Groin and buttock claudication associated with vascular origin due to chronic occlusion of internal iliac artery: A case report

Neurogenic and vascular claudication is sometimes difficult to distinguish from each other due to similarities in symptoms. Symptoms and physical examinations may not always match the severity in both diseases, and when atypical symptoms, such as groin pain, are present, diagnosis can be more challenging. Proper differential diagnosis of the two is important because of the invasiveness of treatment in both diseases. We report a rare case of a patient with severe groin and buttock pain due to chronic occlusion of the internal iliac artery, along with a review of the relevant literature.

Combined third occipital and C3 deep medial branch neurotomy in a patient with C2-3 facet joint osteoarthritis associated cervicogenic headaches: A case report

Cervicogenic headache is pain from the head due to various sources in the cervical spine. The C2-3 zygapophysial joints are the most commonly involved structure, and this type of headache could be relieved by blocks or neurotomy of the third occipital nerve. A 59-years-old female patient suffered from cervicogenic headaches due to severe C2-3 zygapophysial joint hypertrophy. Her pain was partially relieved by the third occipital radiofrequency neurotomy, and was almost completely removed by C3 deep medial branch neurotomy. Herein, we report a case of osteoarthritis associated cervicogenic headaches at the C2-3 zygapophysial joints and proposed a treatment option.

Equianalgesic Concentration of Fentanyl Comparable to 67% N2O during Propofol Based General Anesthesia / 대한마취과학회지

BACKGROUND: When using a target controlled infusion (TCI) of propofol, combination with N2O or fentanyl as an analgesic adjuvant is common in clinical practice. In a previous study, a minimal steady state plasma concentration necessary to prevent a response in 50% of the patients following a skin incision (Cp50i) for propofol was reduced from 6ng/ml to 4.5ng/ml with 67% nitrous oxide/oxygen compared to air/oxygen. The goal of this study was to quantify the effect site concentration of fentanyl required to replace 67% N2O at a propofol effect site target concentration of 4.5ng/ml. METHODS: Forty six ASA class I or II adult patients scheduled for lower extremity surgery were randomly allocated to one of three groups according to assigned effect site concentration of fentanyl. Group 1, n = 15; 0.5 ng/ml, Group 2, n = 15; 1.0 ng/ml, Group 3, n = 15; 1.5 ng/ml. Patients received propofol with target concentration 4.5ng/ml and predetermined target concentration of fentanyl in three groups. A laryngeal mask airway was placed after anesthesia induction and all patients were controlled ventilation with 67% air/33% oxygen. The response to the skin incision was observed and the patients categorized as movers or non-movers according to Eger's criteria. Cp50i for fentanyl was evaluated using nonlinear regression analysis. RESULTS: Non-movers to skin incision was 20%, 43.7%, 73.7% in groups 1 3 respectively. Cp50i for fentanyl combined with propofol 4.5ng/ml was 1.08 ng/ml. CONCLUSIONS: We concluded that the MAC for 67% N2O is equivalent to an effect site target fentanyl concentration of 1.08 ng/ml in terms of no movement to skin incision.

The Effect of Inhaled Concentration of N2O (Nitrous Oxide) during Emergenceon Awakening Time after Propofol-N2O-O2 Anesthesia / 대한마취과학회지

BACKGROUND: N2O has a unique analgesic effect and reduces the amount of hypnotics for preventing surgical stimuli during maintenance of anesthesia. Also, it was reported that high concentrations of N2O affect level of consciousness. The aim of this study was to evaluate the effect of inhaled concentrations of N2O during emergence on awakening time after propofol-N2O-O2 anesthesia. METHODS: Sixty ASA class I or II patients scheduled for lower extremity surgery were randomly allocated to one of three groups according to inhaled concentration of N2O during emergence. Group 1: 0% N2O (n = 20), group 2: 33% N2O (n = 20) and group 3: 50% N2O (n = 20). Anesthesia was induced and maintained with propofol (Ct: 3.5 6 microgram/ml)-67% N2O-33% O2 and the target concentration of propofol was kept at 4 microgram/ml at least 30 min before the end of infusion of propofol using TCI. At the time of skin closure, we discontinued the propofol, maintained the allocated concentration of N2O and continuously checked vital signs, current/effect concentration of propofol, bispectral index (BIS), and elapsed time until eye opening to verbal contact (awakening time). RESULTS: Awakening time and bispectral index significantly increased as the inhaled concentration of N2O was higher. At awakening time, The predicted current/effect site concentrations of propofol significantly decreased as the inhaled concentrations of N2O were increased. CONCLUSIONS: Continuous inhalation of N2O after discontinuation of propofol infusion significantly delayed the awakening time after propofol-N2O-O2 anesthesia using TCI.

