Morphologic changes in the spinal cord following intrathecal palonosetron-HCl injection in rats

BACKGROUND: Intravenous palonosetron-HCl, a second-generation antagonist of selective serotonin type 3 (5-HT3) receptors, can prevent chemotherapy-induced nausea and vomiting (CINV) and postoperative nausea and vomiting (PONV). 5-HT3 receptors are abundant in the lower brainstem and the substantia gelatinosa of the spinal cord, which provides a theoretical rationale for neuraxial administration of 5-HT3 receptor antagonists for CINV, PONV, and opioid-induced nausea and vomiting. However, there are no reports of neuraxial administration of palonosetron-HCl. Before neuraxial administration of a drug is accepted for clinical use, its safety must be proven. This study was conducted to determine whether neuraxial administration of palonosetron-HCl produces neurologic injury. METHODS: Male Sprague-Dawley rats under general anesthesia were catheterized intrathecally and the catheter tip was advanced caudally to the L1 vertebra. After 7 days, 20 µl of normal saline (N group, n = 6) or 20 µl (1 µg) of palonosetron-HCl (P group, n = 6) were injected intrathecally once per day for 2 weeks. Neurotoxic changes were evaluated by light microscopy (LM) and electron microscopy (EM) of the spinal cord. Behavioral changes were also evaluated in both groups. RESULTS: One of the N group rats and three of the P group rats demonstrated abnormal behavior during intrathecal drug injection, but otherwise their behavior was normal. The spinal cords of the N group did not have any abnormal findings by LM or EM. The spinal cords of the P group had multiple vacuoles in the white matter by LM, especially in the dorsal funiculus, and EM revealed myelin, axonal, and mitochondrial swelling. CONCLUSIONS: Results suggest that chronic intrathecal administration of palonosetron-HCl produced microscopic morphologic changes in the spinal cords of rats.

Erratum: Efficacy of noninvasive pulse co-oximetry as compared to invasive laboratory-based hemoglobin measurement during spinal anesthesia

We have corrected the subject area.

Efficacy of noninvasive pulse co-oximetry as compared to invasive laboratory-based hemoglobin measurement during spinal anesthesia

BACKGROUND: The Masimo Radical 7 (Masimo Corp., Irvine, CA, USA) pulse co-oximeter(R) noninvasively determines the hemoglobin concentration using the principle of transcutaneous spectrophotometry. We compared hemoglobin levels determined using this device (SpHb) with those determined using an invasive laboratory-based technique (tHb) during spinal anesthesia. METHODS: Thirty patients received spinal anesthesia with 0.5% hyperbaric bupivacaine. The pulse co-oximeter probe was mounted on the second toe, and arterial blood samples were obtained from a radial artery catheter. SpHb, tHb, and perfusion index (PI) values were recorded before and 20 and 40 min after intrathecal injection of bupivacaine. RESULTS: Before spinal anesthesia, the SpHb and tHb showed a significant difference of -2.86 +/- 1.56 g/dl (P < 0.005), but no significant differences were found between tHb and SpHb at 20 and 40 min after spinal anesthesia (-0.16 +/- 2.45 g/dl and 0.29 +/- 2.68 g/dl). Additionally, PI was significantly increased at 20 and 40 min after spinal anesthesia compared to the pre-anesthetic value (P < 0.001). CONCLUSIONS: The toe is not the monitoring site for pulse co-oximetry in adult patients, but the pulse co-oximetry on the toe appears to be appropriate as a noninvasive hemoglobin monitoring device after spinal anesthesia.

