Dispute cases related to pain management in Korea: analysis of Korea Medical Dispute Mediation and Arbitration Agency data

Background@#Various developments in imaging techniques, interventional procedures, and medications for pain management have beneficial consequences. However, the nature of pain management often results in physicians becoming involved in medico-legal disputes with patients who purposely or accidentally bring litigation. @*Methods@#Data on medical disputes cases related to pain management were collected and analyzed through the Korea Medical Dispute Mediation and Arbitration Agency from 2012 to 2016. @*Results@#In total, we identified 210 public-disclosed cases; of these, we identified 36 cases related to pain management. The department of orthopedics (n = 9, 25%) was the most related to these pain management cases. Pain management was most commonly offered for pain in the lumbar region (n = 13, 37%), lower extremities (n = 12, 34%), and for infection (n = 7, 19%). The time spent resolving disputes ranged from 8.0 to 17.5 months and the final settlement amount ranged from 1,800,000 to 15,000,000 Korean won. Causal relationships and medical malpractice were the most common controversial subjects of legal debate. @*Conclusions@#Various characteristics of medical disputes related to pain management in Korea were identified. Information regarding medical disputes in pain management should be available to help prevent further disputes and litigation, which is also useful to both patients and pain physicians. Guidelines and recommendations for pain management are needed, especially those focused on medico-legal cases.

Repetitive ultrasonographic assessment of adrenal size and shape changes: a clue for an asymptomatic sex hormone-secreting adenoma

Diagnosis of an adrenal tumor without typical clinical signs related to hyperadrenocorticism and elevated alkaline phosphatase is challenging. This report describes a sex hormone-secreting adrenal tumor in a 10-year-old castrated male Shih Tzu evaluated through repetitive ultrasonographic examination. An adrenocorticotropic hormone stimulation test revealed elevated concentrations of androstenedione and 17-hydroxyprogesterone but a normal cortisol concentration. A mass was surgically excised and adenoma was diagnosed histopathologically. In the present case, adrenal tumor was strongly suspected based on a gradual increase in adrenal size and a change from peanut shape to an irregular mass on repetitive ultrasonography. Repetitive ultrasonographic examination of the adrenal gland is recommended when an abnormal ultrasonographic appearance of adrenal gland is identified, even in an asymptomatic dog.

The Synergistic Effect of Intrathecally Administered Dexmedetomidine and Ketorolac on Mechanical Allodynia in Rats with Spinal Nerve Ligation / 고신대학교의과대학학술지

OBJECTIVES: This research was carried out to identify the synergistic effect of dexmedetomidine and ketorolac on neuropathic pain alleviation. METHODS: The anti-allodynic effect of intrathecal dexmedetomidine and ketorolac was investigated in rats after L5 spinal nerve ligation (SNL). Mechanical allodynia was assessed using Von Frey filaments. Every day for 3 consecutive days, beginning on the 10th day after SNL, behavioral tests were carried out at 1, 2, and 4 hr after drug injection. RESULTS: Significant increases in ipsilateral paw withdrawal thresholds (PWTs) were observed 1, 2, and 4 hr after drug injection in the groups of rats which received intrathecal injection of either dexmedetomidine (group D) or ketorolac (group K), compared to group S (P < 0.05). And group DK, which received simultaneous intrathecal injection of both dexmedetomidine and ketorolac, showed statistically significantly higher ipsilateral PWTs than groups D and K, which received only one of them (P < 0.05). CONCLUSIONS: The results of this research demonstrated the anti-allodynic effect of dexmedetomidine and ketorolac on neuropathic pain induced by SNL in rats. They also suggest that synergistic analgesia can be induced by the simultaneous injection of dexmedetomidine and ketorolac, and that combination therapy is an effective approach to treating chronic neuropathic pain syndrome.

