Procedural Sedation of Preterm Neonate with Frequent Apnea during Magnetic Resonance Imaging: A Case Report

Magnetic resonance imaging (MRI) is a useful and safe imaging modality for examining preterm infants. However, MRI examination requires careful precautions, and infants and children are likely to require deep sedation or anesthesia to keep them still during the examination. Sedation has various risks and the greatest concern of sedation is cardiorespiratory events. In addition, delicate titration is also necessary for preterm infants because propofol pharmacokinetics is different from those in older children. We successfully completed sedation of a preterm neonate (gestational age, 32+1 weeks; birth weight, 1,970 g) with a history of frequent apnea through careful assessment and continuous monitoring. We want to suggest alternative options for airway management of the high risk of respiratory complications.

A novel application of Transnasal Humidified Rapid Insufflation Ventilatory Exchange via the oral route in morbidly obese patient during monitored anesthesia care - A case report -

Background@#Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) is used to improve oxygenation, with the added benefit of a smaller increase in CO2 if self-respiration is maintained with THRIVE. Despite these advantages, the use of THRIVE through a nasal cannula is limited in situations such as epistaxis or a basal skull fracture. CaseWe successful used THRIVE, through the oral route under general anesthesia with spontaneous breathing in a morbidly obese patient (weight, 148 kg; height, 183 cm; body mass index, 44.2 kg/m2) who received transnasal steroid injections due to subglottic stenosis. @*Conclusions@#THRIVE through the oral route may be an effective novel option, although further studies are needed.

Development of an analytical method for the determination of dl-methylephedrine hydrochloride in porcine muscle using liquid chromatography-tandem mass spectrometry

This study examined the residue of dl-methylephedrine hydrochloride (MEP) on the muscle of pigs administered orally with MEP 12 g/ton feed for seven consecutive days. Twenty healthy cross swine were administered MEP. Four treated animals were selected arbitrarily to be sacrificed at 1, 2, 3, 4, and 5 days after treatment. MEP residue concentrations in the muscle were determined by liquid chromatography coupled with tandem mass spectrometry. The drug was extracted from muscle samples using 10 mM ammonium formate in acetonitrile followed by clean-up with n-hexane. The analyte was separated on an XBridgeTM hydrophilic interaction liquid chromatography column using 10 mM ammonium formate in deionized distilled water and acetonitrile. The correlation coefficient (R2 ) of the calibration curve was 0.9974, and the limits of detection and quantification were 0.05 and 0.15 μg/ kg, respectively. The recoveries at three spiking levels were 94.5–101.2%, and the relative Standard Deviations was less than 4.06%.In the MEP-treated group, MEP residues on one day post-treatment were below the maximum residue limit in the muscle. The developed method is sensitive and reliable for the detection of MEP in porcine muscle tissues. Furthermore, it exhibits low quantification limits for animal-derived food products destined for human consumption.

Development of an analytical method for the determination of dl-methylephedrine hydrochloride in porcine muscle using liquid chromatography-tandem mass spectrometry

This study examined the residue of dl-methylephedrine hydrochloride (MEP) on the muscle of pigs administered orally with MEP 12 g/ton feed for seven consecutive days. Twenty healthy cross swine were administered MEP. Four treated animals were selected arbitrarily to be sacrificed at 1, 2, 3, 4, and 5 days after treatment. MEP residue concentrations in the muscle were determined by liquid chromatography coupled with tandem mass spectrometry. The drug was extracted from muscle samples using 10 mM ammonium formate in acetonitrile followed by clean-up with n-hexane. The analyte was separated on an XBridgeTM hydrophilic interaction liquid chromatography column using 10 mM ammonium formate in deionized distilled water and acetonitrile. The correlation coefficient (R2 ) of the calibration curve was 0.9974, and the limits of detection and quantification were 0.05 and 0.15 μg/ kg, respectively. The recoveries at three spiking levels were 94.5–101.2%, and the relative Standard Deviations was less than 4.06%.In the MEP-treated group, MEP residues on one day post-treatment were below the maximum residue limit in the muscle. The developed method is sensitive and reliable for the detection of MEP in porcine muscle tissues. Furthermore, it exhibits low quantification limits for animal-derived food products destined for human consumption.