Postoperative Urinary Retention Following Anterior Cervical Spine Surgery for Degenerative Cervical Disc Diseases

BACKGROUND: Postoperative urinary retention (POUR) may cause bladder dysfunction, urinary tract infection, and catheter-related complications. It is important to be aware and to be able to identify patients at risk of developing POUR. However, there has been no study that has investigated the incidence and risk factors for the development of POUR following anterior cervical spine surgery for degenerative cervical disc disease. METHODS: We included 325 patients (164 male and 161 female), who underwent anterior cervical spine surgery for cervical radiculopathy or myelopathy due to primary cervical disc herniation and/or spondylosis, in the study. We did not perform en bloc catheterization in our patients before the operation. RESULTS: There were 36 patients (27 male and 9 female) that developed POUR with an overall incidence of 11.1%. The mean numbers of postoperative in-and-out catheterizations was 1.6 times and mean urine output was 717.7 mL. Thirteen out of 36 POUR patients (36%) underwent indwelling catheterization for a mean 4.3 days after catheterization for in-and-out surgery, because of persisting POUR. Seven out of 36 POUR patients (19%) were treated for voiding difficulty, urinary tract irritation, or infection. Chi-square test showed that patients who were male, had diabetes mellitus, benign prostate hypertrophy or myelopathy, or used Demerol were at higher risk of developing POUR. The mean age of POUR patients was higher than non-POUR patients (68.5 years vs. 50.8 years, p < 0.01). CONCLUSIONS: To avoid POUR and related complications as a result of anterior cervical spine surgery for degenerative cervical disc disease, we recommend that a catheter be placed selectively before the operation in at-risk patients, the elderly in particular, male gender, diabetes mellitus, benign prostate hypertrophy, and myelopathy. We recommend that Demerol not be used for postoperative pain control.

Cardiopulmonary bypass weaning difficulty due to anomalous origin of coronary artery: A case report / 대한마취과학회지

We report a case of hemodynamic instability after aortic valve replacement, due to the anomalous origin of the right coronary artery. During the cardiopulmonary bypass weaning process, hemodynamic instability occurred. The cause was not identified at first, and compression of the anomalous right coronary artery was thought to be the culprit, thereafter.

Urgent craniectomy for subdural hematoma in the 8-month-old infant with unrecognized hemophilia B / 대한마취과학회지

No abstract available.

Anesthetic management with propofol/remifentanil target controlled infusion for awake craniotomy: A case report

Awake craniotomy is indicated for tumor resection involving eloquent cortex. It allows the operator to perform appropriate cortical mapping during surgery and facilitate maximum tumor resection while minimizing neurologic deficit. Therefore anesthesia should provide adequate analgesia and sedation but also importantly a full consciousness and cooperation for neurologic testing. This case reports the use of target-controlled infusion (TCI) and monitoring of sedation and anesthetic depth through bispectral index (BIS), providing good control of sedation and analgesia to meet frequent changes throughout the different levels of the procedure while maintaining good condition for intraoperative brain mapping. We propose that TCI of propofol and remifentanil in combination may be a useful alternative for awake craniotomy requiring intraoperative brain mapping surgery.

The optimal concentrations of propofol at eye opening and orientation after propofol-remifentanil TCI in Koreans

BACKGROUND: The recovery time in propofol target controlled infusion (TCI) can be determined by the context sensitive decrement time (CSDT) using a Multichannel TCI system. Therefore, it is important to obtain the default CSDT in a Multichannel TCI system. The effect-site concentrations for eye opening and orientation in adults after propofol-remifentanil TCI were evaluated according to the CSDT using a Multichannel TCI system. METHODS: After obtaining informed consent and Institutional Review Board approval, 135 ASA Class I or II patients scheduled to undergo elective surgery were divided into 3 groups according to age. The three groups included the following: group 1 (n = 45), 18-19 years; group 2 (n = 45), 30-39 years; and group 3 (n = 45), 40-54 years. The propofol infusion was started at a propofol target effect-site concentration (CeT) of 6microg/ml. Anesthesia was maintained primarily with a propofol CeT of 2.5microg/ml, a remifentanil CeT of 6ng/ml and with 67% nitrous oxide in oxygen. The average effect-site concentrations of propofol at eye opening and orientation in each group were estimated. RESULTS: The average range of the effect-site concentrations of propofol at eye opening and orientation after surgery were 0.9-1.1microg/ml. The range of times to eye opening and orientation after stopping the nitrous oxide and infusion after surgery were 10.9-12.9 min. CONCLUSIONS: The average range of the effect-site concentrations of propofol at eye opening and orientation after propofol-remifentanil TCI in Koreans are 0.9-1.1microg/ml.

