Costoclavicular brachial plexus block reduces hemidiaphragmatic paralysis more than supraclavicular brachial plexus block: retrospective, propensity score matched cohort study

Background@#Hemidiaphragmatic paralysis, a frequent complication of the brachial plexus block performed above the clavicle, is rarely associated with an infraclavicular approach. The costoclavicular brachial plexus block is emerging as a promising infraclavicular approach. However, it may increase the risk of hemidiaphragmatic paralysis because the proximity to the phrenic nerve is greater than in the classical infraclavicular approach. @*Methods@#This retrospective analysis compared the incidence of hemidiaphragmatic paralysis in patients undergoing costoclavicular and supraclavicular brachial plexus blocks. Of 315 patients who underwent brachial plexus block performed by a single anesthesiologist, 118 underwent costoclavicular, and 197 underwent supraclavicular brachial plexus block. Propensity score matching selected 118 pairs of patients. The primary outcome was the incidence of hemidiaphragmatic paralysis, defined as a postoperative elevation of the hemidiaphragm > 20 mm. Factors affecting the incidence of hemidiaphragmatic paralysis were also evaluated. @*Results@#Hemidiaphragmatic paralysis was observed in three patients (2.5%) who underwent costoclavicular and 47 (39.8%) who underwent supraclavicular brachial plexus blocks (P < 0.001; odds ratio, 0.04; 95% confidence interval, 0.01-0.13). Both the brachial plexus block approach and the injected volume of local anesthetic were significantly associated with hemidiaphragmatic paralysis. @*Conclusions@#The incidence of hemidiaphragmatic paralysis is significantly lower with costoclavicular than with supraclavicular brachial plexus block.

Multiple exposures of sevoflurane during pregnancy induces memory impairment in young female offspring mice / 대한마취과학회지

BACKGROUND: Earlier studies have reported conflicting results regarding long-term behavioral consequences after anesthesia during the fetal period. Previous studies also suggest several factors that may explain such conflicting data. Thus, we examined the influence of age and sex on long-term behavioral consequences after multiple sevoflurane exposures during the fetal period. METHODS: C57BL/6J pregnant mice received oxygen with or without sevoflurane for 2 hours at gestational day (GD) 14-16. Offspring mice were subjected to behavioral assays for general activity (open field test), learning, and memory (fear chamber test) at postnatal day 30–35. RESULTS: Multiple sevoflurane exposures at GD 14–16 caused significant changes during the fear chamber test in young female offspring mice. Such changes did not occur in young male offspring mice. However, general activity was not affected in both male and female mice. CONCLUSIONS: Multiple sevoflurane exposures in the second trimester of pregnancy affects learning and memory only in young female mice. Further studies focusing on diverse cognitive functions in an age-, sex-dependent manner may provide valuable insights regarding anesthesia-induced neurotoxicity.

Facilitation of AMPA receptor-mediated steady-state current by extrasynaptic NMDA receptors in supraoptic magnocellular neurosecretory cells

In addition to classical synaptic transmission, information is transmitted between cells via the activation of extrasynaptic receptors that generate persistent tonic current in the brain. While growing evidence supports the presence of tonic NMDA current (INMDA) generated by extrasynaptic NMDA receptors (eNMDARs), the functional significance of tonic I(NMDA) in various brain regions remains poorly understood. Here, we demonstrate that activation of eNMDARs that generate I(NMDA) facilitates the α-amino-3-hydroxy-5-methylisoxazole-4-proprionate receptor (AMPAR)-mediated steady-state current in supraoptic nucleus (SON) magnocellular neurosecretory cells (MNCs). In low-Mg2+ artificial cerebrospinal fluid (aCSF), glutamate induced an inward shift in I(holding) (I(GLU)) at a holding potential (V(holding)) of -70 mV which was partly blocked by an AMPAR antagonist, NBQX. NBQX-sensitive I(GLU) was observed even in normal aCSF at V(holding) of -40 mV or -20 mV. I(GLU) was completely abolished by pretreatment with an NMDAR blocker, AP5, under all tested conditions. AMPA induced a reproducible inward shift in I(holding) (I(AMPA)) in SON MNCs. Pretreatment with AP5 attenuated I(AMPA) amplitudes to ~60% of the control levels in low-Mg2+ aCSF, but not in normal aCSF at V(holding) of -70 mV. I(AMPA) attenuation by AP5 was also prominent in normal aCSF at depolarized holding potentials. Memantine, an eNMDAR blocker, mimicked the AP5-induced I(AMPA) attenuation in SON MNCs. Finally, chronic dehydration did not affect I(AMPA) attenuation by AP5 in the neurons. These results suggest that tonic I(NMDA), mediated by eNMDAR, facilitates AMPAR function, changing the postsynaptic response to its agonists in normal and osmotically challenged SON MNCs.

