Showing papers in "Korean Journal of Anesthesiology in 2009"

Laparoscopic cholecystectomy performed under regional anesthesia in patient who had undergone pneumonectomy: A case report.

Abstract: Seventy-one years old, ASA physical status III, male patient underwent laparoscopic cholecystectomy due to acute cholecystitis with gall bladder (GB stone). He had undergone right pneumonectomy nine years ago. Moderate obstructive and restrictive pattern was found on PFT and hypokinesia of apical anterior and septum segments was seen on echocardiography. Due to patient's refusal of receiving general anesthesia, we decided to perform regional anesthesia. Epidural catheter was inserted at 10th thoracic intervertebral space and segmental spinal anesthesia was performed at L2-L3 intervertebral space with 5 mg of hyperbaric bupivacaine 0.5% and 20 ug of fentanyl. A segmental sensory block, extending from T3 through L2 dermatomes, was obtained. Surgery was performed smoothly and uneventfully. Patient discharged from hospital at 3 days after surgery.

Analysis of factors related to patient refusal of spinal anesthesia

Abstract: Background: Spinal anesthesia is a anesthetic technique that can be easily used and practically applied according to patient's preference and physiologic status, surgical procedures and so forth. The purpose of the present study is to analyze factors related to patient refusal of spinal anesthesia, arising from the previous spinal anesthesia experience associated with side effects or unsatisfactory senses after spinal anesthesia. Methods: One hundred ninety four patients undergoing various surgical procedures under spinal anesthesia were enrolled. We made a questionnaire that consisted of examination items and question items, and checked it during spinal anesthesia and about 24 hours after spinal anesthesia. Factors related to patient refusal of spinal anesthesia were analyzed with multiple logistic regression. Results: Thirty one out of 194 patients (16%) rejected to receive spinal anesthesia if they would have chance to have it again. Significant factors associated with refusal of spinal anesthesia were low back pain (P = 0.005), needle type (Quincke) (P = 0.025) and tingling sensation in the lower extremities immediately after spinal anesthesia induction (P=0.003). Low back pain was significantly associated with the number of attempts of spinal block (P = 0.023). Conclusions: Factors related to patient refusal of spinal anesthesia are low back pain, needle type and tingling sensation. Low back pain is related to the number of attempts of spinal block. Practitioners should give patients appropriate information about spinal anesthesia preoperatively and consider using Whitacre needle and avoid multiple attempts of spinal block so as to increase patient's compliance with spinal anesthesia. (Korean J Anesthesiol 2009; 56: 156～61)

Effect of low dose ketamine to prevent remifentanil-induced cough: a randomized, double-blind, placebo controlled trial.

Abstract: Background: A reflex cough is often observed after an intravenous (IV) bolus of remifentanil. Since ketamine was reported to be effective in modulating the cough reflex, this prospective, randomized, double-blind, placebo-controlled study was designed to evaluate the efficacy of pretreatment with ketamine on remifentanil-induced cough. Methods: 320 patients undergoing general anesthesia for elective surgery were randomly allocated into two groups to receive either IV ketamine 0.1 mg/kg (ketamine group, n=156) or 0.9% saline (saline group, n=154) 1 min before administration of remifentanil at a target effect-site concentration of 5 ng/ml. Severity of cough was graded (mild, 1-2; moderate, 3-4; and severe, 5 or ＞5). Results: The overall incidence of cough was significantly higher in the saline group (43/154 patients; 0.28, 95% CI 0.21, 0.36) than that in the ketamine group (18/156 patients; 0.12, 95% CI 0.07, 0.18) (P＜0.001). However, there was no significant difference in the severity and the onset time of cough between the groups. Conclusions: IV ketamine 0.1 mg/kg one minute before remifentanil was effective in suppressing remifentanil-induced cough without affecting the severity and onset time. (Korean J Anesthesiol 2009; 56: 624~7)

Optimizing the dose of intrathecal morphine when combined with continuous 3-in-1 nerve block after total knee replacement.

Abstract: Background: Continuous femoral 3-in-1 block alone is insufficient for the treatment of severe pain after total knee replacement (TKR). Intrathecal (IT) morphine provides effective postoperative analgesia but may result in many side effects. The optimal dose of spinal morphine when combined with continuous 3-in-1 block after TKR is not known. Methods: Patients were randomized to receive IT morphine in five groups (n = 20 per group): 1) 0.0 mg, 2) 0.05 mg, 3) 0.1 mg, 4) 0.15 mg, and 5) 0.2 mg. All patients received continuous 3-in-1 block performed with 20 ml of 0.25% bupivacaine, followed by a continuous infusion of 0.125% bupivacaine at the rate of 2 ml/h plus PCA boluses of 1 ml with a lockout of 10 minutes. The intensity of pain at rest and on movement of the knee was assessed by using a visual analog scale for the first two postoperative days. Results: All treatment groups produced effective pain relief and decreased cumulative femoral PCA bolus use of 0.125% bupivacaine compared with control, respectively (P ＜ 0.05); however, there were no significant differences among the treatment groups. The incidence of vomiting was significantly more frequent with 0.1−0.2 mg IT morphine groups compared with control, respectively (P ＜ 0.05). The rate of administration of antipruritic medication was increased as IT morphine dose increased (P ＜ 0.05). Conclusions: Use of 0.05 mg IT morphine would appear to provide the optimal balance between pain relief and adverse effects following TKR. (Korean J Anesthesiol 2009; 57: 69∼77)