Conditions for the disinfectant efficacy test under subzero temperatures / 대한수의학회지

To establish appropriate conditions for a disinfectant efficacy test at subzero temperatures, this study examined mixtures of frozen foot-and-mouth disease virus or avian influenza virus solutions and disinfectant diluents at −5℃ and monitored temperature and freezing status of an anti-freezing diluent (AFD, 15% ethanol + 30% propylene glycol + 55% distilled water) over time at various subzero temperatures. Viral solutions and disinfectant diluents froze before the mixtures reached −5℃, whereas the AFD was not frozen at −30℃. The times taken for the AFD to reach −10, −20, −30, and −40℃ from room temperature were 36, 39, 45, and 48 min, respectively.

Conditions for the disinfectant efficacy test under subzero temperatures

To establish appropriate conditions for a disinfectant efficacy test at subzero temperatures, this study examined mixtures of frozen foot-and-mouth disease virus or avian influenza virus solutions and disinfectant diluents at −5℃ and monitored temperature and freezing status of an anti-freezing diluent (AFD, 15% ethanol + 30% propylene glycol + 55% distilled water) over time at various subzero temperatures. Viral solutions and disinfectant diluents froze before the mixtures reached −5℃, whereas the AFD was not frozen at −30℃. The times taken for the AFD to reach −10, −20, −30, and −40℃ from room temperature were 36, 39, 45, and 48 min, respectively.

Comparison of Short-Term Complications of General and Spinal Anesthesia for Primary Unilateral Total Knee Arthroplasty

PURPOSE: To compare the occurrences of perioperative complications of two anesthetic techniques (general anesthesia [GA] and spinal anesthesia [SA] in patients undergoing primary unilateral total knee arthroplasty (TKA). MATERIALS AND METHODS: Patients who underwent unilateral primary TKA due to osteoarthritis from January 2005 to January 2014 were retrospectively reviewed. They were divided into two groups: GA (n=490) and SA (n=746). The operation duration, length of perioperative stay in the operation room and occurrences of adverse events in postoperative 30 days (mean, 29.7±3.1 days) were compared. Before multivariate linear or logistic regression analysis, different baseline characteristics were adjusted in the statistical models. RESULTS: There were significant intergroup differences in mean age (GA, 68.4±7.2 years; SA, 70.7±7.5 years; p<0.001) and mCCI (GA, 3±1.4; SA, 3.2±1.5; p<0.001). The GA group required longer preoperative room time (+9.4 minutes; p<0.001), postoperative room time (+12.7 minutes; p<0.001), and postoperative hospital stay (+2.5 days; p=0.001) and had more surgical site infections (5 [1%] vs. 0 [0%]; p=0.005) and blood transfusion (205 [41.8%] vs. 262 [35.1%]; p=0.01). No differences in operative duration and other adverse events were identified. CONCLUSIONS: We should cautiously consider that GA may be associated with slightly increased preoperative and postoperative room times, postoperative hospital stay, transfusion and surgical site infection rates in primary unilateral TKA.

Development of the Geop-Pain questionnaire for multidisciplinary assessment of pain sensitivity / 대한마취과학회지

BACKGROUND: To assess the multidisciplinary aspects of pain, various self-rating questionnaires have been developed, but there have not been sufficient relevant studies on this topic in South Korea. The aim of this study was to develop a new pain sensitivity-related questionnaire in the Korean language that would be simple and would well reflect Koreans' senses. METHODS: A new pain assessment questionnaire was developed through a pre-survey on "geop", which is the Korean word expressing fear, anxiety, or catastrophizing. We named the new assessment questionnaire the Geop-Pain Questionnaire (GPQ). The GPQ was composed of 15 items divided into three categories and rated on a 5-point scale. As a preliminary study, internal consistency and test-retest reliability analyses were conducted. Subsequently, 109 individuals completed the GPQ along with three pain-related questionnaires translated into Korean (Pain Sensitivity Questionnaire [PSQ], Pain Anxiety Symptoms Scale [PASS], and Pain Catastrophizing Scale [PCS]), and the correlations were analyzed. RESULTS: All items in the GPQ showed appropriate internal consistency, and the test-retest reliability analysis showed no statistically significant differences. The correlations between the GPQ and the existing questionnaires revealed that the GPQ scores had mid-positive correlations with the PSQ scores and strong positive correlations with the PASS and PCS scores. CONCLUSIONS: This study attempted to develop a questionnaire assessing pain sensitivity multidimensionally using the Korean word geop for the first time. The self-rating GPQ showed high correlations with the existing questionnaires and demonstrated potential to be utilized as a pain prediction index in clinical practice.

