Anesthetic management of a patient with Arnold-Chiari malformation type I with associated syringomyelia: A case report

Arnold-Chiari malformation type I (ACM I) is anatomically defined as the displacement of the cerebellar tonsils below the level of the foramen magnum. Syringomyelia is a condition in which a cavity called a syrinx develops in the spinal cord and is filled with cerebrospinal fluid. Here we report the anesthetic management of a case of ACM I with associated syringomyelia scheduled for suboccipital craniectomy, cervical laminectomy and duraplasty.

Treatment of Intractable Hiccups With an Oral Agent Monotherapy of Baclofen: A Case Report

Hiccups are an involuntarily powerful spasm of the diaphragm, followed by a sudden inspiration with a closure of the glottis. Hiccups that are caused by gastric distention, spicy foods and neural dysfunction can resolve themselves without any treatment. Some hiccups are associated with certain diseases or they occur postsurgically, and life-restricting intractable hiccups should be treated. The cause of hiccups should be quickly determined so as to administer the proper treatment. Hiccups often remit spontaneously within a short period of time, but they may also occur without remission for a prolonged period in some cases. We report here on a 36-year-old man who suffered with intractable hiccups for 5 years. We administered a single oral dose of baclofen, and then the hiccups disappeared. We conclude that a single dose of baclofen is a good treatment for intractable hiccups.

The preventive effect on postanesthetic shivering according to the dosages of ketamine / 대한마취과학회지

BACKGROUND: Postanesthetic shivering affects up to 65% of patients after general anesthesia, and it can be very distressing. Various drugs have been used to treat or prevent postanesthetic shivering, but the ideal drug has not yet been found. The aim of this study was to find the minimum dose of ketamine that would show an antishivering effect. METHODS: Ninety patients scheduled for total or subtotal thyroidectomy under general anesthesia were randomly allocated to three groups: Patients received saline 3 cc (Group 1; n = 30), ketamine 0.5 mg/kg (Group 2; n = 30) or ketamine 1.0 mg/kg (Group 3; n = 30) at the end of surgery. The postanesthetic shivering was evaluated by an blind investigator who was "blinded" to the dose of ketamine. The grade of shivering was assessed using a five-point scale at 0, 10, 20 and 30 minutes after the arrival to the recovery room. RESULTS: The number of patients shivering on arrival to the recovery room, and at 10 minutes after the arrival of recovery room was significantly less in Groups 2 and 3 than in Group 1 (P < 0.05). However, at 20 and 30 minutes, the number of patients was not different among the groups. There was no difference within the groups that received ketamine. CONCLUSIONS: The prophylactic use of 0.5 mg/kg intravenous ketamine was effective in preventing shivering after general anesthesia.

The Effect of Preoperative Dexamethasone Administration, according to Age and Gender on Postoperative Pain in Patients who Undergo Laparoscopic Choelecystectomy / 대한통증학회지

BACKGROUND: Preoperative dexamethasone improves the surgical outcome after laparoscopic cholecystectomy (LC). The purpose of this study was to determine the effect of preoperative dexamethasone on the postoperative pain according to age and gender in patients who undergo LC. METHODS: In this double blind prospective study, 400 patients, males or females or = 65 yr (n = 50 in each of eight groups) who undergoing LC were randomized to receive dexamethasone 8 mg (5 ml) or saline 5 ml intravenously 100 minutes before their operation. Postoperative pain was assessed on a visual analog scale (VAS) at 1, 6, 12, and 24 hour, and the time to administering the first postoperative analgesics was recorded. RESULTS: Dexamethasone was administered without consideration for age and gender, and it reduced the postoperative pain VAS score at 1, 6, and 12 hours, and the opioid analgesic requirement, but there was no significant difference between administering saline or dexamethasone in the same gender and age groups. Females or = 65 yr who were administered dexamethasone had the least pain sensitivity. CONCLUSIONS: Preoperative dexamethasone reduces the pain intensity and opioid consumption, but does not reduce the pain intensity, according to age and gender in the patients undergoing LC. As a result, preoperative dexamethasone should be considered for routine use for patients who are undergoing laparoscopic cholecystectomy.

