Stereotactic Neurotomy of the Ganglion Impar through the Sacrococcygeal Junction in Cancer-Related Perianal Pain: A case report / 대한통증학회지

The ganglion impar is a solitary retroperitoneal structure at the caudal end of the paravertebral sympathetic chain. Block of this ganglion has been advocated as a means of managing intractable perineal pain. In 1990, Plancarte et al performed a neurolytic block of the ganglion impar using 4-6 ml of 10% phenol through the intergluteal skin over the anococcygeal ligament. However, technical difficulties are encountered with the placement of the needle while performing this technique, with complications from the injection of phenol also being a possibility. In 1995, a modified approach for blocking the ganglion impar through the sacrococcygeal ligament was introduced by Wemm and Saberski. We used a radiofrequency (RF) lesion generator to create a controlled and localized lesion with a lower incidence of neural damages compared to chemical neurolysis. RF thermocoagulation of the ganglion impar through the sacrococcygeal ligament was performed on a 70-year-old male patient with constant anal pain using a curved TEW electrode. The patient has been relieved of his pain, without serious complication. Therefore, this technique may be an easier and safer approach, which is associated with fewer chances of complications.

Experimental Radiofrequency Lesion Size Utilizing Different Parameters and Neuropathologic Correlation on the Peripheral Nerve / 대한마취과학회지

BACKGROUND: Radiofrequency (RF) lesioning is one of the most frequently used neurolytic techniques for the relief of pain. Technical advances enables one to make a more reliable and reproducible lesion production. If the size at different parameters is known, the maximal effects and reduction of the side effects could be achieved. However, its size can not be measured systematically using thermocouple (TC) electrodes. 'Differential selection of pain fibers' was proposed but there was not any neuropathologic evidence. We studied pathologic changes produced with various sizes and shapes of electrodes using different parameters. METHODS: Using fresh egg white, RF lesions were produced by four different electrodes at 65, 70, 75, 80 and 90degreesC. At each temperature, Photographs were taken at 10, 20, 30, 40, 50, 60, 90 and 120 seconds. Using the sciatic nerve of the rats, we performed RF lesioning utilizing two different electrodes at 70, 80 and 90degreesC and dissected them 1, 7, and 30 days after treatment. The pathologic changes of lesions were studied and analyzed by applying a quantitative experimental scoring system on the light and electron microscopy (LM and EM). RESULTS: The lesion size increased with a higher temperature and larger electrode. Among the electrodes with the same thickness, the lesion size with the longer electrode was larger than the shorter one. In a histopathologic study, there were significant changes with time, but no significant changes with different electrode and temperature. On electron microscope (EM), large myelinated fibers were relatively intact on RF lesion of 80degreesC after 1 day. 7 days after treatment, there were significant inflammatory cell infiltration and axonal regeneration. At 30 days after the same treatment, there were relatively large amount of small myelinated fibers and unmyelinated fibers. CONCLUSIONS: We measured the lesions systematically with different parameters expecting the result can be used as the reference for the RF lesion. There were no histopathologic differences on LM at different electrodes and temperatures. But we found the evidence of 'differential selection of pain fibers' with 22 gauge electrode at 80degreesC. And also we found the axonal regeneration as early as 1 week later. We learned the neuropathic pain can be induced by pathologic changes, such as bleb formation, inflammatory cell infiltration and predominance of small myelinated and unmyelinated fibers.

The Spectral Analysis of EEG according to Change in the Concentration of Isoflurane / 대한마취과학회지

