In-plane three-step needle insertion technique for ultrasound-guided continuous femoral nerve block after total knee arthroplasty: a retrospective review of 488 cases / 대한마취과학회지

BACKGROUND: Continuous femoral nerve block (CFNB) improves postoperative analgesia after total knee arthroplasty (TKA). The aim of this study was to investigate the clinical efficacy and complications of our in-plane three-step needle insertion technique that was devised to reduce the risk of direct femoral nerve injury during CFNB in anesthetized patients. METHODS: This retrospective study included 488 patients who had undergone TKA. Ultrasound (US)-guided CFNB was performed under general or spinal anesthesia using an in-plane, three-step needle insertion technique. The success rate and difficulties of catheter placement, clinical efficacy of analgesia, and complications were recorded. RESULTS: Femoral catheters were placed with a 100% success rate. In 488 patients, real-time US imaging revealed easy separation of the fascia iliaca and the femoral nerve following injection of local anesthetic through a Tuohy needle. Verbal numerical rating scale pain scores (0–10) were 2.0 ± 1.2, 3.5 ± 1.9, 3.2 ± 1.7, 2.9 ± 1.3, and 2.5 ± 1.1 at 1, 6, 12, 24 and 48 h postoperatively. No femoral hematoma, femoral abscess, or neurologic complications, including paresthesia or neurologic deficits, were observed during the 8-week follow-up period. CONCLUSIONS: This retrospective study suggests that an in-plane three-step needle insertion technique for CFNB may reduce the risk of femoral nerve injury in anesthetized patients.

An unexpected increase of entropy in a sleepwalking disorder patient during propofol and remifentanil anesthesia: a case report / 대한마취과학회지

We report a case of increased values of entropy parameters Response Entropy (RE) and State Entropy (SE) during intravenous general anesthesia in a sleepwalking patient. An ASA class II, 64-year-old woman with stress incontinence underwent mid-urethral sling surgery. Prior to surgery, the patient had been administered paroxetine, valproic acid and clonazepam for the treatment of sleepwalking disorder. After 10 min of target-controlled infusion of propofol and remifentanil, entropy values increased up to 94 (RE) and 88 (SE) for 10 min. The target effect-site concentrations of anesthetics increased from 4 to 7 microg/ml propofol and 4 ng/ml remifentanil, at which point values fell back to adequate anesthesia levels. Episodes of recall or of explicit memories did not occur during the anesthesia. In conclusion, sleepwalking patients with long-term use medications may need increment of anesthetic dose caused by the anesthetic drug metabolism activation or impairment or immaturity of inhibitory circuits in brain.

An unexpected increase of entropy in a sleepwalking disorder patient during propofol and remifentanil anesthesia: a case report / 대한마취과학회지

We report a case of increased values of entropy parameters Response Entropy (RE) and State Entropy (SE) during intravenous general anesthesia in a sleepwalking patient. An ASA class II, 64-year-old woman with stress incontinence underwent mid-urethral sling surgery. Prior to surgery, the patient had been administered paroxetine, valproic acid and clonazepam for the treatment of sleepwalking disorder. After 10 min of target-controlled infusion of propofol and remifentanil, entropy values increased up to 94 (RE) and 88 (SE) for 10 min. The target effect-site concentrations of anesthetics increased from 4 to 7 microg/ml propofol and 4 ng/ml remifentanil, at which point values fell back to adequate anesthesia levels. Episodes of recall or of explicit memories did not occur during the anesthesia. In conclusion, sleepwalking patients with long-term use medications may need increment of anesthetic dose caused by the anesthetic drug metabolism activation or impairment or immaturity of inhibitory circuits in brain.

Bispectral index decreased to zero for a patient undergoing orthotopic liver transplantation / 대한마취과학회지

No abstract available.

Severe bronchospasm in a premature infant during induction of anesthesia caused ventilation failure / 대한마취과학회지

No abstract available.

