Pretransplant diastolic wall strain assessed by transthoracic echocardiography and its implication on posttransplant survival rate in liver transplantation

BACKGROUND: In cirrhotic patients, left ventricular diastolic dysfunction is associated with poor outcomes. Diastolic wall strain (DWS) is a new index of left ventricular diastolic function that correlates with the myocardial stiffness. In this study, we aimed to determine whether DWS calculated from preoperative transthoracic echocardiography can predict the survival of liver transplantation recipients. METHODS: A total of 981 patients who underwent liver transplantation were enrolled. We collected the clinical, laboratory and echocardiographic data retrospectively. The left ventricular posterior wall thickness at end-systole (LVPWs) and end-diastole (LVPWd) were measured using M-mode imaging. DWS was calculated as follows: DWS = (LVPWs – LVPWd) / LVPWs. As previously reported, DWS ≤ 0.33 was defined as low DWS and DWS > 0.33 was defined as normal DWS. The primary outcome of this study was 2-years survival after liver transplantation. RESULTS: The 2-years mortality rate following liver transplantation was higher in low DWS group than normal DWS group (14.6% vs.10.0%, P = 0.038). In univariate Cox regression analysis, age, model for end-stage liver disease score, Child-Turcotte-Pugh score, creatinine, b-type natriuretic peptide, heart rate, left ventricular end-diastolic volume index, left ventricular stroke volume index, left ventricular ejection fraction, E/A ratio, e′, E/e′ ratio, and DWS were associated with 2-years survival after liver transplantation. In multivariate Cox regression analysis, DWS was an independent predictor of 2-years survival after adjusting significant univariate covariates. CONCLUSIONS: This study results indicated that the DWS is an independent prognostic predictor in liver transplantation recipients.

Concurrent meralgia paresthetica and radiculopathy of the left leg: A case report

Meralgia paresthetica (MP) is a painful mononeuropathy of the lateral femoral cutaneouse nerve (LFCN) characterized by localized symptoms of numbness, tingling, pain and paresthesia along the anterolateral thigh area. L4 and L5 radiculopathy is set of symptoms that include sharp, burning or shooting pain, which is usually localized to anterolateral leg area and along the dermatomal distribution. When symptoms of MP and lumbar disc disease occur together it is not easy to diagnose MP. We report a case of synchronous post-traumatic MP and radiculopathy due to intervertebral disc herniation at L3–4 and 4–5. A 59-year-old male patient was admitted to the emergency room with symptoms of low back pain with left severe L4, L5 radiculopathy. This patient also complained of numbness and paresthesia in the left anterolateral thigh. After detailed history taking and lateral femoral cutaneouse nerve block, he was diagnosed with MP.

Thalamic Pain Misdiagnosed as Cervical Disc Herniation

Thalamic pain is a primary cause of central post-stroke pain (CPSP). Clinical symptoms vary depending on the location of the infarction and frequently accompany several pain symptoms. Therefore, correct diagnosis and proper examination are not easy. We report a case of CPSP due to a left acute thalamic infarction with central disc protrusion at C5-6. A 45-year-old-male patient experiencing a tingling sensation in his right arm was referred to our pain clinic under the diagnosis of cervical disc herniation. This patient also complained of right cramp-like abdominal pain. After further evaluations, he was diagnosed with an acute thalamic infarction. Therefore detailed history taking should be performed and examiners should always be aware of other symptoms that could suggest a more dangerous disease.

Midazolam protects B35 neuroblastoma cells through Akt-phosphorylation in reactive oxygen species derived cellular injury / 대한마취과학회지

BACKGROUND: Soman, a potent irreversible acetylcholinesterase (AChE) inhibitor, induces delayed neuronal injury by reactive oxygen species (ROS). Midazolam is used in patients with pathologic effects of oxidative stresses such as infection, hemodynamic instability and hypoxia. We investigated whether midazolam protects the Central Nervous System (CNS) from soman intoxication. The present study was performed to determine whether midazolam protects B35 cells from ROS stress for the purpose of exploring an application of midazolam to soman intoxication. METHODS: Glucose oxidase (GOX) induced ROS stress was used in a B35 neuroblastoma cell model of ROS induced neuronal injury. To investigate the effect of midazolam on cell viability, LDH assays and fluorescence activated cell sorting (FACS) analysis was performed. Western blotting was used for evaluating whether Akt-phosphorylation is involved in cell-protective effects of midazolam. RESULTS: GOX derived ROS injury decreased cell viability about 1.6-2 times compared to control; midazolam treatment (5 and 10 microg/ml) dose-dependently increased cell viability during ROS injury. On western blots, Akt-phosphorylation was induced during pretreatment with midazolam; it was diminished during co-treatment with LY-294002, an inhibitor of Akt-phosphorylation. FACS analysis confirmed that the cell protective effect of midazolam is mediated by an anti-apoptotic effect. GOX-induced apoptosis was inhibited by midazolam and the finding was diminished by LY-294002. CONCLUSIONS: Midazolam protects neuronal cells from GOX-induced ROS injury; this effect is mediated by an anti-apoptotic effect through Akt-phosphorylation. This shows that midazolam may be useful in soman intoxication.

