Public awareness about the specialty of anesthesiology and the role of anesthesiologists: a national survey / 대한마취과학회지

BACKGROUND: The aims of this national survey were to determine the views of Korean people regarding the specialty of anesthesiology and the role of anesthesiologists and to consider the ways in which individual anesthesiologists and the Korean Society of Anesthesiologists inform the public. METHODS: This off-line national survey was conducted by a professional research organization to obtain exact and reliable data. The questionnaire included structured questions to identify perceptions of the specialty of anesthesiology and the role of anesthesiologists inside and outside the operating room, people's desire for explanation of anesthesia by anesthesiologists, and their opinion about the best way to raise awareness about anesthesia and anesthesiologists. RESULTS: Of the respondents, 25.2% did not know that anesthesiologists are in charge of anesthesia during surgery. Furthermore, even respondents who knew that had very little knowledge of anesthesiologists' actual roles inside and outside the operating room. Respondents wanted their anesthesiologist to inform them about their anesthesia. CONCLUSIONS: The public's awareness regarding the role of anesthesiologists seems to be inadequate. To improve this awareness, in hospitals, each anesthesiologist should provide patients with more exact and detailed information. Simultaneously, the National Society of Anesthesiology should provide systematic information reflecting the public's thoughts.

Ultrasound-guided Pulsed Radiofrequency of the Third Occipital Nerve

A C2-3 zygapophygeal joint is a major source of cervicogenic headache. Radiofrequency (RF) neurotomy is preformed widely for zygapophygeal joint pain. Conventional RF denervation technique is generally performed under fluoroscopic control. Recently, ultrasound-guided radiofrequency on zygapophygeal joint has emerged as an alternative method. We report our experiences of two successful ultrasound-guided pulsed radiofrequencies on 39-year-old and 42-year-old males, who complained occipital headache and posterior neck pain.

The effects of superior cervical ganglionectomy on the ability of spatial memory using radial arm maze in the rats

BACKGROUND: Stress, elevated sympathetic nervous system, glucocorticoid concentration affect learning and memory. The aim of this study was to evaluate the effects of superior cervical ganglionectomy on the spatial memory using radial arm maze test. METHODS: Male Sprague-Dawley rats were used. Rats were divided into two groups: a superior cervical ganglionectomy group and a control group. Each rat was put into the radial arm maze two times per day for 4 days. We checked the number of the total visit, the total error, the reference memory error, the working memory error. And then a superior cervical ganglionectomy group received bilateral superior cervical ganglionectomy, and a control group received a sham operation. The radial arm maze test was then repeated and we evaluated the effect of superior cervical ganglionectomy on spatial memory. RESULTS: There were no significant differences in ratio of total error, reference memory error, and working memory error. CONCLUSIONS: Bilateral superior cervical ganglionectomy in rats does not effect the spatial memory. However, further studies are needed to determine the effect of superior cervical ganglionectomy on spatial memory.

Temporary cardiac arrest in patient under robotically assisted total thyroidectomy causing carotid sinus hypersensitivity: A case report / 대한마취과학회지

Carotid sinus hypersensitivity (CSH) is an exaggerated response to carotid sinus baroreceptor stimulation. Bradycardia, hypotension, and syncope are common manifestations of CSH. A 31-year-old female patient was scheduled for a robotically assisted endoscopic total thyroidectomy. No problems occurred during anesthetic induction. Sudden cardiac arrest occurred near dissection of the diseased thyroid. However, while atropine was administered, the patient soon recovered to normal sinus rhythm. Subsequent bradycardia or hypotension was not followed until the end of surgery.

