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

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 / 대한마취과학회지

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.

Effect of remifentanil or esmolol on bispectral index and entropy to tracheal intubation during propofol anesthesia

BACKGROUND: The bispectral index (BIS) and entropy (response entropy, state entropy; RE, SE) have been used to monitor the anesthetic depth, and the difference between RE and SE (RE-SE difference) may represent the nociceptive stimuli during general anesthesia. This study was designed to determine whether BIS or entropy (RE, SE, and RE-SE difference) represent the response to tracheal intubation with iv bolus of remifentanil or esmolol forstable hemodynamic control during propofol anesthesia. METHODS: Eighty-nine patients were randomly divided into three groups (the control, esmolol, and remifentanil groups). Patient received propofol by target controlled infusion with air 2 L/min and O2 2 L/min. After the maintenance with target effect site concentration of propofol 5 microgram/ml for 5 min, patients received normal saline or esmolol 1.0 mg/kg or remifentanil 1.0 microgram/kg iv bolus according to group. And rocuronium 0.6 mg/kg iv bolus was administered and tracheal intubation was done. We measured mean arterial pressure (MAP), heart rate (HR), BIS, and entropy (RE, SE, RE-SE difference) during tracheal intubation. RESULTS: Changes in MAP or HR after tracheal intubation were greater in the control and esmolol groups than those in the remifentanil group. Although BIS, RE, and SE did not increase after intubation in all groups, but RE-SE difference significantly increased at 1 min after tracheal intubation in the control and esmolol group, but was unchanged in the remifentanil group. CONCLUSIONS: Among BIS, RE, SE and RE-SE difference, RE-SE difference is the good indicator for estimate of nociception during tracheal intubation.

Posterior auricular pain caused by the trigger points in the sternocleidomastoid muscle aggravated by psychological factors: A case report / 대한마취과학회지

Psychological factors play a significant role in the pain mechanism, and psychological approaches may be useful complements to traditional medical and surgical treatments in pain management. The authors report a case of recurrent severe posterior auricular pain caused by trigger points in the right sternocleidomastoid muscle and influenced by stressful psychological situations (e.g., family affairs, job loss) in a 50-year-old man.

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

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

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.

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

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 / 대한마취과학회지

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.

Comparison of Propofol-Remifentanil and Sevoflurane-Remifentanil Anesthesia for Suspension Laryngoscopic Surgery

BACKGROUND: Suspension laryngoscopic surgery may cause acute hemodynamic changes such as hypertension and tachycardia and requires rapid recovery. The purpose of this study was to compare the hemodynamic responses, and emergence and recovery profiles between propofol-remifentanil and sevoflurane-remfentanil anesthesia. METHODS: Forty patients (ASA I, II) undergoing suspension laryngoscopic surgery were randomly allocated to either a propofol group (Group P) or sevoflurane group (Group S). Anesthesia was induced with target concentration of 5microg/ml using propofol target controlled infusion (TCI) in group P and thiopental sodium 5 mg/kg in group S, respectively. In both groups, after succinylcholine 1 mg/kg IV bolus injection, remifentanil was infused with a target concentration 5 ng/ml using remifentanil TCI for tracheal intubation. Anesthesia was maintained with N2O 2 L/min, O2 2 L/min, remifentanil (2.5-7.0 ng/ml), succinylcholine infusion (0.15 mg/kg/ min) in both groups, with propofol (2.0microg/ml) was used in group P and sevoflurane 3.0 vol% in group S. We compared hemodynamic status, and emergence and recovery profiles during and after operation. RESULTS: MAP and HR after tracheal intubation and suspension laryngoscopy insertion showed significantly smaller changes in group P and were more stable compared with group S. The suction time of the catheter response was shorter in group P compared with group S, and sedation was less deeper in group P than group S. Other recovery profiles were comparable between groups. CONCLUSIONS: During propofol-remifentanil anesthesia, hemodynamics were not increased by intubation or suspension laryngoscopy, and the early emergence and good recovery profiles of patients were appeared favorably compared with sevofluraneremifentanil anesthesia.

Chest Pain Caused by the Trigger Points in the Scalenus Muscle: A case report / 대한마취과학회지

Myofascial pain syndrome is very common disease but cause symptoms that are easily misdiagnosed as other conditions. The authors report a case of chest pain caused by the trigger points in the scalenus muscle. A 43 year-old man had chest pain without any history of trauma or infection. And, there were not any abnormal findings by cardiology and pulmonary evaluation. On physical examination, the scalenus muscle had the trigger points, and the chest pain was successfully treated by trigger point injections.

