Percutaneous osteoplasty for painful bony lesions: a technical survey

Percutaneous osteoplasty (POP) is defined as the injection of bone cement into various painful bony lesions, refractory to conventional therapy, as an extended technique of percutaneous vertebroplasty (PVP). POP can be applied to benign osteochondral lesions and malignant metastatic lesions throughout the whole skeleton, whereas PVP is restricted to the vertebral body. Common spinal metastases occur in the thoracic (70%), lumbosacral (20%), and cervical (10%) vertebrae, in order of frequency. Extraspinal metastases into the ribs, scapulae, sternum, and humeral head commonly originate from lung and breast cancers; extraspinal metastases into the pelvis and femoral head come from prostate, urinary bladder, colon, and uterine cervical cancers. Pain is aggravated in the dependent (or weight bearing) position, or during movement (or respiration). The tenderness and imaging diagnosis should match. The supposed mechanism of pain relief in POP is the augmentation of damaged bones, thermal and chemical ablation of the nociceptive nerves, and local inhibition of tumor invasion. Adjacent (facet) joint injections may be needed prior to POP (PVP). The length and thickness of the applied needle should be chosen according to the targeted bone. Bone cement is also selected by its osteoconduction, osteoinduction, and osteogenesis. Needle route should be chosen as a shortcut to reach the target bony lesions, without damage to the nerves and vessels. POP is a promising minimally invasive procedure for immediate pain relief. This review provides a technical survey for POPs in painful bony lesions.

Percutaneous osteoplasty for painful bony lesions: a technical survey

Percutaneous osteoplasty (POP) is defined as the injection of bone cement into various painful bony lesions, refractory to conventional therapy, as an extended technique of percutaneous vertebroplasty (PVP). POP can be applied to benign osteochondral lesions and malignant metastatic lesions throughout the whole skeleton, whereas PVP is restricted to the vertebral body. Common spinal metastases occur in the thoracic (70%), lumbosacral (20%), and cervical (10%) vertebrae, in order of frequency. Extraspinal metastases into the ribs, scapulae, sternum, and humeral head commonly originate from lung and breast cancers; extraspinal metastases into the pelvis and femoral head come from prostate, urinary bladder, colon, and uterine cervical cancers. Pain is aggravated in the dependent (or weight bearing) position, or during movement (or respiration). The tenderness and imaging diagnosis should match. The supposed mechanism of pain relief in POP is the augmentation of damaged bones, thermal and chemical ablation of the nociceptive nerves, and local inhibition of tumor invasion. Adjacent (facet) joint injections may be needed prior to POP (PVP). The length and thickness of the applied needle should be chosen according to the targeted bone. Bone cement is also selected by its osteoconduction, osteoinduction, and osteogenesis. Needle route should be chosen as a shortcut to reach the target bony lesions, without damage to the nerves and vessels. POP is a promising minimally invasive procedure for immediate pain relief. This review provides a technical survey for POPs in painful bony lesions.

Anesthetic experience of frontotemporal dementia patient with severe autonomic dysfunction: a case report / 대한마취과학회지

Anesthetic experience in frontotemporal dementia (FTD) with severe hypotension associated autonomic dysfunction has not yet been reported. Here in case, we report on the case of treatment with vasopressin to refractory hypotension in FTD patient. A 54-year-old male presented with a ten-year history of FTD with frequent syncope. The patient was scheduled to undergo subtotal gastrectomy for resection of stomach cancer. During the operation, sudden hypotension occurred and it was refractory to fluid and 1 unit of blood resuscitation and did not respond to catecholamine. Transesophageal echocardiography showed normal heart with adequate volume state. After intravenous administration of arginine vasopressin, the patient's vital signs returned to baseline values. Arginine vasopressin might be considered as a valuable alternative for treatment of severe refractory hypotension in autonomic dysfunction patients with FTD.

Hemorrhagic shock occurring due to a concealed hematoma after insertion of a subclavian venous catheter in a patient undergoing anticoagulation therapy: a case report / 대한마취과학회지

A 74-year-old man who had been receiving warfarin for atrial fibrillation, underwent emergency thrombectomy. A central venous catheter (CVC) was inserted via the left subclavian vein, and heparin was administered to prevent preoperative and postoperative thrombotic events. After an uneventful thrombectomy, the patient was transferred to the intensive care unit (ICU). On the second postoperative day, the patient developed syncope and his blood pressure and oxygen saturation decreased. A computed tomography (CT) revealed a huge hematoma under the pectoralis major muscle. The patient was then treated with continuous renal replacement therapy and mechanical ventilation for multiorgan dysfunction syndrome, which developed due to hemorrhagic shock in the ICU. These findings suggest that when a CVC is inserted in patients requiring anticoagulant therapy, the possible risk of excessive bleeding must be carefully considered. Further, choosing a proper insertion site and performing an ultrasound-guided aspiration may be helpful in preventing these complications.

