Comparison of 2 effect-site concentrations of remifentanil with midazolam during transrectal ultrasound-guided prostate biopsy under procedural analgesia and sedation: A randomized controlled study.

BACKGROUND: Until now, target-controlled infusion of remifentanil with midazolam for transrectal ultrasound-guided prostate biopsy has not been described. Here, we investigate 2 effect-site concentrations of remifentanil with intermittent bolus midazolam for transrectal ultrasound-guided prostate biopsy under procedural analgesia and sedation. METHODS: A prospective, randomized controlled trial including patients who received a transrectal ultrasound-guided prostate biopsy between February 2019 and January 2021 was conducted. Group 1 and Group 2 were respectively administered an initial effect-site concentration of remifentanil of 1.0 ng/mL and 2.0 ng/mL by a target-controlled infusion pump with Minto model. In both groups, maintenance of the effect-site concentration of remifentanil was adjusted upward and downward by 0.5 ng/mL to keep patient comfort with acceptable pain (remaining moveless), and mean arterial pressure and heart rate within baseline levels ±â€…30%, and using intermittent bolus midazolam to keep the Observer's Assessment of Alertness/Sedation scale between 2 and 4. The primary outcome was to determine which effect-site concentration of remifentanil provide adequate patient comfort with acceptable pain (remaining moveless) during the procedure. RESULTS: A total of 40 patients in Group 1 and 40 patients in Group 2 were eligible for analysis. Most parameters were insignificantly different between Group 1 and Group 2, except Group 1 having higher peripheral oxygen saturation while probe insertion compared with Group 2. Group 2 patients had less intraoperative movements affecting the procedure (2 vs 18; P < .001), and less total times of target-controlled infusion pump adjustment (0 [0-1] vs 1 [0-3], P < .001) compared with group 1. However, group 1 patients had less apnea with desaturation (peripheral oxygen saturation < 90%; 0 vs 9, P = .002) and less remifentanil consumption (94.9 ±â€…25.5 µg vs 106.2 ±â€…21.2 µg, P = .034) compared to Group 2. CONCLUSION: In transrectal ultrasound-guided prostate biopsy, target-controlled infusion with remifentanil Minto model target 2.0 ng/mL with 3 to 4 mg midazolam use provided sufficient analgesia and sedation, and appropriate hemodynamic and respiratory conditions.

The Occurrence of Pain-Induced Depression Is Different between Rat Models of Inflammatory and Neuropathic Pain.

Various pain conditions may be associated with depressed mood. However, the effect of inflammatory or neuropathic pain on depression-like behavior and its associated time frame has not been well established in rat models. This frontward study investigated the differences in pain behavior, depression-like behavior, and serotonin transporter (SERT) distribution in the brain between rats subjected to spared nerve injury (SNI)-induced neuropathic pain or complete Freund's adjuvant (CFA)-induced inflammatory pain. A dynamic plantar aesthesiometer and an acetone spray test were used to evaluate mechanical and cold allodynia responses, and depression-like behavior was examined using a forced swimming test and sucrose preference test. We also investigated SERT expression by using positron emission tomography. We found that the inflammation-induced pain was less severe than neuropathic pain from days 3 to 28 after induced pain; however, the CFA-injected rats exhibited more noticeable depression-like behavior and had significantly reduced SERT expression in the brain regions (thalamus and striatum) at an early stage (on days 14, 21, and 28 in two groups of CFA-injected rats versus day 28 in SNI rats). We speculated that not only the pain response after initial injury but also the subsequent neuroinflammation may have been the crucial factors influencing depression-like behavior in rats.

Postoperative Drip-Infusion of Remifentanil Reduces Postoperative Pain-A Retrospective Observative Study.

Development of remifentanil-induced hyperalgesia (RIH) postoperatively is an unpleasant experience that requires further treatment. This study assessed the effects of gradual withdrawal combined with drip infusion of remifentanil on postoperative pain and the requirement for rescue analgesics. A total of 559 patients receiving total intravenous anesthesia with propofol and remifentanil were enrolled. All patients either underwent gradual withdrawal of remifentanil (GWR) or gradual withdrawal combined with drip infusion (GWDR) with a dose of 1 mcg·kg-1 for 30 min after extubation. The numeric rating scale (NRS) and the requirement of rescue analgesics were assessed. The requirement for rescue analgesics was significantly lower in the GWDR group than in the GWR group (13.2% vs. 35.7%; p < 0.001). At the post-anesthetic care unit (PACU), patients in the GWDR group had a lower NRS pain score (p < 0.001). In addition, in the postoperative 2nd hour, patients in the GWDR group had a significantly lower NRS than the GWR group (beta, -0.31; p = 0.003). No remifentanil-related adverse effects were observed. We found that gradual withdrawal combined with drip infusion of remifentanil required less rescue analgesics and reduced pain scores. The new way of remifentanil administration may be effective to prevent RIH.