The Effect of Remifentanil on Pain during Local Anesthetic Infiltration in Moderately Sedated Plastic Surgery Patients / 대한마취과학회지

BACKGROUND: This randomized study was designed to evaluate the analgesic effectiveness and to determine the optimal dose of remifentanil when administered as intermittent bolus injection during infiltration of local anesthetics for patients undergoing plastic surgery. METHODS: Forty five ASA I or II patients undergoing plastic surgery were randomly assigned to one of the three bolus doses of remifentanil injection. Five minutes after receiving midazolam 0.05 mg/kg IV, remifentanil was injected intravenously one minute before the infiltration of local anesthetics: A bolus of remifentanil 0.25microgram/kg was injected in Group R0.25 (n = 15), 0.50 microgram/kg in Group R0.5 (n = 15), or 0.75microgram/kg in Group R0.75 (n = 15). After assessment of the patients' Observer's Assessment of Alertness/Sedation (OAA/S) scale, the subjective pain level during local anesthetic infiltration was evaluated. Respiratory rate, SpO2, mean blood pressure, and heart rate were recorded during the study period. Postoperative nausea/vomiting and patient's satisfaction were checked by telephone call. RESULTS: OAA/S scale values were similar among the three groups (3-4). The number of the patients who complained of moderate or severe pain level is significantly higher in group R0.25 than in group R0.5 or group R0.75 (P < 0.05). Adverse events such as hypoventilation, desaturation, and bradycardia were observed with significantly high frequency in R0.75 than in other two groups (P < 0.05). All three groups showed no occurrence of hypotension or postoperative nausea/vomiting. CONCLUSIONS: The above results demonstrate that intermittent bolus injection of remifentanil 0.50microgram/kg is recommended to accomplish desirable pain control during local anesthetic infiltration in those who received midazolam 0.05 mg/kg.

The Effect of Combined Ephedrine and Lidocaine Pretreatment on Tracheal Intubation Condition and Maximum Neuromuscular Block after Rocuronium Administration / 대한마취과학회지

BACKGROUND: Rocuronium is a nondepolarizing muscle relaxants used for trying rapid-sequence intubation due to its relatively rapid onset of action and low side effects. Methods to further reduce the onset time of a muscle relaxant include increasing the dose of muscle relaxant, pretreatment for potentiating neuromuscular block of the muscle relaxants or increasing the cardiac output and muscle blood flow. The purpose of this study was to examine the pretreatment effect of combined lidocaine and ephedrine, as a pretreatment, on the onset time and intubation conditions of rocuronium-induced neuromuscular block in adults. METHODS: Sixty ASA physical stati 1 and 2 patients were randomly allocated to four groups. Normal saline 10 ml was administered to Group NS prior to induction, lidocaine (1.5 mg/kg) to Group L, ephedrine (70microgram/kg) to Group E, and combined lidocaine (1.5 mg/kg) and ephedrine (70microgram/kg) to Group LE. Anesthesia was induced with propofol (2.0 mg/kg) and rocuronium (0.6 mg/kg). Intubation was performed 45 seconds after the administration of rocuronium and the intubation conditions then evaluated. The change in the mean arterial pressure and heart rate were checked and compared during the peri-induction periods. RESULTS: There were no differences in the hemodynamics between the four groups. The intubation conditions were graded as good to excellent in 33.3, 53.3, 66.7 and 93.3% of patients in NS, L, E and LE groups, respectively. The intubation conditions in group LE were significantly better than those in group NS (P < 0.05). CONCLUSIONS: The above results demonstrated that pretreatment with a combination of ephedrine and lidocaine, following rocuronium, improves the tracheal intubation conditions.

Anesthetic Management of Cesarean Section in Parturient with Guillain-Barre Syndrome: A case report / 대한마취과학회지

Guillain-Barre syndrome (GBS) is an acute demyelinating polyneuropathy, associated with symmetrical muscle weakness, areflexia, and ascending paralysis. Although it has been reported during all the three trimesters of pregnancy and in the post-partum period, the occurrence of GBS in the third trimester presents a high maternal risk because of respiratory complications and the risk of premature delivery. We report the successful anesthetic management of a parturient with GBS.

