Midterm-clinical Outcomes after Hip Arthroscopy in Middle-aged Patients with Early Osteoarthritis / 대한고관절학회지

PURPOSE: Although the number of hip arthroscopies is rapidly increasing in non-elderly patients, outcomes of this procedure in middle-aged patients are not well documented or clearly understood. The purpose of this study was to evaluate the clinical and radiological outcomes after hip arthroscopy in middle-aged patients with early osteoarthritis.MATERIALS AND METHODS: This retrospective study analyzed 189 patients with early osteoarthritis of various diagnoses aged 40 years or older who underwent hip arthroscopy between January 2010 and December 2015. Clinical (e.g., modified Harris hip score [mHHS], hip outcome score-activities of daily living [HOS-ADL], visual analogue scale [VAS] for pain, range of motion) and radiological (change of Tönnis grade) outcomes were assessed at a minimum of 3-year follow-up.RESULTS: The mean preoperative and final mHHS and HOS-ADL improved from 61.2 and 60.6 to 79.5 and 81.8, respectively, while the VAS pain score decreased from 6.3 to 3.2 (P<0.001). Although the mean range of internal rotation and flexion increased from 14.2 and 100.7° preoperatively to 30.4 and 110.6° at 1-year postoperatively, they decreased slightly to 27.4 and 105.4° at the final follow-up, respectively. Eight cases (4.2%) underwent revision arthroscopic surgery and three cases (1.6%) were converted to total hip arthroplasty.CONCLUSION: Patients with early-stage osteoarthritis of various diagnoses achieved improved clinical outcomes. Therefore, using hip arthroscopy in middle-aged patients with early osteoarthritis, it is possible to achieve good surgical options.

Pathological Fracture of the Femoral Neck due to Tophaceous Gout: An Unusual Case of Gout / 대한고관절학회지

A 48-year-old man visited the emergency room with right hip pain that started abruptly while walking out of the bathroom. Computed tomography showed an intraosseous mass in the femoral neck. The patient had a 15-year history of gout and had numerous bilateral tophi in his hands, feet, knees, and elbows. After operation, we diagnosed a pathological fracture due to intraosseous tophi. Patients with hip pain who have many subcutaneous tophi and long-standing gout should be diagnosed carefully. Peri-hip joint pain caused by gout is uncommon, however, if a patient complains of pain, a simple X-ray may be required. If intraosseous tophi are present, appropriate treatment (e.g., strict hyperuricemia control with or without prophylactic internal fixation), may be required before fracture occurs.

Radiological and Clinical Effectiveness of a Novel Calcaneal Fracture Brace after Intra-articular Calcaneal Fracture Surgery

BACKGROUND: After calcaneal fracture surgery, a short leg splint and cast are typically applied. However, these restrict joint exercises, which is inconvenient for patients. In addition, there is a risk of complications, such as pressure ulcers or nerve paralysis with a short leg cast. In this study, we evaluated clinical and radiological outcomes of the use of a specially designed calcaneal brace after calcaneal fracture surgery. METHODS: From among patients who underwent open reduction and internal fixation for calcaneal fracture between July 9, 2013 and May 31, 2017, 102 patients who wore a calcaneal fracture brace (group A) and 82 patients who wore a postoperative short leg cast (group B) were randomly chosen for this study. Radiological changes and clinical factors were compared between the two groups. After swelling at the surgical site decreased, a special calcaneal brace was applied to patients in group A. They were allowed to perform early weight bearing and joint motion. Patients in group B were immobilized in a short leg cast and were told to avoid weight bearing for 6 weeks. In each group, the Böhler's angle and Gissane's angle were measured and compared using postoperative and final follow-up radiographs. Pain (measured using a visual analogue scale [VAS]) and ankle joint range of motion (dorsiflexion, plantar flexion, eversion, and inversion) were measured serially until the final follow-up visit. RESULTS: There were no significant differences in the Böhler's angle or Gissane's angle between the two groups as measured postoperatively and at the final follow-up (paired t-test). Differences in the VAS pain score and eversion were also statistically nonsignificant between the two groups. However, group A had a significantly higher range of dorsiflexion (p = 0.021), plantar flexion (p = 0.012), and inversion (p = 0.045) of the ankle than group B (independent t-test). CONCLUSIONS: Application of the calcaneal fracture brace after open reduction and internal fixation of a calcaneal fracture not only maintained the fracture reduction but allowed for greater joint motion than the short leg cast. Thus, the calcaneal fracture brace can be considered an effective postoperative management option that enables early resumption of daily activities and facilitates postoperative joint motion.

