Comparison of the incidence of venous thromboembolism between epidural and general anesthesia for total knee arthroplasty: a retrospective study

BACKGROUND: Substantial variation exists in the reported rates of postoperative venous thromboembolism (VTE) following total knee arthroplasty (TKA) in the Asian population. This retrospective study aimed to compare the early postoperative VTE incidence between patients managed with epidural anesthesia and those managed by general anesthesia at the time of TKA. METHODS: We reviewed 589 cases of unilateral primary TKA performed between January 2011 and June 2014. We selected epidural versus general anesthesia groups as the main anesthetic choices, with postoperative patient-controlled analgesia. All the patients underwent deep vein thrombosis (DVT) computed tomography angiography on postoperative day 7. The incidence of DVT and pulmonary thromboembolism (PTE) was evaluated and compared between epidural and general anesthesia. RESULTS: The overall incidence of VTE was 8.0% in the two groups together. The incidence did not differ between the groups. The odds ratio in the generalized estimation equations analysis showed a higher incidence of DVT and PTE in the epidural group; however, this result was not statistically significant. Although, the odds ratio for age showed that the risk of developing DVT and PTE increased 1.12 times per year. CONCLUSIONS: Total VTE incidence was not significantly different between patients who underwent general anesthesia and those who underwent epidural anesthesia for TKA. A prospective multicenter study is required to evaluate the nature of the Korean VTE status in major orthopedic surgeries, and to prepare guidelines and protocols for medical prophylaxis for DVT and PTE in Korea.

The evaluation of implementing smart patient controlled analgesic pump with a different infusion rate for different time duration on postoperative pain management

BACKGROUND: Control of postoperative pain is an important aspect of postoperative patient management. Among the methods of postoperative pain control, patient-controlled analgesia (PCA) has been the most commonly used. This study tested the convenience and safety of a PCA method in which the dose adjusted according to time. METHODS: This study included 100 patients who had previously undergone orthognathic surgery, discectomy, or total hip arthroplasty, and wished to control their postoperative pain through PCA. In the test group (n = 50), the rate of infusion was changed over time, while in the control group (n = 50), drugs were administered at a fixed rate. Patients' pain scores on the visual analogue scale, number of rescue analgesic infusions, side effects, and patients' satisfaction with analgesia were compared between the two groups. RESULTS: The patients and controls were matched for age, gender, height, weight, and body mass index. No significant difference in the mount of drug administered was found between the test and control groups at 0-24 h after the operation; however, a significant difference was observed at 24-48 h after the operation between the two groups. No difference was found in the postoperative pain score, number of side effects, and patient satisfaction between the two groups. CONCLUSIONS: Patient-controlled anesthesia administered at changing rates of infusion has similar numbers of side effects as infusion performed at a fixed rate; however, the former allows for efficient and safe management of postoperative pain even in small doses.

Catecholamine-Induced Cardiomyopathy associated with Neuroblastoma and Treated with Extracorporeal Membrane Oxygenation as a Bridge to Recovery / 대한구급학회지

Catecholamine-induced cardiomyopathy associated with neuroblastoma is rarely reported. We report a case of catecholamine-induced cardiomyopathy associated with neuroblastoma in a 33-month-old female that was treated with extracorporeal membrane oxygenation (ECMO). She was tentatively diagnosed with acute myocarditis and presented with hypertension. Because of rapid patient deterioration despite pharmacological treatments, ECMO was applied. ECMO can be helpful in cases of catecholamine-induced cardiomyopathy associated with neuroblastoma.

Catecholamine-Induced Cardiomyopathy associated with Neuroblastoma and Treated with Extracorporeal Membrane Oxygenation as a Bridge to Recovery / 대한중환자의학회지

Catecholamine-induced cardiomyopathy associated with neuroblastoma is rarely reported. We report a case of catecholamine-induced cardiomyopathy associated with neuroblastoma in a 33-month-old female that was treated with extracorporeal membrane oxygenation (ECMO). She was tentatively diagnosed with acute myocarditis and presented with hypertension. Because of rapid patient deterioration despite pharmacological treatments, ECMO was applied. ECMO can be helpful in cases of catecholamine-induced cardiomyopathy associated with neuroblastoma.

Extra cardiac tumor misdiagnosed as a left atrial myxoma / 대한마취과학회지

No abstract available.

Extra cardiac tumor misdiagnosed as a left atrial myxoma / 대한마취과학회지

No abstract available.