The optimal concentrations of propofol at eye opening and orientation after propofol-remifentanil TCI in Koreans

BACKGROUND: The recovery time in propofol target controlled infusion (TCI) can be determined by the context sensitive decrement time (CSDT) using a Multichannel TCI system. Therefore, it is important to obtain the default CSDT in a Multichannel TCI system. The effect-site concentrations for eye opening and orientation in adults after propofol-remifentanil TCI were evaluated according to the CSDT using a Multichannel TCI system. METHODS: After obtaining informed consent and Institutional Review Board approval, 135 ASA Class I or II patients scheduled to undergo elective surgery were divided into 3 groups according to age. The three groups included the following: group 1 (n = 45), 18-19 years; group 2 (n = 45), 30-39 years; and group 3 (n = 45), 40-54 years. The propofol infusion was started at a propofol target effect-site concentration (CeT) of 6microg/ml. Anesthesia was maintained primarily with a propofol CeT of 2.5microg/ml, a remifentanil CeT of 6ng/ml and with 67% nitrous oxide in oxygen. The average effect-site concentrations of propofol at eye opening and orientation in each group were estimated. RESULTS: The average range of the effect-site concentrations of propofol at eye opening and orientation after surgery were 0.9-1.1microg/ml. The range of times to eye opening and orientation after stopping the nitrous oxide and infusion after surgery were 10.9-12.9 min. CONCLUSIONS: The average range of the effect-site concentrations of propofol at eye opening and orientation after propofol-remifentanil TCI in Koreans are 0.9-1.1microg/ml.

How should we monitor pediatric patients with Duchenne muscular dystrophy?: A case report / 대한마취과학회지

Duchenne muscular dystrophy is a hereditary disorder characterized by progressive muscle weakness and contracture, and special care during anesthesia is needed in these patients. Because inhalational anesthetics and succinylcholine can cause fatal results, intravenous anesthetics are commonly used. However, monitorings for the pediatric population are not otherwise specified. We report our experience of a 6 year-old boy that underwent muscle biopsy suspicious of muscle dystrophy under general anesthesia. The patient received midazolam, fentanyl, propofol and a small dose of rocuronium. He was monitored with bispectral index (BIS), acceleromyography (TOF). At the end of surgery, recovery of TOF ratio to 90% was evaluated, followed by injection of pyridostigmine and glycopyrrolate. When reversal of neuromuscular block was confirmed quantitatively and clinically, the patient was extubated and he experienced no complication.

Barotrauma developed during intra-hospital transfer: A case report / 대한마취과학회지

A 74-year-old male patient receiving ventilatory support due to aspiration pneumonia developed bilateral pneumothorax, pneumopericardium, pneumomediastinum, pneumo-retroperitoneum, and subcutaneous emphysema, after manual ventilation while being transferred from the intensive care unit (ICU) to the operating room (OR). These complications were assumed to be secondary to inappropriate manual ventilation of the intubated patient. In addition, it is likely that the possible migration of an already marginally acceptable endotracheal tube (ETT) position during transport was the cause of these complications. Finally, aggravation of a latent pneumothorax might have contributed to these complications.

