Generic rocuronium reduces withdrawal movements compared to original rocuronium under target-controlled infusion induction with propofol.

PURPOSE: Rocuronium-induced injection pain often causes withdrawal movements leading to accidental disruption of indwelling needles. Generic rocuronium (Maruishi Pharmaceutical Co., Ltd, Osaka, Japan) with a novel solution has been reported to reduce the injection pain compared to original rocuronium [Esmeron® (Eslax®), MSD Co. Ltd, Tokyo, Japan], however, no reports have compared the injection pain under sedation with propofol, the most frequently used general anesthetic. This study was carried out to compare the injection pain caused by generic rocuronium and that caused by original rocuronium in patients anesthetized by propofol with a target-controlled infusion system. METHODS: Forty patients were randomly assigned to two groups in this single-center, prospective, randomized, double-blind study. One group was administered generic rocuronium after sedation with propofol with a target-controlled infusion system. The other group was administered original rocuronium after anesthesia with propofol. Patient's withdrawal movements were assessed with the scale. The primary outcome was the total incidence of movement after administration of rocuronium. Secondary outcome was the incidence of moderate or severe movement after administration of rocuronium. RESULTS: The total incidence of movement after administration of generic rocuronium (11%) was significantly lower than that after the administration of original rocuronium (79%) (p < 0.01). The incidence of moderate or severe movement after administration of generic rocuronium (0%) was significantly lower than that after the administration of original rocuronium (53%) (p < 0.01). CONCLUSION: Generic rocuronium was considered more suitable than the original rocuronium for induction of anesthesia by propofol performed with a target-controlled infusion system.

Epidural analgesia for the treatment of colic attack with retrocaval ureter in late pregnancy complicated with marginal placenta previa: a case report.

BACKGROUND: Retrocaval ureter was diagnosed in a woman complaining of ureteric pain in the last trimester of pregnancy. We describe the rationale behind the administration of epidural analgesia for her colic attack. CASE PRESENTATION: A 41-year-old pregnant woman was hospitalized with a diagnosis of a marginal placenta previa at 34 weeks and 5 days of pregnancy. Her right ureter encircled the dorsal aspect of the inferior vena cava (IVC) and was compressed by a growing fetus, causing hydronephrosis. Her right lower back pain was exacerbated every day, till an epidural catheter was inserted. Her estimated glomerular filtration rate (eGFR) and hematocrit worsened, and an elective cesarean section was performed. CONCLUSION: Epidural analgesia only provided pain relief for a few days. When a pregnant woman presents with a retrocaval ureter and severe pain, short-term epidural analgesia should be considered after evaluating the complex medical condition and size of the fetus.

Three cases of implantation of a SureScan® system and MRI for investigating causes of pain.

We report three cases of implantation of the SureScan® system and magnetic resonance imaging (MRI) for investigating causes of pain. Although there were metal-induced artifacts on the MR images of 2 patients, the artifacts did not affect the images of structures that needed to be assessed to make the diagnosis. The SureScan® system enabled patients implanted with spinal cord stimulation devices to undergo MRI.

A case of a warfarinized renal cancer patient monitored for prothrombin time-international normalized ratio during methadone introduction.

BACKGROUND: Warfarin, a widely used anticoagulant, interacts with various agents used in palliative care, such as oxycodone, morphine, acetaminophen, and non-steroidal anti-inflammatory drugs (NSAIDs); however, there are no reports of its interaction with methadone. We report a case of a patient receiving warfarin when methadone was introduced for pain control with monitoring of the prothrombin time-international normalized ratio (PT-INR) and deduced the pharmacological background. CASE PRESENTATION: A 60-year-old male was emergently admitted to our university hospital for the sudden onset of severe back pain. Abdominal CT imaging revealed that the vertebral body of the ninth thoracic vertebra was occupied by bone metastasis and crushed, which caused his back pain. He received warfarin 3.5 mg/day for atrial fibrillation and tapentadol 100 mg p.o. daily for pain relief. The prothrombin time-international normalized ratio (PT-INR) was maintained at >2.2. The patient's history included diabetes mellitus and hypertension, but his laboratory test was unremarkable with the exception that his eGFR was 34 ml/min.Initially, a fentanyl dermal patch was used instead of tapentadol to avoid interactions with warfarin. We started concomitant administration of oxycodone and 2.4 g/day of acetaminophen while monitoring the PT-INR because acetaminophen increased the PT-INR to 2.93. A continuous intravenous infusion of oxycodone was introduced, in increments of the dose, resulting in an increase of the PT-INR to 3.41, which is required to reduce the dose of warfarin to 1.5 mg. Because of the lack of effective pain relief, methadone was introduced and the dose was gradually increased. The PT-INR was not changed and the dose of warfarin was not changed. An infusion of oxycodone and oral methadone was used to allow the patient to walk in his room, and he was later transferred to the palliative hospital. CONCLUSIONS: In an oral warfarinized patient, methadone seemed to undergo different metabolism than oxycodone. When warfarin and methadone are used together, we have to consider their interaction by comparing the competitive inhibition of CYP2C9 to the induction of CYP3A4 by methadone, because CYP3A4 metabolize various drugs including oxycodone.

