The Effect of Preoperative Epidural Analgesia with Intravenous Patient-controlled Analgesia (IV-PCA) for Postoperative Pain Control in Bone Fusion and Pedicle Screw Fixation / 대한마취과학회지

BACKGROUND: Postoperative pain control following bone fusion and pedicle screw fixation is insufficient with IV-PCA alone. Therefore, the effect of preoperative epidural analgesia in addition to IV-PCA was evaluated for postoperative pain control following bone fusion and pedicle screw fixation surgery. METHODS: Eighty patients, scheduled to undergo bone fusion and pedicle screw fixation, were randomly assigned to two groups; the study (n = 40) or control groups (n = 40). After induction, the patient was turned into the prone position, and morphine 2 mg and 10 ml of 0.2% ropivacaine were injected into the L1/2 epidural space, after dye confirmation, under C-arm guidance for the study group, with 10 ml normal saline injected into the L1/2 epidural space for the control group. After induction, IV-PCA was applied in both groups. After the operation, the NRS (numerical rating scale) and side effects were evaluated immediately post-op, and at 24 and 48 hours after the operation. RESULTS: In the study group, the NRS was more reduced for all periods compared with the control group, but the incidences of nausea/vomiting and pruritus were no different from the control group. CONCLUSIONS: It was concluded that preoperative epidural analgesia, in addition to IV-PCA, was a good postoperative pain control method following bone fusion and pedicle screw fixation.

The Analgesic Effects of Intercostal Nerve Block in Patients Undergoing Total Ear Reconstruction / 대한마취과학회지

BACKGROUND:Patients usually complain of severe postoperative pain at the rib cartilage recession site after total ear reconstruction surgery. We evaluated the postoperative analgesic effects of an intercostal nerve block (ICNB) in patients undergoing total ear reconstruction. METHODS: We injected normal saline (2 ml/rib space) in the control group (n = 15), and 0.75% ropivacaine (2 ml/rib space) in the ICNB group (n = 15) respectively into the 6th, 7th and 8th intercostal spaces following the induction of general anesthesia for surgery. Mean arterial pressures and heart rates were measured pre-ICNB, post-ICNB, pre-surgical incision, 10, 30 and 60 minutes after incision. Numerical rating scales (NRS: 0 = no pain, 10 = most severe pain) were measured at a postoperative 6, 12, 24, 36 and 48 hours by NRS-resting and NRS-coughing, respectively. RESULTS: Mean arterial pressures and heart rates were significantly more stable (P < 0.05) in the ICNB group at 10, 30 and 60 min after incision, than in the control group. NRS were low in all of the ICNB group throughout the postoperative period versus the control group. CONCLUSIONS: We conclude that ICNB induce stable vital signs during rib recession and has excellent postoperative analgesic effects. Thus, we recommend periop-ICNB for total ear reconstruction surgery for the management of anesthesia and postop-analgesia.

Severe Hypotension Caused by Valve Malfunction in the Self-Inflating Bag-Valve Unit: A case report / 대한마취과학회지

Mishaps related to valve malfunction in a self-inflating bag-valve unit can lead to fatal complications. We report a case of severe hypotension that resulted from the locking of the Laerdal valve in the inspiratory position during transport in the operating room. A 36 year old man had undergone an off-pump coronary artery bypass graft. Immediately before leaving the operating room, severe hypotension developed abruptly. But an EKG showed only a reduction of heart rate. We started closed cardiac massage with an intravenous bolus injection of epinephrine 0.5 microgram and reconnected the anesthesia breathing circuit. The patient was manually ventilated using the anesthesia reservoir bag. Vital signs immediately recovered. At that time, the patient's abdomen was distended and we suspected an expiratory abnormality. The self-inflating bag-valve unit was tested with an anesthesia reservoir bag as a test lung. Expiration did not occur. Another self-inflating bag-valve unit was substituted and normal ventilation was restored. It is essential that before use, a self-inflating bag-valve unit should be tested for proper function during both expiration and inspiration using a test lung such as, an anesthesia reservoir bag.

