The Clinical Significance of Weight Change in Mechanical Ventilated, Critically Ill Patients of ICU / 대한구급학회지

BACKGROUND: Critically ill patients may show significant weight change in their course of disease during ICU stay. However, what weight changes occur and their effects on patient outcome have not yet been reported to our knowledge. Therefore, we evaluated weight change in critically ill patients in the medical ICU and the effect this may have on clinical outcome. METHODS: We measured body weight in patients admitted to the medical ICU daily and evaluated their clinical characteristics and outcome. RESULTS: Thirty-eight patients (M:F = 30:8, mean age = 65.7 +/- 12.5) were enrolled. Thirteen patients (34.2%) showed weight gain and the mean change was 12.8 +/- 4.2%. In contrast, 25 patients (65.8%) showed weight loss and the mean change was 6.3 +/- 6.9%. Patients who showed weight change over 5% or 10% were 26 (68.4%), and 12 (31.6%), respectively, and their mortality rates were 61.5% and 75%, respectively, showing no statistical significance (p > 0.05). However, when the degree of weight change was stratified with 10%, it was associated with death (p = 0.002). Factors like ICU stay, day of mechanical ventilation, initial APACHE II and SOFA score, body mass index (BMI) and serum albumin were not associated with more than 5% change of weight. BMI at admission was only associated with > 10% change of weight (p < 0.05). CONCLUSIONS: The majority of critically ill patients showed a significant weight change during their ICU stay and these patients may have a tendency to have worse clinical outcome.

Effect of Intrathecal COX Inhibitors on Inflammatory Pain and c-Fos Expression in Central Nervous System Induced by Formalin Injection in Rat / 대한마취과학회지

BACKGROUND: Prostaglandins (PGs) play important roles in the transmission of nociceptive information in the spinal cord. PGs are produced by cyclooxygenase (COX). Two forms of COX have been identified: COX-1 and COX-2. c-Fos is a marker of neuronal activity related to the stimulation of primary sensory neuron. We investigated the effect of intrathecal non-selective COX inhibitor, selective COX-1 or COX-2 inhibitors on the inflammatory pain and c-Fos expression in the brain. METHODS: A PE (polyethylene) intrathecal catheter was installed in male Sprague-Dawley rats (250-300 g). Control, nonselective COX inhibitor, COX-1 inhibitor, and COX-2 inhibitor groups (n = 8, each) received intrathecal dimethylsulfoxide (DMSO) solution, ketorolac 50microgram, SC-560 50microgram, or celecoxib 50microgram respectively 7 min before formalin injection. For formalin test, rats received 50microliter of 5% formalin in the right hindpaw subcutaneously. Pain-related behavior was quantified by counting the incidence of flinching for 60 minutes. c-Fos expression in the thalamus, hypothalamus, and amygdala was examined by immunohistochemistry. RESULTS: Nonselective COX inhibitor and COX-2 inhibitor groups showed less frequent phase 2 flinching than the control (P < 0.05). But there was no significant differences in the expression of FLI in the thalamus, hypothalamus, and amygdala between control and experimental groups. And the expression of FLI was not correlated with flinching behavior. CONCLUSIONS: These result represented that COX-2 would play important roles in the transmission of pain induced by formalin test and that FLI in thalamus, hypothalamus, and amygdala could not be a good parameter for evaluating central sensitization.

Effect of Fresh Gas Flow on the Work of Breathing of Closed Circuit Anesthesia Using Semiclosed Circuit System / 대한마취과학회지

BACKGOUND: The effect of anesthetic techniques, such as closed circuit anesthesia (CCA) using semiclosed circuit system and semiclosed circuit anesthesia (SCCA), on the work of breathing has not been studied yet in detail. This study was purposed to compare the work of breathing according to anesthetic technique (CCA, SCCA). METHODS: Thirty patients were assigned to receive either SCCA group or CCA group (n = 15). Anesthesia was induced with propofol 2 mg/kg with 2% lidocaine 1 ml. Two percents isoflurane with O2 and N2O 2 L/min were given for 10 min to patients initially to wash in functional residual capacity and the breathing circuits. In SCCA group, anesthesia was maintained with 2% isoflurane in O2 2 L/min and N2O 2 L/min throughout the surgery. In CCA group, O2 was reduced to 200 ml/min and N2O to 100 ml/min with isoflurane vaporizer setting adjusted to 4% for anesthesia maintenance. When the operation was ended, the vaporizer setting of isoflurane deceased to zero and then O2 was increased to 4 L/min for the arousal of the patient. We measured the inspiratory/expiratory concentration of isoflurane, end-tidal CO2, the hemodynamic parameters, the change of airway pressure, the work of breathing, and compliance at anesthetic induction and emergence in both groups. RESULTS: There were no significant differences in the inspiratory/expiratory concentrations of isoflurane, the hemodynamic parameters, end-tidal CO2, airway pressure, the work of breathing and compliance between the groups. CONCLUSIONS: CCA using semiclosed circuit system does not increase the work of breathing compared to SCCA.

