Cardiac arrest due to coronary vasospasm after sugammadex administration -a case report- / 대한마취과학회지

Clinicians should pay close attention to the potential risk of coronary vasospasm, even cardiac arrest, after sugammadex administration.

Impact of coronavirus disease 2019 on patients with chronic pain: multicenter study in Korea

Background@#The coronavirus disease 2019 (COVID-19) pandemic has caused significant changes. This study aimed to investigate the impact of COVID-19 on patients with chronic pain. @*Methods@#Patients with chronic pain from 23 university hospitals in South Korea participated in this study. The anonymous survey questionnaire consisted of 25 questions regarding the following: demographic data, diagnosis, hospital visit frequency, exercise duration, time outside, sleep duration, weight change, nervousness and anxiety, depression, interest or pleasure, fatigue, daily life difficulties, and self-harm thoughts. Depression severity was evaluated using the Patient Health Questionnaire-9 (PHQ-9). Logistic regression analysis was used to investigate the relationship between increased pain and patient factors. @*Results@#A total of 914 patients completed the survey, 35.9% of whom had decreased their number of visits to the hospital, mostly due to COVID-19. The pain level of 200 patients has worsened since the COVID-19 outbreak, which was more prominent in complex regional pain syndrome (CRPS). Noticeable post-COVID-19 changes such as exercise duration, time spent outside, sleep patterns, mood, and weight affected patients with chronic pain. Depression severity was more significant in patients with CRPS. The total PHQ-9 average score of patients with CRPS was 15.5, corresponding to major depressive orders. The patients’ decreased exercise duration, decreased sleep duration, and increased depression were significantly associated with increased pain. @*Conclusions@#COVID-19 has caused several changes in patients with chronic pain.During the pandemic, decreased exercise and sleep duration and increased depression were associated with patients’ increasing pain.

Multicenter survey of symptoms, work life, economic status, and quality of life of complex regional pain syndrome patients

Background@#Complex regional pain syndrome (CRPS) is an intractable pain disease with various symptoms. Here, we investigated the disease status, work life, sleep problems, medical insurance, economic status, psychological problems, and quality of life (QOL) of CRPS patients. @*Methods@#CRPS patients from 37 university hospitals in South Korea were surveyed.The survey questionnaire consisted of 24 questions on the following aspects of CRPS patients: sex, age, occupation, cause of injury, activities of daily living (ADL), pain severity, sleep disturbance, level of education, economic status, therapeutic effect, and suicidal ideation. Additionally, the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, consisting of 26 questions, was used to identify the status of QOL. @*Results@#A total of 251 patients completed the questionnaire. According to the survey, 54.2% patients could not perform ADL on their own. Over the previous week, the mean pain score was 7.15 ± 1.78 (out of a total of 10 points); 92.1% of patients had sleep disorders and 80.5% had suicidal ideation, with most patients suffering from psychological problems. The average for each domain of WHOQOL-BREF was as follows: 21.74 ± 14.77 for physical, 25.22 ± 17.66 for psychological, 32.02 ± 22.36 for social relationship, and 30.69 ± 15.83 for environmental (out of a total of 100 points each). Occupation, ADL, sleep time, therapeutic effect, and suicidal ideation were statistically correlated with multiple domains. @*Conclusions@#Most patients had moderate to severe pain, economic problems, limitations of their ADL, sleep problems, psychological problems, and a low QOL score.

Multicenter survey of symptoms, work life, economic status, and quality of life of complex regional pain syndrome patients