Delayed Recovery of Neuromuscular Blockade by Rocuronium in a Patient with Charcot-Marie-Tooth Disease: Case reports / 대한마취과학회지

Charcot-Marie-Tooth disease, which is also known as hereditary motor and sensory neuropathy, is a heterogenous group of inherited diseases of the peripheral nerve. The spectrum of severity varies from asymptomatic individuals to those with severe limb abnormalities requiring corrective surgery. We report two brothers who had previously been diagnosed with Charcot-Marie- Tooth disease 3 years earlier and were scheduled to undergo a correction osteotomy of both feet under general anesthesia. General anesthesia was induced with propofol 2 mg/kg, rocuronium 0.8 mg/kg and was maintained with O2-N2O-Sevoflurane. The younger brother showed no delay in recovery of the neuromuscular blockade but the elder brother showed a delay.

The Trial of Continuous Intravenous Infusion of Magnesium in Patients with Postherpetic Neuralgia Refractory in Conventional Treatment: A report of 2 cases / 대한마취과학회지

Postherpetic neuralgia is one of the most troublesome diseases in pain clinics. The N-methyl-D-aspartate (NMDA) receptor antagonist, magnesium, reduces the level of neuropathic pain and hyperalgesia in patients with postherpetic neuralgia. Magnesium has been shown to exert a physiological block of the ion channel on the NMDA receptor, thereby preventing extracellular calcium ions from entering the cell and contributing to secondary neuronal changes. Accordingly, we attempted to administer a continuous intravenous infusion of magnesium, which resulted in a decrease in the VAS without side effects.

The Analgesic Effect of Continuous Intraarticular Infusion of Ropivacaine and Fentanyl after Arthroscopic Shoulder Surgery / 대한마취과학회지

BACKGROUND: Arthroscopic shoulder surgery can result in moderate to severe postoperative pain. This study compared the postoperative analgesic effects of an intra-articular patient-controlled analgesia (PCA) infusion of 0.25% ropivacaine used with or without fentanyl after arthroscopic shoulder surgery. METHODS: Sixty patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly assigned to three groups. After surgery, normal saline 21 ml (group 1; n = 20), and 0.25% ropivacaine 21 ml (group 2 and group 3; n = 20 respectively), was infused into the articular space through a PCA catheter, which was followed by an infusion of normal saline 99 ml (group 1), 0.25% ropivacaine 99 ml (group 2), or 0.25% ropivacaine 99 ml, including fentanyl 400microgram (group 3) through the intra-articular PCA catheter at 2 ml/hr with a bolus dose of 0.5 ml with a lock out time of 15 minutes. The level of pain was assessed using a visual analogue scale (VAS) and a verbal pain score (VPS) 2, 4, 6, 8, 12, 24 and 36 hours after the intra-articular bolus injection. RESULTS: The pain scores were significantly lower after 2, 4, 6 hours in group 2 and 3 than in group 1. However, after 8 hours, the pain scores were significantly lower in group 3 than in the other two groups. CONCLUSIONS: An intra-articular continuous infusion of 0.25% ropivacaine after arthroscopic shoulder surgery is more effective when used in conjunction with 400 microgram fentanyl.

Transient Global Amnesia Developed in Recovery Room following General Anesthesia: A case report / 대한마취과학회지

Transient global amnesia is characterized by a sudden inability to form new memories (anterograde amnesia) that usually last for minutes to several hours but never longer than 24 hours. and there are no other focal neurologic signs or symptoms. Retrograde amnesia from a few hours to many years may also be associated with this condition. We report a case of a 56-year-old female patient who experienced transient global amnesia in the recovery room after general anesthesia. She repeated the same queries several times to persons nearby and appeared perplexed. A detailed neurologic examination was otherwise entirely normal. Her symptoms resolved completely the next day.

