The effect of high concentration of magnesium with ropivacaine, gentamicin, rocuronium, and their combination on neuromuscular blockade / 대한마취과학회지

BACKGROUND: Magnesium, ropivacaine, gentamicin, and rocuronium block neuromuscular (NM) transmission by different mechanisms. Therefore, concurrent administration of these agents may induce prolonged muscle paralysis via synergistic interaction. This study investigated the efficacy and safety of NM block caused by the administration of high concentrations of magnesium in combination with ropivacaine, gentamicin, and rocuronium. METHODS: Eighty-three left phrenic nerve-hemidiaphragms from male SD rats (150-250 g) were hung in Krebs solution. Three consecutive single twitch tension (ST, 0.1 Hz) and one tetanic tension (TT, 50 Hz for 1.9 s) were obtained before drug application and at each new drug concentration. The concentration of MgCl2 and MgSO4 in Krebs solution was increased until an 80 to 90% reduction in ST was reached. To test the effects of combinations of NM agents, a Krebs solution was premixed with MgCl2 alone, MgCl2 and ropivacaine, or MgCl2, ropivacaine, and gentamicin. The concentration of ropivacaine, gentamicin, or rocuronium was then progressively increased until an 80 to 90% reduction in ST was reached. The effective concentrations were estimated with a probit model. RESULTS: The potency of MgCl2 was greater than that of MgSO4, and pretreatment with MgCl2 increased the potency of gentamicin and rocuronium. Unexpectedly, MgCl2 did not potentiate ropivacaine, and the potency of gentamicin and rocuronium failed to show an increase when premixed with 0.5 microM ropivacaine. CONCLUSIONS: The concomitant administration of high concentrations of magnesium and ropivacaine together with clinically relevant concentrations of gentamicin or rocuronium potentiated NM blockade but not with clinically relevant concentrations of ropivacaine.

Using fuzzy-set qualitative comparative analysis / 한국역학회지

No abstract available.

A comparison of i-gel(TM) and LMA Supreme(TM) in anesthetized and paralyzed children / 대한마취과학회지

BACKGROUND: Both the i-gel(TM) (i-gel) and LMA Supreme(TM) (Supreme) are new single-use second generation supraglottic airway devices available in pediatric sizes. This study was designed to investigate the i-gel in comparison with the Supreme in children undergoing general anesthesia. METHODS: One hundred children with American Society of Anesthesiologists physical status I or II undergoing general anesthesia were randomly assigned to either the i-gel or the Supreme group (50 children in each group). The device size was chosen according to weight of the children. We assessed the insertion success rate, insertion time, oropharyngeal leak pressure, grade of the fiberoptic glottic view, number of airway manipulations required, and postoperative complications. RESULTS: There were no differences in the demographic data between the two groups. The success rate of insertion was same in both groups. The insertion time of the i-gel was longer than that of Supreme (P = 0.004). The oropharyngeal leak pressure in the i-gel group was higher than that in the Supreme group (P = 0.013). On fiberoptic examination, the vocal cords were visible in 90% of the children in the i-gel group and in 96% of the children in the Supreme group. The number of airway manipulations required was higher in the i-gel group (14 cases) than in the Supreme group (1 case) (P < 0.001). There were no differences in complications including blood staining of the device and sore throat between both groups. CONCLUSIONS: Both the i-gel and Supreme provided a satisfactory airway during general anesthesia in children. Compared to the Supreme, the i-gel demonstrated a higher oropharyngeal leak pressure, longer time for insertion, and a greater number of airway manipulations during anesthesia.

Effect of ketamine and midazolam on oculocardiac reflex in pediatric strabismus surgery / 대한마취과학회지

BACKGROUND: The oculocardiac reflex (OCR) can be elicited during manipulation of the orbital structures in the strabismus correction surgery. A sinus bradycardia is the most common manifestation of OCR; and cardiac dysrhythmia and asystole may also occur. Various efforts to reduce OCR have been attempted, but without coherent outcome results. METHODS: Sixty one children, undergoing elective strabismus surgery, were randomly allocated into 2 groups: Group K received ketamine 1.0 mg/kg; and Group M received midazolam 0.15 mg/kg for induction of anesthesia. Anesthesia was maintained with 1-1.3 MAC of sevoflurane with 50% N2O in O2. Heart rate and blood pressure were measured 30 seconds before extraocular muscle (EOM) traction and immediately after traction. The OCR was defined as a decrease in heart rate more than 20% of the baseline heart rate, following manipulating EOM. Postoperative nausea and vomiting (PONV) and emergence agitation (EA) were assessed in postanesthetic care unit (PACU). RESULTS: Blood pressure before tightening EOM in Group K was higher than that in Group M (P < 0.05). However Delta HR (2.7 +/- 15% vs. - 0.9 +/- 16%) and incidence of OCR (10.0% vs. 19.4%) after traction an EOM were not different between the two groups. The occurrence of PONV (6.7 vs. 9.7%) and EA (30.0% vs. 22.6%) were similar. CONCLUSIONS: Ketamine does not reduce the incidence of OCR compared with midazolam in pediatric strabismus surgery. In addition, ketamine does not increase the incidence of PONV and EA. In conclusion, it is reliable to use ketamine in pediatric strabismus surgery.

