Effect of midazolam pretreatment on desflurane MAC(BAR) at an effect-site concentration of remifentanil 1.0 ng/ml

BACKGROUND: The goal of this prospective study was to determine the effect of midazolam pretreatment on the desflurane requirement for blunting the sympathetic response after surgical incision (minimum alveolar concentration blockade of adrenergic responses, MAC(BAR)) when desflurane is combined with a target-controlled concentration of remifentanil at 1 ng/ml. METHODS: Sixty-five patients aged 30 to 60 years with American Society of Anesthesiologists physical status of I or II who were undergoing general anesthesia for thyroidectomy were registered for this study. The patients were randomly allocated to receive either 30 microg/kg of midazolam (Group M) or isovolemic saline (Group C) intravenously before anesthetic induction. All patients were anesthetized with propofol, rocuronium, desflurane and remifentanil at a target-controlled effect-site concentration of 3 ng/ml at intubation followed by 1 ng/ml throughout the study. Sympathetic responses to surgical incision were determined 10 minutes after stabilization of end-tidal desflurane and target-controlled remifentanil concentrations. The predetermined end-tidal desflurane concentrations and MAC(BAR) for each group were determined using an up-and-down sequential allocation technique. RESULTS: The MAC(BAR) of desflurane with 1 ng/ml remifentanil concentration was 7.1 and 6.8% without and with midazolam pretreatment, respectively, using Dixon's up-and-down method (P = 0.755). CONCLUSIONS: Midazolam administered intravenously before anesthetic induction does not impact the MAC(BAR) of desflurane with an effect-site concentration of remifentanil 1.0 ng/ml.

The simultaneous application of positive-end expiratory pressure with the Trendelenburg position minimizes respiratory fluctuations in internal jugular vein size / 대한마취과학회지

BACKGROUND: The respiratory cycle alters the size of the right internal jugular vein (RIJV). We assessed the changes in RIJV size during the respiratory cycle in patients under positive pressure ventilation. Moreover, we examined the effects of positive-end expiratory pressure (PEEP) and the Trendelenburg position on respiratory fluctuations. METHODS: A prospective study of 24 patients undergoing general endotracheal anesthesia was performed. Images of the RIJV were obtained in the supine position with no PEEP (baseline, S0) and after applying three different maneuvers in random order: (1) a PEEP of 10 cmH2O (S10), (2) a 10degrees Trendelenburg tilt position (T0), and (3) a 10degrees Trendelenburg tilt position combined with a PEEP of 10 cmH2O (T10). Using the images when the area was smallest and largest, cross-sectional area (CSA), anteroposterior diameter, and transverse diameter were measured. RESULTS: All maneuvers minimized the fluctuation in RIJV size (all P = 0.0004). During the respiratory cycle, the smallest CSA compared to the largest CSA at S0, S10, T0, and T10 decreased by 28.3 8.5, 8.0, and 4.4%, respectively. Furthermore, compared to S0, a 10degrees Trendelenburg tilt position with a PEEP of 10 cmH2O significantly increased the CSA in the largest areas by 83.8% and in the smallest areas by 169.4%. CONCLUSIONS: A 10degrees Trendelenburg tilt position combined with a PEEP of 10 cmH2O not only increases the size of the RIJV but also reduces fluctuation by the respiratory cycle.

Guidewire malposition during central venous catheterization despite the use of ultrasound guidance / 대한마취과학회지

No abstract available.