Clinical usefulness of post-operative 18F-fluorodeoxyglucose positron emission tomography-computed tomography in canine hemangiosarcoma

This report describes the usefulness of positron emission tomography-computed tomography (PET-CT) for evaluating recurrent or residual tumors following surgery. CT and 18F-fluorodeoxyglucose PET-CT were pre- and post-operatively applied to multiple masses in a dog with hemangiosarcoma. The distinction between the left subcutaneous mass and the peritoneum was clarified on pre-operative CT examination, and malignancy was suspected based on PET-CT. A recurrent or residual tumor in the left subcutaneous region was suspected on post-operative PET-CT, and confirmed through histopathologic examination.

Comparison of the rate of successful endotracheal intubation between the "sniffing" and "ramped" positions in patients with an expected difficult intubation: a prospective randomized study / 대한마취과학회지

BACKGROUND: Optimal head and neck positioning and clinical experience are important factors for successful endotracheal intubation in patients with a difficult airway. This study aimed to investigate the rate of successful endotracheal intubation between the sniffing and ramped positions in patients with an expected difficult intubation. METHODS: The study included 204 patients with an expected difficult intubation (airway difficulty score > or = 8) based on the preoperative airway assessment. The patients were randomized into the following groups: group S was placed in the sniffing position, and group R was placed in the ramped position during direct laryngoscopy. The primary outcome was successful endotracheal intubation and the secondary measure was laryngeal view in the ramped or sniffing position when the operating table was placed at two different heights. RESULTS: Group R showed a higher rate of successful endotracheal intubation and better laryngeal view than group S (P < 0.05). The rate of successful endotracheal intubation was higher in group R than in group S at both heights of the operating table; but, it was not different within each group. Laryngeal view was not different between the two groups and within each group when the two heights of the operating table were used. Fully trained and experienced attending anesthesiologists achieved a higher rate of successful endotracheal intubation than less experienced residents in group R (P < 0.05) but not in group S. CONCLUSIONS: Ramped position and clinical experience can be important factors for laryngeal view and success rate of endotracheal intubation in patients with an expected difficult intubation.

Arthroscopic Changes of the Biceps Pulley in Rotator Cuff Tear and Its Clinical Significance in Relation to Treatment

BACKGROUND: In the case of rotator cuff tears, the biceps pulley can be stressed by the unstable biceps tendon, and this can subsequently affect the stability of the subscapularis tendon. Therefore, it is important to distinguish between normal variations and lesions of the biceps pulley that affect anterosuperior lesions in cases of rotator cuff tears. METHODS: From January 2002 through November 2010, we observed biceps pulley and associated anterosuperior lesions in 589 of 634 cases (93%) of arthroscopic rotator cuff repair, including 72 cases (12.2%) of small tears, 219 cases (37.2%) of medium tears, 134 cases (22.8%) of large tears, and 164 cases (27.8%) of massive tears. We classified normal stretched biceps pulleys as type I, stretched biceps pulleys with mild changes as type II, those with a partial tear as type III, and torn pulleys as type IV. RESULTS: We were able to classify 589 cases of biceps pulleys as type I, II, III, or IV associated lesions in rotator cuff tears. Type I was seen in 91 cases (15.4%), type II in 216 cases (36.7%), type III in 157 cases (26.7%), and type IV in 101 cases (17.1%); unidentified cases numbered 24 (4.1%). Nearly three-quarters, 73.3%, of the cases (432/589) had associated anterosuperior lesions, and combined treatment for the associated lesions was administered in 29.2% (172/589) of cases. CONCLUSIONS: Biceps pulley lesions with more than partial tears were identified in 48% of rotator cuff tear cases. The incidence and severity of pulley lesions were related to the rotator cuff tear size, the status of the long head of the biceps tendon and subscapularis tendon lesion, and the treatment methods.

The effect of intrathecal curcumin on mechanical allodynia in rats after L5 spinal nerve ligation / 대한마취과학회지

No abstract available.

