Effects of remote ischemic postconditioning on hepatic injury in lipopolysaccharide-induced endotoxemic rats / 대한마취과학회지

Background@#Remote ischemic postconditioning (RIPoC) is induced by several cycles of brief, reversible, mechanical blood flow occlusion, and reperfusion of the distal organs thereby protecting target organs. We investigated if RIPoC ameliorated liver injury in a lipopolysaccharide (LPS)-induced endotoxemic rats. @*Methods@#Protocol 1) Rats were administered LPS and samples collected at 0, 2, 6, 12, and 18 h. 2) After RIPoC at 2, 6, and 12 h (L+2R+18H, L+6R+18H, and L+12R+18H), samples were analyzed at 18 h. 3) RIPoC was performed at 2 h, analysis samples at 6, 12, 18 h (L+2R+6H, L+2R+12H, L+2R+18H), and RIPoC at 6 h, analysis at 12 h (L+6R+12H). 4) Rats were assigned to a control group while in the RIPoC group, RIPoC was performed at 2, 6, 10, and 14 h, with samples analyzed at 18 h. @*Results@#Protocol 1) Liver enzyme, malondialdehyde (MDA), tumor necrosis factor-α (TNF-α), and nuclear factor-κB (NF-κB) levels increased while superoxide dismutase (SOD) levels decreased over time. 2) Liver enzyme and MDA levels were lower while SOD levels were higher in L+12R+18H and L+6R+18H groups when compared with L+2R+18H group. 3) Liver enzyme and MDA levels were lower while SOD levels were higher in L+2R+6H and L+6R+12H groups when compared with L+2R+12H and L+2R+18H groups. 4) Liver enzyme, MDA, TNF-α, and NF-κB levels were lower while SOD levels were higher in RIPoC group when compared with control group. @*Conclusions@#RIPoC attenuated liver injury in the LPS-induced sepsis model by modifying inflammatory and oxidative stress response for a limited period.

Need for an optimal regimen of programmed intermittent epidural bolus administration for maintenance of labor analgesia / 대한마취과학회지

No abstract available.

Oncologic Results of Breast Conserving Surgery under Procedural Sedation in Elderly Patients

PURPOSE: Although surgery is the most frequently implemented treatment modality for breast cancer, many older patients with breast cancer are under- or untreated because of their high incidence of postoperative complications. We assessed the efficacy and safety of breast surgery under procedural sedation in older patients (aged >70 years) by comparing selected clinical and oncologic factors after surgery for breast cancer under general anesthesia versus procedural sedation. METHODS: Of 79 older patients with breast cancer, 49 underwent breast-conserving surgery, 30 under general anesthesia and 19 under procedural sedation, and relevant clinical and oncologic variables were compared and analyzed between groups. RESULTS: The mean age was younger in the general anesthesia group and the mean operation time, hospital stay, and fasting time shorter in the procedural sedation group. There were no statistically significant differences in oncologic results between the two groups during follow-up. CONCLUSION: Breast surgery under procedural sedation is a safe and effective means of reducing tumor burden in older patients with breast cancer when their American Society of Anesthesiologists (ASA) physical status indicates a high risk of life-threatening perioperative complications associated with general anesthesia. And we also found that the oncologic results may be not inferior to same procedure under general anesthesia.

Postoperative emergence agitation and intraoperative sevoflurane sedation under caudal block in children: a randomized comparison of two sevoflurane doses

