The Effects of Oral Atenolol or Enalapril Premedication on Blood Loss and Hypotensive Anesthesia in Orthognathic Surgery

PURPOSE: The aim of this study was to evaluate the effects of premedication with oral atenolol or enalapril, in combination with remifentanil under sevoflurane anesthesia, on intraoperative blood loss by achieving adequate deliberate hypotension (DH) during orthognathic surgery. Furthermore, we investigated the impact thereof on the amount of nitroglycerin (NTG) administered as an adjuvant agent. MATERIALS AND METHODS: Seventy-three patients undergoing orthognathic surgery were randomly allocated into one of three groups: an angiotensin converting enzyme inhibitor group (Group A, n=24) with enalapril 10 mg, a beta blocker group (Group B, n=24) with atenolol 25 mg, or a control group (Group C, n=25) with placebo. All patients were premedicated orally 1 h before the induction of anesthesia. NTG was the only adjuvant agent used to achieve DH when mean arterial blood pressure (MAP) was not controlled, despite the administration of the maximum remifentanil dose (0.3 microg kg-1min-1) with sevoflurane. RESULTS: Seventy-two patients completed the study. Blood loss was significantly reduced in Group A, compared to Group C (adjusted p=0.045). Over the target range of MAP percentage during DH was significantly higher in Group C than in Groups A and B (adjusted p-values=0.007 and 0.006, respectively). The total amount of NTG administered was significantly less in Group A than Group C (adjusted p=0.015). CONCLUSION: Premedication with enalapril (10 mg) combined with remifentanil under sevoflurane anesthesia attenuated blood loss and achieved satisfactory DH during orthognathic surgery. Furthermore, the amount of NTG was reduced during the surgery.

Retrospective Assessment of the Validity of Robotic Surgery in Comparison to Open Surgery for Pediatric Choledochal Cyst

PURPOSE: We evaluated the validity of robotic surgery (RS) for pediatric choledochal cyst (CC) in comparison to open surgery (OS). MATERIALS AND METHODS: From January 2009 to April 2013, clinical data from 79 consecutive pediatric patients with CC, who underwent RS (n=36) or OS (n=43) performed by a single pediatric surgeon, were analyzed retrospectively. RESULTS: In the RS group, the age of the patients was significantly older, compared to the OS group. Operation and anesthesia times were significantly longer in the RS group than the OS group. Fluid input rates to maintain the same urine output were significantly smaller in the RS group than the OS group. The American Society of Anesthesiologists (ASA) physical status, length of postoperative hospital stay, and the incidence of surgical complications did not differ significantly between the two groups. CONCLUSION: Although early complications could not be avoided during the development of robotic surgical techniques, RS for pediatric CC showed results comparable to those for OS. We believe that RS may be a valid and alternative surgery for pediatric CC. After further development of robotic surgical systems and advancement of surgical techniques therewith, future prospective studies may reveal more positive results.

Effects of Acupuncture Stimulation at Different Acupoints on Formalin-Induced Pain in Rats

Acupuncture is the process of stimulating skin regions called meridians or acupoints and has been used to treat pain-related symptoms. However, the pain-relieving effects of acupuncture may be different depending on acupoints. In the present study, the effects of acupuncture on behavioral responses and c-Fos expression were evaluated using a formalin test in male Sprague-Dawley rats in order to clarify the analgesic effects of three different acupoints. Each rat received manual acupuncture at the ST36 (Zusanli), SP9 (Yinlingquan) or BL60 (Kunlun) acupoint before formalin injection. Flinching and licking behaviors were counted by two blinded investigators. Fos-like immunoreactivity was examined by immunohistochemistry in the rat spinal cord. Manual acupuncture treatment at BL60 acupoint showed significant inhibition in flinching behavior but not in licking. Manual acupuncture at ST36 or SP9 tended to inhibit flinching and licking behaviors but the effects were not statistically significant. The acupuncture at ST36, SP9, or BL60 reduced c-Fos expression as compared with the control group. These results suggest that acupuncture especially at the BL60 acupoint is more effective in relieving inflammatory pain than other acupoints.