Effects of Ondansetron or Naloxone Patient-Controlled Analgesia on Postoperative Analgesia and Side Effects / 대한마취과학회지

BACKGROUND: Opioid delivered by PCA (patient-controlled analgesia) is effective at relieving pain after surgery, but it is associated with side effects, such as nausea, vomiting, pruritus, respiratory depression, and urinary retention. The purpose of this study was to compare fentanyl-related side effects and the quality of analgesia when naloxone or ondansetron was added to IV PCA regimen. METHODS: Ninety patients undergoing lumbar laminectomy were enrolled in this study. General anesthesia was maintained with 50% N2O and enflurane. In the recovery room patients received a 1microgram/kg bolus of fentanyl, and addition normal saline 2 ml (group C), ondansetron 4 mg (group O), or naloxone 0.04 mg (group N). Simultaneously intravenous fentanyl PCA with normal saline (group C), ondansetron 4 mg (group O), or naloxone 0.36 mg (group N) was commenced. Pain scores and side effects were assessed on postoperative days (PODs) 0, 1, and 2 using a VAS (visual analogue scale). RESULTS: The incidences of vomiting in the groups C, O, and N were 13.2%, 13.2%, and 3.3%, respectively. The VAS scores for nausea on PODs 0 and 1 in group N were significantly lower than in group C. The VAS scores for sedation on POD 0 in group N was lower than in group C, and on POD 2 lower than in group O. No differences in the VAS for pain and urinary retention were observed between the three groups. CONCLUSIONS: Low-dose naloxone with IV fentanyl PCA is effective at reducing opioid-related nausea and sedation without attenuating the quality of analgesia.

Anesthetic Management of a Child with Tracheomalacia for Aortopexy: A Case Report / 대한마취과학회지

Tracheomalacia is an uncommon disease but an important cause of respiratory distress in children. Tracheomalacia is often associated with other defects, such as esophageal atresia, tracheoesophageal fistula or paratracheal tumor. Rigid bronscopy is used to confirm tracheomalacia, and aortopexy may be applied for surgical intervention. We experienced a case of a 10 month old male infant with tracheomalacia who had undergone tracheoesophageal fistula correction 2 days after birth. Tracheomalacia was diagnosed under rigid bronchoscopy, and the tracheal wall was compressed in accordance with respiration. After aortopexy, the patient breathed smoothly and was discharged after 9 days uneventfully. Aortopexy does not seem to be familiar with pediatric anesthesiologists. We report this case with references as we were unable to find any case report about this maneuver.

Inhibition of NF-kappaB Activation Increases Oxygen-Glucose Deprivation-Induced Cerebral Endothelial Cell Death

Increasing evidences suggest that ischemia-induced vascular damage is an integral step in the cascade of the cellular and molecular events initiated by cerebral ischemia. In the present study, employing a mouse brain endothelioma-derived cell line, bEnd.3, and oxygen-glucose deprivation (OGD) as an in vitro stroke model, the role of nuclear factor kappa B (NF-kappaB) activation during ischemic injury was investigated. OGD was found to activate NF-kappaB and to induce bEnd.3 cell death in a time-dependent manner. OGD phosphorylated neither 32 Ser nor 42 Tyr of IkappaBalpha. OGD did not change the amount of IkappaB alpha. The extents of OGD-induced cell death after 8 h, 10 h, 12 h and 14 h of OGD were 10%, 35%, 60% and 85%, respectively. Reperfusion following OGD did not cause additional cell death, indicating no reperfusion injury after ischemic insult in cerebral endothelial cells. Three known as NF-kappaB inhibitors, including pyrrolidine dithiocarbamate (PDTC) plus zinc, aspirin and caffeic acid phenethyl ester (CAPE), inhibited OGD-induced NF-kappaB activation and increased OGD-induced bEnd.3 cell death in a dose dependent manner. There were no changes in the protein levels of bcl-2, bax and p53 which are modulated by NF-kappaB activity. These results suggest that NF-kappaB activation might be a protective mechanism for OGD-induced cell death in bEnd.3.