BACKGROUND: Adequate depth of anesthesia requires a sufficient amount of the agent to secure unconsciousness and other components of anesthesia as needed for that particular surgical procedure, without jeopardizing vital organ functions. To evaluate the relationship of depth of anesthesia to EEG, we studied the effects of increasing minimum alveolar concentration (MAC) of isoflurane (arousal, 1, 1.3, 1.5 MAC) on power spectral analysis of the EEG. METHODS: To determine 1 MAC, we studied sixty patients undergoing general anesthesia who were randomly allocated to receive isoflurane at several predetermined end-tidal concentration. A minimum of 15 min was allowed between induction and skin incision to allow steady state condition. Patients were observed for gross purposeful movement for 60 seconds after incision. The MAC was calculated using maximum likelihood solution to a logistic regression model. Another forty patients were randomly allocated to have their EEGs recorded. General anesthesia was induced with oxygen and isoflurane only. After loss of consciousness, succinylcholine 1.5 mg/kg was given and intubation followed. The EEG was recorded awake and after 15 min at steady state conditions of 1, 1.3 and 1.5 MAC isoflurane had been achieved. Spectral edge frequency 95% (SEF95), median spectral frequency (MSF), total power (TP) and relative power in the delta, theta, alpha and beta band were calculated. RESULTS: The MAC of isoflurane was 1.21 vol% (20 - 40 years) and 1.09 vol% (40 - 60 years). The distribution of spectral EEG indices of the EEGs were established and compared. The threshold value of SEF95 14 Hz to differentiate between arousal and 1.3 and 1.5 MAC had a sensitivity of 60.5% (1.3 MAC), 71% (1.5 MAC) and specificity of 74.4% (1.3 and 1.5 MAC) and that of MSF 5 Hz had a sensitivity of 71% (1.3 MAC), 81.5% (1.5 MAC) and specificity of 48% (1.3 MAC), 48.8% (1.5 MAC). CONCLUSIONS: With regard to the dose-related decrease in SEF95 and MSF under increasing end- expiratory concentrations of isoflurane as described in the present study, future studies may have todetermine whether EEG feedback control of volatile anesthetic administration may be used successfully. It seems that if neglected parts by MSF and SEF95, which are really true values are considered in the future studies, those would increase the sensitivity and specificity of EEG could be used as tool for determining depth of anesthesia.

A Comparison of the Size and Shape of Radiofrequency Lesions Produced by Different Temperatures Using Straight and Curved Electrodes / 대한마취과학회지

BACKGROUND: Understanding the electrophysiology of radiofrequency (RF) lesions and determining the size and shape of RF lesions is important for reducing side effects when applied to patients in a clinical setting. We compared the shape and size of RF thermocoagulation produced by straight and curved 20-gauge electrodes and considered its application in clinical settings. METHODS: The white from a fresh hen's egg was warmed to 37oC and placed in a rectangular glass container. Straight and curved 20-gauge electrodes were immersed. The transparency of the egg white and the glass container made it possible to photograph the changes in size of the RF lesions over time. We applied thermocoagulation for 60 seconds at 70, 80, and 90oC. Photographs were taken at 60 seconds. We measured the maximal size of the lesions. A two-way statistical analysis of variance was performed. RESULTS: The thermocoagulations were started at the junction of the insulated and uninsulated portion of the electrode and did not extended beyond the tip. The thermocoagulation size was 4.2 +/- 0.8 at 70oC, 6.1 +/- 2.9 at 80oC and 6.1 +/- 1.9 at 90oC using the 20-gauge, 10 mm active tip, straight electrode and 4.5 +/- 1.1 at 70oC, 7.2 +/- 1.9 at 80oC and 7.9 +/- 2.7 at 90oC using the 20-gauge, 10 mm active tip, curved electrode. There was no observable difference in the size of the lesions produced by the straight and curved electrodes. CONCLUSIONS: We found that temperature was the more important factor in determining lesion size. When the temperature setting is the same, lesions produced by straight and curved electrode of the same gauge are also same size. Therefore the choice of straight or curved electrode should be made to optimize ease of handling and ensure proper location of the electrode tip.