The Analgesic Effect of Nefopam with Fentanyl at the End of Laparoscopic Cholecystectomy

BACKGROUND: Nefopam is a centrally acting analgesic that is used to control pain. The aim of this study was to find an appropriate dose of nefopam that demonstrates an analgesic effect when administered in continuous infusion with fentanyl at the end of laparoscopic cholecystectomy. METHODS: Ninety patients scheduled for laparoscopic cholecystectomy were randomly assigned to receive analgesia with fentanyl alone (50 microg, Group 1, n = 30), or with fentanyl in combination with nefopam 20 mg (Group 2, n = 30) or in combination with nefopam 40 mg (Group 3, n = 30) at the end of surgery. Pain and side effects were evaluated at 10 minutes, 30 minutes, 1 hour, 2 hours, 6 hours, and 12 hours after arrival in the post-anesthesia care unit (PACU). RESULTS: Pain was statistically significantly lower in Groups 2 and 3 than in Group 1 at 10 minutes, 2 hours, and 6 hours after arrival in the PACU. Nausea was statistically significantly lower in Group 2 than in Groups 1 and 3 at 10 minutes after arrival in the PACU. Shivering was statistically significantly lower in Groups 2 and 3 than in Group 1 at 10 minutes after arrival in the PACU. CONCLUSIONS: Nefopam is a drug that can be safely used as an analgesic after surgery, and its side effects can be reduced when fentanyl 50 microg is injected with nefopam 20 mg.

A Case of an Anomalous Hypertrophied Muscle Band in the Left Ventricle

A hypertrophied muscle band (HMB) in the left ventricle (LV), which can be misinterpreted as apical hypertrophic cardiomyopathy, is a rare echocardiographic finding in a patient with normal LV wall thickness. Not only are symptoms produced, but changes in the electrocardiogram (ECG) are limited to the repolarization phase and show no progression even in a large HMB. Hence, we report a case of a 25-year-old woman who visited a local medical clinic due to epigastric discomfort in January 2007. The 24-hour Holter ECG showed multiple premature ventricular complexes. An HMB (3.23 x 10.8 cm) was observed on two-dimensional echocardiography that ran toward the interventricular septum (IVS) across the LV and divided the LV into apical and basal cavities at the apical one-third of the LV. Although LV wall thickness showed normal range, flow acceleration was observed between the HMB and IVS and revealed dagger-shaped with a high pressure gradient up to 30 mmHg in continuous wave Doppler examination. Circumferential band-like myocardial hypertrophy was observed at the LV apex on cardiac magnetic resonance imaging. Myocardial thinning and prominent trabeculae were present from the proximal to distal HMB. However, contractility was normal at the myocardial thinning site, regional wall motion abnormality was not observed in cine images. Focal fatty accumulation was evident at the base of the HMB. Coronary angiography revealed no significant stenosis, whereas left ventriculography showed septation at the apical one-third of the LV. The patient was discharged without any medication.

Impact of Multivessel Coronary Disease With Chronic Total Occlusion on One-Year Mortality in Patients With Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: The impact of multivessel coronary disease (MVD) with chronic total occlusion (CTO) on one-year mortality in patients with acute myocardial infarction (AMI) is not clearly known. We investigated the impact of MVD with concurrent CTO lesion on one-year mortality in patients with AMI. SUBJECTS AND METHODS: We studied 1008 consecutive patients who underwent coronary angiography between November 2005 and December 2008 with a diagnosis of AMI. RESULTS: Among 1008 patients, 432 patients (43%) had MVD, and 88 patients (8.7%) had CTO lesion. The one-year overall mortality was higher in patients with MVD than in patients with single vessel disease (SVD) (10.2% vs. 5.9%, p=0.012). However, the one-year overall mortality was not significantly higher in patients with CTO lesion than in patients without that lesion (12.5% vs. 7.3%, p=0.080). In multivariate analysis, independent predictors of one-year overall mortality were age older than 65 years {hazard ratio (HR) 2.41, 95% confidence interval (CI): 1.43 to 4.08}, Killip class > or =III (HR 3.59, 95% CI: 2.24 to 5.77), ST-elevation myocardial infarction (HR 2.45, 95% CI: 1.49 to 4.05) and MVD (HR 1.76, 95% CI: 1.07 to 2.89). CONCLUSION: Patients with MVD showed higher one-year mortality than patients with SVD. However, the presence of CTO was not an independent predictor of one-year mortality in this study that included patients with successfully revascularized CTO lesion.