Assessment of cerebral oxygen supply-demand balance by near-infrared spectroscopy during induction of anesthesia in patients undergoing coronary artery bypass graft surgery: comparison of midazolam with propofol

Abstract: Background: Near-infrared spectroscopy (NIRS) continuously measures regional cerebral oxygen saturation (rSO2) noninvasively and has been shown to detect even small changes in cerebral oxygen supply-demand balance. Although widely used, only the effect of midazolam on cerebral blood flow has been studied in humans and evidence is lacking about its effect on cerebral metabolic rate. We therefore evaluated the effect of midazolam on cerebral oxygen supply-demand balance with NIRS. Methods: Sixty patients undergoing elective coronary artery bypass graft surgery were randomly allocated into either midazolam (n = 30) or propofol (n = 30) group. rSO2 was recorded before induction while patients were breathing room air as baseline, after pre-oxygenation with 100% oxygen, after administration of either midazolam or propofol, after completion of administration of sufentanil and after tracheal intubation. Hemodynamic variables including cardiac index and mixed venous oxygen saturation were recorded at the same time points. Results: rSO 2 and hemodynamic variables were similar between the groups throughout the study period. After pre-oxygenation, rSO2 significantly increased compared to baseline in each group, and did not show any additional increase after administration of either midazolam or propofol and sufentanil in both groups. Conclusions: Midazolam preserves cerebral blood flow-metabolism coupling to a similar degree to propofol as assessed by near infrared spectroscopy. (Korean J Anesthesiol 2009; 57: 428∼33)

The effect of remifentanil for reducing myoclonus during induction of anesthesia with etomidate

Abstract: Background: Myoclonic movement is a common problem during induction of anesthesia with etomidate. We investigated the influences of pretreatment with remifentanil on etomidate induced myoclonus. Methods: Ninety ASA class I patients were divided randomly into three groups. Group NS received normal saline 2 ml as placebo (n = 30), group R0.5 and group R1.0 were pretreated with remifentanil 0.5 μg/kg (n = 30) or 1.0 μg/kg (n = 30) 1 minute before induction with etomidate 0.3 mg/kg. Orotracheal intubation was performed after administration of rocuronium 0.5 mg/kg. We assessed the incidence, onset, duration and intensity of myoclonus. Mean arterial pressure (MAP), heart rate (HR) and bispectral index (BIS) were recorded during induction. Results: Twenty five patients developed myoclonus in group NS (83.3%), 3 patients in group R0.5 developed myoclonus (10%), as did 5 patients in group R1.0 (16.7%). Moderate to severe myoclonus of grade 3 and 4 were found 66.7% of patients in group NS, whereas no patients in both remifentanil pretreated groups developed this grade of myoclonus. The duration of myoclonus was reduced significantly in the remifentanil groups: 93.8 ± 59.5 sec in group NS, 49.3 ± 34.9 sec in group R0.5, 36.0 ± 27.0 sec in group R1.0 (P ＜ 0.05). HR was decreased by pretreatment with remifentanil prior to induction, while MAP and HR were decreased after induction with etomidate (P ＜ 0.05). BIS changes were not different among the three groups. The dose dependent differences between the two remifentanil doses were not noticed. Conclusions: Pretreatment with remifentanil significantly reduced the incidence, duration and intensity of etomidate induced myoclonus. (Korean J Anesthesiol 2009; 57: 438∼43)

The variation in risk adjusted mortality of intensive care units.

Abstract: Background: This study aimed to estimate risk adjusted mortality rate in the ICUs (Intensive care units) by APACHE (Acute Physiology And Chronic Health Evaluation) III for revealing the performance variation in ICUs. Methods: This study focused on 1,090 patients in the ICUs of 18 hospitals. For establishing risk adjusted mortality predictive model, logistic regression analysis was performed. APACHE III, surgery experience, admission route, and major disease categories were used as independent variables. The performance of each model was evaluated by c-statistic and goodness-of-fit test of Hosmer-Lemeshow. Using this predictive model, the performance of each ICU was tested as ratio of predictive mortality rate and observed mortality rate. Results: The average observed mortality rate was 24.1%. The model including APACHE III score, admission route, and major disease categories was signified as the fittest one. After risk adjustment, the ratio of predictive mortality rate and observed mortality rate was distributed from 0.49 to 1.55. Conclusions: The variation in risk adjusted mortality among ICUs was wide. The effort to reduce this quality difference is needed. (Korean J Anesthesiol 2009; 57: 698∼703)

The preemptive analgesic effect of ketorolac and propacetamol for adenotonsillectomy in pediatric patients.