Sudden Cardiac Arrest Following Cervical Facet Joint Injection: A case report / 대한마취과학회지

The common disorder called facet syndrome exhibits back pain, with or without referred or radiating pain due to facet joint arthropathy. Facet joint injection using local anesthetics is a reliable method for the diagnosis and treatment for facet syndrome. Because the complications secondary to facet block have usually been temporary and infrequent, facet block has been known as a simple and safe procedure. But spinal anesthesia is a serious complication of facet block and can lead to a life threatening conditions. The authors report a patient who developed un-explainable cardiac arrest following facet joint injection. A 64 year-old woman with 4-year history of cervical facet syndrome was admitted for the fourth facet block. Cardiac arrest followed with unconsciousness and apnea occurred 4 minutes after cervical facet joint injection with 2 ml of 2% lidocaine. The patient was immediately resuscitated and recovered without any sequelae. Sudden cardiac arrest can be unexpectedly developed during facet block, and we recommend close monitoring during cervical facet joint block.

Airway Management of Patients with Upper Airway Obstruction and Respiratory Depression during Monitored Anesthesia Care: Use of an Amored Endotracheal Tube: A case report / 대한마취과학회지

These case reports describe the authors' experiences with ten cases in which an amored endotracheal tube (ETT) was partially inserted through a nostril into the nasopharynx to relieve the upper airway obstruction and respiratory depression during monitored anesthesia care. The amored ETT was connected to the semiclosed circuit system of an anesthesia machine equipped with an end-tidal CO2 monitor; assisted positive ventilation was applied if needed. This manuever enabled airway obstruction relief, the oxygen saturation to be increased immediately, and the respiratory pattern to be monitored continuously, but it did not interfere with the surgical procedure. Therefore, we introduce this universally available amored ETT for airway maintenance without interfering with surgical procedure such as facial chemical peeling.

Unilateral Pulmonary Edema in the Lateral Decubitus Position: A Case Report / 대한마취과학회지

Characteristically pulmonary edema is bilateral, unless there is an underlying defect or abnormality in the cardiopulmonary system. Unilateral pulmonary edema following general anesthesia is a rare complication in a healthy patient. The etiology of unilateral pulmonary edema include, the re-expansion of a collapsed lung, unilateral pulmonary veno-occulusive disease, pulmonary contusion, compression of pulmonary vasculatures, cerebral autonomic dysfunction, bronchial obstruction and severe ischemic left ventricular dysfunction. We describe a 52-yr-old patient who developed acute unilateral pulmonary edema after a total hip replacement athroplasty in the lateral decubitus position. The patient recovered following 16 hours of intensive treatment involving fluid restriction, diuretics, sedation, and continuous positive airway pressure ventilation.

Otalgia Caused by a Trigger Point in the Sternocleidomastoid Muscle: A case report / 대한마취과학회지

Myofascial pain syndrome is defined as the sensory, motor and autonomic symptoms caused by the myofascial trigger points. The sternocleidomastoid muscle is a complex muscle that frequently contains multiple trigger points. These trigger points cause symptoms that are easily misdiagnosed as other conditions. Earache of unexplained origin is likely to be caused by trigger points in the clavicular division of the sternocleidomastiod muscle. The authors report a case of earache caused by a trigger point in the sternocleidomastoid muscle. A 34 year-old woman had earache without any history of trauma or infection. The patient did not have any abnormal finding by otolaryngologic testing, except for an earache, which had not subsided. On physical examination, trigger points in the clavicular division of the sternocleidomastiod muscle were found, and the earache was successfully treated by trigger point injections.

Does Level of Sensory Block by Epidural Anesthesia Affect the Degree of Sedation? / 대한마취과학회지

BACKGROUND:Epidural anesthesia has been shown to have a direct sedative effect, and to markedly reduce the hypnotic requirement of intravenous anesthetics. The purpose of this study was to investigate whether the level of sensory block by epidural anesthesia is related with the degree of sedation, and to the hypnotic requirement of propofol. In addition, we tested whether bispectral index (BIS) monitoring can quantify the sedative effects of epidural anesthesia. METHODS: Thirty two patients scheduled for elective upper abdominal or lower extremity surgery were allocated into two groups. 2% lidocaine 15 ml was administered through an epidural catheter at the T9 T10 level (group T, n = 16) or at the L3-L4 level (group L, n = 16). Observer's assessment of alertness/sedation (OAA/S) and BIS were evaluated 20 min after the epidural injection. Hypnotic doses of propofol were then determined by evaluating the loss of open eyes in response to a verbal command as an end point while propofol was administered by target controlled infusion (target effect concentration 5microgram/ml, induction time 3 min). At the time of induction of hypnosis, the target effect concentration and BIS were recorded. RESULTS: The average level of sensory block was up to T3 in group T, and up to T11 in group L. Compared with the group L, more decreases were noticed in group T in terms of the hypnotic dose of propofol (1.13+/-0.31 mg/kg vs. 1.67+/-0.36 mg/kg; P = 0.03). A decrease in the OAA/S scale from 5 to 4 was more frequently noticed in group T than in group L (93.7% vs. 12.5%, P < 0.05). BIS recorded at the time of induction of hypnosis was higher in group T than in group L (94.8+/-2.8 vs. 82.6+/-2.2; P < 0.001). CONCLUSIONS: A higher sensory block observed in group T than in group L induced a more profound sedative effect and hypnotic induction with a lesser dose of propofol. These results support the condition that the level of sensory block by epidural anesthesia affects the degree of sedation. Moreover, BIS monitoring could not quantify the sedative effect induced by epidural anesthesia.