Periarticular Injection with Corticosteroid Has an Additional Pain Management Effect in Total Knee Arthroplasty

PURPOSE: Although the analgesic effects of corticosteroids have been well documented, little information is available on periarticular injection (PI) containing corticosteroids for early postoperative pain management after total knee arthroplasty (TKA). We performed a prospective double-blind randomized trial to evaluate the efficacy and safety of an intraoperative corticosteroid PI in patients undergoing TKA. MATERIALS AND METHODS: Seventy-six consecutive female patients undergoing bilateral staged TKA were randomized to receive steroid or non-steroid PI, with 3 months separating the procedures. The steroid group received PI with a mixture containing triamcinolone acetonide (40 mg). The non-steroid group received the same injection mixture without corticosteroid. During the postoperative period, nighttime pain, functional recovery [straight leg raising (SLR) ability and maximal flexion], patient satisfaction, and complications were recorded. Short-term postoperative clinical scores and patient satisfaction were evaluated at 6 months. RESULTS: The pain level was significantly lower in the PI steroid than the non-steroid group on the night of the operation (VAS, 1.2 vs. 2.3; p=0.021). Rebound pain was observed in both groups at POD1 (VAS, 3.2 vs. 3.8; p=0.248), but pain remained at a low level thereafter. No significant differences were seen in maximal flexion, frequency of acute rescuer, clinical scores, and patient satisfaction. The steroid group was able to perform SLR earlier than the non-steroid group (p=0.013). The incidence of complications was similar between the groups. CONCLUSION: PI containing a corticosteroid provided an additional pain-relieving effect on the night of the operation. In addition, corticosteroid PI did not increase the perioperative complications of TKA.

Fresh Frozen Plasma in Pump Priming for Congenital Heart Surgery: Evaluation of Effects on Postoperative Coagulation Profiles Using a Fibrinogen Assay and Rotational Thromboelastometry

PURPOSE: In this prospective study, the effects of fresh frozen plasma (FFP) included in pump priming for congenital heart surgery in infants and children on post-bypass coagulation profiles were evaluated. MATERIALS AND METHODS: Either 20% albumin (50-100 mL) or FFP (1-2 units) was added to pump priming for patients randomly allocated into control or treatment groups, respectively. Hematologic assays, including functional fibrinogen level, and rotational thromboelastometry (ROTEM(R)) were measured before skin incision (baseline), after weaning from cardiopulmonary bypass (CPB) and heparin reversal, and at 24 hours (h) in the intensive care unit (ICU). RESULTS: All the baseline measurements were comparable between the control and treatment groups of infants and children. After heparin reversal, however, significantly higher fibrinogen levels and less reduced ROTEM parameters, which reflect clot formation and firmness, were demonstrated in the treatment groups of infants and children. At 24 h in the ICU, hematologic assays and ROTEM measurements were comparable between the control and treatment groups of infants and children. Transfusion requirements, excluding FFP in pump prime, and postoperative bleeding were comparable between the control and treatment groups of infants and children. CONCLUSION: Although clinical benefits were not clearly found, the inclusion of FFP in pump priming for congenital heart surgery in infants and children was shown to improve the hemodilution-related hemostatic dysfunction immediately after weaning from CPB and heparin reversal.

Total Intravenous Anesthesia with Propofol Reduces Postoperative Nausea and Vomiting in Patients Undergoing Robot-Assisted Laparoscopic Radical Prostatectomy: A Prospective Randomized Trial

