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During pregnancy, the procoagulant activity increases (manifested by elevation in factor VII, factor VIII, factor X, and fibrinogen levels), while the anticoagulant activity decreases (characterized by reduction in fibrinolysis and protein S activity), resulting in hypercoagulation. Standard coagulation tests, such as prothrombin time or activated partial thromboplastin time, are still used despite the lack of evidence supporting its accuracy in evaluating the coagulation status of pregnant women. Thromboelastography and rotational thromboelastometry, which are used to assess the function of platelets, soluble coagulation factors, fibrinogen, and fibrinolysis, can replace standard coagulation tests. Platelet count and function and the effect of anticoagulant treatment should be assessed to determine the risk of hematoma associated with regional anesthesia. Moreover, anesthesiologists should monitor patients for postpartum hemorrhage (PPH), and attention should be paid when performing rapid coagulation tests, transfusions, and prohemostatic pharmacotherapy. Transfusion of a high ratio of plasma and platelets to red blood cells (RBCs) showed high hemostasis success and low bleeding-related mortality rates in patients with severe trauma. However, the effects of high ratios of plasma and platelets and the ratio of plasma to RBCs and platelets to RBCs in the treatment of massive PPH were not established. Intravenous tranexamic acid should be administered immediately after the onset of postpartum bleeding. Pre-emptive treatment with fibrinogen for PPH is not effective in reducing bleeding. If fibrinogen levels of less than 2 g/L are identified, 2–4 g of fibrinogen or 5–10 ml/kg cryoprecipitate should be administered.

Background The conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum cesarean section (CS) often fails, resulting in intraoperative pain. Spinal anesthesia (SA) can provide a denser sensory block than ESA. The purpose of this prospective, non-blinded, parallel-arm, randomized trial was to compare the rate of pain-free surgery between ESA and SA following ELA for intrapartum CS. Methods Both groups received continuous epidural infusions for labor pain at a rate of 10 ml/h. In the ESA group (n = 163), ESA was performed with 17 ml of 2% lidocaine mixed with 100 µg fentanyl, 1 : 200,000 epinephrine, and 2 mEq bicarbonate. In the SA group (n = 160), SA was induced with 10 mg of 0.5% hyperbaric bupivacaine and 15 µg fentanyl. We investigated the failure rate of achieving pain-free surgery and the incidence of complications between the two groups. Results The failure rate of achieving pain-free surgery was higher in the ESA group than the SA group (15.3% vs. 2.5%, P < 0.001). There was no statistical difference between the two groups in the rate of conversion to general anesthesia; however, the rate of analgesic requirement was higher in the ESA group than in the SA group (12.9% vs. 1.3%, P < 0.001). The incidence of high block, nausea, vomiting, hypotension, and shivering and Apgar scores were comparable between the two groups. Conclusions SA after ELA can lower the failure rate of pain-free surgery during intrapartum CS compared to ESA after ELA.

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.

Background: Spinal anesthesia (SA) after epidural labor analgesia (ELA) can have advantages over augmentation of ELA due to its rapid onset and high-quality analgesia. However, unexpected side effects and diverse failure rates have been reported in women that received SA after ELA. We prospectively ...

Background: Ephedrine, unlike phenylephrine, has a dose-related propensity to depress fetal pH during spinal anesthe sia during cesarean section. A low arterial umbilical cord pH has a strong association with neonatal mortality and morbidity. The purpose of this retrospective study was to investigate influences of vasopressor change on Apgar scores and adverse neonatal outcomes in cesarean section. Methods: In obstetric anesthesia, we changed the prophylactic vasopressor from a combination of phenylephrine and ephedrine to phenylephrine alone in 2000. We evaluated the impact of vasopressor change on Apgar scores (1 and 5 min), incidence of Apgar score < 7 (1 and 5 min), neonatal seizure, continuous positive airway pressure (CPAP), intermittent positive pressure ventilation (IPPV), intraventricular hemorrhage (IVH), periventricular leucomalacia (PVL), and hypoxic ischemic encephalopathy (HIE) in low-risk elective cesarean sections during a period when the combina tion of phenylephrine and ephedrine was used (2008-2009, two years) and the period of phenylephrine use alone (20112012, two years). Results: There were no differences in Apgar scores (1 and 5 min), the incidence of 5 min Apgar score < 7, neonatal sei zure, CPAP, IPPV, IVH, PVL, and HIE between the two time periods. However, the incidence of 1 min Apgar < 7 was decreased during the period of phenylephrine use compared with the period of phenylephrine and ephedrine use (P = 0.002). Conclusions: Conversion from a combination of phenylephrine and ephedrine to phenylephrine alone as a prophylactic anti-hypotensive drug during spinal anesthesia for cesarean section in low-risk pregnancy may be associated with a sig nificant decrease in the incidence of 1 min Apgar < 7. (Korean J Anesthesiol 2014; 67: 38-42)

