Guidelines for prescribing opioids for chronic non-cancer pain in Korea

As the treatment of chronic non-cancer pain gradually increases, clinicians have more opportunities to encounter opioid prescription. However, guidelines for prescribing opioids for chronic non-cancer pain have never been published in Korea. The present guidelines were prepared by reviewing various research data. In cases in which the data were insufficient, recommendations were presented following discussion among experts affiliated with the Opioids Research Group in the Korean Pain Society. The present guidelines may need to be continuously revised and amended as more clinical evidence is acquired.

Intraoperative electrical burn caused by stainless tube tree with noncontact electrosurgical ground: A case report

Noncontact electrosurgical ground is recently developed to provide adequate electrical return to electric surgical unit without direct contact to the patient. It provides full and safe electrical return without direct contact of patient due to oscillating, high frequency nature of the current flow and large surface of pad. It is useful in burn surgery and effective to prevent burn by improper placements of the grounding pad. But it can induce current to conducting object with direct contact. Current induced in conductive materials can produce heat to make burns. We present a patient with full-thickness burn in left third finger which was resulted from current through stainless steel tube tree on the operating table during surgery. The stainless tube tree was placed on noncontact electrosurgical ground which was covered with plastic sheet and linen sheet. Staff in operating room should be educated and remain vigilant for electrical burns caused by metallic object on noncontact grounding pad.

Solitary neurofibroma of the sciatic nerve which was initially misdiagnosed as herniated nucleus pulposus: A case report

Solitary peripheral nerve tumor is rare and difficult to diagnose correctly. We present an unusual case of sciatic nerve tumor in a patient with leg buttock pain. Initial lumbar magnetic resonance imaging (MRI) revealed a herniated nucleus pulposus on L5-S1. Physical examination showed a palpable mass on the left buttock and Tinel's sign was elicited with palpation of the left posterior buttock. MRI examination of the hip revealed a tumor of the sciatic nerve adjacent to the left sciatic notch. Excision of the tumor was easily performed with subsequent slight motor weakness on dorsiflexion. Histopathological examination revealed the tumor to be a neurofibroma. Solitary neurofibroma without any evidence of neurofibromatosis is a rare condition. This case emphasizes the importance of physical examination and continued investigations.

Combined effects of bilateral thoracic sympathectomy and hypercarbia on common carotid blood flow volume in dogs

BACKGROUND: The occurrence of acute hypercarbia during endoscopic thoracic sympathectomy is not rare when CO2 gas is used to collapse lung. Upper thoracic sympathectomy can increases cerebral blood flow (CBF) and hypercarbia also increases CBF. The purpose of this study was to analyze the changes in common carotid blood flow volume (CCBFV) before and after T2 thoracic sympathectomy at normocarbia and hypercarbia. METHODS: In nine anesthetized and mechanically ventilated dogs, we checked CCBFV using an ultrasonic flow probe under four experimental conditions: 1) before T2 sympathectomy at normocarbia, 2) before T2 sympathectomy at hypercarbia, 3) after T2 sympathectomy at normocarbia, and 4) after T2 sympathectomy at hypercarbia. We also measured heart rate, blood pressure and PaCO2 at each time. RESULTS: Hypercarbia increased CCBFV from 105.2 +/- 47.9 ml/min to 192.3 +/- 85.4 ml/min. In T2 sympathectomy/normocarbia state, CCBFV increased to 152.2 +/- 62.0 ml/min. In T2 sympathectomy/hypercarbia state, CCBFV increased to 230.2 +/- 100.1 ml/min. CCBFV in hypercarbia state, sympathectomy state and sympathectomy/hypercarbia state showed significant increases compared with those in baseline (P < 0.05). CCBFV in hypercarbia state and sympathectomy/hypercarbia state showed significant increases compared with those in sympathectomy state (P < 0.05). But CCBFV in hypercarbia state and sympathectomy/hypercarbia did not showed significant differences. CONCLUSIONS: This result suggests that hypercarbia increases CCBFV more than sympathetic denervation and thoracic sympathectomy under hypercarbia condition increases CCBFV more than sympathectomy only.