The Effects of Intraoperative Adenosine Infusion on Acute Opioid Tolerance and Opioid Induced Hyperalgesia Induced by Remifentanil in Adult Patients Undergoing Tonsillectomy

BACKGROUND: Adenosine has been shown to have a wide spectrum of unique pain-relieving effects in various clinical situations. The aim of this study was to investigate the effects of intraoperative adenosine infusion on acute opioid tolerance and opioid induced hyperalgesia induced by remifentanil in adult patients undergoing tonsillectomy. METHODS: For this study, ninety patients were randomly allocated into groups that receive either adenosine (adenosine group) or saline (remifentnail group) intravenously under remifentanil based anesthesia and saline (sevoflurane group) under sevoflurane anesthesia. The patients in adenosine group received adenosine at dose of 80 microg/kg/min, and those in remifentnail group and sevoflurane group received an equal volume of saline 10 minutes after the induction of anesthesia until the end of surgery. Intraoperative evaluation included time weighted mean remifentanil dose, and postoperative evaluations included degree of pain severity at 1, 6, 12, and 24 hours, time to first postoperative requirement, and analgesic dose required during 24 hours after operation. RESULTS: Time weighted mean remifentanil dose during intraoperative period in adenosine group was significantly lower than that of remifentnail group (P = 0.00). The first postoperative analgesic were required earlier in remifentanil group than sevoflurane group or adenosine group (P = 0.00). Pethidine requirement during 24 hours in sevoflurane group and adenosine group was significantly lower than that of remifentnail group (P = 0.00). The visual analog scale scores for pain in sevoflurane group and adenosine group were significantly lower than those of remifentnail group for 12 hours after operation (P = 0.00). Incidence of hypotension (P = 0.024) and number of ephedrine administered (P = 0.011) in adenosine group were significantly higher than those of sevoflurane group. CONCLUSIONS: The above results suggest that intraoperative adenosine infusion prevent acute opioid tolerance and opioid induced hyperalgesia induced by remifentanil.

The Effects of Intraoperative Adenosine Infusion on Acute Opioid Tolerance and Opioid Induced Hyperalgesia Induced by Remifentanil in Adult Patients Undergoing Tonsillectomy

BACKGROUND: Adenosine has been shown to have a wide spectrum of unique pain-relieving effects in various clinical situations. The aim of this study was to investigate the effects of intraoperative adenosine infusion on acute opioid tolerance and opioid induced hyperalgesia induced by remifentanil in adult patients undergoing tonsillectomy. METHODS: For this study, ninety patients were randomly allocated into groups that receive either adenosine (adenosine group) or saline (remifentnail group) intravenously under remifentanil based anesthesia and saline (sevoflurane group) under sevoflurane anesthesia. The patients in adenosine group received adenosine at dose of 80 microg/kg/min, and those in remifentnail group and sevoflurane group received an equal volume of saline 10 minutes after the induction of anesthesia until the end of surgery. Intraoperative evaluation included time weighted mean remifentanil dose, and postoperative evaluations included degree of pain severity at 1, 6, 12, and 24 hours, time to first postoperative requirement, and analgesic dose required during 24 hours after operation. RESULTS: Time weighted mean remifentanil dose during intraoperative period in adenosine group was significantly lower than that of remifentnail group (P = 0.00). The first postoperative analgesic were required earlier in remifentanil group than sevoflurane group or adenosine group (P = 0.00). Pethidine requirement during 24 hours in sevoflurane group and adenosine group was significantly lower than that of remifentnail group (P = 0.00). The visual analog scale scores for pain in sevoflurane group and adenosine group were significantly lower than those of remifentnail group for 12 hours after operation (P = 0.00). Incidence of hypotension (P = 0.024) and number of ephedrine administered (P = 0.011) in adenosine group were significantly higher than those of sevoflurane group. CONCLUSIONS: The above results suggest that intraoperative adenosine infusion prevent acute opioid tolerance and opioid induced hyperalgesia induced by remifentanil.