A comparison of femoral/sciatic nerve block with lateral femoral cutaneous nerve block and combined spinal epidural anesthesia for total knee replacement arthroplasty / 대한마취과학회지

BACKGROUND: Several factors, such as compromised cardiopulmonary function, anticoagulative therapy, or anatomical deformity in the elderly, prevent general anesthesia and neuraxial blockade from being conducted for total knee replacement arthroplasty (TKRA). We investigated the efficacy of femoral/sciatic nerve block with lateral femoral cutaneous nerve block (FSNB) as an alternative procedure in comparison with combined spinal epidural nerve block (CSE) in patients undergoing TKRA. METHODS: In this observational study, 80 American Society of Anesthesiologists physical status I-III patients scheduled for elective unilateral TKRA underwent CSE (n = 40) or FSNB (n = 40). Perioperative side effects, intraoperative medications, duration and remaining amount of intravenous patient-controlled analgesia, rate of satisfaction with the surgical anesthesia and postoperative analgesia, willingness to recommend the same surgical anesthesia and postoperative analgesia to others, and postoperative visual analog scale pain scores were assessed. Statistical analysis was done using Chi-square test, Student's t-test, and repeated-measures analysis of variances. RESULTS: There was significantly more use of antihypertensives, analgesics, and sedatives in the FSNB group. There were no significant differences of perioperative side effects, duration and remaining amount of intravenous patient-controlled analgesia, rate of satisfaction with the surgical anesthesia and postoperative analgesia, willingness to recommend the same surgical anesthesia and postoperative analgesia to others, and postoperative visual analog scale scores between the two groups. CONCLUSIONS: FSNB with a sophisticated use of antihypertensives, analgesics, and sedatives to supplement insufficient block offers a practical alternative to CSE for TKRAs.

Intravenous fentanyl during shoulder arthroscopic surgery in the sitting position after interscalene block increases the incidence of episodes of bradycardia hypotension / 대한마취과학회지

BACKGROUND: Episodes of bradycardia hypotension (BH) or vasovagal syncope have a reported incidence of 13-29% during arthroscopic shoulder surgery in the sitting position after an interscalene block (ISB). This study was designed to investigate whether intravenous fentanyl during shoulder arthroscopy in the sitting position after ISB would increase or worsen the incidence of BH episodes. METHODS: In this prospective study, 20 minutes after being in a sitting position, 160 patients who underwent ISB were randomized to receive saline (S, n = 40), 50 microg of fentanyl (F-50, n = 40), 100 microg of fentanyl (F-100, n = 40) or 30 mg of ketorolac (K-30, n = 40) randomly. We assessed the incidence of BH episodes during the operation and the degree of maximal reduction (Rmax) of blood pressure (BP) and heart rate (HR). RESULTS: The incidence of BH episodes was 10%, 15%, 27.5% and 5% in the S, F-50, F-100 and K-30 groups, respectively. Mean Rmax of systolic BP in the F-100 group was significantly decreased as compared to the S group (-20.0 +/- 4.5 versus -6.3 +/- 1.6%, P = 0.004). Similarly, mean Rmax of diastolic BP in the F-100 group was also significantly decreased (P = 0.008) as compared to the S group. CONCLUSIONS: These results suggest that fentanyl can increase the incidence of BH episodes during shoulder arthroscopic surgery in the sitting position after ISB.

Target-controlled infusion of remifentanil for conscious sedation during spinal anesthesia / 대한마취과학회지

BACKGROUND: The aim of this study was to define the optimal target concentration of remifentanil which effectively achieves conscious sedation without significant vital sign changes and side effects during spinal anesthesia. METHODS: Sixty patients underwent spinal anesthesia with 0.5% hyperbaric bupivacaine (8-16 mg), and were infused with a target controlled infusion (TCI) of remifentanil at 1.0 ng/ml (group R10, n = 15), 2.0 ng/ml (group R20, n = 15), 3.0 ng/ml (group R30, n = 15), and 3.5 ng/ml (group R35, n = 15). Observer's assessment of alertness/sedation (OAA/S) scale, the bispectral index (BIS), anxiety levels and infusion rate of remifentanil were monitored during the operation. RESULTS: OAA/S scale was significantly lower in groups R30 (3.96) and R35 (3.34) than groups R10 (4.31) and R20 (4.26). Incidence of intraoperative respiratory depression events, post operative nausea and vomiting were significantly higher in group R35 than the other groups. There were no significant differences in BIS, anxiety level and incidences of recall of the operative procedure among the groups. CONCLUSIONS: We conclude that the TCI of remifentanil at 3.0 ng/ml produces an effective sedation and anti-anxiety effects without significant side effects during spinal anesthesia.

