the patient sitting for between 3 to 10 min after injection of a drug. This amount of time, however, is long enough to cause prolonged postoperative urinary retention. The trend in this block is to lower the dose of local anesthetics, providing a selective segmental block; however, an optimal dose and method are needed for adequate anesthesia in variable situations. Therefore, in this study, we evaluated the question of whether only 1 min of sitting after drug injection would be sufficient and safe for minor anorectal surgery. METHODS: Two hundred and sixteen patients undergoing minor anorectal surgery under spinal anesthesia remained sitting for 1 min after completion of subarachnoid administration of 1 ml of a 0.5% hyperbaric bupivacaine solution (5 mg). They were then placed in the jack-knife position. After surgery, analgesia levels were assessed using loss of cold sensation in the supine position. The next day, urination and 11-point numeric rating scale (NRS) for postoperative pain were assessed. RESULTS: None of the patients required additional analgesics during surgical manipulation. Postoperative sensory levels were T10 [T8-T12] in patients, and no significant differences were observed between sex (P = 0.857), height (P = 0.065), obesity (P = 0.873), or age (P = 0.138). Urinary retention developed in only 7 patients (3.2%). In this group, NRS was 5.0 +/- 2.4 (P = 0.014). CONCLUSIONS: The one-minute sitting position for spinal saddle block before the jack-knife position is a safe method for use with minor anorectal surgery and can reduce development of postoperative urinary retention.

The Neurological Safety of Epidural Pamidronate in Rats

BACKGROUND: Pamidronate is a potent inhibitor of osteoclast-mediated bone resorption. Recently, the drug has been known to relieve bone pain. We hypothesized that direct epidural administration of pamidronate could have various advantages over oral administration with respect to dosage, side effects, and efficacy. Therefore, we evaluated the neuronal safety of epidurally-administered pamidronate. METHODS: Twenty-seven rats weighing 250-350 g were equally divided into 3 groups. Each group received an epidural administration with either 0.3 ml (3.75 mg) of pamidronate (group P), 0.3 ml of 40% alcohol (group A), or 0.3 ml of normal saline (group N). A Pinch-toe test, motor function evaluation, and histopathologic examination of the spinal cord to detect conditions such as chromatolysis, meningeal inflammation, and neuritis, were performed on the 2nd, 7th, and 21st day following administration of each drug. RESULTS: All rats in group A showed an abnormal response to the pinch-toe test and decreased motor function during the entire evaluation period. Abnormal histopathologic findings, including neuritis and meningeal inflammation were observed only in group A rats. Rats in group P, with the exception of 1, and group N showed no significant sensory/motor dysfunction over a 3-week observation period. No histopathologic changes were observed in groups P and N. CONCLUSIONS: Direct epidural injection of pamidronate (about 12.5 mg/kg) showed no neurotoxic evidence in terms of sensory/motor function evaluation and histopathologic examination.

The Tuberculous Bronchoesophageal Fistula Detected during Induction of General Anesthesia in Brain Abscess Patient: A case report / 대한마취과학회지

We report a case of bronchoesophageal fistula detected during induction of general anesthesia in brain abscess patient. Bubbling sound at substernal area and gas bubble at oral cavity during manually assisted mask ventilation, especially inspiration, were detected. Barium esophagography, gastroscopy and bronchoscophy were performed to know the nature of fistula after neurosurgical operation. The patient had a bronchoesophageal fistula due to unproperly treated old pulmonary tuberculosis. Esophageal opening of fistula located at midesophagus about 27 cm distance from incisor, while bronchial opening located at apical segment of right superior bronchus. It depends on the size, location, and duration of fistula to manifest clinical symptom. In bronchoesophageal fistula, the size of opening tends to be small and gradual symptom onset while relatively large and early in TEF. Therefore, knowledge of the differences of two types of fistula are essential to manage the patient who have these types of fistula.

Perineal Pain due to Bladder Stones after Total Abdominal Hysterectomy: A case report / 대한통증학회지

Perineal pain is a significant diagnostic challenge to the pain practitioner, and accurate diagnosis and treatment is essential. We report a case of 42-years old female patient suffering from excruciating vulvodynia for 5 years. Her pain on the visual analogue scale was 10 out of 10 and her pain was associated with sleep disturbance, dyspareunia, and chronic fatigue. She was diagnosed with a bladder stone by imaging, and The pain was relieved by cystolitholapaxy.