PURPOSE: We investigated the effect of total intravenous anesthesia (TIVA) with propofol on postoperative nausea and vomiting (PONV) after robot-assisted laparoscopic radical prostatectomy (RLRP) in patients at low risk of developing PONV, in comparison to balanced anesthesia with desflurane. MATERIALS AND METHODS: Sixty two patients were randomly assigned to the Des or TIVA group. Propofol and remifentanil were used for induction of anesthesia in both groups and for maintenance of the anesthesia in the TIVA group. In the Des group, anesthesia was maintained with desflurane and remifentanil. In both groups, postoperative pain was controlled using fentanyl-based intravenous patient controlled analgesia, and ramosetron 0.3 mg was administered at the end of surgery. The incidence of PONV, severity of nausea and pain, and requirements of rescue antiemetics and analgesics were recorded. RESULTS: The incidence of nausea in the post-anesthetic care unit was 22.6% in the Des group and 6.5% in the TIVA (p=0.001) group. The incidence of nausea at postoperative 1-6 hours was 54.8% in the Des group and 16.1% in the TIVA group (p=0.001). At postoperative 6-48 hours, there were no significant differences in the incidence of nausea between groups. CONCLUSION: In order to prevent PONV after RLRP in the early postoperative period, anesthesia using TIVA with propofol is required regardless of patient-related risk factors.

c-Fos Expression in the Nucleus of the Solitary Tract in Response to Salt Stimulation in Rats

Salt signals in tongue are relayed to the nucleus of the solitary tract (NST). This signaling is very important to determine whether to swallow salt-related nutrition or not and suggests some implications in discrimination of salt concentration. Salt concentration-dependent electrical responses in the chorda tympani and the NST were well reported. But salt concentration-dependency and spatial distribution of c-Fos in the NST were not well established. In the present study, NaCl signaling in the NST was studied in urethane-anesthetized rats. The c-Fos immunoreactivity in the six different NST areas along the rostral-caudal axis and six subregions in each of bilateral NST were compared between applications of distilled water and different concentrations of NaCl to the tongue of experimental animals. From this study, salt stimulation with high concentration (1.0 M NaCl) induced significantly higher c-Fos expression in intermediate NST and dorsal-medial and dorsal-middle subregions of the NST compared to distilled water stimulation. The result represents the specific spatial distribution of salt taste perception in the NST.

Analgesic Mechanism of Electroacupuncture in an Arthritic Pain Model of Rats: A Neurotransmitter Study

PURPOSE: We investigated what kinds of neurotransmitters are related with electroacupuncture (EA) analgesia in an arthritic pain model of rats. MATERIALS AND METHODS: One hundred rats were assigned to six groups: control, EA, opioid, adrenergic, serotonin and dopamine group. A standardized model of inflammatory arthritis was produced by injecting 2% carrageenan into the knee joint cavity. EA was applied to an acupoint for 30 min in all groups except fo the control group. In the opioid, adrenergic, serotonin and dopamine groups, each receptor antagonist was injected intraperitoneally to their respective group before initiating EA. RESULTS: In the opioid receptor antagonist group, adrenergic receptor antagonist group, serotonin receptor antagonist group, dopamine receptor antagonist group and the control group weight-bearing force decreased significantly from 30 min to 180 min after EA in comparison with the EA group. CONCLUSION: The analgesic effects of EA are related to opioid, adrenergic, serotonin and dopamine receptors in an arthritic pain model of rats.

Risk factors and safety measures in the operation room

Hospital personnel are subject to various occupational hazards. Along with the development of modern medicine, novel and diverse medical appliances have been introduced to enhance the safety of the hospital environment. But paradoxically, some advancement of the appliances have led to exposure to greater risk for the personnel in the operation room. In the past, the greatest risk factor in the operation room was outbreak of fire and explosion, but the risk of explosion has vanished by the development of nonexplosive anesthetics. However, newly introduced electrical appliances and unknown infectious diseases appear to be new risk factors affecting health workers in the operation room. The goal of this review is to investigate the current risk factors and thereby prepare suitable preventive methods. We have reviewed the main occupational hazards affecting health workers in the operation room: accidents such as fires, explosions, electrical accidents; exposure to residual anesthetic gas; radiation; various infections; drug dependencies.

Fluid therapy: classification and characteristics of intravenous fluids

Fluid and electrolyte therapies including nutritional support are markedly developing in medicine and many kinds of commercial fluids are being introduced to clinical practice. Understanding the characteristics and usefulness of intravenous fluids is necessary to manage patients properly. Disputes about the usefulness of crystalloid or colloid solutions for specific clinical conditions still continue. To make ideal fluid therapy possible, many kinds of fluids will be developed and applied to clinical practice in the near future by mimicking the composition and functions of human body fluids. The selection of crystalloid and colloid solutions for fluid therapy should be performed by considering patients' clinical and pathophysiological conditions and the characteristics and usefulness of each intravenous fluid.