Comparison of 2 effect-site concentrations of remifentanil with midazolam during percutaneous transluminal balloon angioplasty under monitored anesthesia care: A randomized controlled study.

BACKGROUND: Until now, target-controlled infusion of remifentanil with midazolam in percutaneous transluminal balloon angioplasty for dysfunctional hemodialysis fistulas has not been described. Here, we investigate 2 effect-site concentrations of remifentanil with intermittent bolus midazolam for percutaneous transluminal balloon angioplasty under monitored anesthesia care. METHODS: A prospective, randomized controlled trial including patients who received a percutaneous transluminal balloon angioplasty between March 2019 and March 2021 was conducted. Group 1 and Group 2 were, respectively, administered an initial effect-site concentration of remifentanil of 1.0 and 2.0 ng/mL by a target-controlled infusion pump with Minto model. In both groups, maintenance of the effect-site concentration of remifentanil was adjusted upward and downward by 0.5 ng/mL with intermittent bolus midazolam to keep the Observer's Assessment of Alertness/Sedation scale between 2 and 4, mean arterial pressure and heart rate at baseline levels ±â€Š30%, and patient comfort (remaining moveless). The primary outcome was to determine the appropriate effect-site concentration of remifentanil for the procedure in terms of patient comfort (remaining moveless), hemodynamic conditions, and adverse events. Secondary endpoints included the total dosage of anesthetics and total times of target-controlled infusion pump adjustments. RESULTS: A total of 40 patients in Group 1 and 40 patients in Group 2 were eligible for analysis. Most parameters were insignificantly different between 2 groups, except Group 1 having higher peripheral oxygen saturation, while local anesthetic injection compared with Group 2. In addition, Group 1 patients had less apnea with desaturation (peripheral oxygen saturation < 90%; 0 vs 6, P = .034), less remifentanil consumption (189.65 ±â€Š69.7 vs 243.8 ±â€Š76.1 µg, P = .001), but more intraoperative movements affecting the procedure (14 vs 4; P = .016), total times of target-controlled infusion pump adjustment [2 (1-4) vs 1 (1-2), P < .001] compared with Group 2. CONCLUSION: In percutaneous transluminal balloon angioplasty for dysfunctional hemodialysis fistulas, target-controlled infusion with remifentanil Minto model target 2.0 ng/mL with 3 to 4 mg midazolam use provided appropriate hemodynamic conditions, sufficient sedation and analgesia, and acceptable apnea with desaturation.

Optimal effect-site concentration of propofol for tracheal suctioning during emergence from ophthalmic surgery.

In ophthalmic surgery, coughing during emergence from general anesthesia may have a detrimental effect on intraocular pressure. Tracheal suction during emergence may elicit this reflex. The optimal effect-site concentration (EC) of propofol to prevent triggering of the cough reflex during tracheal suctioning is unknown. The aim of this study is to assess the optimal EC of propofol for tracheal suctioning during emergence in patients undergoing ophthalmic surgery.Twenty-one patients were enrolled, all of them American Society of Anesthesiologists (ASA) physical status I or II non-smokers undergoing ophthalmic surgery. Anesthesia was induced and maintained under total intravenous anesthesia using target-controlled infusion. During emergence from general anesthesia, tracheal suction was performed at different propofol concentrations as required for Dixon's up-and-down method with a step size of 0.2 µg/ml. A propofol concentration at which the cough reflex was not triggered during tracheal suctioning was considered successful.The EC50 of propofol for tracheal suction without cough was 1.4 µg/ml and the EC95 was 1.6 µg/ml.Tracheal suction may be accomplished without triggering the cough reflex when the propofol effect-site concentration is higher than 1.6 µg/ml.

Baicalein attenuates neuropathic pain and improves sciatic nerve function recovery in rats with partial sciatic nerve transection.