Abstract: Background: Both ketorolac and propacetamol are used postoperatively to control mild to moderate pain. This study compared the analgesic efficacy of ketorolac and propacetamol delivered either preoperatively or postoperatively, and assessed the preemptive analgesic effect of ketorolac and propacetamol for adenotonsillectomy. Methods: One hundred and two pediatric patients were divided randomly into four groups. The K1 and P1 groups received ketorolac 1 mg/kg or propacetamol 30 mg/kg after induction, respectively, whereas the K2 and P2 groups received each drug at the end of the operation, respectively. After adenotonsillectomy, we measured the NRS (Numerical Rating Scale), FPS (Faces Pain Scale) and OPS (Objective Pain scale) at 15, 30 and 60 min after arriving at the postanesthesia care unit. Results: There were no significant differences in the NRS, FPS and OPS between K1 and K2 and between P1 and P2 for 60 min after operation at the postanesthesia care unit. Conclusions: These results suggest that both ketorolac (1 mg/kg) and propacetamol (30 mg/kg) have no preemptive analgesic effects during 1 hour after adenotonsillectomy. (Korean J Anesthesiol 2009; 57: 308∼13)

The effect of sequential compression device on hypotension in the sitting position during shoulder arthroscopy; a comparison with elastic stocking

Abstract: Background: The sitting position under general anesthesia is associated with hemodynamic instability. The purpose of this study was to compare the efficacy of a sequential compression device (SCD) with that of elastic stockings (ES) in reducing the incidence of hypotension and other hemodynamic instability in the sitting position during shoulder arthroscopy. Methods: Fifty-one patients undergoing shoulder arthroscopy were randomly assigned into one of three groups to receive no treat- ment (control group, n = 17), SCD (SCD group, n = 17) or ES (ES group, n = 17). Hemodynamic variables were measured 5 min after induction of anesthesia (baseline values), and every 1 min from 1 to 5 min after raising the patient to a 70 o sitting position (T1-5) with the beach-chair. Results: The incidences of hypotension (proportion, 95% CI) were 12/17 (0.71, 0.47−0.87), 5/16 (0.31, 0.14−0.56) and 7/15 (0.47, 0.25− 0.70) in the control, SCD and ES group, respectively. The incidence was significantly lower in the SCD group than that in the control group (P = 0.038). At 1 min after sitting position, mean arterial pressure in the control group was significantly lower than that in the SCD group and it was significantly decreased from the baseline value. Conclusions: SCD could significantly reduce the incidence of hypotension with less hemodynamic instability in the sitting position during shoulder arthroscopy. Although the incidence of hypotension was decreased with the elastic stocking, there was no statistical significance. (Korean J Anesthesiol 2009; 57: 417∼21)

A comparative evaluation of humidifier with heated wire breathing circuit under general anesthesia

Abstract: Background: Dry and cold anesthetic gas deteriorates patient`s respiratory function and body heat balance. We examined whether a humidifier with heated wire circuit might maintain core temperature and humidity of inspired gas in patient undergoing general anesthesia. Methods: We enrolled forty ASA physical status I, II patients under general anesthesia for this study. We allocated the patients randomly into two groups with (experimental group) or without (control group) Humitube(R) anesthesia circuit, which delivered heated and humidified inspired anesthetic gases. We recorded the temperatures and humidity of the inspired gases throughout the surgery. Results: The temperatures and relative humidity of the inspired gases in experimental group were significantly greater compared to control group (36.2±0.9℃, 89.5±4.8% vs. 30.4±1.8℃, 37.9±5.9%, P＜0.05) during anesthesia. The core temperatures in experimental group were significantly greater compared to control group (36.1±0.3℃ vs. 35.7±0.1℃, P＜0.05) during anesthesia. Conclusions: A humidifier with heated wire system for anesthesia breathing circuit is helpful to maintain core temperature and adequate humidity. (Korean J Anesthesiol 2009; 57: 32~7)

Continuous positive airway pressure improves the immediate post-extubation airway patency