The Effects of Remifentanil on the LMA Insertion with the Administration of Propofol

BACKGROUND: Laryngeal mask airway (LMA) can be inserted without muscle relaxant in patients who have received propofol. Remifentanil that is recently used opioid effectively attenuates the hemodynamic responses to laryngoscopy. This study was to investigate the effects of remifentanil on the quality and hemodynamic response of LMA insertion after intravenous propofol induction without muscle relaxant. METHODS: Forty patients (ASA I or II, 20-65 years) were randomly allocated to control and remifentanil group. Control group received propofol 4microg/ml alone, remifentanil group received propofol 4microg/ml and remifetanil 2 ng/ml by target controlled infusion. LMA insertion condition was assessed by Muzi's score (jaw mobility, coughing, movement). The time interval to loss of eyelash reflex, to BIS < 60 and to insertion of LMA were recorded. The BIS and hemodynamic changes were measured at preinduction (baseline), preinsertion and postinsertion. RESULTS: Loss of consciousness and LMA insertion were more rapid with remifentanil group than control group (P < 0.05). Clinically acceptable insertion of LMA were observed in 35% and 70% of patients in the control and remifentanil group, respectively. There were significant elevations in heart rate, mean blood pressure after insertion of LMA in control group, but no elevations in remifentanil group. And there were no significant differences in BIS in both groups. CONCLUSIONS: The LMA insertion with propofol-remifentanil can provide more favorable condition and stable hemodynamic status compared with propofol alone.

Cushing's Reflex Associated with Ruptured Cerebral Aneurysm during Intracranial Meningioma Surgery : A case report

The intracranial meningioma associated with hidden cerebral aneurysm is rare. We experienced a patient with subarachnoid hemorrhage (SAH) due to the rupture of cerebral aneurysm during intracranial meningioma removal, although preoperative 6-vessel angiographic study did not reveal aneurysmal dilatation. During operation, tumor was resected piece by piece, and totally removed, grossly. After removal of tumor, the brain swollen suddenly along with hypertension and bradycardia suspecting Cushing's reflex was developed. Emergent postoperative CT and CT-angiographic study revealed large amount of SAH and ruptured aneurysmal dilation of A3 segment of anterior cerebral artery. She died from brainstem failure on 4th postoperative day. We report a rare case of anesthesia for coexisting intracranial meningioma and intracranial aneurysm.

The Role of Central Group I mGluRs for CFA-induced Knee Joint Pain Model in Rats / 대한마취과학회지

BACKGROUND: Glutamate is the predominant excitatory neurotransmitter in the central and peripheral nervous system and has known to be involved in nociceptive transmission and central sensitization. It acts through ligand gated ionotropic glutamate receptors (iGluRs) and G protein-coupled metabotropic glutamate receptors (mGluRs). And mGlu 1, 5 receptors have been recognized to play a role in nociceptive processing. We want to investigate whether central mGluR1 and mGluR5 antagonists could reverse the behavioral signs of weight bearing and secondary mechanical hyperalgesia induced by chronic knee joint inflammation. METHODS: MGluR1 antagonist, (RS)-1-aminoindan-1,5-dicarboxylic acid (AIDA: 25, 50, 100 microM/10 microliter, n = 7 per group) and selective mGluR5 antagonist, 2-methyl-6-(phenylethynyl)-pyridine (MPEP: 25, 100, 200 nM/10 microliter, n = 7 per group) were injected intrathecally 5 days after Complete Freund's Adjuvant (CFA, 150 microliter) injection into knee joint and behavior signs of weight bearing and secondary mechanical hyperalgesia were observed. RESULTS: CFA significantly reduced the magnitude of right hind paw weight bearing and decreased the withdrawal threshold to mechanical stimulation compared to contralateral side. Higher dose of AIDA (100 microM) significantly reversed the reduction of weight bearing, but MPEP did not. AIDA reversed the decrease of the paw withdrawal threshold to mechanical stimulation at the dosage of 50 and 100 microM respectively. MPEP significantly increased the paw withdrawal threshold to mechanical stimulation in a dose dependent manner. CONCLUSIONS: Group I mGluRs were involved in maintenance of primary and secondary mechanical hyperalgesia.

Left Ventricular Rupture during Closed-chest Cardiopulmonary Resuscitation after Pneumonectomy: A case report / 대한마취과학회지

We report a case of circulatory collapse and cardiac arrest immediately after the patient was turned from the lateral decubitus position to the supine position following left pneumonectomy. Closed-chest resuscitation with medical and fluid interventions were inadequate. Emergency chest showed the deviation of heart to the left side and blunted apex. Left ventricular rupture during resuscitation was found subsequent thoracotomy. This rupture and inadequacy of closed-chest resuscitation were felt to be associated with the operative pneumonectomy and pericardiotomy.

