Alcohol neurolysis of genicular nerve for chronic knee pain / 대한통증학회지

Radiofrequency neurolysis (RFN) of the genicular nerves has recently become accepted as an effective technique to alleviate knee pain particularly in patients with knee osteoarthritis (OA) or postoperative pain. However, genicular nerve RFN can produce high procedure and equipment costs, longer procedural times, procedure-related pain, and failure rate of over 25%. We are presenting two cases of alcohol neurolysis of the genicular nerve using fluoroscopy and ultrasonography in patients with knee OA or persistent postsurgical pain of the knee. Alcohol neurolysis of the genicular nerve with dual imaging modality can be a cheap, safe and effective method in patients with chronic knee pain.

Anesthetic experience of frontotemporal dementia patient with severe autonomic dysfunction: a case report / 대한마취과학회지

Anesthetic experience in frontotemporal dementia (FTD) with severe hypotension associated autonomic dysfunction has not yet been reported. Here in case, we report on the case of treatment with vasopressin to refractory hypotension in FTD patient. A 54-year-old male presented with a ten-year history of FTD with frequent syncope. The patient was scheduled to undergo subtotal gastrectomy for resection of stomach cancer. During the operation, sudden hypotension occurred and it was refractory to fluid and 1 unit of blood resuscitation and did not respond to catecholamine. Transesophageal echocardiography showed normal heart with adequate volume state. After intravenous administration of arginine vasopressin, the patient's vital signs returned to baseline values. Arginine vasopressin might be considered as a valuable alternative for treatment of severe refractory hypotension in autonomic dysfunction patients with FTD.

Cloudy urine developed during total intravenous anesthesia with 2% propofol in the patient taking hydroxyurea: A case report

We report a case that a 68-year-old man taking hydroxyurea for essential thrombocythemia produced milky urine during propofol infusion. Under microscopic analysis, the cloudy urine sample was revealed to comprise uric acid crystals. Postoperatively, kidney function such as urine output and blood urea nitrogen to creatinine ratio showed no abnormality. We suggest that the cloudy urine may be due to the increased excretion of uric acid after administration of propofol. Although this rare case of cloudy milky urine is resolved on its own, we need to consider the possibility of such urine color changes. It is particularly important to understand that medication, preoperative serum uric acid level, urine pH, and the hypothermal operating room can change the color of urine through the presence of uric acid crystals.

Synergism between rocuronium and cisatracurium: comparison of the Minto and Greco interaction models / 대한마취과학회지

BACKGROUND: This study was conducted to investigate the pharmacodynamic interaction between rocuronium and cisatracurium using the response surface model, which is not subject to the limitations of traditional isobolographic analysis. METHODS: One hundred and twenty patients were randomly allocated to receive one of the fifteen predefined combinations of rocuronium and cisatracurium. To study single drugs, cisatracurium 0.2, 0.15, or 0.1 mg/kg or rocuronium 0.8, 0.6 or 0.4 mg/kg doses were administered alone. To study the pharmacodynamic interaction, drugs were applied in three types of combination ratio, i.e., half dose of each drug alone, 75% of each single dose of rocuronium and 25% of each single dose of cisatracurium, and vice versa. Train-of-four (TOF) ratio and T1% (first twitch of the TOF presented as percentage compared to the initial T1) were used as pharmacodynamic endpoints, and the Greco and Minto models were used as surface interaction models. RESULTS: The interaction term α of the Greco model for TOF ratio and T1% measurements showed synergism with values of 0.977 and 1.12, respectively. Application of the Minto model resulted in U₅₀ (θ) values (normalized unit of concentration that produces 50% of the maximal effect in the 0 <θ< 1 region) less than 1 for both TOF ratio and T1% measurements, indicating that rocuronium and cisatracurium exhibit synergism. CONCLUSIONS: Response surface modeling of the interaction between rocuronium and cisatracurium, based on considerations of their effects on muscle relaxation as measured by TOF ratio and T1%, indicated that the two drugs show considerable synergism.

