Preemptive visceral analgesic effect of thoracic paravertebral block on postoperative opioid consumption in patients undergoing laparoscopic cholecystectomy: a prospective, randomized, assessor-blind study / 대한마취과학회지

Background@#The preemptive visceral analgesic effect of regional nerve block has not been adequately investigated to date. We evaluated the preemptive visceral analgesic effect of thoracic paravertebral block (TPVB) in patients undergoing laparoscopic cholecystectomy (LC) in whom pre-incisional rectus sheath block (RSB) was used to minimize somatic surgical pain. @*Methods@#In this prospective, randomized, assessor-blind study, 70 patients scheduled for elective LC were randomly assigned to the pre-TPVB (n = 35) or the post-TPVB (n = 35) group. Both groups received pre-incisional RSB, and patients in the pre-TPVB group received TPVB before skin incision while those in the post-TPVB group received TPVB after skin closure. The primary outcome was the total rescue analgesic consumption (morphine equianalgesic dose) during the 24 h post-surgery. The secondary outcomes were the cumulative analgesic consumption and pain intensity for 24 h after surgery, and adverse events. @*Results@#Pre-TPVB significantly reduced total rescue analgesic consumption (estimated mean [95% CI]) during the 24 h after surgery than post-TPVB (16.9 [14.5, 19.3] vs. 25.3 [22.8, 27.7] mg, estimated difference: -8.3 [-11.8, -4.9], P < 0.001). The cumulative rescue analgesic consumption was significantly lower in the pre-TPVB group from 2–24 h after surgery (P < 0.001). The postoperative pain intensity was significantly lower in the pre-TPVB group as well at 0.5–6 h after surgery. There were no adverse events in both groups. @*Conclusions@#Pre-incisional TPVB conferred a significant preemptive visceral analgesic effect in patients undergoing LC, and significantly reduced the amount of postoperative opioid consumption.

Changes in the Perception Structure of the Concept of Empathy According to the Educational Experience of Medical Students / 의료커뮤니케이션

Purpose@#: The purpose of this study is to explore changes in the conceptual perception structure of medical students’ empathy according to the educational experience provided at the beginning of the basic medical education. @*Methods@#: The subjects of this study were 116 students in the 2nd year of the pre-medical department of the College of Medicine. @*Results@#: Before and after the basic medical interview class and after the end of the dissection practice, words included in the concept of empathy such as ‘the other person’, ‘emotion’, ‘understanding’, ‘position’, ‘situation’, and ‘thought’ appeared in common. However, these common words appeared mixed before and after the basic medical interview class, but after the end of the dissection practice, they changed to a structure that recognizes the concept of empathy by integrating the core concepts of ‘the other’, ‘understanding’, and ‘emotion’. In particular, after the end of the dissection practice, the word ‘patient’ appeared, expressing the specific object of empathy as a doctor for the first time. @*Conclusion@#: Curriculum related to medical interview within the basic medical education curriculum should be systematically developed so that students can continuously experience practical medical interview situations along with theoretical education.

Application of Three-Dimensional Printed Models in Congenital Heart Surgery: Surgeon's Perspective

To treat congenital heart disease, it is important to understand the anatomical structure correctly. Three-dimensional (3D) printed models of the heart effectively demonstrate the structural features of congenital heart disease. Occasionally, the exact characteristics of complex cardiac malformations are difficult to identify on conventional computed tomography, magnetic resonance imaging, and echocardiography, and the use of 3D printed models can help overcome their limitations. Recently, 3D printed models have been used for congenital heart disease education, preoperative simulation, and decision-making processes. In addition, we will pave the way for the development of this technology in the future and discuss various aspects of its use, such as the development of surgical techniques and training of cardiac surgeons.

Application of Three-Dimensional Printed Models in Congenital Heart Surgery: Surgeon's Perspective

To treat congenital heart disease, it is important to understand the anatomical structure correctly. Three-dimensional (3D) printed models of the heart effectively demonstrate the structural features of congenital heart disease. Occasionally, the exact characteristics of complex cardiac malformations are difficult to identify on conventional computed tomography, magnetic resonance imaging, and echocardiography, and the use of 3D printed models can help overcome their limitations. Recently, 3D printed models have been used for congenital heart disease education, preoperative simulation, and decision-making processes. In addition, we will pave the way for the development of this technology in the future and discuss various aspects of its use, such as the development of surgical techniques and training of cardiac surgeons.