Comparison between a Fentanyl and Clonidine Admixture to Lidocaine in a Brachial Plexus Block / 대한마취과학회지

BACKGORUND: The admixture of clonidine or fentanyl to 1.5% lidocaine for brachial plexus block was studied with regard to onset and duration of anesthesia and postoperative analgesia after a brachial plexus blockade. METHODS: Thirty patients (ASA i-ii) undergoing surgery of the forearm and hand under an interscalene brachial plexus blockade (BPB) were included in this study. Patients were randomly divided into 3 groups. BPB was performed using 40 ml of 1.5% lidocaine added epinephrine 1:200,000 in group E, 1mug/kg of fentanyl in group F, and 2mug/kg of clonidine in group C, respectively. The onset times of blockade in the radial, ulnar, median and musculocutaneous nerve were recorded. Hemodynamic data and sedation scores were monitored. Finally, the duration of the sensory block was assessed. A value of P<0.05 was considered as statistically significant. RESULTS: The clonidine group was shorter in onset time, decreased need for postoperative analgesia and increased analgesic duration than other groups but more sedated than group E. With the admixture of fentanyl, pain scores were lower at 180 and 210 min after the block (VAS:mean 2, 8) than with epinephrine (VAS:mean 27, 30 respectively). Hemodynamic changes were not significantly different in all groups. CONCLUSiONS: The addition of clonidine to 1.5% lidocaine causes a rapid onset of analgesia and prolonged duration of sensory blockade in the brachial plexus blockade when compared to the addition of epinephrine or fentanyl to 1.5% lidocaine.

Can Ketamine Substitute for Fentanyl in Gynecologic Cone Biopsy Anesthesia? / 대한마취과학회지

BACKGROUND: In a gynecologic cone biopsy, fentanyl is commonly used with propofol for its analgesic effect, but it has many side effects, such as bradycardia, respiratory depression and hypotension. A subanesthetic dose of ketamine has an analgesic effect and minimal cardiovascular effects. We wanted to know whether ketamine can be safely used with propofol in a gynecologic cone biopsy instead of fentanyl. METHODS: Forty woman patients were randomly allocated to two groups. All patients were anesthesized with a propofol infusion. Fentanyl 1mug/kg IV was injected 2 minutes before LMA (laryngeal mask airway) insertion in group I, ketamine 0.25 mg/kg IV was injected also in group II. Blood pressure and heart rate were measured before fentanyl or ketamine injection, 1 minute, 3 minutes and 5 minutes after LMA insertion, and during the operation. A numerical rating scale (NRS) for pain and other side effects were checked for 24 hours after the operation. RESULTS: There were no significant differences between the two groups in blood pressure, heart rate, NRS and side effects, but a more stable systolic blood pressure in the ketamine group occured. CONCLUSIONS: For a gynecologic cone biopsy, propofol anesthesia combined with fentanyl or ketamine was not different for stable cardiovascular results, postoperative pain relief and side effects. Therefore, ketamine as an analgesic combined with propofol could replace fentanyl in gynecologic cone biopsy anesthesia.

Sedative Effect and Cardiovascular Stability of Lidocaine during Endotracheal Intubation under Bispectral Index (BIS) Monitoring / 대한마취과학회지

BACKGROUND: Lidocaine's sedative effect has not been known well. The purpose of this study was to evaluate its sedative and cardiovascular effects during induction of anesthesia. METHODS: Twenty patients were randomly allocated to group I or II, with or without lidocaine 1.5 mg/kg intravenously (IV) before induction, respectively. The BIS, blood pressure and heart rate were measured at before and 2 minutes after lidocaine IV injection, preintubation, and 1, 2, 3 and 5 minutes after tracheal intubation. The enflurane concentrations were continuously maintained at 2 volume%. RESULTS: The BIS of group I was more decreased at 1 and 2 minutes after intubation than those of group II. The systolic blood pressures of group I were less increased at 1 and 2 minutes after intubation than those of group II. The diastolic blood pressures and heart rates of group I were not different from those of group II at each stage of the procedure. CONCLUSIONS: Lidocaine reduced BIS and blunted the intubation-induced systolic hypertensive response. In addition it is thought that it has a sedative effect and is effective to maintain cardiovascular stability after tracheal intubation.