BACKGROUND: Modulating the inflammatory response to nerve injury may provide therapeutic opportunities by aborting the neurobiological alterations that support the development of persistent pain. Baicalein, a 12-lipoxygenase inhibitor, has anti-inflammation properties. It also demonstrates anti-inflammatory functions by inhibiting lipopolysaccharide-induced barrier disruption, expression of cell adhesion molecules, and adhesion and migration of leukocytes. The aim of the present study was to assess the possibility of early treatment of neuropathic pain via the systemic injection of baicalein in rats with left partial sciatic nerve transection (PST). METHODS: Wistar rats were divided into Sham, Vehicle, and Baicalein groups. The Vehicle and Baicalein rats underwent PST, whereas the Sham rats were not transected. Baicalein was administered 20 mg/kg/day intraperitoneally for 7 days after PST and after behaviour tests. After PST, rats developed mechanical and cold allodynia, and impaired sciatic nerve function. RESULTS: Baicalein attenuated mechanical and cold allodynia and improved sciatic nerve function after PST. Baicalein significantly inhibited the expression of tumour necrosis factor α (TNF-α), interleukin 6 (IL-6), and IL-1ß on days 14 and 28, and attenuated the activation of astrocytes in the L4-5 spinal cord less than day 28 after PST. CONCLUSION: Our study revealed that early and multiple doses of systemic baicalein attenuated neuropathic pain and improved sciatic nerve function by inhibiting pro-inflammatory cytokine expression and attenuating the activation of astrocytes in the spinal cord.

The Relationship Between Postoperative Pneumonia and Endotracheal Suctioning Under General Anesthesia in Ophthalmic Surgery: A Retrospective Study.

OBJECTIVE: Postoperative pneumonia is the third most common postoperative complication. It may result from aspiration of secretions accumulating in the subglottic space during general anesthesia (GA). However, the relationship between endotracheal suctioning (ETS) during extubation from GA emergence and postoperative pneumonia has not been well investigated. Therefore, the aim of this study was to investigate the effectiveness of ETS during extubation in prevention of postoperative pneumonia in ophthalmic surgery under GA in our medical center from 2011 through 2015. METHODS: Three thousand, seven hundred and ninety-four patients receiving ophthalmic surgery under GA were included and divided into two groups by the anesthesiologists. The first group underwent the conventional ETS during extubation, while the other group was extubated without ETS. The incidences of postoperative pneumonia were compared between the two groups to find the correlation between ETS during extubation and postoperative pneumonia. In addition, other complication such as postoperative hemorrhage was also recorded. RESULTS: Of the 3,794 patients undergoing ophthalmic surgery under GA, 2,187 (58%) patients underwent extubation with ETS, whilst 1,607 (42%) patients were extubated without ETS. The incidence rates of postoperative pneumonia with or without ETS during extubation were both 0%. Besides, the incidence rates of postoperative hemorrhage were also both 0% in two groups. CONCLUSIONS: Extubation from GA without ETS seemed not to increase the risk of postoperative pneumonia. Thus, no routine ETS during extubation seemed not to be a risk factor for postoperative pneumonia under GA in ophthalmic surgery.

Levobuipivacaine-Induced Dissemination of A549 Lung Cancer Cells.

While anaesthetics are frequently used on cancer patients during surgical procedures, their consequence on cancer progression remains to be elucidated. In this study, we sought to investigate the influence of local anesthetics on lung cancer cell dissemination in vitro and in vivo. A549 human non-small lung cancer cells were treated with various local anaesthetics including ropivacaine, lidocaine, levobupivacaine and bupivacaine. Cell barrier property was assessed using an electric cell-substrate impedance sensing (ECIS) system. The epithelial-to-mesenchymal transition (EMT) of treated cells was studied by immunofluorescence staining. In vitro and in vivo cancer cell dissemination were investigated.Gene expression microarray and quantitative real-time PCR (qrt-PCR) assays were used to identify the genes responsible for levobupivacaine-mediated cancer cell dissemination.The results illustrated that only levobupivacaine induced EMT in the treated cells and also caused the dissemination of cancer cells in vitro. In addition, after intravenous injection, levobupivacaine encouraged cancer cell dissemination in vivo. Gene expression microarray, qrt-PCR and immunoblotting revealed that after levobupivacaine treatment, the hypoxia-inducible factor (HIF)- 2α gene was upregulated in cancer cells. Our findings suggest that levobupivacaine may induce A549 lung cancer cell dissemination both in vitro and in vivo. More specifically, HIF-2α signaling possibly contributes to levobupivacaine-mediated A549 lung cancer cell dissemination.