Postoperative renal function in patients is unaltered after robotic-assisted radical prostatectomy / 대한마취과학회지

BACKGROUND: Pneumoperitoneum with an intra-abdominal pressure (IAP) of 14 mmHg is known to decrease renal function. Robotic-assisted radical prostatectomy (RARP) requires an IAP of more than 15 mmHg for operation. Therefore, we retrospectively investigated whether patients who underwent RARP experienced renal insufficiency during the postoperative period (at postoperative days 7 and 30). METHODS: One hundred patients who underwent RARP were enrolled in this study. Preoperative serum blood urea nitrogen (BUN) and serum creatinine (Cr) levels were measured. Creatinine clearance (CrCl) was calculated using the Cockcroft and Gault formula. CrCl was calculated at 1 day before surgery (baseline), 2 hr postoperatively, and at 1, 3, 7, and 30 days postoperatively (POD 1, POD 3, POP 7, and POD 30). Patients were assigned to abnormal CrCl (n = 52) or normal CrCl groups (n = 48) on the basis of these measurements. RESULTS: Significant inter-group differences in BUN, Cr, and CrCl were observed at all postoperative time points. BUN and Cr decreased significantly at postoperative 2 hr and POD 1, 3, and 7 versus baseline in both groups, whereas CrCl increased significantly at postoperative 2 hr and POD 1, 3, and 7 versus baseline in both groups. However, BUN, Cr, and CrCl were similar at POD 30 and preoperatively in the two groups. CONCLUSIONS: RAPR, which requires an IAP of 15-20 mmHg for more than 4 hr, does not induce renal dysfunction during the postoperative period, and even in those patients with an abnormal CrCl.

Feasibility of ultrasound-guided posterior approach for interscalene catheter placement during arthroscopic shoulder surgery / 대한마취과학회지

BACKGROUND: Continuous interscalene block has been known to improve postoperative analgesia after arthroscopic shoulder surgery. This was a prospective study investigating the ultrasound-guided posterior approach for placement of an interscalene catheter, clinical efficacy and complications after placement of the catheter. METHODS: Forty-two patients undergoing elective arthroscopic shoulder surgery were included in this study and an interscalene catheter was inserted under the guidance of ultrasound with posterior approach. With the inplane approach, the 17 G Tuohy needle was advanced until the tip was placed between the C5 and C6 nerve roots. After a bolus injection of 20 ml of 0.2% ropivacaine, a catheter was threaded and secured. A continuous infusion of ropivacaine 0.2% 4 ml/hr with patient-controlled 5 ml boluses every hour was used over 2 days. Difficulties in placement of the catheter, clinical efficacy of analgesia and complications were recorded. All patients were monitored for 48 hours and examined by the surgeon for complications within 2 weeks of hospital discharge. RESULTS: Easy placement of the catheter was achieved in 100% of the patients and the success rate of catheter placement during the 48 hr period was 92.9%. Postoperative analgesia was effective in 88.1% of the patients in the post anesthetic care unit. The major complications included nausea (7.1%), vomiting (4.8%), dyspnea (4.8%) and unintended vascular punctures (2.4%). Other complications such as neurologic deficits and local infection around the puncture site did not occur. CONCLUSIONS: The ultrasound-guided interscalene block with a posterior approach is associated with a success high rate in placement of the interscalene catheter and a low rate of complications. However, the small sample size limits us to draw definite conclusions. Therefore, a well-designed randomized controlled trial is required to confirm our preliminary study.

