Femoral subtrochanteric insufficiency fracture after long-term bisphosphonate therapy masked from foraminal stenosis of lumbar spine: A case report

We present a case of an insufficiency fracture of the subtrochanteric region of the femur in a 78-year-old woman masked by lumbar spinal foraminal stenosis. She complained of pain and a tingling sensation in the anterior and lateral side of the right thigh, leg, and ankle. Selective transforaminal epidural (L4-5, Rt.) and caudal block were done under the diagnosis of lumbar foraminal stenosis. The tingling sensation was completely relieved, but the pain was not completely relieved. The patient had been receiving bisphosphonate therapy for 6 years under the diagnosis of osteoporosis. We performed magnetic resonance imaging, which showed a unicortical break line and marrow edema around the hypertrophied area. Surgery was done. In cases with incomplete relief of the pain in the thigh following epidural block, physicians should keep in mind the possibility of femoral insufficiency fracture in patients who have received long-term bisphosphonate therapy.

Volume-controlled versus pressure-controlled ventilation-volume guaranteed mode during one-lung ventilation / 대한마취과학회지

BACKGROUND: The purpose of this study was to investigate the changes in airway pressure and arterial oxygenation between ventilation modes during one-lung ventilation (OLV) in patients undergoing thoracic surgery. METHODS: We enrolled 27 patients for thoracic surgery with OLV in the lateral decubitus position. The subjects received various modes of ventilation in random sequences during surgery, including volume-controlled ventilation (VCV) and pressure-controlled ventilation-volume guaranteed (PCV-VG) with a tidal volume (TV) of 8 ml/kg of actual body weight. Target-controlled infusion (TCI) with propofol and remifentanil was used for anesthesia induction and maintenance. After double-lumen endobronchial tube (DLT) insertion, the proper positioning of the DLT was assessed using a fiberoptic bronchoscope. Peak inspiratory pressure (Ppeak), exhaled TV, and arterial blood gas were measured 30 min after each ventilation mode. RESULTS: P(peak) was significantly reduced with the PCV-VG mode (19.6 +/- 2.5 cmH2O) compared with the VCV mode (23.2 +/- 3.1 cmH2O) (P < 0.000). However, no difference in arterial oxygen tension was noted between the groups (PCV-VG, 375.8 +/- 145.1 mmHg; VCV, 328.1 +/- 123.7 mmHg) (P = 0.063). The exhaled TV was also significantly increased in PCV-VG compared with VCV (451.4 +/- 85.4 vs. 443.9 +/- 85.9 ml; P = 0.035). CONCLUSIONS: During OLV in patients with normal lung function, although PCV-VG did not provide significantly improved arterial oxygen tension compared with VCV, PCV-VG provided significantly attenuated airway pressure despite significantly increased exhaled TV compared with VCV.

Volume-controlled versus pressure-controlled ventilation-volume guaranteed mode during one-lung ventilation / 대한마취과학회지

BACKGROUND: The purpose of this study was to investigate the changes in airway pressure and arterial oxygenation between ventilation modes during one-lung ventilation (OLV) in patients undergoing thoracic surgery. METHODS: We enrolled 27 patients for thoracic surgery with OLV in the lateral decubitus position. The subjects received various modes of ventilation in random sequences during surgery, including volume-controlled ventilation (VCV) and pressure-controlled ventilation-volume guaranteed (PCV-VG) with a tidal volume (TV) of 8 ml/kg of actual body weight. Target-controlled infusion (TCI) with propofol and remifentanil was used for anesthesia induction and maintenance. After double-lumen endobronchial tube (DLT) insertion, the proper positioning of the DLT was assessed using a fiberoptic bronchoscope. Peak inspiratory pressure (Ppeak), exhaled TV, and arterial blood gas were measured 30 min after each ventilation mode. RESULTS: P(peak) was significantly reduced with the PCV-VG mode (19.6 +/- 2.5 cmH2O) compared with the VCV mode (23.2 +/- 3.1 cmH2O) (P < 0.000). However, no difference in arterial oxygen tension was noted between the groups (PCV-VG, 375.8 +/- 145.1 mmHg; VCV, 328.1 +/- 123.7 mmHg) (P = 0.063). The exhaled TV was also significantly increased in PCV-VG compared with VCV (451.4 +/- 85.4 vs. 443.9 +/- 85.9 ml; P = 0.035). CONCLUSIONS: During OLV in patients with normal lung function, although PCV-VG did not provide significantly improved arterial oxygen tension compared with VCV, PCV-VG provided significantly attenuated airway pressure despite significantly increased exhaled TV compared with VCV.