Functional Mapping of Nervous System Using Optical Imaging Techniques

Functional mapping techniques including functional magnetic resonance imaging (fMRI), positron emission tomography (PET), and magnetoencephalography (MEG) can be used to study the function of the nervous system. Optical imaging is an emerging technique for functional imaging of the nervous tissue. Functional optical imaging can be classified into two major streams; intrinsic signal optical imaging (ISO) and voltage-sensitive dye optical imaging (VDO). ISO is related to hemodynamic changes such as hemoglobin concentration and oxygenation changes, cytochrome oxidation change, and light scattering. On the contrary, VOD measures changes in membrane potentials of neural cells. Therefore, ISO reflects metabolic activity of neurons, while VOD directly reflects neural activity. Recent advances in optical imaging opened the possibility of its application to clinical situations as well as basic researches. Further, development of optical imaging may greatly contribute to the understanding of the function of the nervous system.

New Trend of Pain Study by Brain Imaging Devices

The study of pain has recently received much attention, especially in understanding its neurophysiology by using new brain imaging techniques, such as positron emission tomography (PET) and functional magnetic resonance imaging (fMRI), both of which allow us to visualize brain function in vivo. Also the new brain imaging devices allow us to evaluate the patients pain status and plan to treat patients objectively. Functional activation of brain regions are thought to be reflected by increases in the regional cerebral blood flow in the brain imaging studies. Regional cerebral blood flow increases to noxious stimuli are observed in second somatic (SII) and insular regions and in the anterior cingulate cortex and with slightly less consistency in the first somatic area (S1), motor area, supplementary motor area, prefrontal area, amygdala and contralateral thalamus. These data suggest that pain has multidimensions such as sensory-discrimitive, motivational-affective and cognitive-evaluative.

New Trend of Pain Study by Brain Imaging Devices

The study of pain has recently received much attention, especially in understanding its neurophysiology by using new brain imaging techniques, such as positron emission tomography (PET) and functional magnetic resonance imaging (fMRI), both of which allow us to visualize brain function in vivo. Also the new brain imaging devices allow us to evaluate the patients pain status and plan to treat patients objectively. Functional activation of brain regions are thought to be reflected by increases in the regional cerebral blood flow in the brain imaging studies. Regional cerebral blood flow increases to noxious stimuli are observed in second somatic (SII) and insular regions and in the anterior cingulate cortex and with slightly less consistency in the first somatic area (S1), motor area, supplementary motor area, prefrontal area, amygdala and contralateral thalamus. These data suggest that pain has multidimensions such as sensory-discrimitive, motivational-affective and cognitive-evaluative.

Transtracheal High-frequency Jet Ventilation using a Two-lumen Central Venous Catheter for Laryngomicrosurgery: A case report / 대한마취과학회지

A 33 year old female patient was scheduled for laser laryngomicrosurgery to remove a polyp arising from the posterior one third of the vocal cord.A double lumen central venous catheter was inserted through the cricothyroid membrane and transtracheal high frequency jet ventilation was performed via the distal lumen.The proximal lumen was connected to a capnography monitor, enabling breath by breath monitoring of PETCO2.The surgery was successfully completed, and the patient was discharged from the post anesthesia care unit (PACU) three hours after surgery without any complication.