The Impact of Circadian Variation on 12-Month Mortality in Patients With Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Although circadian variation in the onset of acute myocardial infarction (AMI) has been reported in a number of studies, not much is known about the impact of circadian variation on 12-month mortality. The aim of this study was to investigate the impact of circadian variation on 12-month mortality in patients with AMI. SUBJECTS AND METHODS: Eight hundred ninety two patients (mean age 67+/-12; 66.1% men) with AMI who visited Kyungpook National University Hospital from November 2005 to December 2007 were included in this study. Patients were divided into groups based on four 6-hours intervals: overnight (00:00-05:59); morning (06:00-11:59); afternoon (12:00-17:59) and evening (18:00-23:59). RESULTS: Kaplan-Meier survival curves showed 12-month mortality rates of 9.6%, 9.1%, 12.1%, and 16.7% in the overnight, morning, afternoon, evening-onset groups, respectively (p=0.012). Compared with the morning-onset AMI group, the serum creatinine levels (p=0.002), frequency of Killip class > or =3 (p=0.004), and prescription rate of diuretics (p=0.011) were significantly higher in the evening-onset AMI group, while the left ventricular ejection fraction (p=0.012) was significantly lower. The proportion of patients who arrived in the emergency room during routine duty hours was significantly lower in evening-onset groups irrespective of the presence or absence of ST-segment elevation (p<0.001). According to univariate analysis, the 12-month mortality rate in the evening group was significantly higher compared to the morning group (hazard ratio 1.998, 95% confidence interval 1.196 to 3.338, p=0.008). CONCLUSION: Patients with evening-onset AMI had poorer baseline clinical characteristics, and this might affect the circadian impact on 12-month mortality. Further studies are needed to clarify the role of circadian variation on the long-term outcome of AMI.

Electrocardiography Patterns and the Role of the Electrocardiography Score for Risk Stratification in Acute Pulmonary Embolism

BACKGROUND AND OBJECTIVES: Data on the usefulness of a combination of different electrocardiography (ECG) abnormalities in risk stratification of patients with acute pulmonary embolism (PE) are limited. We thus investigated 12-lead ECG patterns in acute PE to evaluate the role of the ECG score in risk stratification of patients with acute PE. SUBJECTS AND METHODS: One hundred twenty-five consecutive patients (63+/-14 years, 56 men) with acute PE who were admitted to Kyungpook National University Hospital between November 2001 and January 2008 were included. We analyzed ECG patterns and calculated the ECG score in all patients. We evaluated right ventricular systolic pressure (RVSP) (n=75) and RV hypokinesia (n=80) using echocardiography for risk stratification of acute PE patients. RESULTS: Among several ECG findings, sinus tachycardia and inverted T waves in V(1-4) (39%) were observed most frequently. The mean ECG score and RVSP were 7.36+/-6.32 and 49+/-21 mmHg, respectively. The ECG score correlated with RVSP (r=0.277, p=0.016). The patients were divided into two groups {high ECG-score group (n=38): ECG score >12 and low ECG-score group (n=87): ECG score < or =12} based on the ECG score, with the maximum area under the curve. RV hypokinesia was observed more frequently in the high ECG-score group than in the low ECG-score group (p=0.006). Multivariate analysis revealed that a high ECG score was an independent predictor of high RVSP and RV hypokinesia. CONCLUSION: Sinus tachycardia and inverted T waves in V(1-4) were commonly observed in acute PE. Moreover, the ECG score is a useful tool in risk stratification of patients with acute PE.

