Comparison of Axillary and Supraclavicular Approach in Ultrasound-Guided Brachial Plexus Block

PURPOSE: We examined the success rate and adverse effects of ultrasound-guided axillary and supraclavicular approach brachial plexus block. METHODS: From December 2013 to February 2014, 580 cases of patients received ultrasound-guided axillary approach or supraclavicular approach brachial plexus block. All blocks were performed by one anesthesiologist under ultrasound visualization using 0.2% or 0.75% ropivacaine 1% lidocaine with epinephrine in 1:200,000 as the anesthetic mixture. RESULTS: Failure rate of ultrasound-guided brachial plexus block was 1.2% and 0.2% in axillary and supraclavicular approach, respectively. In supraclavicular approach brachial plexus block, Honer's syndrome was observed in 17.9%, chest discomfort in 14.9%, and arterial puncture in 1%. There was no adverse effect in axillary approach brachial plexus block. CONCLUSION: Ultrasound-guided brachial plexus block serves higher success rate and lower occurrence rate of adverse effect and makes it useful for hand and upper extremity surgery. Supraclavicular approach has relatively higher success rate and lower rate of adverse effect than axillary approach.

The Effect of Radiographic Contrast Media on Reperfusion Injury in the Isolated Rat Heart

BACKGROUND AND OBJECTIVES: We investigated the effects of commonly used contrast media (CM) on myocardial ischemia-reperfusion injury in isolated rat hearts. SUBJECTS AND METHODS: Isolated rat hearts were subjected to 30 minutes of regional ischemia and 2 hours of reperfusion. The following CM (1 mL/1 L Krebs-Henseleit buffer) were randomly perfused for 15 minutes beginning 5 minutes before reperfusion and ending 10 minutes after reperfusion: iohexol (n=8), iopromide (n=8), ioversol (n=8), iomeprol (n=8), iopamidol (n=7), ioxaglate (n=8), and iodixanol (n=7). The effects of a direct bolus injection of undiluted iohexol, iopromide, or ioxaglate (each n=6) via the aortic root immediately prior to reperfusion were also evaluated. The area of necrosis, expressed as the percentage of the area at risk (AN/AR), and cardiodynamic variables were measured. RESULTS: The AN/AR of the control and experimental groups in the order described in methods was 33.7+/-6.4%, 30.3+/-7.4%, 34.7+/-12.6%, 29.2+/-10.2%, 20.9+/-7.6%, 22.6+/-8.7%, 18.8+/-7.9%, and 19.9+/-11.4%, respectively. Groups that received iomeprol and ioxaglate exhibited significantly decreased AN/AR values compared to those of control hearts (p=0.042 and p=0.013). No significant differences in the AN/AR were observed between control hearts and the groups injected with a single bolus of CM. No significant hemodynamic changes were noted after reperfusion among the groups. CONCLUSION: The overall effects of the CM on coronary reperfusion were not deleterious, and better effects were noted in two CM groups. However, it is unclear whether this result was attributed to a specific physiochemical property of the CM.

Analysis of Death of Burn Patients in a Burn Specialized Hospital: A Retrospective Clinical Study

PURPOSE: Burns are one of the most important causes of mortality. We tried to analysis of death in severely burned patients in a single burn specialized hospital. METHODS: We reviewed the records of patients admitted to the intensive care unit for 5 years, from 2007 to 2011. Information was collected on age, sex, type of burn, burn surface area, length of intensive care unit stay, presence of inhalation injury and causes of mortality by chart review. RESULTS: During 5 years, 56 patients were died in our intensive care unit. The average was 51.6 years and the sex ratio was 1.95:1 for males and females. The mean burn surface area (BSA) was 67.2%. Eight (32.1%) of the patients died within 48 hrs. The hospital stay of the death was from 1 to 40 days (average 7.6 days). In outdoor accidents, sex ratio and BSA were 4.60:1 (P=0.023) and 75.4+/-22.7% (P=0.021), respectively, while 1.00:1 and 58.8+/-29.7%, respectively, in indoor accidents. CONCLUSION: The mortality in severe burn patient was 12.5%. In accidents occurred outdoors, male was predominant. In outdoor accidents, the BSA was larger than that of indoor disasters.