Rectal ectopic variceal bleeding during liver transplantation: A case report

Portal hypertension can lead to development of new veins, called collateral vessels in the esophagus, stomach, abdominal wall, rectum and so on. In particular, collateral vessels located in other site than the gastroesophageal region are defined as ectopic varices. These varices are fragile and can rupture easily, resulting in a large amount of blood loss that may become serious and occasionally result in death. We experienced a case of massive rectal variceal bleeding after cross-clamping of the inferior vena cava and hepatic portal vein during the living donor liver transplantation in patients who had no history of rectal variceal bleeding. Our case suggests that acute intraoperative hemorrhage from an ectopic varix should be a consideration before liver transplantation.

Clinical evaluation of anesthesia for cesarean section at tertiary medical center: retrospective study for 5 years (2009-2013)

BACKGROUND: Cesarean section anesthesia requires adequate preparation because of maternal physiologic changes, a higher risk for massive maternal bleeding, neonatal considerations, and a higher frequency of emergency operations. Therefore, we retrospectively compared clinical outcomes of cesarean section patients between a high-risk group and non-high-risk group in order to improve anesthesia care. METHODS: We reviewed medical records from cesarean section cases at our tertiary medical center for 5 years (2009-2013). Parameters included the anesthesia and operative time; estimated blood loss, fluid volume and blood products administered during surgery, additional administration of maternal uterotonic medications; as well as the birth weight, Apgar scores, number of neonatal intensive care unit (NICU) admissions, and stillbirth rates of the neonate. RESULTS: The total number of delivery cases was 1935 during the 5 years, and the cesarean section cases accounted for 58.8% (1,138 cases). There were 735 emergency surgery cases (64.6%), and 813 (71.4%) patients were in the high-risk group. Estimated blood loss, fluid volume used, and the frequency and amount of blood transfusions were statistically higher in the high-risk group. Among 1,243 neonates, 918 (73.9%) were born from high-risk mothers. Neonatal birth weights and Apgar scores (1 and 5 minutes) from patients in the high-risk group were statistically lower than those in the non-high-risk group, and NICU admissions and stillbirths were statistically higher in the high-risk group. CONCLUSIONS: Anesthesiologists should be aware of unfavorable clinical outcomes in high-risk cesarean section groups and carefully prepare for anesthesia care in these cases.

Flexible bronchoscopic foreign body removal through the I-gel supraglottic airway: A case report

The daily insertion of endotracheal tubes, laryngeal mask airways, oral/nasal airways, gastric tubes, transesophageal echocardiogram probes, esophageal dilators and emergency airways all involve the risk of airway structure damage. In the closed claims analysis of the American Society of Anesthesiologists, 6% of all claims concerned airway injury. Among the airway injury clams, the most common cause was difficult intubation. Among many other causes, esophageal stethoscope is a relatively noninvasive monitor that provides extremely useful information. Relatively not many side effects that hardly is ratable. Some of that was from tracheal insertion, bronchial insertion resulting in hypoxia, hoarseness due to post cricoids inflammation, misguided surgical dissection of esophagus. Also oropharyngeal bleeding and subsequent anemia probably are possible and rarely pharyngeal/esophageal perforations are also possible because of this device. Careful and gentle procedure is necessary when inserting esophageal stethoscope and observations for injury and bleeding are needed after insertion.

The effects of hydromorphone on astrocytic responses in cerebral ischemia

BACKGROUND: Ischemic insult during operation could cause ischemic-reperfusion injuries in brain and memory impairments. Total intravenous anesthesia (TIVA) is preferred in brain surgery to promote the use of motor evoked potential monitoring and the use of opioids is common in TIVA. However there were few studies about ischemic protective effect of opioids to astrocytes. METHODS: We used astrocytes, which were derived from human brain. We divided groups by conditioning period; i) pre-culture, ii) post-culture, or iii) pre + post-culture. All groups were treated 100 nM hydromorphone. We measured reactive oxygen species (ROS) by flow cytometry with 2',7'-dichloroflurorescin diacetate. Then ROS in astrocytes which treated by opioid receptor antagonist were measured after treating 100 nM hydromorphone. RESULTS: ROS was reduced in hydromorphone treated group, as compared to the control group (only tert-butyl hydroperoxide [TBH] treated). There was no difference in pre-conditioned group and post-conditioned group. However, ROS was much more reduced in pre + post-conditioned group compared to pre-conditioned only or post-conditioned only group. Furthermore each selective micro-, delta- and kappa-opioid receptor antagonists partially negated the effect of hydromorphone. CONCLUSIONS: This study provides evidence that hydromorphone has both preconditioning and postconditioning effects on TBH-induced oxidative stress. Furthermore we proved each micro-, delta- and kappa-opioid receptor relates to protective mechanism of hydromorphone to astrocytes.

