Effective concentration of remifentanil for successful i-gel insertion during remimazolam induction / 대한마취과학회지

Background@#Remifentanil can be used as adjuvants during remimazolam induction without neuromuscular blockade. We evaluated the 95% effective concentration (EC) of remifentanil effect-site concentration (Ce) for the successful insertion of an i-gel using the biased-coin up-and-down method in adult patients during remimazolam induction. @*Methods@#Forty 19–65 year-old patients scheduled to undergo surgery using i-gel were enrolled. Anesthesia was induced using remimazolam infusion (12 mg/kg/h). Simultaneously, remifentanil was infused at a predetermined Ce. After 5 min of anesthesia induction, the i-gel was inserted. The 95% EC (EC95) of remifentanil in each patient was determined using a biased-coin up-and-down method based on a successful insertion in a preceding patient. The step size of remifentanil Ce was 0.4 ng/ml. If the insertion failed, remifentanil Ce was increased in the next patient. Following successful insertions, the corresponding concentration decreased in subsequent patients with a probability of 1/19 or was maintained with a probability of 18/19. The time from remimazolam infusion initiation to a bispectral index (BIS) < 60 (time to BIS60) and hemodynamic variables were measured and recorded. @*Results@#The EC95 (95% CI) of Ce was 2.07 (1.94, 2.87) ng/ml. The overall time to BIS60 was 154.0 ± 39.9 s. No patient experienced significant hypotension or bradycardia during remimazolam induction. @*Conclusions@#The EC95 of remifentanil Ce was 2.07 (1.94, 2.87) ng/ml for successful i-gel insertion during remimazolam induction at 12 mg/kg/h without hemodynamic instability in adult patients. Future studies should measure remifentanil Ce in elderly patients or using remimazolam at various infusion doses.

Effects of different sugammadex doses on the train of four ratio recovery progression during rocuronium induced neuromuscular blockade in the rat phrenic nerve hemidiaphragm / 대한마취과학회지

Background@#In this study, we used an ex-vivo model to investigate the recovery pattern of both the train-of-four (TOF) ratio and first twitch tension of TOF (T1), and determined their relationship during recovery from rocuronium-induced neuromuscular blockade at various concentrations of sugammadex. @*Methods@#Tissue specimens of the phrenic nerve-hemidiaphragm were obtained from 60 adult Sprague-Dawley rats. Each specimen was immersed in an organ bath filled with Krebs buffer solution and stimulated with the TOF pattern using indirect supramaximal stimulation at 20-second intervals. After a 30-minute stabilization period, rocuronium loading and booster doses were serially administered at 10-minute intervals in each sample until > 95% depression of T1 was confirmed. Specimens were randomly allocated to either the control group (washout) or to one of five sugammadex concentration groups (0.75, 1, 2, 4, or 8 times equimolar doses of rocuronium to produce >95% T1 depressions; SGX0.75, SGX1, SGX2, SGX4, and SGX8, respectively). Recovery from neuromuscular blockade was monitored using T1 and the TOF ratio simultaneously until the recovery of T1 to > 95% and the TOF ratio to > 0.9. @*Results@#Statistically significant intergroup differences were observed between the recovery patterns of T1 and the TOF ratio (TOFR, p<0.050), except between SGX2 and SGX4 groups. TOFR/T1 values were maintained at nearly 1 in the control, SGX0.75, and SGX1 groups; however, they were exponentially decayed in the SGX2, SGX4, and SGX8 groups. @*Conclusions@#Recovery of the TOF ratio may be influenced by the sugammadex dose, and a TOF ratio of 1.0 may be achieved before full T1 recovery if administration of sugammadex exceeds that of rocuronium.

Effects of adenosine receptor agonist on the rocuronium-induced neuromuscular block and sugammadex-induced recovery / 대한마취과학회지

