Effect of epidural corticosteroid injection on magnetic resonance imaging findings

BACKGROUND: Magnetic resonance imaging (MRI) of the spine is the preferred diagnostic tool for pathologic conditions affecting the spine. However, in patients receiving epidural corticosteroid injection (ESI) for treatment of spinal diseases, there is a possibility of misreading of MR images because of air or fluid in the epidural space after the injection. Therefore, we defined the characteristics of abnormal changes in MRI findings following an ESI in patients with low back pain. METHODS: We reviewed the medical records of 133 patients who underwent MRI of the lumbar spine within 7 days after ESI between 2006 and 2015.All patients were administered an ESI using a 22-gauge Tuohy needle at the lumbar spine through the interlaminar approach. The epidural space was identified by the loss of resistance technique with air. RESULTS: The incidences of abnormal changes in MRI findings because of ESI were 54%, 31%, and 25% in patients who underwent MRI at approximately 24 h, and 2 and 3 days after ESI, respectively. Abnormal MRI findings included epidural air or fluid, needle tracks, and soft tissue changes. Epidural air, the most frequent abnormal finding (82%), was observed in 41% of patients who underwent MRI within 3 days after injection. Abnormal findings due to an ESI were not observed in MR images acquired 4 days after ESI or later. CONCLUSIONS: Pain physicians should consider the possibility of abnormal findings in MR images acquired after epidural injection using the interlaminar approach and the loss of resistance technique with air at the lumbar spine.

Anaphylactic Shock Following Nonionic Contrast Medium during Caudal Epidural Injection

Caudal epidural injection is a common intervention in patients with low back pain and sciatica. Even though the complications of fluoroscopically directed epidural injections are less frequent than in blind epidural injections, complications due to contrast media can occur. We report a case of anaphylactic shock immediately after injection of an intravenous nonionic contrast medium (iohexol) during the caudal epidural injection for low back pain and sciatica in a patient without a previous allergic history to ionic contrast media (ioxitalamate). Five minutes after the dye was injected, the patient began to experience dizziness, and the systolic blood pressure dropped to 60 mmHg. Subsequently, the patient exhibited a mild drowsy mental state. About 30 minutes after the subcutaneous injection of 0.2 mg epinephrine, the systolic blood pressure increased to 90 mmHg. The patient recovered without any sequela. Life-threatening complications after injection of intravenous contrast medium require immediate treatment.

Intravenous Patient-controlled Analgesia Has a Positive Effect on the Prognosis of Delirium in Patients Undergoing Orthopedic Surgery

BACKGROUND: Postoperative delirium is relatively common. However, the relationship between intravenous patient-controlled analgesia (IV-PCA) and delirium has not been thoroughly investigated. The aim of this study was to evaluate the effects of IV-PCA on the prognosis of postoperative delirium in patients undergoing orthopedic surgery. METHODS: Medical records of 129 patients with postoperative delirium were reviewed. Patients were divided into two groups according to whether they used IV-PCA with fentanyl and ketorolac. The IV-PCA group consisted of 73 patients who were managed with IV-PCA; the NO-PCA group consisted of 56 patients who were managed without PCA. RESULTS: Incidences of multiple psychiatric consultations and prolonged delirium were significantly lower in patients using IV-PCA with fentanyl and ketorolac than in those without PCA. CONCLUSIONS: We recommend the use of IV-PCA for pain control and management of delirium in patients with postoperative delirium.

Hypoventilation and hypokalemia in a patient with poor oral intake in the postanesthesia care unit: A case report

We encountered a case of hypoventilation and hypokalemia in a patient with poor oral intake in the postanesthesia care unit (PACU). A 44-year-old woman underwent a total abdominal hysterectomy under general anesthesia. She was transferred to the PACU after 2 hr of surgery. After 11/2 hr, the patient exhibited hypoventilation, muscle weakness, and mental changes. She was reintubated and transported from the PACU to the intensive care unit. The arterial blood gas analysis results were as follows: pH, 7.27; PaCO2, 65 mmHg; PaO2, 68 mmHg; and serum potassium levels, 2.48 mmol/L. After 6 hr, she recovered with full consciousness.

