Multiple epidural fibrin glue patches in a patient with spontaneous intracranial hypotension:A case report

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a condition caused by spontaneous leakage of cerebrospinal fluid, with postural headache as the primary symptom. Orthostatic headache caused by SIH is often not resolved by conservative management. CASE: We performed 15 epidural blood patch treatments in a 43-year-old female patient; however, they were only transiently effective. To improve the patient's SIH and orthostatic headache, epidural fibrin glue patch treatment was attempted. Fibrin glue is a substance that can act as a bio-friendly adhesive by facilitating the coagulation cascade. In our case, 3 epidural fibrin glue patch treatments were performed and the symptoms completely resolved. CONCLUSIONS: The epidural fibrin glue patch may be beneficial for the treatment of refractory postural headaches caused by SIH.

Paraplegia after celiac plexus neurolysis in a patient with pancreatic cancer: A case report and literature review

A 65-year-old male patient underwent C-arm fluoroscopy-guided bilateral celiac plexus neurolysis to relieve peritoneal seeding-related pain associated with pancreatic cancer. Following confirmation of spreading, and no intravascular injection of contrast media, 7.5 ml of 0.25% chirocaine was injected in each side. The pain subsided after the block, with no motor or sensory deficits. Subsequently, celiac plexus neurolysis with 99.8% alcohol was performed using a posterolateral approach under fluoroscopic guidance. The patient was instructed to maintain a prone position for 2 hours while the procedure was performed. Approximately 4 hours later, the patient experienced paralysis of both lower extremities and hypoesthesia. Emergent magnetic resonance imaging of the thoracic and lumbar spine revealed gray matter signal change in the cord and conus medullaris at the T10-L1 level, and decreased perfusion at the T11-T12 vertebral bodies, suggesting spinal cord infarction. The patient remained paraplegic until his death 24 days later.

Radiation safety: a focus on lead aprons and thyroid shields in interventional pain management

C-arm fluoroscopy is useful equipment in interventional pain management because it helps to guide correct needle targeting for the accurate injection and drug delivery. However, due to increased use of C-arm fluoroscopy in various pain procedures, the risk of radiation exposure is a significant concern for pain physicians. The harmful biological effects of ionizing radiation on the human body are well known. It is therefore necessary to strive to reduce radiation exposure. Lead aprons with thyroid shields are the most fundamental radiation protective devices for interventional procedures, and are very effective. However, the operator's radiation safety cannot be guaranteed because pain physicians seem to lack sufficient interest, knowledge, and awareness about radiation safety. Also, inappropriate care and use of radiation protective devices may result in a higher risk of radiation exposure. The purpose of this article was to review the literature on radiation safety with a focus on lead aprons and thyroid shields and present recommendations related to those devices during C-arm fluoroscopic-guided interventions by pain physicians.

The radiation safety education and the pain physicians' efforts to reduce radiation exposure

BACKGROUND: C-arm fluoroscopy equipment is important for interventional pain management and can cause radiation injury to physicians and patients. We compared radiation safety education and efforts to reduce the radiation exposure of pain specialists. METHODS: A survey of 49 pain specialists was conducted anonymously in 2016. The questionnaire had 16 questions. That questionnaire was about radiation safety knowledge and efforts to reduce exposure. We investigated the correlation between radiation safety education and efforts of radiation protection. We compared the results from 2016 and a published survey from 2011. RESULTS: According to the 2016 survey, all respondents used C-arm fluoroscopy in pain interventions. Nineteen respondents (39%) had received radiation safety education. Physicians had insufficient knowledge about radiation safety. When the radiation safety education group and the non-education group are compared, there was no significant difference in efforts to reduce radiation exposure and radiation safety knowledge. When the 2011 and 2016 surveys were compared, the use of low dose mode (P = 0.000) and pulsed mode had increased significantly (P = 0.001). The number checking for damage to radiation protective garments (P = 0.000) and use of the dosimeter had also increased significantly (P = 0.009). But there was no significant difference in other efforts to reduce radiation exposure. CONCLUSIONS: Pain physicians seem to lack knowledge of radiation safety and the number of physicians receiving radiation safety education is low. According to this study, education does not lead to practice. Therefore, pain physicians should receive regular radiation safety education and the education should be mandatory.