BACKGROUND: Sub-umbilical surgery under caudal block in conjunction with sevoflurane sedation may be safe in terms of maintaining spontaneous breathing and avoiding complications associated with general anesthesia. However, sevoflurane-induced emergence agitation (EA) continues to be a clinically important phenomenon in children. To compare the incidence of EA in children undergoing sub-umbilical surgery under caudal block with two different doses of sevoflurane.METHODS: Forty children (aged 1–5 years) scheduled to undergo inguinal hernia repair under caudal block with sevoflurane sedation via a face mask were randomized into either the low-dose (1.0%) end-tidal sevoflurane concentration group (Group LS) or the high-dose (2.5%) end-tidal sevoflurane concentration group (Group HS). We monitored EA episodes at 5 and 30 min in the post-anesthetic care unit (PACU) by using the four-point agitation scale and the Pediatric Anesthesia Emergence Delirium (PAED) scale.RESULTS: The four-point agitation scale scores and PAED scores were not different between the groups at 5 min. However, the agitation score was higher in Group HS than in Group LS at 30 min after arriving in the PACU. The time required to recover from sedation was longer in Group HS than in Group LS.CONCLUSIONS: Face-mask sedation with 1.0% sevoflurane in conjunction with caudal block may be more effective than that with 2.5% sevoflurane in preventing EA.

Therapy of thermal injury due to bone cement leakage by cooled normal saline irrigation through epidural catheterization: A case report

A 72-year-old woman was diagnosed with Kümmell's disease of the T12 and L3 vertebrae. During bone cement injection under continuous fluoroscopic guidance, bone cement spread beyond the posterior border of the T12 vertebral body. We halted the injection immediately. A few minutes later, the patient complained of increasing right lower quadrant abdominal pain. This was diagnosed as a preceding sign of neurological complication due to thermal injury. Consequently, we administered an epidural steroid injection, followed by cooled normal saline irrigation through an epidural catheter to minimize and treat the thermal injury. The pain gradually decreased after saline irrigation and completely disappeared after approximately 10 minutes. After completing the percutaneous vertebroplasty, the patient's lower back pain improved without neurological complications. In conclusion, immediate epidural steroid injection followed by cooled normal saline irrigation through epidural catheterization can be used to treat thermal injury due to bone cement leakage.

Beneficial Role of Hydrogen Sulfide in Renal Ischemia Reperfusion Injury in Rats

PURPOSE: Hydrogen sulfide (H2S) is an endogenous gaseous molecule with important physiological roles. It is synthesized from cysteine by cystathionine γ-lyase (CGL) and cystathionine β-synthase (CBS). The present study examined the benefits of exogenous H2S on renal ischemia reperfusion (IR) injury, as well as the effects of CGL or CBS inhibition. Furthermore, we elucidated the mechanism underlying the action of H2S in the kidneys. MATERIALS AND METHODS: Thirty male Sprague-Dawley rats were randomly assigned to five groups: a sham, renal IR control, sodium hydrosulfide (NaHS) treatment, H2S donor, and CGL or CBS inhibitor administration group. Levels of blood urea nitrogen (BUN), serum creatinine (Cr), renal tissue malondialdehyde (MDA), and superoxide dismutase (SOD) were estimated. Histological changes, apoptosis, and expression of mitogen-activated protein kinase (MAPK) family members (extracellular signal-regulated kinase, c-Jun N-terminal kinase, and p38) were also evaluated. RESULTS: NaHS attenuated serum BUN and Cr levels, as well as histological damage caused by renal IR injury. Administration of NaHS also reduced oxidative stress as evident from decreased MDA, preserved SOD, and reduced apoptotic cells. Additionally, NaHS prevented renal IR-induced MAPK phosphorylation. The CGL or CBS group showed increased MAPK family activity; however, there was no significant difference in the IR control group. CONCLUSION: Exogenous H2S can mitigate IR injury-led renal damage. The proposed beneficial effect of H2S is, in part, because of the anti-oxidative stress associated with modulation of the MAPK signaling pathways.