The Effect of the Addition of Fentanyl and Midazolam to Lidocaine in a Supraclavicular Brachial Plexus Block / 대한마취과학회지

BACKGROUND: This study was conducted to evaluate the effects of fentanyl and midazolam when used as adjuvant in a supraclavicular brachial plexus block. METHODS: 100 adult patients with an ASA status of I-II that were scheduled to undergo upper extremity surgery performed under a supraclavicular brachial plexus block were prospectively evaluated in this study.The patients were randomly divided into 4 study groups:Group 1, which received 40 ml of 1.5% lidocaine, Group 2, which received 3 mg of midazolam with 40 ml of 1.5% lidocaine, Group 3, which received 100microgram of fentanyl with 40 ml of 1.5% lidocaine, and Group 4, which received 3 mg of midazolam and 100microgram of fentanyl with 40 ml of 1.5% lidocaine.The onset time, as well as the duration of analgesia and motor blocks, proportion of successful blocks, hemodynamic parameters, and adverse events were then noted. RESULTS: The incidence of successful block was higher in group 4 (92%) than in any other groups (68-72%) (P = 0.185). In addition, the mean duration of analgesia was longer in groups 2 and 4 (165 min and 175 min) than in groups 1 and 3 (114 min and 131 min) (P < 0.05).Furthermore, the mean duration of motor block was longer in groups 2 and 4 (169 min and 180 min) than in groups 1 and 3 (123 min and 126 min) (P < 0.05).No significant difference was observed in the onset time of the sensory block and motor block when the groups were compared. CONCLUSIONS: Although the addition of 3 mg of midazolam and 100microgram of fentanyl to lidocaine in a supraclavicular brachial plexus block does not affect the onset of sensory or motor block, it does prolong the duration of analgesia and motor block.

Use of Univent Tube(R) for Tracheal Gas Insufflation during Laparoscopic Surgery / 대한마취과학회지

BACKGROUND: Laparoscopic surgery is replacing conventional surgical techniques due to its many advantages. However the possibility of respiratory complications during CO2-induced pneumoperitoneum remain. Tracheal gas insufflation (TGI) has been shown to be a useful adjunct to mechanical ventilation in hypercapneic patients. This study investigated the effectiveness of TGI in reducing the PaCO2 level in hypercapneic patients during laparoscopic surgery without increasing the peak inspiratory pressure (PIP) and usefulness of a Univent tube(R) as a device for TGI. METHODS:Twenty-four patients who were scheduled to undergo gynecological laparoscopic surgery, were enrolled in this study. Anesthesia was induced and maintained with propofol, rocuronium and N2O-O2-sevoflurane. The suction port of the endobronchial blocker of the Univent tube(R) was used for the path of TGI. Data including the ABGA and respiratory parameters were measured three times, the pre-CO2 peritoneum (pre-CO2 pneumoperitoneum point, PCP), 15 min after CO2 peritoneum (after-CO2 pneumoperitoneum point, ACP) and after 15 min TGI (TGI point, TGIP). RESULTS: At ACP, the PaCO2 and PIP had increased more significantly than PCP. After TGI, the PaCO2 was decreased more significantly than ACP, but the PIP did not increased. CONCLUSIONS: TGI is a useful adjunct to mechanical ventilation in hypercapneic patients during laparoscopic surgery, and a univent tube(R) is an economic and convenient device for TGI.

Aseptic Meningitis after a Lumbar Epidural Steroid Injection: A case report / 대한통증학회지

Complications following a well conducted epidural steroid injection are rare. A 50-year-old man developed a headache and neck stiffness 2 days after a lumbar epidural steroid injection. Under the impression of aseptic meningitis, fluid and nonsteroidal anti-inflammatory drug therapy was started immediately after cerebrospinal fluid (CSF) sampling. The CSF was turbid, and revealed a white blood cell count, protein, glucose and pressure of 550/microl (98% lymphocyte), 107.9 mg/dl, 48 mg/dl (serum 113 mg/dl) and 17 cmH2O, respectively. The CSF stain and culture, and antibody test and polymerase chain reaction for pathogens were negative. A computed tomography (CT) scan of the brain revealed no abnormality, and a chest roentgenogram and the results of the neurological examination were normal. Under the impression of aseptic meningitis, the condition was managed conservatively, without antibiotics. Seven days later, the clinical symptoms had improved, and the patient discharged.

Two-dimensional Ultrasound-guided Cannulation of the Internal Jugular Vein / 대한마취과학회지

BACKGROUND: Internal jugular vein access is an essential part of patient management in many clinical settings and is usually achieved with a blind, anatomical landmark-guided technique. The purpose of this study is to evaluate whether a 2-dimensional ultrasound technique can improve on the traditional method. METHODS: Eighty patients undergoing elective open heart surgery were randomly assigned to an anatomical landmark group or ultrasound group (each n = 40). With the patient in the supine position, the head was rotated 30o to the contralateral side and triangle formed by the clavicle and both heads of the sternocleidomastoid muscle were identified. We accessed the internal jugular vein from the apex of the triangle toward the ipsilateral nipple in the anatomical landmark group. The internal jugular vein and carotid artery were visualized with two-dimensional ultrasound. We compared the number of advances made with the central venous cannulation needle, the time to blood aspiration, complications and failure rate. RESULTS: The failure rate was 22.5% using the anatomical landmark technique and 5% using the ultrasound technique. The vein was entered on the first attempt in 60% of patients using the landmark technique and in 63% using ultrasound (P>0.05). Mean attempts for puncture were 1.9 (anatomical) vs 1.6 (ultrasound-guided) (P>0.05). Complications occurred in 20% of cases using anatomical landmarks and in 5% using ultrasound (P>0.05). The average access time was 26.5 seconds by the anatomical approach and 56 seconds by the ultrasound approach (P< 0.05). CONCLUSIONS: Ultrasound-guided cannulation of the internal jugular vein did not significantly decrease failure rate, access time, complications, and attempts for puncture, nor did it increase the amount of successful first attempts. However an investigation using a larger number of patients will be needed.