Nasogastric tube insertion using airway tube exchanger in anesthetized and intubated patients / 대한마취과학회지

BACKGROUND: A nasogastric tube (NGT) is commonly inserted into patients undergoing abdominal surgery to decompress the stomach during or after surgery. However, for anatomic reasons, the insertion of NGTs into anesthetized and intubated patients may be challenging. We hypothesized that the use of a tube exchanger for NGT insertion could increase the success rate and reduce complications. METHODS: One hundred adult patients, aged 20–70 years, who were scheduled for gastrointestinal surgeries with general anesthesia and NGT insertion were enrolled in our study. The patients were randomly allocated to the tube-exchanger group or the control group. The number of attempts, the time required for successful NGT insertion, and the complications were noted for each patient. RESULTS: In the tube-exchanger group, the success rate of NGT insertion on the first attempt was 92%, which is significantly higher than 68%, the rate in the control group (P = 0.007). The time required for successful NGT insertion in the tube-exchanger group was 18.5 ± 8.2 seconds, which is significantly shorter than the control group, 75.1 ± 9.8 seconds (P < 0.001). Complications such as laryngeal bleeding and the kinking and knotting of the NGT occurred less often in the tube-exchanger group. CONCLUSIONS: There were many advantages in using a tube-exchanger as a guide to inserting NGTs in anesthetized and intubated patients. Compared to the conventional technique, the use of a tube-exchanger resulted in a higher the success rate of insertion on the first attempt, a shorter procedure time, and fewer complications.

Pretreatmet with 5% lidocaine patch reduces cannula-induced and propofol-induced pain: a randomized, double-blind, placebo-controlled study / 대한마취과학회지

BACKGROUND: The purpose of this study was to determine the efficacy of 5% lidocaine patch in reducing propofol-induced pain and cannula-induced pain. METHODS: In a randomized, double-blind study, 126 patients were divided into one of three groups: pretreatment with a 5% lidocaine patch (Lidotop®) and premixed 2 ml of normal saline with 1.5 mg/kg of 1% propofol (Group A); pretreatment with a placebo patch and premixed 2 ml of normal saline with 1.5 mg/kg of 1% propofol (Group B); or pretreatment with a placebo patch and premixed 2 ml of 2% lidocaine (40 mg) with 1.5 mg/kg of 1% propofol (Group C) for induction of anesthesia. Pain severity was evaluated on a four-point verbal rating scale during intravenous cannulation, propofol injection, and 24 h after the operation (recall). RESULTS: Eighteen patients (47.4%) in Group A complained of cannula-induced pain compared with 35 (94.6%) in Group B and 36 (94.7%) in Group C (P < 0.001). Group A patients showed significantly lower incidence of propofol-induced pain and recall of propofol-induced pain compared with Group B (P < 0.001 and P = 0.01), whereas there was no difference compared with Group C. CONCLUSIONS: Preoperative transdermal administration of 5% lidocaine patch is an effective and simple method in reducing propofol-induced pain as well as cannula-induced pain.

Bronchoscopic concerns in Proteus syndrome: a case report / 대한마취과학회지

Proteus syndrome (PS) is a rare congenital hamartomatous disorder with multisystem involvement. PS shows highly clinical variability due to overgrowth of the affected areas, and several features can make anesthetic management challenging. Little is known about the airway problem associated with anesthesia in PS patients. An 11-year-old girl with PS was scheduled for ear surgery under general anesthesia. She had features complicating intubation including facial asymmetry and disproportion, abnormal teeth, limitation of neck movement due to torticollis, and thoracolumbar scoliosis. This study reports on a case of deformed airway of a PS patient under fiberoptic bronchoscopy.

Continuous Ilioinguinal-iliohypogastric Nerve Block for Groin Pain in a Breast-feeding Patient after Cesarean Delivery

Ilioinguinal and iliohypogastric (II/IH) nerve injury is one of the most common nerve injuries following pelvic surgery, especially with the Pfannenstiel incision. We present a case of intractable groin pain, successfully treated with a continuous II/IH nerve block. A 33-year-old woman, following emergency cesarean section due to cephalopelvic disproportion, presented numbness in left inguinal area and severe pain on the labia on the second postoperative day. The pain was burning, lancinating, and exacerbated by standing or movement. However, she didn't want to take additional medicine because of breast-feeding. A diagnostic II/IH nerve block produced a substantial decrease in pain. She underwent a continuous II/IH nerve block with a complete resolution of pain within 3 days. A continuous II/IH nerve block might be a goodoption for II/IH neuropathy with intractable groin pain in breast-feeding mothers without adverse drug reactions in their infants.