Effect of propofol on cardiac function and gene expression after ischemic-reperfusion in isolated rat heart / 대한마취과학회지

BACKGROUND: The aim of this study was to examine the cardiac function and transcriptional response of the heart to propofol after ischemia-reperfusion. METHODS: Rat hearts were Langendorff-perfused using the modified Krebs-Henseleit buffer, and took 20 min stabilizing periods, 40 min ischemia periods, and then 120 min reperfusion period. The hearts were divided into 5 groups; Control: 180 min perfusion after stabilization, Ischemic: 40 min global ischemia after stabilization, followed by 120 min reperfusion, Pre: 2 micrometer propofol treatment was preformed only before ischemia, Post: 2 micrometer propofol treatment was performed only during reperfusion after ischemia, Pre/Post: 2 micrometer propofol treatment was performed both before and after ischemia. The measurement for cardiac performances, such as left ventricular developed pressure (LVDP), rate of left ventricular pressure generation (dP/dt), heart rate, and coronary flow were obtained. The expression profiles of isolated mRNA were determined by using Agilent microarray and real time-polymerase chain reaction (RT-PCR) was used to confirm the microarray results for a subset of genes. RESULTS: The Post group showed better LVDP and dP/dt than the Ischemic group. But there were no significant differences in heart rate and coronary flow among the groups. On the results of RT-PCR, the expressions of Abcc9, Bard1, and Casp4 were increased, but the expressions of Lyz, Casp8, and Timp1 were decreased in the Post group compared with the Ischemic group. CONCLUSIONS: This study suggests that 2 micrometer propofol may provide cardioprotective effect, and modulate gene expression such as apoptosis, and K(ATP) ion channel related-genes during reperfusion in the isolated rat hearts.

Effect of propofol on cardiac function and gene expression after ischemic-reperfusion in isolated rat heart / 대한마취과학회지

BACKGROUND: The aim of this study was to examine the cardiac function and transcriptional response of the heart to propofol after ischemia-reperfusion. METHODS: Rat hearts were Langendorff-perfused using the modified Krebs-Henseleit buffer, and took 20 min stabilizing periods, 40 min ischemia periods, and then 120 min reperfusion period. The hearts were divided into 5 groups; Control: 180 min perfusion after stabilization, Ischemic: 40 min global ischemia after stabilization, followed by 120 min reperfusion, Pre: 2 micrometer propofol treatment was preformed only before ischemia, Post: 2 micrometer propofol treatment was performed only during reperfusion after ischemia, Pre/Post: 2 micrometer propofol treatment was performed both before and after ischemia. The measurement for cardiac performances, such as left ventricular developed pressure (LVDP), rate of left ventricular pressure generation (dP/dt), heart rate, and coronary flow were obtained. The expression profiles of isolated mRNA were determined by using Agilent microarray and real time-polymerase chain reaction (RT-PCR) was used to confirm the microarray results for a subset of genes. RESULTS: The Post group showed better LVDP and dP/dt than the Ischemic group. But there were no significant differences in heart rate and coronary flow among the groups. On the results of RT-PCR, the expressions of Abcc9, Bard1, and Casp4 were increased, but the expressions of Lyz, Casp8, and Timp1 were decreased in the Post group compared with the Ischemic group. CONCLUSIONS: This study suggests that 2 micrometer propofol may provide cardioprotective effect, and modulate gene expression such as apoptosis, and K(ATP) ion channel related-genes during reperfusion in the isolated rat hearts.

Paroxysmal atrial fibrillation developed during incomplete epidural anesthesia: A case report / 대한마취과학회지

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia, and occurs in organic heart disease such as rheumatic, atherosclerotic and hypertensive heart disease. In recent studies, the sympathetic and parasympathetic nervous systems have been shown to have important roles in initiating paroxysmal AF. We report here a patient who developed paroxysmal AF that might be a result of an imbalance of the sympathetic-parasympathetic systems due to epidural anesthesia, and that was potentiated by pain with inadequate analgesia. A 69-year-old woman was scheduled for operation of a right-sided ankle fracture. Twenty minutes after epidural drug injection, paroxysmal AF occurred. Even after intravenous administration of esmolol and digoxin, AF continued. After transfer to the intensive care unit, her heart rate gradually decreased and AF disappeared. During perioperative anesthetic management, the proper preoperative prevention and intraoperative treatment are needed in AF high-risk patients.