The Effect of Preoperative Dexamethasone on Profopol Injection Pain, Postoperative Nausea and Vomiting Undergoing Otolaryngology-Head and Neck Surgery / 대한마취과학회지

BACKGROUND: Induction with propofol has a high incidence of pain, as well as postoperative nausea and vomiting (PONV). The aim of this study was to assess the effect of a course of dexamethasone on the pain, postoperative nausea and vomiting associated with a Propofol injection, in patients undergoing otolaryngology-head and neck surgery. METHODS: One hundred twenty adults, 20-60 years of age, ASA physical status I or II, were allocated to one of two groups. Either dexamethasone 5 ml (8 mg) or saline 5 ml was administered intravenously to each group. After 60 seconds, propofol was injected into the patients' hand veins over a 30 second period and the patient was asked questions regarding the injection pain after 10 seconds. Postoperative nausea, vomiting and post-tonsilectomy pain were recorded in the recovery room (1 h after surgery) and in the hospitalization area (6 h after surgery). RESULTS: The severity and incidence of pain at the time of the propofol injection, PONV, and the level of post-tonsillectomy pain were significantly lower in the dexamethasone group than in the control group. CONCLUSIONS: The prophylactic intravenous administration of 8 mg dexamethasone is effective in reducing the severity of pain after a propofol injection and after the tonsillectomy, and decreased the incidence of PONV.

The Trial of Continuous Intravenous Infusion of Ketamine in Patients with Phantom Limb Pain: A case report / 대한통증학회지

Phantom limb pain is a painful sensation from an absent limb. The onset of pain is generally early, with 75% of patients developing pain within the first few days after amputation. The frequency and duration of attacks tend to be reduced with time, although the prevalence and intensity remain constant. We report here a case of a 38-year-old man who exhibited the signs and symptoms of phantom limb pain due to the above-knee amputations of both legs. He was not responded to opioid therapy and a continuous intravenous infusion of ketamine, an N-methyl-D-aspatate receptor antagonist, reduced his severe pain.

A Case of Malignant Hyperthermia during General Anesthesia with Sevoflurane: A case report / 대한마취과학회지

We experienced a malignant hyperthermia in 24-year-old male with sevoflurane during the mandibular prognathism surgery. The malignant hyperthermia emerged 150 minutes after induction of general anesthesia using propofol, rocuronium, sevoflurane, N2O and O2. Sevoflurane has been reported that it can induce delayed onset of malignant hyperthermia under absence of succinylcholine. The prognosis of malignant hyperthermia is determined by early recognition, vigorous treatment and the time of dantrolene injection. In our case, when we suspected episode, all anesthetics were stopped and dantrolene injection was immediately given intravenously. The patient recovered normal temperature and consciousness without any complication.

The Clinical Effects of a Small-dose of Intrathecal Bupivacaine and Alfentanil for Short-duration Surgery: A Randomized Double-blinded Study / 대한마취과학회지

BACKGROUND: High doses of intrathecal bupivacaine may produce a high level of sensory and motor block, and arterial hypotension and, Intrathecal opioids added to low-dose local anesthetics produced a synergistic effect Thus it may be possible to augment spinal anesthesia without delaying recovery. The aim of this study was to investigate the efficacy and adverse effects of adding alfentanil to intrathecal small-dose bupivacaine for short-duration surgery. METHODS: In this randomized double-blinded, prospective study, 60 patients scheduled for short-duration surgery were randomly assigned to Group B10 (0.5% bupivacaine 10 mg), Group B5AE (0.5% bupivacaine 5 mg + alfentanil 0.25 mg + 0.1% epinephrine 0.2 ml + normal saline 0.3 ml), or Group B5A (0.5% bupivacaine 5 mg + alfentanil 0.25 mg + normal saline 0.5 ml). The final volume of intrathecal injectate was adjusted to 2.0 ml with normal saline. Neural block was assessed by pinprick and a modified Bromage scale. RESULTS: No significant difference was found between three groups at the median peak sensory level, but administered fluid, and the duration of sensory and motor blockade in Group B5A was significantly shorter than in Group B10. CONCLUSIONS: We conclude that alfentanil 0.25 mg with 0.5% bupivacaine 5 mg produced a shorter in neural blockade, than the other groups and that it did not cause hemodynamic instability and produced effective spinal anesthesia for short-duration surgery.

