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Neuropathic pain (NP) is difficult to treat due to complex pathophysiological mechanisms. Pulsed radiofrequency (RRF) has been used widely with neuromodulation effect in refractory chronic pain treatment. A recent study found that PRF treatment may decrease chronic pain-related anxiety-depressant symptoms in patients, even though the mechanisms are unclear. Additionally, accumulated evidence has shown serotonin uptake is correlated with various neuropsychiatric diseases. Therefore, we investigated the effects and underlying mechanisms of PRF on depression-like behaviors, resulting from spared nerve injury (SNI)-induced NP. We examined the indexes of mechanical allodynia, cold allodynia, depression-like behavior, and blood cytokines by dynamic plantar aesthesiometry, acetone spray test, forced swimming test, and ProcartaPlex multiplex immunoassays in male Wistar rats, respectively. Serotonin transporters (SERTs) in rat brains were examined by using 4-[18F]-ADAM/PET imaging. We found that specific uptake ratios (SURs) of SERTs were significantly decreased in the brain regions of the thalamus and striatum in rats with SNI-induced NP and depression-like behaviors. Additionally, the decrease in SERT density was correlated with the development of a depression-like behavior indicated by the forced swimming test results and pronounced IL-6 cytokines. Moreover, we demonstrated that PRF application could modulate the descending serotoninergic pathway to relieve pain and depression behaviors. more...

BACKGROUND The Trachway Videolight Intubating Stylet is a video-assisted system with a rigid but malleable intubating stylet that facilitates endotracheal intubation. Minimizing cervical spine movement with manual in-line stabilization is essential for patients with cervical spine injuries such as multiple trauma. However, the intubation time of the Trachway Videolight Intubating Stylet and complications associated with intubation in patients with manual in-line stabilization in the neutral-head and head-lift positions remain unclear. METHODS Patients (20-80 years old) who were scheduled to undergo surgery that required general anesthesia with tracheal intubation were randomly allocated to either a neutral-head (n = 62) or a head-lift position (n = 62) group. Manual in-line stabilization was performed to limit cervical spine mobility. We aimed to evaluate orotracheal intubation time and success rate in these 2 positions with the Trachway Videolight Intubating Stylet. RESULTS Intubation was faster in the head-lift than in the neutral-head position (20 ± 10 and 25 ± 13 seconds, respectively, P = .000); intubation was equally successful in the 2 positions (96.8% vs 96.8%). Responses to intubation did not differ between positions (heart rate, P = .142; visual analog scale scores for throat soreness, P = .54). The only significant predictor of intubation time was the body mass index in the head-lift position group (P = .005). CONCLUSIONS Intubation using the Trachway Videolight Intubating Stylet with manual in-line stabilization is faster in the head-lift position, and therefore preferable. However, if the head-lift position is not suitable, the neutral-head position is a sensible alternative, with comparable intubation success rate, heart rate change, and postoperative throat soreness. more...

Background Acute water intoxication after hysteroscopy is a rare, life-threatening condition, often accompanied with delayed diagnosis owing to masked symptoms because of general anesthesia. Case presentation Herein we presented a 39-year-old female who presented with cardiac arrest after hysteroscopic myomectomy because of acute water intoxication and survived after extracorporeal membrane oxygenation, continuous venous–venous hemofiltration, and aggressive high sodium fluid resuscitation. Conclusion Failure to recognize and treat this condition appropriately may lead to potentially lethal cardiopulmonary complications. more...

BACKGROUND The pneumatic tourniquet is frequently used in total knee arthroplasty. Tourniquet deflation may result in hypotension and tachycardia caused by the rapid shift of blood volume back to the ischaemic limb and a decrease in cardiac preload. Passive leg raising (PLR) represents a 'self-volume challenge' that can result in an increase in preload. Such a PLR-induced increase in preload was hypothesised to attenuate the decrease in preload resulting from tourniquet deflation. OBJECTIVE To evaluate the effect of PLR on hypotension and tachycardia following tourniquet deflation. DESIGN A randomised controlled trial. SETTING Single medical centre. PATIENTS Seventy patients who underwent unilateral total knee arthroplasty were randomised into two groups: tourniquet deflation with PLR (n = 35) or without PLR (control group, n = 35). INTERVENTION(S) Patients in both groups were administered a single dose of plain bupivacaine for spinal anaesthesia. The pneumatic tourniquet was inflated on the thigh and the surgery was performed. The study composed of four steps: for the PLR group, step 1 - inflation of the tourniquet while the patient was supine; step 2 - the patient's legs were raised to a 45° angle; step 3 - the tourniquet was deflated while the patient's legs were still raised; and step 4 - the legs were returned to the supine position. In the control group, the same perioperative procedure was used, but PLR was not conducted. MAIN OUTCOME MEASURES The patients' blood pressure and heart rate were measured before, during and after tourniquet deflation. RESULTS After tourniquet deflation, the magnitude of the changes in blood pressure and heart rate was less in the PLR group than that in the control group. In addition, the blood pressure nadir also occurred later in the PLR group than in the controls. CONCLUSION Bilateral PLR is a simple, reversible manoeuvre that mimics rapid fluid loading. Bilateral PLR attenuates the severity of, and delays the time to, hypotension and tachycardia following deflation of a lower limb tourniquet. TRIAL REGISTRATION ClinicalTrials.gov number NCT01592669. more...