Risk of continuing planned surgery after endovascular repair of subclavian artery injury: a case report / 대한마취과학회지

Endovascular repair with covered stents has been widely used to treat subclavian and axillary artery injuries and has produced promising early results. The possibility of a thromboembolism occurring in cerebral arteries during an endovascular procedure should be a cause for concern. In the case of endovascular management of arterial traumas, a prompt and sufficient period for check-up of the patient's neurological signs is needed, even if it requires postponing elective intervention for the patient's safety. We report a rare case of liver transplantation immediately after endovascular repair of an iatrogenic subclavian arterial injury to describe the risk of continuing planned surgery without neurologic assessment.

Management of sepsis

Severe sepsis and septic shock are common and life-threatening medical conditions characterized by an overwhelming infection and the body's inflammatory response to that infection. Early and appropriate management of sepsis significantly reduces short-term and long-term mortality. Fluid resuscitation for shock and appropriate early antibiotic therapy have the most impact on survival. Source control should be accomplished within 24 hours where appropriate. Optimal management of sepsis requires early, goal-directed therapy; lung-protective ventilation; and antibiotics. The use of corticosteroids, vasopressin, and intensive insulin therapy requires further study. In this review, we have summarized the key components in the management of sepsis and septic shock, including early recognition, early resuscitation, principles of antibiotic therapy, organ support, and role of adjunctive therapies.

The changes of mitochondrial cytochrome c and GABAergic neuron in neuropathic pain model / 대한마취과학회지

BACKGROUND: Role of cytochrome c (Cyt c) is an apoptogenic agent under certain conditions. The mitochondrial permeability transition pore (MPTP) plays an important role in cell death since it opens, leading to mitochondrial swelling and release of Cyt c, which initiates apoptosis. By inhibiting the opening of MPTP, cyclosporine A (CSA) may contribute to maintaining mitochondrial homeostasis. We investigate the effects of the partial sciatic nerve injury (PSNI)-induced neuropathic pain model on mitochondrial Cyt c release and the effects of CSA on neuroprotection by mitochondrial stabilizing activity in PSNI rats. METHODS: Rats were assigned to two groups that received different operations (Group P; PSNI operation, Group S; sham operation). The changes of cyt c and GABAergic neuron were evaluated in the spinal cord tissue. After which, PSNI rats randomly received CSA (Group C) or saline (Group S), and the changes of mechanical thresholds with Cyt c and GABAergic neuron were checked. RESULTS: PSNI in rats increased the release of cytosolic Cyt c. However, GABAergic cells were not decreased in the spinal cord level on the ipsilateral side to the PSNI. The second experiment reveal a reduction in Cyt c release, using CSA in PSNI model. Rats receiving CSA were afforded the antiallodynia without decrease of GABAergic cell. CONCLUSIONS: The Cyt c probably contributes to nerve dysfunction after PSNI. PSNI induced neuropathic pain was profoundly linked to mitochondrial stabilization. Thus, the potent neuroprotector, CSA, might produce antiallodynia through its capability to inhibit the opening of MPTP.

Dexmedetomidine does not produce vasocontraction on human isolated gastroepiploic artery / 대한마취과학회지

BACKGROUND: Recently, the addition of dexmedetomidine to sedation regimens after cardiac surgery had been reported and there is a possibility that dexmedetomidine can cause vasoconstriction. Vasopressin has been used as a prophylactic treatment for refractory vasodilatory shock during coronary artery bypass graft (CABG). Also, vasopressin may play an important role in initiating spasms at the graft artery. Here we evaluate the direct effect of dexmedetomidine on isolated human gastroepiploic arteries and the synergistic effect of dexmedetomidine and vasopressin. METHODS: Discarded gastroepiploic arteries from elective subtotal gastrectomy (n = 10) were used in this study. We measured the level of contraction in isolated human gastroepiploic arteries induced by increasing concentrations of dexmedetomidine (10(-10) to 10(-6) M) with or without vasopressin (10(-10), 10(-9) M). Arterial contractions caused by increasing concentrations of vasopressin (10(-10) to 10(-7.5) M) with or without dexmedetomidine (10(-9), 10(-7) M) were also measured in the tissue samples. RESULTS: Supraclinical concentrations of dexmedetomidine elicited contractions at concentrations of 10(-7) M and 10(-6) M (P < 0.05 versus resting tension). The same concentrations of dexmedetomidine (10(-7), 10(-6) M) significantly enhanced vasopressin-induced contractions (P < 0.05 versus vasopressin-induced contraction). Vasopressin produced concentration-dependent contractions and vasopressin (10(-10), 10(-9.5), 10(-9) M) also increased the intensity of dexmedetomidine (10(-7) M) induced contractions. CONCLUSIONS: There was a synergistic effect between supraclinical doses of dexmedetomidine and vasopressin on the degree of contraction in isolated human gastroepiploic arteries. However, a sedative dose of dexmedetomidine (clinical dose: 0.2-0.7 microg/kg/hr, plasma concentration: 0.36-1.25 ng/ml) did not enhance vasopressin induced-contraction in isolated human gastroepiploic arteries.