The adsorption of inspired desflurane due to incorrectly mounted air dryer filter of the heated humidifier: A case report

Heated humidifiers are used to prevent respiratory complications associated with mechanical ventilation with an endotracheal tube. One of the heated humidifiers uses an air dryer filter in order to remove humidity from air before it enters the anesthetic machine. We report a case in which the air dryer filter was unintentionally misconnected to the inspiratory limb of the circuit, which caused insufficient volatile anesthetic concentration during anesthesia induction.

Superoxide and Nitric Oxide Involvement in Enhancing of N-methyl-D-aspartate Receptor-Mediated Central Sensitization in the Chronic Post-ischemia Pain Model

BACKGROUND: Recent studies indicate that reactive oxygen species (ROS) are involved in persistent pain, including neuropathic and inflammatory pain. Since the data suggest that ROS are involved in central sensitization, the present study examines the levels of activated N-methyl-D-aspartate (NMDA) receptors in the dorsal horn after an exogenous supply of three antioxidants in rats with chronic post-ischemia pain (CPIP). This serves as an animal model of complex regional pain syndrome type-I induced by hindpaw ischemia/reperfusion injury. METHODS: The application of tight-fitting O-rings for a period of three hours produced CPIP in male Sprague-Dawley rats. Allopurinol 4 mg/kg, allopurinol 40 mg/kg, superoxide dismutase (SOD) 4,000 U/kg, N-nitro-L-arginine methyl ester (L-NAME) 10 mg/kg and SOD 4,000 U/kg plus L-NAME 10 mg/kg were administered intraperitoneally just after O-ring application and on the first and second days after reperfusion. Mechanical allodynia was measured, and activation of the NMDA receptor subunit 1 (pNR1) of the lumbar spinal cord (L4-L6) was analyzed by the Western blot three days after reperfusion. RESULTS: Allopurinol reduced mechanical allodynia and attenuated the enhancement of spinal pNR1 expression in CPIP rats. SOD and L-NAME also blocked spinal pNR1 in accordance with the reduced mechanical allodynia in rats with CPIP. CONCLUSION: The present data suggest the contribution of superoxide, produced via xanthine oxidase, and the participation of superoxide and nitric oxide as a precursor of peroxynitrite in NMDA mediated central sensitization. Finally, the findings support a therapeutic potential for the manipulation of superoxide and nitric oxide in ischemia/reperfusion related pain conditions.

Labor Analgesia with Epidural Blockade in Parturient with Peripartum Cardiomyopathy: A Case Report / 대한구급학회지

Peripartum cardiomyopathy (PPCM) is an unusual and uncommon causes of antepartum and postpartum heart failure, which may result in severe cardiac failure and death. PPCM is often unrecognized as symptoms of normal pregnancy commonly mimic those of mild heart failure but can rapidly progress to cardiac failure. We presented a case of elective labor induction in a patient with peripartum cardiomyopathy. A epidural analgesia technique was performed without difficulty for labor analgesia in parturient with peripartum cardiomyopathy. Her post-delivery course was uncomplicated but her baby has died due to respiratory failure. We suggest that vaginal delivery with careful incremental epidural alnalgesia in patient with PPCM is acceptable methods and close peripartum monitoring is essential in the management of PPCM.

The Influence of Bispectral Index and Hemodynamics during Propofol TCI with Intravenous Injection of Lidocaine / 대한마취과학회지

BACKGROUND: Lidocaine has been used for attenuating cardiovascular responses to endotracheal intubation and thought to have the sedative effect. The sedative effect of lidocaine has not been known well. The BIS (bispectral index) has been used an indicator of the sedative state and has been considered to be related to anesthetic agents and noxious stimulus. The purpose of this study is to evaluate sedative and cardiovascular effects of lidocaine during TCI (target controlled infusion) of propofol by monitoring BIS and hemodynamics. METHODS: Fifty ASA patient status 1 and 2, aged from 20 to 65 years patients (n = 50, 2 groups) undergoing elective surgeries with general anesthesia. These patients were randomly allocated to group C or L. Patients in Group L received 1.5 mg/kg injection and 40microgram/kg/min infusion of lidocaine. Patients in Group C received normal saline. The BIS, blood pressure and heart rate were mesasured before injection of drug, 1, 2 minute after injection of drug, just before intubation, 1, 2, 5 and 10 min after intubation. RESULTS: The BIS of group L more decreased than group C at 1, 2, 5 and 10 min after endotracheal intubation. The blood pressure and heart rate did not show any differences between two groups. CONCLUSIONS: Intravenous injection of lidocaine reduced BIS. Lidocaine had sedative effects under propofol target controlled infusion. But Cardiovascular variables of this study failed to show any differences between two groups (P < 0.05).