Interaction between postoperative shivering and hyperalgesia caused by high-dose remifentanil / 대한마취과학회지

BACKGROUND: High-dose remifentanil-based anesthesia is associated with opioid-induced hyperalgesia (OIH) and postanesthetic shivering (PAS). These effects can be prevented by N-methyl-d-aspartate (NMDA) receptor antagonists. This study aimed to investigate correlations between OIH and PAS caused by high-dose remifentanil and the effects of low-dose ketamine on OIH and PAS. METHODS: Seventy-five patients scheduled for single-port laparoscopic gynecologic surgery were randomly allocated into three groups, each of which received intraoperative remifentanil: group L at 0.1 microg/kg/min; group H at 0.3 microg/kg/min; and group HK at 0.3 microg/kg/min plus 0.25 mg/kg ketamine just before incision, followed by a continuous infusion of 5 microg/kg/min ketamine until skin closure. RESULTS: PAS, postoperative tactile pain threshold, and the extent of hyperalgesia in group H were significantly different (P < 0.05) than in the other two groups. PAS was significantly correlated with OIH, including mechanically evoked pain such as postoperative tactile pain threshold (r = -0.529, P = 0.01) (r = -0.458, P = 0.021) and the extent of hyperalgesia (r = 0.537, P = 0.002) (r = 0.384, P = 0.031), respectively, in group H and group HK. Notably, both groups were treated with high-dose remifentanil. Tympanic membrane temperature, time to first postoperative analgesic requirement, postoperative pain scores, analgesic consumption, and cumulative patient-controlled analgesia volume containing morphine were comparable in all three groups. CONCLUSIONS: OIH, including the enhanced perception of pain, and PAS were both associated with high-dose remifentanil, were significantly correlated and were attenuated by a low dose of ketamine. This suggests that a common mechanism in part mediated through activation of the central glutamatergic system (e.g., NMDA receptors), underlies the two effects caused by high doses of remifentanil.

Acute allergic reaction caused by hyaluronidase used in the pain management: a case report and literature review: A case report

Hyaluronidase is a protein enzyme extracted from goat or ovine testis. It breaks down hyaluronic acid in connective tissues, thereby reducing swelling and edema and increasing drug penetration into tissues after injection. Because of these properties, it is being increasingly used in the field of pain management. The most frequently reported hyaluronidase-induced complications are allergic reactions, and are usually reported in cases involving eye surgery. However, there are only a few cases of allergic reactions reported in the field of pain management. Here, we report a case involving a 52-year-old patient diagnosed with an allergic reaction after receiving epidural administration of hyaluronidase. A literature review and comparison of our case with similar cases suggested the potential mechanisms underlying these allergic reactions and emphasized the importance of considering the possibility of these reactions in patients receiving hyaluronidase during the course of pain management procedures.

Conversion of supraventricular tachycardia to normal sinus rhythm by dexmedetomidine treatment / 대한마취과학회지

No abstract available.

Conversion of supraventricular tachycardia to normal sinus rhythm by dexmedetomidine treatment / 대한마취과학회지

No abstract available.

The effects of magnesium sulfate infiltration on perioperative opioid consumption and opioid-induced hyperalgesia in patients undergoing robot-assisted laparoscopic prostatectomy with remifentanil-based anesthesia / 대한마취과학회지