Anaphylaxis Induced by Intravenous Ranitidine Injection: 2 Case Reports / 대한구급학회지

Histamine type 2 (H2) receptor antagonists are widely used for stress ulcer prophylaxis in critical and postoperative care. Though ranitidine is one of the most commonly used H2 receptor antagonists, with a low incidence of adverse reactions, a few anaphylactic reactions associated with ranitidine have been reported. This report describes 2 additional cases of anaphylaxis induced by ranitidine used for stress ulcer prophylaxis.

Airway Obstruction Caused by Prevertebral Soft Tissue Swelling after Anterior Cervical Discectomy and Fusion: A Case Report / 대한구급학회지

Acute airway obstruction after anterior cervical surgery is rare, but does occur. Airway obstruction due to prevertebral soft tissue swelling is unpredictable, but potentially lethal. We managed a 67-year-old male who developed acute airway obstruction caused by marked prevertebral soft tissue swelling on the first day after anterior cervical discectomy and fusion at the C4-C5 level.

Acute hypertensive pulmonary edema after Cesarean section in a patient with an antepartum myocardial infarction: A case report / 대한마취과학회지

We report a case of 29-year-old, morbidly obese, diabetic primigravida who had undergone previously primary percutaneous coronary intervention with stent placement for an inferior wall myocardial infarction at 10 weeks of gestation. She remained asymptomatic with medication during the remainder of her pregnancy, but preoperative echocardiography revealed left ventricular dilation and a restrictive diastolic dysfunction with a preserved ejection fraction (46%). She developed acute pulmonary edema associated with hypertension after an elective Cesarean delivery under continuous epidural anesthesia despite the meticulous restriction of fluid.

Delayed Human Neutrophil Apoptosis by Trichomonas vaginalis Lysate

Neutrophils play an important role in the human immune system for protection against such microorganisms as a protozoan parasite, Trichomonas vaginalis; however, the precise role of neutrophils in the pathogenesis of trichomoniasis is still unknown. Moreover, it is thought that trichomonal lysates and excretory-secretory products (ESP), as well as live T. vaginalis, could possibly interact with neutrophils in local tissues, including areas of inflammation induced by T. vaginalis in humans. The aim of this study was to investigate the influence of T. vaginalis lysate on the fate of neutrophils. We found that T. vaginalis lysate inhibits apoptosis of human neutrophils as revealed by Giemsa stain. Less altered mitochondrial membrane potential (MMP) and surface CD16 receptor expression also supported the idea that neutrophil apoptosis is delayed after T. vaginalis lysate stimulation. In contrast, ESP stimulated-neutrophils were similar in apoptotic features of untreated neutrophils. Maintained caspase-3 and myeloid cell leukemia-1 (Mcl-1) in neutrophils co-cultured with trichomonad lysate suggest that an intrinsic mitochondrial pathway of apoptosis was involved in T. vaginalis lysate-induced delayed neutrophil apoptosis; this phenomenon may contribute to local inflammation in trichomoniasis.

Pleural effusion and atelectasis during continuous interscalene brachial plexus block: A case report / 대한마취과학회지

An interscalene brachial plexus block is an effective means of providing anesthesia-analgesia for shoulder surgery. However, it has a multitude of potential side effects such as phrenic nerve block. We report a case of a patient who developed atelectasis of the lung, and pleural effusion manifested as chest discomfort during a continuous interscalene brachial plexus block for postoperative analgesia.

A clinical comparison of vertical infraclavicular brachial plexus block using 0.75% or 0.5% ropivacaine for upper limb surgery / 대한마취과학회지

BACKGROUND: We performed a prospective, double blind study to compare the clinical effect of vertical infraclavicular brachial plexus block produced by 0.75% vs 0.5% ropivacaine for upper limb surgery. METHODS: We included 80 patients receiving upper limb surgery under infraclavicular brachial plexus block. The infraclavicular brachial plexus block was performed via the vertical technique with 30 ml of 0.75% or 0.5% ropivacaine. By observation, we determined nerve type was stimulated and scored the level of sensory block and motor block. The quality of blocks was assessed intra-operatively. The duration of sensory block and motor block and their complications were assessed. RESULTS: There were no significant differences in the frequency of stimulated nerve type, evolution of sensory and motor block quality, or success of block. There were no significant differences in the duration of sensory block and motor block. Vascular puncture was noted in 1 patient in the 0.75% ropivacaine. CONCLUSIONS: Both the 0.75% and 0.5% ropivacaine had similar effects in the vertical infraclavicular brachial plexus block.

