Low Extremity Weakness after Cervical Epidural Steroid Injection in Previous Spinal Surgery Patient: A case report / 대한마취과학회지

A 46-year-old woman received one cervical epidural injection for the management of her neck and shoulder pain. The patient was placed in the prone position without sedation. By using the "loss of resistance to injection of air" technique, the epidural space was identified at the level of C7-T1 inter-laminar space. After needle placement was confirmed by biplanar fluoroscopy and contrast dye, mixture composed of 20 mg of triamcinolone acetonide and 0.125% chirocaine (6.5 ml total volume) was injected. The patient reported no reaction or signs of spinal cord irritation during needle placement attempt. She was developed both low extremity motor weakness and the repeated MRI of the cervical spine indicated right focal cervical myelopathy. It is unknown whether the neurologic injury sustained by patient was the result of spinal cord penetration by the needle, adverse effects from neural tissue exposure to the injected drug, or a combination of both factors.

The Role of Central Group I mGluRs for CFA-induced Knee Joint Pain Model in Rats / 대한마취과학회지

BACKGROUND: Glutamate is the predominant excitatory neurotransmitter in the central and peripheral nervous system and has known to be involved in nociceptive transmission and central sensitization. It acts through ligand gated ionotropic glutamate receptors (iGluRs) and G protein-coupled metabotropic glutamate receptors (mGluRs). And mGlu 1, 5 receptors have been recognized to play a role in nociceptive processing. We want to investigate whether central mGluR1 and mGluR5 antagonists could reverse the behavioral signs of weight bearing and secondary mechanical hyperalgesia induced by chronic knee joint inflammation. METHODS: MGluR1 antagonist, (RS)-1-aminoindan-1,5-dicarboxylic acid (AIDA: 25, 50, 100 microM/10 microliter, n = 7 per group) and selective mGluR5 antagonist, 2-methyl-6-(phenylethynyl)-pyridine (MPEP: 25, 100, 200 nM/10 microliter, n = 7 per group) were injected intrathecally 5 days after Complete Freund's Adjuvant (CFA, 150 microliter) injection into knee joint and behavior signs of weight bearing and secondary mechanical hyperalgesia were observed. RESULTS: CFA significantly reduced the magnitude of right hind paw weight bearing and decreased the withdrawal threshold to mechanical stimulation compared to contralateral side. Higher dose of AIDA (100 microM) significantly reversed the reduction of weight bearing, but MPEP did not. AIDA reversed the decrease of the paw withdrawal threshold to mechanical stimulation at the dosage of 50 and 100 microM respectively. MPEP significantly increased the paw withdrawal threshold to mechanical stimulation in a dose dependent manner. CONCLUSIONS: Group I mGluRs were involved in maintenance of primary and secondary mechanical hyperalgesia.

The Effects of Intrathecal Midazolam Added to Bupivacaine on Duration of Sensory Block and BIS Sedation Score / 대한마취과학회지

BACKGROUND: The antinociceptive action of intrathecal midazolam is well documented and the administration of midazolam by centroneuraxis route has been shown to produce segmental antinociception. This study was designed to evaluate the duration of sensory block and BIS sedation score of intrathecal midazolam-bupivacaine mixture in patients undergoing knee arthroscopy. METHODS: In this double-blind prospective study, one hundred twenty seven patinets were randomly assigned to receive 4.5 ml of one of the following intrathecal solutions: 15 mg of 0.5% isobaric bupivacaine plus 1.5 ml of 0.9% saline (Group C; n = 34); 15 mg of 0.5% bupivacaine plus 0.5 ml of 0.1% midazolam and normal saline 1 ml mixture (Group 0.5; n = 28); 15 mg of 0.5% bupivacaine plus 1 ml of 0.1% midazolam and normal saline 0.5 ml mixture (Group 1; n = 27); 15 mg of 0.5% bupivacaine plus 1.5 ml of 0.1% midazolam (Group 1.5; n = 38). Time of sensory block until L5-S1 level regression occurred and sedation score using BIS, duration of effective analgesia connecting IV-PCA pump, blood pressure, heart rate, oxygen saturation and nausea/vomiting were recorded and observed. RESULTS: A significantly longer sensory block duration was seen in group 0.5, 1, 1.5 patients compared with group C (P < 0.01). Correlation coefficent of midazolam dose and sensory block duration was 0.95. Duration of effective analgesia was also prolongated in midazolam-bupivacaine mixture groups (P < 0.01). Blood pressure, heart rate, oxygen saturation and nausea/ vomiting showed no differences among the groups. Sedation score was slightly decreased in only group 1.5, but not to the level of unconsciousness. CONCLUSIONS: The results suggest that addition of midazolam 1.5 mg to 0.5% bupivacaine intrathecally provided prolongation of sensory block without any adverse effects.