Facilitation of serotonin-induced contraction of rat mesenteric artery by ketamine

Ketamine is an anesthetic with hypertensive effects, which make it useful for patients at risk of shock. However, previous ex vivo studies reported vasodilatory actions of ketamine in isolated arteries. In this study, we reexamined the effects of ketamine on arterial tones in the presence and absence of physiological concentrations of 5-hydroxytryptamine (5-HT) and norepinephrine (NE) by measuring the isometric tension of endothelium-denuded rat mesenteric arterial rings. Ketamine little affected the resting tone of control mesenteric arterial rings, but, in the presence of 5-HT (100~200 nM), ketamine (10~100 µM) markedly contracted the arterial rings. Ketamine did not contract arterial rings in the presence of NE (10 nM), indicating that the vasoconstrictive action of ketamine is 5-HT-dependent. The concentration-response curves (CRCs) of 5-HT were clearly shifted to the left in the presence of ketamine (30 µM), whereas the CRCs of NE were little affected by ketamine. The left shift of the 5-HT CRCs caused by ketamine was reversed with ketanserin, a competitive 5-HT(2A) receptor inhibitor, indicating that ketamine facilitated the activation of 5-HT(2A) receptors. Anpirtoline and BW723C86, selective agonists of 5-HT(1B) and 5-HT(2B) receptors, respectively, did not contract arterial rings in the absence or presence of ketamine. These results indicate that ketamine specifically enhances 5-HT(2A) receptor-mediated vasoconstriction and that it is vasoconstrictive in a clinical setting. The facilitative action of ketamine on 5-HT(2A) receptors should be considered in ketamine-induced hypertension as well as in the pathogenesis of diseases such as schizophrenia, wherein experimental animal models are frequently generated using ketamine.

Amyotrophic lateral sclerosis diagnosed after lumbar epidural block for treating low back pain: Two cases report

Lumbar epidural block is one of effective methods for treating low back pain with or without radiculopathy. However, neurologic complications can occur after epidural block due to several causes such as direct nerve injury or epidural hematoma. It is important to determine whether the neurologic complication is related to the procedure or is due to the underlying neurologic disease. We report two cases of patients who complained of weakness in their lower extremities after receiving a lumbar epidural block; they were ultimately diagnosed with amyotrophic lateral sclerosis.

The Radiation Exposure of Radiographer Related to the Location in C-arm Fluoroscopy-guided Pain Interventions

BACKGROUND: Although a physician may be the nearest to the radiation source during C-arm fluoroscope-guided interventions, the radiographer is also near the fluoroscope. We prospectively investigated the radiation exposure of radiographers relative to their location. METHODS: The effective dose (ED) was measured with a digital dosimeter on the radiographers' left chest and the side of the table. We observed the location of the radiographers in each procedure related to the mobile support structure of the fluoroscope (Groups A, M and P). Data about age, height, weight, sex, exposure time, radiation absorbed dose (RAD), and the ED at the radiographer's chest and the side of the table was collected. RESULTS: There were 51 cases for Group A, 116 cases for Group M and 144 cases for Group P. No significant differences were noted in the demographic data such as age, height, weight, and male to female ratio, and exposure time, RAD and ED at the side of the table. Group P had the lowest ED (0.5 +/- 0.8 microSv) of all the groups (Group A, 1.6 +/- 2.3 microSv; Group M, 1.3 +/- 1.9 microSv; P < 0.001). The ED ratio (ED on the radiographer's chest/ED at the side of the table) of Group A was the highest, and the ED radio of Group P was the lowest of all the groups (Group A, 12.2 +/- 21.5%; Group M, 5.7 +/- 6.5%; Group P, 2.5 +/- 6.7%; P < 0.001). CONCLUSIONS: Radiographers can easily reduce their radiation exposure by changing their position. Two steps behind the mobile support structure can effectively decrease the exposure of radiographers by about 80%.