Changes of Arterial Oxygen and Carbon Dioxide Tension according to Apnea Time during Anesthesia / 대한마취과학회지

This study was attempted to observe the rate of fall of arterial oxygen tension and the rate of rise of artetrial carbon dioxide tension after denitrogenation with 100%(Group I, n=10) or 50% oxygen(Group II, n=15) in 25 healthy ASA class I patients scheduled for ear, oromaxillary, head and orthopedic surgery that do not affect respiration or pulmonary function. After 30 minutes of denitrogenation under supine position, apnea was carried out by dis- connecting the endotracheal tube and rebreathing circuit until arterial oxygen saturation decreased to 90-95% by pulse oximetry which was placed at index finger. We calculated the mean rate of decrease of arterial oxygen tension (PaO2(tn)-PaO2(tn+1)) and the mean rate of increase of arterial carbon dioxide tension (PaCO2(tn+1)-PaCO2(tn)) minute by minute by arterial blood gas analysis. The results are as follows. 1) The mean rate of decrease of arterial oxygen tension after apnea was 40.96+/-11.02 in Group I and 43.22+/-5.49 mmHg/min. in Group II 2) The rate of increase of arterial carbon dioxide tension during the first one minute of apnea was 5.94+/-0.85 in Group I and 5.56+0.64 mmHg in Group II 3) The mean rate of increase of arterial carbon dioxide tension after first one minute was 2.46+/-0.78 in Group I and 2.47+/-0.71 mmHg/min. in Group II With the above results, we concluded that healthy human subject who was denitrogenated with 100% oxygen about 30 minutes can withstand apnea as far as 7 minutes, and those who denitrogenated with 50% oxygen can withstand apnea as far as 3 minutes without hypoxic insult.

Does the Temperature of 0.5% Plain bupivacaine Affect the Sensory Level in Spinal Anesthesia? / 대한마취과학회지

The level of sensory blockade in spinal anesthesia is determined by the distribution of local anesthetics within cerebrospinal fluid (CSF) which is affected by the density of local anesthetics. Temperature is one of the factors which can influence the density of local anesthetics. The level of sensory blockade in spinal anesthesia may be altered by the density change of local anesthetics and by the time needed for thermal equilibration in CSF, depending on the storage temperature of local anesthetics. A study was conducted at Inchon Severance hospital on 20 elective surgery patients under spinal anesthesia, to compare the clinical differences between two groups stored at different temperatures. Group I was used 0.5% plain bupivacaine 3 ml (15 mg) stored in a refrigerator for longer than 24 hours and group II was used that stored in operating room temperature. The results were as follows : The level of sensory blockade in group II was significantly higher than that of group I, 3 minutes after spinal anesthesia by segmental level of sensory loss to pinprick test. The degree of motor blockade was significantly greater by Bromage scale in group II than in group I at 2 minutes after spinal anesthesia, but no significant difference was observed after 5 minutes. When 15 minutes elapsed, the complete motor blockade of lower extremities was observed in both groups. The onset of sensory block was significantly faster in group II(3.1+/-0.2 min) than in group I (5.2+/-0.5 min). The onset of maximum sensory block was also significantly faster in group II(9.5+/-0.5 min) than in group I (14.0+/-1.5 min). The maximum sensory block level was significantly higher in group II(T6.7+/-0.3 dermatome) than in group I (8.2+/-0.3 dermatome). However, the regression time was not significantly different between group I (122.0+/-3.8 min) and group II (117.2+/-6.0 min). The above results showed that when 0.5% plain bupivacaine stored in room temperature was used in spinal anesthesia, gave higher level of sensory blockade and faster onset than that kept in a refrigerator, which may due to the time difference needed for thermal equilibration in CSF.

The Effect of Inhalation Anesthetics on Platelet Function / 대한마취과학회지

There is some controversy regarding the effect of general inhalation anesthesia on platelet function. In 20 patients undergoing long operations over 3 hours, and anesthetized with either nitrous oxide-oxygen and enflurane (A group) or nitrous oxide-oxygen and halothane (B group), we could not find any clinically significant impairment of coagulation. Platelet functions were consecutively evaluated on the samples collected at preinduction, during anesthesia (3 hours) and at postoperation (24 hours) using an aggregometer and several aggregating agents including ADP, epinephrine, collagen and ristocetin. There were no statistically significant changes between the maximum aggregation rate of preinduction and that duirng anesthesia in either group.