Background: The purpose of this study was to review incidence, indications, complications, and the anesthetic management of emergency obstetric hysterectomies. Methods: This was a retrospective study of the cases of emergency obstetric hysterectomies performed at the Woman's Hospital over a 3 year period between January 2008 and December 2010. The indication for surgery, anesthetic management, operating time, estimated blood loss, pre- and postoperative hemoglobin and hematocrit values, need for blood transfusion, and perioperative complications were obtained. Results: During the study period there were 46 emergency obstetric hysterectomies for 20147 deliveries, giving an incidence of 2.28/1000 deliveries. The number of emergency hysterectomies was significantly higher with the cesarean deliveries than with the vaginal deliveries. The most common indication for emergency obstetric hysterectomy was placenta accreta. Postoperatively, Dissemimated Intravascular Coagulation (DIC) was the most common complication. Conclusions: Abnormal placenta has been an main indication of emergency hysterectomy. Anesthesiologists should be eligible to aware of high risk of emergency hysterectomy and deal with massive hemorrhage. (Korean J Anesthesiol 2012; 63: 43-47)

Background: This study was conducted to compare the efficacy of a combination of ondansetron and dexamethasone with that of metoclopramide and dexamethasone for prevention of postoperative nausea and vomiting (PONV) in gynecologic patients receiving fentanyl IV-patient controlled analgesia. Methods: One hundred patients were divided into two groups at random. In Group O, 5 mg of dexamethsone was administered after tracheal intubation, while 4 mg of ondansetron was administered at the end of surgery. In Group M, 5 mg of dexamethsone was administered after tracheal intubation and 20 mg metoclopromide was administered at the end of surgery. During the experiment, the PONV was evaluated at regular intervals. In addition, the incidence of nausea, and vomiting and the numerical rating scale (NRS) of nausea was measured (range, 0-10). Results: The overall incidence of PONV in Group O was 22/50 (44%) while that in Group M was 19/50 (38%). There were no significant differences in the incidence of nausea, moderate to severe nausea (NRS of nausea, 4-10), or vomiting between groups. Conclusions: Treatment with a combination of 20 mg metoclopramide and 5 mg dexamethasone is an effective, safe, and inexpensive way to prevent PONV when compared to treatment with 4 mg ondansetron and 5 mg dexamethasone.

Background This study compared the changes in plasma oxytocin, intraoperative hemodynamics and postoperative uterine activity in patients who underwent elective Shirodkar cerclage for cervical incompetence with general or spinal anesthesia. Methods Thirty-seven singleton pregnant patients were enrolled in this prospective, randomized, controlled comparison of general (n=17) and spinal anesthesia (n=20) for elective Shirodkar suture in the second trimester. Plasma oxytocin concentration was measured before, 1 h after, and 24 h after the procedure. Uterine activity was recorded by external tocography twice daily for 30 min over a three-day period. Results Plasma oxytocin concentration did not change significantly after cerclage in either group. There were no significant differences between the two groups at any time. None of the patients reported painful contractions during study period. Two (11.8%) and four patients (20.0%) in the general and spinal groups, respectively (NS), showed increased uterine activity but these symptoms disappeared without treatment. The systolic blood pressure in the spinal group was significantly lower after anesthesia compared with the baseline and was significantly lower than in the general group during the procedure. Conclusions Anesthetic method used for elective Shirodkar procedure did not affect the perioperative changes in plasma oxytocin nor postoperative uterine activity.

analgesia, and catheter migration were compared between groups. The incidence of audible air leak was 35.9 %. Rates of overall failure including unintentional dural puncture and intravenous catheter placement were significantly lower in group A than in group N (Supplementary Table 1). The presence of audible air leak was estimated to have a positive predictive value of 98.6 %, a negative predictive value of 2.7 %, a specificity of 76.2 % and a sensitivity of 38.4 % for successful labor analgesia after catheter placement (Supplementary Table 2). Our study has some limitations. The audibility of air leakage is subjective and depends on the hearing acuity of individual observers as well as the level of ambient noise. In addition, audible air leak may not be a confirmative method for identifying the epidural space. In summary, the occurrence of audible air leak during Tuohy needle placement seems to be associated with a lower incidence of both overall failure and intravenous catheter placement in labor epidural analgesia.