The influence of different mechanical ventilator settings of peak inspiratory pressure on stroke volume variation in pediatric cardiac surgery patients / 대한마취과학회지

BACKGROUND: The usefulness of dynamic parameters derived by heart-lung interaction for fluid responsiveness in pediatric patients has been revealed. However, the effects of peak inspiratory pressure (PIP) that could affect the absolute values and the accuracy in pediatric patients have not been well established. METHODS: Participants were 30 pediatric patients who underwent ventricular septal defect repair. After completion of surgical procedure and sternum closure, mean arterial blood pressure, heart rate, central venous pressure, cardiac output, cardiac index and stroke volume variation (SVV) were measured at PIP 10 cmH2O (PIP10), at PIP 15 cmH2O (PIP15), at PIP 20 cmH2O (PIP20) and at PIP 25 cmH2O (PIP25). RESULTS: SVV at PIP15 was larger than that at PIP10 (13.7 +/- 2.9% at PIP10 vs 14.7 +/- 2.5% at PIP15, P < 0.001) and SVV at PIP20 was larger than that at PIP10 and PIP15 (13.7 +/- 2.9% at PIP10 vs 15.4 +/- 2.5% at PIP20, P < 0.001; 14.7 +/- 2.5% at PIP15 vs 15.4 +/- 2.5% at PIP20, P < 0.001) and SVV at PIP25 was larger than that at PIP10 and PIP15 and PIP20 (13.7 +/- 2.9% at PIP10 vs 17.4 +/- 2.4% at PIP25, P < 0.001; 14.7 +/- 2.5% at PIP15 vs 17.4 +/- 2.4% at PIP25, P < 0.001; 15.4 +/- 2.5% at PIP20 vs 17.4 +/- 2.4% at PIP25, P < 0.001). CONCLUSIONS: SVV is affected by different levels of PIP in same patient and under same volume status. This finding must be taken into consideration when SVV is used to predict fluid responsiveness in mechanically ventilated pediatric patients.

Radiation Exposure of the Hand and Chest during C-arm Fluoroscopy-Guided Procedures

BACKGROUND: The C-arm fluoroscope is an essential tool for the intervention of pain. The aim of this study was to investigate the radiation exposure experienced by the hand and chest of pain physicians during C-arm fluoroscopy-guided procedures. METHODS: This is a prospective study about radiation exposure to physicians during transforaminal epidural steroid injection (TFESI) and medial branch block (MBB). Four pain physicians were involved in this study. Data about effective dose (ED) at each physician's right hand and left side of the chest, exposure time, radiation absorbed dose (RAD), and the distance from the center of the X-ray field to the physician during X-ray scanning were collected. RESULTS: Three hundred and fifteen cases were included for this study. Demographic data showed no significant differences among the physicians in the TFESIs and MBBs. In the TFESI group, there was a significant difference between the ED at the hand and chest in all the physicians. In physician A, B and C, the ED at the chest was more than the ED at the hand. The distance from the center of the X-ray field to physician A was more than that of the other physicians, and for the exposure time, the ED and RAD in physician A was less than that of the other physicians. In the MBB group, there was no difference in the ED at the hand and chest, except for physician D. The distance from the center of the X-ray field to physician A was more than that of the other physicians and the exposure time in physician A was less than that of the other physicians. CONCLUSIONS: In conclusion, the distance from the radiation source, position of the hand, experience and technique can correlate with the radiation dose.