The effects of superior cervical ganglionectomy on the anxiety in the rats / 대한마취과학회지

BACKGROUND: Therapeutic indications for stellate ganglion block range from head and upper arm disease to general disease including psychosomatic disorders. The aim of this study was to evaluate the effects of superior cervical ganglionectomy on anxiety using the elevated plus maze test. METHODS: Male Sprague-Dawley rats (150-250 g) were used. Each rat was put into the elevated plus maze 5 minutes per day for 10 days. We checked the number of entries into each arm (open arm and closed arm) and the duration of time staying in each arm. Rats were then divided into two groups: a group that received bilateral superior cervical ganglionectomy, and a control group that received a sham operation. The elevated plus maze test was then repeated and we evaluated the effect of superior cervical ganglionectomy on anxiety. RESULTS: Although there was an increased tendency of ganglionectomized rats to enter each arm, there were no significant differences in number of entries or in duration of stay between experimental and control groups. CONCLUSIONS: Bilateral superior cervical ganglionectomy in rats does not reduce anxiety. However, further studies are needed, ones combined with neuroendocrine and clinical studies, to determine the effect of superior cervical ganglionectomy on behavioral responses.

Alternating Pseudohemoptysis and Hematemesis during Recovery after General Anesthesia: A case report / 대한마취과학회지

A 22-year-old male patient was admitted for reconstructive surgery after primary orbital fracture operation.Following uneventful intraoperative procedure except postextubation laryngospasm, in PACU area, there were alternately frustrating and confusing events of several times of projectile vomiting of considerable amount of dark blood and hemoptysis with forceful coughing.On rigid nasal endoscopic examination after investigative gastric endoscopy and bronchoscopy, intranasal bleeding at the point of the middle turbinate was found, highly suggestive of anterior ethmoidal artery injury during the operation.Presumably blood swallowing with restoration of spontaneous respiration during emergence and aspiration after extubation resulted in these different features of hematemesis and pseudohemoptysis, respectively.In conclusion, one must keep in mind the potentially dangerous but preventable swallowing and aspiration during the course of emergence and recovery after general anesthesia for surgery or accompanying injury of orofacial structures.

Effect of Nalbuphine on Emergence Agitation and Recovery after Desflurane Anesthesia in Children for Strabismus Surgery / 대한마취과학회지

BACKGROUND: Emergence agitation frequently occurs after desflurane anesthesia in children.Nalbuphine, because of its sedative and analgesic properties, might be useful for the management of this side effect.We studied the effect of nalbuphine on recovery characteristics and emergence agitation after desflurane anesthesia in children for strabismus surgery. METHODS: 41 patients (3-14 yr) scheduled for pediatric strabismus surgery were included.All children received ketamine 0.5 mg/kg intravenously before entering the operating room.After intravenous induction with thiopental and rocuronium to facilitate endotracheal intubation, patients were randomly assigned to receive saline, or nalbuphine 0.2 mg/kg respectively. Anesthesia was maintained with desflurane 4-6% with N2O : O2 = 2 : 1.At the end of anesthesia, time to cough, extubation, movement, eye opening and discharge were recorded.Emergence agitation was recorded by three point rating scale. RESULTS: Agitation scores were significantly different between the two groups (P < 0.01).Time to extubation and movement were similar between two groups.Time to eye opening was significantly increased in nalbuphine group (P < 0.05).But, there was no difference in time to discharge from the recovery room to the ward between the two groups. CONCLUSIONS: In children undergoing strabismus surgery with desflurane anesthesia, nalbuphine 0.2 mg/kg administered immediately after induction reduced incidence of emergence agitation without delaying discharge from recovery room.

Assessment for the Quality of Recovery from General Anesthesia in Patients with Gynecologic Surgery / 대한마취과학회지

BACKGROUND: Quality of recovery, assessed by patients, is related to patients' satisfaction, and even to quality of life. Of numerous patient-based measures to evaluate the quality of recovery, a '40-item-quality of recovery (QoR-40)' has proved to be valid and reliable. Using this questionnaire, we evaluated the quality of recovery in the gynecological patients and tried to identify factors affecting the quality of recovery. METHODS: Patients undergoing gynecological surgery were asked to fill a questionnaire 8 to 9 p.m the day after the completion of anesthesia. Questionnaires were prepared after translation to Korean from 40-item-quality of recovery. From the anesthetic and recovery room records we collected data about patient's age, surgery types, anesthetic and surgical duration, recovery room stay, main anesthetic agents, and recovery room complications. RESULTS: A total of 383 patients completed the questionnaires. Patients aged under 40 got significantly lower QoR-40 scores than those aged over 40, especially in the dimension of pain (P < 0.05). Patients who had undergone laparoscopic surgery got higher scores than those had undergone non-laparoscopic surgery (P < 0.05). Patients who answered the questionnaires in more than 30 hours after the completion of anesthesia showed lower total scores than those who did in less than 30 hours, especially in the dimensions of emotional state and pain (P < 0.05). CONCLUSIONS: In gynecological patients, laparoscopic surgery improved quality of recovery. Quality of recovery was affected by age and survey time. Postoperative pain contributed to the decrease of the quality of recovery.