The effect of the intravenous phenylephrine on the level of spinal anesthesia / 대한마취과학회지

BACKGROUND: Spinal anesthesia causes hypotension and bradycardia due to sympathetic nerve block and it is difficult to predict the level of sensory block and the duration of blockade. Recent studies have reported that intravenous phenylephrine can reduce the rostral spread of spinal anesthesia in pregnant women. We think a phenylephrine infusion will be useful for maintaining the baseline blood pressure by reducing the rostral spread of spinal anesthesia during the elective surgery of non-obstetric patients. METHODS: Sixty patients who were undergoing urologic surgery were randomized into two groups: Group C (the control group without phenylephrine) and Group P (with the addition of phenylephrine). After a bolus infusion of 50 microg phenylephrine following the spinal injection, phenylephrine was continuously infused at the rate of 200 microg/hr. We compared the dermatomal spreads of spinal anesthesia, the hemodynamic parameters (blood pressure, heart rate) and the incidences of hypotension between the two groups. RESULTS: At 20 minutes, the level of the upper dermatome blocked against cold sensation was a median of T8 (interquartile range: T8-T10) for the phenylephrine group, as compared with T4 (interquartile range: T4-T6) for the control group (P < 0.001). CONCLUSIONS: Intravenous phenylephrine can decrease the rostral spread of spinal anesthesia during urologic surgery.

Anesthesia of a dental patient with Angelman syndrome: A case report / 대한마취과학회지

Angelman syndrome is characterized by a partial deficit of paired autosomal chromosome 15, which contains a subunit of the GABA (Gamma-Amino Butyric Acid) receptor. Many drugs that act on the CNS (Central Nerve System) during anesthesia are believed to exert their effects via the GABA receptors. We describe the anesthesia of a 7 year-old female patient with Angelman syndrome who underwent surgery for dental caries. The basic factors that needed to be considered when administering anesthesia to this patient were epilepsy, significant dominance of the vagal tone, craniofacial abnormalities and peripheral muscular atrophy. Inhalational anesthetics (sevoflurane) were employed for this patient. The patient had an uneventful peri-operative period and was discharged home on the same day of the operation.

Anesthesia of a dental patient with Angelman syndrome: A case report / 대한마취과학회지

Angelman syndrome is characterized by a partial deficit of paired autosomal chromosome 15, which contains a subunit of the GABA (Gamma-Amino Butyric Acid) receptor. Many drugs that act on the CNS (Central Nerve System) during anesthesia are believed to exert their effects via the GABA receptors. We describe the anesthesia of a 7 year-old female patient with Angelman syndrome who underwent surgery for dental caries. The basic factors that needed to be considered when administering anesthesia to this patient were epilepsy, significant dominance of the vagal tone, craniofacial abnormalities and peripheral muscular atrophy. Inhalational anesthetics (sevoflurane) were employed for this patient. The patient had an uneventful peri-operative period and was discharged home on the same day of the operation.

Effect of pretreatment with acetaminophen on withdrawal movements associated with injection of rocuronium: a prospective, randomized, double-blind, placebo controlled study / 대한마취과학회지

BACKGROUND: Withdrawal movement during rocuronium injection is a common, unresolved adverse effect. We aimed to investigate the effect of IV acetaminophen pretreatment on withdrawal movement during rocuronium injection. METHODS: This study enrolled 120 American Society of Anesthesiologists (ASA) I-II patients undergoing general anesthesia. They were randomly assigned to three treatment groups. After occluding venous drainage using a tourniquet on the upper arm, the saline group received 5 ml of 0.9% sodium chloride solution, the lidocaine group received 40 mg of lidocaine, and the acetaminophen group received 50 mg of acetaminophen. During injection of pretreatment drug, pain was assessed on a four-point scale. The tourniquet was released after 120 seconds and anesthesia was performed using thiopental sodium 5 mg/kg followed by rocuronium 0.6 mg/kg. The withdrawal movement was graded on a four-point scale in a double-blind manner. RESULTS: The incidence of pain on pretreatment injection in saline, lidocaine, and acetaminophen groups was 7.7%, 5.1%, and 2.5%, respectively. The incidence of withdrawal movements was 77.5% in saline group, 32.5% in lidocaine group, and 37.5% in acetaminophen group (P < 0.05). CONCLUSIONS: Acetaminophen and lidocaine reduced the incidence of withdrawal movement after rocuronium injection compared with saline.

