Pericardial tamponade caused by massive fluid resuscitation in a patient with pericardial effusion and end-stage renal disease: A case report / 대한마취과학회지

Pericardial tamponade can lead to significant hemodynamic derangement including cardiac arrest. We experienced a case of pericardial tamponade in a patient with end-stage renal disease. Hemodynamic changes occurred by unexpectedly aggravated pericardial effusion during surgery for iatrogenic hemothorax. We quickly administered a large amount of fluids and blood products for massive bleeding and fluid deficit due to hemothorax. Pericardial effusion was worsened by massive fluid resuscitation, and thereby resulted in pericardial tamponade. Hemodynamic parameters improved just after pericardiocentesis, and the patient was transferred to the intensive care unit.

Hemidiaphragmatic paralysis and hemohydrothorax following right internal jugular vein catheterization / 대한마취과학회지

No abstract available.

The effect of heated breathing circuit on body temperature and humidity of anesthetic gas in major burns / 대한마취과학회지

BACKGROUND: Cold and dry gas mixtures during general anesthesia cause the impairment of cilliary function and hypothermia. Hypothermia and pulmonary complications are critical for the patients with major burn. We examined the effect of heated breathing circuit (HBC) about temperature and humidity with major burned patients. METHODS: Sixty patients with major burn over total body surface area 25% scheduled for escharectomy and skin graft were enrolled. We randomly assigned patients to receiving HBC (HBC group) or conventional breathing circuit (control group) during general anesthesia. The esophageal temperature of the patients and the temperature and the absolute humidity of the circuit were recorded every 15 min after endotracheal intubation up to 180 min. RESULTS: There was no significant difference of the core temperature between two groups during anesthesia. The relative humidity of HBC group was significantly greater compared to control group (98% vs. 48%, P < 0.01). In both groups, all measured temperatures were significantly lower than that after intubation. CONCLUSIONS: The use of HBC helped maintain airway humidity, however it did not have the effect to minimize a body temperature drop in major burns.

Macintosh laryngoscope vs. Pentax-AWS video laryngoscope: comparison of efficacy and cardiovascular responses to tracheal intubation in major burn patients / 대한마취과학회지

BACKGROUND: Patients with major burns accompanied with airway edema need more attention for airway management. Although the Pentax-AWS has an advantage in managing endotracheal intubation more easily, its usefulness cannot be assured if it does not maintain hemodynamic stability in burn patients. The aim of this study was to compare cardiovascular responses and general efficacy of the Pentax-AWS and Macintosh laryngoscopes in burn patients. METHODS: American Society of Anesthesiologists physical status 2 or 3 adult patients with major burn injury were randomly assigned to group P (AWS, n = 50) or group M (Macintosh, n = 50). Fifty-nine patients assigned to the Macintosh group and no patient to AWS group were excluded because of failure to first intubation. Hemodynamic data at baseline, just before and after intubation as well as 3, 5 and 10 minutes after intubation and grade of sore throat were recorded in two groups. Intubation time, success rate of intubation, number of intubation attempts and the percentage of glottic opening (POGO) scores were also observed and analyzed in all patients. RESULTS: A statistically significant increase in heart rate just after laryngoscopy was seen in group M. The success rate of the first attempt in group P (100%) was greater than with the group M (46%). POGO scores were higher in group P (97 +/- 4%) than in group M (48 +/- 29%) CONCLUSIONS: The use of Pentax-AWS offers a reduced degree of heart rate elevation compared with the Macintosh laryngoscope and better intubation environments in major burn patients.