Sudden Cardiac Arrest Immediately after Tourniquet Release during Epidural Anesthesia: A case report / 대한마취과학회지

Sudden cardiac arrest during epidural anesthesia is a rare but catastrophic complication. It was recently reported that occurs in one per 10,000 epidural anesthesia cases. We report one case of cardiac arrest in a healthy 45-year-old male patient undergoing relatively minor surgery. His preoperative blood pressure was 110-130/70-80 mmHg, heart rate 75-80 beats per minute, and oxygen saturation 98%. Immediately after tourniquet release, cardiac arrest was developed without warning signs. The patient was resuscitated by prompt precordial thump pacing, a fluid bolus, intravenous injection of atropine and ephedrine, and ventilated with oxygen. The procedure was completed and the patient recovered uneventfully.

Role of Morphine in the Glutamate-Induced Oxidative Damage of C6 Glial Cells / 대한마취과학회지

BACKGROUND: Although many studies regarding several neurotransmitters and receptors have been conducted to define the mechanism involved in the development of dependence on opioids, definitive evidence has still not been presented. This study was designed to investigate the effect of morphine on glutamate-induced cytotoxicity of rat C6 glial cells. METHODS: The 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide (MTT) assay was used for cell viability. Morphology of nuclei was observed by fluorescent microscopy. Reduced glutathione (GSH) contents were measured in acid-soluble cell fractions. Generation of hydrogen peroxide (H2O2) was measured from the cultured supernatant of C6 glial cells using the scopoletin-horseradish peroxidase (HRP) assay. RESULTS: Glutamate induced the death of C6 glial cells in a time- and dose-dependent manner. Glutamate-induced cytotoxicity was protected by morphine and antioxidants, such as GSH and N-acetyl-L-cysteine (NAC). However, morphine antagonist, naloxone did not inhibit the protective effect of morphine on glutamate-induced cytotoxicity. In addition, the specific agonists, [D-Ala2, N-Me-Phe4, Gly5-ol]-Enkephalin acetate salt (DAMGO), [D-Pen2,5]-Enkephalin (DPDPE) and U69593 did not protect C6 glial cells from glutamate-induced cytotoxicity. Furthermore, morphine recovered the depletion of GSH by glutamate and inhibited the generation of H2O2 by glutamate in C6 glial cells. CONCLUSIONS: We suggest that morphine protects C6 glial cells from glutamate-induced cytotoxicity via the inhibition of GSH depletion and the generation of H2O2 by glutamate.

Esophageal Motility during General Anesthesia Laryngeal Mask Airway Versus Endotracheal Tube / 대한마취과학회지

BACKGROUND: To know whether the laryngeal mask airway (LMA) triggers a pharyngo-esophago- gastric reflex during general anesthesia, we compared the esophageal motility of patients with an LMA or endotracheal tube (ETT) in place. METHODS: Fifty patients (ASA I or II) scheduled for elective orthopedic surgery with general anesthesia were randomly allocated into LMA (n = 30) or ETT (n = 20) groups. The esophageal manometric inputs were recorded continuously using an ambulatory esophageal manometric recorder and divided into five perioperative phases (preanaesthesia, induction, operation, LMA or ETT rejection, and arousal phase). RESULTS: The peristaltic percent and number of contractions per minute were significantly decreased during induction, operation, LMA or ETT rejection and arousal phases compared with preanesthetic phases in both the LMA and ETT groups. However, there were no significant group differences in any corresponding perioperative phases. CONCLUSIONS: We suggest that during general anesthesia the use of a LMA does not provoke significantly different esophageal peristalsis compared with an ETT. Thus, the LMA is unlikely to potentiate gastric regurgitation and reflux during general anesthesia by stimulating the pharyngo-esophago-gastric reflex.