The Effectiveness of Ultrasound-Guided Thoracic Paravertebral Block for Percutaneous Radiofrequency Ablation of Hepatic Tumors: A Pilot Study

PURPOSE@#The purpose of this study was to evaluate the effectiveness of thoracic paravertebral block (TPVB) for management of pain during and after percutaneous radiofrequency ablation (RFA) of hepatic tumor.@*MATERIALS AND METHODS@#All patients were divided into non-TPVB (4 patients, 4 sessions of RFA for 4 tumors) and TPVB group (5 patients, 7 sessions of RFAs for 7 tumors). Ultrasound (US)-guided TPVB was performed at T7 level. The 15 mL of 0.375% ropivacaine was injected into right paravertebral space before RFA. If patients complained pain and asked analgesics or experienced pain with verbal numerical rating scale (VNRS) of more than 4, fentanyl 25 µg (up to 100 µg), pethidine 25 mg, and midazolam 0.05 mg/kg (up to 5 mg) were sequentially given intravenously during RFA.@*RESULTS@#Total intravenous morphine equivalence of analgesics before, during, and after RFA was 129.1 mg and 0.0 mg in non-TPVB and TPVB group, respectively.@*CONCLUSION@#US-guided TPVB may be an effective and safe anesthetic method for decreasing or eliminating pain during and after RFA for hepatic tumor and helpful in decreasing the usage of opioids.

Post-dural puncture headache following acupotomy using “Wonli-acupuncture needle”: A case report

Acupuncture is a popular technique used worldwide, particularly for clinical pain management. Diverse methods of acupuncture with several types of needle have recently been introduced; however, medical evidence of the treatment and safety of many of these techniques has not been established. In addition, severe, life-threatening acupuncture-related complications have been reported even though the treatment is considered to be safe. We report a case of a post-dural puncture headache that occurred following acupuncture for the treatment of lower back pain, with a literature review. Pain physicians should consider that acupuncture can cause far more serious side effects than those previously known.

An anesthetic experience in severe preeclampsia patient suspected HELLP syndrome with an intraperitoneal hemorrhage caused by a rapidly progressed liver rupture: A case report

The diagnosis of HELLP syndrome associated with preeclampsia-eclampsia during pregnancy uses three test results, including hemolysis, elevated liver enzyme, low platelets and their related clinical symptoms. Liver rupture is a life-threatening and rare complication related to HELLP syndrome. Early diagnosis and rapid treatment are very important for protecting the life of the patient and the fetus. We are reporting an anesthetic experience a sudden-onset suspicious HELLP syndrome with an intraperitoneal hemorrhage caused by a rapidly progressed liver rupture in a severe preeclampsia patient without any abnormalities during gestation.

Real-time ultrasound-guided spinal anesthesia for cesarean section in patient with severe kyphoscoliosis and Duchenne's muscular dystrophy: A case report

Most elective cesarean sections are conducted under spinal anesthesia. Regional anesthesia has become the preferred technique, because general anesthesia is associated with a greater risk of maternal morbidity and mortality. In patients without absolute contraindication, spinal anesthesia is avoided, when procedural difficulty is increased by severe spinal deformity. A 41-year-old female patient was 33 weeks into pregnancy. Her height and weight were 145 cm and 45 kg. The patient was planned for emergency cesarean section, due to cephalopelvic disproportion. Spinal anesthesia was planned since she was suffering from Duchenne's muscular dystrophy, and had risks of respiratory failure and prolonged mechanical ventilation after general anesthesia. However, the patient also had severe kyphoscoliosis, maybe due to Duchenne's muscular dystrophy. We are reporting a successful spinal anesthesia using real-time ultrasound guidance, for cesarean section in this obstetric patient with severe kyphoscoliosis.

Cervical plexus block / 대한마취과학회지

Cervical plexus blocks (CPBs) have been used in various head and neck surgeries to provide adequate anesthesia and/or analgesia; however, the block is performed in a narrow space in the region of the neck that contains many sensitive structures, multiple fascial layers, and complicated innervation. Since the intermediate CPB was introduced in addition to superficial and deep CPBs in 2004, there has been some confusion regarding the nomenclature and definition of CPBs, particularly the intermediate CPB. Additionally, as the role of ultrasound in the head and neck region has expanded, CPBs can be performed more safely and accurately under ultrasound guidance. In this review, the authors will describe the methods, including ultrasound-guided techniques, and clinical applications of conventional deep and superficial CPBs; in addition, the authors will discuss the controversial issues regarding intermediate CPBs, including nomenclature and associated potential adverse effects that may often be neglected, focusing on the anatomy of the cervical fascial layers and cervical plexus. Finally, the authors will attempt to refine the classification of CPB methods based on the target compartments, which can be easily identified under ultrasound guidance, with consideration of the effects of each method of CPB.