BACKGROUND: Opioids not only exert an antinociceptive effect, but also modulate central N-methyl-D-aspartate (NMDA) receptors, resulting in hyperalgesia and acute opioid tolerance. This study was aimed to investigate the effect of the NMDA receptor antagonist, magnesium in preventing remifentanil-induced hyperalgesia. METHODS: For this study, 75 patients scheduled for robot-assisted laparoscopic prostatectomy were randomly allocated into three groups of patients whose incision sites were infiltrated: Group M, with 25% magnesium sulfate 80 mg/kg; Group S, with the same volume of saline under remifentanil-based anesthesia, and Group D, with the same volume of saline under desflurane based anesthesia. All three groups were infiltrated into incision sites after pneumoperitoneum. Intraoperative evaluation included mean remifentanil dose, and postoperative evaluation included pain severity at time intervals of 30 min, 6, 12, 24 and 36 hours, time to first postoperative analgesic requirement, and analgesic dosage required during 24 hours. RESULTS: Mean remifentanil doses during the intraoperative periods in group M were significantly lower than those in group S (P < 0.001). The time to first postoperative analgesic requirement in postoperative period in groups M and D was significantly longer than that in group S (P < 0.001). Visual analog scale scores for pain in groups M and D were significantly lower than those in group S for 12 hours after operation. CONCLUSIONS: A relatively high dose and continuous infusion of remifentanil were associated with opioid induced hyperalgesia. Wound infiltration with magnesium sulfate decreased opioid consumption and reduces opioid induced hyperalgesia.

Effect of early oral intake on postoperative bowel function in patients undergoing lower extremities surgery under epidural anesthesia / 대한마취과학회지

BACKGROUND: Early oral intake (EOI) associated with early recovery of normal bowel function has been shown to be an important determinant for improving patients' satisfaction. We investigated the tolerability of EOI and its effects on the recovery of bowel function after epidural anesthesia. METHODS: A prospective randomized trial of patients undergoing lower extremities surgery under epidural anesthesia was performed. A liquid drink was given to 150 patients in the EOI group 1 hours after surgery, and to 150 patients in the delayed oral intake (DOI) group 8 hours after surgery. We recorded presence of bowel sounds immediately after operation, symptoms of ileus, time to the first flatus, time to the first defecation, degree of appetite before the first meal, and patients' satisfaction. RESULTS: There was no significant difference in the presence of immediate postoperative bowel sounds, the degree of appetite before the first meal, mild ileus, and severe ileus between groups. Time to the first flatus and time to the first defecation in the EOI group were shorter than those of the DOI group. The patients' satisfaction in the EOI group was higher than that of the DOI group. CONCLUSIONS: For uncomplicated patients undergoing lower extremities under epidural anesthesia, beginning oral hydration as early as 1 hour after the operation is safe and well tolerated and resulting in faster recovery of bowel function and higher patients' satisfaction.

The effect of magnesium sulfate on postoperative pain in patients undergoing major abdominal surgery under remifentanil-based anesthesia / 대한마취과학회지

BACKGROUND: Opioid tolerance may involve activation of the N-methyl-D-aspartate (NMDA) system. The possible involvement of the NMDA system suggests that one of the NMDA receptor antagonists, magnesium may be a useful adjunct to opioids for the treatment of postoperative pain following remifentanil infusion. METHODS: For this study, 70 patients scheduled for major abdominal surgery under remifentanil-based anesthesia were randomly allocated into groups that received either magnesium sulfate (group M) or saline (group C) intravenously. The patients in the group M received 25% magnesium sulfate at a dose of 50 mg/kg in 100 ml of saline, and those in the group C received an equal volume of saline prior to the induction of anesthesia. In addition, patients in both groups received 10 mg/kg/h infusion of either magnesium sulfate (group M) or an equal volume of saline (group C) until the end of surgery. Pain was assessed using a visual analog scale at 30 min, and 6, 12, 24, and 36 hours after operation. The time to the first use of postoperative analgesic and cumulative analgesic consumption in both groups were also evaluated. RESULTS: The visual analog scale scores for pain and cumulative analgesic consumption were significantly lower in the group M than in the group C. The time to the first use of postoperative analgesic was significantly shorter in group C than in the group M. CONCLUSIONS: Use of the NMDA-receptor antagonist, magnesium sulfate as an adjuvant analgesic reduced postoperative pain in patients undergoing major abdominal surgery under remifentanil-based anesthesia.