Effect of Fresh Gas Flow on the Work of Breathing of Closed Circuit Anesthesia Using Semiclosed Circuit System / 대한마취과학회지

BACKGOUND: The effect of anesthetic techniques, such as closed circuit anesthesia (CCA) using semiclosed circuit system and semiclosed circuit anesthesia (SCCA), on the work of breathing has not been studied yet in detail. This study was purposed to compare the work of breathing according to anesthetic technique (CCA, SCCA). METHODS: Thirty patients were assigned to receive either SCCA group or CCA group (n = 15). Anesthesia was induced with propofol 2 mg/kg with 2% lidocaine 1 ml. Two percents isoflurane with O2 and N2O 2 L/min were given for 10 min to patients initially to wash in functional residual capacity and the breathing circuits. In SCCA group, anesthesia was maintained with 2% isoflurane in O2 2 L/min and N2O 2 L/min throughout the surgery. In CCA group, O2 was reduced to 200 ml/min and N2O to 100 ml/min with isoflurane vaporizer setting adjusted to 4% for anesthesia maintenance. When the operation was ended, the vaporizer setting of isoflurane deceased to zero and then O2 was increased to 4 L/min for the arousal of the patient. We measured the inspiratory/expiratory concentration of isoflurane, end-tidal CO2, the hemodynamic parameters, the change of airway pressure, the work of breathing, and compliance at anesthetic induction and emergence in both groups. RESULTS: There were no significant differences in the inspiratory/expiratory concentrations of isoflurane, the hemodynamic parameters, end-tidal CO2, airway pressure, the work of breathing and compliance between the groups. CONCLUSIONS: CCA using semiclosed circuit system does not increase the work of breathing compared to SCCA.

Effects of Alfentanil on the Hemodynamic Responses and Recovery Profiles during Laryngoscopic Surgery / 대한마취과학회지

BACKGROUND: Laryngoscopy, tracheal intubation and suspension laryngoscopy may cause acute hemodynamic responses such as hypertension and tachycardia. Thus, anesthetic technique during laryngoscopic surgery should be focused on sufficient anesthetic depth and rapid recovery. We investigated the effects of alfentanil to hemodynamic responses and recovery during laryngoscopic surgery. METHODS: Seventy five patients of ASA class 1 or 2 scheduled for laryngoscopic surgery were randomly divided into three groups. Each group received intravenous normal saline 2 ml (control group), alfentanil 10 microgram/kg (A10 group), alfentanil 20 microgram/kg (A20 group) respectively and then followed by induction of thiopental sodium 5 mg/kg and succinylcholine 1 mg/kg. The systolic blood pressure, diastolic blood pressure, heart rate were measured at baseline, immediately and 1 minute after intubation, immediately and 1, 2, 3 minutes after placement of suspension laryngoscopy. The time of suction catheter response, eye opening and extubation were evaluated during recovery periods. RESULTS: The hemodynamic responses to tracheal intubation were blocked in the A10, A20 groups compared with control group. But the hemodynamic responses to placement of suspension laryngoscopy were blocked only by A20 group. The time of eye opening and extubation were no significant differences among groups. CONCLUSIONS: Alfentanil 20 microgram/kg effectively alleviate the hemodynamic responses by tracheal intubation and suspension laryngoscopy during laryngoscopic surgery.

Life Support Systems in Terms of Energy

BACKGROUND: The pro's and con's of pulsatile versus nonpulsatile perfusion during acute and chronic mechanical circulatory support is a longstanding controversial issue, some investigators have suggested that the simplest explanation for this controversy is a failure to quantitate adequately the pulsatile components of flow in studies. The aim of this study was to examine the pulsatility generated by centrifugal pump (CP) and a pulsatile extracorporeal life support (twin pulse life support, T-PLS) in terms of energy equivalent pressure (EEP) and surplus hemodynamic energy (SHE). METHODS: In each of the 5 cardiac arrested pigs, the outflow cannula of the CP or T-PLS was inserted into the ascending aorta, and the inflow cannula of the CP or T-PLS was placed in the right atrium. Extracorporeal circulation was maintained for 30 minutes using a pump flow of 75 ml/kg/min by CP or T-PLS, respectively. Pressure and flow were measured in the right internal carotid artery. RESULTS: No statistical difference was observed between CP and T-PLS in terms of mean carotid artery pressure. However, pulse pressure, the percent change from mean arterial pressure to EEP, and SHE in T-PLS were higher than CP (pulse pressure: 36.1 +/- 3.6 mmHg vs 9.1 +/- 1.3 mmHg, P < 0.05, the percent change from mean arterial pressure to EEP: 19.8 +/- 6.2% vs 0.2 +/- 0.3%, P < 0.05). CONCLUSIONS: In a cardiac arrested animal model, CP revealed nonpulsatility and pulsatility generated by T-PLS was effective in terms of EEP and SHE.