Feasibility of ultrasound-guided posterior approach for interscalene catheter placement during arthroscopic shoulder surgery.

BACKGROUND: Continuous interscalene block has been known to improve postoperative analgesia after arthroscopic shoulder surgery. This was a prospective study investigating the ultrasound-guided posterior approach for placement of an interscalene catheter, clinical efficacy and complications after placement of the catheter. METHODS: Forty-two patients undergoing elective arthroscopic shoulder surgery were included in this study and an interscalene catheter was inserted under the guidance of ultrasound with posterior approach. With the inplane approach, the 17 G Tuohy needle was advanced until the tip was placed between the C5 and C6 nerve roots. After a bolus injection of 20 ml of 0.2% ropivacaine, a catheter was threaded and secured. A continuous infusion of ropivacaine 0.2% 4 ml/hr with patient-controlled 5 ml boluses every hour was used over 2 days. Difficulties in placement of the catheter, clinical efficacy of analgesia and complications were recorded. All patients were monitored for 48 hours and examined by the surgeon for complications within 2 weeks of hospital discharge. RESULTS: Easy placement of the catheter was achieved in 100% of the patients and the success rate of catheter placement during the 48 hr period was 92.9%. Postoperative analgesia was effective in 88.1% of the patients in the post anesthetic care unit. The major complications included nausea (7.1%), vomiting (4.8%), dyspnea (4.8%) and unintended vascular punctures (2.4%). Other complications such as neurologic deficits and local infection around the puncture site did not occur. CONCLUSIONS: The ultrasound-guided interscalene block with a posterior approach is associated with a success high rate in placement of the interscalene catheter and a low rate of complications. However, the small sample size limits us to draw definite conclusions. Therefore, a well-designed randomized controlled trial is required to confirm our preliminary study.

Posterior auricular pain caused by the trigger points in the sternocleidomastoid muscle aggravated by psychological factors -A case report-.

Psychological factors play a significant role in the pain mechanism, and psychological approaches may be useful complements to traditional medical and surgical treatments in pain management. The authors report a case of recurrent severe posterior auricular pain caused by trigger points in the right sternocleidomastoid muscle and influenced by stressful psychological situations (e.g., family affairs, job loss) in a 50-year-old man.

Paroxysmal atrial fibrillation developed during incomplete epidural anesthesia -A case report-.

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia, and occurs in organic heart disease such as rheumatic, atherosclerotic and hypertensive heart disease. In recent studies, the sympathetic and parasympathetic nervous systems have been shown to have important roles in initiating paroxysmal AF. We report here a patient who developed paroxysmal AF that might be a result of an imbalance of the sympathetic-parasympathetic systems due to epidural anesthesia, and that was potentiated by pain with inadequate analgesia. A 69-year-old woman was scheduled for operation of a right-sided ankle fracture. Twenty minutes after epidural drug injection, paroxysmal AF occurred. Even after intravenous administration of esmolol and digoxin, AF continued. After transfer to the intensive care unit, her heart rate gradually decreased and AF disappeared. During perioperative anesthetic management, the proper preoperative prevention and intraoperative treatment are needed in AF high-risk patients.

Comparative study of neck pain in relation to increase of cervical epidural pressure during percutaneous endoscopic lumbar discectomy.

STUDY DESIGN: A prospective study. OBJECTIVE: By monitoring cervical epidural pressure (EP) changes throughout the procedure, we intend to discover the effect of percutaneous endoscopic lumbar discectomy (PELD) on cervical epidural pressure and whether there is a correlation between posterior neck pain and increased cervical EP, which is known to have a linear correlation with intracranial pressure (ICP). SUMMARY OF BACKGROUND DATA: Patients sometimes complain of posterior neck pain during PELD. Due to the massive irrigation fluid used during the procedure, the possibility of increased ICP as the cause is quite strong. METHODS: Twenty-eight patients undergoing PELD with ASA physical status 1 or 2 were enrolled in this study. In all patients, a cervical epidural catheter was placed at the C6-C7 level before the procedure and was connected to a pressure transducer. Cervical EPs were monitored continuously throughout the procedure. Initial stabilized EP (EP), EP at the time of neck pain, maximal EP during the procedure, and EP at the end of the procedure were checked. Neck pain onset time from the beginning of irrigation and total irrigation time were also checked. RESULTS: Of 28 patients, 8 patients complained of neck pain. Neck pain onset time from the beginning of irrigation was 35.6 +/- 11.3 (mean +/- SD) minutes. The EP at the time of neck pain (52.9 +/- 9.2 mm Hg) was significantly higher than the maximal EP in patients without neck pain (34.8 +/- 14.7 mm Hg). In all patients who complained of neck pain, the cervical EP at the time of neck pain showed pressures above 37 mm Hg. The maximal EP in those with neck pain (73.6 +/- 25.8 mm Hg) was also significantly higher than the EP in those without neck pain (34.8 +/- 14.7 mm Hg). In a correlation study, patients with higher maximal EPs had higher probabilities of having neck pain. In 6 of 8 patients, an abrupt increase in EP was observed after the onset of neck pain, while in the other 2 patients, the procedure ended just after neck pain appeared. CONCLUSION: Neck pain occurring during PELD is associated with a highly increased cervical EP generated by continuous infusion.