BACKGROUND: Several types of receptors are found at neuromuscular presynaptic membranes. Presynaptic inhibitory A1 and facilitatory A2A receptors mediate different modulatory functions on acetylcholine release. This study investigated whether adenosine A1 receptor agonist contributes to the first twitch tension (T1) of train-of-four (TOF) stimulation depression and TOF fade during rocuronium-induced neuromuscular blockade, and sugammadex-induced recovery. METHODS: Phrenic nerve-diaphragm tissues were obtained from 30 adult Sprague-Dawley rats. Each tissue specimen was randomly allocated to either control group or 2-chloroadenosine (CADO, 10 μM) group. One hour of reaction time was allowed before initiating main experimental data collection. Loading and boost doses of rocuronium were sequentially administered until > 95% depression of the T1 was achieved. After confirming that there was no T1 twitch tension response, 15 min of resting time was allowed, after which sugammadex was administered. Recovery profiles (T1, TOF ratio [TOFR], and recovery index) were collected for 1 h and compared between groups. RESULTS: There were statistically significant differences on amount of rocuronium (actually used during experiment), TOFR changes during concentration-response of rocuronium (P = 0.04), and recovery profiles (P < 0.01) of CADO group comparing with the control group. However, at the initial phase of this experiment, dose-response of rocuronium in each group demonstrated no statistically significant differences (P = 0.12). CONCLUSIONS: The adenosine A1 receptor agonist (CADO) influenced the TOFR and the recovery profile. After activating adenosine receptor, sugammadex-induced recovery from rocuronium-induced neuromuscular block was delayed.

Erratum: Effect of needle approach to the axillary artery on transarterial axillary brachial plexus block quality

Figure 1 was printed with incorrect text. In the Figure, “Radial artery” should be corrected to “Axillary artery.”

Effect of needle approach to the axillary artery on transarterial axillary brachial plexus block quality

BACKGROUND: The authors sought to determine whether a shallow needle approach to the axillary artery would improve complete sensory blocks of median, radial, and ulnar nerves as compared with a perpendicular approach when transarterial axillary block is performed using a scalp vein needle (23G, 3/4'). METHODS: Fifty-four patients were allocated equally to a perpendicular group (the PA group) or a shallow approach group (SA group). Sensory and motor scores were evaluated and compared in the two groups at 5-minute intervals for 20 minutes after block. The main outcome variables were rates of blockage of median, radial, and ulnar nerves. RESULTS: Excellent block rates (defined as completion of surgery using brachial plexus block alone) were obtained in both groups (SA group 77.8% vs. PA group 70.3%, P = 0.755). However, the rate of blockage of all three nerves was significantly higher in the SA group (74% vs. 40.7%, P = 0.013). Furthermore, the rate of complete sensory block of the radial nerve at 20 minutes was significantly greater in the SA group (85.2% vs. 59.3%, P = 0.033). CONCLUSIONS: A shallow needle approach to the axillary artery resulted in a significantly higher median, radial, and ulnar nerve block rate at 20 minutes after LA injection than a perpendicular approach.

Effect of needle approach to the axillary artery on transarterial axillary brachial plexus block quality

BACKGROUND: The authors sought to determine whether a shallow needle approach to the axillary artery would improve complete sensory blocks of median, radial, and ulnar nerves as compared with a perpendicular approach when transarterial axillary block is performed using a scalp vein needle (23G, 3/4'). METHODS: Fifty-four patients were allocated equally to a perpendicular group (the PA group) or a shallow approach group (SA group). Sensory and motor scores were evaluated and compared in the two groups at 5-minute intervals for 20 minutes after block. The main outcome variables were rates of blockage of median, radial, and ulnar nerves. RESULTS: Excellent block rates (defined as completion of surgery using brachial plexus block alone) were obtained in both groups (SA group 77.8% vs. PA group 70.3%, P = 0.755). However, the rate of blockage of all three nerves was significantly higher in the SA group (74% vs. 40.7%, P = 0.013). Furthermore, the rate of complete sensory block of the radial nerve at 20 minutes was significantly greater in the SA group (85.2% vs. 59.3%, P = 0.033). CONCLUSIONS: A shallow needle approach to the axillary artery resulted in a significantly higher median, radial, and ulnar nerve block rate at 20 minutes after LA injection than a perpendicular approach.

Palonosetron might not attenuate spinal anesthesia-induced hypotension during orthopedic surgery

