Iatrogenic common carotid artery rupture during neck surgery rescued using covered stent: A case report

Carotid artery rupture during head and neck surgery is a catastrophic, life-threatening emergency. Although recent incidence has declined, it still occurs in many patients. Hemorrhage from the carotid artery is usually massive and uncontrollable. Fast, aggressive treatment to prevent hemodynamic instability is required. Even if patients survive this event, they may experience severe neurological sequelae. A ruptured carotid artery is usually controlled by direct compression and arterial ligation. However, apart from the inherent difficulty of operation, these traditional surgical treatments are associated with high morbidity and mortality. In the past two decades, endovascular management has become a mainstay of carotid rupture treatment. We report a case of successful recovery without any sequelae after cardiovascular collapse due to an unintentional common carotid artery (CCA) rupture during neck surgery. The exposed CCA was treated with a covered stent. In such a case, multidisciplinary cooperation is crucial.

Bupivacaine-induced Vasodilation Is Mediated by Decreased Calcium Sensitization in Isolated Endothelium-denuded Rat Aortas Precontracted with Phenylephrine

BACKGROUND: A toxic dose of bupivacaine produces vasodilation in isolated aortas. The goal of this in vitro study was to investigate the cellular mechanism associated with bupivacaine-induced vasodilation in isolated endotheliumdenuded rat aortas precontracted with phenylephrine. METHODS: Isolated endothelium-denuded rat aortas were suspended for isometric tension recordings. The effects of nifedipine, verapamil, iberiotoxin, 4-aminopyridine, barium chloride, and glibenclamide on bupivacaine concentration-response curves were assessed in endothelium-denuded aortas precontracted with phenylephrine. The effect of phenylephrine and KCl used for precontraction on bupivacaine-induced concentration-response curves was assessed. The effects of verapamil on phenylephrine concentration-response curves were assessed. The effects of bupivacaine on the intracellular calcium concentration ([Ca2+]i) and tension in aortas precontracted with phenylephrine were measured simultaneously with the acetoxymethyl ester of a fura-2-loaded aortic strip. RESULTS: Pretreatment with potassium channel inhibitors had no effect on bupivacaine-induced relaxation in the endothelium-denuded aortas precontracted with phenylephrine, whereas verapamil or nifedipine attenuated bupivacaine-induced relaxation. The magnitude of the bupivacaine-induced relaxation was enhanced in the 100 mM KCl-induced precontracted aortas compared with the phenylephrine-induced precontracted aortas. Verapamil attenuated the phenylephrine-induced contraction. The magnitude of the bupivacaine-induced relaxation was higher than that of the bupivacaine-induced [Ca2+]i decrease in the aortas precontracted with phenylephrine. CONCLUSIONS: Taken together, these results suggest that toxic-dose bupivacaine-induced vasodilation appears to be mediated by decreased calcium sensitization in endothelium-denuded aortas precontracted with phenylephrine. In addition, potassium channel inhibitors had no effect on bupivacaine-induced relaxation. Toxic-dose bupivacaine- induced vasodilation may be partially associated with the inhibitory effect of voltage-operated calcium channels.

Traumatic Lumbosacral Spinal Subdural Hematoma Mimicking Subdural Lipoma: Value of Computed Tomography / 대한정형외과학회잡지

Traumatic lumbosacral spinal subdural hematoma due to anatomical and pathological causes is rare, compared to epidural hematoma. If the time of trauma cannot be determined, intracranial and intraspinal signal intensity according to lapse of time are not coincident, resulting in confusion in terms of differentiation. Fat suppression magnetic resonance image (MRI) and computed tomography (CT) are utilized for differentiation. The intention of this study is to report on a case where spinal subdural hematoma of unknown time of occurrence is differentiated from subdural lipoma by taking advantage of fat suppression MRI and CT in order to perform an early surgical decompression with auxiliary review of literature demonstrating good prognosis of the procedure.

Phantom bladder pain / 대한마취과학회지

No abstract available.

A Patient with Kikuchi's Disease: What Should Pain Clinicians Do?

Kikuchi's disease (KD) is an idiopathic and self-limiting necrotizing lymphadenitis that predominantly occurs in young females. It is common in Asia, and the cervical lymph nodes are commonly involved. Generally, KD has symptoms and signs of lymph node tenderness, fever, and leukocytopenia, but there are no reports on treatment for the associated myofacial pain. We herein report a young female patient who visited a pain clinic and received a trigger point injection 2 weeks before the diagnosis of KD. When young female patients with myofascial pain visit a pain clinic, doctors should be concerned about the possibility of KD, which is rare but can cause severe complications.