Quadratus Lumborum Block: Analgesic Effects and Chronological Ropivacaine Concentrations After Laparoscopic Surgery.

BACKGROUND AND OBJECTIVES: The quadratus lumborum block (QLB) is an abdominal truncal block, similar to transversus abdominis plane block (TAPB). However, the characteristics of QLB with regard to its duration and safety are not well known. The primary aim of this study was to determine the block duration and the cutaneous sensory block area. Our secondary analysis included assessment of the chronological change in arterial local anesthetic concentrations after QLB. METHODS: This study included 11 patients scheduled for laparoscopic ovarian surgery under general anesthesia. The patients received bilateral single-injection QLBs (20 mL of 0.375% ropivacaine per side). Arterial blood was sampled at 10, 20, 30, 45, 60, 90, and 120 minutes after ropivacaine administration. The results were retrospectively compared with the results of our previous study on lateral TAPB. RESULTS: The median duration of analgesia after QLB exceeded 24 hours and was significantly longer than the duration of lateral TAPB (P = 0.003). Quadratus lumborum block affected the T7-T12 dermatomes, whereas TAPB affected T10-T12. Arterial ropivacaine levels after block peaked at comparable time in the QLB and lateral TAPB groups (Tmax: 35 [SD, 13] vs 35 [SD, 11] minutes; P = 0.93). Peak ropivacaine concentrations were significantly lower in QLB than in lateral TAPB (Cmax: 1.0 [SD, 0.5] vs 1.8 [SD, 0.4] µg/mL; P = 0.0003). CONCLUSIONS: Quadratus lumborum block resulted in a widespread and long-lasting analgesic effect after laparoscopic ovarian surgery and resulted in lower peak arterial ropivacaine concentrations as compared with those of lateral TAPB after 150 mg ropivacaine injection.

Chronological Changes in Ropivacaine Concentration and Analgesic Effects Between Transversus Abdominis Plane Block and Rectus Sheath Block.

BACKGROUND AND OBJECTIVES: Transversus abdominis plane block (TAPB) and rectus sheath block (RSB) are popular methods of controlling postoperative pain. Chronological changes in blood concentrations of local anesthetics have not been described, although a large amount of local anesthetic is required to block these compartments. We postulated that blood concentrations of anesthetics would peak earlier during TAPB than RSB (primary end point). Secondary end points were elapsed time from block until first postoperative rescue analgesia and affected dermatomes. METHODS: This prospective, randomized study included 22 patients scheduled for laparoscopic ovarian surgery under general anesthesia. The patients were randomized to receive either a bilateral single-shot TAPB or a bilateral RSB (15 mL of 0.5% ropivacaine per side). Arterial blood was sampled 10, 20, 30, 45, 60, 90, and 120 minutes after ropivacaine administration. This trial was registered at the UMIN-Clinical Trials Registry (UMIN000012133) before patient recruitment. RESULTS: Arterial ropivacaine levels after block peaked earlier in the TAPB than in RSB [Tmax: 35 (12) vs 53 (16) minutes; P = 0.02], whereas peak ropivacaine concentrations did not significantly differ between the groups [Cmax: 1.83 (0.41) vs 1.79 (0.33) µg/mL; P = 0.54]. Peak ropivacaine concentrations exceeded 2.2 µg/mL in 1 and 2 patients in the RSB and TAPB groups, respectively, although symptoms of local anesthetic systemic toxicity were not evident in any of them. The median [interquartile range] duration of analgesia was significantly longer for TAPB than RSB (421 [335-536] vs 196 [168-277] minutes; P = 0.01). CONCLUSIONS: Peak ropivacaine concentrations were comparable during TAPB and RSB, but peaked earlier during TAPB. Although 150 mg of ropivacaine remained effective significantly longer during TAPB than RSB during laparoscopic surgery, this dose could cause local anesthetic systemic toxicity. The analgesic effects of blocks with less ropivacaine should be assessed.