Anesthetic Experience of Spinal Anesthesia after Sedation in Un-cooperated Elderly Patients

Regional anesthesia is mostly used in operations on the lower abdomen or lower extremities in elderly patients. It shows nearly no difference in long-term outcomes compared to general anesthesia, but it is used more often because of the several advantages. However, during the regional anesthetic procedures, the patient must cooperate and has to be lateral decubitus position without physical movement. Therefore, in the case of the patients who are not cooperated, it may be not easy to perform regional anesthesia. In this study, we present 3 case reports that regional anesthesia after sedation is performed in un-cooperated patients. Regional anesthesia after sedation may be a good method to improve outcomes in un-cooperated elderly patients.

The Correlation Study between Plasma Aβ Proteins and Cerebrospinal Fluid Alzheimer's Disease Biomarkers

BACKGROUND AND PURPOSE: Alzheimer's disease (AD) is characterized by the accumulation of amyloid-β proteins (Aβ). In this study we explored the correlation of plasma Aβ40 and Aβ42 concentrations with Aβ42, total tau (tTau) and phosphorylated tau 181 (pTau181) levels in cerebrospinal fluid (CSF) in AD and control subjects to further understand the characteristics of plasma Aβ proteins levels. METHODS: The consecutive subjects (44 AD and 47 controls) in this study were recruited. The plasma levels of Aβ40 and Aβ42 were measured using a commercially available sandwich enzyme-linked immunosorbent assay (ELISA) kits. And the corresponding CSFs were analyzed in terms of Aβ42, tTau and pTau181 concentrations using INNOTEST ELISA kits. Further, the albumin levels were measured both in serum and CSF and albumin ratio was obtained to check the integrity of blood-brain barrier. RESULTS: CSF Aβ42 concentrations were significantly decreased while tTau and pTau181 levels were significantly increased in AD subjects. The plasma levels of Aβ42 were significantly lower (p=0.007), while the Aβ40/Aβ42 ratio was significantly higher (p<0.001) in AD patients than in controls. The overall plasma Aβ42 levels showed a positive correlation with those of CSF Aβ42 (p=0.001), but not with the others in CSF. In subgroup analysis, the CSF Aβ42 demonstrated positive correlation with not only plasma Aβ42 but also Aβ40 levels in controls. However, no significant relationship was noted between plasma and CSF Aβ proteins in AD group. CONCLUSIONS: The plasma Aβ42 and Aβ40 concentrations were shown to have a close relationship with CSF Aβ42 levels in controls, but not in AD subjects. Our results suggest that the correlation between plasma Aβ40 and CSF Aβ42 levels is perturbed in AD.

Logopenic Progressive Aphasia Revealing Positive Cerebrospinal Fluid Biomarkers for Alzheimer's Disease

Primary progressive aphasia (PPA) is classified into agrammatic, semantic, and logopenic variants, but differential diagnosis is often challenging. There is accumulating evidence that the neuropathology of logopenic PPA is distinct from that of the other types. We report herein a woman with logopenic PPA who was diagnosed by clinical, neuropsychological, and radiologic data during 2 years of follow-up. Interestingly, her cerebrospinal fluid biomarkers were found to be similar to those found in Alzheimer's disease, with a decreased concentration of Abeta42 and an increased concentration of pTau181 (tTau).

Preliminary Study for a Multicenter Study of Alzheimer's Disease Cerebrospinal Fluid Biomarkers

BACKGROUND: The usefulness of cerebrospinal fluid (CSF) concentrations of amyloid beta protein 1-42 (Abeta42), phosphorylated tau (pTau) and total tau (tTau) have been increasing in Alzheimer's disease (AD). However, the direct adoption of previously reported standard values is not appropriate due to interlaboratory variability. We started this study to set up an accessible system to measure CSF biomarkers in our country with high reproducibility and validity. METHODS: Including CSFs from four different institutes the levels of Abeta42, pTau181 and tTau were measured in one lab. The intertest variability and difference in the levels of biomarkers depending on diseases were assessed. Through analysis of receiver operating characteristic cut points and binary logistic regression the cut-off values of Abeta42, pTau and tTau level were obtained, and their validity was evaluated. RESULTS: The intertest consistency was high in measuring CSF biomarkers. The value of Abeta42 was markedly decreased in AD (n= 17) and other dementia (n= 9) compared to normal control (n= 12). The levels of pTau181 and tTau were high in AD, but not in other dementia and normal control. The threshold values of Abeta42, pTau181 and tTau were 290.3 pg/mL, 54.3 pg/mL, and 320.7 pg/mL in differentiating AD from normal control showing high sensitivity and specificity. Especially, the ratios of pTau181/Abeta42 (> 0.16) and tTau/Abeta42 (> 0.76) showed the prime validity. CONCLUSIONS: Our data of CSF Abeta42, pTau181, and tTau levels were highly reproducible. PTau181/Abeta42 and tTau/Abeta42 ratios were the greatly helpful in differentiating AD from normal control.

