Dexamethasone or Dexmedetomidine as Local Anesthetic Adjuvants for Ultrasound-guided Axillary Brachial Plexus Blocks with Nerve Stimulation

BACKGROUND: The purpose of this study was to evaluate the effect of dexamethasone or dexmedetomidine added to ropivacaine on the onset and duration of ultrasound-guided axillary brachial plexus blocks (BPB). METHODS: Fifty-one ASA physical status I-II patients with elective forearm and hand surgery under axillary brachial plexus blocks were randomly allocated to receive 20 ml of 0.5% ropivacaine with 2 ml of isotonic saline (C group, n = 17), 20 ml of 0.5% ropivacaine with 2 ml (10 mg) of dexamethasone (D group, n = 17) or 20 ml of 0.5% ropivacaine with 2 ml (100 microg) of dexmedetomidine (DM group, n = 17). A nerve stimulation technique with ultrasound was used in all patients. The onset time and duration of sensory blocks were assessed. RESULTS: The duration of the sensory block was extended in group D and group DX compared with group C (P < 0.05), but there was no significant difference between group D and group DX. However, there were no significant differences in onset time in all three groups. CONCLUSIONS: Dexamethasone 10 mg and dexmedetomidine 100 microg were equally effective in extending the duration of ropivacaine in ultrasound-guided axillary BPB with nerve stimulation. However, neither drug has significantly effects the onset time.

Comparison of Ramosetron Plus Dexamethasone with Ramosetron Alone on Postoperative Nausea, Vomiting, Shivering and Pain after Thyroid Surgery

BACKGROUND: Postoperative nausea and vomiting (PONV), postanesthetic shivering and pain are common postoperative patient complaints that can result in adverse physical and psychological outcomes. Some antiemetics are reported to be effective in the management of postoperative pain and shivering, as well as PONV. We evaluated the efficacy of dexamethasone added to ramosetron on PONV, shivering and pain after thyroid surgery. METHODS: One hundred and eight patients scheduled for thyroid surgery were randomly allocated to three different groups: the control group (group C, n = 36), the ramosetron group (group R, n = 36), or the ramosetron plus dexamethasone group (group RD, n = 36). The patients were treated intravenously with 1 and 2 ml of 0.9% NaCl (group C); or 2 ml of 0.15 mg/ml ramosetron plus 1 ml of 0.9% NaCl (group R); or 2 ml of 0.15 mg/ml ramosetron plus 1 ml of 5 mg/ml dexamethasone (group RD) immediately after anesthesia. RESULTS: Incidence of nausea and the need for rescue antiemetics, verbal rating scale (VRS) 1 hour pain value, ketorolac consumption, and incidence of shivering were significantly lower in group R and group RD, than in group C (P < 0.05). Moreover, these parameters were significantly lower in group RD than in group R (P < 0.05). CONCLUSIONS: Combination of ramosetron and dexamethasone significantly reduced not only the incidence of nausea and need for rescue antiemetics, but also the VRS 1 hour pain value, ketorolac consumption, and the incidence of shivering compared to ramosetron alone in patients undergoing thyroid surgery.

Comparison of the efficacy of a forced-air warming system and circulating-water mattress on core temperature and post-anesthesia shivering in elderly patients undergoing total knee arthroplasty under spinal anesthesia / 대한마취과학회지

BACKGROUND: In the present study, we compared changes in body temperature and the occurrence of shivering in elderly patients undergoing total knee arthroplasty under spinal anesthesia during warming with either a forced-air warming system or a circulating-water mattress. METHODS: Forty-six patients were randomly assigned to either the forced-air warming system (N = 23) or circulating-water mattress (N = 23) group. Core temperature was recorded using measurements at the tympanic membrane and rectum. In addition, the incidence and intensity of post-anesthesia shivering and verbal analogue score for thermal comfort were simultaneously assessed. RESULTS: Core temperature outcomes did not differ between the groups. The incidence (13.0 vs 43.5%, P < 0.05) and intensity (20/2/1/0/0 vs 13/5/3/2/0, P < 0.05) of post-anesthesia shivering was significantly lower in the forced-air system group than in the circulating-water mattress group. CONCLUSIONS: The circulating-water mattress was as effective as the forced-air warming system for maintaining body temperature. However, the forced-air warming system was superior to the circulating-water mattress in reducing the incidence of post-anesthesia shivering.