Faster extubation time with more stable hemodynamics during extubation and shorter total surgical suite time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in lengthy lumbar spine surgery.

OBJECT Anesthesia techniques can contribute to the reduction of anesthesia-controlled time and may therefore improve operating room efficiency. However, little is known about the difference in anesthesia-controlled time between propofol-based total intravenous anesthesia (TIVA) and desflurane (DES) anesthesia techniques for prolonged lumbar spine surgery under general anesthesia. METHODS A retrospective analysis was conducted using hospital databases to compare the anesthesia-controlled time of lengthy (surgical time > 180 minutes) lumbar spine surgery in patients receiving either TIVA via target-controlled infusion (TCI) with propofol/fentanyl or DES/fentanyl-based anesthesia, between January 2009 and December 2011. A variety of time intervals (surgical time, anesthesia time, extubation time, time in the operating room, postanesthesia care unit [PACU] length of stay, and total surgical suite time) comprising perioperative hemodynamic variables were compared between the 2 anesthesia techniques. RESULTS Data from 581 patients were included in the analysis; 307 patients received TIVA and 274 received DES anesthesia. The extubation time was faster (12.4 ± 5.3 vs 7.0 ± 4.5 minutes, p < 0.001), and the time in operating room and total surgical suite time was shorter in the TIVA group than in the DES group (326.5 ± 57.2 vs 338.4 ± 69.4 minutes, p = 0.025; and 402.6 ± 60.2 vs 414.4 ± 71.7 minutes, p = 0.033, respectively). However, there was no statistically significant difference in PACU length of stay between the groups. Heart rate and mean arterial blood pressure were more stable during extubation in the TIVA group than in the DES group. CONCLUSIONS Utilization of TIVA reduced the mean time to extubation and total surgical suite time by 5.4 minutes and 11.8 minutes, respectively, and produced more stable hemodynamics during extubation compared with the use of DES anesthesia in lengthy lumbar spine surgery.

Rosiglitazone attenuates cerebral vasospasm and provides neuroprotection in an experimental rat model of subarachnoid hemorrhage.

BACKGROUND: Glutamate and oxidative stress play important roles after subarachnoid hemorrhage (SAH). The ability to modulate glutamate transporter 1 (GLT-1) and the antioxidative effect of rosiglitazone have been demonstrated. We investigated the neuroprotective effect of rosiglitazone after SAH. METHODS: SAH was induced by double blood injection. The rats were randomly divided into sham, SAH + vehicle, and SAH + rosiglitazone groups and treated with dimethyl sulfoxide, dimethyl sulfoxide, and 6 mg/kg of rosiglitazone, respectively, at 2 and 12 h after SAH induction and then daily for 6 days. Cerebrospinal fluid dialysates were collected 30 min before SAH induction and then daily for 7 days for glutamate measurement. Mortality, body weight, and neurological scores were also measured daily. On day 7 after SAH, the wall thickness and the perimeter of the basilar artery (BA), neuron variability, GLT-1 levels, glial fibrillary acidic protein (GFAP) expression and activity, and malondialdehyde, superoxide dismutase, and catalase activities were also evaluated. RESULTS: Rosiglitazone improved survival (relative risk = 0.325) and neurological functions and reduced neuronal degeneration (5.7 ± 0.8 vs. 10.0 ± 0.9; P < 0.001) compared with the SAH + vehicle group. Rosiglitazone also lowered glutamate levels by 43.5-fold and upregulated GLT-1 expression by 1.5-fold and astrocyte activity by 1.8-fold compared with the SAH + vehicle group. The increase in BA wall thickness was significantly attenuated by rosiglitazone, whereas the perimeter of the BA was increased. In addition, rosiglitazone abated the 1.9-fold increase in malondialdehyde levels and the 1.6-fold increase in catalase activity after SAH. CONCLUSION: Rosiglitazone reduced SAH mortality, neurological deficits, body weight loss, GFAP loss, and cerebral vasospasm by preventing the neurotoxicity induced by glutamate and oxidative stress.

Review of aneurysmal subarachnoid hemorrhage--focus on treatment, anesthesia, cerebral vasospasm prophylaxis, and therapy.

Aneurysmal subarachnoid hemorrhage (aSAH) is a serious and debilitating condition that leads to the development of many complications, which are followed by mortality and morbidity. As anesthesiologists, we may require to manage aSAH at various settings such as in the perioperative period or in a nonoperative setting such as the neuroradiology suite for diagnostic and therapeutic interventions. Therefore, it is important to understand the pathophysiology of aSAH and anesthetic management for operations and interventions. For decades, early brain injury and cerebral vasospasm have played major roles in the outcome following aSAH. The purpose of this article is to review recent advances and future perspectives in the treatment of aSAH, early brain injury, and cerebral vasospasm.

