Search

Background The stroke volume variation (SVV), based on lung-heart interaction during mechanical ventilation, is a useful dynamic parameter for fluid responsiveness. However, it is affected by many factors. The aim of this study was to evaluate the effects of SVV on Trendelenburg (T) and reverse Trendelenburg (RT) position and to further elaborate on the patterns of the SVV with position. Methods Forty-two patients undergoing elective surgery were enrolled in this study. Fifteen minutes after standardized induction of anesthesia with propofol, fentanyl, and rocuronium with volume controlled ventilation (tidal volume of 8 ml/kg of ideal body weight, inspiration : expiration ratio of 1 : 2, and respiratory rate of 10-13 breaths/min), the patients underwent posture changes as follows: supine, T position at slopes of operating table of -5°, -10°, and -15°, and RT position at slopes of operating table of 5°, 10°, and 15°. At each point, SVV, cardiac output (CO), peak airway pressure (PAP), mean blood pressure, and heart rate (HR) were recorded. Results The SVV was significant decreased with decreased slopes of operating table in T position, and increased with increased slopes of operating table in RT position (P = 0.000). Schematically, it was increased by 1% when the slope of operating table was increased by 5°. But, the CO and PAP were significant increased with decreased slopes of operating table in T position, and decreased with increased slopes of operating table in RT position (P = 0.045, 0.027). Conclusions SVV is subjected to the posture, and we should take these findings into account on reading SVV for fluid therapy.

Perioperative ischemic stroke is an uncommon event associated with significant morbidity and mortality. The complexity of the surgical procedure and surgery induced hypercoagulable status also influence the incidence of stroke. The management of stroke involves a decision regarding the quickest suitable revascularization method. Endovascular mechanical thrombectomy, such as intra-arterial mechanical thrombectomy (IAMT), can restore vascular patency of the vessels, providing an alternative or synergistic method to restore blood flow. Although, there are no recommended treatment guidelines, IAMT is eligible to be a treatment of choice for perioperative ischemic stroke. We experienced a case of a patient who demonstrated hemiplegia and aphasia, the early symptom of acute ischemic stroke, in the post-anesthesia care unit and performed IAMT successfully. Thus we report the case with a review of the relevant literature.

Spinal anesthesia with local anesthetics (LAs) can cause toxic effects on the central nervous system, leading to postoperative neurological complications. Although previous studies have suggested that LAs cause ion channel block and mitochondrial dysfunction followed by neuronal cell death, the mechanisms underlying LA toxicity are not fully understood. In this study, we evaluated the neurotoxic mechanisms of bupivacaine and lidocaine related to endoplasmic reticulum (ER) stress using the SH-SY5Y human neuronal cell line. At clinical concentrations used during regional anesthesia, both bupivacaine and lidocaine significantly reduced cell viability in a concentration-dependent manner and differentially induced ER stress responses, including the rapid induction of Grp78 and CHOP expression and phosphorylation of c-jun N-terminal kinase (JNK), p-38 mitogen-activated protein kinase (MAPK) and eukaryotic initiation factor 2 alpha (eIF2α). CHOP induction by bupivacaine and lidocaine was inhibited with a JNK inhibitor (SP600125) and a p38 MAPK inhibitor (SB203580), indicating that apoptotic CHOP expression was mediated by JNK and p38 MAPK activation. In addition, bupivacaine-induced apoptotic cell death was dependent on caspase 3 activity. Bupivacaine cytotoxicity was significantly but not completely inhibited by an endogenous dipeptide, l-carnosine. In conclusion, LAs cause acute ER stress responses and caspase 3-dependent cell death, which can be prevented with the pharmacological chaperone dipeptide l-carnosine.

Background: Although a brachial plexus block can be used to provide anesthesia and analgesia for upper extremity surgery, its effects using MgSO4 on postoperative pain management have not been reported. The aim of this study was to evaluate brachial plexus block using MgSO4 on postoperative analgesia. Methods: Thirty-eight patients who were scheduled to undergo upper extremity surgery were randomly allocated into two groups: patients receiving axillary brachial plexus block with 0.2% ropivacaine 20 ml and normal saline 2 ml (group S) or 0.2% ropivacaine 20 ml and MgSO4 200 mg (group M). Before extubation, the blocks were done and patient controlled analgesia was started, and then, the patients were transported to a postanesthetic care unit. The postoperative visual analogue scale (VAS), opioid consumption, and side effects were recorded. Results: The two groups were similar regarding the demographic variables and the duration of the surgery. No differences in VAS scores were observed between the two groups. There was no statistically significant difference in opioid consumption between the two groups. Nausea was observed in three patients for each group. Conclusions: Axillary brachial plexus block using MgSO4 did not reduce the level of postoperative pain and opioid consumption. (Korean J Pain 2011; 24: 158-163)