Objective To investigate whether target-controlled infusion (TCI) with propofol, a method that has theoretically better control of drug concentration, produces less cardiovascular and respiratory suppression than an intermittent bolus of a sedative cocktail regimen in deep sedation for gastrointestinal endoscopy. Methods In total 100 participants who had undergone esophagoduodenoscopy (EGD) and 120 who had undergone colonoscopy were prospectively and randomly enrolled to receive TCI with propofol or intermittent bolus of cocktail regimen containing midazolam, alfentanil and propofol until they were unresponsive to verbal commands. The target concentration was adjusted and the bolus of the cocktail regimen was added based on their responses. The nadir values of heart rate, blood pressure and oxygen saturation during and after the procedure were recorded. Results The nadir systolic blood pressure during the endoscopy in the cocktail regimen group was significantly lower than that in the TCI with propofol group. In the cocktail regimen group, the incidence of hypotension during colonoscopy and that of bradycardia during EGD were higher than those in the TCI with propofol group. No participants in the TCI with propofol group experienced hypoxia during endoscopy. In the cocktail regimen group, six participants who had undergone EGD and six who had undergone colonoscopy showed transient hypoxic episodes during or after endoscopy. Conclusion TCI with propofol produced less cardiovascular and respiratory suppression than intermittent bolus of a sedative cocktail regimen in deep sedation for gastrointestinal endoscopy. more...

Background/purpose Volatile anesthetics can produce toxic metabolites and lead to postoperative renal or hepatic dysfunction. The aim of this retrospective study is to compare the changes in renal and hepatic function after general anesthesia using two different volatile anesthetics in prolonged surgery for oral malignancy. Materials and methods Patients anesthetized by desflurane or sevoflurane in prolonged surgery (>10 hours) for oral malignancy during past 18 months were included. Common biomarkers such as blood urea nitrogen, serum creatinine, serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) in postoperative week (POW) 1, 2, and 3 were the primary outcomes. The mean values and the incidence of abnormality of these biochemical markers were also compared. Results In this study, 21 and 26 patients receiving desflurane and sevoflurane anesthesia, respectively, were included. Blood urea nitrogen and creatinine levels were not significantly different between the two groups. There was a 2.1-fold and a 3-fold increase in AST in POW1 in the desflurane and sevoflurane groups, respectively. The incidence of marked elevation in AST (greater than 100 IU/L) was significantly higher in the sevoflurane group in POW1. There was a 1.9-fold and a 3.2-fold increase in ALT in POW2 in the desflurane and sevoflurane groups, respectively. The incidence of marked elevation in ALT was significantly higher in the sevoflurane group in POW2. Conclusion Both desflurane and sevoflurane did not cause clinically significant nephrotoxicity but produced a transient deterioration in liver function after prolonged anesthesia for oral cancer surgery. Sevoflurane was associated with a more severe degree of liver damage than desflurane in this study. more...

We conducted a retrospective study to investigate the anesthesia-controlled time and factors that contribute to prolonged extubation in open colorectal surgery. Using our hospital database, demographic data, various time intervals (waiting for anesthesia time, anesthesia time, surgical time, emergence time, exit from operating room after extubation, total operating room time, and post-anesthesia care unit stay time), and incidence of prolonged extubation (≥ 15 mins), were compared between patients who received desflurane/fentanyl-based anesthesia and total intravenous anesthesia via target-controlled infusion with fentanyl/propofol. Logistic regression analyses were performed to assess the association between variables that contributed to prolonged extubation. In conclusion, the anesthesia-controlled time was similar in desflurane anesthesia and propofol-based total intravenous anesthesia for open colorectal surgery in our hospital. Surgical time greater than 210 minutes, as well as age, contributed to prolonged extubation. more...