Anesthesia for Fetal Surgery: Twin Reversed Arterial Perfusion Sequence / 대한마취과학회지

It is important to consider the fetal, uteroplacental, and maternal issues when choosing anesthetic technique for fetal surgery. The twin reversed arterial perfusion (TRAP) sequence, or the acardiac anomaly, occurs in 1:100 monozygous multiple pregnancies and in 1:35,000 births. The TRAP sequence is characterized by placental vascular arterio-arterial anastomosis between twin fetuses, one an acardiac/acephalic twin that receives its blood flow from the normal pumping twin, thereby endangering the normal twin by high output cardiac failure. The acardiac twin is nonviable, and perinatal mortality in the pump cotwin exceeds 50% because of cardiac failure and prematurity. This can be managed by fetal surgery. We report on a patient with a 26-wk gestation complicated by an acardiac/acephalic fetus anesthetized for surgical umbilical cord ligation.

Congenital Tracheomalacia Associated with Esophageal Atresia

This is a case of tracheomalacia associated with esophageal atresia. An 11-month-old- male boy presented with a life-threatening apneic spell after correction of esophageal atresia (Gross type C). After complete exclusion of the other possible causes of the apneic spell, the presumptive diagnosis of tracheomalacia was made with fluoroscopy and 3-dimensional chest CT. The final diagnosis was made with rigid bronchoscopy under spontaneous respiration. The aortopexy was performed with intraoperative bronchoscopic examination. The postoperative period was unremarkably uneventful. The patient was discharged 9 days after the aortopexy and has remained well to date (5 months after the aortopexy).

VD/VT and Arterial Blood Gas Changes during Gynecologic Laparoscopic Surgery under Enflurane or Propofol Anesthesia / 대한마취과학회지

BACKGROUND: Laparoscopic gynecologic surgery is a standard procedure today for its small skin incision and short hospital admission stay. However pneumoperitoneum (PP) and Trendelenberg position induce adverse effects in hemodynamics and pulmonary gas exchange. The purpose of this study is to evaluate the effects of propofol compared with enflurane for pulmonary gas exchange in the Trendelenberg position and pneumoperitoneum. METHODS: Twenty women were randomly allocated to either the enflurane (n = 10) or propofol (n = 10) with fentanyl-N2O/O2 anesthesia. PaCO2, PaO2, PETCO2 were checked at pre-PP, 10 min after PP, 30 min after PP, and 10 min after CO2 deflation. In addition the Vd/Vt ratio was calculated according to the Bohr equation. Vital sign and peak airway pressure were checked at each stage. RESULTS: PaCO2 and PETCO2 increased and PaO2 decreased significantly during PP in both groups. Vd/Vt increased significantly in the enflurane group at 30 min after PP. Peak airway pressure increased significantly in both groups. Blood preassure and heart rate were not changed significantly. All of the parameters were not significantly different between groups. CONCLSIONS: Propofol compared with enflurane did not show any advantage in gas exchange during gynecologic laparoscopic surgery under Trendelenberg position and PP.

The Effects of Magnesium-Pretreatment on the Neuromuscular Blocking Actions of Cis-atracurium in the Cat / 대한마취과학회지