The Heparin Effects Changes before and after Reperfusion and It's Related Effects on Transfusion during Liver Transplantation / 대한마취과학회지

BACKGROUND: One of the difficulties we have in the management of anesthesia for the optimal liver transplantation is involved in coagulopathy. The purpose of this paper is to observe and investigate the variation of the heparin effects occurred before and after the fulfillment of reperfusion done in terms of native thromboelastogram (nTEG) or heparinase-guided Thromboelastogram (hgTEG). METHODS: In 134 patients who had a living related liver transplantation, by grouping them into four according to the presence or the absence of heparin effects, we are to observethe effects on the quantity of transfusion which each group shows and clinical variables like CTP score, UNOS classification, PT, and preoperative platelet count. RESULTS: It is found that 54 out of 134 patients (40.3%) had heparin effects before the reperfusion, while 101 (75.4%) had the effects after the reperfusion to the grafted liver. It is showed that there was no significant difference in a comparison between groups involved with packed red blood cell transfused, fresh frozen plasma, platelet concentrates, fluid by RIS. In the comparison between groups involved in clinical factors, it is disclosed that although there was no significant difference in four factors, that is, CTP score, UNOS classification, PT, and preoperative platelet count. CONCLUSIONS: We can confirm that the occurrence of heparin effect after reperfusion is remarkably increasing compared to that of heparin effect before reperfusion. Also, it can be reported that heparin effects can occur frequently during liver transplantation, but they have no direct relation to transfusion.

The Effect of the Level of Sedation on Recovery in Patients undergoing Target Controlled Propofol Infusion with a Bolus of Fentanyl for Strabismus Surgery / 대한마취과학회지

BACKGROUND: An immediate examination of ocular movement is required during strabismus surgery. The aim of this study was to determine the effect of the level of sedation on the recovery of patients undergoing a target controlled propofol infusion with a bolus of fentanyl for strabismus surgery. METHODS: Twenty-one outpatients scheduled to undergo strabismus surgery were assigned randomly to one of two groups. In both groups, sedation was induced with a bolus of fentanyl 1microgram/kg intravenously followed by an infusion of propofol with a target concentration of 1.0microgram/ml. The target concentration was increased or decreased by 0.1 microgram/ml steps until the patient reached and maintained the observer's assessment of alertness/sedation (OAA/S) scale score of 3 (group A) or 4 (group B). The supplemental analgesics consisted of fentanyl 25-50microgram bolus injection. The target concentration of propofol, the total dose of fentanyl, delayed awakening, and recovery time were recorded. RESULTS: The mean target concentration of propofol (mean +/- SD) in group A (1.8 +/- 0.4microgram/ml) was significantly higher than that of group B (1.3 +/- 0.4microgram/ml) (P<0.05). There were no significant differences in the total dose of fentanyl, delayed awakening and recovery time between the two groups. There was an an increasing trend in the recovery time with the total dose per kilogram of body weight of fentanyl (Spearman's correlation coefficient, r = 0.384, P = 0.086). CONCLUSIONS: The levels of sedation did not affect the recovery time in patients during target propofol infusion with a bolus of fentanyl. However, the addition of fentanyl tended to prolong the recovery time.