Background During coronary anastomosis in off-pump coronary artery bypass surgery (OPCAB), hemodynamic alternations can be induced by impaired diastolic function of the right ventricle. This study was designed to examine the effect of milrinone on right ventricular function and early outcomes in patients undergoing OPCAB. Methods Forty patients undergoing OPCAB were randomly assigned in a double-blind manner to receive either milrinone (milrinone group, n = 20) or normal saline (control group, n = 20). Hemodynamic variables were measured after pericardiotomy (T1), 5 min after stabilizer application for anastomosis of the left anterior descending coronary artery (LAD, T2), the obtuse marginalis branch (OM, T3), the right coronary artery (RCA, T4), 5 min after sternal closure (T5), and after ICU arrival. The right ventricular ejection fraction (RVEF) and right ventricular volumetric parameters were also measured using the thermodilution technique. For evaluation of early outcomes, the 30-day operative mortality and morbidity risk models were used. Results There was no significant difference in hemodynamic variables, including mean arterial pressure, between the 2 groups, except for the cardiac index and RVEF. The cardiac index and RVEF were significantly greater at T3 in the milrinone group than in the control group. Conclusions Continuous infusion of milrinone demonstrated a beneficial effect on cardiac output and right ventricular function in patients undergoing OPCAB, especially during anastomosis of the graft to the OM artery, and it had no adverse effect on early outcomes.

Background: Emergence agitation is associated with increased morbidity and hospital costs. However, there have been few reports in the medical literature on the occurrence of emergence agitation in adults. The aim of this study was to compare emergence agitation between sevoflurane and propofol anesthesia in adults after closed reduction of nasal bone fracture. Methods: Forty adults (ASA I-II, 20-60 yr) undergoing closed reduction of nasal bone fracture were randomly assigned to either sevoflurane or propofol group and anesthesia was maintained with sevoflurane or propofol. The bispectral index (BIS) was monitored and maintained within 40-60. At the end of surgery, patients were transported to the post anesthetic care unit (PACU) and agitation state scale was checked by Aono's four-point scale (AFPS). Emergence agitation was defined as and AFPS score of 3 or 4. Pain score were measured by numeric rating scale (NRS) on arrival and peak value at PACU. Results: Nine (45.0%) patients in the sevoflurane group and 2 (10.0%) patients in the propofol group developed emergence agitation in the PACU (P = 0.031). There was no correlation between peak NRS and Aono's four-point scale. Conclusions: Propofol may decrease incidence of emergence agitation compared to sevoflurane in adults under going closed reduction of nasal bone fracture. (Korean J Anesthesiol 2012; 63: 48-53)

Background: Inhalation induction with desflurane can cause airway irritability and sympathetic stimulation. The aim of this study was to investigate whether lidocaine and fentanyl could reduce these unwanted reactions. Methods: Seventy-five patients who had premedication with midazolam were randomly allocated to one of three groups to receive intravenous saline (S group), lidocaine 1.5 mg/kg (L group), fentanyl 1 μg/kg (F group), respectively, before tidal volume induction with desflurane in oxygen and nitrous oxide. We recorded airway irritability such as cough, apnea, laryngospasm and excitatory movement and hemodynamic changes. Results: Airway irritability was not significantly different between the groups. In F group, mean blood pressure at LOC ver and LOC BIS and heart rate at LOC ver, LOC BIS and just before intubation were lower than those of S group (P ＜ 0.05). Other results were not significantly different. Conclusions: The results of the study showed that intravenous fentanyl and lidocaine had no beneficial effects to reduce airway irritability, but intravenous fentanyl could significantly reduce hemodynamic stimulation during inhalation induction with desflurane in the patients who were premedicated with midazolam. (Korean J Anesthesiol 2009; 57: 693∼7)