Epidemiology of Burn Patients Underwent Mechanical Ventilation Therapy: 4 Year Retrospective Study

PURPOSE: In severe burn injured patients, mechanical ventilation therapy (MVT) is often performed. However, little is known about the mortality and clinical outcomes in these patients. METHODS: A retrospective review of burn patients underwent MVT from January 2008 to December 2011 was conducted. The charts of patients were reviewed. RESULTS: Thirty hundred forty five patients were managed in the intensive care unit during 4 years and 67 patients were received MVT. Among them, 34 (50.7%) patients were intubated before arrival. Mean age was 47.8 years and mean burn surface area (BSA) was 53.4%. Thirty nine patients were died and mortality was 58.2%. The BSA in dead patients was larger (68.9+/-24.9%) than those patients who lived (31.8+/-18.4%) (P<0.001). There were no significant differences in the incidence of inhalation injury and age between survivors and non-survivors. CONCLUSION: The mortality rate was high in patients underwent MVT. BSA is the most important risk factor of mortality in these patients.

Comparison of Inofoam(R) and Medifoam(R) for Donor Site Dressing after Split Thickness Skin Graft in Burn Patients

PURPOSE: Inofoam(R) is a hydrocellular material developed recently for wound dressing. In the present study, the efficacy of Inofoam(R) for donor site dressing after split thickness skin graft (STSG) was evaluated and compared with that of Medifoam(R). METHODS: The study was conducted on 15 patients with third degree of burn underwent STSG from Nov. 2011 to Feb. 2012. Donor sites were divided into groups of Inofoam(R) and Medifoam(R). The duration of wound healing, pain score and exudate absorption ratio were compared between the two groups. RESULTS: The duration of wound healing time was 10.7+/-2.2 days in Inofoam(R) group, 10.5+/-2.0 days in Medifoam(R) group (P>0.05). On postoperative 1 day, the exudate absorption ratio in was 341.6+/-59.3% in Inofoam(R) group and 349.0+/-41.8% in Medifoam(R) group. There were no significant differences in wound healing duration, swelling ratio, and pain score between the two groups (P>0.05). CONCLUSION: The present study shows that the efficacy of a recently used polyurethane foam Inofoam(R) for donor site dressing is as effective as that of Medifoam(R).

Scalding Burns Affected by Instant Ramen in Children

PURPOSE: Ramen is one of the most favorite instant noodles in Korea. Ramen is usually cooked by hot water and it may cause scald burns. The aim of this study was to determine the characteristics of reman-related scald burns (RRSBs) in children. METHODS: From Jan 2007 to Dec 2011, RRSBs in children under 14 years-old were retrospectively evaluated. Age, burn surface area, burn location, ramen source, and seasonal variation were evaluated. RESULTS: During 4 years, 191 children were treated with RRSBs (9.6% of total scalding burns). The average age was 5.6 years and the sex ratio was 1:0.93 for males and females. The mean burn surface area (BSA) was 2.2%. The peak age was 1 year (17.3%) followed by 2 years (12.0%). The packet ramen and cup ramen ratio was 1:0.24. August was the peak month (13.1%) and the most affected skin lesion was lower extremity (45.1%). CONCLUSION: Approximately 5% of scald burn injured children were affected by ramen. Toddlers are the most affected age group. The lower extremity was the most common lesion. Burns from ramen is preventable. Parents and carers should be careful when handle hot water to prevent burns in their children.

Cardiodynamics and Infarct Size in Regional and Global Ischemic Isolated Heart Model: Comparison of 1 Hour and 2 Hours Reperfusion

BACKGROUND AND OBJECTIVES: We investigated whether 1 hour reperfusion is enough to assess cardiodynamics and infarct size in both regional ischemia (RI) and global ischemia (GI) in isolated rat heart models. MATERIALS AND METHODS: Hearts were randomly assigned to one of the following groups (each n=14): 1) Sham hearts for 1 hour; 2) Sham hearts for 2 hours; 3) 30 minutes RI followed by 1 hour reperfusion; 4) 30 minutes of RI followed by 2 hours reperfusion; 5) 30 minutes GI followed by 1 hour reperfusion; and 6) 30 minutes GI followed by 2 hours reperfusion. RESULTS: There were no significant differences in infarct size between 1 hour and 2 hours reperfusion in both RI and GI. Left ventricular developed pressure was significantly decreased at both 1 hour and 2 hours reperfusion in groups of RI and GI compared to baseline (p<0.01). Rate-pressure product and +dP/dtmax also significantly decreased compared to baseline level at both 1 hour and 2 hours reperfusion in groups of RI and GI (p<0.05). CONCLUSION: There was no significant difference in infarct size between 1 hour and 2 hours reperfusion in groups of RI and GI. Cardiodynamic variables measured at 1 hour and 2 hours reperfusion significantly decreased compared to baseline level. Our data suggests that reperfusion of 1 hour is sufficient to assess cardiodynamics in both regional and global ischemic isolated hearts model.