The Effect of Intraoperative and Postoperative Music on Patients of Regional Anesthesia / 대한마취과학회지

BACKGROUND: Music influences the body and mental well-being of humans. Almost all patients undergoing surgery experience perioperative anxiety. This study was designed to determine the effect of music during surgery and the post-operation period under regional anesthesia on the level of anxiety, relaxation and fatigue. METHODS: Sixty-four patients who underwent orthopedic surgery under regional anesthesia were randomly assigned to Group 1 (listening to music) and Group 2 (no music). The premedication and anesthesia were standardized for both groups. The level of anxiety, fatigue and psychological well-being were examined as outcome variables. RESULTS: The level of anxiety and psychological well-being was significantly lower (anxiety: P = 0.012, psychological well-being: P = 0.006) in Group 1 than in Group 2. The level of fatigue was similar in both groups. CONCLUSIONS: The results suggested that music might be effective in reducing the level of intra and post-operative anxiety and improving the psychological well-being of patients undergoing surgery under regional anesthesia.

Respiratory Complications Due to Nitrous Oxide Impurities Six cases / 대한마취과학회지

The impurities potentially contained in nitrous oxide cylinders include NO, NO2, CO and NH3. The consequences of inahaling NO and NO2 are reflex breathing inhibition with laryngospasm and the rapid onset of intense cyanosis due to altered pulmonary gas exchange and methaemoglobinemia. Pulmonary edema may occur in the acute stage. Chronic chemical pneumonitis may follow with resultant pulmonary fibrosis and the respiratory and metabolic acidosis may also occur. Hypotension may be marked and results from the effects of nitrate and nitrite ions on vascular smooth muscle. Since certain clinical features provide clues that allow practicing anesthetists to recognize the toxicities of higher nitrogen oxides, six of our cases will be described in detail, whereas the remaining cases will be only commented. We examined a N2O cylinder at the National Metrology Institute, its NOX concentration was 2359 ppm. Another two cylinders were also abnormal with NOX concentrations of 547 ppm and 180 ppm. We recommend that medical gases be subjected to quality control on a national basis.

The Effect of Ondansetron and Metoclopramide on the Prevention of Postoperative Nausea and Vomiting After Using Epidural Morphine-Butorphanol Mixture / 대한마취과학회지

BACKGROUND: Neuroaxial morphine may produce nausea and vomiting due to cephalad migration. Though it improves post- operative pain, it may have serious complication delaying recovery. The aim of this study was to investigate the efficacy of prophylactic antiemetics such as conventional metoclopramide or more expensive ondansetron. METHODS: Eighty-seven patients who underwent orthopedic knee arthroscopic surgery under epidural anesthesia were randomly assigned to three groups, which are (a) normal saline intravenous injection control group (Group C), (b) metoclopramide intravenous injection and intranasal spray study group (Group M), (c) ondansetron inravenous injection group (Group O). Before the end of surgery, all patients were given 3 mg of morphine and 2 mg of butorphanol mixture via epidural catheter for postoperative pain control. The anesthesia were all standardized. Post-operative nausea and vomiting were observed and used as outcome variables and postoperative pain, itching, somnolence, dizziness, urinary retention were also observed. RESULTS: The incidence of postoperative nausea was significantly lower in Group M (P = 0.0296) and Group O (P = 0.005) compared with Group C. The incidence of postoperative vomiting was significantly lower in Group O (P = 0.01) compared with Group C. But statistically no difference was noted in vomiting between Group C and Group M (P = 0.0579). CONCLUSIONS: The results suggest that ondansetron and metoclopramide are effective in reducing the incidence of post-operative nausea. But ondansetron is more effective in reducing the incidence of post-operative morphine induced vomiting.

Post-exposure Prophylaxis of Needlestick Injury from Asymptomatic HIV Carrier: A case report / 대한마취과학회지

The incidence of AIDS and related disorders continues to rise sharply these days and anesthesologists may expect to encounter such patients more and more frequently during the performance of routine procedures on the seemingly healthy and during indicated procedures on the sick. AIDS is a disease for which there is no cure, and thus prevention becomes even more important. However, the dangers of this disorder should not be exaggerated. We experienced one case of a subcutaneous injury during spinal anesthesia caused by a stylet of an infected asymptomatic carrier. Postexposure prophylaxis was performed with zidobudine and lamibudine, and enzyme linked immunoassay (ELISA) testing for medical personnel has been repeated three times during last 6 months.