Endotracheal cuff pressure change during gynecologic laparoscopic surgery: effect on the incidence of postoperative airway complications

BACKGROUND: Laparoscopic surgery with reverse Trendelenburg position and carbon dioxide pneumoperitoneum has been known to increase the endotracheal tube (ETT) cuff pressure and the incidence of postoperative sore throat. The purpose of this study was to evaluate the effect of the Trendelenburg position and pneumoperitoneum on the ETT cuff pressure and the effect of adjustment of ETT cuff pressure on the incidence of sore throat during laparoscopic gynecologic surgery. METHODS: One hundred fifty-four female patients undergoing laparoscopic gynecologic surgery were randomly assigned to either control group or adjusted group. In control group, initial cuff pressure was set at 30 cmH2O in the supine position without any adjustment during surgery. Cuff pressure of adjusted group was adjusted to maintain 30 cmH2O throughout the operation. Cuff pressures at intubation (P(imme)), at carbon dioxide insufflation and the Trendelenburg position (P0), and at 10 minute intervals throughout surgery (P10-P60 and P(end)) were checked. Postoperative airway complications including sore throat, hoarseness, dysphagia and cough were compared between the two groups at 2 hours and 24 hours after surgery. RESULTS: In control group, P0 and P10 were significantly higher than P(imme). The cuff pressure decreased with time, thereby; P50 (28.2 +/- 4.3), P60 (27.5 +/- 4.0) and P(end) (25.9 +/- 4.2) were significantly lower than P(imme) (P < 0.05). The incidences and severity of airway complications were not different between two groups. CONCLUSIONS: ETT cuff pressure decreased in laparoscopic gynecologic surgery. Therefore, controlled cuff pressure does not decrease the incidence of postoperative airway complications.

Effect of airway pressure on lumbar epidural pressure during positive pressure ventilation / 대한마취과학회지

BACKGROUND: The purpose of this study was to measure lumbar epidural pressure (EP) during the insertion of a Tuohy needle under general anesthesia and to evaluate the influence of airway pressure on EP. METHODS: Lumbar EP was measured directly through a Tuohy needle during intermittent positive pressure ventilation in fifteen patients. Mean and peak EP were recorded after peak inspiratory pressures (PIP) of 0, 15, and 25 cmH2O. RESULTS: All measured lumbar EPs were positive, with the pressure increasing during inspiration and decreasing during expiration. Median EP was 6.0 mmHg (interquartile range, 4.0-8.0) at 0 cmH2O of PIP, 6.5 mmHg (4.5-8.5) at 15 cmH2O, and 8.5 mmHg (6.0-10.5) at 25 cmH2O, increasing significantly at 15 cm H2O PIP, and further increasing at 25 cmH2O (P < 0.001). CONCLUSIONS: We demonstrate the influence of increased airway pressure on lumbar EP measured directly through a Tuohy needle. Lumbar EPs were positive, and increasing PIP levels significantly increased lumbar EP.

Spreading pattern of contrast medium in the high thoracic epidural space in rabbits: the effect of neck flexion and extension / 대한마취과학회지

BACKGROUND: Neck flexion has been shown to increase cranial spread of contrast agent when a small fixed volume was injected into the high thoracic epidural space. The purpose of this study was to evaluate the effect of volume of contrast medium on its distribution through the high thoracic epidural space during neck extension and flexion using the rabbit model. METHODS: An epidural catheter was introduced into the epidural space of New Zealand white rabbits with the tip located at the T3-4 intervertebral level. The neck was extended or flexed (n = 8 for each group), and the contrast medium was injected with the volume increasing by increments of 0.1 ml/kg, up to 0.3 ml/kg. The spread of contrast medium was determined by counting the number of vertebral body units using lateral epidurographic images. RESULTS: In both groups, the total spread of contrast medium was similar, increasing continuously with injected volume. The cranial spread was greater in the flexion group than the extension group. However, the caudal spread was greater in the extension than in the flexion group. In the extension group, the contrast medium spread caudally about twice as far as it spread cranially, but there was no statistically significant difference between cranial and caudal spread in the flexion group. CONCLUSIONS: In the high thoracic epidural space of rabbit, the contrast medium of varying doses showed limited cranial spread. The flexion of the neck increased cranial spread and extension of the neck increased caudal spread.

