Duck Hwan Choi

Bupivacaine-sparing effect of fentanyl in spinal anesthesia for cesarean delivery.

Background and Objectives: Visceral pain decreases in cesarean patients under spinal anesthesia when the dose of local anesthetic is increased. However, larger doses of local anesthetic are associated with higher sensory blocks. We hypothesized that the addition of fentanyl could reduce the dose of bupivacaine necessary to achieve adequate surgical anesthesia. Methods: Two double‐blinded, sequential, prospective studies were performed on 120 patients. In the preliminary study, the patients received 8, 10, or 12 mg of 0.5% hyperbaric bupivacaine intrathecally. In the second, main study, they received each bupivacaine dose with 10 μg of fentanyl. Each group consisted of 20 patients, and the groups were identified as B8, B10, B12, BF8, BF10, and BF12. Sensory and motor block, intraoperative pain defined by visual analogue scale (VAS), muscle relaxation, and side effects were assessed. We also measured the sensory and motor recovery and the onset of pain in the postanesthesia care unit (PACU). Results: Maximal block level and incidence of high block (≥T1) were higher in the 12‐mg groups. There was intraoperative pain in 35% of the B8 patients and 20% of the B10 patients, but none in the B12 patients and all fentanyl groups. Incidences of other side effects were not different. The addition of fentanyl to bupivacaine significantly delayed the onset of postoperative pain and sensory recovery, but motor recovery time did not change with additional fentanyl. Conclusions: The optimal dose of hyperbaric bupivacaine to produce surgical anesthesia was 12 mg, which was accompanied by high sensory block. With the addition of 10 μg of fentanyl, the dose of bupivacaine could be reduced to 8 mg in spinal anesthesia for cesarean delivery.

Comparison of combined spinal epidural anesthesia and epidural anesthesia for cesarean section

Background: Epidural anesthesia (EA) is popular for cesarean section, but has some drawbacks such as incomplete block, inadequate muscle relaxation and delayed onset. Combined spinal epidural anesthesia (CSEA) has gained increasing interest as it combines the reliability of a spinal block and the flexibility of an epidural block. We investigated the efficacy of CSEA that combines the main spinal and the supporting epidural anesthesia, comparing with pH‐adjusted EA, for cesarean section.

A Korean Predictive Model for Postoperative Nausea and Vomiting

Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications after surgery. An identification of risk factors associated with PONV would make it easier to select specific patients for effective antiemetic therapy. We designed a case-controlled study to identify the risk factors for PONV in 5,272 surgical patients. At postoperative 2 and 24 hr, patients were visited and interviewed on the presence and severity of PONV. Thirty nine percent of patients experienced one or more episodes of nausea or vomiting. Five risk factors were highly predictive of PONV: 1) female, 2) history of previous PONV or motion sickness, 3) duration of anesthesia more than 1 hour, 4) non-smoking status, and 5) use of opioid in the form of patient controlled analgesia (PCA), in the order of relevance. The formula to calculate the probability of PONV using the multiple regression analysis was as follows: P (probability of PONV)=1/1+e-Z, Z=-1.885+0.894 (gender)+0.661 (history)+0.584 (duration of anesthesia)+0.196 (smoking status) +0.186 (use of PCA-based opioid) where gender: female=1, male=0; history of previous PONV or motion sickness: yes=1, no=0; duration of anesthesia:more than 1 hr=1, less than or 1 hr=0; smoking status: no=1, yes=0; use of PCA-based opioid: yes=1, no=0.

Effects of epidural injection on spinal block during combined spinal and epidural anesthesia for cesarean delivery

