Delayed Onset Contralateral Reexpansion Pulmonary Edema after Tension Pneumothorax: A Case Report / 대한구급학회지

A 16-year-old male patient presented with left side chest pain. The initial chest radiograph showed tension pneumohtorax on the left side. Air was evacuated by closed thoracostomy. About 72 hours later, during administration of general anesthesia for thoracoscopic bullectomy, unilateral pulmonary edema affecting the contralateral lung developed without definite infiltration in the left lung. The operation was suspended and the patient was admitted to the intensive care unit. A close observation of the patient and conservative therapy were enough to manage this pulmonary edema. This is a very rare manifestation of reexpansion pulmonary edema that is unpredictable and could be fatal. The clinical course is described in this article.

The Effect of a Target Controlled Infusion of Low-Concentration Ketamine on the Heart Rate Variability of Normal Volunteers

BACKGROUND: Ketamine has an indirect sympathetic stimulation effect. We investigated heart rate variability (HRV) as a marker of cardiac autonomic function after a target controlled infusion (TCI) of ketamine with a plasma concentration of 30 or 60 ng/ml. METHODS: In 20 adult volunteers, the mean of the R wave to the adjacent R wave interval (RRI), the range of RRI, the root mean square successive difference of intervals (RMSSD), the total power, the low frequency (LF, 0.04-0.15 Hz) power, the high frequency (HF, 0.15-0.4 Hz) power, the normal unit HF (nuHF), the normal unit LF (nuLF), the LF/HF ratio and the SD1 and the SD2 in the Poincare plot were measured before and after a TCI of ketamine. We observed for any psychedelic symptoms or sedation. RESULTS: There were no differences in the mean and range of the RRI, RMSSD, total power, LF power, HF power, nuHF, nuLF, LF/HF ratio, SD1 and SD2 between before and after ketamine administration. The OAA/S score was higher and there were more psychedelic symptoms with a 60 ng/ml plasma concentration than with a 30 ng/ml plasma concentration. CONCLUSIONS: This study did not show any effect of a low plasma concentration of ketamine on the autonomic nervous system.

Influence of Ketamine and Midazolam on the Analgesic Effect of Epidural Bupivacaine and Fentanyl after Low Abdominal Surgery / 대한통증학회지

BACKGROUND: There are many ways to provide superior analgesia for postoperative pain after abdominal surgery of which epidural analgesics with opioids and local analgesics are the most useful. In an effort to maximize the level of analgesia and to minimize the side effects, ketamine, midazolam, clonidine, and adrenalin can be co-administrated as an adjuvant. This study examined the analgesic effect and side effects of midazolam compared with those given an epidural injection of bupivacaine, fentanyl and ketamine. METHODS: In a double blind randomized controlled trial, 50 patients received either fentanyl 0.3 microgram/kg/h and ketamine 0.1 mg/kg/h (Group FK) or fentanyl 0.3 microgram/kg/h, ketamine 0.1 mg/kg/h and midazolam 0.4 mg/h (Group FKM), added to 0.125% of bupivacaine at a rate of as much as 2 ml/h, for patient controlled epidural analgesia (PCEA) after low abdominal surgery. Ten minutes before surgery, the patients received either 10 ml of 0.125% bupivacaine with 0.5 mg/kg of ketamine or 10 ml of 0.125% bupivacaine with the same amount of normal saline, added to fentanyl 50microgram. The pain score and the side effects were recorded at 1, 3, 6, and 24 hours after surgery. RESULTS: There was no difference in the pain score except for the VAS on coughing 1 hour after surgery. FKM group had fewer side effects. CONCLUSIONS: There was a better analgesic effect and fewer side effects with the addition of epidural midazolam to bupivacaine and fentanyl with ketamine formula. However, more study on the dose and route of administration will be needed.

Influence of Ketamine on the Analgesic Effect of Epidural Bupivacaine and Fentanyl after a Transabdominal Hysterectomy / 대한통증학회지

BACKGROUND: There have been many attempts to alleviate pain after surgery, but there is no common approach to the control of postoperative pain. The use of epidural opioids, with local anesthetics, has been a widely employed formula to date. Ketamine, an N-methyl-d-aspartate receptor antagonist, has an excellent analgesic effect. Although there have been many reports on the dose and route of administrating analgesics, there have been few concerning the continuous epidural infusion of ketamine with fentanyl. We designed this study to find the effects of ketamine compared to those of epidurally injected bupivacaine and fentanyl, and used this trial to study any potential side effects. METHODS: In a double blind trial, 55 patients received either fentanyl, 0.3microgram/kg/h (Group F), or fentanyl, 0.3microgram/kg/h, and ketamine, 0.1 mg/kg/h (Group FK), added to 0.125% bupivacaine, at rates as high as 2 ml/h, for patient controlled epidural analgesia (PCEA) following a transabdominal hysterectomy. Ten minutes before the operation, patients received 10 ml of 0.125% bupivacaine, with either 0.5 mg/kg ketamine or the same amount of normal saline with 50microgram fentanyl added. The pain scores and the side effects were recorded at 1, 3, 6 and 24 hour post operation. RESULTS: There were no differences in the pain scores or side effects between the two groups. CONCLUSIONS: We failed to find any effect of the addition of epidural ketamine compared to the that of the bupivacaine and fentanyl formula. However, it is suggested that further investigations will be required on the dose and route of administration.

The Effect of Lumbar Sympathetic Block in Interstitial Cystitis: A case report / 대한통증학회지

Interstitial cystitis is an extremely painful and distressing condition, characterized by severe suprapubic pain, which increases with bladder filling and is relieved by voiding. The daily frequency of micturition may approach 100 times, but no incontinence is observed. The symptoms persist throughout the night, which consequently affects sleep. The etiology of this condition is still unknown, but includes infection, autoimmune response, allergic reaction, neurogenic inflammation, epithelial dysfunction and inherited susceptibility. Herein, a case of interstitial cystitis, with severe symptoms, which was successfully treated with lumbar sympathetic block, is reported.

Effects of Ondansetron on the Neuromuscular Block of Vecuronium, Rocuronium or Atracurium in a Rat Phrenic Nerve-Hemidiaphragm Preparation / 대한마취과학회지

BACKGROUND: Ondansetron, a 5-HT3 receptor antagonist, is widely used for the prevention of postoperative nausea and vomiting. However, the interaction of ondansetron with non-depolarizing muscle relaxants have not been reported until now. Therefore we studied the effects of ondansetron on the neuromuscular block of vecuronium, rocuronium or atracurium in vitro. METHODS: A square wave 0.1 Hz supramaximal stimuli was applied to the phrenic nerve-hemidiaphragm preparation of a rat, and the twitch height response was recorded mechanomyographically. We measured cumulative concentration response curves of vecuronium, rocuronium or atracurium alone and after pretreating with ondansetron (1microgram/ml). We also measured the effects of ondansetron. The EC50's and EC90's of these muscle relaxants alone and after pretreatment with ondansetron were calculated using an inhibitory sigmoid Emax model. RESULTS: Ondansetron depressed the twitch height in a dose-dependent manner, and its potency was lower than the muscle relaxants. The EC50 and EC90 of ondansetron were 14.7microgram/ml and 33.4microgram/ml, respectively. Pretreated ondansetron (1microgram/ml) significantly reduced the EC50's and EC90's of vecuronium, rocuronium and atracurium (P<0.05). CONCLUSIONS: Ondansetron itself may have neuromuscular blocking properties, and it significantly enhances the neuromuscular blocks induced by vecuronium, rocuronium or atracurium.