Refractory status epilepticus occurred at the end of sevoflurane anesthesia in patient with epilepsy / 대한마취과학회지

No abstract available.

Meningioma related trigeminal neuralgia presenting as odontalgia: A case report

Classical trigeminal neuralgia is characterized by recurrent attacks of lancinating pain in the trigeminal nerve distribution, and no cause of the symptoms can be identified, other than vascular compression. This type of injury may rarely be caused by identifiable conditions, including tumor in the cerebellopontine angle. If the patient is suspected for secondary trigeminal neuralgia, further evaluation is required to diagnose and treat correctly. We report a case of a 49-year-old woman with a 1-month history of facial pain, who was initially misdiagnosed as odontalgia, and even treated with the extraction of her molar teeth. This case with the review of secondary trigeminal neuralgia may highlight the difficulties of diagnosis, and the importance of early diagnostic imaging, when trigeminal neuralgia occurs with a brain tumor.

Spinal Myoclonus Developed during Cervical Epidural Drug Infusion in Postherpetic Neuralgia Patient

Postherpetic neuralgia is the most frequent complication of herpes zoster. Treatment of this neuropathic pain syndrome is difficult and often disappointing. Although postherpetic neuralgia is generally a self-limited condition, it can last indefinitely. Continuous epidural blockade for patients with acute zoster can shorten the duration of treatment. However, continuous epidural block has some complications such as infection, dural puncture, and total spinal and nerve damages. We report a case of myoclonus during continuous epidural block with ropivacaine, morphine, and ketamine in an acute zoster patient.

Anesthesia of a dental patient with Angelman syndrome: A case report / 대한마취과학회지

Angelman syndrome is characterized by a partial deficit of paired autosomal chromosome 15, which contains a subunit of the GABA (Gamma-Amino Butyric Acid) receptor. Many drugs that act on the CNS (Central Nerve System) during anesthesia are believed to exert their effects via the GABA receptors. We describe the anesthesia of a 7 year-old female patient with Angelman syndrome who underwent surgery for dental caries. The basic factors that needed to be considered when administering anesthesia to this patient were epilepsy, significant dominance of the vagal tone, craniofacial abnormalities and peripheral muscular atrophy. Inhalational anesthetics (sevoflurane) were employed for this patient. The patient had an uneventful peri-operative period and was discharged home on the same day of the operation.

Anesthesia of a dental patient with Angelman syndrome: A case report / 대한마취과학회지

Angelman syndrome is characterized by a partial deficit of paired autosomal chromosome 15, which contains a subunit of the GABA (Gamma-Amino Butyric Acid) receptor. Many drugs that act on the CNS (Central Nerve System) during anesthesia are believed to exert their effects via the GABA receptors. We describe the anesthesia of a 7 year-old female patient with Angelman syndrome who underwent surgery for dental caries. The basic factors that needed to be considered when administering anesthesia to this patient were epilepsy, significant dominance of the vagal tone, craniofacial abnormalities and peripheral muscular atrophy. Inhalational anesthetics (sevoflurane) were employed for this patient. The patient had an uneventful peri-operative period and was discharged home on the same day of the operation.

Effect of pretreatment with acetaminophen on withdrawal movements associated with injection of rocuronium: a prospective, randomized, double-blind, placebo controlled study / 대한마취과학회지

BACKGROUND: Withdrawal movement during rocuronium injection is a common, unresolved adverse effect. We aimed to investigate the effect of IV acetaminophen pretreatment on withdrawal movement during rocuronium injection. METHODS: This study enrolled 120 American Society of Anesthesiologists (ASA) I-II patients undergoing general anesthesia. They were randomly assigned to three treatment groups. After occluding venous drainage using a tourniquet on the upper arm, the saline group received 5 ml of 0.9% sodium chloride solution, the lidocaine group received 40 mg of lidocaine, and the acetaminophen group received 50 mg of acetaminophen. During injection of pretreatment drug, pain was assessed on a four-point scale. The tourniquet was released after 120 seconds and anesthesia was performed using thiopental sodium 5 mg/kg followed by rocuronium 0.6 mg/kg. The withdrawal movement was graded on a four-point scale in a double-blind manner. RESULTS: The incidence of pain on pretreatment injection in saline, lidocaine, and acetaminophen groups was 7.7%, 5.1%, and 2.5%, respectively. The incidence of withdrawal movements was 77.5% in saline group, 32.5% in lidocaine group, and 37.5% in acetaminophen group (P < 0.05). CONCLUSIONS: Acetaminophen and lidocaine reduced the incidence of withdrawal movement after rocuronium injection compared with saline.