The Effect of Intraperitoneal Instillation and Trocar Site Infiltration of 0.25% Levobupivacaine on the Postoperative Pain after Performing Laparoscopic Cholecystectomy under Remifentanil Based Anesthesia / 대한통증학회지

BACKGROUND: The use of regional local anesthetics or opioids during laparoscopic cholecystectomy (LC), in combination with general anesthesia, has been investigated in several interventional studies. METHODS: We studied a total of 240 (n = 60, each) patients who were undergoing LC, and they received local infiltration and intraperitoneal instillation with normal saline or 0.25% levobupivacaine 60 ml. Group R (S) received infiltration of normal saline 20 ml before incision and at the end of surgery and then 40 ml intraperitoneal instillation after removal of the gall bladder under remifentanil-based anesthesia. Group R (L) received 0.25% levobupivacaine instead of normal saline in the same method like group R (S). Group S (S) received the same method as group R (S) under sevoflurane based anesthesia in place of remifentanil. Group S (L) received 0.25% levobupivacaine instead of normal saline with the same method as group S (S). Pain was assessed on a visual analog scale at 1, 6, 12 and 24 hours after operation. RESULTS: The pain intensity of Group R (L) was significantly lower than that of group R (S), and the the incisional pain of group S (L) was significantly lower than that of group S (S) in the first six hours. The time delay to first operative analgesics in group R (S) and group S (S) was significantly shorter than that of group R (L) and group S (L). CONCLUSIONS: Infiltration and instillation of levobupivacaine reduced the postoperative pain and remifentanil did not increase the pain severity and opioid requirement when performing the LC.

Delayed Recovery of Neuromuscular Blockade by Rocuronium in a Patient with Charcot-Marie-Tooth Disease: Case reports / 대한마취과학회지

Charcot-Marie-Tooth disease, which is also known as hereditary motor and sensory neuropathy, is a heterogenous group of inherited diseases of the peripheral nerve. The spectrum of severity varies from asymptomatic individuals to those with severe limb abnormalities requiring corrective surgery. We report two brothers who had previously been diagnosed with Charcot-Marie- Tooth disease 3 years earlier and were scheduled to undergo a correction osteotomy of both feet under general anesthesia. General anesthesia was induced with propofol 2 mg/kg, rocuronium 0.8 mg/kg and was maintained with O2-N2O-Sevoflurane. The younger brother showed no delay in recovery of the neuromuscular blockade but the elder brother showed a delay.

Transient Global Amnesia Developed in Recovery Room following General Anesthesia: A case report / 대한마취과학회지

Transient global amnesia is characterized by a sudden inability to form new memories (anterograde amnesia) that usually last for minutes to several hours but never longer than 24 hours. and there are no other focal neurologic signs or symptoms. Retrograde amnesia from a few hours to many years may also be associated with this condition. We report a case of a 56-year-old female patient who experienced transient global amnesia in the recovery room after general anesthesia. She repeated the same queries several times to persons nearby and appeared perplexed. A detailed neurologic examination was otherwise entirely normal. Her symptoms resolved completely the next day.

The Analgesic Effect of Continuous Intraarticular Infusion of Ropivacaine and Fentanyl after Arthroscopic Shoulder Surgery / 대한마취과학회지

BACKGROUND: Arthroscopic shoulder surgery can result in moderate to severe postoperative pain. This study compared the postoperative analgesic effects of an intra-articular patient-controlled analgesia (PCA) infusion of 0.25% ropivacaine used with or without fentanyl after arthroscopic shoulder surgery. METHODS: Sixty patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly assigned to three groups. After surgery, normal saline 21 ml (group 1; n = 20), and 0.25% ropivacaine 21 ml (group 2 and group 3; n = 20 respectively), was infused into the articular space through a PCA catheter, which was followed by an infusion of normal saline 99 ml (group 1), 0.25% ropivacaine 99 ml (group 2), or 0.25% ropivacaine 99 ml, including fentanyl 400microgram (group 3) through the intra-articular PCA catheter at 2 ml/hr with a bolus dose of 0.5 ml with a lock out time of 15 minutes. The level of pain was assessed using a visual analogue scale (VAS) and a verbal pain score (VPS) 2, 4, 6, 8, 12, 24 and 36 hours after the intra-articular bolus injection. RESULTS: The pain scores were significantly lower after 2, 4, 6 hours in group 2 and 3 than in group 1. However, after 8 hours, the pain scores were significantly lower in group 3 than in the other two groups. CONCLUSIONS: An intra-articular continuous infusion of 0.25% ropivacaine after arthroscopic shoulder surgery is more effective when used in conjunction with 400 microgram fentanyl.