Comparison of the Results among Automated Treponema pallidum Latex Agglutination, Rapid Plasma Regain and Treponema pallidum Particle Agglutination, Rapid Plasma Regain Card Test in Blood Donors / 대한수혈학회지

BACKGROUND: The Korean Red Cross blood laboratory centers use Treponema pallidum particle agglutination assay on the PK7300 instrument as a primary donor screening test for syphilis, and semi-quantitative TPPA and RPR card as supplementary tests. We compared the results of Treponema pallidum latex agglutination and RPR tests on the automated analyzer with those of TPPA and RPR card tests. METHODS: A total of 1,000 samples with negative TPPA results and 103 samples with positive TPPA results (> or =1:80 titers) were evaluated in this study. HiSens Auto TP, RPR (HBI, Anyang, Korea) and Mediace TPLA, RPR (Sekisui, Tokyo, Japan) reagents were used on the automated analyzer. FTA-ABS test was performed as a confirmatory test to evaluate the sensitivity and specificity of HiSens Auto TPLA, RPR and Mediace TPLA, RPR reagents. RESULTS: The concordance rate between HiSens Auto TP, Mediace TPLA and TPPA was 95.5% and 95.4%, respectively. The concordance rate between HiSens Auto RPR, Mediace RPR and RPR card was 79.6% and 80.6%, respectively. Sensitivity of HiSens Auto TP and Mediace TPLA was 87.7% and 90.8%, respectively, and specificity was 99.5% and 99.0%, respectively. CONCLUSION: Despite the high concordance rate between TPLA and TPPA, there were negative TPLA results which were positive for both TPPA and FTA-ABS tests. Therefore, changing the primary donor screening test for syphilis from current TPPA to TPLA on the automated analyzer requires further investigation.

Effect of position changes after spinal anesthesia with low-dose bupivacaine in elderly patients: sensory block characteristics and hemodynamic changes / 대한마취과학회지

BACKGROUND: The purpose of this study is to compare the anesthetic characteristics in elderly patients who remain in sitting position for 2 min compared with patients that are placed in supine position after induction of spinal anesthesia. METHODS: Fifty-seven patients scheduled for transurethral surgery were randomized to assume supine position immediately after 6.5 mg hyperbaric bupivacaine were injected (L group) or to remain in the sitting position for 2 minutes before they also assumed the supine position (S group). Analgesic levels were assessed bilaterally, using pin-prick. Motor block was scored using a 12-point scale. The mean arterial pressure and heart rate were also recorded. RESULTS: Sensory block levels were significantly lower at all time points for the L group. However, there were no significant differences in the degree of the motor block and hemodynamic changes between the two groups. However, in the L group, ephedrine or atropine were administered to three patients. CONCLUSIONS: We concluded that performing a spinal anesthesia in sitting position was technically easier and induced less hypotension.

Spinal Subarachnoid Hematoma as a Complication of an Intramuscular Stimulation : Case Report and a Review of Literatures

Intramuscular stimulation (IMS) is widely used to treat myofascial pain syndrome. IMS is a safe procedure but several complications have been described. To our knowledge, spinal subarachnoid hematoma has never been reported as a complication of an IMS. The authors have experienced a case of spinal subarachnoid hematoma occurring after an IMS, which was tentatively diagnosed as intracranial subarachnoid hemorrhage because of severe headache. Patient was successfully treated with surgery. Here, we report our case with a review of literature.

Unidirectional valve malfunction by the breakage or malposition of disc: two cases report / 대한마취과학회지

Malfunction of the unidirectional valve in a breathing circuit system may cause hypercapnia from the rebreathing of expired gas, ventilation failure, and barotrauma. Capnography is a useful method for monitoring the integrity of the unidirectional valve. We experienced two cases of malfunction of a unidirectional valve which caused leakage and reverse flow, diagnosed early as a change of the capnographic waveform. One case was caused by expiratory unidirectional valve breakage. The other was caused by an incorrectly-assembled inspiratory unidirectional valve.