Post-marketing Surveillance of the Safety of Dutasteride Prescribed to Korean Patients with Benign Prostate Hyperplasia

BACKGROUND: Dutasteride is an inhibitor of both types I and II 5 alpha-reductase and was approved in Korea in April 2004. This post-marketing surveillance was to assess the safety of dutasteride in Korean patients with benign prostate hyperplasia in real life and to elucidate the risk factors related adverse events. METHODS: From December 2004 to January 2010, 3,977 patients were enrolled by 184 urologists. According to post-marketing surveillance regulation, patients were enrolled consecutively. Patients administered dutasteride at least once were included in safety assessment. The incidences of any adverse events and serious adverse events were evaluated. Multiple logistic regression method was used to identify risk factors related to adverse events. RESULTS: The safety assessment included 3,870 patients with the mean age of 67.3 years. The incidence of adverse events was 3.8 %. The most frequent adverse event was impotence (75 cases, 1.9 %), libido decrease (49 cases, 1.3 %), ejaculation disorder (30 cases, 0.8 %), and gynecomastia (5 cases, 0.1 %). The incidence of unexpected adverse events was 0.5 % and cerebral infarction, lung cancer, pulmonary embolism, and diarrhea were reported as serious adverse events. CONCLUSION: In this survey, impotence was the most frequently reported adverse events. Dutasteride was well tolerated in Korean patients with benign prostate hyperplasia. These results updated the safety information and would provide important additional information for prescribers.

The BIS and hemodynamic changes in major burn patients according to a slow infusion of propofol for induction / 대한마취과학회지

BACKGROUND: Many pathophysiologic alterations in patients with major burns can cause changes in the response of propofol. The aim of this study is to determine the appropriate induction dose of propofol using a slow infusion rate for major burn patients to obtain desirable sedation and hypnotic conditions with minimal hemodynamic changes. METHODS: 45 adults with major burns and who were electively scheduled for escharectomy less than a week after injury were recruited. For induction with propofol, the patients were randomly allocated to one of two groups (group 1: 1.5 mg/kg, n = 20 and group 2: 2.0 mg/kg, n = 25). The infusion rate was 20 mg/kg/hr. The systolic and diastolic blood pressure (SBP, DBP), the heart rate, the bispectral index and the modified observers' assessment of the alertness/sedation scale (OAA/S) were measured before the induction and after the propofol infusion, as well as immediately, 3 and 5 minutes after intubation. RESULTS: The SBP and DBP were significantly decreased after the propofol infusion in both group, but there were no significant differences between the two groups. The BIS values after the propofol infusion and intubation were 44.2 +/- 16.1 and 43.5 +/- 13.8 in group 1, and 45.6 +/- 10.3 and 46.5 +/- 11.4 in group 2, respectively, and there were no differences between the 2 groups. CONCLUSIONS: When propofol is administrated to major burn patients, an induction dose of 1.5 mg/kg is appropriate and a slow infusion rate of 20 mg/kg/hr is safe for maintaining the desired hypnotic conditions and this dose and rate cause no significant hemodynamic problems.

Cardiovascular crisis after small dose local infiltration of epinephrine in patient with asymptomatic subarachnoid hemorrhage: A case report / 대한마취과학회지

The infiltration of dilute epinephrine solution has been used for many years to provide hemostasis. However, epinephrine has adverse cardiovascular effects, such as arrhythmia, pulmonary edema, and even cardiac arrest. We have experienced epinephrine-induced cardiovascular crisis, with severe hypertension, tachycardia, and cardiac arrest after subcutaneous infiltration of a 2% lidocaine and 1 : 200,000 epinephrine solution in a patient with an asymptomatic subarachnoid hemorrhage. We provided successfully advanced cardiac life support in the operating room and cardioverted the patient back into a sinus rhythm with no untoward effects. The patient recovered without any apparent sequelae after intensive care.

Recombinant DNA and Protein Vaccines for Foot-and-mouth Disease Induce Humoral and Cellular Immune Responses in Mice

BACKGROUND: Foot-and-mouth disease virus (FMDV) is a small single-stranded RNA virus which belongs to the family Picornaviridae, genus Apthovirus. It is a principal cause of FMD which is highly contagious in livestock. In a wild type virus infection, infected animals usually elicit antibodies against structural and non-structural protein of FMDV. A structural protein, VP1, is involved in neutralization of virus particle, and has both B and T cell epitopes. A RNA-dependent RNA polymerase, 3D, is highly conserved among other serotypes and strongly immunogenic, therefore, we selected VP1 and 3D as vaccine targets. METHODS: VP1 and 3D genes were codon-optimized to enhance protein expression level and cloned into mammalian expression vector. To produce recombinant protein, VP1 and 3D genes were also cloned into pET vector. The VP1 and 3D DNA or proteins were co-immunized into 5 weeks old BALB/C mice. RESULTS: Antigen-specific serum antibody (Ab) responses were detected by Ab ELISA. Cellular immune response against VP1 and 3D was confirmed by ELISpot assay. CONCLUSION: The results showed that all DNA- and protein-immunized groups induced cellular immune responses, suggesting that both DNA and recombinant protein vaccine administration efficiently induced Ag-specific humoral and cellular immune responses.