The Effect of Preoperative Dexamethasone on Profopol Injection Pain, Postoperative Nausea and Vomiting Undergoing Otolaryngology-Head and Neck Surgery / 대한마취과학회지

BACKGROUND: Induction with propofol has a high incidence of pain, as well as postoperative nausea and vomiting (PONV). The aim of this study was to assess the effect of a course of dexamethasone on the pain, postoperative nausea and vomiting associated with a Propofol injection, in patients undergoing otolaryngology-head and neck surgery. METHODS: One hundred twenty adults, 20-60 years of age, ASA physical status I or II, were allocated to one of two groups. Either dexamethasone 5 ml (8 mg) or saline 5 ml was administered intravenously to each group. After 60 seconds, propofol was injected into the patients' hand veins over a 30 second period and the patient was asked questions regarding the injection pain after 10 seconds. Postoperative nausea, vomiting and post-tonsilectomy pain were recorded in the recovery room (1 h after surgery) and in the hospitalization area (6 h after surgery). RESULTS: The severity and incidence of pain at the time of the propofol injection, PONV, and the level of post-tonsillectomy pain were significantly lower in the dexamethasone group than in the control group. CONCLUSIONS: The prophylactic intravenous administration of 8 mg dexamethasone is effective in reducing the severity of pain after a propofol injection and after the tonsillectomy, and decreased the incidence of PONV.

The Trial of Continuous Intravenous Infusion of Ketamine in Patients with Phantom Limb Pain: A case report / 대한통증학회지

Phantom limb pain is a painful sensation from an absent limb. The onset of pain is generally early, with 75% of patients developing pain within the first few days after amputation. The frequency and duration of attacks tend to be reduced with time, although the prevalence and intensity remain constant. We report here a case of a 38-year-old man who exhibited the signs and symptoms of phantom limb pain due to the above-knee amputations of both legs. He was not responded to opioid therapy and a continuous intravenous infusion of ketamine, an N-methyl-D-aspatate receptor antagonist, reduced his severe pain.

Thyrotoxic Crisis in Graves' Patient with Severe Uncontrolled DM during Surgery: One case report / 대한마취과학회지

Thyrotoxic crisis is a medical emergency with an associated mortality of 10-75%. It is usually encountered in patients with poorly controlled or undiagnosed Graves' disease. The occurrence of thyrotoxic crisis is rare due to routine function tests, which enable a diagnosis to be made even in its subclinical form. However, a thyrotoxic crisis can develop rapidly and bears little relationship to circulating thyroid hormone levels. We present a case of a thyrotoxic crisis in a 52-year-old woman, whose emergent thyroid function tests revealed a near normal euthyroid level. Her Hb A1c was 10.5% before the operation.

A Case of Malignant Hyperthermia during General Anesthesia with Sevoflurane: A case report / 대한마취과학회지

We experienced a malignant hyperthermia in 24-year-old male with sevoflurane during the mandibular prognathism surgery. The malignant hyperthermia emerged 150 minutes after induction of general anesthesia using propofol, rocuronium, sevoflurane, N2O and O2. Sevoflurane has been reported that it can induce delayed onset of malignant hyperthermia under absence of succinylcholine. The prognosis of malignant hyperthermia is determined by early recognition, vigorous treatment and the time of dantrolene injection. In our case, when we suspected episode, all anesthetics were stopped and dantrolene injection was immediately given intravenously. The patient recovered normal temperature and consciousness without any complication.