Satisfaction in patients with chronic renal failure during the surgical creation of an arteriovenous fistula under monitored anesthesia care using remifentanil

BACKGROUND: Remifentanil is a rapid and short-acting drug that can be used for analgesia and sedation during monitored anesthesia care. This study was designed to evaluate the effect of remifentanil on pain and satisfaction of patients during creation of an arterio-venous fistula (AVF). METHODS: Forty chronic renal failure (CRF) patients, undergoing creation of an AVF, were assigned to receive remifentanil (0.05 microg/kg/min) (group R) or saline infusion (group S). Systolic blood pressure, diastolic blood pressure, heart rate, SpO2, Observer's Assessment Alertness/Sedation scale score, respiratory depression, dizziness, nausea and vomiting, pain intensity and frequency, satisfaction score, and operating time were measured. RESULTS: Pain frequency in group R was lower than group S (P < 0.01). The median (interquartile ranges) of pain frequency was 0 (0, 1) in group R and 1 (0.5, 4.0) in group S. In group R, 6 patients experienced respiratory depression, but responded readily to calling of the name in normal tone and recovered well. Satisfaction scores in group R were higher than that of group S (P < 0.05). The median (interquartile ranges) satisfaction score was 4.5 (4, 5) in group R and 4 (3.0, 4.5) in group S. There were no differences in others between the two groups. CONCLUSIONS: Remifentanil infusion at the rate of 0.05 microg/kg/min effectively reduces pain and increases satisfaction of CRF patients during the creation of an AVF.

Delayed diagnosis of impacted partial denture in a patient with mental retardation

Foreign body ingestion is a common problem. To minimise any complications arising from an ingested foreign body, early diagnosis and proper treatment are essential. However, this may be a diagnostic challenge, especially in patients who have psychiatric disorders or are mentally challenged. We report a case of delayed diagnosis of an impacted partial denture in the pharynx of a man with mental retardation.

Phorbol 12-Myristate 13-Acetate Enhances Long-Term Potentiation in the Hippocampus through Activation of Protein Kinase Cdelta and epsilon

Many intracellular proteins and signaling cascades contribute to the sensitivity of N-methyl-D-aspartate receptors (NMDARs). One such putative contributor is the serine/threonine kinase, protein kinase C (PKC). Activation of PKC by phorbol 12-myristate 13-acetate (PMA) causes activation of extracellular signal-regulated kinase (ERK) and promotes the formation of new spines in cultured hippocampal neurons. The purpose of this study was to examine which PKC isoforms are responsible for the PMA-induced augmentation of long-term potentiation (LTP) in the CA1 stratum radiatum of the hippocampus in vitro and verify that this facilitation requires NMDAR activation. We found that PMA enhanced the induction of LTP by a single episode of theta-burst stimulation in a concentration-dependent manner without affecting to magnitude of baseline field excitatory postsynaptic potentials. Facilitation of LTP by PMA (200 nM) was blocked by the nonspecific PKC inhibitor, Ro 31-8220 (10microM); the selective PKCdelta inhibitor, rottlerin (1microM); and the PKCepsilon inhibitor, TAT-epsilonV1-2 peptide (500 nM). Moreover, the NMDAR blocker DL-APV (50microM) prevented enhancement of LTP by PMA. Our results suggest that PMA contributes to synaptic plasticity in the nervous system via activation of PKCdelta and/or PKCepsilon, and confirm that NMDAR activity is required for this effect.

Effects of increasing the dose of ropivacaine on vertical infraclavicular block using neurostimulation / 대한마취과학회지