Sympathetic Block for Treating Primary Erythromelalgia

Primary erythromelalgia is a rare condition that's characterized by erythema, an increased skin temperature and burning pain in the extremities. The pain is often very severe, and treating erythromelalgia is frustrating and difficult. We report here on the case of a 12-year old girl with primary erythromelalgia in both lower extremities. The pain was refractory to medical treatment, but a bilateral sympathetic block with lidocaine and triamcinolone resulted in relief from the pain. Our experience with this disease demonstrates that sympathetic blocks are effective in improving the symptoms and they may be attempted on erythromelalgia patients who do not respond to other treatments, including medication and epidural blocks.

Contralateral allodynia and central change in the chronic post-ischemic pain model rats / 대한마취과학회지

BACKGROUND: Mirror-image allodynia is a mysterious phenomenon that occurs in association with many clinical pain syndromes including complex regional pain syndromes (CRPS). Underlying mechanisms for the development of such pain are still a matter of investigation. Several studies suggest that activation of the N-methyl-D-aspartate (NMDA) receptor is essential for central sensitization as a base for persistent pain. The aim is to assess whether alteration of NMDA receptor expression correlates with the contralateral allodynia in the chronic post-ischemia pain (CPIP) model rats representing CRPS-Type I. METHODS: Application of a tight-fitting tourniquet for a period of 3 hours before reperfusion produced CPIP in male Sprague-Dawley rats. The mechanical paw withdrawal thresholds to von Frey stimuli (using a dynamic plantar aesthesiometer) were measured as pain indicators in ipsilateral and contralateral hindpaws. Phosphorylation of the NMDA receptor 1 subunit (pNR1), assessed with Western blot, was measured in the contralateral L4-6 spinal cord. RESULTS: Ipsilateral and contralateral mechanical allodynia is present at 4 hours after reperfusion, peaked at 3 days, and continued for 7 days after reperfusion. The relative density of pNR1 of CPIP rats significantly decreased in the contralateral L4-6 spinal cord compared to baseline value (P < 0.05). There was significant correlation between paw withdrawal threshold and the relative density of pNR1 (ipsilateral; R2 = 0.75, P < 0.01, contralateral; R2 = 0.60, P < 0.01). CONCLUSIONS: These data suggest that pNR1 is correlated to the contralateral mechanical allodynia in CPIP rats.

Zoster Paresis Misconceived as a Radiculopathy due to Herniated Intervertebral Disc

Herpes zoster is a viral disease of the posterior root ganglion and sensory nerve fiber, which presents clinically with vesicular eruption of the skin, radicular pain and sensory changes in the distribution of the affected ganglion. However, involvement of the motor neurons can be seen as well. If classic cutaneous lesions are present, herpes zoster-related motor paresis is easily diagnosed. Otherwise, the diagnosis may be more difficult and suspicious, especially if weakness occurs as a symptom before cutaneous lesions appear, or abnormal findings on the MRI are consistent with the signs. There have been few reports of sciatica with motor loss preceding skin lesions. Here, we report a patient with herpes zoster-related motor paresis preceding skin lesions. In the preliminary diagnosis, the herpes zoster-related motor paresis was confused for some structural disorder.