Abstract: Background: Endotracheal tube extubation can cause laryngospasm, aspiration, upper airway obstruction and hypoxia. In addition, the risk of pulmonary complication increases during extubation for the patients with a difficult airway or a cervical spine injury. The aim of this study was to exam the effect of continuous positive airway pressure (CPAP) on the post-extubation airway patency and the recovery from anesthesia at the recovery room. Methods: 30 adult patients who were scheduled for spine surgery were randomly allocated into 2 groups depending on the using of CPAP before extubation. Neuromuscular monitoring was performed via accelomyography. Tracheal extubation was performed at a TOF ratio of 70%. The incidence of spontaneous recovery of respiration, without airway manipulation and hypoxia, at the recovery room was measured for each group. The time to get a PAR score of 10 at the recovery room and the discharge time from the recovery room were checked too. Results: The incidence of spontaneous recovery of respiration without airway manipulation was 67% in the CPAP group, which was significantly greater than that of the control group (13%). Yet there was no difference between the CPAP and control groups for the incidence of hypoxia in the recovery room (13% and 20%, respectively). There were also no differences in the time to get a PAR score of 10 at the recovery room and the discharge time from the recovery room. Conclusions: CPAP that is applied for tracheal tube extubation improves the immediate post-extubation airway patency, but it does not reduce the recovery room pulmonary complications and the recovery room discharge time. (Korean J Anesthesiol 2009;57:450∼4)

Comparison of ramosetron plus dexamethasone with ramosetron alone in the prevention of nausea and vomiting after gynecologic laparoscopic surgery

Abstract: Background: Postoperative nausea and vomiting (PONV) is extremely distressing and uncomfortable, and is noted frequently in patients who have undergone gynecologic laparoscopic surgery. In this study, we compared the efficacy of a combination of ramosetron plus dexamethasone and ramosetron alone in reducing of PONV after gynecologic laparoscopic surgery. Methods: Sixty patients who received gynecologic laparoscopic surgery were randomly divided into two groups: the R group (ramosetron 0.3 mg) and RD group (ramosetron 0.3 mg plus dexamethasone 5 mg). Dexamethasone, 5 mg, or saline, 1 ml, was administered randomly before the induction of anesthesia in each group. The two groups received intravenous ramosetron, 0.3 mg, at the end of surgery. General anesthesia was induced using thiopental and rocuronium, and maintained with sevoflurane in nitrous oxide. The incidence and severity of nausea, frequency of vomiting and rescue medication, VAS score, and adverse events were evaluated for 48 hours after the operation. Results: In the first 12 hours after operation, the incidence of PONV in the RD group (33%) was significantly lower than the R group (67%; P ＜ 0.05). However, there were no significant differences between two groups in PONV incidence 12−48 h postoperatively. Adverse events and VAS scores were similar in the two groups. Conclusions: The combination of ramosetron plus dexamethasone is superior to ramosetron alone for prevention of PONV during the first 12 hours after gynecologic laparoscopic surgery. (Korean J Anesthesiol 2009; 56: 169～74)

The prophylactic effect of acupressure (P6) on the postoperative nausea and vomiting in patients underwent thyroidectomy.

Abstract: Background Postoperative nausea and vomiting (PONV) is a common problem in patients recovering from anesthesia and surgery. P6 point is the acupressure point for prevention of postoperative nausea and vomiting. We evaluated the efficacy of acupressure at the P6 point in 94 patients undergoing thyroidectomy in a randomized, prospective and placebo-controlled study. Methods Ninety-four female patients, aged 18 to 60, scheduled for elective thyroidectomy, were randomized to have either placebo band or acupressure band (Sea-Band(R) UK Ltd., Leicestershire, England, UK) applied to the P6 point of both hands before induction of anesthesia. The acupressure bands removed 24 h later. Postoperative nausea and vomiting was evaluated 1, 6 and 24 h following surgery. In addition, the need for rescue antiemetic medication during 24 h was registered. Results The incidence of postoperative nausea was lower in acupressure group at 0-1 h (16.7% vs. 39.1%; P = 0.015) and at 6-24 h (0% vs. 15.2%; P = 0.05). The need for rescue antiemetic medication was also lower at 0-1 h (4.2% vs. 23.9%; P = 0.006), at 1-6 h (6.2% vs. 20.9%; P = 0.039) and at 6-24 h (0% vs. 13%; P = 0.012). Conclusions In patients undergoing thyroidectomy, nausea and need of rescue antiemetic medication were reduced by acupressure at the P6 point.

Usefulness of new technique using a disposable syringe for endotracheal tube cuff inflation.

Abstract: BACKGROUND Risk for injuries resulting from overinflated or underinflated endotracheal tube cuff warrants adequate cuff inflation technique. Thus, this study was designed to measure the actual intracuff pressures obtained by new estimation techniques. METHODS 95 adult surgical patients requiring tracheal intubation were randomized to two groups with respect to the endotracheal tube model: Portex(R) (n = 55) and Euromedical(R) (n = 40). After induction of anesthesia, the cuff was inflated using new estimation techniques with two different syringes: PR10 or PR20 (passive release technique using a 10-ml or 20-ml syringe, respectively). Subsequently, an aneroid manometer was used to measure the actual intracuff pressures. These inflation techniques were repeated two times. A direct cuff measurement range of 25 to 40 cmH2O was used as a reference for optimal intracuff pressure. Size 7.0 mm internal diameter (ID) tubes were used for women and size 7.5 mm ID for men. RESULTS 88 eligible patients were studied: Portex group (n = 50) and Euromedical group (n = 38). With respect to the rate of optimal cuff inflation, PR10 was significantly higher than PR20 in both groups (56% vs. 10% in Portex group; 63.2% vs. 0% in Euromedical group, respectively) (P < 0.05). CONCLUSIONS When direct intracuff measurement is not available, a new method, named "passive release technique" using a 10-ml syringe, is a useful alternative cuff inflation method.

