Association between tumor necrosis factor alpha 308G/A polymorphism and increased proinflammatory cytokine release after cardiac surgery with cardiopulmonary bypass in the Korean population.

OBJECTIVES: The G-308A polymorphism of the tumor necrosis factor alpha (TNF-alpha) gene has been suggested to be linked to high TNF promoter activity in in vitro studies. However, there have been some controversies in in vivo studies. This study investigated whether A allele at TNF-308 site is associated with (1) the changes in plasma cytokine levels during and after cardiopulmonary bypass (CPB) and (2) an increased incidence of pulmonary morbidity after CPB. DESIGN: Prospective and observational investigation. SETTING: A university hospital, single institution. PARTICIPANTS: Patients scheduled for cardiac surgery with CPB. INTERVENTION: TNF genotype was determined by the real-time polymerase chain reaction method. IL-6 and TNF-alpha levels were measured by enzyme-linked immunosorbent assay at the following time points: T1, before initiation of CPB; T2, 30 minutes of CPB; T3, 30 minutes after CPB; T4, 2 hours after CPB; and T5, 24 hours after CPB. The oxygen index, serum creatinine level, 24-hour blood loss, intubation time, and length of intensive care unit (ICU) stay were examined. MEASUREMENTS AND MAIN RESULTS: The levels of TNF-alpha in group A (TNF-308GA/AA, n = 25) were higher at T3, T4, and T5 than group G (TNF-308GG, n = 225). The levels of IL-6 showed no statistical difference. The oxygenation index, serum creatinine level, 24-hour blood loss, intubation time, and length of ICU stay showed no statistical difference. CONCLUSIONS: TNF G-308A polymorphism may be associated with excess TNF-alpha secretion in this study and may not be associated with excess IL-6 secretion and postoperative morbidity after CPB.

Comparison of the temperature and humidity in the anesthetic breathing circuit among different anesthetic workstations: Updated guidelines for reporting parallel group randomized trials.

BACKGROUND: For patients undergoing general anesthesia, adequate warming and humidification of the inspired gases is very important. The aim of this study was to evaluate the differences in the heat and moisture content of the inspired gases with low-flow anesthesia using 4 different anesthesia machines. METHODS: The patients were divided into 11 groups according to the anesthesia machine used (Ohmeda, Excel; Avance; Dräger, Cato; and Primus) and the fresh gas flow (FGF) rate (0.5, 1, and 4 L/min). The temperature and absolute humidity of the inspired gas in the inspiratory limbs were measured at 5, 10, 15, 30, 45, 60, 75, 90, 105, and 120 minutes in 9 patients scheduled for total thyroidectomy or cervical spine operation in each group. RESULTS: The anesthesia machines of Excel, Avance, Cato, and Primus did not show statistically significant changes in the inspired gas temperatures over time within each group with various FGFs. They, however, showed statistically significant changes in the absolute humidity of the inspired gas over time within each group with low FGF anesthesia (P < .05). The anesthesia machines of Cato and Primus showed statistically significant changes in the absolute humidity of the inspired gas over time within each group with an FGF of 4 L/min (P < .05). However, even with low-flow anesthesia, the temperatures and absolute humidities of the inspired gas for all anesthesia machines were lower than the recommended values. CONCLUSION: There were statistical differences in the provision of humidity among different anesthesia workstations. The Cato and Primus workstations were superior to Excel and Avance. However, even these were unsatisfactory in humans. Therefore, additional devices that provide inspired gases with adequate heat and humidity are needed for those undergoing general anesthetic procedures.

A Novel and Simple Method for Tracheal Intubation in a Swine Model: Preparing for the Era of Xenotransplantation.