Effect of ketamine versus thiopental sodium anesthetic induction and a small dose of fentanyl on emergence agitation after sevoflurane anesthesia in children undergoing brief ophthalmic surgery / 대한마취과학회지

BACKGROUND: Emergence agitation (EA) in children after sevoflurane anesthesia is common. The purpose of this study was to compare the incidences of EA between ketamine and thiopental sodium induction in children underwent sevoflurane anesthesia. We also evaluated if a small dose of fentanyl could reduce the incidence of EA. METHODS: The patients who were scheduled for strabismus or entropion surgery were divided into 4 groups. The patients in Groups 1 and 2 were induced anesthesia with ketamine 1.5 mg/kg; those in Groups 3 and 4 were induced with thiopental sodium 5 mg/kg. The patients in Groups 1 and 3 received an injection of fentanyl 1.5 microgram/kg, whereas the patients in Groups 2 and 4 received IV saline of the same volume. Anesthesia was maintained with sevoflurane. The recovery characteristics and EA in recovery room were assessed. RESULTS: The incidence of EA was significantly higher in Groups 2 and 4 and there was no difference between Groups 2 and 4. Group 2 had almost an eleven-fold higher risk of developing EA than did Group 1, and the incidence of EA in Group 4 was sixty-nine-fold higher than that of Group 1. The risk factor for EA was only the kind of medication. Preoperative anxiety had no significant correlation with EA. CONCLUSIONS: The incidence of EA after sevoflurane anesthesia is similar between ketamine and thiopental sodium anesthetic induction in children undergoing pediatric ophthalmic surgery. Also, the addition of a small dose of fentanyl after anesthetic induction decreases the incidence of EA.

Effect of ketamine versus thiopental sodium anesthetic induction and a small dose of fentanyl on emergence agitation after sevoflurane anesthesia in children undergoing brief ophthalmic surgery / 대한마취과학회지

BACKGROUND: Emergence agitation (EA) in children after sevoflurane anesthesia is common. The purpose of this study was to compare the incidences of EA between ketamine and thiopental sodium induction in children underwent sevoflurane anesthesia. We also evaluated if a small dose of fentanyl could reduce the incidence of EA. METHODS: The patients who were scheduled for strabismus or entropion surgery were divided into 4 groups. The patients in Groups 1 and 2 were induced anesthesia with ketamine 1.5 mg/kg; those in Groups 3 and 4 were induced with thiopental sodium 5 mg/kg. The patients in Groups 1 and 3 received an injection of fentanyl 1.5 microgram/kg, whereas the patients in Groups 2 and 4 received IV saline of the same volume. Anesthesia was maintained with sevoflurane. The recovery characteristics and EA in recovery room were assessed. RESULTS: The incidence of EA was significantly higher in Groups 2 and 4 and there was no difference between Groups 2 and 4. Group 2 had almost an eleven-fold higher risk of developing EA than did Group 1, and the incidence of EA in Group 4 was sixty-nine-fold higher than that of Group 1. The risk factor for EA was only the kind of medication. Preoperative anxiety had no significant correlation with EA. CONCLUSIONS: The incidence of EA after sevoflurane anesthesia is similar between ketamine and thiopental sodium anesthetic induction in children undergoing pediatric ophthalmic surgery. Also, the addition of a small dose of fentanyl after anesthetic induction decreases the incidence of EA.

Management of tracheal compression that's caused by an innominate artery aneurysm: A case report / 대한마취과학회지

An aneurysm of the innominate artery could compress the tracheal lumen, and this requires special care. Intubation without intensive monitoring and antihypertensive agents could aggravate the hypercapnia and completely rupture the aneurysm. There are few reports on the airway management of tracheal compression that's caused by an innominate artery aneurysm. We report here on a patient who had a severe hypercapnia after endotracheal intubation above the stenotic area of the tracheal compression, which was caused by an artery aneurysm. Permissive hypercapnia was inadvertently enforced without our knowledge, but the patient recovered without any neurologic problems.