Objective: The aim of this study is to use stroke volume variation (SVV) as an indicator to predict fluid responsiveness in patients undergoing protective one-lung ventilation (OLV) in pressure-controlled ventilation mode. Design and Setting: A prospective clinical study in an operating room in a medical center. Patients: Fourteen patients receiving video-assisted thoracic surgery while undergoing OLV in pressure-controlled ventilation mode. Methods: After starting OLV in pressure-controlled ventilation mode, all patients were administered 6 ml/kg 6% hydroxyethyl starch for 20 min. Vigileo-FloTrac system was used to record hemodynamic variables before and after volume loading. The ability of SVV to predict fluid responsiveness was tested by calculating the area under the receiver operating characteristic (ROC) curve for an increase in stroke volume index of ≥10% after volume loading, and the optimal threshold value of SVV was calculated. Results: The area under the ROC curve for SVV to discriminate between responders and nonresponders was 0.89 (95% confidence interval, 0.700–1; P = 0.03). The optimal threshold value of SVV was 8.5% (sensitivity 88.89%; specificity 75%). Conclusions: SVV may be suitable for predicting fluid responsiveness in patients undergoing protective OLV in pressure-controlled ventilation mode. more...

Nasogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. We report a case of fatal hemorrhagic shock immediately after nasogastric tube insertion in a patient undergoing debridement by video-assisted thoracoscopic surgery for mediastinitis. Emergency endoscopy showed that the bleeding came from the nasogastric tube which had perforated the esophagus and possibly tore an intrathoracic large vessel. The nasogastric tube insertion was considered to have directly produced the perforation because no esophageal perforation had been found on preoperative endoscopy. Factors contributing to the risk of esophageal perforation in this case included coexisting mediastinitis, surgical manipulation, endotracheal intubation, inability to cooperate during general anesthesia, and repetitive advancement of the nasogastric tube. Prompt clamping of the nasogastric tube or delayed insertion after failed attempts might have improved the outcome. This report illustrates the complication of massive bleeding that can occur immediately after misplaced insertion of a nasogastric tube. Extraordinary care should be taken to avoid misplacement of the nasogastric tube during insertion. more...

We studied the hypothermic effect of adding 150 microg morphine during spinal anaesthesia in 60 parturients scheduled for elective caesarean section. All the parturients received intrathecal injection of a solution containing 150 mug morphine or normal saline in addition to 10-12 mg hyperbaric bupivacaine 0.5%. In both groups, a significant decrease in body temperature was noted. There was no difference in the area under the curve for temperature against time for the two groups; however, the maximum decrease in temperature from baseline was significantly larger after morphine than after saline injection (mean (SD) 1.11 (0.61) degrees C vs 0.76 (0.39) degrees C, respectively; p = 0.01) and the time to nadir temperature was significantly longer (59.5 (17.6) min vs 50.4 (15.9) min, respectively; p = 0.047). The lowest temperature observed in the morphine group was 34.3 degrees C. We conclude that intrathecal injection of 150 microg morphine intensified the intra-operative hypothermic effect of bupivacaine spinal anaesthesia for caesarean section. more...

Motorcycle exhaust (ME) is a major source of air pollution and a potential health hazard in urban areas where motorcycles are a popular means of transportation. The main objectives of this study were to determine the ability of ME to cause cardiotoxicity in rats and investigate the possible mechanisms of toxicity. Male rats were exposed to 1:10 diluted ME by inhalation 2 h daily and Monday through Friday for 8 weeks. Exposure to ME increased heart weight and decreased cardiac antioxidant enzymes glutathione S-transferase (GST), superoxide dismutase and glutathione peroxidase activities in a concentration- and time-dependent manner. Analysis of echocardiographic parameters indicated that ME increased left ventricle posterior wall thickness, interventricular septum thickness and left ventricle mass. Histopathological examinations of the hearts revealed that ME exposure caused focal cardial degeneration and necrosis, mononuclear cell infiltration, and fibrosis. The results of reverse transcriptase-polymerase chain reaction studies showed that ME decreased GST-M1 and GST-P1 mRNA expression and increased the expression of proinflammatory cytokine interleukin-1β, hypertrophy marker atrial natriuretic peptide, fibrosis markers type I and III collagen, profibrotic cytokine connective tissue growth factor, and hypertrophy and fibrosis mediator transforming growth factor (TGF)-β1 in the heart. The data of Western blot analysis showed that cardiac TGF-β1 protein was induced by ME. These findings demonstrate that subchronic ME exposure caused hypertrophy and fibrosis, and modulated GST and TGF-β1 expression in rat heart possibly by mechanisms involving oxidative stress and inflammation. more...