OBJECTIVES: Organ transplant in humans is an established therapy for a variety of end-stage organ diseases. However, due to organ shortages and lack of donors, the need for xenotransplant has gradually increased. Xenotransplantation has great potential to solve many of the problems facing organ transplantation. Pigs are being developed as xenogeneic organ donors for use in humans. In this study, we propose a novel and simple method for tracheal intubation in a swine model using neuromuscular blocking agents and laryngeal mask airway. MATERIALS AND METHODS: Eight Yorkshire pigs were used for the 2 separate experiments, which were conducted 1 week apart. In the first experiment, an anesthesiologist with no previous comparable experience performed endotracheal intubation of pigs. One week later, using the same pig, a second experiment was performed by an experienced anesthesiologist. Anesthesia was induced with intramuscular injection of a mixture of 1 mg/kg xylazine (Rompun, Bayer Korea Ltd., Seoul, Korea) and 7 mg/kg Zoletil (a mixture of tiletamine hydrochloride and zolazepam hydro-chloride, Virbac Laboratory, Carros, France). The laryngeal mask was then placed, and 0.15 mg/kg vecuronium bromide was injected intravenously. Tracheal intubation was attempted after mask removal. The duration and number of intubation attempts were recorded, and the degree of intubation difficulty was scored. RESULTS: In all cases, the laryngeal mask was easily inserted, and endotracheal intubation was successfully completed. Oxygen saturation did not fall below 95%, and there were no hypoxemia episodes. Degree of intubation difficulty and duration were not significantly different between the 2 anesthesiologists. CONCLUSIONS: Tracheal intubation in our swine model was successfully performed using neuromuscular blocking agents and laryngeal masks without resulting in hypoxemia, with even anesthesiologists who are unfamiliar with endotracheal intubation of pigs easily able to do so using our protocol. Therefore, our protocol will enable all investigators to perform successful tracheal intubation in swine models.

Polymorphism rs4263535 in GABRA1 intron 4 was related to deeper sedation by intravenous midazolam.

OBJECTIVE: To evaluate whether polymorphisms in the gamma-aminobutyric acid A receptor α1 subunit (GABRA1) gene influence sleep induction time, bispectral index score (BIS) during sleep induction and the total dose of midazolam required to reach a Ramsay Sedation Assessment Scale (RSAS) score of 4. METHODS: Patients scheduled for elective orthopaedic surgery were enrolled. All patients received initial doses of 0.02 mg/kg intravenous midazolam. If the RSAS score did not reach 4, an additional 1-mg dose of midazolam was administered. Results were compared among groups of patients with five single-nucleotide polymorphisms (SNPs) in GABRA1: rs4263535, rs980791, rs6556562, rs998754 and rs2279020. RESULTS: A total of 104 patients were evaluated. Polymorphism rs4263535 was associated with the lowest BIS during sedation induction. Multinomial logistic regression analysis demonstrated that polymorphism rs4263535 was significantly associated with the total dose of midazolam required for sedation induction. CONCLUSIONS: Polymorphism rs4263535 in GABRA1 intron 4 was associated with deeper sedation by intravenous midazolam. Patients with the A/A rs4263535 genotype required a smaller dose of midazolam.

Effects of botulinum toxin type A on the superior cervical ganglia in rabbits.

Sympathetic neurolysis is very important in treating chronic pain, especially sympathetically maintained pain. However, conventional neurolytic agents destroy nerve fibers nonselectively and may leave serious complications. Botulinum toxin type A (BTA) selectively acts on cholinergic nerves and inhibits the secretion of acetylcholines (Ach) at the involved nerve endings. Because cholinergic nerves also exist in autonomic ganglia, it is believed that BTA has pharmacological effects on sympathetic ganglia. In this study, after the administration of BTA into the superior cervical ganglion (SCG) in rabbits, the possible clinical use of BTA as a neurolytic agent was evaluated. In the normal saline-treated control group, miosis was not observed in all 12 rabbits. However, in the BTA-treated group, 15 cases of miosis were observed among 40 rabbits (37.5%). Furthermore, BTA induced miosis in a dose-dependent manner, though onset time and duration of miosis varied. Mean time of onset and duration were 1.8 days and 5.3 weeks, respectively. By eosin-hematoxylin (H&E) staining finding, no significant chronological and histological changes between the control and the experimental groups were observed. In conclusion, BTA was found to have a sympathetic ganglion blocking effect over a period of more than 1 month without causing considerable pathologic changes in the SCG, that is, this toxin may be used in the case of sympathetically maintained pain control as a sympatholytic.