Availability of preoperative anxiety scale as a predictive factor for hemodynamic changes during induction of anesthesia / 대한마취과학회지

BACKGROUND: The current study evaluated whether the level of preoperative anxiety assessed by the state-trait anxiety inventory (STAI) affects cardiovascular response during anesthetic induction. Furthermore, we evaluated the utility of the preoperative anxiety scale as a predictive factor for hemodynamic changes. METHODS: One hundred twenty patients who were scheduled to undergo elective surgery under general anesthesia were enrolled in this prospective study. The patients were asked to fill out STAI questionnaires the night before the day of surgery. For 5 minutes after tracheal intubation, changes in vital signs were recorded. The correlation between STAI scores and the percent changes in vital signs during the induction of anesthesia for each subgroup was assessed. In addition, the predictability of the 20% change in vital signs by STAI scores was analyzed using receiver operating characteristics curves. RESULTS: The state anxiety scores of patients 45 years of age or older showed a significant correlation with percent changes in mean blood pressure and heart rate, whereas the state anxiety scores in other subgroups showed no significant correlation with changes in vital signs during the induction of anesthesia. Furthermore, the state anxiety scores in patients 45 years of age or older were shown to be useful in predicting a 20% change in vital signs during anesthetic induction. CONCLUSIONS: The state anxiety scores of patients 45 years of age or above could be a useful tool for predicting changes in vital signs during anesthetic induction. Thus, physician should be mindful of preoperative anxiety.

Pulmonary edema and hyponatremia after hysteroscopic uterine septectomy : A case report

The hysteroscope has become a standard part of gynecologists' armamentarium, and hysteroscopy is taught routinely in residency curriculums. In recent years, its use in gynecology has changed from a diagnostic tool only to an instrument for gynecologic operations. An electrolyte-free irrigation fluid is used for hysteroscopic surgery, and it has a possibility of substantial absorption of irrigation fluid. The absorption depends on the rate, volume and nature of the irrigation fluid. Fortunately, large-scale fluid absorption is rare but leads to symptoms severe enough to require intensive care. Several methods have been proposed to reduce the risk but none of them is capable of preventing the complication from fluid absorption. In this case, the patient had pulmonary interstitial edema with hyponatremia after hysteroscopic uterine septectomy but that had resolved without sequelae.

Effect of thromboembolic deterrent stockings at spinal anesthesia-induced hypotension / 대한마취과학회지

BACKGROUND: Hypotension during spinal anesthesia is mainly result of sympathetic blockade, which causes pooling of blood into the lower extremities. Mechanical compression of lower limbs prevents venous pooling of blood. Thromboembolic deterrent (TED) stockings are in general surgical use for prophylaxis against lower limb deep vein thrombosis and TED stockings also supply pressure to lower limb. So we investigated the effect of TED stockings to prevent hypotension during spinal anesthesia. METHODS: Sixty patients were randomized to receive fluid loading (crystalloid, 10 ml/kg) or TED stockings. After spinal anesthesia (heavy bupivacaine 14 mg), patients were placed in supine position for 12 minutes and in lithotomy position for 18 minutes. Blood pressure, pulse rates, shivering, and nausea were checked every 3 minutes for 30 minutes. If the systolic blood pressure was less than 90 mmHg or mean blood pressure was less than 80% of baseline mean blood pressure then i.v. ephedrine 5 mg was administered. RESULTS: There was no statistically significant difference in baseline characteristics and blocked sensory level between the two groups. There was no statistically significant difference in the incidence of hypotension and mean arterial blood pressure at each time. CONCLUSIONS: We conclude that, under the conditions of this study, TED stockings decrease the pooling of blood into the lower limbs and prevent hypotension after spinal anesthesia. Although TED stockings prevent hypotension after spinal anesthesia, it does not reduce the incidence of hypotension.

