A Comparison of the Spread Level of the Cervical Epidural Block in Terms of Volume / 대한통증학회지

BACKGROUND: Cervical epidural injection, performed via the interlaminar approach, represents a useful interventional pain management procedure indicated in patients with a cervical herniated disk. Due to thedecreased epidural space in the cervical region, cervical epidural injections may result in potentially serious complications, especially during a large volume injection. METHODS: Thirty-four patients with neck pain due to a cervical herniated disk that were referred to the pain clinic for cervical epidural steroid injection were randomized into two groups. One group received a cervical epidural injection of 4 ml drug and the other group received 2 ml drug. The injected mixture included triamcinolon, ropivacaine and omnipaque. Spread levels of the drug after injection were estimated with the use of C-arm fluoroscopy. RESULTS: Spread levels to the cephalad for patients in the two groups were 4.88 +/- 0.78 segments and 4.53 +/- 0.49 segments, respectively. Spread levels to the caudad for patients in the two groups were 4.59 +/- 0.93 segments and 4.47 +/- 0.51 segments, respectively. The results showed no significant difference in the spread level between the two groups. CONCLUSIONS: Use of a small volume of drug (2 ml) can provide a sufficient spread level of the injected drug that is desirable for patients with a cervical herniated disk.

Encephalitis and Motor Paresis Caused by Herpes Zoster: A case report / 대한통증학회지

Encephalitis is known as a rare complication of varicella zoster virus (VZV) reactivation. It is usually regarded as a complication of a cutaneous infection in patients with impaired cellular immunity. The reported incidence of herpetic motor involvement range between 0.5 and 31%, but is possibly more frequent as the weakness is readily obscured by pain. A 53-years-old woman, who presented with severe shoulder pain, fever, headache and seizure, which developed the day after skin eruptions, also developed motor paresis 7 days after the seizure. Her cerebrospinal fluid (CSF) was VZV-Polymerase chain reaction (PCR) negative, but VZV specific IgG antibody positive, and her brain MRI was found to be normal. With the early diagnosis and proper treatment, such as intravenous administration of acyclovir, stellate ganglion block and Yamamoto New Scalp Stimulation (YNSS), the patient completely recovered, without psychoneurological sequelae. Herein, we present this case, with a discussion of the relevant literature on the incidence, pathophysiology, diagnosis and management of central nervous system VZV involvement.

Morphine Protects Peroxynitrite-induced Cell Death in Primary Rat Neonatal Astrocytes / 대한마취과학회지

BACKGROUND: Astrocytes, representing a major non-neuronal cell population in the central nervous system (CNS), contain opioid receptors and are actively involved in several brain functions. This study is designed to evaluate the effects by which morphine contributes to cytotoxicity of nitric oxide (NO) species including NO and peroxynitrite (ONOO(-)) in primary astrocytes isolated from the cerebral cortexes of 1 - 2 day Sprague-Dawley rats. METHODS: The cultured cells were pretreated with morphine and exposed to 3-morpholinosydnonimine (SIN-1) which simultaneously generates NO and superoxide, thus possibly forming peroxynitrite. The cell damage was assessed by using an MTT (methylthizol-2-yl-2, 5-diphenyl, tetrazolium bromide) assay. Morphological nuclear changes of the cells after exposure to SIN-1 for 24 hours was evaluated by using 4', 6-diamidino-2-phenylindole (DAPI) staining. RESULTS: Morphine significantly protected primary rat astrocytes in a dose-dependent manner from the death mediated by sodium nitroprusside (SNP), a donor of nitric oxide, and SIN-1. Moreover, it was found that naloxone antagonized the protective effect of morphine on SIN-1-induced cell death, revealed as apoptosis by the occurrence of morphological nuclear changes characteristic of apoptosis. Morphine also inhibited the nuclear condensation of SIN-1-treated cells, however the action of morphine was antagonized by pretreatment of naloxone. The protective role of morphine on SIN-1-induced cytotoxicity was inhibited by DL-Buthionine-[S, R]-sulfoximine (BSO). Furthermore, the effects of morphine on SIN-1-induced cytotoxicity were blocked by pretreatment of Gi protein inhibitor, pertussis toxin, and phosphoinositide 3-kinase (PI3 kinase) inhibitors, Wortmannin and LY294002. CONCLUSIONS: These results suggest that morphine may protect primary rat astrocytes from NO species via the signaling cascades involving G-protein and PI3-kinase, and possibly regulates the anti-oxidant, glutathione (GSH).