Background and Objectives Epidural injection has been known to enhance spinal anesthesia in combined spinal and epidural (CSE) anesthesia. Saline and local anesthetics have been reported to have a volume effect, elevating sensory level when supplementing a volume into the epidural space. We evaluated the effects of epidural injection when using the CSE technique for cesarean delivery. Methods Sixty-six parturients were allocated randomly into group C (control, n = 21), S (saline, n = 21), or B (bupivacaine, n = 24): epidural injections of 10 mL saline and 0.25% bupivacaine were given in groups S and B, respectively, 10 minutes after they received 8 mg of 0.5% hyperbaric bupivacaine intrathecally, and no injection was given in group C. The sensory level at 10 minutes, the maximal level and the time to reach it, and degree of motor block and muscle relaxation were compared. We also investigated intraoperative side effects and postoperative findings in the postanesthesia care unit. Results Epidural injection raised the sensory level significantly in groups S and B, but the maximal height of sensory block and degree of muscle relaxation did not differ among the groups. Fewer patients complained of intraoperative pain in group B than in the other groups (P < .001). Conclusions We could not achieve satisfactory surgical analgesia with 8 mg of hyperbaric bupivacaine injected into the subarachnoid space using the needle-through-needle technique in cesarean deliveries. An epidural saline injection elevated the sensory level, which did not improve the spinal block, whereas an epidural injection of 10 mL of 0.25% bupivacaine enhanced the spinal block and sustained the block postoperatively.

Differentiating xanthogranulomatous cholecystitis from wall-thickening type of gallbladder cancer: Added value of diffusion-weighted MRI

AIM To evaluate the benefit of diffusion-weighted imaging (DWI) in differentiating xanthogranulomatous cholecystitis from the wall-thickening type of gallbladder cancer. MATERIALS AND METHODS This retrospective study was approved by the institutional review board. Fourteen patients with xanthogranulomatous cholecystitis and 19 patients with the wall-thickening type of gallbladder cancer were included. Qualitative (visual diffusion restriction compared to liver parenchyma) and quantitative [apparent diffusion coefficient (ADC)] analyses were performed. Conventional MRI findings including dynamic enhancement pattern between the two groups were also analysed. Two observers independently reviewed conventional magnetic resonance imaging (MRI) images and subsequently reviewed combined conventional MRI and DWI images. Pairwise comparison of the receiver operating characteristic (ROC) curves was used to compare diagnostic performances. RESULTS In conventional MRI findings, xanthogranulomatous cholecystitis showed significant continuity of enhancing mucosal line [79% (11/14) versus 26% (5/19), p = 0.003] and intramural T2-high signal intensity [64% (9/14) versus 21% (4/19), p = 0.012] compared to the wall-thickening type of gallbladder cancer. The enhancement pattern of gallbladder cancer compared to liver parenchyma showed earlier onset than that of xanthogranulomatous cholecystitis (p = 0.001). Diffusion restriction was more frequently seen in the wall-thickening type of gallbladder cancer (68%, 13/19) than in xanthogranulomatous cholecystitis (7%, 1/14; p < 0.001). The mean ADC value of xanthogranulomatous cholecystitis was higher than that of the wall-thickening type of gallbladder cancer with statistical significance (1.637 × 10(-3) mm(2)/s versus 1.076 × 10(-3) mm(2)/s, p = 0.005). Diagnostic performance [area under ROC curve (Az)] of both observers improved significantly after additional review of DWI; Az improved from 0.737 to 0.930 (p = 0.027) for observer 1 and from 0.675 to 0.938 (p = 0.008) for observer 2. CONCLUSION Addition of DWI to conventional MRI improves discrimination between xanthogranulomatous cholecystitis and the wall-thickening type of gallbladder cancer.

First-line radiofrequency ablation with or without artificial ascites for hepatocellular carcinomas in a subcapsular location: Local control rate and risk of peritoneal seeding at long-term follow-up