Continuous epidural analgesia versus continuous intravenous analgesia with peri-articular infiltration following total knee arthroplasty in geriatric patients / 대한마취과학회지

BACKGROUND: Postoperative continuous intravenous analgesia may not provide effective postoperative analgesia following total knee arthroplasty. This study was conducted to determine if combined continuous intravenous analgesia and peri-articular infiltration provided a better quality of analgesia following total knee arthroplasty than epidural analgesia. METHODS: A prospective, double-blind study involving 50 patients who had undergone total knee arthroplasty was conducted. Patients were divided into control group and an experimental group. Patients in the control group (n = 25) received peri-articular infiltration with 47 mL normal saline prior to closure of the wound and postoperative epidural analgesia for 48 hours. Patients in the experimental group (n = 25) received a mixture of peri-articular infiltration of 16 mL of 0.75% ropivacaine, 6 mg morphine, 0.2 mg of epinephrine and 25 mL normal saline prior to closure of the wound and postoperative continuous intravenous analgesia for 48 hours. The analgesic efficacy was then evaluated using the verbal numeric rating scale at 1, 2, 6, 12, 24, and 48 hours postoperatively. The side effects and the dosage of rescue analgesics were then recorded. RESULTS: The experimental group showed a significantly higher pain score than the control group 2 and, 6 hours postoperatively at rest and 2 hours postoperatively following passive knee movement (P < 0.05). In addition, the rescue analgesic requirement was higher for the experimental group during the first 24 hours following surgery than for the control group (P < 0.05). CONCLUSIONS: We found that combined continuous intravenous analgesia and peri-articular infiltration of a mixture of ropivacaine and, morphine injected into the peri-articular tissue provided minimal benefits for pain control during the early postoperative period when compared to epidural analgesia after total knee arthroplasty.

Atypical presentation of Kawasaki disease resembling a retropharyngeal abscess / 소아과

Kawasaki disease is an acute systemic inflammatory disorder, the etiology of which has not yet been established. The clinical manifestations are non-specific and are common to many pediatric infectious and immunologic diseases. In 2 cases presenting fever, cervical lymphadenopathy, and retropharyngeal abscess-like lesions on the neck shown in a computerized tomography (CT) scan, the diagnosis of Kawasaki disease was delayed. The patients were not responsive to antibiotic therapy, and fluid collection was not found during retropharyngeal aspiration. They showed typical Kawasaki manifestations over time and atrioventricular valve regurgitation in the echocardiogram. A diagnosis of Kawasaki disease should be considered in similar cases of fever and cervical lymphadenopathy. A CT scan that shows a retropharyngeal abscess-like lesion on the neck can be a false positive finding, and other laboratory exams, including echocardiography, should be performed as early as possible to avoid unnecessary medical and surgical procedures.

Identification of the L4-5 interspinous space using difference in heights of two consecutive spinous processes / 대한마취과학회지

BACKGROUND: The appropriate landmark of spinal puncture is important for preventing spinal cord injury. L4 spinous process (SP) is the largest in size and L5 is the smallest. In this study 'height of SP' is the longitudinal length of SP on lumbar AP view. The purpose of this study was to identify the L4-5 interspinous space (ISS) using difference between L4, 5 SP heights. METHODS: Sixty-six patients scheduled for spine surgery were enrolled. After induction of general anesthesia, patients were changed to a prone position. The lumbar vertebrae were palpated from the lowest point of the lumbar spine and cranially. We palpated the difference in spinous process heights and marked the point of step-off from L4 SP to L5 SP. The level was radiologically confirmed. Direction of estimation error and the effects of spondylolisthesis, sex, and obesity were also analyzed. RESULTS: The number of accurate identification of the L4-5 ISS in males was 36 (85.7%), in females was 17 (70.8%), and in total 53 (80.3%). The difference between L4 and L5 SP heights (DL4-5SPHs) and sex affect the results. DL4-5SPHs were larger in concordant patients than in discordant patients (7.2 +/- 4.9 mm: 5.0 +/- 1.6 mm, P < 0.05). Among errors, there were more cephalad identified cases compared to caudad identified ones (12.1%: 7.6%). CONCLUSIONS: The identification of L4-5 ISS using SP height difference was considerably accurate. So, we considered this might be a useful method for spinal anesthesia.