Comparison of volume-control and pressure-control ventilation during one-lung ventilation.

Abstract: Background: We hypothesized that pressure control ventilation allows a more even distribution in the lung and better maintenance of the mean airway pressure than is achieved with volume control ventilation. We try to compare the effect of pressure control ventilation (PC) with that of volume control ventilation without an end-inspiratory pause (VC) during one-lung ventilation (OLV) in an anesthetized, paralyzed patient for performing thoracopic bullectomy of the lung. Methods: We ventilated 20 patients with VC and PC after the insertion of a thoracoscope in continual order for, at least for 15 minutes, for each, VC and PC procedure. At the end of VC and PC, the respiratory mechanics, gasometrics, and hemodynamic parameters were measured and collected. Results: We found no significant differences between VC and PC except for the peak inspiratory airway pressure (PIP), the mean airway pressure and the arterial oxygen partial pressure (PaO2). The PIP was significantly decreased from 27.0 ± 6.0 cmH2O (VC) to 21.8 ± 5.4 cmH2O (PC). The mean airway pressure was significantly increased from 8.6 ± 1.6 cmH2O (VC) to 9.4 ± 2.0 cmH2O (PC), and the PaO2 was significantly increased from 252.9 ± 97.3 mmHg (VC) to 285.2 ± 103.8 mmHg (PC). Conclusions: If PC allows mechanical ventilation with the same tidal volume and respiratory rate as VC during OLV, then PC significantly increases the PaO2 but this is not clinically significant, and the PC significantly decreases the PIP, which induces barotrauma or volutrauma when the PIP is excessively high. (Korean J Anesthesiol 2009; 56: 492～6)

Low dose ketamine reduces the induction of ERK1/2 and CREB signaling protein in a neuropathic pain model of rats

Abstract: Background In addition to causing the loss of voluntary sensory and motor function, spinal cord injury (SCI) often creates a state of central neuropathic pain. Rats given SCI display increases in the activated form of transcription factors ERK 1/2 MAPK and CREB in the spinal cord, which correspond to allodynia in a model of neuropathic pain. This study was conducted to determine if low dose ketamine had an effect on the activation of ERK 1/2 and CREB in the development of neuropathic pain. Methods This study was conducted to evaluate ERK 1/2 and CREB protein in a sham operated (control) group, neuropathic pain and normal saline (NP + NS) group and neuropathic pain and ketamine (NP + Keta) group. To accomplish this, male Sprague-Dawley rats were anesthetized and then subjected to L5-L6 spinal nerve ligation (SNL, neuropathic rats). The total amounts of ERK 1/2 and CREB protein were then assessed by western blot analysis. In addition, changes in the amounts of ERK 1/2 and CREB mRNA were evaluated by RT-PCR. Results There was a significant increase in the amount of ERK 1/2 and CREB in the NP + NS group when compared with the sham group. However, the amount of ERK 1/2 and CREB protein induced due to SNL were significantly reduced by continuous infusion with ketamine in the NP + Keta group. Conclusions The results of this study revealed a positive linkage between NMDA receptors and the ERK-CREB signaling pathway. Therefore, NMDA receptors could be the target of future therapeutic approaches. Additionally, the results of the present study provide additional evidence that low dose ketamine effectively prevents and treats central neuropathic pain following SNL.

Administration of large fluid volumes decreases the incidence of postoperative nausea and vomiting as effectively as ondansetron

Abstract: Background: The possibility that large fluid volumes reduce postoperative nausea and vomiting (PONV) remains unclear due to conflicting data. We examined if administering large fluid volumes to high risk patients would decrease the incidence of PONV and compared the results with ondansetron administration. Methods: Ninety ASA I, II patients who presented for laparoscopic cholecystectomy were randomized to 1 of 3 groups. They received either (group I) 5 ml/kg/hr of Hartmann's solution, (group II) 30 ml/kg/hr of Hartmann's solution or (group III) 4 mg of ondansetron and 5 ml/kg/hr of Hartmann's solution. The incidence of PONV and severity of pain were assessed at 1, 12 and 24 hours postoperatively. Results: The number of PONV episodes was significantly reduced in group II and III compared to group I during the 1−12 hr postoperative period and for total incidence. However, there was no significant difference between group II and III. There were no differences among groups regarding the severity of pain. Conclusions: Intraoperative correction of intravascular volume deficits with 30 ml/kg/hr of Hartmann's solution decreases the incidence of PONV as effectively as administration of ondansetron. (Korean J Anesthesiol 2009; 56: 403～7)