Previous study showed that patients under general anesthesia (GA) had nasopharyngeal secretions on the face at the end of ocular surgery, especially in propofol-based total intravenous anesthesia (TIVA), it might induce postoperative endophthalmitis. Therefore, we conducted a retrospective study to compare the incidence of endophthalmitis after ocular surgery under topical, inhalation anesthesia, and propofol-based TIVA in our medical center from 2011 to 2015. A total of 21,032 patients were included, and we evaluated epidemiologic factors, systemic diseases, other ocular pathologic characteristics, complications during the surgery, technique of ocular surgery, method of antibiotic prophylaxis, vitreous culture, and vision outcome in these patients. Fifteen endophthalmitis cases among 21,032 operations reported, equaling an incidence of 0.071%. The incidence rates under topical, inhalation anesthesia, and propofol-based TIVA were 0.083%, 0.039%, and 0%, respectively (P = 0.39). Moreover, the risk of endophthalmitis under GA (0.024%) was significantly lower than topical anesthesia (0.083%) (P more...

An 84-year-old male was scheduled for coronary artery bypass graft surgery under general anesthesia. During cardiopulmonary bypass, the leakage of blood into the syringe being used for balloon inflation and the thermistor connector of the pulmonary artery catheter (PAC) was detected. Resistance was encountered when trying to withdraw the PAC. A surgical suture of the right atrium cannulation was stitched to PAC and was immediately released. Early detection of surgical damage to PAC and recognition of the entrapped PAC by gently withdrawing it avoided possible life-threatening complications, including pulmonary air embolism, and the inevitable of resternotomy. Transesophageal echocardiography, chest radiography, and fluoroscopy can help confirm any postoperative surgical damage following closure of the sternum or while in the intensive care unit. more...

Background: Ketamine has been shown to induce rat cytochrome P-450 in a way similar to phenobarbital. However, whether ketamine is able to induce glutathione S-transferase (GST) and UDP-glucuronosyltransferase (UGT), two major phase II drugmetabolizing enzymes, remains unclear. The present study aimed to investigate the effect of ketamine on GST and UGT activities in rats. Methods: In a dose-response study, male adult Wistar rats were treated with 10, 20, 40 or 80 mg/kg ketamine intraperitoneally twice daily for 4 days. Livers were removed 1 day after ketamine treatment and hepatic GST and UGT activities were determined. In a reversibility study, rats were treated with 80 mg/kg ketamine intraperitoneally twice daily for 4 days and killed 1, 2, 3 or 4 days after the last dose of ketamine. Livers were removed and hepatic GST and UGT activities were determined. Results: The results of the dose-response study showed that treatment of rats with 10, 20, 40, or 80 mg/kg ketamine produced 19%, 20%, 18%, and 25% increases respectively in the catalytic activity of hepatic cytosolic GST, and 41%, 41%, 35%, and 38% increases respectively in the catalytic activity of microsomal UGT. The results of the reversibility study showed that the GST activities of the rats killed 1, 2, 3, or 4 days after ketamine treatment were 62%, 88%, 46% and 65% higher than the activity of the control group. The UGT activities of the rats killed 1, 2, 3, or 4 days after ketamine treatment were 56%, 53%, 54% and 72% higher than the activity of the control group. Conclusion: Ketamine is able to induce the activities of hepatic GST and UGT in rats. The induced GST and UGT activities persist for at least 4 days after cessation of ketamine. The results suggest the possibility of interactions of drugs related to phase II enzyme induction in chronic ketamine users. more...

Background In a series of ex vivo and in vivo studies we investigated the ability of repetitive ketamine administration to alter the metabolism and anaesthetic effect of propofol and the role of ketamine-mediated P-450 2B induction in rats. Methods Male Wistar rats were pretreated with 80 mg kg −1 ketamine i.p. twice daily for 4 days. Pentoxyresorufin O -dealkylation (PROD), P-450 2B protein and mRNA were determined. Residual propofol concentration was measured after incubating hepatic microsomes with 100 μM propofol. Sleeping times induced by i.p. 80 mg kg −1 propofol were determined. Orphenadrine, a P-450 2B inhibitor, was added in both ex vivo and in vivo studies. Finally, serial whole blood propofol concentrations were determined after i.v. infusion of 15 mg kg −1 propofol. Results Ketamine pretreatment produced 5.4-, 3.4- and 1.7-fold increases in hepatic PROD activity, P-450 2B protein and mRNA, respectively. Residual propofol concentration was 46% lower after incubation with microsomes from ketamine-pretreated rats than in the control group. The addition of orphenadrine to ketamine-pretreated microsomes produced an increase in residual propofol concentration in a concentration-dependent manner. Ketamine pretreatment reduced propofol sleeping time to 12% of the control, which was reversed by orphenadrine. The whole blood propofol concentration in ketamine-pretreated rats was significantly lower than that of control rats at 1, 2, 4 and 8 min after cessation of propofol infusion. Conclusions Repetitive ketamine administration enhances propofol metabolism and reduces propofol sleeping time in rats. We suggest that P-450 2B induction may produce ketamine–propofol interaction in anaesthetic practice. more...