Sudden Cardiac Arrest Immediately after Tourniquet Release during Epidural Anesthesia: A case report / 대한마취과학회지

Sudden cardiac arrest during epidural anesthesia is a rare but catastrophic complication. It was recently reported that occurs in one per 10,000 epidural anesthesia cases. We report one case of cardiac arrest in a healthy 45-year-old male patient undergoing relatively minor surgery. His preoperative blood pressure was 110-130/70-80 mmHg, heart rate 75-80 beats per minute, and oxygen saturation 98%. Immediately after tourniquet release, cardiac arrest was developed without warning signs. The patient was resuscitated by prompt precordial thump pacing, a fluid bolus, intravenous injection of atropine and ephedrine, and ventilated with oxygen. The procedure was completed and the patient recovered uneventfully.

Inhibitory Effects of Propofol Mixed with Lidocaine on Fentanyl Induced Cough Reflex / 대한마취과학회지

BACKGROUND: Propofol and lidocaine have been purported to attenuate bronchoconstriction induced by fentanyl administration during induction of anesthesia. The purpose of the present study was to study the synergic bronchodilation effect of propofol mixed with lidocaine. METHODS: Two hundred and thirty four patients were randomly allocated to five groups: Group 1 (n = 60, normal saline 0.25 ml/kg followed by fentanyl 3ng/kg), Group 2 (n = 30, propofol 2 mg/kg mixed with normal saline 0.05 ml/kg followed by normal saline 0.06 ml/kg), Group 3 (n = 50, propofol 2 mg/kg mixed with normal saline 0.05 ml/kg followed by fentanyl 3ng/kg), Group 4 (n = 33, propofol 2 mg/kg mixed with lidocaine 1 mg/kg followed by normal saline 0.06 ml/kg) and Group 5 (n = 61, propofol 2 mg/kg mixed with lidocaine 1 mg/kg followed by fentanyl 3ng/kg). All patients were injected with fentanyl or normal saline two minutes after administration of propofol premixed with lidocaine or normal saline, respectively. We checked the cough reflex, injection pain, oxygen desaturation and chest wall rigidity. RESULTS: There was a significant difference in the incidence of cough reflex between group 1 and 3 or 5. The incidience of group 5 was significantly lower than in group 3. CONCLUSIONS: This study suggests that a propofol-lidocaine mixture should be considered when patients require bronchodilation during induction of anesthesia.

Receptor Activation is Not the Main Rescue Mechanism of Morphine in Peroxynitrite-Induced Death of Human Neuroblastoma SH-SY5Y Cells / 대한마취과학회지

BACKGROUND: In the present study, we examined the effect of morphine on NO- and peroxynitrite-induced cell death using a human neuroblastoma SH-SY5Y cell line which abundantly expresses micro, delta and K-opioid receptors. METHODS: The cultured cells were pretreated with morphine (100 micrometer) and exposed to 3-morpholinosydnonimine (SIN-1, 1mM). Agarose gel electrophoresis of DNA was done with the extracts from SH-SY5Y cells. The cells were treated with selective ligands for opioid receptor subtypes and with PI3-kinase inhibitors. Cell damage was assessed by using an MTT assay. Spectrophotometric absorption spectra were measured from the mixture of morphine (100 micrometer) plus peroxynitrite (1 mM) at room temperature. RESULTS: SIN-1 treated cells showed the occurrence of a specific form of chromosomal DNA fragmentation which pretreatment with morphine inhibited. The selective ligands for opioid receptor subtypes, [D-Ala2, N-Me-Phe4, Gly-ol5]enkephalin (DAMGO, micro-opioid receptor agonist), [D-Pen2,5] enkephalin (DPDPE, delta-opioid receptor agonist) and U-69593 (K-opioid receptor agonist) at a concentration of 10 micrometer did not prevent the cell death induced by SIN-1. Naloxone (20 micrometer) hardly antagonized the effect of morphine in SIN-1-induced cell death. The PI3-kinase inhibitors Wortmannin and LY294002 did not inhibit the action of morphine on apoptotic cell death. In the measurements of spectrophotometric absorption spectra, the peak of the absorbance of the mixture of morphine plus peroxynitrite at 295 300 nm disappeared three minutes after mixing. CONCLUSIONS: The present study showed that morphine protected the human neuroblastoma cell line,SH-SY5Y, from peroxynitrite-induced apoptotic cell death. However, it is suggested that the protective action of morphine is not via the activation of opioid receptors and/or the PI3-kinase pathway but possibly via direct chemical reaction.