Propofol infusion associated metabolic acidosis in patients undergoing neurosurgical anesthesia: a retrospective study.

OBJECTIVE: Propofol and volatile anesthesia have been associated with metabolic acidosis induced by increased lactate. This study was designed to evaluate changes in pH, base excess (BE), and lactate in response to different anesthetic agents and to characterize propofol infusion-associated lactic acidosis. METHODS: The medical records of patients undergoing neurosurgical anesthesia between January 2005 and September 2012 were examined. Patients were divided into 2 groups : those who received propofol (total intravenous anesthesia, TIVA) and those who received sevoflurane (balanced inhalation anesthesia, BIA) anesthesia. Propensity analysis was performed (1 : 1 match, n=47), and the characteristics of the patients who developed severe acidosis were recorded. RESULTS: In the matched TIVA and BIA groups, the incidence of metabolic acidosis (11% vs. 13%, p=1) and base excess (p>0.05) were similar. All patients in the TIVA group who developed severe acidosis did so within 4 hours of the initiation of propofol infusion, and these patients improved when propofol was discontinued. CONCLUSIONS: The incidence of metabolic acidosis was similar during neurosurgical anesthesia with propofol or sevoflurane. In addition, severe acidosis associated with propofol infusion appears to be reversible when propofol is discontinued.

Sugammadex versus neostigmine reversal of moderate rocuronium-induced neuromuscular blockade in Korean patients.

BACKGROUND: Rapid and complete reversal of neuromuscular blockade (NMB) is desirable at the end of surgery. Sugammadex reverses rocuronium-induced NMB by encapsulation. It is well tolerated in Caucasian patients, providing rapid reversal of moderate (reappearance of T2) rocuronium-induced NMB. We investigated the efficacy and safety of sugammadex versus neostigmine in Korean patients. METHODS: This randomized, safety assessor-blinded trial (NCT01050543) included Korean patients undergoing general anesthesia. Rocuronium 0.6 mg/kg was given prior to intubation with maintenance doses of 0.1-0.2 mg/kg as required. Patients received sugammadex 2.0 mg/kg or neostigmine 50 µg/kg with glycopyrrolate 10 µg/kg to reverse the NMB at the reappearance of T2, after the last rocuronium dose. The primary efficacy endpoint was the time from sugammadex or neostigmine administration to recovery of the train-of-four (TOF) ratio to 0.9. The safety of these medications was also assessed. RESULTS: Of 128 randomized patients, 118 had evaluable data (n = 59 in each group). The geometric mean (95% confidence interval) time to recovery of the TOF ratio to 0.9 was 1.8 (1.6, 2.0) minutes in the sugammadex group and 14.8 (12.4, 17.6) minutes in the neostigmine group (P < 0.0001). Sugammadex was generally well tolerated, with no evidence of residual or recurrence of NMB; four patients in the neostigmine group reported adverse events possibly indicative of inadequate NMB reversal. CONCLUSIONS: Sugammadex was well tolerated and provided rapid reversal of moderate rocuronium-induced NMB in Korean patients, with a recovery time 8.1 times faster than neostigmine. These results are consistent with those reported for Caucasian patients.

Feasibility of ultrasound-guided posterior approach for interscalene catheter placement during arthroscopic shoulder surgery.

BACKGROUND: Continuous interscalene block has been known to improve postoperative analgesia after arthroscopic shoulder surgery. This was a prospective study investigating the ultrasound-guided posterior approach for placement of an interscalene catheter, clinical efficacy and complications after placement of the catheter. METHODS: Forty-two patients undergoing elective arthroscopic shoulder surgery were included in this study and an interscalene catheter was inserted under the guidance of ultrasound with posterior approach. With the inplane approach, the 17 G Tuohy needle was advanced until the tip was placed between the C5 and C6 nerve roots. After a bolus injection of 20 ml of 0.2% ropivacaine, a catheter was threaded and secured. A continuous infusion of ropivacaine 0.2% 4 ml/hr with patient-controlled 5 ml boluses every hour was used over 2 days. Difficulties in placement of the catheter, clinical efficacy of analgesia and complications were recorded. All patients were monitored for 48 hours and examined by the surgeon for complications within 2 weeks of hospital discharge. RESULTS: Easy placement of the catheter was achieved in 100% of the patients and the success rate of catheter placement during the 48 hr period was 92.9%. Postoperative analgesia was effective in 88.1% of the patients in the post anesthetic care unit. The major complications included nausea (7.1%), vomiting (4.8%), dyspnea (4.8%) and unintended vascular punctures (2.4%). Other complications such as neurologic deficits and local infection around the puncture site did not occur. CONCLUSIONS: The ultrasound-guided interscalene block with a posterior approach is associated with a success high rate in placement of the interscalene catheter and a low rate of complications. However, the small sample size limits us to draw definite conclusions. Therefore, a well-designed randomized controlled trial is required to confirm our preliminary study.