Pneumomediastinum after arthroscopic shoulder surgery: A case report / 대한마취과학회지

An 86-year-old female with a history of right rotator cuff injury was admitted for arthroscopic shoulder surgery under general anesthesia. There were no remarkable immediate postoperative complications. However, while recovering in the general ward, she developed dyspnea with hypoxia. She was immediately treated with oxygen, and antibiotics after pneumomediastinum was confirmed on both chest x-ray and chest computed tomography. Subcutaneous emphysema on either face or neck followed by arthroscopic shoulder surgery was common, but pneumomediastinum with hypoxia is a rare but extremely dangerous complication. Thus we would like to report our case and its pathology, the diagnosis, the treatment and prevention, with literature review.

A Randomized Controlled Trial about the Levels of Radiation Exposure Depends on the Use of Collimation C-arm Fluoroscopic-guided Medial Branch Block

BACKGROUND: C-arm fluoroscope has been widely used to promote more effective pain management; however, unwanted radiation exposure for operators is inevitable. We prospectively investigated the differences in radiation exposure related to collimation in Medial Branch Block (MBB). METHODS: This study was a randomized controlled trial of 62 MBBs at L3, 4 and 5. After the patient was laid in the prone position on the operating table, MBB was conducted and only AP projections of the fluoroscope were used. Based on a concealed random number table, MBB was performed with (collimation group) and without (control group) collimation. The data on the patient's age, height, gender, laterality (right/left), radiation absorbed dose (RAD), exposure time, distance from the center of the field to the operator, and effective dose (ED) at the side of the table and at the operator's chest were collected. The brightness of the fluoroscopic image was evaluated with histogram in Photoshop. RESULTS: There were no significant differences in age, height, weight, male to female ratio, laterality, time, distance and brightness of fluoroscopic image. The area of the fluoroscopic image with collimation was 67% of the conventional image. The RAD (29.9 +/- 13.0, P = 0.001) and the ED at the left chest of the operators (0.53 +/- 0.71, P = 0.042) and beside the table (5.69 +/- 4.6, P = 0.025) in collimation group were lower than that of the control group (44.6 +/- 19.0, 0.97 +/- 0.92, and 9.53 +/- 8.16), resepectively. CONCLUSIONS: Collimation reduced radiation exposure and maintained the image quality. Therefore, the proper use of collimation will be beneficial to both patients and operators.

Spectral entropy for assessing the depth of propofol sedation / 대한마취과학회지

BACKGROUND: For patients in the intensive care unit (ICU) or under monitored anesthetic care (MAC), the precise monitoring of sedation depth facilitates the optimization of dosage and prevents adverse complications from underor over-sedation. For this purpose, conventional subjective sedation scales, such as the Observer's Assessment of Alertness/Sedation (OAA/S) or the Ramsay scale, have been widely utilized. Current procedures frequently disturb the patient's comfort and compromise the already well-established sedation. Therefore, reliable objective sedation scales that do not cause disturbances would be beneficial. We aimed to determine whether spectral entropy can be used as a sedation monitor as well as determine its ability to discriminate all levels of propofol-induced sedation during gradual increments of propofol dosage. METHODS: In 25 healthy volunteers undergoing general anesthesia, the values of response entropy (RE) and state entropy (SE) corresponding to each OAA/S (5 to 1) were determined. The scores were then analyzed during each 0.5 mcg/ml- incremental increase of a propofol dose. RESULTS: We observed a reduction of both RE and SE values that correlated with the OAA/S (correlation coefficient of 0.819 in RE-OAA/S and 0.753 in SE-OAA/S). The RE and SE values corresponding to awake (OAA/S score 5), light sedation (OAA/S 3-4) and deep sedation (OAA/S 1-2) displayed differences (P < 0.05). CONCLUSIONS: The results indicate that spectral entropy can be utilized as a reliable objective monitor to determine the depth of propofol-induced sedation.