Effect of Glutathione on Oxidant-induced Neurotoxicity in Cultured Spinal Motor Neurons / 대한마취과학회지

BACKGROUND: Free radical reactions are a part of normal human metabolism. When produced in excess, radicals can cause tissue injury. The present study was aimed to investigate neurotoxic effect of oxygen free radicals and neuroprotective effect of antioxidant(glutathione). METHODS: Neurotixic effect of oxygen radicals was evaluated by MTT[3-(4,5-dimethylthiazol-2,5- diphenyltetrazolium bromide] assay and neurofilament enzyme-immunoassay after culturing of spinal motor neuron cell line of mouse(NSC-34). Then these cells were exposed to various concentrations of xanthine oxidase(XO) and hypoxanthine(HX). In addition, neuroprotective effect of antioxidant against oxidant-induced neurototoxicity on these cultures was examined. RESULTS: Exposure of neurons to 25mU/ml XO and 0.2mM HX for 3 hours resulted in a significant cell death and also glutathione(GSH) blocked the neurotoxicity induced by oxygen radicals in cultured mouse spinal motor neurons. CONCLUSION: From the above results, it is suggested that oxygen radicals are toxic in NSC-34. Selective antioxidants such as GSH are effective in blocking oxidant-induced neurotoxicity on these cultures.

Effects of Morphine, Fentanyl and Ketorolac Tromethamine, Droperidol Intravenous Infusion for Postoperative Pain Control / 대한마취과학회지

Continuous intravenous infusions of opioids can provide better pain relief than intermittent injection but may be associated with increased incidence of undesirable side effects including respiratory depression, nausea, vomiting and urinary retention. Ketorolac tromethamine is a new, nonsteroidal anti-inflammatory agent. It has significant analgesic properties without respiratory and cardiovascular depression. Mixing of opioids and ketorolac may lessen these complications without reducing analgesic effect. In six groups, we assessed the effect of postoperative pain control using morphine or fentanyl, ketorolac and droperidol, Each group consists of 100 patients. Patients in group 1, group 2, and group 3 received 2 mg of morphine via intravenous injection following the induction of anesthesia. Patients in group 1 were then continuously infused with additional 48 mg of morphine, patients in group 2 received additional 18 mg of morphine plus 120 mg of ketorolac, and patients in the group 3 were treated with the same protocol as group 2 but 2.5 mg of droperidol was added. For patients in group 4, group 5, and group 6 initially received 20 ug of fentanyl after induction of anesthesia. The rest of dose were treated with similar protocols as group I, group 2, group 3, respectively. In group 4, group 5, and group 6, morphine was substituted to 500 ug, 200 ug, and 200 ug of fentanyl, respectively. In all patients, initial dose of drug was given by bolus of intravenous injection and the rest of dose was delivered via intravenous using a Baxter Two Day Infusor or a Paragon 100. Pain scores and side effects were recorded every twelve hours for three days. No significant difference was found between the groups although pain control effect was excellent in all groups. Untoward effects were least in morphine or fentanyl-ketorolac-droperidol(group 3, group 6). It could be concluded that mixing of opioids, ketorolac and dtoperidol would be better than opioids alone.

Tracheal Tube Cuff Inflation in Oropharynx : An Useful Method in Blind Nasotracheal Intubation / 대한마취과학회지

We designed a study to determine if the tracheal tube cuff inflation in the oropharynx improves the success rate of blind nasotracheal intubation in normal, paralyzed patients because of lacking of controlled study about it. In prospective, randomized fashion, 100 ASA I or II patients undergoing elective oral surgery were studied. The trachea was intubated once keeping the tracheal tube cuff deflated throughout the maneuver and once using the technique of tracheal tube cuff inflation in the oropbarynx. A maximum of two attempts was allowed for each technique. If the first attempt was failed, the second attempt was tried with an addition of application of thyroid cartilage compression in each technique. Witb the tracheal tube cuff inflated, the success rate was significantly higher than the cuff-deflated technique(p<0.05). A application of thyroid cartilage compression increased the success rate of the blind nasotracheal intubation in each technique, but it was more useful in the cuff inflation technique(p<0.05). Time taken to intubate the trachea was longer in the cuff inflation technique. We suggest that, in normal paralyzed patients, the tracheal tube cuff inflation in the oropharynx increases the success rate of blind nasotracheal intubation.