Central Venous Catheter-related Infection in Major Burn Patients: Comparison of Subclavian Vein and Femoral Vein / 대한구급학회지

BACKGROUND: A central venous catheter (CVC) is usually inserted in patients with severe burns and the selection of the CVC is often difficult due to widespread burned skin. We investigated the incidences of colonization and catheter-related blood stream infection (CRBSI) according to the insertion site of the CVC in major burn patients METHODS: In 63 adult massive burn patients in the intensive care unit, 93 CVCs (47 polyurethane standard CVCs and 46 Oligon anti-mocrobial CVCs) were randomly inserted via the subclavian vein (SCV group, n = 66) or femoral vein (FEV group, n = 27). All catheter tips removed were routinely cultured. Bacterial findings from the burn wound and peripheral blood were also monitored in all patients RESULTS: There was no significant difference in the average insertion length of the CVC (14.3 +/- 6.8 days in SCV and 13.6 +/- 3.8 days in FEV) between the two groups. There were no significant differences in CVC colonization (48.5% in SCV and 63.0% in FEV) and CRBSI (7.6% in SCV and 11.1% in FEV) between the two groups. Logistic analysis found that the use of polyurethane standard CVC is significantly associated with increased risk of CVC colonization (odds ratio = 2.68) CONCLUSIONS: The placement of the CVC via the femoral vein does not increase the incidence of CVC colonization in massive burn patients. The use of Oligon anti-microbial CVC may be helpful to reduce CVC colonization in major burn patients.

Kappa-opioid receptor activation during reperfusion limits myocardial infarction via ERK1/2 activation in isolated rat hearts / 대한마취과학회지

BACKGROUND: We investigated whether p42/p44 extracellular signal-regulated kinases (ERK1/2) and/or phosphatidylinositol-3-OH kinase (PI3K)-Akt play a crucial role in cardioprotection by kappa-opioid receptor (KOP) activation. METHODS: Langendorff perfused rat hearts were subjected to 30 min of regional ischemia and 2 h of reperfusion. Antagonists of ERK1/2 and PI3K were perfused in hearts treated with the KOP agonist U50488H (U50). Infarct size was measured after 2 h of reperfusion. The phosphorylation states of ERK1/2 and Akt by Western immunoblots were determined. Drugs were perfused for a period of 5 min before and 30 min after reperfusion. RESULTS: Inhibition of ERK1/2 (26.8 +/- 2.9%, P 0.05 vs. U50) completely abrogated the anti-infarct effect of U50488H. Western blot analysis revealed a significant increase in ERK1/2 but not Akt phsophorylation in U50488H-treated hearts as compared to control hearts when measured immediately after reperfusion. CONCLUSIONS: KOP activation effectively reduces myocardial infarction. The anti-infarct effect of U50488H is mediated by the ERK1/2, but not the PI3K-Akt pathway.

Antimicrobial Central Venous Catheter Dose Not Reduce Catheter-related Bacteremia in Major Burn Injured Patients

PURPOSE: We previously reported that antimicrobial central venous catheter (CVC) reduced catheter colonization in major burn patients. In this study, we investigated whether antimicrobial CVC could reduce catheter-related blood stream infection (CRBSI) in major burn patients. METHODS: Burn patients with over 20% of total body surface area were randomly assigned to undergo catheterization with standard CVC (STD group, n=50) or antimicrobial Vantex(R) CVC (VTX group, n=50). Upon removal of CVC, bacterial cultures for wound, catheter tip, and blood were performed. RESULTS: Colonization rate was significantly decreased in VTX group (42%) compared to STD group (64%) (P0.05). CONCLUSION: Even though the antimicrobial CVC could reduce the catheter colonization, the CRBSI rate was not reduced by antimicrobial CVC in major burn patients.