Antiallodynic Effects of Acupuncture in Neuropathic Rats

Peripheral nerve injury often results in abnormal neuropathic pain such as allodynia or hyperalgesia. Acupuncture, a traditional Oriental medicine, has been used to relieve pain and related symptoms. However, the efficiency of acupuncture in relieving neuropathic pain is not clear. The aim of this study was to investigate the anti-allodynic effects of acupuncture through behavioral and electrophysiological examinations. Male Sprague-Dawley rats were subjected to neuropathic surgery consisting of a tight ligation and transection of the left tibial and sural nerves, under pentobarbital anesthesia. The acupuncture experiment consisted of four different groups, one treated at each of three different acupoints (Zusanli (ST36), Yinlingquan (SP9), and a sham-acupoint) and a control group. Behavioral tests for mechanical allodynia and cold allodynia were performed for up to two weeks postoperatively. Extracellular electrophysiological recordings were made from the dorsal roots using platinum wire electrodes. Mechanical and cold allodynia were significantly reduced after acupuncture treatment at the Zusanli and Yinlingquan acupoints, respectively. Electrophysiological neural responses to von Frey and acetone tests were also reduced after acupuncture at the same two acupoints. These results suggest that acupuncture may be beneficial in relieving neuropathic pain.

Antiallodynic Effects of Acupuncture in Neuropathic Rats

Peripheral nerve injury often results in abnormal neuropathic pain such as allodynia or hyperalgesia. Acupuncture, a traditional Oriental medicine, has been used to relieve pain and related symptoms. However, the efficiency of acupuncture in relieving neuropathic pain is not clear. The aim of this study was to investigate the anti-allodynic effects of acupuncture through behavioral and electrophysiological examinations. Male Sprague-Dawley rats were subjected to neuropathic surgery consisting of a tight ligation and transection of the left tibial and sural nerves, under pentobarbital anesthesia. The acupuncture experiment consisted of four different groups, one treated at each of three different acupoints (Zusanli (ST36), Yinlingquan (SP9), and a sham-acupoint) and a control group. Behavioral tests for mechanical allodynia and cold allodynia were performed for up to two weeks postoperatively. Extracellular electrophysiological recordings were made from the dorsal roots using platinum wire electrodes. Mechanical and cold allodynia were significantly reduced after acupuncture treatment at the Zusanli and Yinlingquan acupoints, respectively. Electrophysiological neural responses to von Frey and acetone tests were also reduced after acupuncture at the same two acupoints. These results suggest that acupuncture may be beneficial in relieving neuropathic pain.

Comparison of Continuous Epidural and Intravenous Analgesia for Postoperative Pain Control in Pediatric Lower Extremity Surgery

In recent years epidural anesthesia and analgesia techniques were used in pediatric surgery owing to the development of pediatric epidural catheter needles. And the need of postoperative pain control in pediatric patients is also increasing. We compared combined general-epidural anesthesia and analgesia technique with intravenous fentanyl analgesia after general anesthesia for postoperative analgesic effect and complications in these pediatric patients. We randomly allocated 91 pediatric patients undergoing lower extremities surgery into epidural lidocaine group (n=61) and IV fentanyl group (n=30). During the operation, end-tidal sevoflurane concentration (ETsev) was controlled to maintain the blood pressure and heart rate within 10% of preoperative value. At the postoperative period, Parent Visual Analog Scale (PVAS), Objective Pain Score (OPS) and the incidence of nausea/ vomiting were checked immediately, 6 hours and 24 hours after the patient's arrival at general ward. ETsev was significantly low in epidural lidocaine group (p < 0.05). Compare to IV fentanyl group, epidural lidocaine group had significantly lower OPSs at 6 hours after arrival. Epidural lidocaine group had significantly lower PVASs immediately, 6 hrs and 24 hours after arrival. There was no significant difference in the incidence of postoperative nausea and vomiting. A combined general-epidural anesthesia technique significantly reduces intraoperative end-tidal sevoflurane concentration compared to general anesthesia alone. And continuous patient-controlled epidural analgesia reduces postoperative pain scores significantly more than continuous patient-controlled IV fentanyl analgesia without any serious complications in pediatric lower extremity surgery.