The characteristics of neurocardiogenic syncope in children / 소아과

Purpose: Syncope is relatively common in children and adolescents. Among the etiologies of syncope, neurocardiogenical syncope is the most common, but it is often confounded with seizure. We investigated the clinical features of patients under the age of 15 with neurocardiogenical syncope, compared to patients with neurologic disorders including epilepsy. Methods: Among the children who visited the Department of Pediatrics at Cheongju St. Mary's Hospital and Chungbuk National University Hospital from March 2005 to February 2007, we retrospectively analyzed 69 patients whose chief complaint was syncope. We classified the patients by syncope etiology and made comparisons between the neurocardiogenical syncope (NCS) group and the neurological disorders (ND) group regarding to age; location; time and season in which syncope occurred; associated symptoms, including seizures, provocation factors; prodromes; duration of syncope; frequency of previous syncope; birth history; associated disease; past medical history; family history; neurological exam; physical exam; laboratory findings; electrocardiography; electroencephalography (EEG); head-up tilt test; brain CT; and MRI. Results: Among 69 syncope patients, 53 (76.8%) were in the NCS group and 11 (15.9%) were in the ND group. There were no statistically significant differences between the two study groups except for the presence of prodromes and EEG abnormalities. The presence of prodromes in the NCS group was more common than in the ND group [46.9% (23/49) vs. 9.1% (1/11), (P=0.038)]. The EEG abnormality in the ND group was more common than in the NCS group [90% (9/10) vs. 5.8% (3/52), (P<0.01)]. Conclusion: Our study suggests that detailed history-taking, including that concerning prodromes, is important for the accurate diagnosis of neurocardiogenical syncope, and EEG should be obtained if neurological disorders are suggested.

Brain wave results in children with attention deficit hyperactivity disorder and treatment result with central nervous system stimulants / 소아과

PURPOSE: Attention deficit hyperactivity disorder (ADHD) is a syndrome characterized by inattention, impulsive disruptive behavior, impaired concentration, and motor restlessness. This study examined the relationships among electroencephalographic (EEG) findings, stimulant use, and seizure occurrence in children with ADHD. METHODS: We retrospectively studied 308 children with ADHD who visited the neuropsychiatric clinic of our hospital from January 2001 to December 2005. We retrospectively analyzed age distribution, etiology, abnormal EEG findings, and use of CNS stimulants. Among these children, brain waves was recorded in 84 patients. RESULTS: Eighty-four children (72 males, 85.7%, 9.3 years mean age; 12 females, 14.3%, 8.0 years mean age) with ADHD had electroencephalograms (EEGs) performed at our institute. Nineteen patients (22.6%) demonstrated epileptiform abnormalities, and 65 (77.4%) demonstrated normal EEGs. Stimulant therapy was applied to 59 of 84 patients (70.2%). Seizures occurred in 1 of 65 patients with a normal EEG (incidence, 1.5%) and 3 of 19 treated patients with epileptiform EEGs (incidence, 15.7%). CONCLUSION: These data suggest that patients with normal EEGs have minor risk for seizure. In contrast, patients with epileptiform EEGs have higher risk for seizure than patients with normal EEGs.

Postoperative Epidural Analgesia using 0.1% Levobupivacaine or 0.1% Ropivacaine Combined with Sufentanil in Gynecologic Surgery / 대한마취과학회지

BACKGOUND: Ropivacaine and levobupivacaine are recently introduced amide local anesthetics that are structurally similar to bupivacaine. In this study, we compared the quality of postoperative analgesia and the side effects of 0.1% ropivacaine/sufentanil and 0.1% levobupivacaine/sufentanil. METHODS: Sixty patients scheduled for gynecologic surgery under general anesthesia were randomized to receive either 0.1% ropivacaine with sufentanil (ropivacaine group) or 0.1% levobupivacaine with sufentanil (levobupivacaine group) for postoperative epidural analgesia using a patient-controlled analgesia pump at a rate of 5 ml/h during the 48 hour period following surgery. Visual analogue scale (VAS) scores at rest and on coughing, sitting and movement, the degree of ambulation, additional analgesic requirements and side effects were assessed. RESULTS: In the levobupivacaine group, VAS scores at rest and on coughing, sitting and movement were lower than in the ropivacaine group (P < 0.05). In the ropivacaine group more patients were able to walk unaided (P < 0.05). There were no differences in local anesthetic consumption, additional analgesic requirements and side effects between the groups. CONCLUSIONS: Both 0.1% ropivacaine with sufentanil and 0.1% levobupivacaine with sufentanil provided effective postoperative epidural analgesia, but ropivacaine produced lesser motor block.