Myocardial protective effect by ulinastatin via an anti-inflammatory response after regional ischemia/reperfusion injury in an in vivo rat heart model / 대한마취과학회지

BACKGROUND: Ulinastatin has anti-inflammatory properties and protects organs from ischemia/reperfusion-induced injury. The aim of this study was to investigate whether ulinastatin provides a protective effect on a regional myocardial ischemia/reperfusion injury in an in vivo rat heart model and to determine whether the anti-inflammatory response is related to its myocardial protective effect. METHODS: Rats were randomized to two groups. One group is received ulinastatin (50,000 U/kg or 100,000 U/kg) diluted in normal saline and the other group is received normal saline, which was administered intraperitoneally 30 min before the ischemic insult. Reperfusion after 30 min of ischemia of the left coronary artery territory was applied. Hemodynamic measurements were recorded serially during 6 h after reperfusion. After the 6 h reperfusion, myocardial infarct size, cardiac enzymes, myeloperoxidase activity, and inflammatory cytokine levels were compared between the ulinastatin treated and untreated groups. RESULTS: Ulinastatin improved cardiac function and reduced infarct size after regional ischemia/reperfusion injury. Ulinastatin significantly attenuated tumor necrosis factor-alpha expression and reduced myeloperoxidase activity. CONCLUSIONS: Ulinastatin showed a myocardial protective effect after regional ischemia/reperfusion injury in an in vivo rat heart model. This protective effect of ulinastatin might be related in part to ulinastatin's ability to inhibit myeloperoxidase activity and decrease expression of tumor necrosis factor-alpha.

Propofol has delayed myocardial protective effects after a regional ischemia/reperfusion injury in an in vivo rat heart model / 대한마취과학회지

BACKGROUND: It is well known that propofol protects myocardium against myocardial ischemia/reperfusion injury in the rat heart model. The aim of this study was to investigate whether propofol provides a protective effect against a regional myocardial ischemia/reperfusion injury in an in vivo rat heart model after 48 h of reperfusion. METHODS: Rats were subjected to 25 min of left coronary artery occlusion followed by 48 h of reperfusion. The sham group received profopol without ischemic injury. The control group received normal saline with ischemia/reperfusion injury. The propofol group received profopol with ischemia/reperfusion injury. The intralipid group received intralipid with ischemia/reperfusion injury. A microcatheter was advanced into the left ventricle and the hemodynamic function was evaluated. The infarct size was determined by triphenyltetrazolium staining. The serum level of cardiac troponin-I (cTn-I) was determined by ELISA (enzyme-linked immunosorbent assay). RESULTS: Propofol demonstrated protective effects on hemodynamic function and infarct size reduction. In the propofol group, the +dP/dt(max) (P = 0.002) was significantly improved compared to the control group. The infarct size was 49.8% of the area at risk in the control group, and was reduced markedly by administration of propofol to 32.6% in the propofol group (P = 0.014). The ischemia/reperfusion-induced serum level of cTn-I was reduced by propofol infusion during the peri-ischemic period (P = 0.0001). CONCLUSIONS: Propofol, which infused at clinically relevant concentration during the peri-ischemic period, has delayed myocardial protective effect after regional myocardial ischemia/reperfusion injury in an in vivo rat heart model after 48 h of reperfusion.

The Effectiveness of a Three Phase Bone Scan for Making the Diagnosis of Complex Regional Pain Syndrome

BACKGROUND: Complex regional pain syndrome (CRPS) is still difficult to diagnose in the field of chronic pain management. CRPS is diagnosed by purely clinical criteria based on the characteristic signs and symptoms, which have to be differentiated from similar pain conditions like posttraumatic neuropathic pain. Until now, there has been a lack of objective diagnostic tools to confirm the diagnosis of CRPS. The aim of this study was to evaluate the usefulness of a three phase bone scan (TBS) for making the diagnosis of CRPS. METHODS: A total of 121 patients who had been diagnosed with CRPS were evaluated. All the patients were examined by performing a TBS as a part of the diagnostic work-up. A diffuse increased tracer uptake on the delayed image (phase III) was defined as a positive finding for CRPS. RESULTS: Forty-one patients (33.9%) out of 121 showed the positive results on the TBS. The patients with a duration of pain of less than 24 months had a significantly higher positive result (43.4%) on the TBS than did the patients with duration of pain longer than 24 months (12.1%). CONCLUSIONS: A TBS could give a better objective result for diagnosing CRPS for patients with a shorter duration of pain and a TBS gives little information for the diagnosis of CRPS in patients with a duration of pain longer than 24 months.

Implantable Intrathecal Drug Delivery Pump in Complex Regional Pain Syndrome Patient : A case report

Implantable intrathecal pump is one of the therapeutic options for intractable pain. A 24-year-old male with complex regional pain syndrome was suffering from right lower extremity pain. He had all modalities of treatment including spinal cord stimulator. However, his pain had been worse in the past 6 months. His visual analogue pain scale (VAS) was 8-10 and he could not sit or walk. Only opioid was thought to be effective. Then, intrathecal pump was considered. We estimated the minimal effective dose of spinal morphine before implantation. 0.3 mg of morphine was injected intrathecally as a starting dose. Dosage had been increased up to 0.8 mg in 10 days. His VAS score decreased from 8 to 5. He could sleep without pain and walk with crutch. Therefore, intrathecal pump was inserted. He could tolerate to pain. This case suggests that intrathecal morphine delivery can provide effective treatment for intractable non-malignant pain.

