Effect of subcutaneous treatment with human umbilical cord blood-derived multipotent stem cells on peripheral neuropathic pain in rats

In this study, we aim to determine the in vivo effect of human umbilical cord blood-derived multipotent stem cells (hUCB-MSCs) on neuropathic pain, using three, principal peripheral neuropathic pain models. Four weeks after hUCB-MSC transplantation, we observed significant antinociceptive effect in hUCB-MSC–transplanted rats compared to that in the vehicle-treated control. Spinal cord cells positive for c-fos, CGRP, p-ERK, p-p 38, MMP-9 and MMP 2 were significantly decreased in only CCI model of hUCB-MSCs-grafted rats, while spinal cord cells positive for CGRP, p-ERK and MMP-2 significantly decreased in SNL model of hUCB-MSCs-grafted rats and spinal cord cells positive for CGRP and MMP-2 significantly decreased in SNI model of hUCB-MSCs-grafted rats, compared to the control 4 weeks or 8weeks after transplantation (p<0.05). However, cells positive for TIMP-2, an endogenous tissue inhibitor of MMP-2, were significantly increased in SNL and SNI models of hUCB-MSCs-grafted rats. Taken together, subcutaneous injection of hUCB-MSCs may have an antinociceptive effect via modulation of pain signaling during pain signal processing within the nervous system, especially for CCI model. Thus, subcutaneous administration of hUCB-MSCs might be beneficial for improving those patients suffering from neuropathic pain by decreasing neuropathic pain activation factors, while increasing neuropathic pain inhibition factor.

Intravenous Administration of Substance P Attenuates Mechanical Allodynia Following Nerve Injury by Regulating Neuropathic Pain-Related Factors

This study aimed to investigate the analgesic effect of substance P (SP) in an animal model of neuropathic pain. An experimental model of neuropathic pain, the chronic constriction injury (CCI) model, was established using ICR mice. An intravenous (i.v.) injection of SP (1 nmole/kg) was administered to the mice to examine the analgesic effects of systemic SP on neuropathic pain. Behavioral testing and immunostaining was performed following treatment of the CCI model with SP. SP attenuated mechanical allodynia in a time-dependent manner, beginning at 1 h following administration, peaking at 1 day post-injection, and decaying by 3 days post-injection. The second injection of SP also increased the threshold of mechanical allodynia, with the effects peaking on day 1 and decaying by day 3. A reduction in phospho-ERK and glial fibrillary acidic protein (GFAP) accompanied the attenuation of mechanical allodynia. We have shown for the first time that i.v. administration of substance P attenuated mechanical allodynia in the maintenance phase of neuropathic pain using von Frey’s test, and simultaneously reduced levels of phospho-ERK and GFAP, which are representative biochemical markers of neuropathic pain. Importantly, glial cells in the dorsal horn of the spinal cord (L4–L5) of SP-treated CCI mice, expressed the anti-inflammatory cytokine, IL-10, which was not seen in vehicle saline-treated mice. Thus, i.v. administration of substance P may be beneficial for improving the treatment of patients with neuropathic pain, since it decreases the activity of nociceptive factors and increases the expression of anti-nociceptive factors.

Usefulness of intraoperative real-time three-dimensional transesophageal echocardiography for pre-procedural evaluation of mitral valve cleft: a case report / 대한마취과학회지

A precise pre-procedural evaluation of mitral valve (MV) pathology is essential for planning the surgical strategy for severe mitral regurgitation (MR) and preparing for the intraoperative procedure. In the present case, a 38-year-old woman was scheduled to undergo MV replacement due to severe MR. She had a history of undergoing percutaneous balloon valvuloplasty due to rheumatic mitral stenosis during a previous pregnancy. A preoperative transthoracic echocardiography suggested a tear in the mid tip of the anterior mitral leaflet. However, the "en face" view of the MV in the left atrial perspective using intraoperative real time three-dimensional transesophageal echocardiography (RT 3D-TEE) provided a different diagnosis: a torn cleft in the P2-scallop of the posterior mitral leaflet (PML) with rupture of the chordae. Thus, surgical planning was changed intraoperatively to MV repair (MVRep) consisting of patch closure of the PML, commissurotomy, and lifting annuloplasty. The present case shows that intraoperative RT 3D-TEE provides more precise and reliable spatial information of MV for MVRep and facilitates critical surgical decision-making.