Risk Factors of Pressure Sore in Patients undergoing General Anesthesia / 대한마취과학회지

BACKGROUND: The occurrences of pressure sores have an extensive impact on patients and the medical team. Pressure sores decrease quality of life and productivity, as well as increase the overall cost of treatment. The purpose of this study was to identify the risk factors associated with pressure ulcers among surgical patients. METHODS: Data were collected from 588 patients who underwent general anesthesia. The data included age, gender, weight, height, body mass index, ASA status, surgical position, anesthesia time, pre-and postoperative hemoglobin concentration, serum albumin, NYHA class, co-morbidity, steroid use, body temperature, use of warming water mattress and preoperative hospital admission day. The patient's skin was inspected closely before surgery and again within 24 hours after surgery and the locations and severity of skin breakdowns were assessed. RESULTS: Twenty-five patients (4.3%) developed pressure sores during surgery. The hemoglobin concentration change between the preoperative and postoperative period (> or =2 g/dl), position during surgery, length of stay before operation (> or =4 days), anesthesia time (> or =5 hours) and decrease in body temperature (> or =0.5degrees C) were significantly related to the development of pressure sores (P < 0.05). CONCLUSIONS: Five risk factors for pressure ulcers were confirmed. The anesthesiologist can decrease hemoglobin and modify body temperature; therefore, attention should be given to these risk factors during the operation.

Spinal Anesthesia for a Formerly Premature Infant with Unilateral Vocal Cord Paralysis Undergoing Inguinal Herniorrhaphy: A case report / 대한마취과학회지

In premature infants, the incidence of inguinal hernia has been reported to be 14-30%. It is generally accepted that inguinal hernia should be repaired as soon as possible, as the incidence of incarceration is higher in infant than in children. However, the risk of life-threatening apnea after surgery is significant in this age group. Spinal anesthesia in premature infants offer a safe alternative to general anesthesia, especially if intubation should be avoid because of coexisting disease. We present a case of successful spinal anesthesia for inguinal herniorraphy in a premature female infant at a postconceptual age 44 + 6 weeks weighing 2,620 g with coexisting unilateral vocal cord paralysis to illustrate technical details and feasibility of this technique even in very low birth weight (birth weight < 1,500 g) infants.

The Examination of Internal Jugular Vein and Carotid Artery in Trendelenburg Position with Head Rotation; A Prospective, Randomized Study / 대한마취과학회지

BACKGROUND: This study evaluated the position and relationship between the right internal jugular vein (IJV) and the surrounding external landmarks using ultrasonography. METHODS: Fifty-four patients undergoing central vein access for cardiac surgery were enrolled in this study. The IJV, carotid artery (CA) and sternocleidomastoid muscle (SCM) at the cricoid cartilage level in 15o trendelenburg position with 30o head rotation were examined using a two dimensional ultrasound transducer of a TEE machine. Images of the vessels and the demographic data of the patients were recorded and analysed. RESULTS: At the level of the cricoid cartilage, the position of the right IJV was medial to middle of the clavicular head of the SCM muscle in 26 cases (48.2%), lateral in 11 cases (20.4%) and just above the middle of clavicular head of the SCM muscle in 17 cases (31.5%). In 43 patients (79.6%), the IJV overlapped the CA anterolaterlly < 5 mm, and these cases were regarded as normal. Ten patients (18.5%) had a medially positioned IJV overlapping the CA more than 5 mm and the IJV was positioned lateral to CA in 1 (2%) patient. The mean ratio of the overlapped diameter and the diameter of the CA was 33.6% and the overlapping ratios were greater than 50% in 10 patients (31.4%). The mean skin-to-vein distance at the angle of 30degrees was 1.82 cm. CONCLUSIONS: In 18.5% of patients positioned in the 15o Trendelenburg position, with their head turned to the left 30degrees, the IJV overlapped the CA medially more than 5 mm, which increased the risk of a carotid puncture using the blind technique.