BACKGROUND: Cis-atracurium is more potent, and less likely to release histamine and has better autonomic and cardiovascular stability, compared to atracurium. It is eliminated mainly by Hofmann reaction and produces less amounts of laudanosine, the first metabolite which has the CNS stimulating property. However, drug interactions with several ions, such as magnesium that is popular in treating eclampsia have not yet to be known. METHODS: Using sciatic nerve-anterior tibialis preparation in the cat, we tried to find out whether cis-atracurium has the cumulation effect by administering four consecutive 100 microgram/kg of cis-atracurium. After confirming that the cis-atracurium had no cumulation effect, we proceeded the dose-response study to find out the ED50, ED95 and action duration of cis-atracurium in control group(II) and magnesium-pretreated group(III). After cumulative dose -response study, in the half of the group II and III, the infusion rate to maintain 90% twitch depression at least for 20 minutes was obtained, and afterwards, the recovery index was measured after the discontinuation of infusion. In the other half of the group II and III, while maintaining 90% twitch depression at least for 20 minutes through continuous infusion of cis-atracurium, we administered the 10 microgram/kg of neostigmine to measure the onset time, action duration and antagonism effect of the drug. RESULTS: The cis-atracurium did not have the cumulation effect and in group III, ED50 and ED95 were decreased significantly from 234+/-82 microgram/kg to 103+/-18 microgram/kg and from 399+/-123 microgram/kg to 173+/-28 microgram/kg, respectively, compared with group II. The action duration of cis-atracurium ED95 in group III(190+/-52 sec) was significantly longer than in group II(143+/-29 sec). The infusion rate of cis-atracurium to maintain 90% twitch depression was significantly higher in group II in the spontaneous recoveryand the neostigmine-induced antagonism(6.63+/-2.37 and 4.47+/-1.58 microgram/kg/min), respectively. CONCLUSION: The cis-atracurium do not have the cumulation effect. And, the magnesium potentiates the neuromuscular blocking actions of cis-atracurium. However, it has no effect on the antagonism action of neostigmine.

The Effects of Acute Renal Failure on Mivacurium-induced Neuromuscular Blockade in the Cat / 대한마취과학회지

BACKGROUND: Mivacurium is mainly metabolized by plasma cholinesterase. However, the duration of action may be changed in various conditions such as liver dysfunction. To evaluate the action duration and recovery of mivacurium under the experimental acute renal failure, the pharmacodynamic studies were done. METHODS: The pharmacodynamic studies were done using a common peroneal nerve-anterior tibialis muscle preparation in 12, either sex, adult cats(weight 2.0~4.0 kg). The acute renal failure was made by the ligation of bilateral renal pedicles 1 hour prior to the pharmacodynamic study. All the cat received 5XED95 of mivacurium. The action durations and recovery indices were measured. And plasma cholinesterase activities were measured at each event. RESULTS: The duration of mivacurium was not prolonged with acute renal failure group(17.20 5.48 min.) compared to control group(13.48 4.30 min.). The recovery indices were not increased in the acute renal failure group(3.56 0.58 min.) as compaired with the control group(2.82 0.99 min.). CONCLUSIONS: The mivacurium-induced neuromuscular blockade is not prolonged by the experimental acute renal failure.

There is not Different Between the Patient-Controlled Lumber Epidural and Thoracic Epidural Analgesia with Morphine for Postthoracotomy Pain / 대한마취과학회지

BACKGROUND: With different injection levels, the dose-requirements of epidural opioids association with lipid solubility are controversial. The purpose of this study was to compare the effect of patient controlled lumbar(L group) and thoracic(T group) epidural morphine on dose-requirements, analgesia and side effects after thoracotomy. METHODS: Twenty patients were randomly assigned into one of two groups. Before the induction of general anesthesia, the epidural taps with 17G with Tuohy needle were done on the 6th or 7th thoracic and 2nd or 3rd lumbar intervertebral levels, respectively. The epidural catheter tips were placed 3~4 cm above the needle tips in either groups . Morphine 3 mg in 3 ml normal saline was administered via the epidural catheter in all the patients immediately at the end of surgical manipulation. PCA/basal infusion dose and lockout interval was 0.02 mg/once, 0.08 mg/hr and 5min respectively. After the initial dose dose-requirements were checked at 4, 8, 24 and 48hour and pain was assessed on visual analogue scale at 1, 4, 8, 24 and 48hour. Side effects were observed. RESULTS: There were no significant difference between groups in the dose-requirements of morphine, their analgesia and side effects. CONCLUSIONS: Lumbar epidural morphine provides postoperative analgesia after thoracotomy that is clinically indistinguishable from that provided by thoracic epidural morphine with respect to dosage, quality of analgesia and side effect.