Trajectory avoiding kidney and ureter injury for percutaneous lumbar sympathetic block / 대한마취과학회지

No abstract available.

Postoperative pain and side effects after thyroidectomy: randomized double blind study comparing nefopam and ketorolac

BACKGROUND: Nefopam is a centrally acting, non-opioid analgesic drug used to reduce opioid consumption and so reduce the prevalence of postoperative nausea and vomiting (PONV). This study compared and assessed the effects of nefopam and ketorolac on postoperative pain and PONV after thyroid surgery. METHODS: Two hundred patients underwent total thyroidectomy with central compartment neck dissection in our hospital during a 5 month enrollment period. Group N and Group T was administered nefopam 20 mg and ketorolac 30 mg, respectively, during the last 30 minutes of surgery. Pain was measured using a 10-point numerical rating scale. Pain scores and PONV were assessed 30 min, 1, 6, and 24 h postoperatively. RESULTS: Pain scores and episodes of vomiting and shivering did not differ significantly between the two groups. Group N patients experienced fewer episodes of nausea at 30 min, 1 h and 6 h after the operation. CONCLUSIONS: Nefopam and ketorolac are similarly effective in reducing postoperative pain after thyroid surgery. Postoperative nausea was less in Group N patients within 6 h postoperatively, especially 1 h. Nefopam is favored for pain management after thyroidectomy.

Hypertensive Crisis during Removal of Retroperitoneal Mass in a Patient with Undiagnosed Paraganglioma - A Case Report - / 대한구급학회지

Paragangliomas have been reported on multiple locations. A diagnosis of a catecholamine-secreting tumor was considered only after induction of anesthesia, when BP (blood pressure) increased. A 61-year-old male patient was referred for removal of a retroperitoneal mass suspected hemangiopericytoma. He was on medications for hypertension. There was a surge of ABP (arterial blood pressure) to 186/117 mmHg when the tumor was manipulated at the beginning of the surgery, and this was treated by bolus of diltiazem. After resection of the tumor, ABP dropped to 57/36 mmHg. In order to improve the patient's hemodynamic parameters, crystalloid fluid was given, and ephedrine was administered intravenously. Persistent hypotension was treated with titrated vasopressors (epinephrine and norepinephrine). When paraganglioma is suspected due to a sudden hypertensive crisis during surgery, the surgeon must decide whether to proceed with the surgical procedure or to stop and restart the surgery after proper management of the crisis.

Optimal dose of dexmedetomidine for sedation during spinal anesthesia / 대한마취과학회지

BACKGROUND: Sedation in spinal anesthesia can reduce patient's anxiety and discomfort. Dexmedetomidine has a sedative, hypnotic, analgesic, and minimal respiratory depression effect. However, use of the dexmedetomidine is associated with prolonged recovery. This study was designed to investigate the optimal dose of intravenous dexmedetomidine for proper sedation with minimal recovery time in spinal anesthesia. METHODS: One hundred twenty eight patients, aged 20-70 years (58.8 +/- 0.7), were recruited. After performing the spinal anesthesia with hyperbaric bupivacaine (13 mg), a loading dose of dexmedetomidine (1 microg/kg) was administered for 10 min, followed by the maintenance infusion of the following: Group A (n = 33; normal saline), Group B (n = 35; dexmedetomidine 0.2 microg/kg/hr), and Group C (n = 39; dexmedetomidine 0.4 microg/kg/hr). Heart rate, blood pressure, and the bispectral index score (BIS) were recorded during the operation. In the recovery room, modified aldrete score (MAS) was measured. RESULTS: There were no significant differences in mean blood pressure and heart rate among the three groups. BIS was not significantly different among the three groups from baseline to 60 min after the infusion of dexmedetomidine. BIS were significantly increased in Group A after 70 and 80 min, and Group A and B after 90, 100, 110 min of dexmedetomidine infusion (P < 0.05). MAS was higher in Group A as compared to Group B and C, within 30 min after admission in the recovery room (P < 0.05). CONCLUSIONS: The loading dose (1 microg/kg/10 min) of dexmedetomidine was sufficient for surgery of less than 60 min. Dexmedetomidine infusion followed by maintenance dose (0.2 microg/kg/hr) was sufficient for surgery within 90 min.