A survey on informed consent process for epidural analgesia in labor pain in Korea / 대한마취과학회지

BACKGROUND: There is a legal obligation to explain the procedure and use of epidural analgesia in labor primarily due to the possibility of potential risks and associated complications. The present study details on the survey carried out to ascertain the current status of obtaining informed consent (IC) for explaining the epidural analgesia in labor. METHODS: The present study is based on a survey through a telephone questionnaire that covered all the hospitals in Korea where the anesthesiologists' belonged to and are registered with Korean Society of Anesthesiologists. The questionnaire included questions pertaining to administration of epidural analgesia to a parturient, information on different steps of obtaining an IC, whether patient status was evaluated, when the consent was obtained, and the reasons behind, if the consent had not being given. RESULTS: A total of 1,434 respondents took part in the survey, with a response rate of 97% (1,434/1,467). One hundred seventy-four hospitals had conducted epidural analgesia on the parturient. The overall rate of obtaining IC for epidural analgesia during labor was 85%, of which only 13% was conducted by anesthesiologists. The rate of evaluating preoperative patient status was 74%, of which 45% was conducted by anesthesiologists. Almost all of the consent was obtained prior to the procedure. CONCLUSIONS: The rate of obtaining IC for epidural analgesia in labor is relatively high (85%) in Korea. However, it is necessary to discuss the content of the consent and the procedure followed for obtaining IC during the rapid progress of labor.

Laparoscopic cholecystectomy under epidural anesthesia: a clinical feasibility study / 대한마취과학회지

BACKGROUND: Laparoscopic cholecystectomy (LC) has traditionally been performed under general anesthesia, however, owing in part to the advancement of surgical and anesthetic techniques, many laparoscopic cholecystectomies have been successfully performed under the spinal anesthetic technique. We hoped to determine the feasibility of segmental epidural anesthesia for LC. METHODS: Twelve American Society of Anesthesiologists class I or II patients received an epidural block for LC. The level of epidural block and the satisfaction score of patients and the surgeon were checked to evaluate the efficacy of epidural block for LC. RESULTS: LC was performed successfully under epidural block, with the exception of 1 patient who required a conversion to general anesthesia owing to severe referred pain. There were no special postoperative complications, with the exception of one case of urinary retention. CONCLUSIONS: Epidural anesthesia might be applicable for LC. However, the incidence of intraoperative referred shoulder pain is high, and so careful patient recruitment and management of shoulder pain should be considered.

Spinal Cord Stimulation in Management of Intractable Chronic Pain: A 5-Year Experience / 대한마취과학회지

BACKGROUND: We investigated the effect of spinal cord stimulation on intractable chronic pain retrospectively and report our 5-year experience. METHODS: 49 patients with the medical history of trial spinal cord stimulation have been retrospectively analyzed. They consist of 34 men and 15 women, ranging in age from 22 to 89 years. Causes of intractable chronic pain included postherpetic neuralgia, failed back surgery syndrome, complex regional pain syndrome, chronic back and leg pain, cauda equina syndrome, perineal pain, diabetic polyneuropathy, and spinal cord injury. RESULTS: The pain due to failed back surgery syndrome, complex regional pain syndrome, chronic low back and leg pain, and spinal cord injury was well controlled by using spinal cord stimulation system. After a trial period of stimulation, 20 patients had permanent stimulators implanted. Most of them reported satisfactory pain relief for maximum 60 months and minimum 9 months. Noticeable complications included electrode displacement and hemorrhage. CONCLUSIONS: We may suggest that spinal cord stimulation is an effective and safe therapy for chronic intractable pain.