Percutaneous Cordotomy Using Thermocouple Electrodes / 대한마취과학회지

Effective noninvasive modalities such as radiotherapy and pharmacologic treatments have become highly developed in the treatment of intractable cancer pain. Although epidural narcotics have been considered particularly useful, limitations still remain in their effectiveness for some patients. Surgical therapy can be a useful alternative to these treatments. Cordotomy is one of the most effective surgical treatments. The first percutaneous cordotomy was attempted by Mullan and his associates in 1963. Rosomoff and his associates modified the procedure using radiofrequency two years later. Cordotomy was widely used by the late 1960's but due to its limited effectiveness and serious complications it was abandoned until 1980 when a new electrode was developed by Levin. A thermocouple cordotomy electrode such as the Levin electrode allows monitoring of impedance and tissue temperature. A radiofrequency lesion can be made by increasing the current directly to the desired temperature rather than by gradual heating with the usual incremental increases in lesion current and time. With the use of this electrode, consistent clinical effects are assured and operating time is reduced. The chances of boiling or charring are also minimized. Since this electrode was developed, cordotomy has received renewed attention virtually everywhere except in Korea. Five terminal cancer patients in whom conservative treatments had failed were treated by cordotomy using the three types of thermocouple electrodes: the levin cordotomy electrode; the TCE thermocouple electrode, and the Kanpolat CT electrode. Due to the small number of patients, a comparison of the effectiveness of these three types could not be made. Although complete pain relief was not achieved in every case, dosages of narcotics could be reduced as a result of this procedure. There were no serious complications except a transient paralysis of the ipsilateral arm in one case and headaches in four cases.

Intravenous Regional Block of Bretylium: Treatment of Reflex Sympathetic Dystrophy / 대한마취과학회지

BACKGROUND: Interruption of efferent sympathetic fibers is the mainstay of therapy in reflex sympathetic dystrophies(RSD) and be accomplished by temporary or permanent anesthetic blockade of sympathetic ganglia, surgical lesions of the sympathetic trunk, intravenous injecton of guanethidine or reserpine, or by systemic administration of adrenergic blocking drugs. In this study, the effects and the side effects of intravenous regional bretylium for the treatment of RSD were studied. METHODS: Seven patients have been administered with 2.0 mg/kg bretylium in 0.25% lidocaine with 100U of heparin three times weekly. A standard intravenous regional technique was used with 250~300 mmHg tourniquet pressure for 30 minutes. Blood pressure and pulse rate were monitored before injection, 1 minute and 5 minutes after injection, immediately before deflation of tourniquet, 1 minute, 5 minutes and 30 minutes after deflation of tourniquet. Pain and temperature evaluations were made before injection and at 1 week after every injection. RESULTS: The increase in skin temperature and decrease in pain score of the affected limb were noted after the use of bretylium in 5 patients out of 7 patients. These clinical effects probably resulted from bretylium,s ability to accumulate in adrenergic nerves and block norepinephrine release. One patient had hypotension immediately after tourniquet deflation. CONCLUSIONS: Intravenous regional bretylium provides significant pain relief for treatment of RSD.

Epidural Anesthesia in a Patient with Pompe's Disease: A case report / 대한마취과학회지

A case report of a 19-year-old girl with the juvenile form of Pompe's disease, who underwent thoracic epidural anesthesia, is presented. Pompe's disease, glycogen storage disease type II, is an autosomal recessive disorder characterized by the lysosomal accumulation of glycogen. Patients with the juvenile form are distinguished by involvement of limb-girdle, and respiratory muscles without cardiac or nervous system manifestations. She had been managed with nasal intermittent positive pressure ventilation (NIPPV) and nightly ventilatory support. She had scoliosis with vertebral rotation and showed respiratory muscular weakness. In order to prevent postoperative respiratory complication and to achieve cardio- pulmonary stability, we chose the thoracic epidural block to perform appendectomy. Epidural injection of 0.8% lidocaine gave good sensory block without motor block and maintained cooperative state throughout the operation. Postoperatively, she remained well, but with NIPPV.

Percutaneous Tracheostomy: a comparison with standard surgical tracheostomy / 대한마취과학회지

A prospective study was undertaken to compare, in intensive care patients, the safety and utility of a percutaneous tracheostomy teehnique with a surgieal tracheostomy technique. Between March of 1992 and June of 1993 we randomly selected 40 patients of the many who were in need of a tracheostomy. After dividing those patients into 2 groups, we per- formed the procedures. Twenty patients received a standard surgicsl traeheostomy, the other twenty received a percutaneous tracheostomy. We found complications occurring in 6 patients who received the standard surgical tracheostomy while only 1 patient suffered complications from the group having the percutaneous tracheostomy. The most common complications being subcutaneous emphysema, pneumothorax, pnemonia, and hemorrhage. Post-decannulation scar was 3.286+/-1.204mm in percutaneous group, 20.36+/-7.26mm in standard group. In comparison to standard surgical tracheoatomy, percutaneous tracheostomies were rapidly and easily performed and asaociated with significantly fewer complication and small post-decannulation scars.