A Case of Hemoperitoneum due to Spontaneous Rupture of Visceral Artery Aneurysm after Ingestion of Puffer Fish / 대한구급학회지

Ingestion of puffer fish can cause intoxication, which produces a wide range of symptoms due to the presence of neurotoxins, such as tetrodotoxin, in puffer fish. Abdominal pain is just one of the symptoms that should be treated with symptomatic and supportive therapy. This study reports a case of a 56-year-old male patient with abdominal pain, who was admitted to the emergency room with a diagnosis of puffer fish poisoning. In this case, the abdominal pain did not improve, but rather, the symptoms worsened. Finally, the cause of the abdominal pain was found to be hemoperitoneum due to active bleeding at the greater omentum, as observed on abdominal computed tomography; the source of bleeding was the right colic artery branch. Embolization was performed successfully, and the post-intervention course was uneventful. The patient was discharged without any complications within 13 days after admission.

The EC50 of remifentanil to minimize the cardiovascular changes during head holder pinning in neurosurgery / 대한마취과학회지

BACKGROUND: During neuroanesthesia, head holder pinning commonly results in sympathetic stimulation manifested by hemodynamic changes, such as increased heart rate and arterial blood pressure. Remifentanil has been used successfully to control acute autonomic responses during neurosurgical procedures. The objective of this study was to determine effect-site concentration of remifentanil for suppressing the hemodynamic response to head holder pinning with the probability of 50% (EC50). METHODS: Forty-one ASA physical status I or II patients, between the ages of 20-70, who were scheduled for neurosurgery were recruited into this study. After arrival in the operating room, standard monitoring was applied throughout the study, which included a bispectral index monitor. Both propofol and remifentanil were administered by Target-control infusion device. The Dixon "up-and-down" sequential allocation method was used to determine the EC50 of remifentanil. RESULTS: The EC50 of remifentanil was 2.19 +/- 0.76 ng/ml by the turning point estimate (TPE). In probit analysis, EC50 was 2.42 ng/ml (95% CI : -0.62-4.66) and EC95 was 5.70 ng/ml (95% CI : 4.02-67.53). The EC50 estimator comes from isotonic regression is 2.90 ng/ml (95% CI : 1.78-3.65). The EC95 estimator comes from isotonic regression is 4.28 ng/ml (95% CI : 3.85-4.41). CONCLUSIONS: This study showed that EC50 of remifentanil was 2.19 +/- 0.76 ng/ml by TPE. EC50 was 2.42 ng/ml (95% CI -0.62-4.66) in probit analysis, as back up analysis. The EC50 estimator comes from isotonic regression is 2.90 ng/ml (95% CI : 1.78-3.65).

Two Cases of Descending Aortic Dissection with Compromised Visceral Artery, Renal Artery, and Iliac Artery Treated with Percutaneous Stent Insertions / 대한내과학회지

The involved area is an important guide to the treatment of an acute aortic dissection. Generally, a Stanford type A aortic dissection requires surgery, whereas an uncomplicated Stanford type B aortic dissection is managed medically. However, managing a Stanford type B aortic dissection involving the visceral, renal, or iliac arteries is controversial because surgical perioperative mortality is higher than that for medically managed patients. Some researchers have attempted endovascular treatment to reduce perioperative mortality and protect vital organs. We experienced two cases of descending aortic dissection with compromised visceral, renal, and iliac arteries that were successfully treated by percutaneous stent insertion.

The Modified Chimney Technique With a Thoracic Aortic Stent Graft to Preserve the Blood Flow of the Left Common Carotid Artery for Treating Descending Thoracic Aortic Aneurysm and Dissection

While thoracic endovascular aortic repair is an effective treatment option for descending thoracic aorta pathology, it does have limitations. The main limitation is related to the anatomical difficulties when disease involves the aortic arch. A fenestrated, branched aortic stent graft and hybrid operation has been introduced to overcome this limitation, but it is a custom-made device and is time consuming to manufacture. Furthermore, these devices cannot be used in an emergency setting. We report two patients with massive descending thoracic aortic aneurysm and ruptured aortic dissection very near the aortic arch who underwent a procedure which we named the modified chimney technique. The modified chimney technique can be used as a treatment option in such an emergency situation or as a rescue procedure when aortic pathology is involved near the supra-aortic vessels.