Development of complex regional pain syndrome at independent arm associated with lateral decubitus position: A case report

A 27-year-old man underwent excision of a mediastinal mass using video-assisted thoracoscopic surgery (VATS) performed in the right lateral position. Postoperatively, he complained of pain in the left upper arm and chest wall, limitation of the left shoulder joint, allodynia, hyperalgesia, spontaneous pain in left finger, edema, hypohidrosis, and change of skin color of the left hand. We diagnosed the patient with complex regional pain syndrome (CRPS) by using the proposed modified International Association of the Study of Pain (IASP) research diagnostic criteria, and initiated treatment through medication and interventional management. After 3 months of treatment, the pain intensity reduced to below 2 cm on the VAS. In this study, we describe a case of postoperative CRPS, which is believed to have been caused by excessive stretching of the brachial plexus. Careful positioning of patients on the operating table with proper padding will reduce injuries to the peripheral nerves.

Assessment of coagulation with 6% hydroxyethyl starch 130/0.4 in cesarean section / 대한마취과학회지

BACKGROUND: Third-generation hydroxyethyl starch (HES) solutions have been developed to minimize negative effects on hemostasis. In normal pregnancy, the coagulation activity increases, reaching a maximum around term. This study examined the effects of hemodilution with HES 130/0.4 (6%) on blood coagulation in parturients in vivo and in vitro. METHODS: Forty parturients scheduled for cesarean sections were assigned randomly to receive either 500 or 1,000 ml of HES 130/0.4 (6%). Rotation thromboelastometry (ROTEM(R)) measurements were performed before and after administering HES 130/0.4 (6%). In addition, blood samples obtained from 20 randomly selected parturients were diluted 10% to 40% using HES 130/0.4 (6%), and ROTEM(R) measurements were performed before and after dilution. The changes from baseline and the effects of dilution were analyzed by ROTEM(R) parameters. RESULTS: Infusions of 500 or 1,000 ml of HES 130/0.4 (6%) in the parturients altered the clot formation time, alpha angle, and maximal clot firmness, although all remained within normal ranges. HES 130/0.4 (6%) affected in vitro blood coagulation in parturients' blood containing 10, 20, 30, and 40% HES. The clotting time was prolonged at each dilution percentage, but remained within the normal range. Other parameters showed an impairment of the coagulation system. CONCLUSIONS: Blood coagulation in parturients may be compromised at high dilution ratios of HES 130/0.4 (6%) to blood. Nevertheless, the infusion of 1,000 ml of HES 130/0.4 (6%) in normal parturients did not significantly affect blood coagulation.

A Study to Compare the Radiation Absorbed Dose of the C-arm Fluoroscopic Modes

BACKGROUND: Although many clinicians know about the reducing effects of the pulsed and low-dose modes for fluoroscopic radiation when performing interventional procedures, few studies have quantified the reduction of radiation-absorbed doses (RADs). The aim of this study is to compare how much the RADs from a fluoroscopy are reduced according to the C-arm fluoroscopic modes used. METHODS: We measured the RADs in the C-arm fluoroscopic modes including 'conventional mode', 'pulsed mode', 'low-dose mode', and 'pulsed + low-dose mode'. Clinical imaging conditions were simulated using a lead apron instead of a patient. According to each mode, one experimenter radiographed the lead apron, which was on the table, consecutively 5 times on the AP views. We regarded this as one set and a total of 10 sets were done according to each mode. Cumulative exposure time, RADs, peak X-ray energy, and current, which were viewed on the monitor, were recorded. RESULTS: Pulsed, low-dose, and pulsed + low-dose modes showed significantly decreased RADs by 32%, 57%, and 83% compared to the conventional mode. The mean cumulative exposure time was significantly lower in the pulsed and pulsed + low-dose modes than in the conventional mode. All modes had pretty much the same peak X-ray energy. The mean current was significantly lower in the low-dose and pulsed + low-dose modes than in the conventional mode. CONCLUSIONS: The use of the pulsed and low-dose modes together significantly reduced the RADs compared to the conventional mode. Therefore, the proper use of the fluoroscopy and its C-arm modes will reduce the radiation exposure of patients and clinicians.