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.

Usefulness of intraoperative real-time three-dimensional transesophageal echocardiography in preprocedural evaluation of cortriatriatum: a case report / 대한마취과학회지

Cortriatriatum is a rare congenital cardiac disorder with fibromuscular band (diaphragm) dividing the left atrium (LA) into the proximal and distal parts. Surgical correction of cortriatriatum requires full preoperative evaluation of the structural anomalies including the LA diaphragm and their pathophysiology. In the present case, a 44 year-old lady diagnosed as cortriatriatum underwent surgical correction. Intraoperative three-dimensional transesophageal echocardiography provided detailed information regarding the shape and extent of the LA diaphragm, which had been partially evaluated by preoperative two-dimensional transthoracic and transesophageal echocardiography, and facilitated the intraoperative patient management and surgical decision making.

Large left atrial myxoma causing mitral annular dilation, functional mitral stenosis with concealed atrial septal defects / 대한마취과학회지

No abstract available.

Effect of ulinastatin on perioperative organ function and systemic inflammatory reaction during cardiac surgery: a randomized double-blinded study / 대한마취과학회지

BACKGROUND: This study evaluated the efficacy of ulinastatin for attenuating organ injury and the release of proinflammatory cytokines due to cardiopulmonary bypass (CPB) during cardiac surgery. METHODS: Patients undergoing valvular heart surgery employing CPB were assigned to receive either ulinastatin (group U, n = 13) or a placebo (group C, n = 11) before the commencement of CPB. Hemodynamic data, parameters of major organ injury and function, and proinflammatory cytokines were measured after the induction of anesthesia (T1), after CPB (T2), at the end of anesthesia (T3), and at 24 hours after surgery (POD). RESULTS: The demographic data, CPB duration, and perioperative transfusions were not different between the groups. PaO2/FiO2 in group U was significantly higher than that in group C at T3 (3.8 +/- 0.8 vs. 2.8 +/- 0.7, P = 0.005) and at POD (4.0 +/- 0.7 vs. 2.8 +/- 0.7, P < 0.001). Creatine kinase-MB at POD in group U was significantly lower than that in group C (17.7 +/- 8.3 vs. 33.7 +/- 22.1, P = 0.03), whereas troponin I at POD was not different between the groups. Creatinine clearance and the extubation time were not different between the groups at POD. The dopamine infusion rate during the post-CPB period in group U was significantly lower than that in group C (1.6 +/- 1.6 vs. 5.5 +/- 3.3 microg/kg/min, P = 0.003). The interleukin-6 and tumor necrosis factor-alpha concentrations at T1, T2, and T3 as well as the incidences of postoperative cardiac, pulmonary and kidney injuries were not different between the groups. CONCLUSIONS: Ulinastatin pretreatment resulted in an improved oxygenation profile and reduced inotropic support, probably by attenuating the degree of cardiopulmonary injury; however, it did not reduce the levels of proinflammatory cytokines.

The effect of dexmedetomidine on the adjuvant propofol requirement and intraoperative hemodynamics during remifentanil-based anesthesia / 대한마취과학회지