Major Obstacles to Implement a Full-Time Intensivist in Korean Adult ICUs: a Questionnaire Survey / 대한구급학회지

BACKGROUND: Critical care physician staffing is a crucial element of the intensive care unit (ICU) organization, and is associated with better outcomes in ICUs. Adult ICUs in Korea have been suffering from inadequate full-time intensivists and nurses because of insufficient reimbursement rates (<50% of the original critical care cost) from the National Health Insurance System. Recently, full-time intensivists have been introduced as a prerequisite for adult ICUs of tertiary hospitals in Korea. The purpose of this study was to examine the perception of intensivist staffing among critical care program directors regarding the barriers and solutions when implementing an intensivist model of critical care in Korea. METHODS: An email survey of critical care program directors in designated teaching hospitals for critical care subspecialty training by the Korean Society of Critical Care Medicine was performed. The survey domains included vision, culture, resources, barriers, and potential solutions to implementing intensivist physician staffing (IPS). RESULTS: Forty-two critical care program directors were surveyed. A total of 28 directors (66.7%) responded to email queries. Of these, 27 directors (96.4%) agreed that IPS would improve the quality of care in the ICU, although half of them reported a negative perception of relevant clinical colleagues for the role of full-time intensivists and poor resources for IPS in their hospitals. Increased financial burden due to hiring full-time intensivists and concerns regarding exclusion from the management of their critically ill patients in the ICU, together with loss of income for primary attending physicians were stated by the respondents to be major barriers to implementing IPS. Financial incentives for the required cost from the health insurance system and enhancement of medical law relevant to critical care were regarded as solutions to these issues. CONCLUSIONS: Critical care program directors believe that intensivist-led critical care can improve the outcome of ICUs. They indicated the financial burden due to IPS and underestimation of a full-time intensivist's role to be major barriers. The program directors agreed that a partnership between hospital leaders and the Ministry of Health and Welfare was needed to overcome these barriers.

Erratum: Major Obstacles to Implement a Full-Time Intensivist in Korean Adult ICUs: a Questionnaire Survey / 대한구급학회지

We found an error in this article. The author's name should be corrected as following: from "Younsuk Koh" to "Younsuck Koh".

Erratum: Major Obstacles to Implement a Full-Time Intensivist in Korean Adult ICUs: a Questionnaire Survey / 대한중환자의학회지

We found an error in this article. The author's name should be corrected as following: from "Younsuk Koh" to "Younsuck Koh".

Major Obstacles to Implement a Full-Time Intensivist in Korean Adult ICUs: a Questionnaire Survey / 대한중환자의학회지

BACKGROUND: Critical care physician staffing is a crucial element of the intensive care unit (ICU) organization, and is associated with better outcomes in ICUs. Adult ICUs in Korea have been suffering from inadequate full-time intensivists and nurses because of insufficient reimbursement rates (<50% of the original critical care cost) from the National Health Insurance System. Recently, full-time intensivists have been introduced as a prerequisite for adult ICUs of tertiary hospitals in Korea. The purpose of this study was to examine the perception of intensivist staffing among critical care program directors regarding the barriers and solutions when implementing an intensivist model of critical care in Korea. METHODS: An email survey of critical care program directors in designated teaching hospitals for critical care subspecialty training by the Korean Society of Critical Care Medicine was performed. The survey domains included vision, culture, resources, barriers, and potential solutions to implementing intensivist physician staffing (IPS). RESULTS: Forty-two critical care program directors were surveyed. A total of 28 directors (66.7%) responded to email queries. Of these, 27 directors (96.4%) agreed that IPS would improve the quality of care in the ICU, although half of them reported a negative perception of relevant clinical colleagues for the role of full-time intensivists and poor resources for IPS in their hospitals. Increased financial burden due to hiring full-time intensivists and concerns regarding exclusion from the management of their critically ill patients in the ICU, together with loss of income for primary attending physicians were stated by the respondents to be major barriers to implementing IPS. Financial incentives for the required cost from the health insurance system and enhancement of medical law relevant to critical care were regarded as solutions to these issues. CONCLUSIONS: Critical care program directors believe that intensivist-led critical care can improve the outcome of ICUs. They indicated the financial burden due to IPS and underestimation of a full-time intensivist's role to be major barriers. The program directors agreed that a partnership between hospital leaders and the Ministry of Health and Welfare was needed to overcome these barriers.