Sympathetic Block for Treating Primary Erythromelalgia

Primary erythromelalgia is a rare condition that's characterized by erythema, an increased skin temperature and burning pain in the extremities. The pain is often very severe, and treating erythromelalgia is frustrating and difficult. We report here on the case of a 12-year old girl with primary erythromelalgia in both lower extremities. The pain was refractory to medical treatment, but a bilateral sympathetic block with lidocaine and triamcinolone resulted in relief from the pain. Our experience with this disease demonstrates that sympathetic blocks are effective in improving the symptoms and they may be attempted on erythromelalgia patients who do not respond to other treatments, including medication and epidural blocks.

Contralateral allodynia and central change in the chronic post-ischemic pain model rats / 대한마취과학회지

BACKGROUND: Mirror-image allodynia is a mysterious phenomenon that occurs in association with many clinical pain syndromes including complex regional pain syndromes (CRPS). Underlying mechanisms for the development of such pain are still a matter of investigation. Several studies suggest that activation of the N-methyl-D-aspartate (NMDA) receptor is essential for central sensitization as a base for persistent pain. The aim is to assess whether alteration of NMDA receptor expression correlates with the contralateral allodynia in the chronic post-ischemia pain (CPIP) model rats representing CRPS-Type I. METHODS: Application of a tight-fitting tourniquet for a period of 3 hours before reperfusion produced CPIP in male Sprague-Dawley rats. The mechanical paw withdrawal thresholds to von Frey stimuli (using a dynamic plantar aesthesiometer) were measured as pain indicators in ipsilateral and contralateral hindpaws. Phosphorylation of the NMDA receptor 1 subunit (pNR1), assessed with Western blot, was measured in the contralateral L4-6 spinal cord. RESULTS: Ipsilateral and contralateral mechanical allodynia is present at 4 hours after reperfusion, peaked at 3 days, and continued for 7 days after reperfusion. The relative density of pNR1 of CPIP rats significantly decreased in the contralateral L4-6 spinal cord compared to baseline value (P < 0.05). There was significant correlation between paw withdrawal threshold and the relative density of pNR1 (ipsilateral; R2 = 0.75, P < 0.01, contralateral; R2 = 0.60, P < 0.01). CONCLUSIONS: These data suggest that pNR1 is correlated to the contralateral mechanical allodynia in CPIP rats.

Comparison of Morphine and Fentanyl IV-PCA in Gastrectomy Patient

BACKGROUND: Morphine and fentanyl have potent analgesic effects and these agents are widely used for intravenous patient controlled analgesia (IV-PCA); however, these drugs have some side effects. The purpose of this study was to compare the postoperative analgesic effects and side effects of morphine and fentanyl, employing IV-PCA after gastrectomy. METHODS: Fifty patients undergoing gastrectomy were randomized to receive either morphine (M goup, n = 25) or fentanyl (F group, n = 25) via an IV-PCA pump for 48 hours after the end of surgery. The loading dose was administered when a patient first complained of pain, followed by a bolus dose of 2 mg morphine for the M group and 20microg fentanyl for the F group, with a lockout interval of 10 minutes between doses. The VAS pain score, PCA opioid consumption, rescue analgesic requirement, and side effects were assessed at 2, 6, 12, 24 and 48 hours after the end of surgery. RESULTS: No significant differences were observed between the two groups in terms of the VAS pain score, satisfaction score and total and hourly dose for 48 hours. The side effects were similar in both groups except that pruritus and urinary retention were significantly lower in the F group of patients. CONCLUSIONS: We conclude that both morphine and fentanyl have good analgesic effects with few side effects in gastrectomy patients, but the fentanyl group of patients experienced less pruritus and urinary retention than the morphine group of patients.