Prediction of difficult intubation in patients with postburn sternomental contractures: modified onah class / 대한마취과학회지

BACKGROUND: Postburn sternomental contractures cause various changes in mouth, oral cavity, pharynx, larynx and related structures. Although there are many methods to predict difficult intubation, the modified Mallampati test (mMT) and the El-Ganzouri multivariate risk index (EGRI) are popular tests. The authors wanted to compare modified Onah class with these 2 tests and also explored the possibility that Onah class could be an adequate independent predictor for difficult intubation. METHODS: One hundred and nine patients, aged 18 to 60 years of age, scheduled for elective surgery for reconstruction of postburn sternomental contractures were divided according to the modified Onah class. We made assessments prior to general anesthesia with respect to mouth opening, thyromental distance, mMT, neck movement, ability to prognath, body weight, and history of difficult tracheal intubation. The accuracy, specificity, positive and negative predictive values were calculated from the data of the 3 tests, and as the 3 tests were compared with patient's laryngoscopic view grade according to Cormack and Lehane criteria by using the Chi-square test. RESULTS: The incidence of Cormack and Lehane grade III, IV was 39.4%. Onah class showed significantly higher accuracy, specificity, and positive predictive value than mMT and EGRI. There were significant correlations between modified Onah class 2b, 3 and the Cormack and Lehane grade III, IV. CONCLUSIONS: Application of modified Onah class for preoperative prediction of the degree of difficulty with laryngeal visualization can reduce the frequency of both an unanticipated failure to visualize laryngeal structures as well as potential unnecessary interventions related to over-prediction of airway difficulty in patients with postburn sternomental contractures.

Tracheal intubation without the use of muscle relaxant in severe burn patients using propofol and varying doses of remifentanil / 대한마취과학회지

BACKGROUND: Severe burn patients often have a difficult airway. Tracheal intubation can be conducted safely in patients in a stable hemodynamic condition using a propofol in conjunction with remifentanil without employing muscle relaxant. However, no studies have been conducted to date to evaluate intubation of severe burn patients. Therefore, this study was conducted to evaluate the condition of tracheal intubation with propofol and varying doses of remifentanil without muscle relaxants in severe burn patients. METHODS: Eighty severe burn patients were divided into four groups at random. Anesthesia was intravenously induced by continuous infusion of propofol (4 microgram/ml of effect site concentration)and slowly injected remifentanil. Groups 1, 2, 3, and 4 received 1, 1.5, 2, and 2.5 microgram/kg of remifentanil, respectively. Ninety seconds after the administration of remifentanil, tracheal intubation was attempted. We used a scoring system in which jaw relaxation, the state when laryngoscopy was inserted, vocal cord opening, cough, limb movement, and difficulty with laryngoscopy were divided into or = 3 (not acceptable). In addition, the hemodynamic changes were measured at baseline, before intubation, and 1, 2, 3, 4, and 5 min after intubation. RESULTS: Clinically acceptable intubating conditions were observed in 35%, 40%, 55%, and 70% of the patients in groups 1-4, respectively. The mean arterial pressure and heart rate decreased immediately before intubation in all groups. One patient was treated for bradycardia however, no patients manifested hypotension. CONCLUSIONS: Propofol and slowly injected remifentanil (2.5 microgram/kg) without muscle relaxant can provide clinically acceptable intubating conditions and stable hemodynamic conditions in major burn patients. However, further studies should be conducted to evaluate the effects of increased doses of remifentanil.