AIM To compare the long-term local control of hepatocellular carcinoma (HCC) and risk of peritoneal seeding via percutaneous radiofrequency ablation (RFA) using artificial ascites with those of RFA without artificial ascites. MATERIALS AND METHODS The Institutional Review Board approved this retrospective study. From April 2005 to February 2008, 160 patients (121 men, 39 women; age range 36-79 years) with a single subcapsular HCC (mean size 2.19 cm) were treated with ultrasonography-guided percutaneous RFA as a first-line therapy. Forty-four patients were treated with RFA using artificial ascites, whereas the other 116 patients were treated without artificial ascites. The cumulative local tumour progression (LTP) and peritoneal seeding were compared in both groups using follow-up computed tomography (CT). Cumulative LTP rates were analysed using the Kaplan-Meier method and the log-rank test. Risk of peritoneal seeding was investigated by means of multivariate analysis. RESULTS The overall median follow-up period was 52.5 months (range 13-76 months). The 1, 2, 4, and 6 year cumulative LTP rates were 17.1, 27.6, 35.2, and 35.2%, respectively, in the group with artificial ascites, and 8, 15.2, 26.6, and 34.4% in the group without artificial ascites, without significant difference (p = 0.332). The rates of peritoneal seeding were 6.8% (3/44) in the group with artificial ascites and 2.6% (3/116) in the group without artificial ascites, a non-significant difference (p = 0.347). The biopsy prior to RFA was the independent risk factor of peritoneal seeding regardless of the use of artificial ascites. CONCLUSION Long-term local tumour control and risk of peritoneal seeding were comparable for RFA with or without artificial ascites when used as a first-line therapy for subcapsular HCC.

Combination of Antiemetics for the Prevention of Postoperative Nausea and Vomiting in High-Risk Patients

It was previously reported that the Korean predictive model could be used to identify patients at high risk of postoperative nausea and vomiting (PONV). This study investigated whether PONV in the high-risk and very high-risk patients identified by the Korean predictive model could be prevented by multiple prophylactic antiemetics. A total of 2,456 patients were selected from our previous PONV study and assigned to the control group, and 374 new patients were recruited consecutively to the treatment group. Patients in each group were subdivided into two risk groups according to the Korean predictive model: high-risk group and very high-risk group. Patients in the treatment group received an antiemetic combination of dexamethasone 5 mg (minutes after induction) and ondansetron 4 mg (30 min before the end of surgery). The incidences of PONV were examined at two hours after the surgery in the postanesthetic care unit and, additionally, at 24 hr after the surgery in the ward, and were analyzed for any differences between the control and treatment groups. The overall incidence of PONV decreased significantly from 52.1% to 23.0% (p≤0.001) after antiemetic prophylaxis. Specifically, the incidence decreased from 47.3% to 19.4% (p≤0.001) in the high-risk group and from 61.3% to 28.3% (p≤0.001) in the very high-risk group. Both groups showed a similar degree of relative risk reductions: 59.0% vs. 53.8% in the high-risk and very high-risk groups, respectively. The results of our study showed that the antiemetic prophylaxis with the combination of dexamethasone and ondansetron was effective in reducing the occurrence of PONV in both high-risk and very high-risk patients.

Prolonged inspiratory time produces better gas exchange in patients undergoing laparoscopic surgery: A randomised trial

Laparoscopic surgery performed with a patient in the Trendelenburg position is known to have adverse effects on pulmonary gas exchange and respiratory mechanics. We supposed that prolonged inspiratory time can improve gas exchange at lower airway pressure.

Epidural anesthesia for cesarean section in a patient with Marfan syndrome and dural ectasia -A case report-

Pregnancy is considered a period of high risk for cardiovascular complications in patients with Marfan syndrome. Therefore the choice of anesthetic technique for delivery should be focused on minimizing hemodynamic fluctuations, and preferably provide adequate post-operative pain control. For this purpose, neuraxial blocks, such as spinal or epidural anesthesia, may be deemed a safe option. However, dural ectasia is present in 63-92% of patients with Marfan syndrome, and the increased amount of cerebrospinal fluid volume is thought to be one of main reasons for spinal anesthesia failure. We report herein the peri-operative management of a patient with Marfan syndrome and dural ectasia for cesarean section using epidural anesthesia.

Multiple infarcted regenerative nodules in liver cirrhosis after systemic hypotension due to septic shock: radiologic findings.

We describe a case of multiple infarcted regenerative nodules in a patient with advanced liver cirrhosis who had experienced an episode of septic shock. Sonography showed multiple hypoechoic or isoechoic nodules; contrast-enhanced computed tomography showed multiple, low-attenuating nodules with rim enhancement; and magnetic resonance imaging showed multiple nodules of low, iso-, or high signal intensity. Explanted liver showed coagulation necrosis of multiple regenerative nodules. Peribiliary cysts in chronic liver diseases, liver abscesses, spontaneous necrosis of hepatocellular carcinomas, and metastasis should be differentiated.