BACKGROUND: 5-Hydroxytryptamine3 (5-HT3) receptor antagonists have been reported to attenuate spinal anesthesia-induced hemodynamic changes. This study was conducted to determine whether the second generation 5-HT3, antagonist palonosetron attenuates hypotension and bradycardia during spinal anesthesia. METHODS: Sixty adult patients scheduled for lower limb surgery were enrolled in this study. Patients were randomly assigned to receive either normal saline (Control group, N = 30) or palonosetron (0.075 mg, i.v.) (Palonosetron group, N = 30) prior to spinal anesthesia. Hemodynamic variables were recorded during anesthesia. RESULTS: The mean blood pressure (MBP) were 89.2 ± 11.4 mmHg in the control group and 87.6 ± 12.1 mmHg in the palonosetron group at 10 min after intrathecal injection (P = 0.609). The median blocked levels of the control group and the palonosetron group were T10 (interquartile range, 9-10) and T10 (8-10) at 20 min after intrathecal injection (P = 0.939). Requirements for ephedrine, phenylephrine, and atropine were similar (P = 0.652, 0.533 and 0.417, respectively). The incidences of hypotension (40% vs. 41%) and bradycardia (7% vs. 17%) were comparable (P = 0.562, P = 0.198, respectively) between the control and the palonosetron group. There were no significances in the changes of systolic blood pressure, diastolic blood pressure, MBP and heart rate by the group (P = 0.632, 0.287, 0.556, 0.733, respectively). CONCLUSIONS: Intravenous palonosetron (0.075 mg) prior to spinal anesthesia might not attenuate spinal anesthesia-induced hypotension during low level of neuroaxial block for lower limb surgery.

The relationship between the serum lactate level and in-hospital mortality after decompressive craniectomy in traumatic brain Injury

BACKGROUND: The patients with traumatic brain injury showed ischemia due to increased intracranial pressure. This study evaluated the relationship of pre-anesthetic serum lactate level with in-hospital mortality. METHODS: The archived medical records of 121 patients were retrospectively reviewed. Demographics and preoperative serum lactate level were analyzed. RESULTS: Of the 121 patients, 32 patients expired in the hospital after decompressive craniectomy. Preoperative serum lactate levels were 3.2 +/- 2.2 mmol/L in the survivors and 5.4 +/- 3.0 mmol/L in the dead (P = 0.001), and the receiver operating characteristic curve revealed that a cut off value of 3.60 mmol/L was reasonable for predicting mortality. CONCLUSIONS: Preoperative serum lactate level is highly correlated with in-hospital mortality after decompressive craniectomy in traumatic brain injury.

Analysis of pre-operative aspartate aminotransferase and alanine aminotransferase in 14,185 pediatric patients

BACKGROUND: The aim of this study was to investigate the efficacy of routine pre-anesthetic aspartate aminotransferase (AST) and alanine aminotransferase (ALT) tests for detection of hepatic abnormalities and usefulness in perioperative management. METHODS: The laboratory findings of 14,185 pediatric patients younger than 18 years from October 2004 to December 2010 were investigated by retrospective review of medical records. All of the patients had undergone preoperative AST and ALT screening. RESULTS: Among the 14,185 patients, 221 patients experienced elevation of both AST and ALT. However, only 21 patients were suspicious for hepatic disease defined as persistent elevation of AST and ALT preoperatively. Among the 221 patients with elevation of both AST and ALT, 20 patients were examined by additional abdominal ultrasonography and hepatic abnormalities were detected in 13 of these patients (65%) and 40 patients were consulted to the department of pediatrics or internal medicine. CONCLUSIONS: In this single-center, retrograde study, the usefulness of preoperative routine AST and ALT testing was shown to be limited for detection of hepatic abnormalities in pediatric patients undergoing general anesthesia. Further multi-center, large-scale investigation would be required.

A comparison of general anesthesia versus axillary brachial plexus block for hand and wrist surgery in the view of patient satisfaction

BACKGROUND: We evaluated whether the analgesic superiority of regional block over general anesthesia improves patient satisfaction. METHODS: Patients were anesthetized with either general anesthesia (GA) (n = 30) or axillary brachial plexus block (BPB) (n = 30). GA was standardized to include induction with propofol and alfentanil and maintenance with desflurane in an oxygen/nitrous oxide mixture. BPB was performed using an axillary perivascular approach, and 1.5% lidocaine 20 ml with epinephrine (1 : 200,000) and 0.5% levobupivacaine 20 ml were injected. Pain scores and numbers of times pushing the patient-controlled analgesia (PCA) button were measured preoperatively and at 2, 6, and 24 hours after the end of surgery. On the first day after the operation, one of our researchers visited the patients to document their opinions of their anesthetic experiences and their satisfaction scores. RESULTS: Group BPB had lower visual analog scale scores at 2 hours and 6 hours postoperatively. Numbers of times pushing the PCA button was also lower in Group BPB within the first 2 hours and between 2-6 hours postoperatively. However, patient satisfaction scores were not statistically different between the two groups (84 +/- 11 vs. 88 +/- 12, P = 0.177). CONCLUSIONS: BPB provided superior analgesia after upper limb surgery compared to GA, but for a complete understanding of patients' satisfaction, detailed consideration of factors such as sedation would be necessary.