Influence of Sex on Gap Junctional Distribution and Vascular Dilatation in the Rat Mesenteric Arteries / 대한마취과학회지

BACKGROUND: Besides prostacyclin and nitric oxide, the endothelium-derived hyperpolarizing factor (EDHF), which is another distinct endothelium-dependent vasodilator, is involved in relaxing the vascular smooth muscle cells. The myoendothelial gap junction (MEGJ) and female sex hormone play important roles in the EDHF-mediated responses. Therefore, this study was designed to determine the influence of gender on the gap junctional distribution and endothelium-dependent vasodilation in the rat mesenteric arteries. METHODS: Male and female Sprague-Dawley rat were euthanized and the tertiary branch of the mesenteric artery was harvested. Immunohistochemistry and confocal microscopic examination of the arterial wall were performed after treating them with specific antibodies to delineate the distribution of connexin 43, a gap junctional protein. Segments of the mesenteric artery, 5 mm in length, were connected to two tungsten wires under isometric tension. The arterial segments were suspended in a modified Krebs solution (37 degrees C) aerated with 95% O2 and 5% CO2 in a vertical water-jacketed temperature-controlled tissue bath. The standard dose-response curve for acetylcholine (10(-9)-10(-5) M) was drawn in the presence of the NO synthase inhibitor, N(omega)-nitro-L-arginine methyl ester (L-NAME; 10(-4) M) plus indomethacin (10(-5) M) and/or gap junctional inhibitor, carbenoxolone (10(-4) M). RESULTS: In the female rat mesenteric artery, the gap junctional plagues were more prevalent particularly along the endothelial layer. The inhibition of the relaxation response to acetylcholine was depressed in the presence of L-NAME plus indomethacin and augmented in the presence of carbenoxolone when compared with the male rat mesenteric arteries (P < 0.05). CONCLUSIONS: Gender differences in the rat mensenteric arteries have an effect on the expression of connexin 43 and the release of EDHF through MEGJ may play a key role in controlling the female arterial tone.

The Effects of Fluoroscopy Guided Interventional Microadhesiolysis and Nerve Stimulation (FIMS) in Lumbar Spinal Stenosis / 대한마취과학회지

BACKGROUND: Intramuscular stimulation (IMS) shows good results in the treatment of chronic pain patients who did not respond to other treatments such as oral analgesics, trigger point injection, nerve block and epidural steroid injection. Fluoroscopy Guided Interventional Musculoskeletal Adhesiolysis and Nerve Stimulation (FIMS) was used to stimulate the correct anatomic point using fluoroscopy. We present the results of FIMS in spinal stenosis. METHODS: 106 patients with ages ranging from 39 to 87 years were enrolled in this study. All the patients were postoperatively evaluated for the clinical outcomes such as numeric rating scale (NRS) for pain at 1 month, reduction in the analgesics dose, and the overall satisfaction rate. The patients considered to have received clinical benefit from FIMS were evaluated for the recurrence of pain by either a follow-up or telephone interview. RESULTS: FIMS reduced the level of pain compared with the pretreatment (P < 0.001). In addition, 61% of patients reported that they were satisfied. There were no procedural related serious complications. Three months after FIMS, there was continuing pain relief in 50% of the patients treated successfully. CONCLUSIONS: FIMS is a safe and effective treatment modality for spinal stenosis.

Clinical Outcomes of Percutaneous Lumbar Discectomy Using Dekompressor(R) / 대한통증학회지

BACKGROUND: Discogenic leg pain is a major cause of health problems, often due to herniation of the intervertebral disc, and has traditionally been treated conservatively or with an open surgical discectomy. Conventional open surgery has many complications, such as nerve root injury, discitis and a relatively high mortality rate; failure of conservative treatments is also common. Recently, the Dekompressor(R) Percutaneous Lumbar Discectomy probe was developed. Herein, we present the early results for a percutaneous lumbar discectomy in herniated lumbar disc disease. METHODS: Eleven patients, including 8 men and 3 women, with ages ranging from 22 to 78 years, were enrolled in this study. Those patients with a previous history of back surgery were not excluded from the study. All patients were postoperatively evaluated for their clinical outcomes, such as visual analogue scale (VAS) for pain after 1 and 3 months, reduction in analgesics, functional improvement and overall satisfaction. RESULTS: The percutaneous lumbar discectomy was completed in 11 patients (17 levels), with average reductions in pre-VAS of 61.3 and 60.2% at 1 and 3 months, respectively. Also, 72.7% of patients reported functional improvement, with 81.1% expressing overall satisfaction. There were no procedural related complications. CONCLUSIONS: We concluded that a percutaneous lumbar discectomy is a safe and effective treatment modality for a herniated lumbar disc.