Percutaneous Tracheostomy: a comparison with standard surgical tracheostomy / 대한마취과학회지

A prospective study was undertaken to compare, in intensive care patients, the safety and utility of a percutaneous tracheostomy teehnique with a surgieal tracheostomy technique. Between March of 1992 and June of 1993 we randomly selected 40 patients of the many who were in need of a tracheostomy. After dividing those patients into 2 groups, we per- formed the procedures. Twenty patients received a standard surgicsl traeheostomy, the other twenty received a percutaneous tracheostomy. We found complications occurring in 6 patients who received the standard surgical tracheostomy while only 1 patient suffered complications from the group having the percutaneous tracheostomy. The most common complications being subcutaneous emphysema, pneumothorax, pnemonia, and hemorrhage. Post-decannulation scar was 3.286+/-1.204mm in percutaneous group, 20.36+/-7.26mm in standard group. In comparison to standard surgical tracheoatomy, percutaneous tracheostomies were rapidly and easily performed and asaociated with significantly fewer complication and small post-decannulation scars.

Hemodynamic and Metabolic Changes during Orthotopic Liver Transplantation in Dogs / 대한마취과학회지

Skilled and experienced anestheia is of great importance for patients undergoing orthotopic liver transplantation, because of multiple preexisting medical problems in such patients as well as the intraoperative problems of rapid hemodynamic, metabolic, and coagulation changes. In this study, the intraoperative hemodynamic and laboratory data were analyzed in ten dogs that underwent an orthotopic liver transplantation procedure by veno-venous bypass using Biopump. Liver transplantation can be divided into three distinct periods: stage I, or preanhepatic stage, which begins with the induction of anesthesia and continues until cross clamping of portal vein and IVC; stage II, or anhepatic stage, which begins at the anhepatic time and continues until the donor liver is reperfused by the recipients circulating blood; and stage III, or postanhepatic stage, which begins at the time of reperfusion and continues until the end of surgical procedure. The hemodynamic changes at the time of IVC and portal vein cross clamping were decreases in CVP, PCWP, and pulmonary artery pressure in spite of using Biopump. The significant metabolic alternations during anhepatic stage were decrease in blood glucose levels and increase in blood lactate levels. The more significant hemodynamic changes occurred at the time of reperfusion. Systolic pressure decreased suddenly to 58+/-6 mmHg and cardiac output decreased to 1.08+/-0.1l L/min. However heart rate, pulmonary artery pressure, CVP, and PCWP did not change significantly. During stage III, hyperglycemia occurred quite frequently. Significant abnormal coagulation chages could not be found, probably because the dogs were healthy. In conclusion, during anhepatic stage, we have to compensate for alternations of fluid balance. At the time of reperfusion, we should prevent severe hemodynamic changes and treat them immediately if they occur. However, it seems that glucose administration is not necessary to the liver recipient during stage II because there is no significant hemodynamic depression due to hypoglycemia at this time and hyperglycemia occurs later.

Comparison of Interpleural Block and Paravertebral Block with Bupivacaine for Pain Relief after Cholecystectomy / 대한마취과학회지