Surgical excision of the breast giant fibroadenoma under regional anesthesia by Pecs II and internal intercostal plane block: a case report and brief technical description: a case report / 대한마취과학회지

A 22-years-old female patient at 171 cm and 67 kg visited the Department of Breast Surgery of the hospital with a mass accompanied with pain on the left side breast as chief complaints. Since physical examination revealed a suspected huge mass, breast surgeon decided to perform surgical excision and requested anesthesia to our department. Surgery of breast tumor is often under local anesthesia. However, in case of big size tumor, surgery is usually performed under general anesthesia. The patient feared general anesthesia. Unlike abdominal surgery, there is no need to control visceral pain for breast and anterior thoracic wall surgery. Therefore, we decided to perform resection under regional anesthesia. Herein, we report a successful anesthetic and pain management of the patient undergoing excision of a huge breast fibroadenoma under regional anesthesia using Pecs II and internal intercostal plane block.

Risk of Encountering Dorsal Scapular and Long Thoracic Nerves during Ultrasound-guided Interscalene Brachial Plexus Block with Nerve Stimulator

BACKGROUND: Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach. METHODS: A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded. RESULTS: Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). Neither was encountered in 21 cases (30.4%). The average current measured immediately before the disappearance of muscle twitches was 0.44 mA and 0.50 mA at DSN and LTN, respectively. CONCLUSIONS: Physicians should be cautious on the risk of injury related to the anatomical structures of nerves, including DSN and LTN, during ultrasound-guided IBPB by posterior approach. Nerve stimulator could be another option for a safer intervention. Moreover, if there is a motor response, it is recommended to select another way to secure better safety.

Clinical Outcomes between Living Related and Living Unrelated Kidney Transplantation in ABO-Incompatible Kidney Transplant Recipients / 대한내과학회지

BACKGROUND/AIMS: Kidney transplantation (KT) is the best treatment for end-stage renal disease patients. Although previous studies have demonstrated that the clinical outcome following living related (LR) KT is better than that following unrelated (LUR) KT in ABO-compatible KT recipients, recent studies showed no differences in clinical outcomes between the two treatments. In this study, we compared the clinical outcomes of LR and LUR KT in ABO-incompatible KT recipients. METHODS: From January 2011 to August 2013, 19 cases of ABO-incompatible KT were analyzed retrospectively. Eight kidneys (7 cases of parent-offspring and 1 case of siblings, Group 1) were donated from living-related donors and 11 (all spousal donors, Group 2) from living-unrelated donors. We investigated patient survival, graft survival, acute rejection, graft function, and complications. RESULTS: On Kaplan-Meier analysis, patient and graft survival during follow-up were 87.5% and 87.5% in Group 1; both were 100% in Group 2. Acute rejection, graft function, and medical and surgical complications were not significantly different between the two groups. CONCLUSIONS: The short-term clinical outcomes between LR and LUR KT in ABO-incompatible KT recipients were equivalent. Most domestic cases of LUR KT are from spousal donors and the spousal donor will be a major donor in ABO-incompatible KT patients.

Successful treatment of pediatric intervertebral disc calcification using ultrasound-guided cervical root block / 대한마취과학회지

No abstract available.

Successful treatment of pediatric intervertebral disc calcification using ultrasound-guided cervical root block / 대한마취과학회지

No abstract available.

Arterial Switch Operation in Patients with Intramural Coronary Artery: Early and Mid-term Results