Anesthetic management of hypertensive crisis in a three-year-old patient with undiagnosed severe renal artery stenosis: a case report / 대한마취과학회지

Pediatric hypertensive crisis is a potentially life threatening medical emergency, usually secondary to an underlying disease. Hypertension commonly occurs during general anesthesia, and is usually promptly and appropriately treated by anesthesiologists. However in children with severe, unexplained, or refractory hypertension, it has the potential to cause morbidity and even mortality in susceptible patients. We report an anesthetic management of an unexpected hypertensive crisis that developed during general anesthesia in a three-year-old girl with undiagnosed severe left renal artery stenosis.

Anesthetic management of hypertensive crisis in a three-year-old patient with undiagnosed severe renal artery stenosis: a case report / 대한마취과학회지

Pediatric hypertensive crisis is a potentially life threatening medical emergency, usually secondary to an underlying disease. Hypertension commonly occurs during general anesthesia, and is usually promptly and appropriately treated by anesthesiologists. However in children with severe, unexplained, or refractory hypertension, it has the potential to cause morbidity and even mortality in susceptible patients. We report an anesthetic management of an unexpected hypertensive crisis that developed during general anesthesia in a three-year-old girl with undiagnosed severe left renal artery stenosis.

Beneficial Effects of Adding Ketamine to Intravenous Patient-Controlled Analgesia with Fentanyl after the Nuss Procedure in Pediatric Patients

PURPOSE: The aim of this prospective, double-blind, randomized study was to investigate the analgesic effects of low-dose ketamine on intravenous patient-controlled analgesia (IV-PCA) with fentanyl for pain control in pediatric patients following the Nuss procedure for pectus excavatum. MATERIALS AND METHODS: Sixty pediatric patients undergoing the Nuss procedure were randomly assigned to receive fentanyl (Group F, n=30) or fentanyl plus ketamine (Group FK, n=30). Ten minutes before the end of surgery, following the loading dose of each solution, 0.5 microg/kg/hr of fentanyl or 0.5 microg/kg/hr of fentanyl plus 0.15 mg/kg/hr of ketamine was infused via an IV-PCA pump (basal rate, 1 mL/hr; bolus, 0.5 mL; lock out interval, 30 min). Fentanyl consumption, pain score, ketorolac use, nausea/vomiting, ondansetron use, pruritus, respiratory depression, hallucination, dreaming, and parent satisfaction with pain control were measured throughout the 48 hours following surgery. RESULTS: The pain scores, ketorolac use, and fentanyl consumption of Group FK were significantly lower than in Group F (p<0.05). The incidence of nausea/vomiting and ondansetron use in Group FK was significantly lower than in Group F (p<0.05). There were no reports of respiratory depression, hallucination or dreaming. Parent satisfaction with pain control was similar between the two groups. CONCLUSION: We concluded that low-dose ketamine added to IV-PCA with fentanyl after the Nuss procedure in pediatric patients can reduce pain scores, consumption of fentanyl, and incidence of nausea/vomiting without increasing side effects.

The effect of ketamine on the separation anxiety and emergence agitation in children undergoing brief ophthalmic surgery under desflurane general anesthesia / 대한마취과학회지

BACKGROUND: Emergence agitation (EA) frequently occurs after desflurane anesthesia in children. Ketamine, because of its sedative and analgesic properties, might be useful for the management of separation anxiety and EA. We investigated the preventive effect of ketamine on separation anxiety and EA after desflurane anesthesia in children for brief ophthalmic surgery. METHODS: Sixty children, ranging in age from 2-8 years old, undergoing brief ophthalmic surgery were randomly allocated to one of the 3 groups: group C received normal saline, group K1.0 received ketamine 1.0 mg/kg intravenously before entering the operating room, or group K0.5 received ketamine 0.5 mg/kg 10 min before the end of the surgery. Before induction, the separation anxiety score was evaluated. Extubation time, post-anesthesia care unit stay time, postoperative nausea and vomiting, emergence agitation, and pain were assessed. RESULTS: The group K1.0 had a lower separation anxiety score compared with groups K0.5 and C. Extubation time in group K0.5 was significantly prolonged compared with groups K1.0 and C. The incidence of EA and the modified Children's Hospital of Eastern Ontario Pain Scale were significantly lower in group K1.0 and group K0.5 compared to group C, but there was no significant difference between groups K1.0 and K0.5. CONCLUSIONS: In children undergoing brief ophthalmic surgery with desflurane anesthesia, ketamine 1.0 mg/kg administered before entering the operating room reduced separation anxiety, postoperative pain, and incidence of EA without delay in recovery.

