The Effects of GABA-receptor Antagonists on the Spinal Cord Stimulation-induced Antinociception in Cats / 대한마취과학회지

BACKGROUND: Spinal cord stimulation (SCS) is a clinical off spring of the gate-control theory and known as an effective treatment for pain from a neurogenic origin. The prolonged pain relief following a short stimulation period is believed to be related with the GABAergic system. The aims of this study were to see if the SCS, similar to that being used in clinical condition, suppressed the nociceptive transmission in the spinal dorsal horn, and if so, which type of GABA receptor may be involved in the antinociceptive process. METHODS: The cord dorsum potential (CDP) was recorded at the dorsal root entry zone of the lumbosacral enlargement for a long time period (60 min) in response to electrical stimulation of the dorsal root, respectively, after SCS in anesthetized cats. CDP was recorded after intrathecal application of bicuculline (GABA (A) receptor antagonist) and phaclofen (GABA (B) receptor antagonist) and 20 min after SCS that followed the intrathecal application of bicuculline or phaclofen. Asigma- and C-fiber wave responses were differentiated according to the conduction velocity. RESULTS: The C-fiber wave decreased significantly after SCS but the Asigma-fiber wave did not on the CDP. After intrathecal administration of bicuculline, the Asigma- and C-fiber waves increased significantly and bicuculline also prevented a SCS-induced reduction of the C-fiber wave. Phaclofen did not change the amplitude of Asigma- and C-fiber wave. When the phaclofen was administered intrathecally, SCS did not decrease the amplitude of the Asigma- and C-fiber waves. CONCLUSIONS: In conclusion, the present results indicate that SCS suppresses C-fiber transmission of acute nociceptive electrical stimuli and both GABA (A) and (B) receptors mediate the long-lasting antinociceptive effect of SCS.

Anesthetic Management of Cesarean Section in Parturient with Systemic Sclerosis / 대한마취과학회지

Systemic sclerosis is a multisystemic disorder of unknown etiology characterized by fibrosis of skin, blood vessel, and visceral organ. A 38-week pregnant, 29 year-old woman with systemic sclerosis and migraine was scheduled for cesarean section under lumbar epidural anesthesia because of dyspnea, decreased diffusion lung capacity and Raynaud's phenomenon. She suffered from sudden onset of severe headache, repetitive nausea, vomiting, and hypertension during cesarean section under the epidural anesthesia. The above symptoms did not respond to beta-blocker, vasodilator during the operation period. In the recovery room, the headache and vomiting were relieved by intravenous injection of ketorolac and metoclopramide. She experienced single tonic-clonic generalized seizure and intermittent migraine after operation in the ward, and discharged 7 days after operation.

Outcomes of Epiduroscopy Using Less Than 50 ml of Normal Saline in Low Back and Lower Extremity Pain Patients / 대한마취과학회지

BACKGROUND: Epidural adhesion can cause pain from compression and irritation of nerves. But a simple injection into the lumbar epidural space usually goes into the area of least resistance and cannot deliver the medication to the target area. Thus, the adhesiolysis of the affected area is sometimes mandatory. We performed an adhesiolysis, irrigating with normal saline, and targeted an injection of a local anesthetic and steroid mixture to the epidural space, using a flexible catheter-secured epiduroscopic unit in 15 patients with low back pain, and assessed the pain score changes. METHODS: With the patient in the prone position, the epidural space was entered with a 17-gauge Tuohy needle. A guide-wire was inserted through the needle and advanced under fluoroscopic guidance to the level of the suspected pathology. A catheter was then advanced over the guide-wire. After the removal of the guide-wire, an adapter was then attached to the proximal end of the catheter, and its side arm was connected to a syringe containing normal saline flush. The 0.9 mm diameter fiberoptic scope was introduced into the catheter via the adaptor, and a video camera was then attached. Gentle irrigation of normal saline less than 50 ml distended the epidural space. The catheter and fiberoptic scope were advanced to the adhesion area and adhesiolysis was done by moving the tip of the steering catheter. Assuming that original NRS (Numeric Rating Scale) before the procedure was 10, we asked the NRS at 1, 4, 8, 12, 16 weeks after the epiduroscope. RESULTS: NRS at 1, 4, 8, 12, 16 weeks after the epiduroscope showed significant decrease of both low back pain and radiating pain, compared with the original pain (P<0.05). CONCLUSIONS: The flexible catheter-secured epiduroscopic unit proved to be painless, safe, and more simple, than an operation, it is, thus, a practical method for pain relief using adhesiolysis and irrigation of epidural space under the direct visualization of the epidural space in patients with low back and lower extremity pain.

Tracheo-Innominate Artery Fistula in Long Term Tracheostomy Patient / 대한마취과학회지

Tracheo-innominate artery fistula (TIF) is a life-threatening complication of tracheostomy that manifests with acute and massive bleeding. We present a patient who deveoloped a TIF and underwent a division of the fistula, interrupting the innominate artery. Successful management of a patient with TIF requires the rapid institution of specific resuscitative and operative measures. The patient arrived at the emergency room with acute massive tracheal bleeding, respiratory difficulty, decreased consciousness and ensuing cardiac arrest. After the tracheal cuff was fully inflated, cardiopulmonary resuscitation was started. Fortunately, the bleeding was stopped and heart rate and blood pressure were normalized. Before performing the cerebral angiography, the patient was intubated orally for rebleeding. The patient was admitted to the intensive care unit and stayed for 29 days due to weaning failure from the ventilator. After repair of tracheal stenosis, a permanent tracheostomy was instituted. The patient had no respiratory difficulty or massive tracheal bleeding during the 2 months after discharge except one episode of minor bleeding.