Effects of the Speed of Crystalloid Preload in Preventing of Hypotension during Spinal Anesthesia for Caesarean Section / 대한마취과학회지

Hypotension during spinal anesthesia for cesaresn section remains as a common and serious complication despite the use of uterine displacement and volume preloading. This study was designed to compare the efficacy of the speed of crystalloid preload for reduc- ing the incidence of hypotension during spinal anesthesia for elective cesarean section. Twenty ASA I parturients were randomly allocated to receive 20ml/kg of crystalloid over either 20min (group 1) or 10min(group 2) before spinal anesthesia. Both groups showed a significant increase in central venous pressure during and immediately after preload, but there was no significant difference between the groups. Six patients in group 1 developed hypotension(a decrease in systolic pressure below 100mmHg and a fall of 20% from baseline values) and so did seven patients in group 2. We concluded that rapid crystalloid preloading did not reduce the incidence of hypotension during cesarean section under spinal anesthesia and its effectiveness in questionable.

Effects of Preoperative Oral Water Intake on Gastric Content and Emotional State of Patients / 대한마취과학회지

Because the most impcetant goal of anesthetic management is patient safety, it is accepted practice that pre-operative patients take nothing by mouth for at least 6 to 8 hours before surgery. However, recent studies have questioned this conventional pre-operative fasting, showing that a fixed volume of water at various time pre-operatively may either improve the characteristics of gastric contents, or else have no effect. The present study was designed to investigate the effect of aUowing patients unlimited access to oral water drinks regardless of time. Fifty-eight fit adult patients scheduled for elective surgery normally requiring endotracheal intubation were recruited. They were randomly allocated to two groups; "Fasters" and "Drinkers", and the effects on plasma osmolality, gastric contents and patient comfort were compared, respectively. This protocol was associated with a reduction in pre-operative anxiety, although the mechanism of this is not clear. No effects were found on plasma osmolality or on the volume or acidity of the gastric contents. No regurgitation occurred during induction and/or emergence in "Drinkers".

Effect of Propranolol on Decreased K+ Concentration under Axillary Block of Brachial Plexus by Lidocaine with Epinephrine / 대한마취과학회지

Recently, interest has been increased on the role of catecholamines in extrarenal potassium homeostasis. This study has undertaken to investigate the effects of epinephrine added to lidocaine for axillary block in HR, MAP, ABG, blood sugar and electrolytes (Na+, K+), and the effects of propranolol, beta-adrenergic blocker, on the data. The patients admitted to our hospital for operation of upper extremities were divided into three groups. Group I was 10 patients blocked with lidocaine 30 ml. Group II was 14 patients blocked with lidocaine 30 ml with epinephrine 0.3 mg(1:100,000). Group III was 10 patients pretreated with propranolol (10u/kg) and blocked with lidocaine 30 ml with epinephrine. After block, the results were as follows. 1) MAP decreased in all group and group III decreased more than group I. 2) HR increased all group and group III decreased more than group I. 3) ABG showed hypoventilatory pattern due to sedative effect by diazepam (0.15mg/kg). 4) Blood sugar value was increased in group I and II, showed increasing tendency in group III, but this tendency was not significant. 5) Blood K+ concentration decreased significantly and the maximal decrease was 0.5 mEq/L in 30 min after block, but there was not significant decrease in group III. This results indicate that clinical dose of epinephrine(1;100,000) decrease blood K+ concentration significantly and propranolol (10u/kg) pretreatment prevent K+ decreasing effect of epinephrine. In clinical practice, it is suggested that much care must be paid to use of local anesthetics with epinephrine to hypokalemic patients.

Effect of Propranolol on Decreased K+ Concentration under Axillary Block of Brachial Plexus by Lidocaine with Epinephrine / 대한마취과학회지