Emergence Agitation after Sevoflurane Anesthesia in Burn Injured Children

PURPOSE: Sevoflurane is a well accepted anesthetic in children but results high incidence of undesirable emergence agitation (EA). We investigated the EA in burn injured children. METHODS: In 219 un-premedicated burn injured children aged 2~8 years, mask induction with sevoflurane was performed. On arriving operating room, modified Yale preoperative anxiety scale (m-YPAS) was checked. In the postanesthesia care unit, EA scale was recorded as follows; EA1 (no EA), EA2 (mild EA) and EA3 (marked EA). RESULTS: The incidence of EA was 50.2%. The m-YPAS was significantly higher in EA2 and EA3 compared to EA1 (P<0.001). Burn surface area was significantly wider in EA3 compared to EA1 (P<0.05). In deep second-degree burned children, the incidence of EA1 was greatest, whereas EA3 was the greatest in third-degree burned children. CONCLUSION: The incidence of EA after sevoflurane anesthesia in burn injured children was higher as the burn surface areas was greater. In addition, the symptoms of EA in third-degree burned children were more severe than in second-degree burned children.

Morphine and remifentanil-induced cardioprotection: its experimental and clinical outcomes / 대한마취과학회지

During the past few decades, a large number of animal studies demonstrated that commonly used opioids could provide cardioprotection against ischemia-reperfusion (I/R) injury. Opioid-induced preconditioning or postconditioning mimics ischemic preconditioning (I-Pre) or ischemic postconditioning (I-Post). Both delta- and kappa-opioid receptors (OPRs) play a crucial role in opioid-induced cardioprotection (OIC). Down stream signaling effectors of OIC include ATP-sensitive potassium (KATP) channels, protein kinase C (PKC), tyrosine kinase, phosphatidylinositol-3-kinase (PI3-kinase), extracellular signal regulated kinase1/2 (ERK1/2), glycogen synthase kinase-3beta (GSK-3beta), and mitochondrial permeability transition pore (MPTP), among others. Recently, various reports also suggest that opioids could provide cardioprotection in humans. This review will discuss OIC using mostly morphine and remifentanil which are widely used during cardiac anesthesia in addition to the clinical implications of OIC.

Morphine-induced postconditioning modulates mitochondrial permeability transition pore opening via delta-1 opioid receptors activation in isolated rat hearts / 대한마취과학회지

BACKGROUND: It is generally accepted that morphine affords cardioprotection against ischemia/reperfusion injury. Inhibition of the mitochondrial permeability transition pore (MPTP) is considered an end target for cardioprotection. The aim of this study was to investigate the involvement of opioid receptors (OR) and MPTP in morphine-induced postconditioning (M-Post). METHODS: Isolated rat hearts were subjected to 30 min of regional ischemia and 2 h of reperfusion. Hearts were treated with 1 microM morphine, with or without the OR antagonists or a MPTP opener at early reperfusion. Infarct size was measured with 2,3,5-triphenyltetrazolium chloride staining. RESULTS: There were no significant differences in cardiodynamic variables except a decrease in heart rate in the M-Post group (P 0.05). The nonspecific OR antagonist naloxone (25.7 +/- 1.9%, P < 0.01), the delta-OR antagonist naltrindole (27.8 +/- 4.3%, P < 0.05) and delta1-OR antagonist 7-benzylidenenaltrexone (24.7 +/- 3.7%, P < 0.01) totally abrogated the anti-infarct effect of M-Post. In addition, the anti-infarct effect by M-Post was also totally blocked by the MPTP opener atractyloside (26.3 +/- 5.2%, P < 0.05). CONCLUSIONS: M-Post effectively reduces myocardial infarction. The anti-infarct effect by M-Post is mediated via activation of delta-OR, especially delta1-OR, and inhibition of the MPTP opening.