BACKGROUND: Use of an infraclavicular block is appropriate for surgery of the upper limb. However, it does not consistently block the entire brachial plexus. The aim of this study was to investigate whether increasing the dose of ropivacaine could enhance the success rate, onset time, and efficacy of the sensory and motor block during the use of a vertical infraclavicular block using neurostimulation in upper limb surgery. METHODS: Two hundreds and ten patients were prospectively randomized into three groups: Group 1 (30 ml of 0.5% ropivacaine; n = 70), Group 2 (40 ml of 0.5% ropivacaine; n = 70), and Group 3 (40 ml of 0.75% ropivacaine; n = 70). Patients in each group received a vertical infraclavicular block using neurostimulation and obtained a distal motor response of the ulnar or median nerve. Recorded outcome measures included block success rate, onset time, sensory and motor blocks, and adverse events. RESULTS: No differences were found in the block success rate among the three groups (92.8%, 97.1%, and 94.2% for Groups 1, 2, and, 3, respectively; P = 0.346). There were no significant differences in onset time (P = 0.225) among groups, nor was there enhancement in the sensory block, but the motor block was enhanced. Local anesthetic toxicity was observed in five female patients from group 3 (P = 0.006). CONCLUSIONS: Although the efficacy of the motor block was significantly improved, success rate, onset time, and efficacy of sensory block were not enhanced significantly among groups despite differences in volume and volume/concentration of the local anesthetic.

Cervicofacial Emphysema and Pneumomediastinum Following Pediatric Adenotonsillectomy

Many patients regard tonsillectomy as a minor operation because it is performed frequently. Although tonsillectomy is considered a relatively safe surgical procedure, numerous complications have been described. The common complications are hemorrhage, infection, and following anesthesia, aspiration, cardiac arrhythmia, and laryngeal trauma. Cervicofacial emphysema and pneumomediastinum are rarely observed sequelae of surgical intervention in the upper aerodigestive tract. Although these complications resolve spontaneously in most cases, a few cases result in tension pneumothorax and other life-threatening conditions. Symptoms include chest pain, neck pain, dyspnea and odynophagia. Treatment involves frequent assessment of the airway and extent of the emphysema. The authors of the present study report of a patient who developed pneumomediastinum shortly after an adenotonsillectomy as well as a review of the related literature.

Pneumothorax during laparoscopic totally extraperitoneal inguinal hernia repair: A case report / 대한마취과학회지

We experienced an extremely rare complication during performance of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair for a 57-year-old healthy man. About 50 minutes after CO2 insufflation, the patient developed tachycardia, hypoxemia, hypercapnia and an increased airway pressure. Right pneumothorax with subcutaneous emphysema was recognized on the emergency chest X-ray and this was successfully treated by chest tube insertion. Anesthesiologists should be aware of the possible occurrence of pneumothorax during laparoscopic TEP hernia repair.

Long QT syndrome provoked by induction of general anesthesia: A case report / 대한마취과학회지

Long QT syndrome (LQTS) is an arrhythmogenic cardiovascular disorder resulting from mutations in cardiac ion channels. LQTS is characterized by prolonged ventricular repolarization and frequently manifests itself as QT interval prolongation on the electrocardiogram (ECG). A variety of commonly prescribed anesthetic drugs possess the adverse property of prolonging cardiac repolarization and may provoke serious ventricular tachyarrhythmia called 'torsades de pointes', ventricular fibrillation, and sudden death. We experienced a case of ventricular tachycardia and ventricular fibrillation after anesthetic induction and it came out into the open that anesthetic induction provoked long QT syndrome.

Effect of remifentanil on consumption of sevoflurane in entropy monitored general anesthesia / 대한마취과학회지

BACKGROUND: Monitoring of anesthetic depth is important for successful general anesthesia. It is well known that entropy or BIS monitoring assisted titration of anesthetic drugs decreases their consumption. This study evaluated the effect of remifentanil on consumption of sevoflurane during entropy monitored general anesthesia. METHODS: Patients were randomly assigned to two groups. The R group was administered 0.1 microgram/kg/min of remifentanil and inhaled sevoflurane, while the S group was administered only inhaled sevoflurane. Anesthesia was maintained using sevoflurane with nitrous oxide, and entropy was monitored. In both groups, the concentration of sevoflurane was adjusted to keep the state entropy (SE) value between 40 and 60. End-tidal sevoflurane concentration (ET), entropy value, systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were measured at 5 minute intervals, during a 25 minute period after intubation, skin suture and the end of surgery. RESULTS: ET was significantly lower in the R group than the S group. There were no significant differences in entropy value between R and S groups. CONCLUSIONS: Entropy monitored titration of sevoflurane with remifentanil administration decreased ET with stable hemodynamics.