Recently, interest has been increased on the role of catecholamines in extrarenal potassium homeostasis. This study has undertaken to investigate the effects of epinephrine added to lidocaine for axillary block in HR, MAP, ABG, blood sugar and electrolytes (Na+, K+), and the effects of propranolol, beta-adrenergic blocker, on the data. The patients admitted to our hospital for operation of upper extremities were divided into three groups. Group I was 10 patients blocked with lidocaine 30 ml. Group II was 14 patients blocked with lidocaine 30 ml with epinephrine 0.3 mg(1:100,000). Group III was 10 patients pretreated with propranolol (10u/kg) and blocked with lidocaine 30 ml with epinephrine. After block, the results were as follows. 1) MAP decreased in all group and group III decreased more than group I. 2) HR increased all group and group III decreased more than group I. 3) ABG showed hypoventilatory pattern due to sedative effect by diazepam (0.15mg/kg). 4) Blood sugar value was increased in group I and II, showed increasing tendency in group III, but this tendency was not significant. 5) Blood K+ concentration decreased significantly and the maximal decrease was 0.5 mEq/L in 30 min after block, but there was not significant decrease in group III. This results indicate that clinical dose of epinephrine(1;100,000) decrease blood K+ concentration significantly and propranolol (10u/kg) pretreatment prevent K+ decreasing effect of epinephrine. In clinical practice, it is suggested that much care must be paid to use of local anesthetics with epinephrine to hypokalemic patients.

An Experimental Study of Local Anesthetic Injection Injury to Peripheral Nerves / 대한마취과학회지

Injury to a peripheral nerve due to a drug injection is of particular concern, because of both its clinical and medicolegal implications. Among numerous agents, local anesthetic solutions are most frequently injected near the main nerve trunks. In spite of the low incidence of nerve fiber injury associated with these local anesthetic agents, there are several clinical reports of injury. The author experimentally induced injection injury into the rat sciatic nerve with 2% lidocaine HCL and 0.5% bupivacaine. The neurotoxicity of these agents to the peripheral nerve was observed by light and electron microscope. The results are as follows: 1) Some inflammatory round cells and vasodilation were observed in the surrounding loose areolar tissues immediately after injection. No fibroblast or fibrosis was observed on light and electron microscopic examinations. 2) Immediately after injection, the axons were seperated by the splitting of the collagen fibers between the axons. But within one week, the collagen fibers were reunited and compacted. 3) Most cytoplasmic organelles of the axon, including the microtubules and micro filaments, were quite normal and were not altered by injection injury. But the shape of the axon was changed and shrinked to create a large space from the myelin sheath. The above change returned to normal within one week. 4) The Schwann cells, maintained the normal structure of their cytoplasm and nucleus, but some Schwann cells were seperated from the axons, and floated in the collagen tissue. They were reunited with the axons within one week. 5) There were no significant histologic differences between lidocaine and bupivacaine. 6) The above changes were easily reversible and not severe enough to interfere with nerve function permanently. In conclusion, local injection of these agents is very safe to the peripheral nerve.

Clinical Evaluation of Effect of IV Lidocane and Devided dose of Pancuronium on IOP / 대한마취과학회지

Many techniques have been tried to avoid the adverse effect of succinylcholine administe-red for endotracheal intubation especially wish the complication of increased IOP, hyperk-alemia, aspirationl pneumonia and post operative muscle pain, One of these is that the prior administration of a small, subparalyzing dose(15 ug/kg) of non-depolarizing muscle relaxant would shorten the onset time of an intubating dose(80 ug/kg) of muscle relaxant. Intra-venous lidocaine has bean effective in attenuating the reflex intra-ocular response to laryngoscopy Therefore, we determined the effectiveness of this drug regimen with and without intra venous lidocaine to attenuate the IOP, blood pressure and heart rate response to laryngos-copy and endotracheal intubation. Forty patients were divided intro two groups. Group l (n=20) administered saline 5 ml. Group ll(n=70) administered 2% preservative free lidocaine(1.5 mg/kg) as pretreatment drug. The results are as follows : 1) There was no statistically significant difference of intubation condition between one and another group. Among the forer patients, Grade 1,2,3,4 are 8(20%), 19(47.5%), 13(32.5%),0, in orders. 2) In the Saline Group, IOP, BP, HR increased significantly after laryngoscopy compared wiith control value. (p<0.001, P<0.05/p<0,001, p<0.005) and maintained above control values to 4~5 minutes later. 3) In the Lidocaine Group, IOP, BP, HR increased slightly after laryngoscopy compared with control value, but thege changes were not statistically significant, and decreased below control values in 2 min, 2min, 3 min after laryngoscopy each to each. From the above results, it is suggested that combined method of pretreatment of 2% lidofaine(1.5 mg/tg) and divided dose of pancuronium is valuable in general anesthesia of ophthalmic patient who need to attenuate the IOP.