Risk factors of emergence agitation after general anesthesia in children: multicenter study

BACKGROUND: Emergence agitation (EA) frequently occurs after general anesthesia in children. This multicenter study was investigated to determine incidence and risk factors of EA after general anesthesia in children. METHODS: This prospective study evaluated 816 pediatric patients receiving elective surgery under general anesthesia at 10 university hospitals. Emotional and behavioral status of the patients upon emergence from anesthesia was assessed by Aono's four point scale. Those with an Aono's four point scale of 3 or 4 were considered to be affected by EA. Patient physical, anesthetic, and surgical variables were analyzed to find the risk factors of EA. RESULTS: One-hundred-fifty-two children (18.6%) developed EA. No relationships between the incidence of EA and age, sex, ASA physical status, premedicants, anesthetic induction agents, anesthetic maintenance methods, or postoperative analgesia were found. A multivariate analysis identified preanesthetic emotional status (OR = 1.774, P < 0.001), perioperative airway complication (OR = 1.867, P < 0.007) and rhinolaryngologic surgery (OR = 1.597, P < 0.017) as risk factors of EA. CONCLUSIONS: Preanesthetic emotional status, perioperative airway complication and rhinolaryngologic surgery were risk factors of EA after general anesthesia in children.

Effect of ketorolac and diclofenac on the impairment of endothelium-dependent relaxation induced by reactive oxygen species in rabbit abdominal aorta / 대한마취과학회지

BACKGROUND: Reactive oxygen species (ROS) induce lipid peroxidation and tissue damage in endothelium. We studied the influences of ketorolac and diclofenac on ROS effects using the endothelium of rabbit abdominal aorta. METHODS: Isolated rabbit aortic rings were suspended in an organ bath filled with Krebs-Henseleit (K-H) solution bubbled with 5% CO2 and 95% O2 at 37.5degrees C. After being stimulated to contract with phenylephrine (PE, 10(-6) M), changes in arterial tension were recorded following the cumulative administration of acetylcholine (ACh, 3 x 10(-8) to 10(-6) M). The percentages of ACh-induced relaxation of aortic rings before and after exposure to ROS, generated by electrolysis of K-H solution, were used as the control and experimental values, respectively. The aortic rings were pretreated with ketorolac or diclofenac at the same concentrations (10(-5) M to 3 x 10(-4) M), and the effects of these agents were compared with the effects of ROS scavengers: catalase, mannitol, sodium salicylate and deferoxamine and the catalase inhibitor, 3-amino-1,2,4-triazole (3AT). RESULTS: Both ketorolac and diclofenac maintained endothlium-dependent relaxation induced by ACh in a dose-related manner inspite of ROS attack (P < 0.05 vs. control value). The 3AT pretreated ketorolac (3 x 10(-3) M) group was decreased more significantly than un-pretreated ketorolac (P < 0.05). CONCLUSIONS: These findings suggest that ketorlac and diclofenac preserve the endothelium-dependent vasorelaxation against the attack of ROS, in a concentration-related manner. One of the endothelial protection mechanisms of ketorolac may be hydrogen peroxide scavenging.

Invasive Squamous Cell Carcinoma of the Oral Mucosa Associated with HPV Type 53

A 77-year old man presented with a fungating mass on the oral mucosa and lip, which had an irregular margin. An incisional biopsy of the mass revealed an invasive squamous cell carcinoma. PCR analysis detected HPV DNA in the biopsy specimen. The HPV type was determined as HPV-53 by direct cycle sequencing. This is the first report of HPV-53 in an oral malignant tumor.