Background@#Complex regional pain syndrome (CRPS) is an intractable pain disease with various symptoms. Here, we investigated the disease status, work life, sleep problems, medical insurance, economic status, psychological problems, and quality of life (QOL) of CRPS patients. @*Methods@#CRPS patients from 37 university hospitals in South Korea were surveyed.The survey questionnaire consisted of 24 questions on the following aspects of CRPS patients: sex, age, occupation, cause of injury, activities of daily living (ADL), pain severity, sleep disturbance, level of education, economic status, therapeutic effect, and suicidal ideation. Additionally, the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, consisting of 26 questions, was used to identify the status of QOL. @*Results@#A total of 251 patients completed the questionnaire. According to the survey, 54.2% patients could not perform ADL on their own. Over the previous week, the mean pain score was 7.15 ± 1.78 (out of a total of 10 points); 92.1% of patients had sleep disorders and 80.5% had suicidal ideation, with most patients suffering from psychological problems. The average for each domain of WHOQOL-BREF was as follows: 21.74 ± 14.77 for physical, 25.22 ± 17.66 for psychological, 32.02 ± 22.36 for social relationship, and 30.69 ± 15.83 for environmental (out of a total of 100 points each). Occupation, ADL, sleep time, therapeutic effect, and suicidal ideation were statistically correlated with multiple domains. @*Conclusions@#Most patients had moderate to severe pain, economic problems, limitations of their ADL, sleep problems, psychological problems, and a low QOL score.

Patients’ perception about opioids and addiction in South Korea

Background@#Chronic pain affects approximately 22% of the world’s population. Opioids can be useful in chronic pain management. However, some patients have negative perception of opioids. The purpose of this research was to evaluate patients’ perception about opioids and investigate problems associated with prescribing and taking opioids in South Korea. @*Methods@#Patients who visited a pain clinic in 14 university hospitals of South Korea from September through October 2018 were asked to complete anonymous questionnaires about taking opioids. @*Results@#Of the 368 patients that were surveyed (female 53.3%, male 46.7%), 56.8% were prescribed opioids. In the opioid group, 92.8% patients had heard of opioids from their doctor and 72.6% of them had a positive perception about opioids. The side effects associated with opioid use were constipation (35.4%), dizziness (24.6%), nausea and vomiting (17.4%), dysuria (6.2%), and addiction (2.0%). In the no opioid group, the primary sources of information about opioids were doctors (49.2%), mass media (30.8%), and the internet (16.2%). The main reasons why 39.0% patients did not take opioids were fear of addiction (57.7%) and side effects (38.5%). There were 71.5% and 60.9% patients in the opioid and no opioid group, respectively, who wished to take opioids when their numeric rating scale pain score was ≥ 7. @*Conclusions@#Perception of opioids among patients who take them was either neutral or positive. However, 39.0% patients who have not been prescribed opioids did not want an opioid prescription, citing fear of addiction and side effects as the primary reasons.

Pneumocephalus following fluoroscopy-guided lumbar epidural injection in elderly patients: two cases report and a review of Korean literatures - Two cases report -

Background@#Pneumocephalus can originate from accidental dural puncture while performing epidural block using the loss-of-resistance (LOR) technique with an air-filled syringe. Case: We present two cases of pneumocephalus after lumbar epidural block under fluoroscopy for pain control in elderly patients. @*Conclusions@#Lumbar epidural block should be performed under fluoroscopic guidance in elderly patients with severe lesions. The physician should be aware of the increased possibility of a dural puncture occurring due to anatomical changes in older patients. The use of saline is recommended for the LOR technique. A contrast injection should be used together with the LOR technique to locate the epidural space. If a dural puncture occur, the patient should be carefully monitored to determine whether pneumocephalus has developed.

Ultrasonography for lumbar neuraxial block

Ultrasonography can be useful to perform a lumbar neuraxial block. It aids in understanding the anatomy of the lumbar spine before the procedure. Pre-procedural ultrasound imaging provides information about the accurate intervertebral level for puncture, optimal needle insertion point, and depth of needle advancement for a successful neuraxial block. The key ultrasonographic views for lumbar neuraxial block include the transverse midline interlaminar and parasagittal oblique views. Ultrasonography can facilitate lumbar neuraxial block in difficult cases, such as the elderly, obese patients, and patients with anatomical abnormality of the lumbar spine. This review elucidates the basics of spinal ultrasonography for lumbar neuraxial block and the current evidence regarding ultrasound-guided neuraxial block in adults.