Attenuation of neurological injury with early baicalein treatment following subarachnoid hemorrhage in rats.

OBJECT: Baicalein has been shown to offer neuroprotection in the ischemic brain, but its effect in subarachnoid hemorrhage (SAH) is unknown. The authors used a double-hemorrhage model to study the role of early baicalein treatment in SAH. METHODS: Subarachnoid hemorrhage was induced in male Wistar rats through a repeat injection of autologous blood at a 48-hour interval. Rats subjected or not subjected to SAH received a 30-mg/kg baicalein injection 3 hours after SAH and daily for 6 consecutive days, and results were compared with those obtained in vehicle-treated control rats. Mortality of the rats was recorded. Neurological outcome was assessed daily. Cerebrospinal fluid dialysates were collected and examined for glutamate concentrations. Cerebral vasospasm (CVS), brain water content, neuron variability, expression of glutamate transporter-1 (GLT-1), immunoreactivity of astrocyte, and level of malondialdehyde, activities of superoxide dismutase (SOD), and catalase in brain tissues content were determined on post-SAH Day 7. RESULTS: Mortality rate, neuronal degeneration, brain water content, and CVS were decreased and neurological function improved in the baicalein-treated rats. Baicalein increased astrocyte activity and preserved GLT-1, which attenuated the glutamate surge after SAH. Baicalein also provided antioxidative stress by preserving activities of SOD and catalase and decreased malondialdehydelevel after SAH. The glutamate, body weight, neurological scores, and glial fibrillary acidic protein activity were significantly correlated. The CVS was correlated with neuronal degeneration, and GLT-1 was correlated with oxidative stress. CONCLUSIONS: Early baicalein treatment attenuated CVS and limited neurological injury following SAH. These data may indicate clinical utility for baicalein as an adjunct therapy to reduce brain injury and improve patient outcomes.

Priming dose of intravenous rocuronium suppresses fentanyl-induced coughing.

OBJECTIVES: An intravenous bolus of fentanyl often induces a cough reflex. This study investigates whether priming with rocuronium can effectively attenuate fentanyl-induced coughing. METHODS: The study involved 260 participants, aged between 18 and 80 years of age, who were undergoing various elective surgeries. They were randomly assigned to two groups. Patients in the study group (the rocuronium group) were treated with intravenous (IV) 0.06 mg/kg rocuronium, whereas those in the control group were treated with the same volume of normal saline. Fentanyl (1.5 µg/kg IV, given over 2 seconds) was administered 30 seconds after the injection of rocuronium or normal saline. We recorded the number of coughs for 1 minute after the fentanyl injection. RESULTS: Patients in the rocuronium group showed a significantly lower incidence of coughing (8.5% vs. 23.1%, in the control group; p < 0.05) and a milder severity of cough in comparison with the patients in the control group. CONCLUSION: Pretreatment with IV rocuronium (0.06 mg/kg) suppressed the cough reflex induced by fentanyl. Therefore, priming with rocuronium may be a clinically useful method for preventing fentanyl-induced cough.

Comparison between intraoperative fentanyl and tramadol to improve quality of emergence.

BACKGROUND: Cough causes poor quality of emergence from anesthesia and risks of several complications. We compared fentanyl and an antitussive action of tramadol on the quality of emergence and postoperative outcome. METHODS: A total of 110 adults (18 to 83 y) of American Society of Anesthesiologists physical status I-III undergoing elective lumbar microdiscectomy with intubated total intravenous anesthesia were randomly divided into 2 groups of 55 each. The patients assigned to the fentanyl group received a dose of 1 µg/kg of fentanyl, whereas those assigned to the tramadol group received 1 mg/kg of tramadol, at the beginning of skin closure. We recorded the incidence of cough, quality of extubation at fixed times, maximal heart rates, maximal blood pressure during emergence, postoperative pain scores, and consumption of fentanyl. In addition, postoperative sore throat (POST), hoarseness, postoperative nausea and vomiting, and other anesthetic and surgical-related complications were recorded. RESULTS: Tramadol reduced cough incidence, improved extubation quality, and provided more stable hemodynamics during emergence. There was no significant difference in postoperative pain, fentanyl consumption, incidence and severity of POST, hoarseness, and postoperative nausea and vomiting between groups. Moreover, we found that the incidence of POST did not correlate with cough incidence. CONCLUSIONS: A dose of 1 mg/kg of tramadol administered intravenously 30 minutes before the expected extubation, compared with 1 µg/kg of fentanyl, decreased cough incidence, improved emergence quality, and provided stable hemodynamics. However, there was no significant difference between tramadol and fentanyl in pain scores and fentanyl consumption postoperatively.