Blockade of vascular angiogenesis by Aspergillus usamii var. shirousamii-transformed Angelicae Gigantis Radix and Zizyphus jujuba

The matrix metalloproteinases (MMP) play an important role in tumor invasion, angiogenesis and inflammatory tissue destruction. Increased expression of MMP was observed in benign tissue hyperplasia and in atherosclerotic lesions. Invasive cancer cells utilize MMP to degrade the extracellular matrix and vascular basement membrane during metastasis, where MMP-2 has been implicated in the development and dissemination of malignancies. The present study attempted to examine the antiangiogenic activity of the medicinal herbs of Aspergillus usamii var. shirousamii-transformed Angelicae Gigantis Radix and Zizyphus jujube (tAgR and tZj) with respect to MMP-2 production and endothelial motility in phorbol 12-myristate 13-acetate (PMA)- or VEGF-exposed human umbilical vein endothelial cells (HUVEC). Nontoxic tAgR and tZj substantially suppressed PMA-induced MMP-2 secretion. In addition, 25 microg/mL tAgR and tZj prevented vascular endothelial growth factor-stimulated endothelial cell transmigration and tube formation. The results reveal that tAgR and tZj dampened endothelial MMP-2 production leading to endothelial transmigration and tube formation. tAgR and tZj-mediated inhibition of endothelial MMP may boost a therapeutic efficacy during vascular angiogenesis.

Anesthetic management for a patient with aberrant right subclavian artery: A case report / 대한마취과학회지

Aberrant right subclavian artery (ARSA) is a congenital anomaly that usually does not produce symptoms. However, patients with symptoms may require surgical intervention. Surgical procedures consist of division of ARSA from the descending aorta and reimplantation to the right common carotid artery or ascending aorta. Specific anesthetic management includes invasive monitoring of blood pressure in both radial arteries, monitoring of adequate cerebral perfusion, and ventilatory strategy to facilitate surgical exposure. Although many reports are available regarding its surgical treatment, there are few reports, to the author's best knowledge, that describe anesthetic management for its surgical correction. This case report will focus on important aspects of the anesthetic management of patients with ARSA.

The Hemodynamic Effect of the Local Epinephrine Injection to a Burn Scar

BACKGROUND: As a method for reducing bleeding, epinephrine local infiltration is used in hypertrophic scar release. However, this can induce unexpected increased absorption and increase the cardiovascular risk. Therefore we evaluated the hemodynamic effects of epinephrine local infiltration. METHODS: Sixty patients underwent hypertropic scar release under general anesthesia. Thirty patients who do not have a history of hypertension were classified as group 1, and thirty patients who had a history of hypertension were classified as group 2. The heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were observed before injection of epinephrine and every minute up to six minutes after injection of epinephrine. RESULTS: Even though the HR significantly increased at 1 and 2 minutes in each group, the difference between the two groups was not significant. The SBP, DBP and MAP were significantly increased in group 2 compared to group 1. The SBP of group 2 significantly increased at every minute up to six minutes and group 1 had a significant increased for 2 minutes. The DBP of group 2 significantly increased for 3 minutes and group 1 significantly increased for 2 minutes. The MAP of group 2 significantly increased for 2 minutes and group 1 significantly increased for 2 minutes (P < 0.05). CONCLUSIONS: Local infiltration of epinephrine in hypertrophic scar temporarily increases the heart rate and blood pressure. Therefore, the patient with hypertension can have an increased the cardiovascular risk and this should be carefully considered.

The Effect of Intraoperative Autotransfusion using a Continuous Autotransfusion System (CATS(R)) on for Homologous Transfusion in Children / 대한마취과학회지

BACKGROUND: Until recently, it was not easy to conduct intraoperative autotransfusion in children due to technical limitations, however, due to advanced technology this is now possible. This study was conducted to determine if the intraoperative use of the continuous autotransfusion system (CATS(R)) can reduce homologous transfusion during pediatric orthopaedic surgery. METHODS: Fifty-five children scheduled for elective orthopaedic surgery were reviewed and divided into two groups according to the availability of the CATS(R). The control group (n = 29) had surgery without the cell saver, whereas the CATS(R) group (n = 26) had surgery with the cell saver. The amounts of perioperative homologous transfusion were then compared between the two groups. RESULTS: The amount of homologous blood transfusion required during the operation was significantly less in the CATS(R) group 5 +/- 10 (ml/kg) than in the control group 15 +/- 13 (ml/kg) (P < 0.01). There was no difference in the amount of homologous blood transfusion required after operation between the groups. CONCLUSIONS: CATS(R) can reduce the need for intraoperative homologous transfusion during pediatric orthopaedic surgery.