The Effect of Intravenous Lipo-Prostaglandin E1 Injectioin in a Rat Foraminal Stenosis Model / 대한통증학회지

BACKGROUND: Lipo-prostaglandin E1 (Lipo-PGE1) has vasodilating and platelet aggregation inhibitory characteristics and it has been used as a treatment for patients with blood flow dysfunction disease. Based on the mechanisms of lumbar spinal stenosis, including veno congestion, neuro-ischemia and mechanical compression, we aimed to study whether intravenous Lipo-PGE1 injection has any therapeutic effect on hyperalgesia in a rat foraminal stenosis model. METHODS: In this study, twenty male Sprague-Dawley rats were divided into the control (n = 10) and Lipo-PGE(1)(n = 10) groups. A small stainless steel rod was inserted into the L5-6 intervertebral foramen to induce intervertebral foramen stenosis and chronic DRG compression. In the Lipo-PGE1 group, 0.15micron g/kg of Lipo-PGE(1) were injected intravenously via a tail vein for 10 days starting from the 3rd day after operation. Behavioral testing for mechanical and thermal hyperalgesia was performed for 3 weeks after the injections. RESULTS: From the 10th day after Lipo-PGE(1) injection, the rats in the experimental group showed significant recovery of their mechanical threshold, and this effect was maintained for 3 weeks. No significant differences of the thermal hyperalgesia were observed between the two groups. CONCLUSIONS: These findings suggest that intravenously injected Lipo-PGE1 may be effective for alleviating neuropathic pain, which isthe main symptom of spinal stenosis, by improving the blood flow dysfunction.

The Usefulness of Three-phase Bone Scan and Thermography for Making the Diagnosis of CRPS-I / 대한통증학회지

BACKGROUND: Complex regional pain syndrome (CRPS) is a painful and disabling disease, yet the diagnosis of this can be difficult to confirm by purely objective measures. Therefore, we performed three-phasic bone scans and thermography as a work up in order to determine their predictive value and usefulness for making the diagnosis of CRPS. METHODS: 44 patients who had been diagnosed with CRPS type-1, according to the modified criteria, were evaluated. All the patients were examined by performing a three-phasic bone scan and thermography as part of a work-up for diagnostic confirmation. The diffuse increased tracer uptake in the delayed image (phase III) was estimated by the positive findings. The findings were considered positive for CRPS if the thermographic findings showed temperature asymmetries between the affected and non-affected extremities of more than 1.00 degrees C RESULTS: A review of the three-phasic bone scan for 44 patients indicated that 16 patients (36.4%) had diffusely positive scans, and thermographic abnormalities were noted in 35 of 44 patients (79.5%). CONCLUSIONS: The use of thermography in clinical settings can play an important role in the diagnosis of CRPS. However, a three-phasic bone scan alone cannot provide a completely accurate diagnosis, so it is imperative that the three-phasic bone scan data be integrated with the clinical evaluation and the other relevant tests.

A Case of Toxic Epidermal Necrolysis Treated with Intravenous Immunoglobulin / 대한피부과학회지

Toxic epidermal necrolysis (TEN) is a rare, life-threatening, mucocutaneous drug reaction, which causes extensive epidermal detachment and serious complications involving ocular structures and internal organs. Recently, intravenous immunoglobulin (IVIG) was suggested to be effective in treating TEN through the blockage of Fas receptors which initiate keratinocyte apoptosis. Herein, we tried IVIG teratment (0.6 g/kg/day for 4 consecutive days) for a case of TEN. As a result, the progression of epidermal detachment was interrupted within 2 days and epithelialization was completed in 3 weeks without significant side effects.

A Case of Toxic Epidermal Necrolysis Treated with Intravenous Immunoglobulin / 대한피부과학회지

Toxic epidermal necrolysis (TEN) is a rare, life-threatening, mucocutaneous drug reaction, which causes extensive epidermal detachment and serious complications involving ocular structures and internal organs. Recently, intravenous immunoglobulin (IVIG) was suggested to be effective in treating TEN through the blockage of Fas receptors which initiate keratinocyte apoptosis. Herein, we tried IVIG teratment (0.6 g/kg/day for 4 consecutive days) for a case of TEN. As a result, the progression of epidermal detachment was interrupted within 2 days and epithelialization was completed in 3 weeks without significant side effects.

A Case of Epithelioid Angiosarcoma on the Back / 대한피부과학회지

Epithelioid angiosarcoma has recently been described as a variant of angiosarcoma, based on its pathologic feature which is characterized by epithelioid or histiocytoid morphology of the malignant tumor cells. We report a case of epithelioid angiosarcoma on the lower back of a 65-year-old man. The patient had several, variable-sized, pedunculated, fungating masses. On histopathologic examination, the tumor was chiefly composed of solid sheets of atypical epithelioid cells with prominent eosinophilic cytoplasm, a large vesicular nuclei, and occasional intracytoplasmic vacuoles. Primitive vascular spaces, and a cleft with malignant cells and proliferating vessels were also found in some areas. The reticulum stain and immunohistochemical stain using factor VII-related antigen and CD 31 were focally positive in the tumor. He was treated by wide surgical excision.