Effect of ketamine on intravenous patient-controlled analgesia using hydromorphone and ketorolac after the Nuss surgery in pediatric patients / 대한마취과학회지

BACKGROUND: Nuss surgery is preferred in pectus excavatum repair because this procedure produces excellent cosmetic results and prevents postoperative distressed pulmonary function. However, the procedure causes severe pain due to thoracic expansion. This study was designed to investigate the analgesic effect of small doses of ketamine on an intravenous patient-controlled analgesia (IV-PCA) using hydromorphone and ketorolac for pain control after Nuss surgery. METHODS: Forty-four patients undergoing elective Nuss surgery were randomly assigned to receive hydromorphone 3 microg/kg/hr, ketorolac 0.05 mg/kg/hr and ondansetron 0.1 mg/kg/day (Group HO, n = 22) or hydromorphone 3 microg/kg/hr, ketorolac 0.05 mg/kg/hr, ondansetron 0.1 mg/kg/day and ketamine 0.15 mg/kg/hr (Group HK, n = 22) via an IV-PCA pump after surgery. A blind observer evaluated each patient using the Modified Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) for the assessment of pain control. The total administered PCA volume, side effects and parents satisfaction with pain control were assessed at postoperative 1, 4, 8, 12, 24, and 48 hours. RESULTS: There were no significant differences in Modified CHEOPS between the groups during postoperative 48 hours. The total PCA volume in group HK was significantly lower than that in group HO (P < 0.05). The side effects in both groups did not significantly differ except for pruritus. The levels of satisfaction from the parents were not significantly different between the groups. CONCLUSIONS: A small dose of ketamine on IV-PCA reduced the total administered dose of IV-PCA with hydromorphone and ketorolac and reduced the incidence of pruritus after the Nuss procedure in pediatric patients.

Anesthetic management of a patient with nitric acid inhalation injury for extracorporeal membrane oxygenation / 대한마취과학회지

No abstract available.

Anesthetic experience using total intra-venous anesthesia for a patient with Wolf-Hirschhorn syndrome: A case report / 대한마취과학회지

We present here the case of a 33-month-old male patient with Wolf-Hirschhorn syndrome (WHS) and who underwent tympanoplasty and myringotomy. WHS is caused by a rare chromosomal abnormality, which is the deletion of the short arm of chromosome number 4. The typical craniofacial features of WHS patients such as micrognathia, microcephaly and the muscular weakness can make using neuromuscular blocking agents and performing intubation difficult. Moreover, there are a few previous case reports showing that malignant hyperthermia occurred during and after an operation in which the anesthesia was done with inhalation agents, so special anesthetic care is needed when operating on a WHS patient. By carefully intubating the patient and using total intravenous anesthesia, we performed successful anesthesia without any complications. We describe here the anesthetic management of a WHS patient and we review the relevant literature.

Morphine Attenuates Endothelial Cell Adhesion Molecules Induced by the Supernatant of LPS-Stimulated Colon Cancer Cells

A large reservoir of bacterial lipopolysaccharide (LPS) is available in the colon and this could promote colon cancer metastasis by enhancing tumor cell adhesion, intravasation, and extravasation. Furthermore, adhesion molecules like ICAM-1, VCAM-1, and E-selectin play important roles in the adhesion of tumor cells to endothelium. This study was designed to determine whether morphine can attenuate the expressions of adhesion molecules up-regulated by the supernatant of LPS-stimulated HCT 116 colon cancer cells (LPS-Sup). In this study, we divided to three groups by cell-growth medium of human umbilical vascular endothelial cells (HUVECs): the control group was incubated in growth factor-free endothelial medium, the Sup group was incubated in the supernatant of HCT 116 cells (Sup), and the LPS-Sup group was incubated in LPS-Sup. To observe effect of morphine to the adhesion molecules expressions in the LPS-Sup group, we co-treated morphine with LPS or added it to LPS-Sup. Adhesion molecule expressions on HUVECs in all three groups were measured during incubation period. Consquentially, ICAM-1, VCAM-1, and E-selectin expressions on HUVECs were significantly lower when morphine was co-treated with LPS than not co-treated. Thus, we suggest that morphine affects the expressions of adhesion molecules primarily by attenuating LPS stimuli on tumor cells.