The Effect of Spinal Cord Stimulation in Patients with Complex Regional Pain Syndrome / 대한통증학회지

BACKGROUND: Complex regional pain syndrome (CRPS) is a painful, disabling disorder for which no proven treatment has been established. The purpose of this investigation was to assess the evidence of the efficacy of spinal cord stimulation (SCS) in the management of pain in CRPS patients. METHODS: Between March 2004 and June 2006, 11 patients with CRPS were treated with SCS. The visual analog scale (VAS) score for pain (0-10) and pain disability index (PDI) were obtained in all patients prior to treatment, and 1, 3 and 6 months post-implantation. RESULTS: All 11 patients, 5 men and 6 women, with a median age and duration of CRPS of 44 years and 48.8 months, respectively, successfully received a lead implantation for SCS. The mean VAS pain score prior to the treatment was 85.5 out of 100 mm. After SCS implantation, the mean VAS pain scores were 49.5, 57.0 and 56.0 at 1, 3 and 6 months after the procedure, respectively. The mean pain score for allodynia was decreased by 50%, with a significant reduction of the PDI also observed after the treatment. CONCLUSIONS: Our current study suggests that SCS implantation is a safe and effective method in the management of CRPS patients.

Assessment of Blood Glucose Values Measured by Blood Gas Analyzer or Portable Glucometer / 대한마취과학회지

BACKGROUND: A portable glucometer is commonly used to immediately check the blood glucose level. In the anesthetic field, some blood gas analyzers can also give a rapid indication of the blood sugar level but the accuracy is unknown. Therefore, this study assessed the accuracy of the blood glucose values measured by either a blood gas analyzer or portable glucometer. METHODS: Venous blood from diabetic patients was used to measure the glucose level with either a blood gas analyzer or a portable glucometer. The difference and 5% deviation from reference values was analyzed. These values were also assessed using a Bland-Altman plot and clinical significance was examined using a Clarke error grid. RESULTS: The differences from the reference values were smaller using the blood gas analyzer (1.3 +/- 7.8 mg/dl) than using the portable glucometer (-5.1 +/- 16.7 mg/dl)(P < 0.01). 73.4% of the values measured by the blood gas analyzer and 40.0% of those measured by the portable glucometer were within 5% of the reference value. The 95% limits of agreement in the difference ranged from -14.3 to 16.9 in the blood gas analyzer and -38.5 to 28.2 in the portable glucometer. Error grid analysis showed that 100% of the values measured by the blood gas analyzer were located in zone A. When locating the values measured using the portable glucometer, 95.6% were located in zone A, and the remaining 4.4% are located in zone B. CONCLUSIONS: The blood gas analyzer measures the blood glucose more accurately than the portable glucometer. However, the blood glucose values measured by the portable glucometer are clinically acceptable.

Thoracic Spinal Cord Stimulation and Radiofrequency Thermocoagulation of Lumbar Sympathetic Ganglion in a Patient with Complex Regional Pain Syndrome in the Lower Extremity: A case report / 대한통증학회지

Herein is described the successful treatment of complex regional pain syndrome type II with the combination treatment of spinal cord stimulation and radiofrequency thermocoagulation of the lumbar sympathetic ganglion. A 62 years old male patient, suffering from CRPS type II in his left lower extremity, visited our pain clinic. Medication and nerve blockade produced only slight improvement in his symptoms and signs. Therefore, a linear type spinal cord simulator was inserted into the thoracic epidural space, using a non-surgical percutaneous approach, with the cephalad lead located at the T11 level. Two months later, the repositioning of the electrode to the T12 level for more effective pain control, with radiofrequency thermocoagulation of lumbar sympathetic ganglion also performed at the left L2 and 3 levels for the control of trophic change. These resulted in significant pain relief and decreased trophic change, with no complications, after which the patient was able to resume a normal life.

The Spontaneous Resorption of Herniated Lumbar Disc: A case report / 대한통증학회지

The most effective treatment methods for a herniated lumbar disc remain questionable. This report follows the patients course, from the onset of pain through the completion of the non-surgical treatment, and shows that a lumbar herniated disc, with radiculopathy, can be successfully treated with a non-surgical approach. This report discusses the possible explanations for disc resorption: retraction into the intervertebral space, dehydration/shrinkage and resorption due to an inflammatory reaction. A non-surgical approach can be an effective treatment option for a herniated lumbar disc.