The changes of heart rate, blood pressure and cardiac index in burn surgery under propofol-remifentanil anesthesia and desflurane anesthesia

BACKGROUND: Major burns can alter the hemodynamic effect caused by anesthesia. Total intravenous anesthesia induces little hemodynamic change and desflurane has a rapid induction advantage among the different kinds of inhalation anesthesia. The study compared propofol and remifentanil anesthesia with desflurane anesthesia during induction and maintenance anesthesia. METHODS: Forty patients, who were scheduled for burn surgery, were randomly assigned to either Group 1 (n = 20) or Group 2 (n = 20). Group 1 was induced and maintained with an infusion of propofol and remifentanil. After inducing anesthesia with propofol and rocuromium, group 2 was maintained with desflurane. The heart rate and mean arterial pressure, and cardiac index were measured in the operation room, after induction (AI), after intubation (AT) and at 5, 10, 15 and 20 minutes after intubation. RESULTS: There was a significantly lower heart rate in group 1 than in group 2. The heart rate of group 2 showed a significant increase at AI, AT, 5, 10, 15 and 20 minutes after intubation. There was no significant difference in the mean arterial blood pressure and cardiac index between the two groups. CONCLUSIONS: During burn surgery, total intravenous anesthesia was effective in attenuating the hemodynamic effects.

Comparison of emergence agitation between sevoflurane, desflurane, and propofol with bispectral index monitoring in pediatric anesthesia / 대한마취과학회지

BACKGROUND: Sevoflurane, desflurane, and propofol are widely used in pediatric anesthesia because of their rapid recovery. However, emergence agitation is more reported with sevoflurane or desflurane than with propofol. Our clinical experience indicates emergence agitation with propofol is also frequent. We tested the hypothesis that depth of anesthesia could lead to frequent emergence agitation with propofol. METHODS: Sixty children, ASA 1, aged 3-12 years, undergoing general anesthesia for adenotonsillectomy were randomized to receive maintenance anesthesia with sevoflurane, desflurane, or propofol. The bispectral index was monitored and maintained within 40-65. Time to extubation, duration of postanesthetic care units stay, bispectral index just before stopping the anesthetic agent, anesthetic time, early and late postoperative Pediatric Anesthesia Emergence Delirium Scale (PAEDS), and Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) were compared among the 3 groups. Data were analyzed using ANOVA (demographic data, measured time interval, BIS) and Kruskal-Wallis test (PAEDS and CHEOPS). The Spearman correlation coefficient was used to confirm the correlation between the two scales. RESULTS: Although desflurane resulted in the fastest extubation, other scales were not statistically different. PAEDS and CHEOPS for sevoflurane showed a positive correlation in the early recovery period, but desflurane and propofol did not. CONCLUSIONS: With the same depth of anesthesia, emergence agitation among desflurane, sevoflurane, and propofol was not different in children.

Hemoptysis and obstruction of the endotracheal tube by blood clot in a pediatric patient: A case report / 대한마취과학회지

Hemoptysis leading to airway obstruction by blood clot is a serious and potentially lethal condition in pediatric patients because of the unpredictable course and technical difficulty of managing small airways. An 11-month-old male patient with a contact burn on his left foot was intubated uneventfully during induction for general anesthesia. After 15 minutes, we noted blood in his endotracheal tube along with high airway pressure and desaturation. Immediate suction was performed, and the oxygen saturation recovered, but the airway pressure and small exhaled tidal volume were unchanged. We had difficulty differentiating endotracheal tube obstruction from bronchial spasm at that time. We successfully managed the endotracheal obstruction by extubation with removal of the blood clot and reintubation after the diagnosis was made using fiberoptic bronchoscopy. We review the etiology and management of airway obstruction and hemoptysis in the operating room.