Remifentanil is a new member of fentanyl family and a short-acting, esterase-metabolized opioid.This study compared the perioperative characteristics of a remifentanil infusion with those of fentanyl bolus administration as an adjuvant to propofol infusion for the anesthetic management of patients undergoing ureteroscopic lithotripsy. Methods: Eighty patients were randomly assigned to receive either remifentanil target controlled infusion (R group, effect-site concentration of 4.0 ng/ml for induction followed by 2.0 ng/ml) or fentanyl bolus (F group, 2.0μg/kg before induction).All patients received propofol infusion as the part of the induction and maintenance.We investigated recovery profiles, adverse events and the ease of insertion of laryngeal mask airway (LMA) between the two groups.Heart rate (HR) and mean blood pressure (MBP) were also compared at baseline (T0), loss of consciousness (T1), insertion of LMA (T2), beginning and end of operation (T3, T4) and removal of LMA (T5). Results:The time from the end of anesthesia to spontaneous respiration, eye opening and LMA removal were significantly shorter for patients receiving remifentanil than for those receiving fentanyl.HR at T3 and T4 were lower in the R group than in the F group.Aldrete recovery score, time to discharge from recovery ward, the ease of insertion of the LMA, MAP and adverse events did not differ significantly between the two groups. Conclusions:Target controlled infusion of remifentanil combined with propofol can significantly shorten the early recovery time than fentanyl bolus administration without increasing adverse events in patients undergoing ureteroscopic lithotripsy.

Background: Many studies have suggested that propofol in combination with remifentanil may provide adequate conditions for tracheal intubation without the use of muscle relaxants. Other hypnotic drugs have not been thoroughly investigated in this regard. The goal of our study was to evaluate the effect of thiopental, propofol or etomidate on tracheal intubating conditions and hemodynamic changes using remifentanil in the absence of muscle relaxants. Methods: A total of 45 healthy adults were divided randomly into three groups. After iv lidocaine 1.5 mg/kg, thiopental 5 mg/kg (thiopental group) or propofol 2.5 mg/kg (propofol group), or etomidate 0.4 mg/kg (etomidate group) were injected. After the injection of study drugs, remifentanil 2 mcg/kg was administered. Ninety seconds after the administration of remifentanil, laryngoscopy and intubation were attempted. Intubating conditions were assessed and the mean arterial pressure and the heart rate was measured. Results: There were no significant differences in intubating conditions between patients in the three groups. The heart rate was significantly lower in the propofol and etomidate group patients when compared to the thiopental group patients after anesthetic induction. The mean arterial pressure was significantly lower in the propofol group patients when compared to the thiopental and etomidate group patients. Both heart rate and mean arterial pressure after tracheal intubation were significantly elevated in etomidate group patinets when compared to their preintubation value. Conclusions: The use of thiopental 5 mg/kg, propofol 2.5 mg/kg, and etomidate 0.4 mg/kg did not differ in effect under intubating conditions for tracheal intubation using remifentanil in the absence of muscle relaxants. Thiopental provided the best

Spontaneous intracranial hypotension due to spinal cerebrospinal fluid leakage is uncommon, relatively benign and usually self-limiting. However it is being increasingly recognized as a cause of postural headaches. The treatment options range from conservative supportive measures to an pidural blood patch. We report a 40-year-old woman who developed intracranial hypotention without any preceding events such as lumbar puncture, back trauma, surgical procedures or medical illnesses. The site of the cerebrospinal fluid leakage was identified at between the C1 to C2 level using computerized tomographic myelography. Consequently, the patient underwent a CT-guided autologous epidural blood patch at the C3-C4 level. Her symptoms were relieved immediately without recurrence.

Background: Angiotensin-converting enzyme inhibitors (ACE-I) have been widely used for cardiac patients. This study investigated the effect of omitting ACE-I medication on hemodynamics during induction of anaesthesia and operation in patients chronically treated with ACE-I undergoing off pump coronary artery bypass graft surgery (OPCAB). Methods: Sixty patients scheduled for OPCAB were included in this study. Patients not treated with ACE-I were included in control group (Group 1, n = 20). And then, patients treated with ACE-I more than 4 weeks were randomly divided into two groups: continuing group including patients who continued ACE-I medication until the morning of surgery (Group 2, n = 20) and discontinuing group including patients who discontinued ACE-I one day before the surgery (Group 3, n = 20). Norepinephrine (8μg/ml) was infused when systolic blood pressure decreased below 90 mmHg during induction and operation. Amount of norepinephrine infused and hemodynamic data were recorded. Results: Significantly larger amount of norepinephrine was infused in Group 2 than in other two groups during obtuse marginal artery anastomosis. Total amount of norepinephrine infused during the all coronary anatsomosis was significantly larger in Group 2 than those values in other two groups. Conclusions: Continuing ACE-I treatment until the morning of surgery significantly increased the use of norepinephrine during the anastomosis. In contrast, there was no significant difference in the use of norepinephrine between Group 1 and Group 3. Discontinuing ACE-I before the surgery may helpful to maintain hemodynamics stable during coronary anastomosis in OPCAB. (Korean J Anesthesiol 2007; 52: 34～41)