The usefulness of single question for problem drinker

BACKGROUND: Brief intervention with problem drinkers have been shown to be effective, but physicians often do not ask about alcohol use because of time constraints and lack of knowledge. If a sin gle question can be used to screening for problem drinker effectively, primary care physicians could detect problem drinker earlier and reduce future complication and morbidity. The purpose of this study was to evaluate the usefulness of single question. METHODS: One family medicine's resident interviewed 163 patients who visited Dongdaemun Hospital's Health care management center of Ewha Woman's university from January 27th 1999 to February 26th 1999, and the patients answered the written forms of questionnares. This written forms contained the followings: (1) age, sex, education, income level, occupation, smoking, drunken driving, (2) "On any single occasion during the past 3 months have you had more than a bottle of Soju or three bottles of beer or five glasses of whisky?" (3) CAGE, NAST test. Quantity of alcohol was determined by the calendar based review in the past 4 weeks. At risk drinker defined as drinking more than 56 g on one occasion, or more than 196 g of pure alcohol during a week for men ; more than 42 g on one occasion, or more than 98 g of pure alcohol during a week for women. Also alcohol use disorder was defined by the DSM IV criteria and problem drinker was defined as either at risk drinker or a alcohol use disorder. RESULTS: The single question had a positive predictive value of 82.2%, and negative predictive value of 95.5% with a sensitivity of 93.8% and a specificity of 86.9% for problem drinkers. CONCLUSION: A single question about alcohol use would be a effective tool for detecting problem drinker.

Comparison of the time and change test with the Mini Mental status examination as a cognitive screening tool for elderly patients

BACKGROUND: The prevalence of dementia is estimated to be as high as 5 10% over 65 years of age in Korea. It is important to evaluate of dementia for the elderly, because of the chronicity and progressiveness of the disease. However, cognitive impairment often goes unrecognized by physician because the many previous tools to evaluate cognitive function in the clinical setting are complex, time consuming and sometimes questionable correlation with real world functioning. The purpose of this study is to assess the usefulness of The Time and Change test as screening test for dementia ,on the basis of the correlation between this measure(T&C) and MMSE K. METHODS: The subject for this study consisted of 64 elderly who visited to the outpatient department of family medicine of the Ehwa Mok dong hospital or Elderly Welfare Center in Seoul. They received the T&C test and MMSE K examination. Sensitivity, specificity, negative predictive value, and Pearson' Correlation coefficient were calculated using standard formulas. RESULTS: The T&C had a sensitivity of 50%, a specificity of 88 %, a positive predictive value of 69%, a negative predictive value of 77 %, respectably. when timed cutpoints were added, The T&C test had a sensitivity of 95%, specificity of 83 %, a positive predictive value of 75%, a negative predictive value of 97 %. respectibaly. CONCLUSION: The Time and Change(T&C) tests can be an effective, simple and performance based tool to recognize dementia. Further validation with a representative elderly sample is needed to establish screening value in primary care or community populations.

Effect of Changes in Fraction of Inspired Oxygen(F1O2) on Pulmonary Shunt Ratio in Respiratory Intensive Care / 대한마취과학회지

For the purpose of recommending appropriate fraction of inspired oxygen(F1O2) for long term mechanical ventilation support by evaluating the effect of changes in F1O2 on pulmonary shunt ratio in respiratory intensive care, the effects of various F1O2 on pulmonary shunt ratio were investigated and analysed with 20 pediatric intensive care patients who had received open heart surgeries for their congenital heart diseases in the department of Pediatrics, Seoul National University Hospital. The results were as follows ; 1. Through the whole process of control of mechanical ventilation the arterial CO2 tension(PaCO2) showed hyperventilation with the average of 31-34mmHg and pH showed pure respiratory alkalosis with the average of 7.45-7.51. As the fraction of inspired oxygen decreased, the arterial oxygen tension decreased. 2. Inspite of the change of F1O2, analysis of central venous blood gas showed no significant change. 3. The alveolar-arterial oxygen tension difference(AaDO2) was positively related to F1O2. 4. The pulmonary shunt ratio(Q's/Q'T) showed no significant difference in the F1O2 range of 0.6 to 1.0. But the Q's/Q'T in the F1O2 range of 0.3 to 0.4 decreased significantly comparing to that of 0.6 to 1.0 F1O2 range. Linear regression analysis of Q's/Q'T showed that the Q's/Q'T was positively related to F1O2 and AaDO2, respectively.