Inhibitory Effects of Propofol Mixed with Lidocaine on Fentanyl Induced Cough Reflex / 대한마취과학회지

BACKGROUND: Propofol and lidocaine have been purported to attenuate bronchoconstriction induced by fentanyl administration during induction of anesthesia. The purpose of the present study was to study the synergic bronchodilation effect of propofol mixed with lidocaine. METHODS: Two hundred and thirty four patients were randomly allocated to five groups: Group 1 (n = 60, normal saline 0.25 ml/kg followed by fentanyl 3ng/kg), Group 2 (n = 30, propofol 2 mg/kg mixed with normal saline 0.05 ml/kg followed by normal saline 0.06 ml/kg), Group 3 (n = 50, propofol 2 mg/kg mixed with normal saline 0.05 ml/kg followed by fentanyl 3ng/kg), Group 4 (n = 33, propofol 2 mg/kg mixed with lidocaine 1 mg/kg followed by normal saline 0.06 ml/kg) and Group 5 (n = 61, propofol 2 mg/kg mixed with lidocaine 1 mg/kg followed by fentanyl 3ng/kg). All patients were injected with fentanyl or normal saline two minutes after administration of propofol premixed with lidocaine or normal saline, respectively. We checked the cough reflex, injection pain, oxygen desaturation and chest wall rigidity. RESULTS: There was a significant difference in the incidence of cough reflex between group 1 and 3 or 5. The incidience of group 5 was significantly lower than in group 3. CONCLUSIONS: This study suggests that a propofol-lidocaine mixture should be considered when patients require bronchodilation during induction of anesthesia.

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).

Effects of Morphine on Free Radical-induced Apoptosis of Human Neuroblastoma SH-SY5Y Cells / 대한마취과학회지

BACKGROUND: The effect of opioids on nitric oxide (NO)- and peroxynitrite-induced neuronal cell death is largely unknown. In the present study, we examined the effect of morphine on NO- and peroxynitrite-induced cell death using a human neuroblastoma SH-SY5Y cell line, which abundantly expresses micro, delta, kappa-opioid receptors. METHODS: The cultured cells were pretreated with morphine and exposed to 3-morpholinosydnonimine (SIN-1) that simultaneously generates NO and superoxide, thus possibly forming peroxynitrite. The cell damage was assessed by using MTT assay and crystal violet staining. Morphological nuclear changes and enzymatic evidences of apoptosis of the cells after exposure to SIN-1 for 24 hours were evaluated by using 4', 6-diamidino-2-phenylindole (DAPI) staining and the measurement of pro-apoptotic protease (caspase-3) activity, respectively. Levels of reduced glutathion (GSH) were measured by monochloronimane (MCB) assay. RESULTS: Pretreatment of SH-SY5Y with morphine significantly inhibited the apoptotic cell death. Morphine also inhibited SIN-1-induced caspase-3 (pro-apoptotic protease) activity in a dose-dependent manner. However, naloxone (20 microM) could not antagonize completely the effect of morphine in SIN- 1-induced cell death. Pre-administered GSH and N-acetylcysteine (NAC) have been found to protect SIN-induced apoptosis, and the neuroblastoma cells treated with morphine had significantly elevated the levels of GSH. CONCLUSIONS: The present study shows that morphine protects the human neuroblastoma cell line SH- SY5Y from peroxynitrite-induced apoptotic cell death through elevated GSH levels. The protective actionof morphine seems to be associated with inhibition of the apoptotic pathway. However, it is suggested that morphine protects the cells possibly via other unknown mechanisms in addition to the activation of opioid receptors.