Examining the Relationship Between Triggering Activities and the Circadian Distribution of Acute Aortic Dissection

BACKGROUND AND OBJECTIVES: There are limited data examining triggering activities and circadian distribution at the onset of acute aortic dissection (AAD) in the context of diagnostic and anatomical classification. The aim of this study was to further investigate this relationship between triggering activities and circadian distribution at the onset of AAD according to diagnostic and anatomic classification. SUBJECTS AND METHODS: A total of 166 patients with AAD admitted to Kyungpook National University Hospital between July 2001 and June 2009 were included. To assess the influence of diagnostic and anatomical classification, we categorized the patients into intramural hematoma (IMH) group (n=67)/non-IMH group (n=99) and Stanford type A (AAD-A, n=94)/type B (AAD-B, n=72). To evaluate circadian distribution, the day was divided into four 6-hour periods: night (00-06 hours), morning (06-12 hours), afternoon (12-18 hours), and evening (18-00 hours). RESULTS: Most (72%) AAD episodes were related to physical (53%) and mental activities (19%), with about one-third occurring during the afternoon, and only 12% occurring at night. No differences in triggering activities or circadian distribution were observed among the groups. Waking hours including morning, afternoon, and evening correlated with triggering activities (p=0.003). These relationships were observed for the non-IMH (p=0.008) and AAD-B (p=0.003) cases. The remaining categories had similar relationships, but did not reach statistical significance. CONCLUSION: Our findings suggest differences in the relationship between triggering activities and the circadian distribution of the onset of AAD according to diagnostic and anatomical classification.

Clinical analysis of early reoperation cases after orthognathic surgery

The factors influencing the relapse and recurrence of skeletal deformity after the orthognathic surgery include various factors such as condylar deviation, the amount of mandibular set-back, stretching force by the soft tissues and muscles around the facial skeleton. The purpose of this report is to recognize and analyze the possible factors of reoperation after orthognathic surgery, due to early relapses. Six patients underwent reoperation after the orthognathic surgeries out of 110 patients from 2006 to 2009 were included in this study. In most cases, clincal signs of the insufficient occlusal stability, anterior open bite, and unilateral shifting of the mandible were founded within 2 weeks postoperatively. Although elastic traction was initiated in every case, inadequate correction made reoperation for these cases inevitable. The chief complaints of five cases were the protruded mandible combined with some degree of asymmetric face and in the other one case, it was asymmetric face only. Various factors were considered as a major cause of post-operative instability such as condylar sagging, counter-clockwise rotation of the mandibular segment, soft tissue tension related with asymmetrical mandibular set-back, preoperatively existing temporomandibular disorder (TMD), poor fabrication of the final wafer, and dual bite tendency of the patients.

Treatment of Intractable Hiccups With an Oral Agent Monotherapy of Baclofen: A Case Report

Hiccups are an involuntarily powerful spasm of the diaphragm, followed by a sudden inspiration with a closure of the glottis. Hiccups that are caused by gastric distention, spicy foods and neural dysfunction can resolve themselves without any treatment. Some hiccups are associated with certain diseases or they occur postsurgically, and life-restricting intractable hiccups should be treated. The cause of hiccups should be quickly determined so as to administer the proper treatment. Hiccups often remit spontaneously within a short period of time, but they may also occur without remission for a prolonged period in some cases. We report here on a 36-year-old man who suffered with intractable hiccups for 5 years. We administered a single oral dose of baclofen, and then the hiccups disappeared. We conclude that a single dose of baclofen is a good treatment for intractable hiccups.