The Effect Site Concentration of Propofol Comparable to BIS 50 and Awakening in Pediatric Patients / 대한마취과학회지

BACKGROUND: Propofol offers the advantages of rapid onset of action and recovery. However, the pharmacokinetics of propofol in children is different from that of adults. Therefore, infusion of propofol by target-controlled infusion (TCI) has same difficulties in use. Also, bispectral index has shown a close relationship with plasma concentration of propofol. In this study, we measured the effect site concentration comparable to Bispectral index (BIS) 50 during induction and the awakening concentration. Furthermore, we tried to demonstrate age-related differences. METHODS: Forty five premedicated (atropine 0.02 mg/kg) children (ASA class I) scheduled for elective surgery were assigned to one of three groups (Group 1: 1-5 years, Group 2: 6-10 years, Group 3: 11-15 years). After intravenous injection of lidocaine 0.5 mg/kg, a propofol infusion was started at a target concentration of 6 microgram/ml by using a Stelpump. Anesthesia was maintained with propofol 4-6 microgram/ml and 67% nitrous oxide in oxygen. During anesthesia induction, we checked the effect site concentration comparable to BIS 50 and plasma/effect concentration for awakening during an emergence period. RESULTS: The effect site concentrations comparable to BIS 50 were 5.7 +/- 0.5 microgram/ml (group 1), 4.9 +/- 0.8 microgram/ml (group 2) and 3.8 +/- 1.1 microgram/ml (group 3), so there are significant differences among the groups (P < 0.05)(Table 2). At the moment of awakening, the current/effect site concentration in group 1 (2.0 +/- 0.1 microgram/ml, 2.6 +/- 0.2 microgram/ml) was significantly higher than those of group 3 (1.6 +/- 0.2 microgram/ml, 2.0 +/- 0.30 microgram/ml). CONCLSIONS: The effect site concentration comparable to BIS 50 showed significantly age-related differences and was higher in younger children. The current/effect site concentration at awakening was highest in group 1.

Is the Administration of Fentanyl Useful for Hemodynamic Stability during Propofol Induction Using Target Controlled Infusion(TCI) Mode? / 대한마취과학회지

BACKGROUND: Because the propofol TCI software commands the syringe pump to deliver a rapid infusion at a rate of 1200 ml/hr until the pharmacokinetic model predicts that the selected target concentration has been reached, the hemodynamic changes are predicted. To this change, several methods could be considered and the fentanyl injection is one of them. METHODS: Sixty adult patients scheduled for orthopedic surgery were randomly alldegrees Cated into four groups according to amount of fentanyl injected during induction period(group 1: no fentanyl, group 2: 0.75 microgram/kg, group 3: 1.5 microgram/kg, group 4: 3.0 microgram/kg). Target plasma concentration of propofol was selected as 4.0 microgram/ml and this concentration was achieved using modification of Prys-Roberts method. We evaluated the hemodynamic effect of various doses of fentanyl that injected at Vdpeak effect time and determined the optimal dose of fentanyl during propofol induction using TCI mode. RESULTS: Induction dose(range: 1.25~1.31 mg/kg) of propofol and induction time(range: 46~76 sec) showed no difference among groups. Use of fentanyl was effective for blood pressure stability immediately after intubation, but not effective before and 3 min following intubation. The higher the dosage of fentanyl, the more stable the heart rate. CONCLUSION: It suggest that use of fentanyl for the prevention of abrupt hemodynamic change during propofol induction using target controlled infusion mode is not necessary.