The adverse effects of pain in post-surgery or trauma patients are well documented. A reliable, safe approach to achieving unilateral analgesia in multiple contiguous thoracic dermatomes would be of great benefit to anesthesiologists in acute pain setting following thoracic or upper abdominal surgery. The aim of this study of post-cholecystectomy pain was to compare two methods of postoperative analgesia with interpleural block and paravertebral block with bupivacaine. Thirty otherwise healthy patients who had undergone elective cholecystectomy through a subcostal incision were randomly allocated to two groups of fifteen patients each and given either interpleural block(group 1) or paravertebral block(group 2) with 20 ml 0.5% bupivacaine mixed with 1:200,000 epinephrine through a single catheter. The degree of analgesia was assessed by a verbal rating scale, Prince Henry pain score and a visual analogue scale(VAS 1-10 cm ; O=no pain, 10=worst pain). These pain scores and vital signs were assessed just before and 10, 20, 30, 60 and 120 minutes after injection of bupivacaine. The onset time of analgesia was similar in both groups(6.6+/-3.74 minutes in group 1 and 5.5+/-2.88 minutes in group 2), but the duration of analgesia was significantly longer in group 1(6.5+/-1.92 hours) than group 2(4.5+/-2.17 hours)(p<0.05). In both groups Prince Henry pain scores significantly decreased 10 minutes after injection of bupivacaine and VAS also significantly decreased 10 and 20 minutes after injection(p<0.05), but there was no significant difference between two groups. The systolic blood pressure decreased 10 minutes after the injection of bupivacaine in both groups(Group 1-3.7%, Group 2-6.5%) and the diastolic blood pressure decreased 10 minutes after the injection of bupivacaine only in group 1(2.5%), (p<0.05), however, these changes in arterial blood pressure were of minimal clinical significance. There is no complication in group 1, but 2 out of 15 patients in group 2 showed bilateral blockade without any serious hemodynamic derangement clinically. In conclusion, both techniques showed similarity in the onset and the degree of analgesia except the duration of analgesia, and presented only a few minor complications. Therefore, we feel that paravertebral block can be used in case that coexisting pulmonary or pleural pathology limits the use of interpleural block for post-cholecystectomy pain management. Furthermore, either of the two techniques may be used alternatively in management of thoracic or upper abdominal pain according to technical skill and preference of anesthesiologists.

Comparison of Lidocaine , Bupivacaine and Lidocaine - Bupivacaine Mixture for Epidural Blockade for Cesarean Section / 대한마취과학회지

In a double-blind clinical study, single-dose lumbar epidural blockade was instituted in 45 healthy patients undergoing cesarean section. Patients were randomly assigned to one of three groups. Each group received treatment with a different local anesthetic solution used were 2.0% Lidocaine HCL 20 ml in group I, 0.5% Bupivacaine HCL 20 ml in group II and Lidocaine-Bupivacaine Mixture in the ratio of 1:1 20 ml in group III The injections were made at the third lumbar interspace. The local anesthetic was injected directly through 176 Tuohy needle at 1 ml/s with the bevel directed cephalad(11 ml) and caudad(9 ml), The onset times were fastest in group I and slowest in group III. The durations were shortest in group L The times reguired to reach the highest level in group I and III were shorter than group II. The Apgar scores and blood pressure changes were similar in the diifferent groups. The frequency of pain sense was highest in group II. It is concluded that Lidocaine and Lidocaine-Bupivacine Mixture are superior to Bupivacaine for lumbar epidural blockade for cesarean section.

Pulse Rate Changes after Increased Doses of Glycopyrrolate in Combination with Neostigmine / 대한마취과학회지

Glycopyrrolate is frequently administered in combination with neostigmine to reverse a neuromus- cular blockade. The dosage was well established at 1/5 of neostigmine. But the authers have often observed a delayed manifestation of relative bradycardia after such a recommended dosage. This is not mentioned in the literature, but this may be due to an insufficient observation period. The authors monitored the change of pulse rate for 1 hour after the administration of the recom. mended dose. Further, the data wIns compared with that obtained after studies of lower and higher doses. The doses were 0.004, 0.008 and 0.012mg/kg of glycopyrrolate with 0.04mg/kg of neostigmine. 1) At all doses, bradycardia relative to the pre-reversal pulse rate was progressive until 30 minutes after injection. 2) As the glycopyrrate dose was increased the degree of bradycardia decreased (-24.7, -20.5, - 15.0 at 30 min.). 3) There was no difference in the immediate change in the pulse rate between the dcsages of 0.008 and 0.012 mg/kg. Change occured at 9 mins. 4) At dosages of 0.004 and 0.008 mg/kg, the pulse rates at 60 min were comparable to their ward pulses, but at a dosage of 0.012 mg/kg, the pulse rate was 8.5 beats/min higher.