Association between tumor necrosis factor alpha 308G/A polymorphism and increased proinflammatory cytokine release after cardiac surgery with cardiopulmonary bypass in the Korean population.

OBJECTIVES: The G-308A polymorphism of the tumor necrosis factor alpha (TNF-alpha) gene has been suggested to be linked to high TNF promoter activity in in vitro studies. However, there have been some controversies in in vivo studies. This study investigated whether A allele at TNF-308 site is associated with (1) the changes in plasma cytokine levels during and after cardiopulmonary bypass (CPB) and (2) an increased incidence of pulmonary morbidity after CPB. DESIGN: Prospective and observational investigation. SETTING: A university hospital, single institution. PARTICIPANTS: Patients scheduled for cardiac surgery with CPB. INTERVENTION: TNF genotype was determined by the real-time polymerase chain reaction method. IL-6 and TNF-alpha levels were measured by enzyme-linked immunosorbent assay at the following time points: T1, before initiation of CPB; T2, 30 minutes of CPB; T3, 30 minutes after CPB; T4, 2 hours after CPB; and T5, 24 hours after CPB. The oxygen index, serum creatinine level, 24-hour blood loss, intubation time, and length of intensive care unit (ICU) stay were examined. MEASUREMENTS AND MAIN RESULTS: The levels of TNF-alpha in group A (TNF-308GA/AA, n = 25) were higher at T3, T4, and T5 than group G (TNF-308GG, n = 225). The levels of IL-6 showed no statistical difference. The oxygenation index, serum creatinine level, 24-hour blood loss, intubation time, and length of ICU stay showed no statistical difference. CONCLUSIONS: TNF G-308A polymorphism may be associated with excess TNF-alpha secretion in this study and may not be associated with excess IL-6 secretion and postoperative morbidity after CPB.

A case of facial myofascial pain syndrome presenting as trigeminal neuralgia.

Facial pain has many causes, including idiopathic factors, trigeminal neuralgia, dental problems, temporomandibular joint disorders, cranial abnormalities, and infections. However, the clinical diagnosis of facial pain is sometimes difficult to establish because clinical manifestations commonly overlap. The diagnosis of trigeminal neuralgia is based solely on clinical findings. Therefore, a careful evaluation of the patient history and a thorough physical examination are essential. This case describes a patient with facial myofascial pain syndrome involving the right zygomaticus, orbicularis oculi, and levator labii muscles, which presented as trigeminal neuralgia.

Common peroneal nerve palsy after robotic assisted laparoscopic colectomy: A case report.

Common peroneal nerve palsy after surgery with lithotomy position has been widely reported, but it is an unexpected complication after surgery with supine position. We report a patient who developed common peroneal nerve palsy after surgery with supine position. A 55-year old man is planed for robotic assisted laparoscopic right hemicolectomy because of colon cancer. The patient was placed supine with Trendelenburg position at an angle about 5 degrees and tilted left about 15 degrees. The operation is uneventful, but he developed common peroneal nerve palsy on the first postoperative day. The patient was fully recovered with conservative treatment after 2 months. We consider that nerve palsy as a result of compression of common peroneal nerve related to patient positioning. So we should be careful not to develop common peroneal nerve palsy even if the patient was placed in the supine position during robotic assisted surgery.

Effect of muscle relaxant on entropy during propofol anesthesia.

BACKGROUND: The purpose of this study was to investigate whether muscle relaxant affect the values of Entropy, response entropy (RE) or state entropy (SE) during propofol anesthesia. METHODS: Eighty patients (ASA I) scheduled for elective surgery under general anesthesia were randomly assigned to four groups. Anesthesia was maintained at a SE value of 80 (80 +/- 2) using target controlled infusion (TCI) of propofol. After maintaining SE 80 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group I and same volume of normal saline was intravenously injected in group II. After maintaining SE 60 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group III and same volume of normal saline was injected intravenously in group IV. The mean arterial pressure, heart rate, SE and RE were measured before anesthetic induction and up to 5 min after vecuronium or normal saline injection in each group. RESULTS: SE and RE were not changed in group II, but significantly decreased in group I (P < 0.05, respectively). In group III and IV, SE and RE were not changed in both groups. There were no significant hemodynamic changes among the four groups. CONCLUSIONS: These results suggest that the effect of muscle relaxant on Entropy vary according to the baseline values of RE or SE during propofol anesthesia.