Regional anesthetic management of elderly patients

In general, elderly patients are less able to respond to perioperative stress and are more likely to suffer from postoperative complications and even death because of the decline in their functional organ reserve. Although no definitive evidence indicates that regional anesthesia is superior to general anesthesia in terms of the long-term prognosis in the elderly, regional anesthesia appears to be beneficial in many ways because it reduces bleeding during surgery, the stress response, and the incidence of thromboembolic complications, as well as facilitating excellent postoperative pain control. However, some issues specific to the elderly should also be considered. Age-related anatomical changes in elderly patients may make it difficult to perform epidural and spinal anesthesia, and physiologic and pharmacodynamic responses to local anesthetics may change with age. Elderly patients also show a greater extent of sensory and motor block, and are at a greater risk of hypotension after epidural and spinal block. In order to provide optimal anesthetic care and to facilitate a rapid recovery and improved outcomes in elderly patients, clinicians must have a better understanding of age-related changes when regional anesthesia is administered. Additionally, tailored anesthetic techniques should be used, as well as good perioperative care, in accordance with the type of surgery and the individual physical status of elderly patients.

PONV prevention: still not enough / 대한마취과학회지

No abstract available.

Treatment of radiation-induced cystitis and vulvodynia via a ganglion impar block using a lateral approach under computed tomography guidance: a case report / 대한마취과학회지

Adjuvant radiation therapy (RT) after colorectal cancer surgery can prevent local recurrence, but has several side effects. Precise injection of drugs into the affected areas is complicated by radiation-induced fibrosis of soft or connective tissue. A 48-year-old woman experienced severe intractable perineal pain, dysuria, urinary urgency, and frequent urination after rectal cancer surgery and adjuvant RT, and was diagnosed with radiation-induced cystitis and vulvodynia. Her symptoms persisted despite two fluoroscopy-guided ganglion impar blocks. Fluoroscopy revealed atypical needle tip positioning and radiolucent dye distribution, presumably due to radiation-induced fibrosis in the target region. We performed two computed tomography (CT)-guided ganglion impar blocks by using a lateral approach, which allowed more accurate po-sitioning of the needle tip. Her pain visual analog score decreased from 9 to 3, and she recently resumed sexual intimacy. CT guidance is a viable alternative to fluoroscopy guidance when performing ganglion impar blocks in fibrotic areas.

Postdural puncture headache / 대한마취과학회지

Postdural puncture headache (PDPH) is a common complication after inadvertent dural puncture. Risks factors include female sex, young age, pregnancy, vaginal delivery, low body mass index, and being a non-smoker. Needle size, design, and the technique used also affect the risk. Because PDPH can be incapacitating, prompt diagnosis and treatment are mandatory. A diagnostic hallmark of PDPH is a postural headache that worsens with sitting or standing, and improves with lying down. Conservative therapies such as bed rest, hydration, and caffeine are commonly used as prophylaxis and treatment for this condition; however, no substantial evidence supports routine bed rest and aggressive hydration. An epidural blood patch is the most effective treatment option for patients with unsuccessful conservative management. Various other prophylactic and treatment interventions have been suggested. However, due to a lack of conclusive evidence supporting their use, the potential benefits of such interventions should be weighed carefully against the risks. This article reviews the current literature on the diagnosis, risk factors, pathophysiology, prevention, and treatment of PDPH.

Bronchoconstriction following instillation of phenylephrine eye drops in premature infants with bronchopulmonary dysplasia: two cases report / 대한마취과학회지

Premature infants requiring an ophthalmic examination or even surgery for retinopathy of prematurity (ROP) have a high prevalence of co-existing bronchopulmonary dysplasia (BPD). Reactive airway is one of the clinical presentations of BPD. We report two cases of bronchoconstriction following instillation of mydriatic eye drops. One occurred during induction of anesthesia for laser photocoagulation and the other before screening of ROP. The most likely cause in each case was phenylephrine eye drops. We recommend that the minimal dosage of phenylephrine needed to attain proper mydriasis should be instilled to infant patients, and the possibility of bronchoconstriction occurrence kept in mind, especially for infants with low body weight with BPD.