Effects of Insulin on the Resuscitation by Epinephrine for Bupivacaine-Induced Cardiovascular Depression in Dogs / 대한마취과학회지

BACKGROUND: Because of the difficulty of resuscitation caused by bupivacaine-induced cardiotoxicity, the choice of resuscitation medication is still unclear. We investigated whether insulin can improve outcomes of resuscitation by epinephrine from bupivacaine-induced cardiovascular collapse. METHODS: Twenty-four mongrel dogs were randomly allocated to one of the two groups: an EPI group (n = 12), and an EPI + RI group (n = 12). Sixty minutes after induction of general anesthesia, baseline measurement of hemodynamic parameters and arterial blood gas tension was performed. Bupivacaine infusion was started at a rate of 0.5 mg/kg/min and kept until mean arterial blood pressure fell below 40 mmHg and heart rate 40 beats per minute. At this point, bupivacaine infusion was stopped and resuscitation was started, with epinephrine in EPI group and epinephrine combined with regular insulin in EPI + RI group. RESULTS: Bupivacaine infusion caused significant decreases in mean arterial blood pressure, heart rate, cardiac output, and systemic vascular resistance and increases in mean pulmonary blood pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, and central venous pressure. The recovery rate of EPI + RI group (8/12) was higher than that of EPI group (2/12). CONCLUSIONS: Combined administration of epinephrine and regular insulin improves outcomes of resuscitation of bupivacaine-induced cardiovascular collapse. Therefore, we believe that prompt administration of insulin should be strongly considered in case of bupivacaine-induced cardiotoxicity.

Anesthetic Management of Premature Infant with Severe Respiratory Distress Syndrome Who Underwent Surgical Closure of Patent Ductus Arteriosus: A case report / 대한마취과학회지

Premature infants with respiratory distress syndrome may have clinically significant shunting through a patent ductus arteriosus (PDA). Left-to-right shunting through the PDA may lead to left ventricular volume overload and pulmonary edema. We present a case of perioperative management for severe respiratory distress syndrome in a premature infant who underwent surgical closure of PDA. Under general anesthesia, the infant was successfully managed by inhaled nitric oxide, high frequency oscillation ventilation with intermittent mandatory ventilation despite intermittent hypoxia. The operation was performed safely in the neonatal intensive care unit.

A Comparison of Hydromorphone-Bupivacaine and Fentanyl-Bupivacaine in Patient Controlled Epidural Analgesia after Thoracotomy / 대한통증학회지

BACKGROUND: Hydromorphone has an intermediate lipid solubility range that falls between morphine and fentanyl. Lipophilic activity during opioid epidural administration is important in relation to both the side effects and analgesic efficacy. The purpose of this study was to compare epidural hydromorphone and fentanyl when concomitantly infused with bupivacaine in patients undergoing a thoracotomy. METHODS: Seventy-seven thoracotomy patients, with patient-controlled epidural analgesia (PCEA), were blindly allocated into two groups [group F (n = 34); 0.1% bupivacaine and fentanyl 5microgram/ml, group H (n = 34); 0.1% bupivacaine and hydromorphone 16microgram/ml)]. The basal PCEA rate and demand dose were 4 ml/hr and 3 ml, respectively. The visual analogue scale (VAS) for pain, and pruritus, sedation and nausea were measured at 6, 12 and 24 hours after the operation. RESULTS: There were no significant differences in the VAS pain scores and the incidences of pruritus, nausea and sedation between the two groups. The total infused volume after 24 hours was lower in H compared to that of F group (P < 0.05). CONCLUSIONS: We conclude that epidural hydromorphone or fentanyl administration has a similar analgesic efficacy and shows similar incidences of side effects, when concomitantly infused with bupivacaine, in the management of acute pain following a thoracotomy.

Herpes Sine Zoster: Is the Cause for the Segmental Intercostal Neuralgia of Unknown Cause?: A case report / 대한통증학회지

Zoster sine herpete (ZSH) is a varicella zoster virus (VZV) reactivation without a zoster that is difficult to diagnose early after onset. This study examined 12 patients who presented with intercostal neuralgia, had no history of trauma, cutaneous eruption and no scar of a herpes zoster on the lesion. Two patients had a vertebral compression fracture. Two patients had a history of a zoster in the other site. No other suspicious findings were observed. Ten of the twelve patients were checked for the IgG and IgM varicellar zoster virus antibody. All the patients tested positive to the Ig G antibody test and only one patient tested positive to the IgM antibody test. One patient was confirmed to have ZSH and the other patients were suspected of having ZSH. All the patients were treated for postherpetic neuralgia, resulting in a significant decrease in the intercostal neuralgia.