Priming technique can alleviate the withdrawal responses associated with intravenous administration of rocuronium

Abstract: Background: Intravenous injection of rocuronium is associated with withdr awal responses which are attributable to the pain from the injection of rocuronium. Several methods have been proposed to abolish and attenuate rocuronium-induced pain. We hypothesized priming dose of rocuronium could reduce withdrawal responses associated with administering a second large dose of rocuronium for tracheal intubation. We compared the efficacy of the priming dose technique of rocuronium with intravenous lidocaine as a pre-treatment for the prevention of withdrawal responses associated with rocuronium injection. Methods: We recruited 150 patients aged between 18 and 60 years, ASA physical status 1 or 2, who were going to undergo elective surgery requiring general anesthesia. Patients were allocated into three groups. Group C received normal saline, Group L received lidocaine 1 mg/kg, and Group P received rocuronium 0.06 mg/kg 2 minutes before administering a second large dose of rocuronium for tracheal intubation. After the loss of consciousness, rocuronium 0.6 mg/kg was administered intravenously over 10 seconds for tracheal intubation. The withdrawal responses to the injection of rocuronium were evaluated. Results: The incidence of withdrawal responses associated with rocuronium injection for tracheal intubation was 56, 50, 24% in group C, group L, and group P, respectively. The incidence of withdrawal responses was lower in group P than group C and group L, but there was no difference between group L and group C. Conclusions: Priming dose technique is a useful clinical method to alleviate withdrawal responses associated with rocuronium injection. (Korean J Anesthesiol 2009; 56: 628～33)

Difference in Core temperature in response to propofol-remifentanil anesthesia and sevoflurane-remifentanil anesthesia

Abstract: Background: Hypothermia following the induction of anesthesia is caused by core to peripheral redistribution of body heat. It has been reported that propofol causes more severe hypothermia than sevoflurane by inhibiting thermoregulatory vasoconstriction during surgical procedures. Therefore, we evaluated the induction and maintenance of anesthesia with intravenous propofol to determine if it causes more core hypothermia than inhaled sevoflurane. Methods: Forty-five patients who underwent hysterectomy were divided into two groups randomly, a propofol-remifentanil (PR) anesthesia group and a sevoflurane-remifentanil (SR) anesthesia group. Each group was subjected to anesthetic induction with either 1.5 mg/kg propofol or inhalation of 5% sevoflurane, respectively. Anesthesia in the former group was maintained with propofol while it was maintained with sevoflurane in the latter group. Specifically, 6−10 mg/kg/hr propofol, 3 L/min medical air, 2 L/min O2, and 0.25 mg/kg/hr remifentanil were used in the PR group for maintenance, while 1.5 vol% sevoflurane, 3 L/min medical air, 2 L/min O2 and 0.25 mg/kg/hr remifentanil were used for maintenance in the SR group. We measured the core temperature 8 times, prior to induction and 10, 20, 30, 45, 60, 75 and 90 minutes after induction. Results: Core temperatures decreased in both the PR and SR group during surgical operation, but there was no significant difference between the two groups. Conclusions: Anesthesia induced and maintained by propofol did not cause a greater degree of hypothermia than sevoflurane. (Korean J Anesthesiol 2009; 57: 704∼8)

Perioperative pulmonary embolism.

Abstract: Pulmonary thromboembolism (PTE) is a perioperative complication that requires prompt diagnosis and treatment to minimize mortality. Detection of deep vein thrombosis (DVT) suggests the presence of PTE. The clinical presentation of PTE is mainly hemodynamic and gas exchange abnormalities. Diagnostic tools include ventilation/perfusion scan, pulmonary angiography, spiral CT, and echocardiography. Therapeutic options include hemodynamic support with inotropics, anticoagulation, systemic thrombolysis, surgical embolectomy and an inferior vena cava filter. DVT prophylaxis should be considered in all operative patients with high risk. Anesthesiologists should consider the appropriate anticoagulant management before and after surgery to optimize anesthetic choices.

Cardiomyopathy after local infiltration or application of epinephrine for plastic surgery under general anesthesia : Two cases report.

Abstract: Catecholamine-induced cardiomyopathy rarely occurs after local epinephrine infiltration. We experienced two patients with catecholamine induced cardiomyopathies. An 8-yr-old girl was scheduled for closed reduction of a nasal bone fracture. Propofol and rocuronium bromide were used for induction of anesthesia. After induction, lidocaine mixed with epinephrine was infiltrated to the block of supratrochlear and infraorbital nerves. About 10 sec later ventricular tachycardia, hypotension, hypoxemia, and pulmonary edema developed. The other case was a 23-yr-old woman with a nasal bone fracture. Propofol, rocuronium bromide, and fentanyl were used for the induction of anesthesia. After induction, epinephrine-containing wet gauze was packed in the nasal cavity for mucosal shrinkage. About 1 minute later, hypertension, tachycardia, and hypoxemia developed. After each operation, a transthorcic echo-cardiogram revealed hypokynesia of the myocardium.