BACKGROUND: The intramural coronary artery has been known as a risk factor for early death after an arterial switch operation (ASO). We reviewed the morphological characteristics and evaluated the early and mid-term results of ASO for patients with an intramural coronary artery. MATERIALS AND METHODS: From March 1994 to September 15th 2010, 158 patients underwent ASO at Dong-A and Pusan National University Hospitals for repair of transposition of the great arteries and double outlet right ventricle. Among these patients, 14 patients (8.9%) had an intramural coronary artery. Mean age at operation was 13.4+/-10.2 days (4 to 39 days) and mean body weight was 3.48+/-0.33 kg (2.88 to 3.88 kg). All patients except one were male. Eight patients had TGA/IVS and 4 patients had an aortic arch anomaly. Two patients (14.3%) had side-by-side great artery relation, of whom one had an intramural right coronary artery and the other had an intramural left anterior descending coronary artery. Twelve patients had anterior-posterior relation, all of whom had an intramural left coronary artery (LCA). The aortocoronary flap technique was used in coronary transfer in 8 patients, of whom one patient required a switch to the individual coronary button technique 2 days after operation because of myocardial ischemia. An individual coronary button implantation technique was adopted in 6, of whom 2 patients required left subclavian artery free graft to LCA during the same operation due to LCA injury during coronary button mobilization and LCA torsion. RESULTS: There was 1 operative death (7.1%), which occurred in the first patient in our series. This patient underwent an aortocoronary flap procedure for coronary transfer combining aortic arch repair. Overall operative mortality for 144 patients without an intramural coronary artery was 13.2% (19/144). There was no statistical difference in operative mortality between the patients with and without an intramural coronary artery (p>0.1). There was no late death. The mean follow-up duration was 52.1+/-43.0 months (0.5 to 132 months). One patient who had a subclavian artery free graft required LCA stenting 6.5 years after surgery for LCA anastomotic site stenosis. No other surviving patient needed any intervention for coronary problems. All patients had normal ventricular function at latest echocardiography and were in NYHA class 1. CONCLUSION: The arterial switch operation in Transposition of Great Arteries or Double Outlet Right Ventricle patients with intramural coronary can be performed with low mortality; however, there is a high incidence of intraoperative or postoperative coronary problems, which can be managed with conversion to the individual coronary button technique and a bypass procedure using a left subclavian free graft. Both aortocoronary flap and individual coronary button implantation techniques for coronary transfer have excellent mid-term results.

Treatment of Venous Stasis Ulcer with 3M(TM) Coban(TM) 2 Layer Compression System: A Case Report

PURPOSE: Venous stasis ulcer is the most severe form of chronic venous insufficiency and this commonly appears in the lower limb. Pharmacological therapy, reconstruction of the venous system, surgical management, cellular therapy and compression therapy are known as the treatments of venous stasis ulcer, but relapses are common, which make it a typical chronic wound. We report here on a case of recurrent venous stasis ulcer that healed with compression therapy without any other treatment. METHODS: A 35-year-old man with a 13 years history of venous stasis had developed an ulcer on the distal third portion of the lower left limb which was developed 12-year before enrollment in this study. He had been treated with vacuum assist closure, 2 times of cell therapy and 3 times of skin graft for 8 years, but the lesion recurred. From November, 2008 compression therapy was done with the 3M Coban(TM) 2 Layer Compression System(3M, St. Paul, USA). The ulcer at that time was oval shaped and 3x4cm in size. A comfort layer bandage was applied from the proximal phalanx of the great toe to the knee. A compression layer bandage was applied on the previous layer with it being overlapped one half the width of the comfort layer bandage. The dressing was changed every 4 days and the change was recorded with photography. RESULTS: A total of 12 Coban(TM) 2 Layer Compression Systems were used. The size of the ulcer decreased to 2.5x2.5cm in one month, to 2x2cm in 2 months, it was 1x1.8cm in size at 3 months and it completely healed in 4 months. CONCLUSION: The venous stasis ulcer was completely healed using the 3M Coban(TM) 2 Layer Compression System. This method was easy to apply, made the patient comfortable and it provided an excellent compression effect. As in the previous studies, this compression therapy has been proven to play an important role for the treatment and prevention of venous stasis ulcer.

Outcome of Staged Repair of Tetralogy of Fallot with Pulmonary Atresia and a Ductus-dependent Pulmonary Circulation: Should Primary Repair Be Considered?