Current practice in hemodynamic monitoring and management in high-risk surgery patients: a national survey of Korean anesthesiologists / 대한마취과학회지

BACKGROUND: Hemodynamic optimization improves postoperative outcomes in high-risk surgery patients. The monitoring of cardiac output (CO) and dynamic parameters of fluid responsiveness can guide hemodynamic optimization. We conducted a survey to assess the current hemodynamic monitoring and management practices of Korean anesthesiologists during high-risk surgery. METHODS: E-mails containing a link to our survey, which consisted of 33 questions relating to hemodynamic monitoring during high-risk surgery, were sent to 3,943 members of the Korean Society of Anesthesiologists (KSA). The survey web page was open from December 30, 2011 to March 31, 2012. RESULTS: A total of 139 anesthesiologists responded during the survey period. Invasive arterial pressure (97.2%) and central venous pressure (93.4%) were routinely monitored. CO was monitored in 58.5% of patients; stroke volume variations were monitored in 50.9% of patients. However, CO was consistently optimized by < 20% of anesthesiologists. An arterial pressure waveform-derived CO monitor was the most frequently used device to monitor CO (79.0%). Blood pressure, urine output, central venous pressure, and clinical experience were considered to be the best indicators of volume expansion than CO or dynamic parameters of fluid responsiveness. CONCLUSIONS: The survey revealed that KSA members frequently monitor CO and dynamic parameters of fluid responsiveness during high-risk surgery. However, static indices were used more often to judge volume expansion. The current study reveals that CO is not frequently optimized despite the relatively high incidence of CO monitoring during high-risk surgery in Korea.

Complete atrioventricular nodal block after propofol administration in an elderly patient undergoing total knee replacement arthroplasty: A case report / 대한마취과학회지

Complete atrioventricular (AV) block is defined as a dissociation of atrial and ventricular activities. Complete AV block that occurs during the perioperative period is difficult to reverse and usually requires implantation of a pacemaker. Propofol does not affect a normal AV conduction system but may act as a trigger for AV block. It can also potentiate vagal stimulation factors and reduce sympathetic activity. We report a case of complete AV block that may have been related to administration of propofol.

The Effect of Low-dose Ketamine on Post-caesarean Delivery Analgesia after Spinal Anesthesia

BACKGROUND: Ketamine, an N-methyl-D-aspartate receptor antagonist, might play a role in postoperative analgesia, but its effect on postoperative pain after caesarean section varies with study design. We investigated whether the preemptive administration of low-dose intravenous ketamine decreases postoperative opioid requirement and postoperative pain in parturients receiving intravenous fentanyl with patient-controlled analgesia (PCA) following caesarean section. METHODS: Spinal anesthesia was performed in 40 parturients scheduled for elective caesarean section. Patients in the ketamine group received a 0.5 mg/kg ketamine bolus intravenously followed by 0.25 mg/kg/h continuous infusion during the operation. The control group received the same volume of normal saline. Immediately after surgery, the patients were connected to a PCA device set to deliver 25-microg fentanyl as an intravenous bolus with a 15-min lockout interval and no continuous dose. Postoperative pain was assessed using the cumulative dose of fentanyl and visual analog scale (VAS) scores at 2, 6, 24, and 48 h postoperatively. RESULTS: Significantly less fentanyl was used in the ketamine group 2 h after surgery (P = 0.033), but the difference was not significant at 6, 12, and 24 h postoperatively. No significant differences were observed between the VAS scores of the two groups at 2, 6, 12, and 24 h postoperatively. CONCLUSIONS: Intraoperative low-dose ketamine did not have a preemptive analgesic effect and was not effective as an adjuvant to decrease opioid requirement or postoperative pain score in parturients receiving intravenous PCA with fentanyl after caesarean section.