Effect of muscle relaxant on entropy during propofol anesthesia / 대한마취과학회지

BACKGROUND: The purpose of this study was to investigate whether muscle relaxant affect the values of Entropy, response entropy (RE) or state entropy (SE) during propofol anesthesia. METHODS: Eighty patients (ASA I) scheduled for elective surgery under general anesthesia were randomly assigned to four groups. Anesthesia was maintained at a SE value of 80 (80 +/- 2) using target controlled infusion (TCI) of propofol. After maintaining SE 80 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group I and same volume of normal saline was intravenously injected in group II. After maintaining SE 60 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group III and same volume of normal saline was injected intravenously in group IV. The mean arterial pressure, heart rate, SE and RE were measured before anesthetic induction and up to 5 min after vecuronium or normal saline injection in each group. RESULTS: SE and RE were not changed in group II, but significantly decreased in group I (P < 0.05, respectively). In group III and IV, SE and RE were not changed in both groups. There were no significant hemodynamic changes among the four groups. CONCLUSIONS: These results suggest that the effect of muscle relaxant on Entropy vary according to the baseline values of RE or SE during propofol anesthesia.

Tracheal laceration detected by high end-tidal CO2 during endoscopic thyroidectomy / 대한마취과학회지

Endoscopic thyroidectomy is frequently used for cosmetic reasons, such as reducing cervical scarring. Subcutaneous gas insufflation with CO2 is needed to maintain the surgical space, and optimal surgical techniques and careful attention are required when conducting this procedure due to the limited space available for the endoscopic instruments. We report here a case of a tracheal laceration with a tear in the cuff of a reinforced tube, which was detected by an abrupt increase in end-tidal CO2 to 90 mmHg. Reintubation was achieved using a tube exchanger and the patient was effectively ventilated without complications.

Common peroneal nerve palsy after robotic assisted laparoscopic colectomy: A case report / 대한마취과학회지

Common peroneal nerve palsy after surgery with lithotomy position has been widely reported, but it is an unexpected complication after surgery with supine position. We report a patient who developed common peroneal nerve palsy after surgery with supine position. A 55-year old man is planed for robotic assisted laparoscopic right hemicolectomy because of colon cancer. The patient was placed supine with Trendelenburg position at an angle about 5 degrees and tilted left about 15 degrees. The operation is uneventful, but he developed common peroneal nerve palsy on the first postoperative day. The patient was fully recovered with conservative treatment after 2 months. We consider that nerve palsy as a result of compression of common peroneal nerve related to patient positioning. So we should be careful not to develop common peroneal nerve palsy even if the patient was placed in the supine position during robotic assisted surgery.

The effect of intermittent levator massage with caudal block on management of levator ani syndrome: A case report / 대한마취과학회지

Levator ani syndrome (LAS) is a functional disorder of the pelvic floor muscles in which recurrent and persistent distressing pain is felt in the anus without detectable organic pathology. Eighty one percent of coccygodynia was alleviated by the levator massage when the massage motion was repeated 10 to 15 times on each side of the pelvis daily for 5 or 6 days. The authors encountered the LAS patient for whom successive visit to pain clinic was economic burden. Therefore, the authors managed the patient by intermittent levator massage with caudal block, once a week for 3 times, resulting in two years of pain free status. Intermittent levator massage with caudal block may be as effective as successive levator massage and induce longer painless period in the management of LAS.