BACKGROUND: The tetralogy of Fallot (TOF) with pulmonary atresia (PA) and a ductus-dependent pulmonary circulation (no major aorto-pulmonary collateral arteries (MAPCAs)) has been treated with staged repair or primary repair depending on the preference of surgeons or institutions. We evaluated the 19-year outcome of staged repair for this anomaly to find out whether our surgical strategy should be changed. MATERIALS AND METHODS: Forty-four patients with TOF/PA with patent ductus arteriosus (PDA) who underwent staged repair from June 1991 to October 2010 were included in this retrospective study. The patients with MAPCAs were excluded. The average age at the first palliative shunt surgery was 40.8+/-67.5 days (range: 0~332 days). Thirty-one patients (31/44, 70%) were neonates. The average weight was 3.5+/-1.6 kg (range: 1.6~8.7 kg). A modified Blalock-Taussig (BT) shunt was performed in 38 patients, classic BT shunt in 4 patients, and central shunt in 2 patients. Six patients required concomitant procedures: pulmonary artery angioplasty was performed in 4 patients, pulmonary artery reconstruction in one patient, and re-implantation of the left pulmonary artery to the main pulmonary artery in one patient. Four patients required a second shunt operation before the definitive repair was performed. Thirty-three patients underwent definitive repair at 24.2+/-13.3 months (range: 7.3~68 months) after the first palliative operation. The average age at the time of definitive repair was 25.4+/-13.5 months (range: 7.6~68.6 months) and their average weight was 11.0+/-2.1 kg. For definitive repair, 3 types of right ventricular outflow procedures were used: extra-cardiac conduit was performed in 30 patients, trans-annular patch in 2 patients, and REV operation in 1 patient. One patient was lost to follow-up after hospital discharge. The mean follow-up duration for the rest of the patients was 72+/-37 months (range: 4~160 months). RESULTS: Ten patients (10/44, 22.7%) died before the definitive repair was performed. Four of them died during hospitalization after the shunt operation. Six deaths were thought to be shunt-related. The average time of shunt-related deaths after shunt procedures was 8.7 months (range: 2 days~25.3 months). There was no operative mortality after the definitive repair, but one patient died from dilated cardiomyopathy caused by myocarditis 8 years and 3 months after the definitive repair. Five-year and 10-year survival rates after the first palliative operation were 76.8% and 69.1%, respectively. CONCLUSION: There was a high overall mortality rate in staged repair for the patients with TOF/PA with PDA. Majority of deaths occurred before the definitive repair was performed. Therefore, primary repair or early second stage definitive repair should be considered to enhance the survival rate for patients with TOF/PA with PDA.

Outcome of the Modified Norwood Procedure: 7 Years of Experience from a Single Institution / 대한흉부외과학회지

BACKGROUND: We assessed the early and mid-term results of the modified Norwood procedure for first-stage palliation of hypoplastic left heart syndrome (HLHS) and its variants to identify the risk factors for hospital mortality. MATERIAL AND METHOD: Between March, 2003, and December, 2009, 23 patients (18 males and 5 females) with HLHS or variants underwent the modified Norwood procedure. The age at operation ranged from 3 to 60 days (mean, 11.7+/-13.2 days) and weight at operation ranged from 2.2 to 4.8 kg (mean, 3.17+/-0.52 kg). We used a modified technique that spared the anterior wall of the main pulmonary artery in 20 patients. The sources of pulmonary blood flow were RV-PA conduit in 15 patients (group I) and RMBTS in 8 (group II). Follow-up was completed in 19 patients (19/20, 95%) in our hospital (mean 26.0+/-22.8 months). RESULT: Early death occurred in 3 patients (3/23, 13%), of whom 2 had TAPVC. Fourteen patients underwent subsequent bidirectional cavopulmonary connection (BCPC, stage 2) and seven underwent the Fontan operation (stage 3). Three patients died between stages, 2 before stage 2 and one before stage 3. The estimated 1-year and 5-year survival rates were 78% and 69%, respectively. On multivariate regression analysis, aberrant right subclavian artery (RSCA) and associated total anomalous pulmonary venous connection (TAPVC) were risk factors for hospital mortality after stage 1 Norwood procedure. CONCLUSION: HLHS and its variants can be palliated by the modified Norwood procedure with low operative mortality. Total anomalous pulmonary venous connection adversely affects the survival after a stage 1 Norwood procedure, and interstage mortality rates need to be improved.

Staged Repair of Esophageal Atresia with Tracheoesophageal Fistula in a Very Low-birth-weight Infant: A case report / 대한흉부외과학회지

There are still some controversies in treatment strategy for the very low-birth-weight baby with esophageal atresia even though the result of primary repair has been improving. We report a successful end to end anastomosis with staged approach in one of twin weighing 1,270 g at birth.

Successful Treatment of Recurrent Methicillin-resistant Staphylococcus aureus Bacteremia and Endocarditis by Linezolid, Valve Replacement, and Excisional Surgery of Limb in a Patient with Complicated Arteriovenous Malformation

Vancomycin treatment failure in methicillin-resistant Staphylococcus aureus (MRSA) bacteremia patients has increased over the past decade. We experienced a case of repeated MRSA bacteremia resulting in left-side endocarditis in 38-year-old male with a huge complicated arteriovenous malformation in the left thigh. After vancomycin treatment failure, the patient was successfully treated with the administration of linezolid, leg amputation, and mitral valve replacement.