Effect of Ascorbic Acid at Early Fluid Resuscitation in Severe Burn Injured Patients

PURPOSE: Ascorbic acid is a potent antioxidant capable of scavenging oxygen free radicals. We investigated the effect of ascorbic acid on initial management of a major burn. METHODS: A total of twenty two patients with extent of burn injury greater than 30% of the body surface area (BSA) were enrolled. Early fluid resuscitation was performed with Parkland formula ( or =40% BSA). In ascorbic acid group, ascorbic acid was continuously infused at a dose of 30 mg/kg/h during first 24 hours of fluid resuscitation. Target urine output was 0.5~1 ml/kg/h. RESULTS: There were no significant differences in age, sex, and BSA among the groups. In the cases of Parkland formula, there was no significant difference in the fluid requirement between control group (4.26+/-1.29 ml/kg/%burn) and ascorbic acid group (3.53+/-0.87 ml/kg/%burn). However, in the cases of modified hypertonic formula, there was significant difference in the fluid requirement between control group (3.31+/-0.95 ml/kg/%burn) and ascorbic acid group (2.34+/-0.35 ml/kg/%burn). CONCLUSION: High-dose ascorbic acid reduces fluid requirement at early fluid resuscitation in severely burned patients managed with modified hypertonic formula.

Epidemiology in Preschooler Burn Injuries in a Single Burn Unit Hospital for 3 Years

PURPOSE: Burns are an important cause of injury to young children. The aim of this study was to investigate epidemiology in preschooler's burns. METHODS: A retrospective study was reviewed age, sex, burn surface area, and burn type in preschool children underwent burn surgery. Children were classified into three age groups: infant group ( or =10% of the body surface area) in groups of infant, toddler, and early childhood were 7.9%, 5.6%, and 4.7%, and the mean burn size were 18.7+/-1.7% (P=0.003 vs. toddler group), 13.7+/-0.4%, and 17.7+/-2.7%, respectively. CONCLUSION: The major etiology in preschool children' burns was scalding. Toddler was most affected age group. In severe burns, infant group showed larger burn size than toddler group.

Effects of postconditioning with N,N,N'N'-tetrakis-2-pyridylmethyl-ethylenediamine in isolated rat hearts / 대한마취과학회지

BACKGROUND: It was reported that N,N,N'N'-tetrakis-[2-pyridylmethyl]-ethylenediamine (TPEN), a transition metal chelator, confers cardioprotection against myocardial ischemic injury. In this study, we investigated the effect of TPEN targeting reperfusion period in isolated rat hearts. METHODS: Langendorff perfused rat hearts were subjected to 30 min of regional ischemia and 2 h of reperfusion. Hearts were randomly assigned to either control (n = 9) or 10 micrometer of TPEN (n = 8) groups. TPEN was perfused for a period of 5 min before and 30 min after reperfusion. RESULTS: The ratio of infarct area/ischemic area (AN/AR) was significantly reduced in TPEN treated hearts (6.9 +/- 1.7%, P 0.05). CONCLUSIONS: Pharmacological postconditioning with TPEN reduces myocardial infarction however, TPEN does not modify post-ischemic systolic dysfunction in isolated rat hearts.

Rocuronium bromide induced anaphylaxis in a child: A case report / 대한마취과학회지

Anaphylaxis or anaphylactoid reaction in pediatric patient during anesthesia is rare. We report a rocuronium induced anaphylactic reaction in a 33-month-old female. The patient was scheduled to undergo escharectomy due to injuries suffered from a major burn. Shortly after administration of rocuronium, the patient developed severe hypotension, tachycardia, and hypoxia. A similar reaction occurred after administration of rocuronium on subsequent anesthesia. She underwent uneventful anesthesia with volatile induction and maintenance of anesthesia with sevoflurane on her next 7 operations without using of muscle relaxant.

Volatile Induction and Maintenance of Anesthesia without Intravenous Access in Mild to Moderate Burn Injured Pediatric Patients