A survey of patients’ perspectives of steroid injection (ppyeojusa) in Korea / 대한통증학회지

BACKGROUND: Steroid injections are commonly used in pain clinics to relieve pain and treat inflammation. In Korea, these steroid injections are well known as ‘ppyeojusa’, which means to inject into the bone in Korean. Some patients often have a negative perception of this treatment method due to inaccurate information about the treatment and side effects of steroids. The purpose of this study is to investigate patients’ perception and knowledge of ppyeojusa. METHODS: A questionnaire about ppyeojusa was completed by patients who visited one of the pain clinics in nine university hospitals, from August 1 to September 10, 2017. RESULTS: Three-hundred seventy-four patients completed the survey. Eighty-five percent of patients had had ppyeojusa, and 74% of the respondents had heard of ppyeojusa from the mass media, friends or relatives. Only 39% of the patients answered that this injection was safe without side effects if properly spaced. Of the patients surveyed, 21% responded that ppyeojusa are “injections into the bone”; while 15% responded that ppyeojusa are “terrible injections that melted ‘the bone if used a lot’”. Half of the patients did not know what the active constituent is in ppyeojusa. If steroid injections are advised by the pain specialists, 89% of the patients would consent. CONCLUSIONS: Most pain clinic patients have heard of ppyeojusa. Most patients obtained information about ppyeojusa from mass media, rather than their physicians. Therefore, it is likely that most patients have inaccurate knowledge.

Experience of Conflict in Three Shift Nurses Rearing more than Two Kids: Phenomenological Study

PURPOSE: To understand the essentials of rearing conflict experience by three shift nurses in advanced general hospitals. METHODS: The design was a qualitative research of phenomenology. Participants were 7 shift nurses working in advanced general hospitals who were rearing young children. Data were collected individually through in-depth interview on their life experiences. Data were analyzed by Colaizzi's phenomenological methodology. RESULTS: Eighteen themes were drawn from 256 meaningful experiences and these themes were integrated to six theme clusters. The most influencing themes were ‘Regret that I cannot satisfy even the slightest wish’, ‘Fail to care for kids’, and ‘Mutual feeling to care giver between appreciation and inconvenience’. Other themes were as follows: ‘Body and mind are broken’, ‘The need for a three-shift system to support nurses who are rearing children’, ‘Doing my best for work and child rearing’. CONCLUSION: The nature of three-shift nurses working in advanced hospital and caring kids is explained as ‘lives with conflict’ between work and home. This study suggests it is necessary to establish a 24-hour care center for 3-shift nurses to keep working while rearing their children.

Upper limb nerve injuries caused by intramuscular injection or routine venipuncture

The reported cases of upper limb nerve injury followed by needle procedure such as intramuscular injection or routine venipuncture are rare. However, it should not be overlooked, because neurological injury may cause not only minor transient pain but also severe sensory disturbance, hand deformity and motor dysfunction with poor recovery. Recognizing competent level of anatomy and adept skill of needle placement are crucial in order to prevent this complication. If a patient notices any experience of abnormal pain or paresthesia during the needle procedures, an administrator should be alert to the possibility of nerve injury and should withdraw the needle immediately. Careful monitoring of the injection site for hours is required for early detection of nerve injury.

Learning curve of skilled anesthesiologists for endotracheal intubation using Optiscope™

BACKGROUND: Optiscope™ is a semi-rigid fiberscope for endotracheal intubation. A camera attached to the distal end of the stylet shows the laryngeal view through an adjustable LCD-monitor attached at the handle. The aim of this study was to evaluate the learning curve of skilled anesthesiologists in the use of Optiscope™. METHODS: Eighty-patients with normal airways were randomly assigned to four anesthesiologists, who did not have previous experience of intubation with Optiscope™. After induction of general anesthesia, the four investigators performed 20 intubations each, using the Optiscope™. Time to intubation (TTI), number of intubation attempts, and reasons of prolonged TTI were evaluated. RESULTS: The success rate of intubation was 98.8%. The TTI was significantly faster in 16th–20th patients (35.0 s, interquartile range 27.3–41.4) than in the first 10 patients (54.1 s, interquartile range 31.2–75.5) (P = 0.006). All patients after the 16th intubation were intubated at the first attempt. Frequent problems encountered were difficulty in getting the stylet tip under the epiglottis, and mucous secretion obscuring the laryngeal anatomy. CONCLUSIONS: Optiscope™ is an effective device for endotracheal intubation. About 15 intubations in patients with normal airways provided clinically adequate experience to the skilled anesthesiologists. Additional maneuver of airway opening such as jaw thrust and sufficient removal of oral secretion, are suggested to reduce TTI.