Myocardial protective effects of nicorandil and verapamil during ischemia-reperfusion in an isolated perfused rat heart

BACKGROUND: To reduce or prevent myocardial injury during an ischemia-reperfusion episode, some pharmacological interventions, including administering nicorandil or verapamil, have becomepopular in clinical situations. Nicorandil is a N-(2-hydroxyethyl)- nicotinamide nitrate ester, and it's effective mainly by opening the K+ ATP channels in the mitochondrial membrane, and verapamil is useful for reducing the endothelial injury of coronary vessels during ischemia. In this study, we aimed to determine the cardioprotective effect when both drugs are used simultaneously. METHODS: Isolated rat hearts (the Langendorff perfusion model) were perfused with Krebs-Henseleit bicarbonate buffer. After 30 minutes of controlled perfusion, we added nicorandil or verapamil separately and both drugs were administered together in another group (the mixed group) and we then induced ischemia for 30 minutes. We measured the heart rate, the developed ventricularpressure and the dP/dT during the control period during drug infusion and during reperfusion at 15, 30, 45 and 60 minutes. RESULTS: During reperfusion, the mixed group showed more favorable results for the developed left ventricular pressure (LVP), the dP/dT and the rate pressure product (RPP). The heart rate was significantly decreased as reperfusion processed in all the groups. CONCLUSIONS: For myocardial protection during ischemia-reperfusion, a mixed drug regimen is more beneficial than a single drug regimen, and this occurs without inducing a significant decrease of the heart rate.

Acute Massive Pulmonary Thromboembolism Occurring during Femur Surgery: The Key Role of Transesophageal Echocardiography : A case report

We experienced a case, which showed the sudden drop of arterial oxygen saturation and capnographic score in a femur surgery patient under general anesthesia. We installed a transesophageal echocardiography probe in the patient and detected free-floating emboli in the right atrium, enlargement of the right atrium and the right ventricle, and global hypokinesia of the right ventricle. Because the patient's vital sign was so unstable, emergent cardiac and pulmonary embolectomy was performed with the use of cardiopulmonary bypass. The postoperative course was uneventful and the patient was discharged without any neurologic sequale. We concluded that transesophageal echocardiography was a useful device for the diagnosis of intraoperative massive pulmonary thromboembolism.

Effects of Propofol on Phenylephrine Induced Vascular Smooth Muscle Contraction in Rat Thoracic Aorta / 대한마취과학회지

BACKGROUND: Propofol decreases arterial blood pressure. This has been ascribed to vasodilation and decreased cardiac output occuring separately or in combination. The goal of the present study was to assess the effects of propofol on the phenylephrine induced vasoconstriction in rat thoracic aortic rings. METHODS: All aortic rings were removed endothelium and isometric tension was recorded under a resting tension of 3 g. Isolated aortic rings were precontracted with phenylephrine (0.3micrometer) and propofol (1 to 100micrometer) was added cumulatively. We induced the phenylephrine preconstriction after treatment of verapamil 10micrometer in the other vascular rings. RESULTS: Propofol (1 to 100micrometer) attenuated phenylephrine (0.3micrometer) induced preconstriction dose-dependently. The administration of propofol (1 and 10micrometer) did not change the tonic constriction. The contractile response were significantly attenuated in verapamil pretreated rings but propofol did not affect on constriction in all dose range. CONCLUSIONS: Propofol attenuated phenylephrine precontracted rat thoracic aortic rings with inhibition of Ca2+ movement through the L-type calcium channel in the sarcolemmal membrane.

Airway Management

Airway management is still perceived as the greatest patient safety issue and the key task that anesthesiologists perform. Management includes mask ventilation, use of a laryngoscope, and the endotracheal intubation and extubation of the patient. Difficulty can be encountered at any of these stages, and can be a major cause of anesthesia-related morbidity and mortality. Competence in airway management requires knowledge of the anatomy and physiology of the airway, ability to access the patient's airway for the anatomic features that correlate with difficulties in airway management, skill with the many devices used in airway management, including a variety of recently-introduced airway tools, and the appropriate application of the sophisticated algorithm for difficult airway management. Development and clinical distribution of supraglottic airway devices and their enhancement, as well as the broad acceptance of awake fiber-optic intubation, has led to profound changes in the strategy for managing a difficult airway. Including the American Society of Anesthesiologists, many countries have developed their own airway management algorithm these days. Nevertheless, massive national and international deficits still exist in implementing these guidelines into practice as well as the implicated structural requirements with respect to education, reflection, team building and equipment concerning each individual institution. In regard to this situation, it is the recommendation of the author that our country develop and institute such a standardized system of airway management.