Comparison of Propofol-Remifentanil and Sevoflurane-Remifentanil Anesthesia for Suspension Laryngoscopic Surgery

BACKGROUND: Suspension laryngoscopic surgery may cause acute hemodynamic changes such as hypertension and tachycardia and requires rapid recovery. The purpose of this study was to compare the hemodynamic responses, and emergence and recovery profiles between propofol-remifentanil and sevoflurane-remfentanil anesthesia. METHODS: Forty patients (ASA I, II) undergoing suspension laryngoscopic surgery were randomly allocated to either a propofol group (Group P) or sevoflurane group (Group S). Anesthesia was induced with target concentration of 5microg/ml using propofol target controlled infusion (TCI) in group P and thiopental sodium 5 mg/kg in group S, respectively. In both groups, after succinylcholine 1 mg/kg IV bolus injection, remifentanil was infused with a target concentration 5 ng/ml using remifentanil TCI for tracheal intubation. Anesthesia was maintained with N2O 2 L/min, O2 2 L/min, remifentanil (2.5-7.0 ng/ml), succinylcholine infusion (0.15 mg/kg/ min) in both groups, with propofol (2.0microg/ml) was used in group P and sevoflurane 3.0 vol% in group S. We compared hemodynamic status, and emergence and recovery profiles during and after operation. RESULTS: MAP and HR after tracheal intubation and suspension laryngoscopy insertion showed significantly smaller changes in group P and were more stable compared with group S. The suction time of the catheter response was shorter in group P compared with group S, and sedation was less deeper in group P than group S. Other recovery profiles were comparable between groups. CONCLUSIONS: During propofol-remifentanil anesthesia, hemodynamics were not increased by intubation or suspension laryngoscopy, and the early emergence and good recovery profiles of patients were appeared favorably compared with sevofluraneremifentanil anesthesia.

The Effects of Remifentanil on the LMA Insertion with the Administration of Propofol

BACKGROUND: Laryngeal mask airway (LMA) can be inserted without muscle relaxant in patients who have received propofol. Remifentanil that is recently used opioid effectively attenuates the hemodynamic responses to laryngoscopy. This study was to investigate the effects of remifentanil on the quality and hemodynamic response of LMA insertion after intravenous propofol induction without muscle relaxant. METHODS: Forty patients (ASA I or II, 20-65 years) were randomly allocated to control and remifentanil group. Control group received propofol 4microg/ml alone, remifentanil group received propofol 4microg/ml and remifetanil 2 ng/ml by target controlled infusion. LMA insertion condition was assessed by Muzi's score (jaw mobility, coughing, movement). The time interval to loss of eyelash reflex, to BIS < 60 and to insertion of LMA were recorded. The BIS and hemodynamic changes were measured at preinduction (baseline), preinsertion and postinsertion. RESULTS: Loss of consciousness and LMA insertion were more rapid with remifentanil group than control group (P < 0.05). Clinically acceptable insertion of LMA were observed in 35% and 70% of patients in the control and remifentanil group, respectively. There were significant elevations in heart rate, mean blood pressure after insertion of LMA in control group, but no elevations in remifentanil group. And there were no significant differences in BIS in both groups. CONCLUSIONS: The LMA insertion with propofol-remifentanil can provide more favorable condition and stable hemodynamic status compared with propofol alone.

Left Ventricular Rupture during Closed-chest Cardiopulmonary Resuscitation after Pneumonectomy: A case report / 대한마취과학회지

We report a case of circulatory collapse and cardiac arrest immediately after the patient was turned from the lateral decubitus position to the supine position following left pneumonectomy. Closed-chest resuscitation with medical and fluid interventions were inadequate. Emergency chest showed the deviation of heart to the left side and blunted apex. Left ventricular rupture during resuscitation was found subsequent thoracotomy. This rupture and inadequacy of closed-chest resuscitation were felt to be associated with the operative pneumonectomy and pericardiotomy.

Anesthesia and Sedation

Anesthetic care is usually provided for patients undergoing surgical procedures to make them unconscious and painless during surgery. Nowadays there are increasing therapeutic or diagnostic procedures performed outside operating room. Sedation is more frequently provided as healthcare during procedures for patient's comfort and safety by non-anesthesiologist or anesthesiologist. Early in 1999, ASA (the American Society of Anesthesiologists defined sedation and analgesia and established 4 states: minimal sedation, moderate sedation, deep sedation, and general anesthesia. Monitored anesthetic care implies the potential for a deep sedation and is always administered by an anesthesiologist. It is not always possible to predict how an individual patient will respond by nature of being a continuum of sedation. Hence, practitioners intending to induce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. The standards for preoperative evaluation, intraoperative monitoring, anesthetic care, etc. are not different from those for general anesthesia.