A questionnaire study investigating the prevalence of chronic postoperative pain / 대한마취과학회지

BACKGROUND: Chronic postoperative pain (CPOP) is defined as pain of at least 2 months duration after a surgical procedure. Until recently, it has been a neglected topic, because it can occur after a wide spectrum of operations; however, little is known regarding its underlying mechanism, prevalence, risk factors, and treatments. We investigated characteristics of CPOP after various operations via a questionnaire. METHODS: Patients were contacted at > 2 months after surgery, irrespective of sex, type of operation or anesthesia method, and a follow-up pain questionnaire was administered by phone. RESULTS: One hundred forty-five of 400 patients (36.3%) described CPOP. The prevalence of CPOP was significantly lower in laparoscopic surgery (29/159, 18.2%) than open surgery (116/241, 48.1%). The prevalence of CPOP was higher with the use of PCA (patient controlled analgesia), (45.3%) than without PCA (24.6%). There were no significant differences regarding sex, anesthetic method, or duration of operation. CONCLUSIONS: Our results indicate that the prevalence of CPOP may be related to use of an endoscope and PCA. However, it is difficult to completely explain the correlation, because this is a complex area of research. More research is needed to improve the quality of pain relief.

Anesthetic management of a patient with Lowe syndrome accompanied by end stage renal disease: A case report

Lowe syndrome is a rare genetic condition that involves three major organs: eyes, brain, and kidney. Anesthetic management can be challenged by problems associated with high ocular pressure, mental retardation, and renal tubular dysfunction. We report a case of a 17 year-old boy with Lowe syndrome accompanied by end-stage renal disease who underwent general anesthesia for arteriovenous fistula formation. The Anesthetic implications of this syndrome are also described.

Ultrasound-guided interscalene brachial plexus block in a pediatric patient with acute hepatitis: A case report / 대한마취과학회지

The interscalene brachial plexus block is not commonly used in pediatric regional anesthesia. The increasing popularity of ultrasound has allowed more anesthesiologists to perform regional anesthesia with high success rates in pediatric patients with the direct visualization of the target nerve and spread of local anesthetics. We present a case of interscalene brachial plexus block under ultrasound guidance in a 17-month-old child with acute drug-induced hepatitis who required fixation of a fracture of the lateral humeral condyle.

A comparison of sufentanil and fentanyl for patient-controlled epidural analgesia in arthroplasty / 대한마취과학회지

BACKGROUND: The use of lipid soluble opioids such as fentanyl, alfentanil and sufentanil are recently on the increase for patient-controlled epidural analgesia (PCEA). In this study, the effects and adequate dose of sufentanil in arthroplasty were investigated. METHODS: Eighty patients scheduled for arthroplasty were enrolled for the study. Seventy-one patients (ASA physical status I-III) were randomly allocated into four groups. All groups received 0.1% ropivacaine through PCEA and each group received either fentanyl (group F: fentanyl 4 microg/ml) or sufentanil (group S1: sufentanil 0.5 microg/ml, group S2: sufentanil 0.75 microg/ml, and group S3: sufentanil 1.0 microg/ml). Postoperative pain scores were evaluated using VAS (visual analog scale, 0-10) and side effects such as hypotension, nausea/vomiting, pruritus and the degree of satisfaction were evaluated at 1, 6, 12, 24, 48 hours after surgery. RESULTS: Postoperative pain score (VAS) decreased gradually and the highest VAS score was recorded at 1 hour postoperative for all four groups. There were no differences in the degree of satisfaction and postoperative pain score between all groups. The incidence of pruritus was significantly lower in group S1 than in groups S2 and S3. CONCLUSIONS: The incidence of side effects were significantly lower in group S1 (0.1% ropivacaine plus sufentanil 0.5 microg/ml). Therefore, 0.5 microg/ml of sufentanil through PCEA is the recommended dose for postoperative pain control in arthroplasty.

Evaluation of a portable hemoglobin photometer for assessment of intra-operative hemoglobin concentrations

BACKGROUND: To evaluate the accuracy of a portable hemoglobin photometer, the HemoCue, during surgery, hemoglobin concentrations (Hb) of HemoCue were compared with those of the SYSMEX XE-2100, in the situation of bleeding. METHODS: Hemoglobin concentrations were measured with HemoCue and by the SYSMEX XE-2100 at the same time, on 100 blood samples obtained from patients who were bleeding more than 500 ml, during surgery. The limits of agreement between the two methods were calculated from the results according to the method of Bland & Altman. The results of HemoCue were adjusted by adding the mean bias, defining the corrected values, and reevaluated the agreement with the results of the SYSMEX XE-2100. RESULTS: The differences in results between the two methods were 1.12 +/- 0.37 g/dl. The limits of agreement were 0.38-1.86 g/dl, which means disagreement between the two methods. However, the corrected values represented agreement with the values of the SYSMEX XE-2100. The limits of agreement were -0.74-0.74 g/dl. CONCLUSIONS: The corrected Hb values of HemoCue were comparable to the values of SYSMEX XE-2100. It is useful to evaluate the hemoglobin concentration using HemoCue intraoperatively.