Learning curve of skilled anesthesiologists for endotracheal intubation using Optiscope™

BACKGROUND: Optiscope™ is a semi-rigid fiberscope for endotracheal intubation. A camera attached to the distal end of the stylet shows the laryngeal view through an adjustable LCD-monitor attached at the handle. The aim of this study was to evaluate the learning curve of skilled anesthesiologists in the use of Optiscope™. METHODS: Eighty-patients with normal airways were randomly assigned to four anesthesiologists, who did not have previous experience of intubation with Optiscope™. After induction of general anesthesia, the four investigators performed 20 intubations each, using the Optiscope™. Time to intubation (TTI), number of intubation attempts, and reasons of prolonged TTI were evaluated. RESULTS: The success rate of intubation was 98.8%. The TTI was significantly faster in 16th–20th patients (35.0 s, interquartile range 27.3–41.4) than in the first 10 patients (54.1 s, interquartile range 31.2–75.5) (P = 0.006). All patients after the 16th intubation were intubated at the first attempt. Frequent problems encountered were difficulty in getting the stylet tip under the epiglottis, and mucous secretion obscuring the laryngeal anatomy. CONCLUSIONS: Optiscope™ is an effective device for endotracheal intubation. About 15 intubations in patients with normal airways provided clinically adequate experience to the skilled anesthesiologists. Additional maneuver of airway opening such as jaw thrust and sufficient removal of oral secretion, are suggested to reduce TTI.

The effect-site concentration of remifentanil for blunting hemodynamic responses: comparative study in single-lumen endotracheal and double-lumen endobronchial intubation

BACKGROUND: This study undertook to compare the effect-site concentration of remifentanil for prevention of hemodynamic responses to endotracheal intubation, employing the single-lumen tracheal tube and the double-lumen bronchial tube during total intravenous anesthesia. METHODS: Based on the nature of the surgery, 38 patients undergoing general anesthesia were assigned either to the single-lumen tube group or the double-lumen tube group. Anesthesia was induced by a target controlled infusion of propofol, with an effect-site concentration of 4 µg/ml. Remifentanil was then administered to the first patient in each group, with an effect-site concentration of 3.5 ng/ml. Subsequent concentration of remifentanil was determined by hemodynamic responses of the previous patient to intubation, based on the up-and-down method. RESULTS: The effect-site concentrations of remifentanil for prevention of hemodynamic responses to endotracheal intubation in 50% of patients (EC₅₀) were 2.8 ng/ml (95% CI, 2.0–3.7 ng/ml) in the single-lumen tube group, and 2.9 ng/ml (95% CI, 2.5–3.2 ng/ml) in the double-lumen tube group. No significant difference was observed between the two groups. CONCLUSIONS: The effect-site concentration of remifentanil for prevention of hemodynamic responses to endotracheal intubation did not differ during total intravenous anesthesia, using either the single-lumen tracheal tube or the double-lumen bronchial tube.

Ultrasound Guided Low Approach Interscalene Brachial Plexus Block for Upper Limb Surgery

BACKGROUND: The interscalene brachial plexus block is widely used for pain control and anesthetic purposes during shoulder arthroscopic surgeries and surgeries of the upper extremities. However, it is known that interscalene brachial plexus block is not appropriate for upper limb surgeries because it does not affect the lower trunk (C8-T1, ulnar nerve) of the brachial plexus. METHODS: A low approach, ultrasound-guided interscalene brachial plexus block (LISB) was performed on twenty-eight patients undergoing surgery of the upper extremities. The patients were assessed five minutes and fifteen minutes after the block for the degree of block in each nerve and muscle as well as for any complications. RESULTS: At five minutes and fifteen minutes after the performance of the block, the degree of the block in the ulnar nerve was found to be 2.8 +/- 2.6 and 1.1 +/- 1.8, respectively, based on a ten-point scale. Motor block occurred in the median nerve after fifteen minutes in 26 of the 28 patients (92.8%), and in all of the other three nerves in all 28 patients. None of the patients received additional analgesics, and none experienced complications. CONCLUSIONS: The present study confirmed the achievement of an appropriate sensory and motor block in the upper extremities, including the ulnar nerve, fifteen minutes after LISB, with no complications.