Cholecystectomy of a patient with Churg-Strauss syndrome: A case report / 대한마취과학회지

Churg-Strauss syndrome is an allergic granulomatous angitis and the organ most commonly involved in this condition is the lung. However, this syndrome also affects the skin, cardiovascular system, kidney, peripheral nervous system and gastrointestinal system. Cardiac involvement is a rare complication but can lead to rapid-onset heart failure as the result of specific cardiomyopathy. Pericardial effusion may also occur. Acalculous cholecystitis is also a rare complication of Churg-Strauss syndrome. Here, we present a case of a patient with Churg-Strauss syndrome and severe heart failure scheduled for cholecystectomy due to acalculous cholecystitis. The patient had mild asthma symptoms, peripheral neuritis in both legs, and severe heart failure. During the preoperative period, steroids, beta2 agonists, diuretics, and antihypertensive drugs were administered. During anesthesia we attempted to prevent compromising the patient's cardiac and pulmonary functions. The surgery was completed successfully, and the patient was discharged without any complications.

Clinical Investigation of Children with Severe Atopic Dermatitis / 소아알레르기및호흡기학회지

PURPOSE: We attempted to investigate clinical characteristics of children with severe atopic dermatitis. METHODS: A total of 204 children diagnosed with Atopic dermatitis at the Pediatric Allergy Respiratory Center in Busan St. Mary's Medical Center from June 2006 to June 2008 were enrolled in this study. Cases were divided into 3 groups according to SCORAD index: severe, moderate and mild groups. We collected birth, environment, and allergic family history, and tested serum IgE, total eosinophil count, specific IgE, ECP (Eosinophil Cationic Protein) and the SCORAD index between the 3 groups. RESULTS: Of the 204 patients, 100 (49.02%) were included in the severe group, 51 (25.0%) in the moderate group, and 53 (25.98%) in the mild group. There were no differences in serum total IgE, serum total eosinophil counts and ECP between the severe and moderate groups. Serum total IgE, serum total eosinophil counts and ECP were relatively higher in the severe group than mild group. Food allergen sensitization rate was relatively higher in the infantile severe group than in the childhood severe group, while inhalant allergen sensitization rate was relatively higher in the childhood severe group than in the infantile severe group. There was no correlation between serum total IgE, serum total eosinophil counts, ECP and the number of sensitized allergens relative to SCORAD index in the severe group. CONCLUSION: Serum IgE, total eosinophil count, specific IgE and ECP may be specific indicators of children with severe atopic dermatitis. Further studies are needed to determine a clear distinction between severe and moderate atopic dermatitis patients.

Effect of remifentanil on postoperative pain in gynecologic surgery with sevoflurane anesthesia / 대한마취과학회지

BACKGROUND: Rapid development of acute opioid tolerance and hyperalgesia is well established in animal studies and is more likely to occur with large doses of short-acting drugs. Several experimental and clinical studies of varied design that have been conducted in humans comparing remifentanil with other routinely used anesthetics or placebo preparations have produced conflicting results. The aim of this study was to investigate whether remifentanil had any impact on postoperative pain after gynecologic surgery. METHODS: Sixty patients undergoing gynecological surgery were randomly allocated into three groups (each n=20): N group with normal saline, L group with target-controlled infusion (TCI) of 1 ng/ml remifentanil, and H group with TCI of 3 ng/ml remifentanil. All patients were anesthetized with sevoflurane to maintain mean arterial pressure within 20% of basal values. Thirty minutes before the end of surgery, patients received morphine sulfate through a patient-controlled infusion device. Pain scores, sedation scores, and analgesic requirements were recorded for 48 hours postoperatively. RESULTS: The mean remifentanil infusion dose of the H group was significantly higher than that of the L group. The VAS scores of the L and H groups were significantly higher than those of the N group only at the postanesthetic care unit and not at the ward. CONCLUSIONS: Intraoperative use of remifentanil with sevoflurane may be related to increased postoperative pain during early postanesthetic period. Provision for effective preventive and therapeutic management strategies in case of intraoperative remifentanil use may be reasonable.