Effect of Morphine on c-fos Expression of Incisional Pain Rat Brain / 대한마취과학회지

BACKGROUND: Not many recent studies have shown that morphine antinociception may be directly expressed in forebrain structures. It is generally accepted that c-fos is a marker of neuronal activity and its expresson is correlated with nerve pathway activated by nociceptive stimuli. The aim of this study is to examine the effect of morphine on c-fos expression in the incisional pain rat brain. METHODS: A 1 cm longitudinal incision was made through the skin, fascia and muscle of the plantar aspect of the hindpaw in enflurane-anesthetized rats. 10 mg/kg of morphine was injected intraperitoneally 1 hour before (pre-morphine group; n = 15) and 30 minutes after surgery (post-morphine group; n = 15). The same amount of saline was injected 30 minutes after surgery (control group; n = 15). Two hours later c-fos protein expressions in the thalamus, hypothalamus, cerebral cortex and amygdala were examined by immunohistochemistry using a specific antibody. RESULTS: Numerous c-fos positive cells were observed in thalamus, hypothalamus, cerebral cortex, and amygdala in all groups. There were no significant differences in c-fos expression between pre-morphine, post-morphine and control group (P <0.05). CONCLUSIONS: In this study we expected to decreased c-fos expression in incisional pain rat brain by morphine injection. But no differences were observed compared to control group in thalamus and cortex which transmitting pain to CNS, also in hypothalamus and amygdale which transmitting emotional stress to CNS. These results suggests that intraperitoneal morphine can not protect the c-fos expression of ascending pathway to thalamus, hypothalmus, amygdala and cerebral cortex. Also we can not support the effect of morphine on the descending pathway of pain. So we thought for the more information, additional study, for example, behavior test, PCR (polymerase chain reaction)study, may be needed.

The Effects of Superior Cervical Ganglionectomy on C-fos Expression in Rat Brain / 대한마취과학회지

BACKGROUND: C-fos is a marker of neuronal activity and its expression may be related to various types of stimulation of primary sensory neurons. We evaluated the effect of superior cervical ganglionectomy on c-fos expression in rat brain, which was expected to have the same effect as stellate ganglion block in human. METHODS: Male Sprague-Dawley rats (140-150 g) were divided into 4 groups; a no treatment (control group, n = 10), a 2 hour enflurane inhalation (anesthesia group, n = 10), a cervical skin incision only group (sham group, n = 10) and a superior cervical ganglionectomy group (sympathectomy group, n = 10). Two hours after each procedure, rats were killed and perfused with formaldehyde solution. c-fos protein expressions in the thalamus, hypothalamus, cortex, amygdala and cingulate gyrus were examined by immunohistochemistry using a specific antibody. RESULTS: In the thalamus, c-fos expression increased in the sympathectomy group vs. the control and the anesthesia groups, and in the sham group vs. the control group. In amygdala, the sham group showed significantly higher c-fos expression than the control group. In the hypothalamus and cortex no significant differences among the 4 groups were apparent. In the cingulate gyrus higher c-fos expression was observed than the control and anesthesia group but no differences with sham group. CONCLUSIONS: Superior cervical ganglionectomy itself may not affect c-fos expression in rat brain. For best results special effort should be made to avoid surgical or emotional stress.

Fos Expression in the Brain of Neuropathic Pain Rats / 대한마취과학회지

BACKGROUND: There have been some investigations regarding expression of c-fos, as a marker of altered neuronal expression in the spinal cord of neuropathic rats. However, the expression of c-fos in the brain of a neuropathic pain model has not yet been investigated. The purpose of this study was to evaluate the time course of c-fos expression in the brain of neuropathic pain rats. METHODS: The experimental rats were divided into two group; neuropathic pain (n = 16) and control (n = 16) groups. The left L5 L6 spinal nerves of the neuropathic pain group were ligated but those of the control group not ligated (sham operation). Two hours, 1st day, 3rd day and 7th day after the operation, we examined the expression of Fos in the cerebral cortex, the amygdala, the thalamus and the hypothalamus of the coronary sectioned brains of the rats. RESULTS: C-fos expressions in the cerebral cortex and the amygdala of the neuropathic pain group were greater at 2 hours, the 3rd and the 7th day than the control group, but those of the thalamus and hypothalamus of the neuropathic pain group were greater on the 3rd and 7th day than the control group (P< 0.05). In the neuropathic pain group, c-fos expressions of four brain regions were greater on the 3rd and 7th day than those at 2 hours and day 1, but there was no difference between the 3rd and 7th day's (P< 0.05). CONCLUSIONS: There were significant expressions of Fos protein in the brain of the neuropathic pain group at 2 hours, the 3rd day and 7th day of the operation, but the meaning of each expression was different. The expression of Fos at postoperative 2 hours resulted from acute pain but that at the 3rd and 7th day of the operation resulted from neuropathic pain.