Cerebral hemorrhage presenting as alteration of consciousness during the anesthesia recovery period: A case report

Catastrophic neurological events can occur rarely in anesthetic recovery period and they must be quickly diagnosed. We report here on a spontaneous intracerebral hemorrhage (SICH) that developed during the anesthesia recovery period in a 52-year-old man who had undergone uneventful orthopedic surgery. He had predisposing factors including 25 year history of heavy alcohol consumption and smoking. The risk of spontaneous intracerebral hemorrhage following non-cardiovascular and non-neurovascular surgery is exceedingly small during the anesthesia recovery period, especially for a patient with no history of hypertension and coagulopathy. We also describe the differential diagnosis of an altered mental status that occurs during anesthetic recovery period.

Morphine Postconditioning Attenuates ICAM-1 Expression on Endothelial Cells

The purpose of this study is to determine 1) whether morphine postconditiong (MPostC) can attenuate the intercellular adhesion molecules-1 (ICAM-1) expression after reoxygenation injury and 2) the subtype(s) of the opioid receptors (ORs) that are involved with MPostC. Human umbilical vein endothelial cells (HUVECs) were subjected to 6 hr anoxia followed by 12 hr reoxygenation. Three morphine concentrations (0.3, 3, 30 microM) were used to evaluate the protective effect of MPostC. We also investigated blockading the OR subtypes' effects on MPostC by using three antagonists (a micro-OR antagonist naloxone, a kappa-OR antagonist nor-binaltorphimine, and a delta-OR antagonist naltrindole) and the inhibitor of protein kinase C (PKC) chelerythrine. As results, the ICAM-1 expression was significantly reduced in the MPostC (3, 30 microM) groups compared to the control group at 1, 6, 9, and 12 hours reoxygenation time. As a consequence, neutrophil adhesion was also decreased after MPostC. These effects were abolished by coadministering chelerythrine, nor-binaltorphimine or naltrindole, but not with naloxone. In conclusion, it is assumed that MPostC could attenuate the expression of ICAM-1 on endothelial cells during reoxygenation via the kappa and delta-OR (opioid receptor)-specific pathway, and this also involves a PKC-dependent pathway.

The effect of ketamine on the incidence of emergence agitation in children undergoing tonsillectomy and adenoidectomy under sevoflurane general anesthesia / 대한마취과학회지

BACKGROUND: The rapid emergence and recovery from general anesthesia afforded by sevoflurane is associated with a high incidence of emergence agitation in children. Small doses of ketamine reduce the incidence of emergence agitation. This study compared the effects of ketamine 0.25 mg/kg and 0.5 mg/kg on emergence agitation and postoperative pain. METHODS: The effects of added intravenous ketamine were evaluated in 93 children, ASA I-II, 2-14 years old, undergoing an adenotonsillectomy. The patients were allocated randomly to one of three groups receiving saline (group C), ketamine 0.25 mg/kg (group K0.25) or ketamine 0.5 mg/kg (group K0.5). The children in each group were administered the study drugs 10 minutes before the end of surgery. The recovery characteristics, including the time to extubation, delivery time from the PACU, postoperative nausea and vomiting, agitation and pain were assessed. RESULTS: There were no significant differences in the extubation time, delivery time and postoperative nausea and vomiting between the three groups. There were significant differences in modified CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) between the three groups. The incidence of emergence agitation was low in the K0.25 and K0.5 groups compared to the control group. However, there was no significant difference between the K0.25 and K0.5 groups. CONCLUSIONS: There was no significant difference in the incidence of emergence agitation between K0.25 and K0.5 groups. However, K0.5 group showed a lower pain score than K0.25 group.

A case of malignant hyperthermia during anesthesia induction with sevoflurane: A case report / 대한마취과학회지

We experienced a case of malignant hyperthermia (MH) in 6-year-old boy during anesthesia induction for strabismus surgery. It has been generally reported that sevoflurane can induce the delayed onset of MH in the absence of succinylcholine. Our case of MH was elicited after about 2-3 min of sevoflurane administration with N2O, O2 and rocuronium. However, we successfully treated the patient by early recognition of his condition and administering symptomatic treatment and dantrolene.

Anaphylaxis with angioedema by rocuronium during induction of general anesthesia: A case report / 대한마취과학회지

Perioperative anaphylaxis is characterized by severe respiratory and cardiovascular manifestations. Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anesthesiologist. A 34-year-old woman was scheduled to undergo endo venous laser therapy of varicose veins. She had no history of allergies and had never undergone general anesthesia. General anesthesia was induced with propofol and rocuronium bromide. Approximately three minutes after rocuronium administration, hypotension and tachycardia developed and angioedema around the eyelids and skin rashes and urticaria appeared. The patient received ephedrine and hydrocortisone with hydration. After achieving stable vital signs and symptom relief, surgery was performed without complications. A postoperative skin dermal test performed to identify the agent responsible revealed a positive skin test for rocuronium.