Effects of Propofol on Arginine Vasopressin-induced Contraction in Isolated Human Gastroepiploic Artery / 대한마취과학회지

BACKGROUND: Arginine vasopressin has been used by prophylactic treatment of vasodilatory shock during coronary artery bypass graft (CABG). Vasopressin may be a cause of spasm in graft artery during CABG. We evaluated the effect of propofol on vasopressin-induced contraction in human gastroepiploic artery (GEA). METHODS: Human GEA were obtained from 35 patients (43-74 yr), undergoing subtotal gastrectomy. Vasopressin-induced a concentration contractions (10(-9) to 10(-6) M) were measured after exposed to without propofol, propofol 10(-5), 10(-4), 10(-3) M. After endothelium denuding vasopressin-induced a concentration contractions were measured with or without propofol 10(-3) M in calcium free solution. In the denuded vascular rings, with or without pretreatment of glibenclamide (10(-5) M), nicorandil (10(-5) M), or diltiazem (10(-5) M) were exposed to with or without propofol 10(-3) M, and vasopressin-induced concentration contractions were measured. RESULTS: Vasopressin-induced concentration contraction on human GEA was independent of functional endothelium. Propofol (10(-4), 10(-3) M) attenuated the vasopressin-induced contraction in the human GEA. Diltiazem attenuated the vasopressin-induced contraction in the human GEA. ATP-sensitive potassium channel does not affect the inhibition effect of propofol on vasopressin-induced contraction CONCLUSIONS: Usual anesthetic dose of propofol does not inhibit vasopressin-induced contraction on human GEA. High dose (>10(-4) M) propofol attenuated vasopresssi-induced contraction on GEA.

The effect of 4-Methylcatechol treatment in chronic constrictive injury of the rat sciatic nerve on the allodynia and spinal neurotrophic factors / 대한마취과학회지

BACKGROUND: The effect of chronic administration of 4-methylcatechol known as a neurotrophic factor inducer on the allodynia and spinal neurotrophic factors was investigated in chronic constrictive injury of sciatic nerve in rats. METHODS: With the Sprague Dawly rat, sciatic nerve was loosely ligated with 4-0 chromic catgut and neuropathic pain model was made. The threshold for tactile allodynia was measured with von Frey hair by up-down method and cold allodynia was measured by dropping 20microliter of 100% acetone on the dorsum of the injured foot. 4-Methylcatechol (100microgram/kg, intraperitoneal) was injected once a day for 14 days and the effect on allodynia was compared with saline injected group. At 3, 7 and 14 days after injection, lumbar spinal cord was harvested and the mRNA content of nerve growth factor (NGF) and brain derived neurotrophic factor (BDNF) was measure by real time PCR. RESULTS: Mechanical and cold allodynia improved from 7 days after 4-methylcatechol administration. NGF and BDNF in spinal cord decreased compared to sham operated group. BDNF in lumbar spinal cord has increased tendency after treatment without statistical significance. CONCLUSIONS: Chronic intraperitoneal administration of 4-methylcatechol may improve tactile and cold allodynia in chronic constrictive injury rat model of neuropathic pain. The BDNF mRNA in spinal cord might increase after 4-methylcatechol treatment.

The Effects of Propofol and Sevoflurane on Neuronal Apoptosis and Bcl-2 Family Protein Expression after Transient Forebrain Ischemia in the Rat / 대한마취과학회지

BACKGROUND: Anesthetic preconditioning and anesthetics itself have been known to prevent ischemic injury in brain and heart. The purpose of this study was to evaluate the effects of anesthetics and anesthetic preconditioning on neuronal apoptosis and Bcl-2 family protein expression in transient forebrain ischemia. METHODS: Rats were divided into 3 groups and anesthetized with intraperitoneal propofol (P group) or sevoflurane (S and SP groups). In SP group, rats were anesthetized with sevoflurane during 30 minutes and then anesthesia was maintained with intraperitoneal propofol. Forebrain ischemia was produced by both induced hypotension and 10 minutes of common carotid artery clamping. RESULTS: At 2 days after ischemia, the numbers of necrotic cells in hippocampal CA1 area in S group were less than P and SP groups, and the number of apoptotic cells in S and SP groups were less than P group. The expressions of Bcl-xl in P and SP groups were less than S group. The expression of Bax in P group was less than S and SP groups. At 2 weeks after ischemia, the numbers of necrotic cells in hippocampal CA1 area in S and SP groups were less than P group, and the numbers of apoptotic cells in S group were less than P and SP groups. The expressions of Bcl-xl in S group were more than P and SP groups. CONCLUSIONS: Sevoflurane could reduce ischemic injury during transient forebrain ischemia. However the anesthetic preconditioning with sevoflurane could not help to prevent delayed neuronal apoptosis after forebrain ischemia.