Gender differences in paclitaxel-induced neuropathic pain behavior and analgesic response in rats / 대한마취과학회지

BACKGROUND: Females show greater sensitivity than males to several modalities of experimental pain. However, the gender differences in paclitaxel-induced neuropathic pain have not been studied. The current study examined the gender differences in neuropathic pain behavior and the effect of analgesics in a paclitaxel-induced neuropathic pain model in rats. METHODS: Neuropathic pain was induced by intraperitoneal injection of paclitaxel (2 mg/kg) on 4 alternate days in Sprague-Dawley rats of both genders. Mechanical allodynia was measured using a von Frey filament. The gender differences in analgesic responses were determined after administration of morphine (2 or 5 mg/kg), ketamine (2 or 5 mg/kg), or combined morphine (2 mg/kg) and ketamine (2 mg/kg). RESULTS: Paclitaxel induced mechanical allodynia, which began to manifest on day 4, peaked within 10 days, and plateaued for at least 2 months after the first paclitaxel injection. No gender difference in the manifestation of mechanical allodynia was observed. A 2 mg/kg dose of ketamine increased the mechanical threshold only in males. The 5 mg/kg dose of ketamine significantly increased the mechanical threshold in both genders. Morphine (2 and 5 mg/kg) dose-dependently increased the mechanical thresholds in both genders. The 2 mg/kg dose of ketamine enhanced the antinociceptive effect of 2 mg/kg morphine only in females. CONCLUSIONS: No gender difference in paclitaxel-induced neuropathic pain or analgesic response to ketamine or morphine was observed in Sprague-Dawley rats. Low dose ketamine enhanced the analgesic effect of morphine on paclitaxel-induced mechanical allodynia but only in female rats.

Thoracic Endovascular Aortic Repair of a Penetrating Aortic Ulcer in the Thoracic Aorta Combined with an Abdominal Aortic Aneurysm / 대한내과학회지

Penetrating aortic ulcers (PAUs) are part of acute aortic syndrome and can cause aortic rupture. We report a case of abdominal aortic aneurysm (AAA) with a PAU in the thoracic aorta. The patient was treated with thoracic aortic endovascular repair (TEVAR) for the PAU and open repair for the AAA. A 78-year-old man was admitted due to abdominal discomfort. Computed tomography (CT) showed a 6.8-cm AAA with a short neck and a large (4.2 x 3.3 cm) thoracic PAU. The patient was scheduled for AAA repair. Due to the risk of rupture of the thoracic PAU, TEVAR was performed in the PAU before surgery for the AAA. After stent graft insertion, the patient underwent surgery to repair the AAA. A follow-up CT scan showed no endoleakage or thrombus formation in the PAU. The patient had no specific symptoms during 1 year of follow-up.

Thoracic Endovascular Aortic Repair of a Penetrating Aortic Ulcer in the Thoracic Aorta Combined with an Abdominal Aortic Aneurysm / 대한내과학회지

Penetrating aortic ulcers (PAUs) are part of acute aortic syndrome and can cause aortic rupture. We report a case of abdominal aortic aneurysm (AAA) with a PAU in the thoracic aorta. The patient was treated with thoracic aortic endovascular repair (TEVAR) for the PAU and open repair for the AAA. A 78-year-old man was admitted due to abdominal discomfort. Computed tomography (CT) showed a 6.8-cm AAA with a short neck and a large (4.2 x 3.3 cm) thoracic PAU. The patient was scheduled for AAA repair. Due to the risk of rupture of the thoracic PAU, TEVAR was performed in the PAU before surgery for the AAA. After stent graft insertion, the patient underwent surgery to repair the AAA. A follow-up CT scan showed no endoleakage or thrombus formation in the PAU. The patient had no specific symptoms during 1 year of follow-up.

Two Cases of Descending Aortic Dissection with Compromised Visceral Artery, Renal Artery, and Iliac Artery Treated with Percutaneous Stent Insertions / 대한내과학회지

The involved area is an important guide to the treatment of an acute aortic dissection. Generally, a Stanford type A aortic dissection requires surgery, whereas an uncomplicated Stanford type B aortic dissection is managed medically. However, managing a Stanford type B aortic dissection involving the visceral, renal, or iliac arteries is controversial because surgical perioperative mortality is higher than that for medically managed patients. Some researchers have attempted endovascular treatment to reduce perioperative mortality and protect vital organs. We experienced two cases of descending aortic dissection with compromised visceral, renal, and iliac arteries that were successfully treated by percutaneous stent insertion.