Postanesthetic Complications of Outpatient Surgery / 대한마취과학회지

BACKGROUND: Outpatient surgery has grown in many hospitals. This rapid recently been on the increase in ambulatory surgery would not have been possible without the changing role of the anesthesiolosist and the development of new and short-acting anesthetic drugs. Specific care and knowledge are required for outpatient anesthesia. The aim of this study was to review the clinical experiences of postanesthetic patients at the Oneday Surgery Center (OSC). METHODS: We reviewed the 720 records of the recovery unit in OSC and the 620 records of telephone interviewers? after discharge from January to December 1997. The PACU Record contained Aldrete scores and discharge summaies (about such things as vital signs, alertness and orientation, dizziness, nausea and vomiting, pain, the state of the neurovascular system, the ability to ambulate or dress, voiding, oral intake, etc). Records of telephone interviewers? after discharge contained questionnaires about wound status, limitations a activity and other abnormal symptoms relating to feeding, nausea and vomiting, pain, and medications. RESULTS: The most largest percentages of parameters of patients were below 10 years of age; They had undergone general anesthesia in method, and Herniorraphies. All the patients achieved Alderete score of 7 10 on arrival at the First recovery unit (1st RU) in OSC and achieved 10 points within an hour, when they were transfered to the Second recovery unit (Comfortable room). 41 (5.4%) patients suffered from nausea or vomiting in the Recovery unit. One (0.1%) patient had nausea or vomiting and 5 (0.7%) patients had pain at discharge. The mean durations of stay at the 1st RU and Comfortable room were 90 min and 240 min respectively. Records of telephone visits after discharge showed that 30 (4.8%) patients had nausea or vomiting and 27 (4.3%) patients had postoperative pain after discharge. 20 patients (3.2%) had abnormal symptoms (e.g., fever, coughing, dysuria, epistaxis). There were no limitations in activities or feeding. CONCLUSIONS: For the assurance of a rapid and complication-free recovery in the increasings needed ambulatory surgery, much effort is reguired to increase its quality and safety.

Postanesthetic Complications of Outpatient Surgery / 대한마취과학회지

BACKGROUND: Outpatient surgery has grown in many hospitals. This rapid recently been on the increase in ambulatory surgery would not have been possible without the changing role of the anesthesiolosist and the development of new and short-acting anesthetic drugs. Specific care and knowledge are required for outpatient anesthesia. The aim of this study was to review the clinical experiences of postanesthetic patients at the Oneday Surgery Center (OSC). METHODS: We reviewed the 720 records of the recovery unit in OSC and the 620 records of telephone interviewers? after discharge from January to December 1997. The PACU Record contained Aldrete scores and discharge summaies (about such things as vital signs, alertness and orientation, dizziness, nausea and vomiting, pain, the state of the neurovascular system, the ability to ambulate or dress, voiding, oral intake, etc). Records of telephone interviewers? after discharge contained questionnaires about wound status, limitations a activity and other abnormal symptoms relating to feeding, nausea and vomiting, pain, and medications. RESULTS: The most largest percentages of parameters of patients were below 10 years of age; They had undergone general anesthesia in method, and Herniorraphies. All the patients achieved Alderete score of 7 10 on arrival at the First recovery unit (1st RU) in OSC and achieved 10 points within an hour, when they were transfered to the Second recovery unit (Comfortable room). 41 (5.4%) patients suffered from nausea or vomiting in the Recovery unit. One (0.1%) patient had nausea or vomiting and 5 (0.7%) patients had pain at discharge. The mean durations of stay at the 1st RU and Comfortable room were 90 min and 240 min respectively. Records of telephone visits after discharge showed that 30 (4.8%) patients had nausea or vomiting and 27 (4.3%) patients had postoperative pain after discharge. 20 patients (3.2%) had abnormal symptoms (e.g., fever, coughing, dysuria, epistaxis). There were no limitations in activities or feeding. CONCLUSIONS: For the assurance of a rapid and complication-free recovery in the increasings needed ambulatory surgery, much effort is reguired to increase its quality and safety.