BACKGROUND: The effects of dexmedetomidine on the propofol-sparing effect and intraoperative hemodynamics during remifentanil-based propofol-supplemented anesthesia have not been well investigated. METHODS: Twenty patients undergoing breast surgery were randomly allocated to receive dexmedetomidine (group DEX) or placebo (group C). In the DEX group, dexmedetomidine was loaded (1 microg/kg) before anesthesia induction and was infused (0.6 microg/kg/h) during surgery. Anesthesia was induced with a target-controlled infusion (TCI) of propofol (effect site concentration, Ce; 3 microg/ml) and remifentanil (plasma concentration, Cp, 10 ng/ml). The Ce of TCI-propofol was adjusted to a bispectral index of 45-55, and Cp of TCI-remifentanil was fixed at 10 ng/ml in both groups. Mean arterial blood pressure (MAP) and heart rate (HR) were recorded at baseline (T-control), after the loading of study drugs (T-loading), 3 min after anesthesia induction (T-induction), tracheal intubation (T-trachea), incision (T-incision), 30 min after incision (T-incision30), and at tracheal extubation (T-extubation). MAP% and HR% (MAP and HR vs. T-control) were determined and the propofol infusion rate was calculated. RESULTS: The propofol infusion rate was significantly lower in the DEX group than in group C (63.9 +/- 16.2 vs. 96.4 +/- 10.0 microg/kg/min, respectively; P < 0.001). The changes in MAP% at T-induction, T-trachea and T-incision in group DEX (-10.0 +/- 3.9%, -9.4 +/- 4.6% and -11.2 +/- 6.3%, respectively) were significantly less than those in group C (-27.6 +/- 13.9%, -21.7 +/- 17.1%, and -25.1 +/- 14.1%; P < 0.05, respectively). CONCLUSIONS: Dexmedetomidine reduced the propofol requirement for remifentanil-based anesthesia while producing more stable intraoperative hemodynamics.

Abrupt formation of intracardiac thrombus during cardiopulmonary bypass with full heparinization: A case report / 대한마취과학회지

Intracardiac thrombus during cardiopulmonary bypass (CPB) with full heparinization is very rare but fatal. A 60-year-old woman was scheduled for aortic and mitral valve repairs with a maze procedure for mixed aortic and mitral valvular heart disease with atrial fibrillation. Preoperative transthoracic echocardiography and cardiac computed tomography showed moderate aortic regurgitation and moderate mitral stenosis with regurgitation. There was no intracardiac thrombus. Aortic and mitral valve repairs with the maze procedure were successfully performed without unexpected events. During CPB weaning, a mobile hyper-echogenic mass in the left atrium was detected on transesophageal echocardiography. After cardiac arrest, it was surgically removed. On completion of the operation, weaning from CPB was accomplished uneventfully. The patient fully recovered and was discharged from the intensive care unit on her third postoperative day.

Cerebral oximetry monitoring during aortic arch aneurysm replacement surgery in Jehovah's Witness patient -A case report- / 대한마취과학회지

Anesthetic management for aortic arch aneurysm (AAA) surgery employing deep hypothermic circulatory arrest in a Jehovah's Witness (JW) patient is a challenge to anesthesiologist due to its complexity of procedures and their refusal of allogeneic transfusion. Even in the strict application of intraoperative acute normovolemic hemodilution (ANH) and intraopertive cell salvage (ICS) technique, prompt timing of re-administration of salvaged blood is essential for successful operation without allogeneic transfusion or ischemic complication of major organs. Cerebral oximetery (rSO2) monitoring using near infrared spectroscopy is a useful modality for detecting cerebral ischemia during the AAA surgery requiring direct interruption of cerebral flow. The present case showed that rSO2 can be used as a trigger facilitating to find a better timing for the re-administration of salvaged blood acquired during the AAA surgery for JW patient.

Cerebral oximetry monitoring during aortic arch aneurysm replacement surgery in Jehovah's Witness patient -A case report- / 대한마취과학회지

Anesthetic management for aortic arch aneurysm (AAA) surgery employing deep hypothermic circulatory arrest in a Jehovah's Witness (JW) patient is a challenge to anesthesiologist due to its complexity of procedures and their refusal of allogeneic transfusion. Even in the strict application of intraoperative acute normovolemic hemodilution (ANH) and intraopertive cell salvage (ICS) technique, prompt timing of re-administration of salvaged blood is essential for successful operation without allogeneic transfusion or ischemic complication of major organs. Cerebral oximetery (rSO2) monitoring using near infrared spectroscopy is a useful modality for detecting cerebral ischemia during the AAA surgery requiring direct interruption of cerebral flow. The present case showed that rSO2 can be used as a trigger facilitating to find a better timing for the re-administration of salvaged blood acquired during the AAA surgery for JW patient.