A Case of Prurigo Nodularis Treated with Narrow-band UVB and Naltrexone / 대한피부과학회지

Prurigo nodularis is a distressing, chronic disease, which is considered to be very resistant to therapy. Treatment choice is quite limited. Among them, opiate antagonist and phototherapy have been used with satisfactory results. We report a case of treatment-resistant prurigo nodularis. Narrow band-UVB phototherapy was performed twice weekly for 3 months. Naltrexone 50mg was also taken daily before sleep. Pruritus was midly reduced after 1 week, and had almost completely disappeared after 3 months of treatment.

Anesthetic Management of a Pregnant Patient with Severe Form of Preeclampsia and Cardiac Tamponade associated with Hypothyroidism for Emergency Cesarean Section: A case report / 대한마취과학회지

A 29-year-old gravida 1, para 0 patient was admitted at 31 weeks gestation with hypertension, proteinuria and generalized edema. Three days after admission, she developed cardiac tamponade, a severe form of preeclampsia, and premature labor. Anesthesia for pericardiocentesis consisted of local anesthetic infiltration of the anterior chest wall, supplemented with an oxygen mask(5 L/min). After drainage of pericardial fluid, emergency cesarean section was performed under general anesthesia. After surgery, she was studied for the cause of the cardiac tamponade, and subsequently was diagnosed to have hypothyroidism. Pericardial effusion as a hypothyroidism associated sign, is something that is frequently found; nevertheless, cardiac tamponade as the first sign of this disease may be considered exceptional especially in a pregnant woman. We exprienced a case of hypothyroidism during a 29-year-old woman's first pregnancy, complicated by a severe form of preeclampsia and pericardial effusion.

Extrasinusal Dural Arteriovenous Malformation Misdiagnosed as Intraorbital Tumor

Dural arteriovenous malformations are rare, accounting for 10-15% of all intracranial arteriovenous malformation and are thought to be acquired lesion caused by dural sinus thrombosis. The authors report a rare case of extrasinusal dural arteriovenous fistula in the right middle fossa adjacent to the superior orbital fissure. During the preceding 17 years, this 31-year-old female had complained of proptosis and ocular pain in the right eye. Computed tomography and magnetic resonance imaging showed a retrobular intraconal mass in the right orbit; Angiography revealed an extrasinusal dural arteriovenous fistula in the right middle fossa adjacent to the superior orbital fissure, which drains into the superior ophthalmic and inferior temporal vein. After embolization of the fistula by injection of N-butylcyanoacrylate(NBCA), we intended to remove the retrobulbar intraconal mass seen on CT and MRI by means of a unilateral partial orbitotomy on the supraorbital rim and orbital roof, and to this end, explored the right orbit. We were unable, however, to locate any mass lesion in the orbital cavity, and postoperative CT and MRI showed no such lesion. We were of the opinion that the mass shown on preoperative CT and MRI was a dilated intraorbital vein structure which disappeared after embolization, operative ligation and cutting of the dural arterivenous fistula. Finally, proptosis and ocular pain disappeared, and the patient recovered with any no neurologic deficit.

Effects of Nimodipine Treatment on Aneurysmal Subarachnoid Hemorrhage

Nimodipine, a potent, central active, calcium channel blocker, is known to relieve vasospasm, increase cerebral blood flow(CBF) and affect positively on clinical outcome in patients with subarachnoid hemorrhage. Experimentally, the potent effects on both vascular dilatation and increasing CBF were proven. However, there are still controversies and many debates at present about the actual clinical effects of nimodipine on subarachnoid hemorrhage. To evaluate the clinical effectiveness of nimodipine on aneurysmal subarachnoid hemorrhage in our series, we analyzed 122 consecutive patients with ruptured aneurysms who underwent operations between October, 1993 and June, 1995. These patients were grouped as follow: Group I consisted of 63 cases(52%) in which the patients were treated with nimodipine and Group II consisted of 59 cases(48%) in which the patients were treated conventionally. Administration of nimodipine was started immediately after the radiological diagnosis of ruptured aneurysm. The dose of nimodipine was 0.5microg/kg/min via continuous intravenous infusion for 7 to 10 days after the subarachnoid hemorrhage. After a course of intravenous treatment, oral administration of nimodipine was then continued for up to 21 days after subarachnoid hemorrhage in a dose of 60mg every four hours. We analyzed two groups based on patient's age, sex, aneurysmal location and size, timing of surgery, presence of hypertension, Hunt-Hess grade, presence of vasospasm on preoperative angiography and Fisher's CT classification. We also analyzed the incidence of delayed ischemic deficits(DID) and outcome(GOS) in each group. There were no significant differences in any of these parameters between nimodipine-treated group and the control group(p>0.05) and also, no significant differences in the distribution of DID or outcome between two groups (p>0.05). Based on these results, we conclude that nimodipine does not provide any significant beneficial effects on the prevention of DID and outcome in the patients with aneurysmal subarachnoid hemorrhage.