Effect of Different Concentration of Fentanyl on Maintenance, Recovery and Postoperative Pain Relief in Propofol-Fentanyl-N2O Anesthesia / 대한마취과학회지

BACKGROUND: Skin incision has been used as a standard stimulus in most concentration versus response relationship studies for anesthetics. However, skin incision is not the most intense stimulation and inconvenient method during operation. Mean arterial blood pressure, but not heart rate, is convenient and predicts surgical stress as well as propofol blood concentration. We evaluated the effects of different fentanyl concentration on propofol-fentanyl-N20 anesthesia using mean arterial blood pressure as an indicator of surgical stress during operation. METHODS: Eighty ASA I or II patients (age: 20~55 yrs) scheduled for spine fusion were randomly allocated to four groups according to expected fentanyl blood concentration (Group 1, 2, 3, 4: 0, 1.5, 3.0, 4.5 ng/ml respectively, n=20 for each group). Fentanyl was infused according to isoconcentration nomogram, and propofol infusion rate was titrated by changes of mean arterial blood pressure (0~12 mg/kg/hr). Fifteen minutes before expected end of surgery, propofol and fentanyl infusion were discontinued. Thereafter IV-PCA using fentanyl was applied for postoperative pain relief. Average propofol flow rate, recovery of orientation, verbal rating scale were cheked. RESULTS: Group 2, 3, 4 showed decreased average propofol flow rate, delayed recovery and decreased postoperative 24 hr fentanyl requirement for pain relief gradually compared with group 1. Group 4 showed ceiling effect in terms of average propofol flow rate, recovery of orientation and 24 hr fentanyl requirement for postoprerative pain relief compared with group 1~3. CONCLUSIONS: Keep the fentanyl concentration below 3.0~4.5 ng/ml and titrate propofol flow rate was reasonable method for adequate control of drug infusion during a propofol-fentanyl-N20 anesthesia.

Anesthesia Induction with Propofol Using a Target Controlled Infusion (TCI) / 대한마취과학회지

BACKGROUND: Target Controlled Infusion (TCI) is designed to achieve a predicted target blood concentration based on population pharmacokinetics and it provides the closest approximation for any individual patients. This study determined which target is appropriate for propofol induction using a TCI in korean adullt patients premedicated with midazolam. METHODS: Sixty six patients (ASA I or II, 18~55 years) premedicated with midazolam were allocated randomly to receive an infusion to achieve and maintain a target blood concentration of 3, 4, 5 and 6 microgram/ml using a TCI. Induction time was measured as the interval from the start of the infusion to loss of verbal contact and induction within 3 min was considered as successful. Calculated concentration, induction dose, context sensitive decrement time, vital signs, pain score and side effects were checked and compared each other during induction period. RESULTS: The success rate when the target was 3 microgram/ml was 25%, 58.8%, 77.8% and 100% when targets were 4 microgram/ml, 5 microgram/ml and 6 microgram/ml respectively. EC50 for induction was 3.87 microgram/ml and EC95 was 5.71 microgram/ml. Calculated concentration, induction dose, context sensitive decrement time in 3, 4, 5 microgram/ml group showed no differences among groups, but 6 microgram/ml group showed statistically significant differences compared with other groups. Vital signs, pain score and side effects showed no differences among groups. CONCLUSIONS: Target concentration of 5~6 microgram/ml would successfully induce anesthesia in the majority of patients premedicated with midazolam without major hemodynamic changes.

Evaluation of the Changes of Coagulation-Fibrinolysis System during Transurethral Resection of the Prostate by Thromboelastography / 대한비뇨기과학회지

We studied intraoperative changes of transurethral resection of the prostate in blood coagulation-fibrinolysis system by thromboelastography (TEG) in 31 patients with benign prostatic hyperplasia. As TEG parameters reaction time (R), clot formation time (K), maximum amplitude (MA), coagulation time (R+K), clot lysis index after 60 minutes (Ly60) were measured. The coagulability was evaluated by R and R+K, the absolute strength of clot by MA, and fibrinolysis by Ly60. Coagulation time (R+K) was shortened in patients with decreased platelet count under 30,000 u/L (p<0.05), irrigating fluid volume over 20,000 ml (p<0.05) and had a tendency of shortening in patient with resection time over 50minutes (p=0.078). MA had a tendency of increasing but significant contributing factor was not detected. The mean value of Ly60 was increased significantly but the change was in normal range. Irrigating fluid volume (r=-0.407, p<0.05) and resection time (r=-0.456, p<0.05) showed negative correlation significantly with the change of R + K. There was no significant correlation between resected prostatic weight and TEG parameters. We concluded that coagulability is increased during TURP suggesting a possible role in postoperative clot retention, but the risk of fibrinolysis is not increased in patients with normal coagulation-fibrinolysis system.