Percutaneous Cervical Discectomy Using Dekompressor(R): A case report / 대한통증학회지

Cervical radicular pain has been recognized as a common cause of neck, shoulder and arm pain. The initial recommended therapy is based on the medical treatment by anti-inflammatory, analgesic agents, rest, traction and physical therapy. In the case of failure with these therapies, the classical alternative is a surgical discectomy, but this is associated with numerous risks inherent to invasive procedures. As a result, a number of percutaneous intradiscal therapies have developed over the last 3 decades, which have specifically focused on the pathology of the disc. However, these treatments have considerable limitations and success rates, and none allow for the extraction of a quantifiable amount of nucleus pulposus via a 17 gauge introducer using fluoroscopic guidance alone. Herein, we describe our experience using a Dekompressor(R) on a 52 year-old female patient with a cervical disc herniation. Percutaneous decompression in the treatment of cervical disc herniation was successfully performed, with a good outcome.

Biplane Fluoroscopy Guided Maxillary Nerve Block and Pulsed Radiofrequency Lesioning of the Mandibular Nerve: A report of two cases / 대한통증학회지

Biplane fluoroscopy is usually used in angiography. Biplane fluoroscopy gives a biplane image with high resolution during the performance of operations. Trigeminal nerve blocks are effective treatment modalities for trigeminal neuralgia, and maxillary nerve block is the most dangerous procedure among them. The anatomic structures can change after head and neck surgery, so the trigeminal nerve block procedures cannot be done so easily. We used biplane fluoroscopy in these difficult cases. Our first case was a 60-year-old man who had undergone maxillary nerve block. The second case was of a 64-year-old man who had pulsed radiofrequency lesioning of mandibular nerve performed after head and neck surgery. With biplane fluoroscopy, we got good results without any complications.

Effects of Intravascular Volume Therapy with a Hydroxyethyl Starch (HES 130/0.4) on Blood Coagulation in Children Undergoing Cardiac Surgery / 대한마취과학회지

BACKGROUND: Hydroxyethyl starch (HES) is used for intravascular volume expansion in cardiac surgery. Studies have produced conflicting data on the effects of intraoperative HES administration on postoperative bleeding. We evaluated the effects of intraoperative HES infusion, shortly after the termination of cardiopulmonary bypass (CPB), on hemostasis following a cardiac operation. METHODS: According to a prospective, random sequence, 30 children undergoing cardiac surgery received one of the following; fresh frozen plasma (FFP)(n = 10), HES 130/0.4 (n = 10), or HES 200/0.5 (n = 10) shortly after CPB termination. Standard coagulation variables were measured using arterial blood samples RESULTS: While the use of allogenic blood/ blood products and aPTT did not differ significantly among the groups, blood loss during the 24 hours following surgery increased significantly in the HES 200 group and PT after fluid infusion increased in both HES groups. CONCLUSIONS: Our study shows that the administration of moderate dose of HES (130/0.4) in children undergoing cardiac surgery did not cause more bleeding than FFP administration. Thus, this HES (130/0.4) solution appears to be a safe alternative plasma substitute for intravascular volume replacement in this patient population.