Unexpected and severe postintubation croup after a very short day surgery in a pediatric patient: a case report / 대한마취과학회지

An 18 month-old boy underwent endoscopic foreign body removal under anesthesia on an outpatient basis and the operation took approximately 5 minutes. Stridor developed in both lung fields 6 hours after emergence from anesthesia, and severe croup developed, with cyanosis of the lips and aggravated stridor 20 hours after the end of the procedure. The croup resolved with oxygen therapy, intravenous dexamethasone, and epinephrine nebulization therapy. In this report, we suggest that thorough investigations of the patient's past history, including history of any airway problems, and careful monitoring after emergence from anesthesia be done in order to decide the proper discharge time of the patient. Further, proper prophylaxis following risk stratification is important, especially in patients at high risk of postoperative airway obstruction.

Unexpected and severe postintubation croup after a very short day surgery in a pediatric patient: a case report / 대한마취과학회지

An 18 month-old boy underwent endoscopic foreign body removal under anesthesia on an outpatient basis and the operation took approximately 5 minutes. Stridor developed in both lung fields 6 hours after emergence from anesthesia, and severe croup developed, with cyanosis of the lips and aggravated stridor 20 hours after the end of the procedure. The croup resolved with oxygen therapy, intravenous dexamethasone, and epinephrine nebulization therapy. In this report, we suggest that thorough investigations of the patient's past history, including history of any airway problems, and careful monitoring after emergence from anesthesia be done in order to decide the proper discharge time of the patient. Further, proper prophylaxis following risk stratification is important, especially in patients at high risk of postoperative airway obstruction.

Anaphylactic Shock Following Intravenous Injection of Cisatracurium and Sufentanil During Anesthesia Induction / 계명의대학술지

Anaphylaxis under general anesthesia is rare but can present as cardiovascular collapse, airway obstruction, and/or skin manifestation. A high level of suspicion is required for the recognition and prompt management and anaphylaxis can be diagnosed through clinical findings. The most common causes of anaphylaxis during general anesthesia are neuromuscular blocking agents, antibiotics, and latex. We present a case of anaphylactic shock following intravenous injection of cisatracurium and sufentanil. The patient was under anesthesia induction and within minutes after injection of these drugs, generalized erythema, bronchospasm, and severe hypotension developed. The Patient was managed with epinephrine, proper hydration, hydrocortisone, and pheniramine and the surgery was decided to be postponed. Subsequent surgery should be performed after conducting skin tests which can help identify the causal agents and determine alternative drugs. Anesthesiologists should be aware that not only expeditious diagnosis and management of anaphylaxis but also further evaluation in order to determine the safe method of subsequent anesthesia.

Neuraxial analgesia: a review of its effects on the outcome and duration of labor / 대한마취과학회지

Labor pain is one of the most challenging experiences encountered by females during their lives. Neuraxial analgesia is the mainstay analgesic for intrapartum pain relief. However, despite the increasing use and undeniable advantages of neuraxial analgesia for labor, there have been concerns regarding undesirable effects on the progression of labor and outcomes. Recent evidence indicates that neuraxial analgesia does not increase the rate of Cesarean sections, although it may be associated with a prolonged second stage of labor and an increased rate of instrumental vaginal delivery. Even when neuraxial analgesia is administered early in the course of labor, it is not associated with an increased rate of Cesarean section or instrumental vaginal delivery, nor does it prolong the labor duration. These data may help physicians correct misconceptions regarding the adverse effects of neuraxial analgesia on labor outcome, as well as encourage the administration of neuraxial analgesia in response to requests for pain relief.

Antiallodynic effects of vitamin C and vitamin E in chronic post-ischemia pain rat model / 대한마취과학회지