Optimal clinical dose of rocuronium bromide for laryngeal mask airway insertion during sevoflurane anesthesia in children / 대한마취과학회지

BACKGROUND: The median effective dose, ED(50), of rocuronium bromide for inserting the laryngeal mask airway (LMA) in children was not known. The purpose of this study was to determine the clinical ED(50) (cED(50): median value of rocuronium dose of 6 set of crossing success and failure by Dixon's up-and-down method) of rocuronium to insert a LMA in pediatric patients. METHODS: Children aged 2 to 12 years (n = 21) and scheduled for urologic, orthopedic, plastic or ophthalmic surgery lasting less than 2 hr under general anesthesia were enrolled in this study. After applying a standard cardiorespiratory monitor, all patients received thiopental sodium 5 mg/kg for induction of anesthesia. Insertion of LMA was attempted 90 seconds after administration of rocuronium and manual ventilation with 8 vol% of sevoflurane. We recorded the movement of patients, blood pressure and heart rate. The initial dose of rocuronium was 0.3 mg/kg, and in accordance with Dixon's up-and-down method, the rocuronium concentration for consecutive patients in each patient was varied with increments or decrements of 0.05 mg/kg based on the result of previous patient. RESULTS: The cED(50) of rocuronium required to insert a LMA was 0.09 mg/kg with 8 vol% sevoflurane. With isotonic regression, cED95 of rocuronium was 0.13 mg/kg (95% confidence intervals 0.096-0.14 mg/kg). CONCLUSIONS: This study demonstrated that the cED(50) and cED(95) of rocuronium were 0.09 mg/kg and 0.13 mg/kg in children respectively. It provides satisfactory conditions for LMA insertion in anesthetized children and decreases the excessive hemodynamic change.

The use of Pentax-Aws(R) for difficult intubation due to postburn contracture: Two cases report / 대한마취과학회지

The causes of difficult intubation associated with post-burn contracture from the face to the upper torso include the limitations of neck movement and opening the mouth. Fiberoptic oral intubation can be the final alternative technique that overcomes those difficulties. However, a small inter-incisor gap about 2 cm, a fixed head or neck position and the large tongue in these cases makes fiberoptic intubation difficult. The Pentax-AWS video display unit (Pentax-AWS(R), Pentax, Japan) (Pentax-AWS) allows indirect visualization of the glottis without a straightened line of orophalyngolaryngeal axis and its attached tracheal tube and this makes the intubation easier. We experienced rapid, easy intubation with Pentax-AWS following multiple attempts of fiberoptic intubation or confirming a bad glottic view with a Macintosh laryngoscope. Further study is needed on the availibility of Pentax-AWS and comparing it with fiberoptic intubation for the management of a difficult airway.

Protective actions of Rubus coreanus ethanol extract on collagenous extracellular matrix in ultraviolet-B irradiation-induced human dermal fibroblasts

Solar ultraviolet (UV) irradiation leads to distinct changes in the skin connective tissues by degradation of collagen, which is a major structural component in the extracellular matrix. UV irradiation induces the production of matrix metalloproteinases (MMP) capable of attacking native fibrillar collagen and responsible for inhibiting the construction of collagenous extracellular matrix. In this study, we attempted to investigate the protective actions of Rubus coreanus ethanol extract (RCE) on the MMP production and the consequent procollagen/collagen degradation in UV-B-irradiated human dermal fibroblasts. The analytical data showed that Rubus coreanus ethanol extract was mostly comprised of cyanidin 3-rutinoside. Pre-treatment of fibroblasts with this extract inhibited UV-B-induced production of MMP-1, MMP-8 and MMP-13 in dose-dependent manners. In addition, Western blot analysis and immunocytochemical staining assay revealed that RCE markedly augmented the cellular levels of procollagen/collagen declined in UV-B-exposed dermal fibroblasts. These results demonstrate that RCE blocks UV-B-induced increase of the collagen degradation by inhibiting MMP production. Thus, RCE may act as an agent inhibiting excessive dermal collagen degradation leading to the skin photoaging.