A Comparison of Three Methods for Postoperative Pain Control in Patients Undergoing Arthroscopic Shoulder Surgery

BACKGROUND: Arthroscopic shoulder operations (ASS) are often associated with severe postoperative pain. Nerve blocks have been studied for pain in shoulder surgeries. Interscalene brachial plexus blocks (ISB) and an intra-articular injection (IA) have been reported in many studies. The aim of the present study is to evaluate the effect of ISB, a continuous cervical epidural block (CCE) and IA as a means of postoperative pain control and to study the influence of these procedures on postoperative analgesic consumption and after ASS. METHODS: Fifty seven patients who underwent ASS under general anesthesia were randomly assigned to one of three groups: the ISB group (n = 19), the CCE group (n = 19), and the IA group (n = 19). Patients in each group were evaluated on a postoperative numerical rating scale (NRS), their rescue opioid dosage (ROD), and side effects. RESULTS: Postoperative NRSs were found to be higher in the IA group than in the ISB and CCE groups both at rest and on movement. The ROD were 1.6 +/- 2.3, 3.0 +/- 4.9 and 7.1 +/- 7.9 mg morphine equivalent dose in groups CCE, ISB, and IA groups (P = 0.001), respectively, and statistically significant differences were noted between the CCE and IA groups (P = 0.01) but not in between the ISB and CCE groups. CONCLUSIONS: This prospective, randomized study demonstrated that ISB is as effective analgesic technique as a CCE for postoperative pain control in patients undergoing ASS.

Prevalence and Predictors of Postoperative Complications in Patients Older Than 80 Years

BACKGROUND: The number of elderly patients undergoing surgery is steadily growing. Therefore, this study was designed to determine the prevalence and predictors of postoperative complications in patients older than 80 years. METHODS: The medical records of 532 patients above 80 years in age who underwent elective or emergent noncardiac surgery between June 2011 and May 2013 were reviewed retrospectively. Preoperative concomitant disease, operation site, anesthetic technique, and postoperative complications were analyzed. RESULTS: A total of 81.4% of the patients had pre-existing concomitant diseases, while 22.9% had severe systemic diseases. The incidence of severe complications within the first month after operation was 4.1%, and the in-hospital mortality rate was 1.3%. Among the severe postoperative complications, respiratory and cardiovascular complications were commonly observed. In multivariate logistic regression analysis, the predictors of postoperative severe complications included American Society of Anesthesiologists physical status classification of 3 or greater (odds ratio [OR], 5.271; 95% confidence interval [CI], 2.019-13.758; p=0.001), neurosurgery (OR, 23.132; 95% CI, 2.528-211.707; p=0.005) and duration of operation (OR, 1.006; 95% CI, 1.001-1.012; p=0.027). CONCLUSION: Proper preoperative evaluation and appropriate treatment for age-related concomitant diseases are suggested for patients older than 80 years in order to reduce postoperative complications. After operation, the respiratory and cardiovascular systems should be carefully monitored.

Variations in Entrance of Vertebral Artery in Korean Cervical Spine: MDCT-based Analysis

BACKGROUND: Knowledge of the anatomical variation of the vertebral artery has clinical importance not only for the performance of interventional or surgical procedures itself but also to ensure their safety. We conducted a study of the anatomical variation by reviewing multi-detector computed tomography (MDCT) images of the cervical spine from 460 Korean patients. METHODS: 16-row MDCT data from 460 patients were used in this study. We observed 920 vertebral arteries. Examination points included level of entrance of the artery into the transverse foramen of the cervical vertebra, origin site of the vertebral artery, course of a vertebral artery with aberrant entrance. RESULT: The vertebral artery in 2 (0.2%) cases in this study entered into the transverse foramen of the 7th cervical vertebra from the left. In 45 (4.9%) cases, the vertebral artery entered into the transverse foramen of the 5th cervical vertebra. Of these, the entrance was on the right in 15 (1.6%) and on the left in 30 (3.3%). We found 17 (1.8%) cases in which the artery entered into the transverse foramen of the 4th cervical vertebra, 10 (1.1%) on the right and 7 (0.7%) on the left side. As is commonly acknowledged, the 6th cervical vertebra was the most common site of entry; the vertebral artery entered the transverse foramen of the 6th cervical vertebra in the remaining 855 (93.0%) cases, on the right in 434 (47.2%) and on the left in 421 (45.8%). CONCLUSIONS: In conclusion, the possibility of an atypical course of the vertebral artery in segments V1 and V2 should be evaluated with magnetic resonance imaging (MRI) or CT images before carrying out procedures involving the anterior cervical vertebrae.