There are few consistent guidelines in choosing anesthesia for cesarean section for a parturient with placenta previa. This prospective randomized trial was organized to compare the maternal hemodynamics, blood loss and neonatal outcome of general versus epidural anesthesia for cesarean section with the diagnosis of grade 4 placenta previa. After giving informed consent, 12 patients received general anesthesia and 13 received epidural. Intraoperative blood pressures demonstrated a more stable course in the epidural group than in the general group. Blood loss did not differ significantly between the groups (1622 +/- 775 mL vs. 1418 +/- 996 mL). General anesthesia resulted in lower immediate postoperative hematocrit level (28.1 +/- 3.5% vs. 32.5 +/- 5.0%, P < 0.05). The patients in the general group received a significantly larger transfusion than the epidural group (1.08 +/- 1.6 vs. 0.38 +/- 0.9 units, P < 0.05). The Apgar scores at 1 and 5 min were similar in the two groups (8 [4-9] vs. 8 [7-9] and 10 [6-10] vs. 9 [9-10], respectively). We concluded that epidural anesthesia is superior to general anesthesia in elective cesarean section for grade 4 placenta previa with regard to maternal hemodynamics and blood loss. There was no difference in neonatal outcome.

The purpose of this study was to evaluate the effect of ondansetron on excitatory amino acid transporter type 3 (EAAT3) and to elucidate the roles of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K) in the effect. EAAT3 was expressed in Xenopus oocytes following the injection of rat EAAT3 mRNAs. Using the two-electrode voltage clamping method, the inward currents induced by l -glutamate were measured for 1 min in the presence and absence of ondansetron (1–1000 μM). Different concentrations of l -glutamate (3–300 μM) were used to determine the kinetic characteristics of EAAT3. To identify the involvement of PKC and PI3K in the effect, oocytes were exposed to a PKC activator and to PKC inhibitors and PI3K inhibitors, and l -glutamate-induced currents were recorded. Ondansetron decreased EAAT3 activity in a dose-dependent manner. In a kinetic study, ondansetron (10 μM for 3 min) reduced V max , but not K m compared with the control group. The PKC activator abolished the ondansetron-induced decrease in EAAT3 activity. The PKC inhibitors (staurosporine and chelerythrine) and ondansetron had not additive or synergistic effects on EAAT3 activity. The PI3K inhibitors (wortmannin and LY294002) decreased the EAAT3 response, although there were no differences among the groups comprising ondansetron, PI3K inhibitors, and PI3K inhibitors plus ondansetron. Our results demonstrate that ondansetron attenuates EAAT3 activity and this effect seems to be mediated by PKC and PI3K.

Dexmedetomidine, an α2 adrenergic agonist, has neuroprotective and anticonvulsant properties in addition to its sedative and anxiolytic effects. We hypothesized that dexmedetomidine would increase the activity of excitatory amino acid transporter type 3 (EAAT3) and that this effect would involve protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K), two protein kinases known to regulate EAAT3 activity. EAAT3 was expressed in Xenopus oocytes by injecting its mRNA. Two-electrode voltage clamping was used to record membrane currents before, during, and after application of 30 μM l-glutamate in the presence of 0.1-30 nM dexmedetomidine. Dexmedetomidine-treated oocytes were also exposed to a PKC activator (phorbol-12-myristate-13-acetate [PMA]), PKC inhibitors (chelerythrine, staurosporine, and calphostin C), and PI3K inhibitors (wortmannin and LY294002) before current measurement. Dexmedetomidine application resulted in a concentration-dependent increase in the EAAT3 activity in response to l-glutamate. The kinetic study showed that dexmedetomidine significantly increased the Vmax without changing Km. Treatment of oocytes with PMA significantly increased transporter currents compared with controls, but treatment with dexmedetomidine plus PMA did not further increase the response compared with PMA or dexmedetomidine alone. In addition, pre-treatment of oocytes with PKC inhibitors and PI3K inhibitors significantly abolished the dexmedetomidine-enhanced EAAT3 activity. These results suggest that dexmedetomidine increases the activity of EAAT3 expressed in Xenopus oocytes. PKC and PI3K seem to mediate this effect. These findings may explain the neuroprotective and anticonvulsant effects of dexmedetomidine.