BACKGROUND: Recent research has shown that reactive oxygen species (ROS) play a significant role in the development and persistence of neuropathic pain through central sensitization via N-methyl-D-aspartate (NMDA) receptor activation. In the present study, we examined whether the intraperitoneal administration of vitamins C and E alone or together could alleviate mechanical allodynia in a chronic post-ischemia pain (CPIP) rat model. METHODS: Vitamins C and E were administered intraperitoneally to 48 male Sprague Dawley rats once per day for 3 days before hindpaw ischemia-reperfusion (I/R) injury was induced. On the third day, the CPIP rat model was produced by inducing ischemia in the left hindpaw by applying an O-ring for 3 h, followed by reperfusion. Three days after reperfusion, hindpaw mechanical allodynia was assessed by measuring the withdrawal response to von Frey filament stimulation. The rats were sacrificed immediately after behavioral testing to determine the phosphorylated NMDA receptor subunit 1 (pNR1) and extracellular-signal-regulated kinases (pERK) levels in the spinal cord. RESULTS: When the antioxidant vitamins C and E were administered intraperitoneally to CPIP rats, I/R injury-induced mechanical allodynia was attenuated, and pNR1 and pERK levels were decreased in the rat spinal cord. Additionally, the co-administration of both vitamins had an increased antiallodynic effect. CONCLUSIONS: The reduced phosphorylated NR1 and ERK levels indicate that vitamins C and E inhibit the modulation of spinal cord neuropathic pain processing. Co-administration of vitamins C and E had a greater antiallodynic effect.

Computed tomography-guided cervical selective transforaminal epidural block for a patient with bilateral anatomical variations of vertebral artery: a case report / 대한마취과학회지

A 56-year-old woman complained of radiating pain to the left arm. She was diagnosed with left-sided foraminal stenosis at the C5-6 level. The neurosurgeon requested a left C6 cervical selective transforaminal epidural block (CSTE). Cervical MRI showed a left-sided large tortuous vertebral artery (VA) at the C5-6 level. Before performing CSTE, a CT angiogram was carried out and showed bilateral tortuous VAs. To minimize adverse events, CSTE was performed with non-particulated steroids and under CT guidance. Following the procedure, the patient's symptoms were relieved completely. Although complication rates of CSTE are generally low, if it occurs, disastrous situation could be. Additionally, if the patient has anatomical variations, the possibility of a complication occurring is greatly increased. It is therefore important to determine whether the patient has any anatomical variations of the VA before performing procedures such as CSTE, and to ensure that needle placement is correct during the procedure and an appropriate drug, such as a non-particulated steroid, is selected.

Rocuronium-induced withdrawal movement: influence of ketorolac or a combination of lidocaine and ketorolac pretreatment / 대한마취과학회지

BACKGROUND: Pain on injection of rocuronium is a common clinical problem. We compared the efficacy of lidocaine, ketorolac, and the 2 in combination as pretreatment for the prevention of rocuronium-induced withdrawal movement. METHODS: For this prospective, randomized, placebo-controlled, double-blind study a total of 140 patients were randomly allocated to one of 4 treatment groups to receive intravenously placebo (saline), lidocaine (20 mg), ketorolac (10 mg), or both (n = 35 for each group), with venous occlusion. The tourniquet was released after 2 min and anesthesia was performed using 5 mg/kg thiopental sodium followed by 0.6 mg/kg rocuronium. The withdrawal response was graded on a 4-point scale in a double-blind manner. RESULTS: The overall incidence of withdrawal movements after rocuronium was 34.3% with lidocaine (P = 0.001), 40% with ketorolac (P = 0.004), and 8.6% with both (P < 0.001), compared with 74.3% with placebo. There was a significantly lower incidence of withdrawal movements in patients receiving the lidocaine/ketorolac combination than in those receiving lidocaine or ketorolac alone (P = 0.009 and 0.002, respectively). The incidence of moderate to severe withdrawal movements was 14.3% with lidocaine, 17.2% with ketorolac, and 2.9% with lidocaine/ketorolac combination, as compared to 45.7% with the placebo. There was no significant difference in withdrawal movement between the lidocaine group and the ketorolac group. CONCLUSIONS: Ketorolac pretreatment had an effect comparable to that of lidocaine in attenuating rocuronium-induced withdrawal movements and the lidocaine/ketorolac combination pretreatment, compared with lidocaine or ketorolac alone, effectively reduced withdrawal movements during rocuronium injection.

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.

Airway obstruction following palatoplasty of a patient with sleep disturbance / 대한마취과학회지

No abstract available.