Management of Chronic Pain

Chronic pain defined as pain that persists beyond the period of healing, in the absence of ongoing pathology, usually means pain over 3 to 6 months after the cure of the original disease. In this situation, the pain itself loses its protective function only to fall into a disease entity. There have been many efforts to treat chronic pain, with analgesics being the most commonly used modality, which include non-steroidal anti-inflammatory drug, opioids, antidepressant, and anxiolytic agents. Pain clinicians especially use nerve blocks for the control of intractable pain. Although the effect of nerve block or trigger point injection with local anesthetics is temporary, its effect of breaking the vicious cycle of pain patheway gives a long-term effect of analgesia. There are many diseases managed at pain clinics, including headache, trigeminal neuralgia, neck and shoulder pain, low back pain, complex regional pain syndrome, herpes zoster and postherpetic neuralgia, fantom pain, peripheral neuralgia, and vascular disease. The main nerve indicated for pain control may be any kind of somatic and sympathetic nerves and ganglions responsible for the pain.

Effects of Intrathecal Magnesium Sulphate in a Rat Model of Postoperative Pain / 대한마취과학회지

BACKGROUND: The mechanical hyperalgesia that follows peripheral tissue injury results from peripheral and central sensitization. Central sensitization is initiated and maintained by windup that can be prevented by N-methyl-D-aspartate (NMDA) antagonists. NMDA antagonists, therefore, have the potential to prevent and treat pain, although clinical uses are limited because of their side effects. This study was designed to evaluate the analgesic action of intrathecal (IT) magnesium sulphate in a rat model of postoperative pain and investigate the analgesic mechanism of magnesium. METHODS: Forty-two Sprague-Dawley rats (300 +/- 20 g) were prepared with a chronic IT catheter. Under brief enflurane anesthesia, a 1-cm incision including skin, muscle and fascia was made in the plantar aspect of the hind paw and closed. Normal saline, magnesium (30, 100, 300, 600 microgram), NMDA 50 ng or NMDA 50 ng with magnesium 300 microgram was administered via the IT catheter after recovery. Response frequency, using Von Frey filaments, cumulative pain scores and motor deficits were assessed. RESULTS: The mechanical hyperalgesia and nonevoked pain behaviors decreased significantly at 1 h or 1 h and 3 h after IT injection of magnesium 100 microgram or 300 microgram compared to the saline group without profound motor deficits in a rat model of postoperative pain. However, the rats administered with magnesium 600 microgram were lethargic due to severe motor weakness. Effective duration of magnesium decreased significantly in the group of NMDA 50 ng with magnesium 300 microgram compared to that of magnesium 300 microgram administered alone, but the initial effects were similar between the two groups. CONCLUSIONS: We conclude that IT magnesium sulphate can modulate nociceptive processing after tissue injury and the analgesic mechanism of magnesium is involved in NMDA receptors. Magnesium,therefore, may offer a therapeutic agent for postoperative pain and may be an agent that prevents postoperative pain from changing to persistent pathological pain.

Desaturation of Pulse Oximetry by Intraoperative Using of Subcutaneous Blue Dye: A case report / 대한마취과학회지

Pulse oximetry is a noninvasive, reusable device that is being used routinely in anesthesia procedure for monitoring oxygen saturation. This is a very beneficial device that can quickly detect of hypoxia, the most common cause of anesthesia-related death. However, in clinical uses, false desaturation readings are frequently found to be caused by various factors. Such as by the use of intraoperative blue dye, which can falsely decrease oxygen saturation as determined by pulse oximetry. We therefore report our findings concerning prolonged decreased pulse oximetry readings due to the intraoperative use of blue dye subcutaneously.