Postoperative residual neuromuscular blockade

Postoperative residual neuromuscular blockade or residual paralysis in the postanesthesia care unit is associated with postoperative complications such as muscle weakness, difficulty in breathing, airway obstruction, and hypoxemia. Residual paralysis can be defined by inadequate neuromuscular recovery as measured by objective neuromuscular monitoring. The train-of-four ratio threshold less than or equal to 0.9 is considered to indicate inadequate neuromuscular recovery. Careful management of residual paralysis may decrease the occurrence of adverse events associated with residual neuromuscular blockade. In this review, the clinical implications of residual neuromuscular blockade are summarized.

Protease-Activated Receptor-2 Is Associated with Terminal Differentiation of Epidermis and Eccrine Sweat Glands

BACKGROUND: Protease-activated receptor 2 (PAR-2) participates in various biological activities, including the regulation of epidermal barrier homeostasis, inflammation, pain perception, and melanosome transfer in the skin. OBJECTIVE: To evaluate the basic physiological role of PAR-2 in skin. METHODS: We investigated PAR-2 expression in human epidermis, skin tumors, and cultured epidermal cells using western blot and immunohistochemical analysis. Additionally, we examined the effect of the PAR-2 agonist, SLIGRL-NH2, on cultured keratinocytes. RESULTS: Strong PAR-2 immunoreactivity was observed in the granular layer of normal human skin and the acrosyringium of the eccrine sweat glands. In contrast, weak PAR-2 immunoreactivity was seen in the granular layer of callused skin and in the duct and gland cells of the eccrine sweat glands. Interestingly, PAR-2 immunoreactivity was very weak or absent in the tumor cells of squamous cell carcinoma (SCC) and syringoma. PAR-2 was detected in primary keratinocytes and SV-40T-transformed human epidermal keratinocytes (SV-HEKs), an immortalized keratinocyte cell line, but not in SCC12 cells. SV-HEKs that were fully differentiated following calcium treatment displayed higher PAR-2 expression than undifferentiated SV-HEKs. Treatment of cultured SV-HEKs with PAR-2 agonist increased loricrin and filaggrin expression, a terminal differentiation marker. CONCLUSION: Our data suggest that PAR-2 is associated with terminal differentiation of epidermis and eccrine sweat glands.

The Usefulness of Intensivist-Performed Bedside Drainage of Pleural Effusion via Ultrasound-Guided Pigtail Catheter / 대한구급학회지

BACKGROUND: There has been little data reporting the usefulness of intensivist-performed bedside drainage of pleural effusion via ultrasound (US)-guided pigtail catheter. The objective of this study is to clarify the usefulness and safety of these methods in comparison with radiologist-performed procedures. METHODS: Data of patients with pleural effusion treated with US-guided pigtail catheter drainage were analyzed. All procedures were performed from September 2012 to September. 2013 by a well-trained intensivist or radiologist. RESULTS: Pleural effusion was drained in 25 patients in 33 sessions. A radiologist performed 21 sessions, and an intensivist performed 12 sessions. Procedures during mechanical ventilation were performed in 15 (71.4%) patients by a radiologist and in 10 (83.3%) by an intensivist (p = 0.678). The success rate was not significantly different in radiologist- and intensivist-performed procedures, 95.2% (20/21) and 83.3% (10/12), respectively (p = 0.538). The average duration for procedures (including in-hospital transfer) was longer in radiologist-performed cases (p = 0.001). Although the results are limited because of the small population size, aggravation of oxygenation, CO2 retention, and decrease of mean arterial blood pressure were not statistically different in the groups. Pigtail-associated complications including hemothorax, pneumothorax, hepatic perforation, empyema, kink in the catheter, and subcutaneous hematoma were not found. CONCLUSIONS: Intensivist-performed bedside drainage of pleural effusion via ultrasound (US)-guided pigtail catheter is useful and safe and may be recommended in some patients in an intensive care unit.