Analysis of Transfusion of Packed RBC in Elderly Patients Over 75 Years in Bipolar Hemiarthroplasty / 대한수혈학회지

BACKGROUND: Bipolar hip hemiarthroplasty (BH) was known to require a large amount of transfusion. And, patients who underwent BH were extreme old age and had underlying medical diseases such as hypertension and diabetes mellitus. The aim of this study was to evaluate packed RBC (Red blood cell) transfusion and pre- and intraoperative variables during BH in elderly patients over 75 years in one university hospital. METHODS: A total of 36 patients who underwent BH from September 2013 to August 2014 in our hospital were evaluated through a retrospective study using computerized medical records and archived documents. RESULTS: Average age of patients was 81.5+/-5.3 years and packed RBC transfusion was performed in 41.6% of all enrolled patients. There was no significant difference in age, weight, height, and time of operation between transfused patients and non-transfused patients. Intraoperative volume of packed RBC transfusion was 0.6 (minimum value: 0, maximum value: 4) units. CONCLUSION: Preparation of blood components such as packed RBC is required in elderly patients over 75 years who were planned BH.

Electroconvulsive therapy for CRPS with depression: A case report

Complex regional pain syndrome (CRPS) is a chronic painful condition that may arise in the site of an earlier injury or operation to a limb. Like all chronic painful condition, it is associated with depressed mood. Electroconvulsive therapy (ECT) is a procedure when traditional management with systemic medications, nerve blocks, and behavioral pain management were unsuccessful. ECT has been used in the treatment of chronic pain for over 50 years. CRPS and comorbid depression have also been treated successfully with ECT. However, not much has been done to clarify the ECT target in patients, whether the pain or the depression. We report a case of intractable chronic regional pain syndrome with secondary depression in which both of that were treated successfully with an initial ECT course.

The Effects of Preemptive Analgesia to Blood Transfusion in Total Knee Arthroplasty / 대한수혈학회지

BACKGROUND: Total knee arthroplasty (TKA) is associated with moderate to severe postoperative pain. In recent studies, preemptive analgesia was useful for control of postoperative pain in patients undergoing TKA. In particular, cyclooxygenase-2 inhibitor (celecoxib) is recommended for preemptive analgesia. As a large amount of blood is lost during TKA, blood transfusion is often required. In this study, we evaluated the difference of intraoperative blood loss, complications of operation, and hemodynamic change between the celecoxib group and the control group in TKA surgeries. METHODS: A total of 58 patients who underwent TKA from January 2013 to June 2013 in our hospital were evaluated through a retrospective study. Patients in the celecoxib group received 200 mg of oral celecoxib 1 to 2 hours before TKA. Those in the control group received no medication 1 to 2 hours before TKA. Preoperative and postoperative hemoglobin level, estimated blood loss, infused fluid volume, and intraoperative complications (nausea, vomiting) were assessed. Mean blood pressure was recorded immediately, and 30, 60, and 90 minutes after spinal anesthesia, after transfer to the post anesthesia care unit. RESULTS: No significant differences in demographic data (age, height, weight, operation time, nausea, and vomiting) were observed between the two groups. The intraoperative fluid volume of the celecoxib group was lower than that of the control group (782.8+/-240.6 vs 1382.4+/-369.2; P<0.05). No differences in hemodynamic changes (intraoperative blood pressure) were observed between the two groups. CONCLUSION: Perioperative use of an inhibitor of cyclooxygenase 2 is an effective component of multimodal analgesia, which has no effect on hemodynamic change and side effects during TKA.