The effects of magnesium on the course of atrial fibrillation and coagulation in patients with atrial fibrillation undergoing mitral valve annuloplasty / 대한마취과학회지

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia. Magnesium has been reported to be effective in reducing the incidence or prophylaxis of AF. Magnesium is also an essential constituent of many enzyme systems and plays a physiological role in coagulation regulation. The aim of the present study was to examine the effects of magnesium, whether magnesium infusion might decrease the incidence of AF and induce hypocoagulable state in patients with AF, who were undergoing mitral valve annuloplasty. METHODS: This prospective laboratory study was performed using blood from patients with AF undergoing mitral valve annuloplasty. The radial artery was punctured with a 20 gauge catheter and used for monitoring continuous arterial pressure and blood sampling. After anesthesia induction, 4 g of magnesium was mixed with 100 ml normal saline and infused for 5 minutes. Magnesium, calcium, activated clotting time (ACT) and thromboelastographic parameters were checked before and 60 minutes after the magnesium infusion. The electrocardiography changes after magnesium infusion were also checked before commencing cardiopulmonary bypass. RESULTS: After magnesium infusion, the serum level of magnesium increased significantly but serum calcium did not change significantly. ACT did not change significantly before or after magnesium infusion. The thromboelastographic parameters showed no significant changes before or after magnesium infusion. None of the patients converted to sinus rhythm from AF after the magnesium infusion. CONCLUSIONS: A magnesium infusion did not influence the course of AF and coagulation in patients during prebypass period with AF undergoing mitral valve annuloplasty.

Combined general-epidural anesthesia for cesarean section in acute fatty liver of pregnancy under monitoring bispectral index: A case report

Acute fatty liver of pregnancy is a rare but usually fatal complication of the third trimester. We report the case of a 28-year-old primigravida at 37 weeks of gestation with an acute fatty liver. Continuous fetal heart rate monitoring demonstrated frequent late fetal heart decelerations and the lack of beat-to-beat variability during the induction of vaginal delivery. We decided to perform an emergency cesarean section under a combined general-epidural anesthesia with bispectral index. No complications occurred during or after surgery except for a delayed recovery from the muscle relaxant. The patient made an uneventful recovery and discharged at eight days after cesarean section.

Incidentally detected laryngeal granuloma during orotracheal intubation under direct laryngoscope: A case report

Intubation granuloma is a delayed complication of endotracheal intubation in adults.The most frequent complaint of the patient with laryngeal granuloma is hoarseness and the most common location of the granuloma is the vocal process of arytenoid cartilage.We report a female patient with incidentally detected granuloma during endotracheal intubation who had no preoperative vocal symptoms.

Anesthetic managements for correction of aortic valve regurgitation in a patient with Loeys-Dietz Syndrome: A case report / 대한마취과학회지

Loeys-Dietz Syndrome (LDS) is a recently described autosomal dominant aortic aneurysm syndrome with widespread systemic involvement. It is characterized by the triad of 1) arterial tortuosity and aneurysms, 2) hypertelorism, and 3) bifid uvula or cleft palate. A 12-year-old boy with LDS was scheduled to undergo correction of aortic valve regurgitation due to aortic annuloectasia. We report our clinical experiences of a case of LDS patient with brief review of related literatures and relevant anesthetic problems.

Nucleoplasty in a patient with cervical disc extrusion with radiating pain of an upper extremity

Conventional open discectomy is considered as the standard treatment for cervical disc herniation.However, open discectomy does not always yield a successful result.Nucleoplasty is a newly developed minimal invasive spinal surgery that uses the Coblation technique.The concept of Coblation involves the use of radiofrequency energy to ablate the nucleus pulposus tissue in a controlled approach leading to reduction of pressure on the nerve roots.Inclusion criteria for candidates for nucleoplasty include complaints of symptoms related to a contained herniated disc or focal protrusion.We describe here our experience with the use of nucleoplasty for a 49-year-old male patient with a cervical disc extrusion.Percutaneous decompression with nucleoplasty using the Coblation technique for the treatment of cervical disc extrusion was successfully performed with an excellent result.