The effect of warmed inspired gases on body temperature during arthroscopic shoulder surgery under general anesthesia / 대한마취과학회지

BACKGROUND: Perioperative hypothermia can develop easily during shoulder arthroscopy, because cold irrigation can directly influence core body temperature. The authors investigated whether active warming and humidification of inspired gases reduces falls in core body temperature and allows redistribution of body heat in patients undergoing arthroscopic shoulder surgery under general anesthesia. METHODS: Patients scheduled for arthroscopic shoulder surgery were randomly assigned to receive either room temperature inspired gases using a conventional respiratory circuit (the control group, n = 20) or inspired gases humidified and heated using a humidified and electrically heated circuit (HHC) (the heated group, n = 20). RESULTS: Core temperatures were significantly lower in both groups from 30 min after anesthesia induction, but were significantly higher in the heated group than in the control group from 75 to 120 min after anesthesia induction. CONCLUSIONS: In this study the use of a humidified and electrically heated circuit did not prevent core temperature falling during arthroscopic shoulder surgery, but it was found to decrease reductions in core temperature from 75 min after anesthesia induction.

Transient hemiparesis following laparoscopic cholecystectomy in a patient with uncontrolled diabetes mellitus: A case report

The patients with diabetes mellitus (DM) have abnormal cerebral auto-regulation and preexisting DM is one of the major factors related to adverse postoperative neurological deficits. New onset hemiparesis is a rare and devastating event in a patient awakening from general anesthersia. We report a case of transient hemiparesis after general anesthesia in a patient underwent laparoscopic cholecystectomy with uncontrolled DM.

Anesthetic management of HELLP syndrome complicating primary antiphospholipid syndrome: A case report / 대한마취과학회지

Antiphospholipid syndrome (APS) is defined as an autoimmune disorder characterized by recurrent thrombosis or obstetrical morbidity. A 29-year-old woman who was diagnosed with APS underwent emergency cesarean delivery at 23 weeks' gestation. She had a seizure attack and her laboratory findings were: AST/ALT 1459/1108 IU/L, LDH 1424 IU/L, 30% hematocrit, a platelet count of 43 x 10(3)/ml and urine protein (4+). We describe the anesthetic experience of catastrophic HELLP syndrome with antiphospholipid syndrome and we review the relevant literature.

Extrapyramidal side effects after metoclopramide administration in a post-anesthesia care unit: A case report / 대한마취과학회지

Although the incidence of extrapyramidal reactions associated with metoclopramide has been reported to be approximately 0.2%, such reactions are rare in the anesthetic field. Several anesthetic adjuvants, including ondansetron and pregabalin, have also been associated with extrapyramidal side effect. Here, the authors report the case of a 47-year-old patient, previously administered pregabalin and ondansetron, who developed extrapyramidal side effects after a single injection of metoclopramide (10 mg) in a post-anesthesia care unit.

Effects of different sample volumes on arterial blood gas and electrolytes testing

BACKGROUND: Insufficient sample volume can cause unnecessary blood loss and inaccurate arterial blood gas and electrolytes testing. The aim of this study was to determine the adequate sample volume, that is required for accurate arterial blood gas and electrolyte testing from arterial catheters. METHODS: Patients had four different arterial blood samples (0.2 ml, 0.4 ml, 0.6 ml and 1 ml [control], respectively) taken sequentially in random order. Samples were analyzed for pH, PaCO2, PaO2, hematocrit, Na+, K+, Ca2+ and Mg2+ using NOVA blood gas analyzer. RESULTS: A total of 27 patients were recruited for the study. All sample volumes tested provided the results of pH, PaCO2, PaO2 and hematocrit that were statistically similar to control values. However, the results of electrolytes (K+, Ca2+ and Mg2+) in all sample volumes tested were significantly lower than the control values and an increasing sample volume equated to blood results trending closer to those obtained with the control sample. CONCLUSIONS: This study showed that there is not one sample volume that will provide accurate results for all blood components. The study tested a variety of sample volumes and found that although even small sample volume of 0.2 ml provided accurate results for pH, PaCO2, PaO2 and hematocrit. No sample volume that was tested provided accurate results for K+, Ca2+ and Mg2+.