Receptor Activation is Not the Main Rescue Mechanism of Morphine in Peroxynitrite-Induced Death of Human Neuroblastoma SH-SY5Y Cells / 대한마취과학회지

BACKGROUND: In the present study, we examined the effect of morphine on NO- and peroxynitrite-induced cell death using a human neuroblastoma SH-SY5Y cell line which abundantly expresses micro, delta and K-opioid receptors. METHODS: The cultured cells were pretreated with morphine (100 micrometer) and exposed to 3-morpholinosydnonimine (SIN-1, 1mM). Agarose gel electrophoresis of DNA was done with the extracts from SH-SY5Y cells. The cells were treated with selective ligands for opioid receptor subtypes and with PI3-kinase inhibitors. Cell damage was assessed by using an MTT assay. Spectrophotometric absorption spectra were measured from the mixture of morphine (100 micrometer) plus peroxynitrite (1 mM) at room temperature. RESULTS: SIN-1 treated cells showed the occurrence of a specific form of chromosomal DNA fragmentation which pretreatment with morphine inhibited. The selective ligands for opioid receptor subtypes, [D-Ala2, N-Me-Phe4, Gly-ol5]enkephalin (DAMGO, micro-opioid receptor agonist), [D-Pen2,5] enkephalin (DPDPE, delta-opioid receptor agonist) and U-69593 (K-opioid receptor agonist) at a concentration of 10 micrometer did not prevent the cell death induced by SIN-1. Naloxone (20 micrometer) hardly antagonized the effect of morphine in SIN-1-induced cell death. The PI3-kinase inhibitors Wortmannin and LY294002 did not inhibit the action of morphine on apoptotic cell death. In the measurements of spectrophotometric absorption spectra, the peak of the absorbance of the mixture of morphine plus peroxynitrite at 295 300 nm disappeared three minutes after mixing. CONCLUSIONS: The present study showed that morphine protected the human neuroblastoma cell line,SH-SY5Y, from peroxynitrite-induced apoptotic cell death. However, it is suggested that the protective action of morphine is not via the activation of opioid receptors and/or the PI3-kinase pathway but possibly via direct chemical reaction.

Effects of Verapamil Combined with Esmolol on Blood Pressure and Heart Rates during Tracheal Intubation / 대한마취과학회지

BACKGROUND: Antihypertensive agents such as verapamil and esmolol are well known for their effects of hemodynamic stabilization on tracheal intubation. However, our previous study, Verapamil and esmolol did not attenuate heart rate and blood pressure. The aim of the present study was to evaluate the efficacy of combined administration of these drugs for controlling hemodynamic responses to tracheal intubation. METHODS: Forty-eight patients, ASA physical status I or II, were randomly assigned to one of four groups (n = 12 each):normal saline (control), verapamil 0.1 mg/kg, esmolol 1 mg/kg, and verapamil 0.05 mg/kg mixed with esmolol 0.5 mg/kg. Anesthesia was induced with thiopental 5 mg/kg intravenously, and then saline, verapamil, esmolol or the mixed drugs were administered as an intravenous bolus, and immediately followed by succinylcholine 1.5 mg/kg. Tracheal intubation was performed 90 s after intravenous injection of experimental drugs. Systolic and diastolic blood pressure and heart rate were measured before induction and every minute for 5 minutes after tracheal intubation. RESULTS: There was a significant attenuation in systolic blood pressure after tracheal intubation in the verapamil and mixed groups compared to the control and esmolol groups. Heart rates were significantly lower in the esmolol and mixed groups than in the verapamil groups after tracheal intubation. CONCLUSIONS: Combined administration of Verapamil 0.05 mg/kg with esmolol 0.5 mg/kg attenuated increases in blood pressure and heart rate after tracheal intubation.