Continuous nimodipine infusion during mitral valvuloplasty for infective endocarditis after mycotic cerebral aneurysmal clipping: A case report

We describe a patient with infective endocarditis (IE) complicated by mycotic cerebral aneurysms (MCAs). Transarterial embolization of a larger MCA was attempted but failed. Aneurysmal clipping through craniotomy was followed by mitral valvuloplasty. During mitral valvuloplasty for IE, the low values of cerebral oxygen saturation after aneurysmal clipping were improved by continuous nimodipine infusion. We also review anesthetic management of patients with IE complicated by MCAs.

Anesthetic managements for repair of atrial septal defect in a patient with Young-Simpson Syndrome: A case report / 대한마취과학회지

Young-Simpson Syndrome (YSS) is a rare malformation syndrome characterized by facial dysmorphism, congenital heart abnormalities, congenital hypothyroidism and severe growth retardation. A 5-month-old girl was scheduled to undergo patch closure of atrial septal defect. She had been diagnosed with YSS preoperatively. We report out clinical experience of a case of YSS patient with brief review of related literatures and relevant anesthetic problems.

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.

Cerebral oxygen saturation monitoring for off-pump coronary bypass graft surgery with Moyamoya disease: A case report / 대한마취과학회지

We report a case using cerebral oxygen saturation (rCbO2) for off-pump coronary artery bypass graft (OPCAB) surgery in a patient with co-existing Moyamoya disease. The rCbO2 with the routine monitoring for OPCAB surgery were monitored intraoperatively. In spite of infusing nimodipine (0.2 microgram/kg/min) and maintaining the end-tidal CO2 tension at 35-40 mmHg, a sudden reduction in the right-side rCbO2 from the base line value of 70-80%/78-83% (Left/Right) to 70-72%/65-70% was developed during the harvesting of the vascular graft. We increased the rate of phenylephrine infusion to increase systemic and cerebral perfusion pressure, and both rCbO2 values were elevated to 80%/70% within 3 minutes. However, the preferential reduction in the right-side rCbO2 compared with the left-side value was not corrected. While suspecting cerebral ischemia due to cerebral vascular spasm, we administered nimodipine 2 mg bolus and increased infusion rate to 0.5 microgram/kg/min. Finally, the preferential rCbO2 reduction in the right-side was corrected and both rCbO2 reached 84%/91%. We concluded rCbO2 monitoring is useful for detecting an intraoperative episode of cerebral ischemia and maintaining the optimal cerebral perfusion during OPCAB surgery with Moyamoya disease.

Cardiac arrest that developed during anesthetic induction in a patient with abdominal gas gangrene: A case report / 대한마취과학회지

We report here on a fatal case of abdominal gas gangrene. Two days after gastrectomy, a 56-year-old man presented with intractable abdominal pain and fever of a sudden onset, which quickly progressed over several hours to septic shock. Despite of the unexplained gas collections in the abdominal muscle, fascia, and subcutaneous layers on computed tomography scan, its clinical significance was overlooked. Emergency laparotomy was initially scheduled because of concern that there may have been a perforated viscus. At the time of monitoring for the anesthesia, we noticed marbled skin discoloration and the subcutaneous emphysema had spread on his flank. Shortly after the initial suspicion of gas gangrene, cardiac arrest developed during the arterial line cannulation. Despite prompt resuscitation measures, including the administration of catecholamines and the application of extracoporeal membrane oxygenation, he eventually died. Anesthesiologists need to understand this fulminant disease because extensive debridement under general anesthesia is essential for the treatment of abdominal gas gangrene.