Nicotine, the main ingredient of tobacco, elicits seizures in animal models and cigarette smoking is regarded as a behavioral risk factor associated with epilepsy or seizures. In the hippocampus, the origin of nicotine-induced seizures, most glutamate uptake could be performed primarily by excitatory amino acid transporter type 3 (EAAT3). An association between temporal lobe epilepsy and EAAT3 downregulation has been reported. Therefore, we hypothesized that nicotine may elicit seizures through the attenuation of EAAT3 activity. We investigated chronic nicotine exposure (72 h) cause reduction of the activity of EAAT3 in a Xenopus oocyte expression system using a two-electrode voltage clamp. The roles of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K) were also determined. Nicotine (0.001-1 μM) resulted in a time- and dose-dependent decrease in EAAT3 activity with maximal inhibition at nicotine concentrations of 0.03 μM or higher and at an exposure time of 72 h. Vmax on the glutamate response was significantly reduced in the nicotine group (0.03 μM for 72 h), but the Km value of EAAT3 for glutamate was not altered. When nicotine-exposed oocytes (0.03 μM for 72 h) were pretreated with phorbol-12-myristate-13-acetate (PMA, a PKC activator), the nicotine-induced reduction in EAAT3 activity was abolished. PKC inhibitors (staurosporine, chelerythrine, and calphostin C) significantly reduced basal EAAT3 activity, but there were no significant differences among the PKC inhibitors, nicotine, and PKC inhibitors+nicotine groups. Similar response patterns were observed among PI3K inhibitors (wortmannin and LY294002), nicotine, and PI3K inhibitors+nicotine. In conclusion, this study suggests that nicotine decreases EAAT3 activity, and that this inhibition seems to be dependent on PKC and PI3K. Our results may provide an additional mechanism for nicotine-induced seizure.

The use of regional anesthesia for spontaneous delivery and cesarean section has significantly increased, due to both patient demand and the reduced risk of maternal mortality and morbidity compared with general anesthesia [1]. Despite the benefits, inadvertent intravascular and intrathecal injection of a local anesthetic may cause severe complications, including systemic toxicity, total spinal anesthesia, and a high spinal block.

In order to simplify the array manufacturing process of FFS TFT-LCD, novel four-mask process which is adopted to the optimum multiple-slit design in the common electrode and contact hole has been developed. The adoption of the optimum multiple-slit design is able to support stable process margin without ripple of gray-tone. Moreover, continuous process by etching of the gate and transparent common electrode simplify array process of FFS devices.

Background: The purpose of this study was to evaluate the correlations between mean blood pressure (MBP), cardiac index (CI), and systemic vascular resistance index (SVRI) in patients undergoing laparoscopically-assisted vaginal hysterectomy (LAVH). Methods: The authors enrolled 47-female patients prior to a LAVH. Hemodynamic parameters were measured before anesthetic induction, just after tracheal intubation, before skin incision, and 2, 5, 10, 20, and 30 min after pneumoperitoneum with by noninvasive cardiac output measurement using the partial carbon dioxide rebreathing method. Results: CI was significantly reduced 2 and 5 min after pneumoperitoneum (2.6 0.7 L/min/, and 2.5 0.7 L/min/, respectively), and then returned to the pre-skin incision level. SVRI increased significantly after pneumoperitoneum and was then restored to that measured pre-skin incision at 20 min after pneumoperitoneum. MBP before anesthetic induction was found to be correlated with CI at 20 and 30 min after pneumoperitoneum (R = 0.37, P = 0.022, R = 0.37, P = 0.036, respectively). A moderate correlation was observed between MBP before anesthetic induction and SVRI at 2, 5, 10, 20, and 30 min after pneumoperitoneum (R = 0.39 0.60, P