Anthropometric Variables and Security against Fecal Contamination due to Caudal Catheter Indwelling in Children / 대한마취과학회지

BACKGROUND: There is an increasing interest in regional anesthesia for pediatric patients, in particular, the efficacy of the caudal approach is similar to that of lumbar epidural anesthesia, and reduces the risk of damage to the spinal cord and vessels. Although caudal catheterization may increase the likelihood of urofecal contamination, especially in children who are not toilet trained, no significant infection has been reported after caudal epidural catheter indwelling. The purpose of this study was to clarify the anatomic characteristics of the sacrococcygeal area in children by comparing the anthropometric variables of children and adults, and to reconsider the caudal epidural catheter safety with respect to fecal contamination. METHODS: Thirty-eight children aged 3-9 years and 47 adults aged 30-75 years, without bony deformities, were enrolled in this study. In left lateral position, Tuffier's line (A), sacral hiatus (B) and greater trochanter (C) were marked. The shortest distances from A to B, from A to C and from B to the anus (D) were measured and the ratios of BD to subject height, BD to AB and BD to AC were calculated. RESULTS: The shortest AB, AC and BD distances were significantly shorter in children and conversely the ratios of BD/height, BD/AB and BD/ AC were significantly larger. CONCLUSION: Considering anatomical characteristics of pediatric patients, if a child is toilet trained and the catheter insertion site is well sealed, there should be no difference between the incidence of infection in adults and children after caudal epidural catheter indwelling.

Effect of Preoperative Angiotensin-Converting Enzyme Inhibitor on Hemodynamics and Vasoconstrictor Requirements in Patients Undergoing Off-Pump Coronary Artery Bypass Surgery / 대한마취과학회지

BACKGROUND: This study examined the effect of chronic preoperative ACEI treatment on hemodynamics and the amount of vasoconstrictor used to maintain mean arterial pressure (MAP) during off-pump coronary artery bypass surgery (OPCAB) METHODS: Sixty patients undergoing OPCAB were divided into two groups: ACEI group, in which patients were treated with ACEI preoperatively (n = 30) and control group, in which patients were not treated with ACEI preoperatively (n = 30). Norepinephrine was infused when MAP decreased below 70 mmHg during operation. Hemodynamic variables and amount of norepinephrine infused were obtained during pericardiotomy and during the anastomosis of each coronary artery including left anterior descending artery (LAD), obtuse marginal artery (OM) of left circumflex coronary artery, and posterior descending artery (PDA) of right coronary artery. RESULTS: During LAD, OM, and PDA anastomosis, cardiac index and mixed venous oxygen saturation were decreased and central venous pressure and systemic vascular resistance index were increased significantly in both group. There was no significant difference in hemodynamic variables, including MAP, between two groups during all study period. During OM anastomosis, amount of norepinephrine infused to maintain MAP was significantly greater in ACEI group than in control group CONCLUSIONS: Preoperative treatment with ACEI significantly increased amount of vasoconstrictor used to maintain target MAP during OM anastomosis, which has been known as hemodynamically unstable period during OPCAB, and cautious management is required to maintain MAP.

The Incidence of Nausea and Vomiting in Immediate Postanesthetic Period / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) continues to be a common complication of surgery and patients report that avoidance of PONV is of greater concern than avoidance of postoperative pain. The overall incidence of postoperative nausea and vomiting has been reported to be in the 20-30%. The incidence of PONV in the recovery room was 9-10% but it was increased 30% during the first 24 hours after surgery. This retrospective study was designed to find the incidence of PONV in immediate postanesthetic period as well as the difference in incidence of PONV due to gender, age, duration of surgery, different inhalation agents and method of patient controlled analgesia. METHODS: The anesthesia and postanesthesia records for 12,895 patients receiving surgery under general and regional anesthesia between September 2001 and August 2002 one year were retrospectively reviewed. RESULTS: The overall incidence of nausea, vomiting and nausea/vomiting (either nausea, vomiting or both) in immediate postanesthetic period was 1.5%, 2.0% and 2.9% of patients, respectively. The incidence of nausea, vomiting and nausea/vomiting in immediate postanesthetic period was significantly higher in female than in male, general anesthesia with enflurane than with sevoflurane or isoflurane, and patients receiving patient controlled analgesia (PCA) via intravenous route than via epidural route. The incidence of nausea, vomiting and nausea/vomiting in immediate postanesthetic period was significantly lower in surgery duration less than 60 minutes. CONCLUSIONS: Patients with female gender, intravenous PCA and under enflurane anesthesia had significantly higher incidence of nausea, vomiting and nausea/vomiting in immediate postanesthetic period.