Inhibitory Effect of Fentanyl on Phenylephrine-Induced Contraction of the Rat Aorta

PURPOSE: Fentanyl was reported to inhibit the alpha1-adrenoceptor agonist-induced contraction. The goal of this in vitro study was to identify the alpha1-adrenoceptor subtype primarily involved in the fentanyl-induced attenuation of phenylephrine-induced contraction in isolated endothelium-denuded rat aorta. MATERIALS AND METHODS: Aortic rings were suspended in order to record isometric tension. Concentration-response curves for phenylephrine (10-9 to 10-5 M) were generated in the presence or absence of one of the following drugs: fentanyl (3x10-7, 10-6, 3x10-6 M), 5-methylurapidil (3x10-8, 10-7, 3x10-7 M), chloroethylclonidine (10-5 M) and BMY 7378 (3x10-9, 10-8, 3x10-8 M). Phenylephrine concentration-response curves were generated in the presence or absence of fentanyl in rings pretreated with either 3x10-9 M prazosin, 10-9 M 5-methylurapidil or 3x10-9 M BMY 7378. RESULTS: Fentanyl (10-6, 3x10-6 M) attenuated phenylephrine-induced contraction in the rat aorta. 5-Methylurapidil and BMY 7378 produced a parallel rightward shift in the phenylephrine concentration-response curve. The pA2 values for 5-methylurapidil and BMY 7378 were estimated to be 7.71 +/- 0.15 and 8.99 +/- 0.24, respectively. Fentanyl (10-6 M) attenuated phenylephrine-induced contraction in rings pretreated with 10-9 M 5-methylurapidil, but did not alter the rings when pretreated with 3x10-9 M BMY 7378. Pretreatment of the rings with chloroethylclonidine showed a 72.9 +/- 2.3% reduction in phenylephrine-induced maximal contraction. CONCLUSION: The results suggest that fentanyl attenuates phenylephrine-induced contraction by inhibiting the pathway involved in the alpha1D-adrenoceptor-mediated contraction of the rat aorta.

The Effect of the Spinal Block Level on the Requirements of Propofol for Sedation / 대한마취과학회지

BACKGROUND: It has been reported that spinal anesthesia has a sedative effect and so this decreases the hypnotic requirement of intravenous anesthetic. Therefore, we have conducted a prospective randomized study to investigate the effect of the spinal anesthesia level on the hypnotic requirements for conscious sedation. METHODS: Forty adult patients were scheduled to undergo spinal anesthesia, and they were randomly allocated to one of the two groups. After subarachnoid injection of 0.5% hyperbaric bupivacaine 16 mg, the patients in group 1 and group 2 were maintained in a reversed Trendelenburg position and a Trendelenburg position, respectively. After fifteen minutes, the target controlled infusion of propofol was started for achieving a target concentration of 1 microgram/ml, and the mean BIS for 1 min was checked after an effect site concentration (Ce) of 1 microgram/ml was reached. The target controlled infusion of propofol was restarted at a target concentration (Tc) of 1.5 microgram/ml, and the mean BIS for 1 min was checked after the Ce level of 1.5 microgram/ml was reached. RESULTS: The mean BIS at 1 microgram/ml Ce was 90.0 +/- 8.5 and 77.8 +/- 10.3 in group 1 and group 2, respectively. The mean BIS at 1.5 g/ml Ce was 73.6 +/- 19.4 and 60.0 +/- 13.1, respectively. CONCLUSIONS: There was a significant difference in the requirements of propofol for conscious sedation between the below T12 block group and the above T4 block group.

Comparison of Ventilations with LMA and Endotracheal Tube during Closed Circuit Anesthesia / 대한구급학회지

BACKGROUND: LMA has larger dead-space than tracheal tube, ventilation may be influenced by difference of dead space. Closed circuit mechanical ventilation has high risk of hypercarbia because of inadequate CO2 elimination or gas supply. Thus, end-tidal carbon dioxide tension (EtCO2) and arterial carbon dioxide tension (PaCO2) were compared during closed circuit mechanical ventilation with LMA or tracheal tube. METHODS: Thirty adult patients scheduled for general anesthesia were divided into 2 groups. After induction of general anesthesia, laryngeal mask airway (Group 1, n=15) or tracheal tube (Group 2, n=15) were randomly inserted and closed circuit mechanical ventilation was initiated. When steady state had been reached, PaCO2 and EtCO2 were recorded. RESULTS: The PaCO2 was 32.2+/-2.8 (Group 1), 31.5+/-2.2 (Group 2) and the EtCO2 was 33.0+/-2.9, 31.6+/-2.4 respectively and there was no statistical significance between groups. The difference of arterial and end-tidal carbon dioxide tension in each group was -0.8+/-2.6, -0.03+/-2.2 respectively and there was no statistical significance between groups. CONCLUSIONS: The results indicate that in patients who are mechanically ventilated via the closed circuit system, EtCO2, PaCO2, and the difference between arterial and end-tidal carbon dioxide tension were not significantly different between groups.