Effects of Morphine on Free Radical-induced Apoptosis of Human Neuroblastoma SH-SY5Y Cells / 대한마취과학회지

BACKGROUND: The effect of opioids on nitric oxide (NO)- and peroxynitrite-induced neuronal cell death is largely unknown. In the present study, we examined the effect of morphine on NO- and peroxynitrite-induced cell death using a human neuroblastoma SH-SY5Y cell line, which abundantly expresses micro, delta, kappa-opioid receptors. METHODS: The cultured cells were pretreated with morphine and exposed to 3-morpholinosydnonimine (SIN-1) that simultaneously generates NO and superoxide, thus possibly forming peroxynitrite. The cell damage was assessed by using MTT assay and crystal violet staining. Morphological nuclear changes and enzymatic evidences of apoptosis of the cells after exposure to SIN-1 for 24 hours were evaluated by using 4', 6-diamidino-2-phenylindole (DAPI) staining and the measurement of pro-apoptotic protease (caspase-3) activity, respectively. Levels of reduced glutathion (GSH) were measured by monochloronimane (MCB) assay. RESULTS: Pretreatment of SH-SY5Y with morphine significantly inhibited the apoptotic cell death. Morphine also inhibited SIN-1-induced caspase-3 (pro-apoptotic protease) activity in a dose-dependent manner. However, naloxone (20 microM) could not antagonize completely the effect of morphine in SIN- 1-induced cell death. Pre-administered GSH and N-acetylcysteine (NAC) have been found to protect SIN-induced apoptosis, and the neuroblastoma cells treated with morphine had significantly elevated the levels of GSH. CONCLUSIONS: The present study shows that morphine protects the human neuroblastoma cell line SH- SY5Y from peroxynitrite-induced apoptotic cell death through elevated GSH levels. The protective actionof morphine seems to be associated with inhibition of the apoptotic pathway. However, it is suggested that morphine protects the cells possibly via other unknown mechanisms in addition to the activation of opioid receptors.

Comparison of Verapamil and Esmolol for Controlling the Blood Pressure and Heart Rate to Tracheal Intubtion / 대한마취과학회지

BACKGROUND: The antihypertensive agents such as verapamil and esmolol are well known about effects of hemodynamic stabilization to tracheal intubation. The aim of the present study was to compare and evaluate the efficacy of those for controlling hemodynamic responses to tracheal intubation. METHODS: Thirty six patients, ASA physical status I or II, were randomly assigned to one of three groups (n=12 each): saline (control), verapamil 0.1 mg/kg and esmolol 1 mg/kg. Anesthesia was induced with thiopental 5 mg/kg intravenously, and then saline, verapamil and esmolol were administered as an intravenous bolus, and immediately followed by succinylcholine 1.5 mg/kg. Tracheal intubation was done 60 s and 90 s after intravenous injection of verapamil and esmolol, respectively. Systolic and diastolic blood pressure and heart rate were measured before induction and every min for 5 minutes after tracheal intubation. RESULTS: There was a significant attenuation in systolic and diastolic arterial pressure after tracheal intubation in verapamil group compared to control group. Heart rate was significantly lower in esmolol group than in verapamil group after tracheal intubation. CONCLUSIONS: Verapamil 0.1 mg/kg and esmolol 1 mg/kg attenuated the increases in blood pressure and heart rate after tracheal intubation, respectively.