[Craniotomy in a pediatric patient complicated with insufficiently controlled diabetes mellitus: intraoperative management with remifentanil and an electrolyte-containing glucose solution].

An 8-year-old girl of Type 1 diabetes mellitus on insulin therapy, was surgically treated for brain cavernous hemangioma. Since the hemangioma gradually became larger, the medical team including anesthesiologists, neurosurgeons, and pediatricians discussed and decided to perform craniotomy. Preoperative blood sugar level was around 40 to 300 mg x dl(-1) and appeared poorly controlled. During the surgery, opioid-based anesthesia and 1.3% glucose infusion were given to the patient to avoid surgical stress-induced hyperglycemia and to avoid starvation. Intraoperative blood sugar levels were maintained exactly at 100 to 120 mg x dl(-1) without insulin medication, and cortisol levels were below the limit of detection. Postoperative sugar level was difficult to control at the preoperative level Tumor was completely removed and the patient was discharged without any neurological sequelae. This report suggests that sufficient analgesia with remifen tanil and appropriate glucose infusion may be useful for the metabolic management not only in patients without diabetes but also in those with diabetes.

Tracheal Intubation through the I-gel for Emergency Cesarean Section in a Patient with Multidrug Hypersensitivity: A New Technique.

31-year-old female with hypersensitivity to local anesthetics and neuromuscular blocking agents presented for emergency Cesarean section. We successfully performed I-gel-assisted tracheal intubation without using neuromuscular blockers. We believe this method would be helpful in selected situations.

[Acute cervical spinal cord injury].

Cervical spinal cord injury is a tragic trauma causing immediate serious quadriplegia and respiratory paralysis. In unstable injuries with paralysis, emergency surgery must be performed immediately to achieve spinal cord decompression and spinal column stabilization. In the treatment of dislocation fractures, first priority should be given to reducing the dislocation, by which the spinal cord is decompressed. A successful attempt to reduce the dislocation using skeletal traction is followed by elective surgery for fixation. In the case of a failure in reducing the dislocation, surgery with a posterior approach is performed to reduce the dislocation and provide internal fixation. In patients with considerably affected anterior column stability and those with any anterior compression that must be eliminated, such as intervertebral disc herniation or a vertebral body fragment, anterior decompression and fixation surgery is indicated.

Different inhibitory effects of sevoflurane on hyperreactive airway smooth muscle contractility in ovalbumin-sensitized and chronic cigarette-smoking guinea pig models.

BACKGROUND: The authors hypothesized that sevoflurane had different inhibitory effects on hyperreactive airway smooth muscle contractility in different types of hyperreactive airway models. METHODS: The effects of sevoflurane on hyperreactive airways in ovalbumin-sensitized and chronic cigarette-smoking guinea pig models were investigated by measuring (1) total lung resistance, (2) smooth muscle tension and intracellular concentration of free Ca, (3) voltage-dependent Ca channel activity, and (4) cyclic adenosine monophosphate levels. RESULTS: Ovalbumin and muscarinic airway hyperreactivity was seen in ovalbumin-sensitized animals. Enlarged alveolar ducts/alveoli and lesser muscarinic hyperreactivity were observed in chronic cigarette-smoke animals. Although sevoflurane inhibited the acetylcholine-induced increase in total lung resistance in the control and ovalbumin-sensitized models, the anesthetic had a smaller effect in the chronic cigarette-smoking model. Similarly, in the chronic cigarette-smoking model, sevoflurane had a smaller inhibitory effect on carbachol-induced muscle contraction and increase in intracellular concentration of free Ca. Sevoflurane also had a smaller inhibitory effect on voltage-dependent Ca channel activity in the chronic cigarette-smoking group than in the other two groups. The sevoflurane-induced increase in cyclic adenosine monophosphate that was seen in the control and ovalbumin-sensitized groups was significantly suppressed in the chronic cigarette-smoking group. CONCLUSIONS: Although sevoflurane potently inhibited airway contractility in control and ovalbumin-sensitized models, the anesthetic had a smaller effect in a chronic cigarette-smoking model. The different inhibitory effects of sevoflurane on airway contractility depend, at least in part, on different effects on voltage-dependent Ca channel activity and cyclic adenosine monophosphate level.