Usefulness of new technique using a disposable syringe for endotracheal tube cuff inflation / 대한마취과학회지

BACKGROUND: Risk for injuries resulting from overinflated or underinflated endotracheal tube cuff warrants adequate cuff inflation technique. Thus, this study was designed to measure the actual intracuff pressures obtained by new estimation techniques. METHODS: 95 adult surgical patients requiring tracheal intubation were randomized to two groups with respect to the endotracheal tube model: Portex(R) (n = 55) and Euromedical(R) (n = 40). After induction of anesthesia, the cuff was inflated using new estimation techniques with two different syringes: PR10 or PR20 (passive release technique using a 10-ml or 20-ml syringe, respectively). Subsequently, an aneroid manometer was used to measure the actual intracuff pressures. These inflation techniques were repeated two times. A direct cuff measurement range of 25 to 40 cmH2O was used as a reference for optimal intracuff pressure. Size 7.0 mm internal diameter (ID) tubes were used for women and size 7.5 mm ID for men. RESULTS: 88 eligible patients were studied: Portex group (n = 50) and Euromedical group (n = 38). With respect to the rate of optimal cuff inflation, PR10 was significantly higher than PR20 in both groups (56% vs. 10% in Portex group; 63.2% vs. 0% in Euromedical group, respectively) (P < 0.05). CONCLUSIONS: When direct intracuff measurement is not available, a new method, named "passive release technique" using a 10-ml syringe, is a useful alternative cuff inflation method.

Early detection of ruptured bulla by capnography during off pump coronary artery bypass grafting surgery: A case report / 대한마취과학회지

Capnography is monitoring of concentration or partial pressure of CO2 in respiratory gases. It provides information about CO2 production, pulmonary perfusion, alveolar ventilation, respiratory patterns and elimination of CO2 from the anesthesia circuit and ventilator. Thus it gives us a rapid and reliable method to detect life threatening conditions such as malposition of tracheal tube, ventilatory failure, circulatory failure and defective breathing circuits. Authors experienced that change of capnogram during off pump coronary artery bypass grafting surgery helped early detecting ruptured bulla and prevented intraopertive or postoperative pneumothorax.

Anesthesia for noncardiac surgery in a neonate with interrupted aortic arch: A case report / 대한마취과학회지

Interrupted aortic arch (IAA) is a rare congenital cardiovascular anomaly in which there is no direct continuity between the aortic arch and the descending aorta. A patent ductus arteriosus (PDA) usually feeds the descending aorta. But, as ductus constricts, IAA is lethal in nearly 100% of the cases, if untreated. The cause of death is a combination of greatly increased left to right shunt with increased pulmonary blood flow, which results in heart failure, pulmonary edema, and sequelae of the reduced perfusion of all structures distal to the interruption. During the noncardiac surgery in such patients, adequate managements with prostaglandin infusion, careful manipulation of the pulmonary-systemic blood flow ratio, inotropic support, and aggressive treatment of acidosis should be provided to ensure optimal outcomes of subsequent surgical reconstruction. We present the anesthetic experience of abdominal surgery in a neonate with a type A IAA combined with PDA and ventricular septal defect.

Folding of Right Atrium Misdiagnosed as a Thrombus after Mitral Valve Replacement: A case report / 대한마취과학회지

Transesophageal echocardiography (TEE) can provide real time information about anatomic and hemodynamic state and guide management in cardiac surgery.Despite greater technical advances, TEE has artifacts and pitfalls.This report describes a 68-year-old female patient underwent mitral valve replacement and Maze operation.After the procedures, TEE found right atrial mass which did not exist before cardiopulmonary bypass.After discussing with operator, right atrium was explored because it was thought to be a thrombus attached on pulmonary arterial catheter.However, it was revealed as folding of right atrium.The pitfalls of TEE resulted in misdiagnosis and unnecessary procedure.Therefore, authors reviewed echocardiographical artifacts and pitfalls in right atrium which could be misdiagnosed.