The aim of this study was to evaluate the effectiveness of lidocaine, propofol and ephedrine in suppressing fentanyl-induced cough.One hundred and eighteen patients were randomly assigned into four groups and the following medications were given intravenously: patients in Group I (n = 31) received normal saline 2 mL, Group II (n = 29) received lidocaine 2 mg.kg(-1), Group III (n = 30) received propofol 0.6 mg.kg(-1) and Group IV (n = 28) received ephedrine 5 mg. At one minute after the study medication, fentanyl 2.5 microg.kg(-1) was given intravenously within two seconds. The occurrence of cough and vital sign profiles were recorded within two minutes after fentanyl bolus by an anesthesiologist blinded to study design.Sixty-five percent of patients in the placebo group had cough, whereas the frequency was significantly decreased in Groups II (14%) and IV (21%). Although a numerically lower frequency of cough was noted in Group III (37%), it was not statistically different from that of the placebo group. SpO(2) decreased significantly in patients of Group III compared to placebo; one patient experienced hypoxemia necessitating mask ventilation. Patients in Group III showed a decrease in heart rate and systolic blood pressure (2 beats.min(-1) and 8 mmHg vs baseline). Patients in Group IV showed an increase in both measurements (5 beats.min(-1) and 8 mmHg vs baseline). No truncal rigidity was observed throughout the study.Intravenous lidocaine 2 mg.kg(-1) or ephedrine 5 mg, but not propofol 0.6 mg.kg(-1), was effective in preventing fentanyl-induced cough. The results provide a convenient method to decrease fentanyl-induced cough. more...

Pruritus is a common side effect of intrathecal morphine injection for postoperative pain control. Its incidence is especially high in patients undergoing cesarean delivery. We investigated the effectiveness of ondansetron in preventing intrathecal morphine-induced pruritus in such patients. We included 60 consecutive nonbreastfeeding women who were scheduled for elective cesarean delivery. After the administration of spinal anesthesia with bupivacaine and intrathecal morphine 0.15 mg injection, the patients were randomly divided into three groups. Group 1 received placebo (normal saline) IV injection, Group 2 diphenhydramine 30 mg IV injection, and Group 3 ondansetron 0.1 mg/kg IV injection. The incidence of pruritus was significantly lower in the ondansetron group (25%) when compared with that in the placebo group (85%) and in the diphenhydramine group (80%) (both P0.05). The postoperative pain score and time to flatus passage were not significantly different among the three groups. There were no headache or extrapyramidal signs associated with ondansetron use. In conclusion, ondansetron prophylaxis significantly reduced the incidence of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery.Ondansetron prophylaxis significantly decreases the incidence of pruritus, a common side effect of intrathecal morphine used to treat postcesarean delivery pain. more...

Nasotracheal intubation for airway anatomy distorted patients is often frustrating. Here, we describe a redo oral cancer patient who received awake nasotracheal intubation under flexible fiberoptic bronchoscopy (FFB) guidance with assistance of the Trachway ® intubating stylet. After repeated failures of locating the epiglottis or vocal cords with the FFB, we put Trachway stylet into the oropharynx to assist identifying glottic structures. With the assistance of Trachway, glottic structures and the tip of FFB were identified, and fiberoptic intubation was achieved without complications. Therefore, this feasible application may be applied to patients with distorted airway who requires nasotracheal intubation. more...

For decades, water-mill murmur, decrease in end-tidal CO(2) (Petco(2)), hypotension, and hypoxemia have been accepted as diagnostic criteria for gas embolism. In this case report, a 19-yr-old male patient developed a sudden reduction in Petco(2) and profound circulatory collapse 15 min after intramedullary irrigation with H(2)O(2). However, arterial oxygen desaturation never developed throughout the entire course of resuscitation from presumed massive oxygen embolism. more...