The impact of nasogastric tube placement on the postoperative nausea and vomiting of patients who are undergoing cardiac surgery

BACKGROUND: The incidence of postoperative nausea and vomiting after cardiac surgery is 30-40%.The role of a nasogastric tube for reducing the PONV is still controversial. METHODS: 92 patients who were undergoing cardiac surgery with cardiopulmonary bypass were randomized to a receive nasogastric tube after induction of anesthesia (Group 2) or they were placed in the control group (no nasogastric tube) (Group 1).The patients with a history of gastric/esophageal surgery, esophageal varix, esophageal stricture and/or a history of antiemetic treatment were excluded.Routine fast-track cardiac anesthesia and postoperative care were employed for all the patients.The incidence of PONV was recorded hourly for the first four hours after extubation and then every 4 h afterwards for 24 h.The usage of antiemetics and pain medication was also recorded.The data was analyzed with t-tests and chi-square tests for the continuous variables and the categorical data, respectively.P values < 0.05 were considered statistically significant. RESULTS: The groups were similar with respect to the demographic data, the surgical characteristics and the opioid usage.There was no significant difference in the incidence of PONV and the antiemetic usage between the two groups. CONCLUSIONS: This study showed that placement of a nasogastric tube did not have an impact on the incidence of PONV or the requirements for antiemetics after cardiac surgery.The results of this study do not support the use of a nasogastric tube to reduce PONV after cardiac surgery.

Vaginal Delivery under Epidural Analgesia in a Patient with Takayasu Arteritis : A case report

Takayasu arteritis is a nonspecific chronic inflammatory disease of the aorta and its major branches, which has a higher incidence during the child-bearing years. There have been several reports of Takayasu arteritis during pregnancy with Cesarean delivery under general or epidural anesthesia. However, there have been few reports of successful vaginal delivery under epidural analgesia. We report a case of successful vaginal delivery under epidural analgesia in a 31-year-old primigravida with a history of Takayasu arteritis.

Retropharyngeal Abscess after an Unexpected Difficult Tracheal Intubation: A case report / 대한마취과학회지

A retropharyngeal abscess is a rare complication of tracheal intubation.A case of retropharyngeal abscess after unexpected difficult tracheal intubation is presented with a review of the medical literature.A 45-year-old female patient underwent excision and biopsy of the left false vocal cord mass under general anesthesia with tracheal intubation.There was unexpected difficulty of the tracheal intubation and several trials of intubations were performed.The patient complained of pain on the left side of the neck, a sore throat, dysphagia, and chest discomfort one day postoperatively.The patient had fever of 38.7degrees C.Flexible laryngoscopy, neck X-ray, neck computed tomography, and pharyngoesophagographic studies were performed, which revealed a retropharyngeal abscess.The patient was treated with antibiotics, nil per os, nasogastric tube feeding and underwent surgery for incision and drainage of the retropharyngeal abscess under local anesthesia.The patient recovered without complications, and the patient was discharged 12 days postoperatively.

Effect of Administration Method of Isoflurane on Bispectral Index Values in the Early Period of Cesarean Section: A Comparison of End-Tidal or Vaporizer Concentration using Overpressure / 대한마취과학회지

BACKGROUND: Patients undergoing a cesarean section under general anesthesia are at risk of intraoperative awareness due to the use of low concentration of volatile anesthetics used. This study investigated the effect of different methods for administering isoflurane on the anesthetic adequacy using bispectral index (BIS) in the early period of cesarean section. METHODS: Eighty-two parturients undergoing a cesarean section were randomly assigned to receive 1 vol% isoflurane (Group EQ), 1.5 vol% isoflurane for the first 5 minutes and 1 vol% for the next 5 minutes (Group CO), 0.6 vol% end-tidal isoflurane immediately after intubation (Group ET). Thiopental 4 mg/kg was used to induce anesthesia. The bispectral index value, systolic and diastolic arterial pressure, heart rate and end-tidal concentration of isoflurane were recorded every minute for 10 minutes after intubation. RESULTS: There were no significant differences in the systolic and diastolic pressure, and heart rate between the groups. The BIS values from 1 to 8 minutes after intubation were significantly lower in the ET group than in the EQ group. BIS values from 4 to 8 minutes after intubation were significantly lower in the CO group than in the EQ group. CONCLUSIONS: The administration of volatile anesthetics using the end-tidal concentration after thiopental induction shows the best anesthetic efficacy in the early period of cesarean section. This method may further reduce the level of intraoperative awareness.