The Effect of Remifentanil on Pain during Local Anesthetic Infiltration in Moderately Sedated Plastic Surgery Patients / 대한마취과학회지

BACKGROUND: This randomized study was designed to evaluate the analgesic effectiveness and to determine the optimal dose of remifentanil when administered as intermittent bolus injection during infiltration of local anesthetics for patients undergoing plastic surgery. METHODS: Forty five ASA I or II patients undergoing plastic surgery were randomly assigned to one of the three bolus doses of remifentanil injection. Five minutes after receiving midazolam 0.05 mg/kg IV, remifentanil was injected intravenously one minute before the infiltration of local anesthetics: A bolus of remifentanil 0.25microgram/kg was injected in Group R0.25 (n = 15), 0.50 microgram/kg in Group R0.5 (n = 15), or 0.75microgram/kg in Group R0.75 (n = 15). After assessment of the patients' Observer's Assessment of Alertness/Sedation (OAA/S) scale, the subjective pain level during local anesthetic infiltration was evaluated. Respiratory rate, SpO2, mean blood pressure, and heart rate were recorded during the study period. Postoperative nausea/vomiting and patient's satisfaction were checked by telephone call. RESULTS: OAA/S scale values were similar among the three groups (3-4). The number of the patients who complained of moderate or severe pain level is significantly higher in group R0.25 than in group R0.5 or group R0.75 (P < 0.05). Adverse events such as hypoventilation, desaturation, and bradycardia were observed with significantly high frequency in R0.75 than in other two groups (P < 0.05). All three groups showed no occurrence of hypotension or postoperative nausea/vomiting. CONCLUSIONS: The above results demonstrate that intermittent bolus injection of remifentanil 0.50microgram/kg is recommended to accomplish desirable pain control during local anesthetic infiltration in those who received midazolam 0.05 mg/kg.

The Effect of Combined Ephedrine and Lidocaine Pretreatment on Tracheal Intubation Condition and Maximum Neuromuscular Block after Rocuronium Administration / 대한마취과학회지

BACKGROUND: Rocuronium is a nondepolarizing muscle relaxants used for trying rapid-sequence intubation due to its relatively rapid onset of action and low side effects. Methods to further reduce the onset time of a muscle relaxant include increasing the dose of muscle relaxant, pretreatment for potentiating neuromuscular block of the muscle relaxants or increasing the cardiac output and muscle blood flow. The purpose of this study was to examine the pretreatment effect of combined lidocaine and ephedrine, as a pretreatment, on the onset time and intubation conditions of rocuronium-induced neuromuscular block in adults. METHODS: Sixty ASA physical stati 1 and 2 patients were randomly allocated to four groups. Normal saline 10 ml was administered to Group NS prior to induction, lidocaine (1.5 mg/kg) to Group L, ephedrine (70microgram/kg) to Group E, and combined lidocaine (1.5 mg/kg) and ephedrine (70microgram/kg) to Group LE. Anesthesia was induced with propofol (2.0 mg/kg) and rocuronium (0.6 mg/kg). Intubation was performed 45 seconds after the administration of rocuronium and the intubation conditions then evaluated. The change in the mean arterial pressure and heart rate were checked and compared during the peri-induction periods. RESULTS: There were no differences in the hemodynamics between the four groups. The intubation conditions were graded as good to excellent in 33.3, 53.3, 66.7 and 93.3% of patients in NS, L, E and LE groups, respectively. The intubation conditions in group LE were significantly better than those in group NS (P < 0.05). CONCLUSIONS: The above results demonstrated that pretreatment with a combination of ephedrine and lidocaine, following rocuronium, improves the tracheal intubation conditions.