Experience of Laryngeal Tube Insertion in a Patient of Expected Difficult Intubation : A case report / 대한마취과학회지

Airway management is important during general anesthesia. Difficulty with a direct laryngoscopy can be routinely successfully managed using a laryngeal mask airway. However, a laryngeal mask airway may not be suitable for the patients having a small oral cavity volume or narrow interincisor distance. A 19-year-old man, scheduled for right clavicular fracture had no specific underlying medical problems. However, he had difficultly opening his mouth, and was Mallampati class IV. Also, he had difficultly in extending his neck. Airway management was successfully performed using a laryngeal tube instead of a laryngeal mask airway. The patient was successfully managed, without complications, until the end of the surgery.

Comparison of Three Diffferent Modalities for Combined Spinal Epidural Anesthesia and Spinal Anesthesia in Geriatric Patients / 대한마취과학회지

BACKGROUND: Combined spinal epidural anesthesia (CSE) combines the rapid onset and intensity of a subarachnoid blockade with the flexibility of an epidural catheter, thereby allowing the intraoperative extension of anesthesia and postoperative epidural analgesia. This study investigated the effects of hyperbaric bupivacaine during CSE for lower limb orthopedic surgery in geriatric patients. METHODS: Group 1 received a subarachnoid injection of 8 mg of bupivacaine and an epidural catheter. Group 2 received a subarachnoid injection of 5 mg of bupivacaine and fentanyl, 10 microgram and an epidural top-up with 3 ml saline. Group 3 received a subarachnoid injection of 5 mg of bupivacaine and fentanyl 10 microgram with an epidural top-up of 6 ml saline. Group 4 received a subarachnoid injection of 6 mg of bupivacaine and an epidural top-up with 6 ml saline. The maximal level of the sensory blockade, the time of onset to the maximal sensory blockade, the two segment regression time, the time for sensory regression to the tenth thoracic dermatome (T10) and the motor recovery to modified Bromage Scale 0 were compared. After recording the baseline systolic blood pressure and heart rate, the systolic blood pressure and heart rate were recorded at 5 min intervals. RESULTS: There were significant differences in the two-segment regression times, the times to motor recovery between the groups. However, the intraoperative blood pressure and heart rate were similar. CONCLUSIONS: In terms of the peri-operative side effects and recovery from the blocks, CSE was better for lower limb orthopedic surgery in geriatric patients than spinal anesthesia.

Hemothorax Due to Diaphragm Laceration Induced Osteochondroma of Rib: A case report / 대한흉부외과학회지

Spontaneous hemothorax vary in cause and are rare for hemothorax induced osteochondroma. Sometimes hemothroax is reported due to osteochondroma induced injury of diaphragm, lung, pericardium, heart, or pleura. We report a patient with diaphragm laceration due to osteochondroma.

Comparison of Premixed NaHCO3 and Lidocaine on Rocuronium Injection Pain / 대한마취과학회지

BACKGROUND: Rocuronium administration is associated with a severe burning pain during injection in 50-80% patients. The purpose of this study was to evaluate mixtures of saline, lidocaine, sodium bicarbonate (NaHCO3) and lidocaine-NaHCO3 with rocuronium to reduce injection pain and withdrawal movement. METHODS: One hundred and twenty patients were randomly assigned to one of four groups in a double blinded, prospective study; Group S (0.9% normal saline 5 ml mixed with rocuronium 50 mg/5 ml, n = 30), Group L (2% lidocaine 5 ml mixed with rocuronium 50 mg/5 ml, n = 30), Group B (8.4% NaHCO3 5 ml mixed with rocuronium 50 mg/5 ml, n = 30) and Group LB (4% lidocaine 2.5 ml and 8.4% NaHCO3 2.5 ml mixed with rocuronium 50 mg/5 ml, n = 30). After all patients had received an intubating dose (0.6 mg/kg) of premixed rocuronium over 5 seconds, we investigated the incidence and severity of pain and withdrawal movement. We measured the onset and duration of muscle relaxation using train-of-four (TOF) and the pH values and osmolalities of each mixture. RESULTS: The incidence and severity of pain during injection were significantly reduced in Groups B and LB compared with Group S. The withdrawal movement was observed 8 patients (26.7%) in Group S, but in no patient in Groups B or LB. No significant difference in the incidence of pain or withdrawal response was observed between Groups S and L. CONCLUSIONS: We conclude that premixed NaHCO3 with rocuronium is effective at reducing injection pain and withdrawal movement whereas the addition of lidocaine has little effect.