Gender Differences Among Korean Patients With Coronary Spasm

BACKGROUND AND OBJECTIVES: The gender differences among Korean patients with coronary spasm have not been defined. We thus determined the gender differences among Korean patients with coronary spasm. SUBJECTS AND METHODS: Patients with chest pain and/or syncope who were admitted to Kyungpook National University Hospital between January 2001 and August 2008 were included. Provocation of coronary vasospasm with intracoronary ergonovine maleate was performed when baseline coronary angiography showed no significant stenosis or there was a strong clinical suspicion of coronary spasm. The clinical characteristics were analyzed from 104 consecutive patients (56+/-9 years of age; 21 females) who were diagnosed with coronary spasm. RESULTS: Female patients were younger (52+/-7 vs. 57+/-10 years, p=0.046) with lower rates of smoking and alcohol consumption histories than male patients (19% vs. 65%, p<0.001; and 43% vs. 89%, p<0.001, respectively). The other clinical characteristics were not significantly different, except for the triglyceride levels. CONCLUSION: The majority of patients with coronary spasm were males who were smokers and alcohol consumers. The female patients had lower rates of smoking and alcohol consumption, and they were younger than the male patients. Further studies are needed to investigate the relevance of gender differences in the pathogenesis of coronary spasm.

Magnesium Sulfate Attenuate Opioid Tolerance in Patients undergoing Major Abdominal Surgery

BACKGROUND: Magnesium is a noncompetitive antagonist of the N-methyl-D-aspartate (NMDA) receptor. Magnesium is thought to be involved in opioid tolerance by way of inhibiting calcium entry into cells. METHODS: The patients were randomly assigned to three groups according to the anesthetic regimens: Group M received magnesium sulfate and Group C received saline intravenously under remifentanil-based anesthesia. Group S received saline intravenously under sevoflurane based anesthesia in place of remifentanil. The patients in the group M received 25% magnesium sulfate 50 mg/kg in 100 ml of saline, and those patients in groups C and S received an equal volume of saline before induction of anesthesia; this was followed by 10 mg/kg/h infusion of either magnesium sulfate (group M) or an equal volume of saline (groups C and S) until the end of surgery. Pain was assessed on a visual analog scale at 1, 6, 12, 24, and 36 hours after the operation. The time to the first postoperative analgesic requirement and the cumulative analgesic consumption were evaluated in the three groups. RESULTS: The visual analog scales for pain and the cumulative analgesic consumption were significantly greater in group C than in other groups. The time to first postoperative analgesic requirement was significantly shorter in group C than that in the other groups. There were no differences between group M and S for side effects. CONCLUSIONS: A relatively high dose and continuous remifentanil infusion is associated with clinically relevant evidence of acute opioid tolerance. NMDA-receptor antagonist, magnesium sulfate as an adjuvant analgesic prevents opioid tolerance in patients who are undergoing major abdominal surgery under high dose and continuous remifentanil infusion-based anesthesia.

Prognosis and Natural History of Drug-Related Bradycardia

BACKGROUND AND OBJECTIVES: The prognosis and natural history of bradycardia related to drugs such as beta-blockers and non-dihydropyridine calcium channel blockers are not well known. SUBJECTS AND METHODS: We retrospectively analyzed 38 consecutive patients (age 69+/-11, 21 women) with drug-related bradycardia (DRB) between March 2005 and September 2007. A drug-associated etiology for the bradycardia was established based on the medical history and patient response to drug discontinuation. The mean follow-up duration was 18+/-8 months. RESULTS: The initial electrocardiogram (ECG) showed sinus bradycardia (heart rate < or =40/min) in 13 patients, sinus bradycardia with junctional escape beats in 18 patients, and third-degree atrioventricular (AV) block in seven patients. Drug discontinuation was followed by resolution of bradycardia in 60% of patients (n=23). Among them, five (17.8%) patients resumed taking the culprit medication after discharge and none developed bradycardia again. Bradycardia persisted in 10 (26.3%) patients despite drug withdrawal, and a permanent pacemaker was implanted in seven of them. Third-degree AV block, QRS width, and bradycardia requiring temporary transvenous pacing were significantly associated with the bradycardia caused by drugs. CONCLUSION: Beta-blockers were the most common drugs associated with DRB. However, in one quarter of the cases the DRB was not associated with drugs; in these patients permanent pacemaker implantation should be considered.