Comparison of Intra-articular versus Intra-venous Patient Controlled Analgesia (PCA) following Arthroscopic Shoulder Surgery / 대한마취과학회지

BACKGROUND: The purpose of this study was to compare the postoperative analgesic effects and side effects of an intra-articular PCA infusion of bupivacaine and morphine using an intravenous PCA infusion of morphine following arthroscopic shoulder surgery. METHODS: Seventy-one patients, undergoing arthroscopic shoulder surgery under general anesthesia, were randomly assigned to one of two groups. In group 1 (n = 32), morphine and ondansetron, 8 and 4 mg, respectively, were intravenously injected following surgery, with the subsequent infusion of normal saline 100 ml, including morphine and ondansetron, 32 and 12 mg, respectively, through an intra-venous PCA catheter. In group 2 (n = 39), 0.25% bupivacaine, 40 ml, including an intra-articular injection of morphine, 3 mg, followed by an infusion of 0.25% bupivacaine, 100 ml, including morphine, 5 mg, were administered through an intra-articular PCA catheter. In groups 1 and 2, the PCA infusion rate was 2 ml/h, with a bolus dose of 0.5 ml, with a lock out time of 8 min. The VAS for pain at rest, and the range of motion (ROM) exercise and side effects were assessed 0.5, 1, 2, 4, 12, 18 and 24 h postoperatively. RESULTS: The patients in group 2 had significantly lower VAS for pain for the ROM than those in group 1 30 min postoperatively. However, the VAS for pain at rest was significantly lower in group 1 than 2 after 18 and 24 h, but the VAS for pain for the ROM was significantly lower in group 1 than 2 24 h postoperatively. There was no significant difference in the side effects between the two groups, with the exception of dizziness, which was more severe in group 2 at 1, 2 and 4 h postoperatively. CONCLUSIONS: An intra-articular PCA infusion of bupivacaine and morphine is no more effective than an intra-venous PCA infusion of morphine and ondansetron with respect to postoperative analgesia and side effects.

Anatomical Investigations for Appropriate Needle Positioning in Thoracic Paravertebral Blockade / 대한마취과학회지

BACKGROUND: Thoracic paravertebral blockade (TPVB) can be effective in many clinical settings. However, many clinicians are reluctant to use this technique due to its adverse effects such as pneumothorax. The aim of this study was estimate the appropriate depth and width for safe needle positioning. METHODS: The depth from skin to the paravertebral space (PVS) and the width from the spinous process (SP) to the PVS and the lateral tip of the transverse process (LTTP) were measured in all available sections from 84 patients examined by chest computed tomography (CT). The correlation between age, gender, body mass index (BMI) and each measured value was analyzed. RESULTS: All 828 sections from the 84 patients aged between 19 and 65 years old were evaluated. The minimum and maximum values of the mean depth from the skin to PVS were 40.3-52.4 mm in men and 41.2-55.9 mm in women. The minimum and maximum values of the mean width from the SP to LTTP were 29.2-34.6 mm in men and 23.7-31.0 mm in women. At every thoracic level, the depth to PVS was similar in both genders but the width from the SP to the NEP in men was significantly higher than in women. Weight significantly influenced the width from the SP to LTTP in men but height and BMI did not. Also weight and BMI significantly influenced the depth from skin to PVS in almost all of the thoracic region at both sex, but height did not influence the depth from skin to PVS in both sex. CONCLUSIONS: We report clinically useful estimates that may be used to help avoid side effects such as pneumothorax and achieve a successful thoracic paravertebral blockade.