Background: Opioids are known to increase the incidence of postoperative nausea and vomiting (PONV). Remifentanil is an ultrashort-acting opioid with a potent analgesic effect and is useful for rapid emergence. This study compared the effect of remifentanil on the incidence and severity of PONV and postoperative pain with that of fentanyl in patients undergoing laparoscopic surgery, which is normally associated with a high incidence of PONV. Methods: Forty-four adult female patients, who were scheduled for laparoscopic ovarian cyst enucleation, were randomly assigned to either the remifentanil or fentanyl group. Anesthesia was induced with propofol after injecting fentanyl 2g/kg or remifentnail 1g/kg and was maintained with sevoflurane. Remifentanil and fentanyl was infused continuously in the range of 0.2-0.5g/kg/min and 0.03-0.05g/kg/min, respectively. Ketorolac 0.5 mg/kg was injected 30 min before the end of surgery. The incidence and severity of PONV and pain were recorded upon arrival at the recovery room and 2, 6, 12 and 24 hours thereafter. Results: The incidence and severity of PONV and pain were significantly higher in the remifentanil group upon arrival at the recovery room than in the fentanyl group. The incidence and severity of PONV and pain at the other measurement times were similar. Conclusions: Despite the ultrashort action duration of the remifentanil, the incidence and severity of PONV and postoperative pain immediately after awakening was higher in the remifentanil group undergoing laparoscopic ovarian cyst enucleation than in the fentanyl group. However, there were no significant differences after two hours in the recovery phase.

Brugada syndrome is an arrhythmic syndrome characterized by right bundle branch block, ST segment elevation in the precordial lead (), and sudden death caused by ventricular fibrillation, but with no evidence of an underlying structural heart disease. We report one case of spinal anesthesia for an appendectomy in a 44-year-old male patient diagnosed as having Brugada syndrome by characteristic ECG findings without untoward cardiovascular events.

Endoscopic thyroidectomy is being performed increasingly, because it is less invasive and more cosmetically advantageous, and thus improves the postoperative quality of life. However, the technical aspects of this procedure can increase the risk of certain complications, which include subcutaneous emphysema, hypercarbia, pneumothorax, and pneumomediastinum. This report describes the case of a 37-year-old female patient who had subcutaneous emphysema and hypercarbia due to increased carbon dioxide absorption during endoscopic thyroidectomy. After increasing minute ventilation, paying cautious attention to signs of other complications, the operation proceeded and blood gas findings improved. The operation ended successfully and she showed no further problems.

Background: Opioids are increasingly being administered intrathecally as adjuncts to local anesthetics. They enhance spinal anesthesia without prolonging motor recovery. We evaluated the effect of 10 of fentanyl to bupivacaine on sensory, motor block and side effects. Methods: Thirty six patients undergoing urologic surgery were randomized into two groups. Control group received bupivacaine 10 mg combined with normal saline 0.2 ml, and Fentanyl group received bupivacaine 10 mg with fentanyl 10 (0.2 ml). Results: There were no significant differences between two groups in the peak level of sensory block, onset of peak level, duration of motor block, and side effects. However, the time of regression from peak level to T10 in Fentanyl group was longer significantly than that of Control group. Conclusions: Intrathecal small dose fentanyl (10) on bupivacaine spinal blockade prolonged duration of sensory block and did not augment side effects and provide reliable anesthesia for urologic surgery.

Background : The purpose of this study was to assess the effects of succinylcholine(Sch) for insertion of laryngeal mask airway(LMA) during general anesthesia. We compare the bronchoscopic grade, incidence and severity of postoperative sore throat. Methods : Seventy patients were randomly divided into two groups. The succinylcholine(Sch) group received Sch 1.0 mg/kg, saline group received the same volume of saline 1 minute before the insertion of LMA. Anesthesia was induced with fentanyl 2 g/kg and propofol 2.5 mg/kg. Once the LMA was in the hypopharynx and the cuff inflated, a fiberoptic bronchoscope was immediately passed down through the LMA, and its position was graded from the mask aperture bars. No. of attempts, postoperative sore throat and other complications were also noted. Results : The bronchoscopic grade were aggravated in the Sch group(grade I, n=12; grade II, n=13; grade III, n=10), compared with saline group(22;9;4). The incidence and severity of postoperative sore throat in the recovery room were reduced in the Sch group. No. of attempts were not significantly different. Conclusion : The use of Sch for insertion of LMA during general anesthesia aggravated the bronchoscopic grade. However, the incidence and severity of postoperative sore throat could be reduced in the Sch group. (Korean J Anesthesiol 1997; 32: 919∼923)