PURPOSE: Peripheral intravenous (I.V.) access is a common but stressful procedure in children, their parents and medical staffs. We evaluated the efficacy of volatile induction and maintenance of anesthesia (VIMA) without intravenous access for brief procedures in mild to moderate burn-injured pediatric patients. METHODS: VIMA without I.V. was conducted to healthy pediatric patients. Adverse events such as cough, breath holding, airway obstruction, arrhythmia, bradycardia and tachycardia, etc. were evaluated. RESULTS: From July 2008 to December 2009, 1,495 cases of VIMA with sevoflurane were performed in 859 children. Burn-injured patients were 94.9% and patients with hypertrophic scar were 5.1%. Scalding burn and contact burn were 90.1% of the burn-injured patients. Mean anesthesia duration was 29.3+/-6.2 min. In 1,495 VIMA cases, 47 cases had cardiovascular adverse events, including tachycardia (36), bradycardia (7), arrhythmia (3), and hypertension (1). All of these cardiovascular events returned normal after anesthesia. The respiratory adverse events occurred in 72 cases, including cough (49), breath holding (10), partial airway obstruction (8), hypoxia (4), and laryngospasm (1). None of the patients had bronchospasm. Most of the respiratory adverse events could be controlled by manual ventilation with mask, and oropharyngeal airway or laryngeal mask insertion. In four cases with hypoxia, the duration was less than 1 minute and these cases were no eventful after anesthesia. CONCLUSION: VIMA without I.V. access can be effective in brief procedures with mild to moderate burn-injured pediatric patients, even though a longer period of study may be required to assess the efficacy and safety.

Cardioprotection by kappa-opioid receptor agonist U50488H is mediated by opioidergic regulation but not by calcium current modulation / 대한마취과학회지

BACKGROUND: Because the kappa-opioid receptor (OR) agonist U50488H stimulates opioidergic regulation and inhibits L-type Ca2+ channels, this study was aimed at assessing the roles of OR and L-type Ca2+ channels on U50488H-induced cardioprotection. METHODS: Langendorff-perfused rat hearts were subjected to 30 min of regional ischemia and 2 h of reperfusion. Isolated hearts were treated with U50488H with or without the kappa-OR antagonist nor-binaltorphimine (nor-BNI) or the Ca2+ channels activator BAY K 8644. Infarct size was measured with 2,3,5-triphenyltetrazolium chloride staining. RESULTS: U50488H treatment at reperfusion: (1) significantly reduced infarct size (11.3 +/- 1.3%) compared to control hearts (27.7 +/- 1.1%, P 0.05 vs. U50488H); (2) significantly increased left ventricular developed pressure (65.3 +/- 4.8%) after 2 h of reperfusion compared to control hearts (44.8 +/- 3.6%, P 0.05 vs. control) but not by BAY K 8644 (64.3 +/- 5.6%, P < 0.01 vs. control); and (3) significantly decreased heart rate (P < 0.01 vs. control), an effect that was completely abrogated by both nor-BNI and BAY K 8644. CONCLUSIONS: U50488H significantly limits myocardial infarction and stunning in isolated rat hearts after ischemia-reperfusion induction. The infarct size limitation and contractility improvement observed with U50488H treatment during reperfusion are entirely mediated by OR stimulation and not by Ca2+ channel modulation.

Cardioprotection by kappa-opioid receptor agonist U50488H is mediated by opioidergic regulation but not by calcium current modulation / 대한마취과학회지

BACKGROUND: Because the kappa-opioid receptor (OR) agonist U50488H stimulates opioidergic regulation and inhibits L-type Ca2+ channels, this study was aimed at assessing the roles of OR and L-type Ca2+ channels on U50488H-induced cardioprotection. METHODS: Langendorff-perfused rat hearts were subjected to 30 min of regional ischemia and 2 h of reperfusion. Isolated hearts were treated with U50488H with or without the kappa-OR antagonist nor-binaltorphimine (nor-BNI) or the Ca2+ channels activator BAY K 8644. Infarct size was measured with 2,3,5-triphenyltetrazolium chloride staining. RESULTS: U50488H treatment at reperfusion: (1) significantly reduced infarct size (11.3 +/- 1.3%) compared to control hearts (27.7 +/- 1.1%, P 0.05 vs. U50488H); (2) significantly increased left ventricular developed pressure (65.3 +/- 4.8%) after 2 h of reperfusion compared to control hearts (44.8 +/- 3.6%, P 0.05 vs. control) but not by BAY K 8644 (64.3 +/- 5.6%, P < 0.01 vs. control); and (3) significantly decreased heart rate (P < 0.01 vs. control), an effect that was completely abrogated by both nor-BNI and BAY K 8644. CONCLUSIONS: U50488H significantly limits myocardial infarction and stunning in isolated rat hearts after ischemia-reperfusion induction. The infarct size limitation and contractility improvement observed with U50488H treatment during reperfusion are entirely mediated by OR stimulation and not by Ca2+ channel modulation.