Tracheal laceration detected by high end-tidal CO2 during endoscopic thyroidectomy.

Endoscopic thyroidectomy is frequently used for cosmetic reasons, such as reducing cervical scarring. Subcutaneous gas insufflation with CO2 is needed to maintain the surgical space, and optimal surgical techniques and careful attention are required when conducting this procedure due to the limited space available for the endoscopic instruments. We report here a case of a tracheal laceration with a tear in the cuff of a reinforced tube, which was detected by an abrupt increase in end-tidal CO2 to 90 mmHg. Reintubation was achieved using a tube exchanger and the patient was effectively ventilated without complications.

The effect of intermittent levator massage with caudal block on management of levator ani syndrome: A case report.

Levator ani syndrome (LAS) is a functional disorder of the pelvic floor muscles in which recurrent and persistent distressing pain is felt in the anus without detectable organic pathology. Eighty one percent of coccygodynia was alleviated by the levator massage when the massage motion was repeated 10 to 15 times on each side of the pelvis daily for 5 or 6 days. The authors encountered the LAS patient for whom successive visit to pain clinic was economic burden. Therefore, the authors managed the patient by intermittent levator massage with caudal block, once a week for 3 times, resulting in two years of pain free status. Intermittent levator massage with caudal block may be as effective as successive levator massage and induce longer painless period in the management of LAS.

The effects of propofol on cardiac function after 4 hours of cold cardioplegia and reperfusion.

OBJECTIVE: To examine whether propofol protects against postischemic myocardial dysfunction and apoptosis during reperfusion after prolonged cold ischemia in isolated rat hearts. DESIGN: A prospective, randomized, controlled study. SETTING: A university laboratory. PARTICIPANTS: Animals. INTERVENTIONS: The isolated hearts of 40 Sprague-Dawley male rats were perfused with modified Krebs-Hennseleit solution for 15 minutes for a stabilization period and 15 minutes for a perfusion period and then underwent 4 hours of global cold ischemia followed by 60 minutes of reperfusion. Four groups were studied (n = 10 for each group). Ten hearts served as an untreated control group. Propofol (2 micromol/L) treatment was performed only before ischemia in the PRE group, only during reperfusion in the POST group, and both before and after ischemia in the ALL group. MEASUREMENTS AND MAIN RESULTS: Infusion of propofol during reperfusion improved recovery of left ventricular-developed pressure (LVDP) from 61.2% +/- 8.5% (control) to 86.3% +/- 12.1% (POST) and 74.9% +/- 13.2% (ALL, both p < 0.05), whereas preischemic infusion of propofol (64.3% +/- 9.7%, PRE) did not improve recovery of LVDP. Infusion of propofol during reperfusion significantly reduced the number of apoptotic cells and led to a smaller infarct size than control and PRE groups (p < 0.05, respectively). CONCLUSIONS: Propofol infusion during the reperfusion period produced a cardioprotective effect and inhibited apoptosis of cardiomyocytes in the ischemia-reperfusion model, with prolonged cold ischemia, in isolated rat hearts.

Arousal with iv epinephrine depends on the depth of anesthesia.

PURPOSE: To investigate whether the depth of anesthesia affects the change in the bispectral index (BIS) caused by iv epinephrine during propofol anesthesia. METHODS: Forty women undergoing elective lower abdominal surgery received a propofol target controlled infusion (TCI) to maintain a modified Observer's Assessment of Alertness/Sedation (OAA/S) score of 2 (sedation period). Subsequently anesthesia was induced with propofol TCI 5 mug.mL(-1) and rocuronium 0.9 mg.kg(-1), and propofol continued so as to maintain general anesthesia at a BIS of 50 (general anesthesia period). Intravenous epinephrine at a dose of 10 mug.5 mL(-1) in normal saline (epinephrine group, n = 20) or normal saline 5 mL (control group, n = 20) was administered during both periods. The BIS, mean arterial pressure (MAP) and heart rate (HR) were measured immediately before, and one, two, three, four, six, eight, and ten minutes after injection. The modified OAA/S scale was evaluated during the sedation period. RESULTS: There was no significant change in the modified OAA/S scale, BIS, or hemodynamic variables compared to preinjection values during either sedation or general anesthesia in the control group. Intravenous epinephrine increased the BIS and modified OAA/S scale during sedation, but there was no increase in BIS during general anesthesia. Increases in HR and MAP were observed during both periods after iv epinephrine. CONCLUSION: Intravenous epinephrine 10 mug resulted in an arousal effect and an increase in BIS during sedation, but did not change the BIS during general anesthesia. These results suggest that the arousal effect of iv epinephrine during propofol anesthesia depends on anesthetic depth.