Risk factors of postoperative delirium following liver transplantation.

Abstract: Background: Postoperative delirium (POD) after liver transplantation is a serious complication. This study investigated the incidence and the risk factors of POD in liver transplantation recipients. Methods: Three hundred and sixty eight adult recipients who had undergone liver transplantation were included. We reviewed medical records and the POD was determined by either psychiatric consultation or established diagnostic criteria. Recipients were divided into two groups according to the occurrence of POD: POD group (n = 150) and non-POD group (n = 218), and risk factors were assessed. Results: One hundred fifty (40.8%) of the 368 recipients developed POD after liver transplantation. History of alcohol consumption and alcoholic liver disease, history of hepatic encephalopathy, preoperative mental status changes, ventilator care, dialysis, hypotension, and ICU care were significantly higher in the POD group. In the preoperative laboratory test, sodium was lower while bilirubin, PT (INR) and MELD score were higher in the POD group. Postoperative variables including dialysis, ventilator care duration, ICU stay, hospital stay, glucose and ammonia were significantly higher in the POD group. Three variables were identified as independent predictors of POD in a multiple regression analysis: history of alcohol consumption (odds ratio, 2.04; 95% confidence interval [CI], 1.12−3.72; P = 0.02), history of hepatic encephalopathy (odds ratio, 2.54; 95% CI, 1.46−4.41, P ＜ 0.01), and MELD score (odds ratio, 1.03; 95% CI, 1.00−1.06; P = 0.02). Conclusions: The development of POD and related morbidity and mortality would be reduced if we identified the recipients with risk factors preoperatively and applied early intervention. (Korean J Anesthesiol 2009; 57: 584∼9)

Acute liver injury after sevoflurane anesthesia: A case report.

Abstract: Halothane, isoflurane and desflurane are metabolized to hepatotoxic trifluoroacetyl proteins. But sevoflurane is metabolized to hexafluoroisopropanol. Hexafluoroisopropanol has a low binding affinity for liver protein and is therefore rapidly converted to glucuronidate that are excreted in the urine. Thus sevoflurane has been considered to have a very low potential for hepatotoxicity. We report a case of a 67 years old woman who developed acute hepatic dysfunction after sevoflurane anesthesia.

Spinal anesthesia during cesarean section in a patient with severe osteogenesis imperfecta - A case report -

Abstract: Obstetric anesthesia in a parturient with severe osteogenesis imperfecta is challenging in many aspects, particularly concerning maternal pathophysiological problems and the technical difficulties of anesthesia. Here, we report a case of successful spinal anesthesia, instead of general or epidural anesthesia, during a cesarean delivery in a patient with severe osteogenesis imperfecta.

Comparison of antiallodynic effect of intrathecal morphine, brimonidine and rilmenidine between neuritis and ligation injury induced neuropathic pain

Abstract: Background: Mechanical allodynia is generally resulted from nerve damage by direct injury or inflammation. Thus, this study was designed to compare the antiallodynic effect of morphine, brimonidine and rilmenidine in two models of neuropathic pain, that is, induced by nerve ligation and neuritis. Methods: Rats were prepared with tight ligation of the L5/L6 spinal nerves (SNL group) or with Freund’s complete adjuvant (FCA) administration evoked sciatic inflammatory neuritis (SIN group). Antiallodynic effects by intrathecal morphine, brimonidine and rilmenidine were measured by applying von Frey filaments to the lesioned hind paw. Thresholds for withdrawal response were assessed and converted to % MPE to obtain an effective dose 50% (ED 50) and a dose response curve. Results: Either SNL group or SIN group showed marked mechanical allodynia in the lesioned hind paw. Antiallodynic effects of morphine were different between two groups. That is ED 50 was 0.16 μg (SIN) and 8.12 μg (SNL), and dose response curve of the SIN group shifted left from that of the SNL group. The difference between SIN and SNL groups was statistically significant (P ＜ 0.05). With the brimonidine or rilmenidine administration, ED 50 s were 0.12 μg (SNL) and 0.37 μg (SIN) and 2.16 μg (SIN) and 11.46 μg (SNL), respectively. And the shift to left of dose response curve from the SNL group is more prominent with rilmenidine administration. Conclusions: These results suggest morphine and rilmenidine showed a better effect on reducing the mechanical allodynia induced by FCA administration. (Korean J Anesthesiol 2009; 56: 425～32)

Prediction of difficult intubation in patients with postburn sternomental contractures: modified onah class.