Air embolism during anesthesia in the beach chair position for shoulder surgery: A case report

A 60-year-old man was scheduled for elective right shoulder surgery. The patient was placed in the beach chair position. A venous air embolism was suspected because of a sudden decrease in the end-tidal carbon dioxide concentration, hypoxemia, tachycardia, and hypotension 5 mins after a stab incision in the surgical site. We inserted a central venous access catheter and provided hemodynamic support and cardiopulmonary resuscitation, but the patient died. We present this case to make surgeons and anesthesiologists aware of the possibility of air embolism during shoulder surgery in the beach chair position.

The Effects of Intravenous Adenosine Infusion on Intraoperative Remifentanil Requirements and Postoperative Pain in Elective Tonsillectomies Are Influenced by the Time of Day the Operation Is Performed

BACKGROUND: The chronobiology of postoperative pain is an interesting topic. This study was performed to evaluate the effects of adenosine on inta-operative remifentanil requirements and on postoperative pain in patients undergoing tonsillectomies and how those effects change with changing time of day the surgery is performed. METHODS: For this study, 120 patients were randomly allocated into four groups. Patients in groups B and D received adenosine at a dose of 50microgram/kg/min, and those in group A and C received an equal volume of saline from 10 minutes after the induction of anesthesia until the end of surgery. Group A (saline) and B (adenosine) patients entered the operating room after 08:30 and finished before 11:00, Group C (saline) and D (adenosine) patients entered the operating room after 13:30 and finished before 16:00. We evaluated the intraoperative time-weighted mean remifentanil dose, and postoperative pain scores at 1, 6, 12, and 24 hours, and the analgesic dose required during the following 24 hours. RESULTS: Time-weighted mean remifentanil doses during the intraoperative period and the analgesic requirement during the following 24 hours in group D was significantly lower than in the other groups. The numeric rating scale for pain at 1, and 6 hours in group D was significantly lower (P < 0.01) than that of group A. There were no significant differences in side effects among groups. CONCLUSIONS: Use of intraoperative adenosine infusion provides perioperative analgesia. Postoperative pain is affected by the time of day the operation is performed.

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.

Antinociceptive Effects of the Essential Oil of Ocimum Basilicum in Mice

BACKGROUND: The essential oil of Ocimum basilicum (EOOB) has a pleasant aroma and is known to have antimicrobial and insecticidal activities. In addition, it is used as a pain reliever in folk medicine. However, there are few reports on the antinociceptive activities of EOOB. METHODS: This study examined the antinociceptive effects of EOOB using formalin and a plantar test in mice. In the formalin test, EOOB (50 mg/kg, 100 mg/kg, 150 mg/kg) was administered intraperitoneally and the licking time of the mice was measured. In the plantar test, intraperitoneal EOOB (50 mg/kg, 100 mg/kg) was administered and the withdrawal latency was measured using the Hargreaves method. RESULTS: In the formalin test, EOOB (50 mg/kg, IP) showed significant decreases in licking time in the second phase. On the other hand, in the plantar test, there were no significant effects in any of the groups examined. CONCLUSIONS: These results support the traditional use of EOOB for the treatment of painful conditions. However, there is a need for more research to determine the active chemical constituents and the precise mechanism.

The changes of skin temperature in lower extremity during spinal anesthesia and general anesthesia

BACKGROUND: Skin temperature is well known to increase after spinal anesthesia due to sympathetic blockade and vasodilation. The purpose of this study is to find the changes of skin temperature in lower extremities during spinal and general anesthesia. METHODS: Patients were divided into three groups: SA (spinal anesthesia), GA (general anesthesia) and control (N) group. Skin temperature was recorded in the ventral aspect of mid thigh before induction and 5, 15, 30 min after induction. RESULTS: In all groups, skin temperature increased after 5, 15, 30 min significantly. And temperature gradients between before induction and after 30 minutes did not differ significantly in the three groups (P < 0.05). CONCLUSIONS: The changes of skin temperature in the lower extremities are similar with spinal anesthesia and general anesthesia.