An Association Between Coronary Artery Calcification Score, C-Reactive Protein, and Antibodies to Infectious Disease in Patients on Maintenance Hemodialysis / 대한신장학회잡지

BACKGROUND: Cardiovascular mortality is high in patients with end-stage renal disease (ESRD). Although the factors contributing to ESRD-related vascular disease are incompletely understood, recent studies suggest that inflammatory reaction or chronic infectious disease may play an important role as new risk factors. The aim of present study was to measure coronary artery calcification score (CACs) and to investigate the association with various markers of systemic inflammatory reaction. METHODS: We conducted a cross-sectional study in 33 patients (M: F=23: 10, age=57+/-2 years) on maintenance hemodialysis. Multirow spiral CT (MSCT) was performed in all patients to measure CACs utilizing area and volume calculations. We measured high sensitivity C-reactive protein (hs- CRP) and interleukin-6 (IL-6) as indicators of inflammatory reaction, and measured IgA and IgG antibodies to C. pneumoniae, and IgG antibodies to H. pylori, cytomegalo virus, and herpes simplex. RESULTS: Median CACs equaled 379 (range, 0- 3, 662) by area and 338 (range, 0-2, 968) by volume. CACs more than 100 was present in 24 (73%) patients. Log (hs-CRP) was positively correlated with log (CACs) (area: r=0.37, p<0.05, volume: r=0.39, p< 0.05), but log (IL-6) was not. There was no significant relationship between CACs and antibody titers to C. pneumoniae, H. pylori, cytomegalovirus, and herpes simplex. Age was positively correlated with log (CACs) (area: r=0.39, p<0.05, volume: r=0.39, p< 0.05), but the presence of diabetes, smoking history, the duration of dialysis, body mass index, blood pressure, and serum cholesterol, albumin, PTH, calcium, and phosphorous levels were not. CONCIUSION: Coronary artery calcification was common in ESRD patients on hemodialysis, and associated with increased hs-CRP, an indicator of the presence of inflammatory reaction. There was no significant relationship between antibodies to chronic infections such as C. pneumoniae, but large-scale longitudinal studies are needed to evaluate fully that.

An Association Between Coronary Artery Calcification Score, C-Reactive Protein, and Antibodies to Infectious Disease in Patients on Maintenance Hemodialysis / 대한신장학회잡지

BACKGROUND: Cardiovascular mortality is high in patients with end-stage renal disease (ESRD). Although the factors contributing to ESRD-related vascular disease are incompletely understood, recent studies suggest that inflammatory reaction or chronic infectious disease may play an important role as new risk factors. The aim of present study was to measure coronary artery calcification score (CACs) and to investigate the association with various markers of systemic inflammatory reaction. METHODS: We conducted a cross-sectional study in 33 patients (M: F=23: 10, age=57+/-2 years) on maintenance hemodialysis. Multirow spiral CT (MSCT) was performed in all patients to measure CACs utilizing area and volume calculations. We measured high sensitivity C-reactive protein (hs- CRP) and interleukin-6 (IL-6) as indicators of inflammatory reaction, and measured IgA and IgG antibodies to C. pneumoniae, and IgG antibodies to H. pylori, cytomegalo virus, and herpes simplex. RESULTS: Median CACs equaled 379 (range, 0- 3, 662) by area and 338 (range, 0-2, 968) by volume. CACs more than 100 was present in 24 (73%) patients. Log (hs-CRP) was positively correlated with log (CACs) (area: r=0.37, p<0.05, volume: r=0.39, p< 0.05), but log (IL-6) was not. There was no significant relationship between CACs and antibody titers to C. pneumoniae, H. pylori, cytomegalovirus, and herpes simplex. Age was positively correlated with log (CACs) (area: r=0.39, p<0.05, volume: r=0.39, p< 0.05), but the presence of diabetes, smoking history, the duration of dialysis, body mass index, blood pressure, and serum cholesterol, albumin, PTH, calcium, and phosphorous levels were not. CONCIUSION: Coronary artery calcification was common in ESRD patients on hemodialysis, and associated with increased hs-CRP, an indicator of the presence of inflammatory reaction. There was no significant relationship between antibodies to chronic infections such as C. pneumoniae, but large-scale longitudinal studies are needed to evaluate fully that.