Comparison of the effects of sevoflurane and propofol on core body temperature during laparoscopic abdominal surgery / 대한마취과학회지

BACKGROUND: A decrease in core body temperature caused by heat distribution depends on the anesthetic agent used. The purpose of this study is to investigate the effects of sevoflurane and propofol on core temperature during laparoscopic major abdominal surgery requiring pneumoperitoneum of more than 90 min. METHODS: Fifty adult patients undergoing laparoscopic major abdominal surgery were randomly assigned to either a sevoflurane group (n = 25) or a propofol group (n = 25). In the sevoflurane group, anesthesia was induced with propofol 2 mg/kg, remifentanil 1.0 microg/kg, and maintained with 0.8-2.0 vol% sevoflurane and 0.1-0.2 microg/kg/min remifentanil. In the propofol group, anesthesia was induced with the effect-site concentration of propofol of 5.0 microg/ml and remifentanil 4 ng/ml, and maintained with the effect-site concentration of propofol of 2-3.5 microg/ml and remifentanil 3-5 ng/ml. Core body temperature was measured with an esophageal stethoscope with a temperature sensor after the start of the pneumoperitoneum (baseline) and at 15-min intervals until completion of surgery. RESULTS: During the study period, core temperature was comparable between the two groups. When compared with baseline values, core temperatures in both groups were significantly decreased 45 min after pneumoperitoneum. CONCLUSIONS: This study demonstrated that in patients undergoing prolonged laparoscopic surgery, a decrease in core body temperature during sevoflurane-remifentanil anesthesia was not different than propofol-remifentanil anesthesia, and the incidence of hypothermia of the two groups did not differ.

Anesthetic management of a patient with bilateral common carotid and subclavian arteries occlusion using cerebral oximetry monitoring: A case report

The common carotid artery is an artery which supplies the head and neck with oxygenated blood. Although unilateral common carotid artery occlusion or bilateral internal carotid artery occlusion have been reported, the incidence of both common carotid artery occlusion is very rare. As previous report which reviewed 5400 carotid duplex ultrasonograms, 2.5% of internal carotid artery occlusion, 0.24% of unilateral common carotid artery occlusion and none of bilateral common carotid artery occlusion were reported. Common carotid and subclavian arteries are important in the blood supply to the vasculatures of head and upper extremities. Bilateral common carotid artery occlusion might be a cause of stroke, transient ischemic attack or other neurologic sequalae. Cerebral oximetry is a simple method of measuring regional cerebral oxygen saturation (rSO2), which appears to reflect changes in cerebral perfusion and it has been increasingly applicated in many clinical situations such as vascular surgeries involving head/ neck and operations adopting cardiopulmonary bypass. This case describes a successful anesthetic management in a patient with occlusion of bilateral common carotid and subclavian arteries using continuous cerebral oxygenation monitoring during laparoscopic cholecystectomy.

Venous air embolism during hepatic resection in a patient with liver cirrhosis: A case report

Venous air embolism (VAE) is a potentially fatal complication in patients with chronic liver disease during liver surgery, although VAE is unlikely to occur during laparotomy in a supine position. We report a case presenting unexpected cardiovascular collapse due to venous air embolism in a patient with liver cirrhosis during hepatic resection.

Anesthetic experience in a pediatric patient with mastocytosis / 대한마취과학회지

No abstract available.

The clinical effective dose of alfentanil for suppressing cough during emergence from desflurane anesthesia / 대한마취과학회지

BACKGROUND: The administration of short-acting opioids before emergence is useful for preventing emergence cough induced by an endotracheal tube. This study examined the clinically effective dose of alfentanil for suppressing cough during emergence from desflurane anesthesia. METHODS: Twenty-nine adult patients undergoing elective oral surgery were enrolled in this study. During emergence from anesthesia, the patients received alfentanil diluted in 10 ml normal saline when the end-tidal vol% of desflurane decreased to 3%. The initial alfentanil dose was 16 microg/kg. The alfentanil dose for consecutive patients, determined by Dixon's up-and-down method, increased or decreased by 2 microg/kg according to a previous patient's result. RESULTS: The 50% effective dose (ED50) of alfentanil for suppressing cough during emergence from desflurane anaesthesia was 9.3 +/- 1.5 microg/kg according to Dixon's up-and-down method. Isotonic regression revealed an ED50 and ED95 (95% confidence interval) of alfentanil 10.0 microg/kg (6.8-13.2 microg/kg) and 14.0 microg/kg (7.7-19.4 microg/kg), respectively. CONCLUSIONS: The ED95 of alfentanil for suppressing emergence cough was 14.0 microg/kg. A single bolus administration of alfentanil during emergence from anesthesia was useful for suppressing emergence cough.