Paroxysmal atrial fibrillation developed during incomplete epidural anesthesia -A case report-.

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia, and occurs in organic heart disease such as rheumatic, atherosclerotic and hypertensive heart disease. In recent studies, the sympathetic and parasympathetic nervous systems have been shown to have important roles in initiating paroxysmal AF. We report here a patient who developed paroxysmal AF that might be a result of an imbalance of the sympathetic-parasympathetic systems due to epidural anesthesia, and that was potentiated by pain with inadequate analgesia. A 69-year-old woman was scheduled for operation of a right-sided ankle fracture. Twenty minutes after epidural drug injection, paroxysmal AF occurred. Even after intravenous administration of esmolol and digoxin, AF continued. After transfer to the intensive care unit, her heart rate gradually decreased and AF disappeared. During perioperative anesthetic management, the proper preoperative prevention and intraoperative treatment are needed in AF high-risk patients.

Common peroneal nerve palsy after robotic assisted laparoscopic colectomy: A case report.

Common peroneal nerve palsy after surgery with lithotomy position has been widely reported, but it is an unexpected complication after surgery with supine position. We report a patient who developed common peroneal nerve palsy after surgery with supine position. A 55-year old man is planed for robotic assisted laparoscopic right hemicolectomy because of colon cancer. The patient was placed supine with Trendelenburg position at an angle about 5 degrees and tilted left about 15 degrees. The operation is uneventful, but he developed common peroneal nerve palsy on the first postoperative day. The patient was fully recovered with conservative treatment after 2 months. We consider that nerve palsy as a result of compression of common peroneal nerve related to patient positioning. So we should be careful not to develop common peroneal nerve palsy even if the patient was placed in the supine position during robotic assisted surgery.

Effect of muscle relaxant on entropy during propofol anesthesia.

BACKGROUND: The purpose of this study was to investigate whether muscle relaxant affect the values of Entropy, response entropy (RE) or state entropy (SE) during propofol anesthesia. METHODS: Eighty patients (ASA I) scheduled for elective surgery under general anesthesia were randomly assigned to four groups. Anesthesia was maintained at a SE value of 80 (80 +/- 2) using target controlled infusion (TCI) of propofol. After maintaining SE 80 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group I and same volume of normal saline was intravenously injected in group II. After maintaining SE 60 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group III and same volume of normal saline was injected intravenously in group IV. The mean arterial pressure, heart rate, SE and RE were measured before anesthetic induction and up to 5 min after vecuronium or normal saline injection in each group. RESULTS: SE and RE were not changed in group II, but significantly decreased in group I (P < 0.05, respectively). In group III and IV, SE and RE were not changed in both groups. There were no significant hemodynamic changes among the four groups. CONCLUSIONS: These results suggest that the effect of muscle relaxant on Entropy vary according to the baseline values of RE or SE during propofol anesthesia.

The effect of intermittent levator massage with caudal block on management of levator ani syndrome: A case report.

Levator ani syndrome (LAS) is a functional disorder of the pelvic floor muscles in which recurrent and persistent distressing pain is felt in the anus without detectable organic pathology. Eighty one percent of coccygodynia was alleviated by the levator massage when the massage motion was repeated 10 to 15 times on each side of the pelvis daily for 5 or 6 days. The authors encountered the LAS patient for whom successive visit to pain clinic was economic burden. Therefore, the authors managed the patient by intermittent levator massage with caudal block, once a week for 3 times, resulting in two years of pain free status. Intermittent levator massage with caudal block may be as effective as successive levator massage and induce longer painless period in the management of LAS.