Abstract: Background: Postburn sternomental contractures cause various changes in mouth, oral cavity, pharynx, larynx and related structures. Although there are many methods to predict difficult intubation, the modified Mallampati test (mMT) and the El-Ganzouri multivariate risk index (EGRI) are popular tests. The authors wanted to com pare modified Onah class with these 2 tests and also explored the possibility that Onah class could be an adequate independent predictor for difficult intubation. Methods: One hundred and nine patients, aged 18 to 60 years of age, scheduled for elective surgery for reconstruction of postburn sternomental contractures were divided according to the modified Onah class. We made assessments prior to general anesthesia with respect to mouth opening, thyromental distance, mMT, neck movement, ability to prognath, body weight, and history of difficult tracheal intubation. The accuracy, specificity, positive and negative predictive values were calculated from the data of the 3 tests, and as the 3 tests were compared with patient’s laryngoscopic view grade according to Cormack and Lehane criteria by using the Chi-square test. Results: The incidence of Cormack and Lehane grade III, IV was 39.4%. Onah class showed significantly higher accuracy, specificity, and positive predictive value than mMT and EGRI. There were significant correlations between modified Onah class 2b, 3 and the Cormack and Lehane grade III, IV. Conclusions: Application of modified Onah class for preoperative prediction of the degree of difficulty with laryngeal visualization can reduce the frequency of both an unanticipated failure to visualize laryngeal structures as well as potential unnecessary interventions related to over-prediction of airway difficulty in patients with postburn sternomental contractures. (Korean J Anesthesiol 2009; 57: 290∼5)

Unilateral vocal cord palsy occurred after difficult endotracheal intubation using intubating laryngeal mask airway: A case report.

Abstract: Airway management is important during general anesthesia. Difficulties with a direct laryngoscopy can be managed successfully in a routine manner using a laryngeal mask airway. A 65-year-old woman was scheduled to undergo gynecologic surgery. After injecting the intravenous induction agents and muscle relaxants, intubation was attempted with a direct laryngoscope. However, the vocal cords could not be observed with only the epiglottis being slightly visible. Although intubation was re-attempted by another anesthesiologist, it failed. Intubation was successfully performed via an intubating laryngeal mask airway (ILMA) after additional 100% oxygen mask ventilation. We report a case of vocal cord palsy subsequent to tracheal extubation after endotracheal intubation via ILMA.

Measuring depth of anesthesia with EEG and ECG in children.

Abstract: Background: Heart rate is tightly controlled by brain. If activity of brain and electroencephalograph (EEG) are changed by anesthetics, electrocardiograph (ECG) might be changed. We investigated whether there is a correlation between EEG and ECG, ECG could replace EEG as a monitor for depth of anesthesia. Methods: We recruited 50 patients, aged 2−8 years. Inspired and expired end-tidal sevoflurane concentrations were held constant at 1.0 or 2.5 vol%, after which ECG and EEG were obtained for 15 minutes. Total power (TP), low-frequency power (LFP), high-frequency power (HFP), approximate entropy (ApEn), and Hurst exponent (H) were calculated from the ECG. The relationship between EEG and ECG indices at the two sevoflurane concentrations was measured by Pearson’s correlation coefficient. Results: As anesthesia deepened, ApEn, H of ECG and beta wave decreased and those of delta and theta increased in 4 channels. In FP2, changes of beta and theta wave were negatively correlated with ApEn and H of ECG (P ＜ 0.05), and changes of delta wave was positively correlated with ApEn (P ＜ 0.05) and H (P ＜ 0.01). In F8, changes of beta and theta wave were negatively correlated with ApEn (P ＜ 0.05) and only theta wave was negatively correlated with H (P ＜ 0.05). In C4, change of delta wave was positively correlated with ApEn (P ＜ 0.001) and H (P ＜ 0.05). Conclusions: EEG and ECG indices are correlated during sevoflurane anesthe sia in children, and ECG-derived indices could possibly be used to monitor depth of anesthesia. (Korean J Anesthesiol 2009; 57: 56∼61)

Phrenic nerve palsy following coracoid infraclavicular brachial plexus block.

Abstract: Various methods of infraclavicular brachial plexus block have been introduced in the past, of which Wilson's coracoid infraclavicular brachial plexus block, a more lateral approach, consequently thought to be easier and safer. While only a few cases of transient ipsilateral phrenic nerve palsy after infraclavicular brachial plexus block have been reported, we describe a rare case of phrenic nerve palsy after Wilson's coracoid infraclavicular brachial plexus block.

How much are patients willing to pay for prevention of postoperative nausea and vomiting

Abstract: Background: Postoperative nausea and vomiting (PONV) remains a common complication of anesthesia. We tried to assess the amount patients were willing to pay for a hypothetical antiemetic that would completely prevent PONV. Methods: Trained residents interviewed 86 patients, who were scheduled to undergo general anesthesia, and questionnaires were completed. Results: Patients were willing to pay a median of 30,000 won for an antiemetic that would completely prevent PONV. The amounts patients were willing to pay correlated with age, previous history of PONV, and patient income. Conclusions: Patients assigned a value for avoidance of PONV. It is sugge sted that more efforts to prevent PONV would be helpful for the increase in patient satisfaction. (Korean J Anesthesiol 2009; 57: 151∼4)