Background: Pneumoperitoneum and head-down tilt during a laparoscopic hysterectomy causes significant alterations in the hemodynamics including decreased cardiac output. The aim of this study was to evaluate the effects of a crystalloid preload on the hemodynamics after a hysterectomy (LAVH). Methods: The patients were randomized to receive either no crystalloid fluid preload (control group: 29 women) or 10 ml/kg of a crystalloid fluid preload over 10 min (preloading group: 30 women) before the pneumoperitoneum. The hemodynamic parameters were measured before inducing anesthesia, immediately after the tracheal intubation, before the skin incision, and 2, 5, 10, 20, and 30 min after the pneumoperitoneum with with noninvasive cardiac output measurements using the partial rebreathing method. Results: The cardiac index (CI) was reduced 2 and 5 min after the pneumoperitoneum, and then returned to normal. There were no significant differences in the CI after the pneumoperitoneum between the two groups (P ＜ 0.05). Conclusions: The administration of a 10 ml/kg crystalloid preload did not attenuate the decrease in the CI after pneumoperitoneum.

Background: In an outcome-based health care environment, the demonstration of patient satisfaction with postoperative care has become an important criterion for quality of care assessment. The purpose of this study was to evaluate the effects of hand massage therapy and preoperative information on postoperative patient satisfaction. Methods: One hundred full term patients scheduled for elective cesarean section under combined spinal- epidural anesthesia were randomly assigned to either the control group (n = 50) or the experimental group (n = 50). The experimental group received a hand massage and preoperative information about their surgery and anesthesia, whereas the control group did not. Twenty-four h after surgery, postoperative patient satisfaction was assessed with questionnaire consisting of 20 items in a blind manner. Results: The mean postoperative satisfaction score of the experimental group was significantly higher than that of the control group (94.9 15.6 vs. 52.2 8.5). The pain score postoperatively of the experimental group was significantly lower than that of the control group (0.4 2.1 vs. 2.1 0.6), but the pain score at a postoperative 24 h and total analgesic requirement were similar in the two groups. Conclusions: Preoperative information supply and hand massage therapy are useful interventions that improve postoperative patient satisfaction.

Background: The purpose of this study was to find additional effects of intrathecal nalbuphine 1 mg to morphine 0.1 mg for pain relief during a cesarean section. Methods: Sixty healthy patients at full term who were scheduled for an elective cesarean delivery with spinal anesthesia were enrolled in the study. They received 0.5% bupivacaine 10 mg with either morphine 0.1 mg (group M), or nalbuphine 1 mg (group N), or morphine 0.1 mg + nalbuphine 1 mg (group M + N). Analgesic effects were evaluated by a verbal rating scale on the duration of complete analgesia (time from the intrathecal injection to the first pain report), effective analgesia (time from the intrathecal injection to the first analgesic request), and cumulative doses of additional analgesics. Hemodynamic changes and adverse effects were also observed. Results: The duration of complete analgesia increased significantly in group M, compared with group N and group M + N. Effective analgesia was longer in group M and group M + N, compared with group N. The incidence of pruritus was significantly lower in group N, compared with group M and M + N. The incidence of nausea and vomiting was the same among all groups. Conclusions: We concluded that intrathecal addition of nalbuphine 1mg to morphine 0.1 mg during spinal anesthesia for a cesarean delivery reinforced intraoperaitive analgesia compared with intrathecal morphine 0.1 mg. However, it reduced the duration of complete analgesia and had no effect on the incidence of pruritus.

Background: This study was performed to accurately discover the correlation between the epidural depth and physical measurements. Methods: We measured the L2-3, L3-4 epidural depth pre-marked on the needle shaft only when the block was successful. Correction of the depth was made by the angulation of the needle from the perpendicular line (with regard to both the xand y-axis) to the skin. Height and weight from the medical record was noted and neck, waist, and hip circumferences of each subject was measured. Physical parameters such as waist/neck (waist circumference-to-neck circumference ratio), waist/height (waist circumference-to-height ratio), waist/hip (waist circumference-to-hip circumference ratio), weight/neck (weightto-neck circumference ratio), weight/height (weight-to-height ratio) and body mass index (BMI) were calculated. Peason's correlation and a regression test between the epidural depth and the physical measurements were performed. Results: Significant correlation with epidural depth was found in weight, waist, hip, neck, BMI, waist/height, waist/hip, weight/neck, and weight/height. With the regression test, we found weight to be the most important for predicting epidural depth (R square = 0.330, P < 0.05). Conclusions: Weight has the highest predictive value for lumbar epidural depth. (Korean J Anesthesiol 2001; 40: 308∼312) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