Tracheal laceration detected by high end-tidal CO2 during endoscopic thyroidectomy.

Endoscopic thyroidectomy is frequently used for cosmetic reasons, such as reducing cervical scarring. Subcutaneous gas insufflation with CO2 is needed to maintain the surgical space, and optimal surgical techniques and careful attention are required when conducting this procedure due to the limited space available for the endoscopic instruments. We report here a case of a tracheal laceration with a tear in the cuff of a reinforced tube, which was detected by an abrupt increase in end-tidal CO2 to 90 mmHg. Reintubation was achieved using a tube exchanger and the patient was effectively ventilated without complications.

The effects of propofol on cardiac function after 4 hours of cold cardioplegia and reperfusion.

OBJECTIVE: To examine whether propofol protects against postischemic myocardial dysfunction and apoptosis during reperfusion after prolonged cold ischemia in isolated rat hearts. DESIGN: A prospective, randomized, controlled study. SETTING: A university laboratory. PARTICIPANTS: Animals. INTERVENTIONS: The isolated hearts of 40 Sprague-Dawley male rats were perfused with modified Krebs-Hennseleit solution for 15 minutes for a stabilization period and 15 minutes for a perfusion period and then underwent 4 hours of global cold ischemia followed by 60 minutes of reperfusion. Four groups were studied (n = 10 for each group). Ten hearts served as an untreated control group. Propofol (2 micromol/L) treatment was performed only before ischemia in the PRE group, only during reperfusion in the POST group, and both before and after ischemia in the ALL group. MEASUREMENTS AND MAIN RESULTS: Infusion of propofol during reperfusion improved recovery of left ventricular-developed pressure (LVDP) from 61.2% +/- 8.5% (control) to 86.3% +/- 12.1% (POST) and 74.9% +/- 13.2% (ALL, both p < 0.05), whereas preischemic infusion of propofol (64.3% +/- 9.7%, PRE) did not improve recovery of LVDP. Infusion of propofol during reperfusion significantly reduced the number of apoptotic cells and led to a smaller infarct size than control and PRE groups (p < 0.05, respectively). CONCLUSIONS: Propofol infusion during the reperfusion period produced a cardioprotective effect and inhibited apoptosis of cardiomyocytes in the ischemia-reperfusion model, with prolonged cold ischemia, in isolated rat hearts.

Arousal with iv epinephrine depends on the depth of anesthesia.

PURPOSE: To investigate whether the depth of anesthesia affects the change in the bispectral index (BIS) caused by iv epinephrine during propofol anesthesia. METHODS: Forty women undergoing elective lower abdominal surgery received a propofol target controlled infusion (TCI) to maintain a modified Observer's Assessment of Alertness/Sedation (OAA/S) score of 2 (sedation period). Subsequently anesthesia was induced with propofol TCI 5 mug.mL(-1) and rocuronium 0.9 mg.kg(-1), and propofol continued so as to maintain general anesthesia at a BIS of 50 (general anesthesia period). Intravenous epinephrine at a dose of 10 mug.5 mL(-1) in normal saline (epinephrine group, n = 20) or normal saline 5 mL (control group, n = 20) was administered during both periods. The BIS, mean arterial pressure (MAP) and heart rate (HR) were measured immediately before, and one, two, three, four, six, eight, and ten minutes after injection. The modified OAA/S scale was evaluated during the sedation period. RESULTS: There was no significant change in the modified OAA/S scale, BIS, or hemodynamic variables compared to preinjection values during either sedation or general anesthesia in the control group. Intravenous epinephrine increased the BIS and modified OAA/S scale during sedation, but there was no increase in BIS during general anesthesia. Increases in HR and MAP were observed during both periods after iv epinephrine. CONCLUSION: Intravenous epinephrine 10 mug resulted in an arousal effect and an increase in BIS during sedation, but did not change the BIS during general anesthesia. These results suggest that the arousal effect of iv epinephrine during propofol anesthesia depends on anesthetic depth.