Comparison of A-line autoregressive index and observer assessment of alertness/sedation scale for monitored anesthesia care with target-controlled infusion of propofol in patients undergoing percutaneous vertebroplasty.

BACKGROUND: Percutaneous vertebroplasty (PV) with monitored anesthesia care (MAC) is a growing trend. Without adequate sedation, patient movement can affect and even interrupt the procedure during MAC. The aim of this study was to compare the performance of the auditory-evoked potential (AEP) index and the Observer Assessment of Alertness/Sedation (OAA/S) scale as indicators of depth of sedation in patients undergoing PV. METHODS: Two hundred and twenty patients in ASA II to III, aged 43 to 92 years, undergoing elective PV with MAC, were randomly allocated to the AEP or the OAA/S group (n = 110 each). Initially, all patients received 1 µg/kg of fentanyl and 0.02 mg/kg of midazolam intravenously and sedation with a target-controlled infusion (TCI) of propofol at a target concentration of 1.2 µg/mL. The concentration for the propofol TCI was adjusted in 0.2 µg/mL increments or decrements according to the A-Line autoregressive index (AAI) or the OAA/S scale. A blinded study nurse recorded the measured parameters. RESULTS: Some parameters were significantly different in the AEP group compared with the OAA/S group: lower AAI, lower OAA/S score, lower respiratory rates, and higher end-tidal carbon dioxide pressure were noted from local anesthetic infiltration to bone cement implantation, fewer patients whose movements affected the procedure (10 vs. 36, respectively, P < 0.001), and more adjustments of TCI (twice vs. once, respectively, P < 0.006). The surgeons' satisfaction was greater for the AEP group than for the OAA/S group. CONCLUSIONS: TCI propofol with AEP monitoring can provide less patient movement, better sedation, and higher surgeon satisfaction in patients during prone-position PV procedures than can TCI propofol with OAA/S monitoring.

Changes in regional cerebral blood flow and three-phase bone scan after repeated somatic nerve blocks for sympathetically independent pain.

OBJECTIVE: The pathophysiology of complex regional pain syndrome type 1 (CRPS 1) correlates with variances in both the peripheral and central nerve system. We attempted to explore the topographic correlation between changes in regional cerebral blood flow (rCBF) and 3-phase bone scans during treatments of a series of somatic nerve blocks. CASE REPORT: The case we present here is a 24-year-old man, who suffered CRPS 1 in his right upper extremity for 4 months, and conservative therapy proved to be ineffectual to him. As he did not respond to stellate ganglion block, the syndrome was regarded as sympathetically independent pain (SIP). However, after administering a series of brachial plexus block and local anesthetics, complete resolution of pain, and restoration of function were manifested. In addition, an increase in rCBF, evidenced by single-photon emission computed tomography (SPECT), and changes in the 3 phase bone scan before and after the nerve block appear to correlate well with the clinical improvement. CONCLUSIONS: The changes in rCBF seem to support the theory that the pathogenesis of CRPS is also related to the central nervous system. Multiple somatic nerve blocks (SNB) not only improved physical function but also reversed the CRPS symptoms, for which we presume that reduced nociceptive input signals led to cortical reorganization.

Subglottic stenosis after thoracotomy--a case report.

Traumatic intubation, reintubation, intubation with endotracheal tube of inappropriate size, and failure to firmly secure the tube may contribute to the development of subglottic stenosis. Systemic factors such as sepsis, hypotension, autoimmune and granulomatous disorders have all been implicated as contributing causes. In addition, a risky circumstance that might be considered important in the development of airway damage is the occurrence of gastreoesophageal reflux (GER), particularly in thoracotomy operations, where the patients are placed in the lateral position. The purpose of this report is to describe a patient who developed subglottic stenosis following a thoracotomy. The possible causes are macrotrauma due to multiple intubations and microtrauma due to inappropriate tube size in the course of anesthesia. Furthermore, GER may worsen mucosal injuries, which may be precipitated by the lateral position.