Eun Hee Chun

Which is your choice for prolonging the analgesic duration of single-shot interscalene brachial blocks for arthroscopic shoulder surgery? intravenous dexamethasone 5 mg vs. perineural dexamethasone 5 mg randomized, controlled, clinical trial

AbstractThe aim of this study was to compare the effect of intravenous (I.V.) dexamethasone with that of perineural dexamethasone on the prolongation of analgesic duration of single-shot interscalene brachial plexus blocks (SISB) in patients undergoing arthroscopic shoulder surgery. We performed a prospective, randomized, double-blind, placebo-controlled study. Patients undergoing elective arthroscopic shoulder surgery with ultrasound-guided SISB were enrolled and randomized into 2 groups. A total volume of 12 mL of the study drug was prepared with a final concentration of 0.5% ropivacaine. In the I.V. group, patients received SISB using ropivacaine 5 mg mL−1 with normal saline (control) with dexamethasone 5 mg I.V. injection. In the perineural group, patients received SISB using ropivacaine 5 mg mL−1 with dexamethasone 5 mg, with normal saline 1 mL I.V. injection. The primary outcome was the time to the first analgesic request, defined as the time between the end of the operation and the first request of analgesics by the patient. The secondary outcomes included patient satisfaction scores, side effects, and neurological symptoms. Patients were randomly assigned to 1 of the 2 groups using a computer-generated randomization table. An anesthesiologist blinded to the group assignments prepared the solutions for injection. The patients and the investigator participating in the study were also blinded to the group assignments. One hundred patients were randomized. Data were analyzed for 99 patients. One case in the I.V. group was converted to open surgery and was therefore not included in the study. Perineural dexamethasone significantly prolonged analgesic duration (median, standard error: 1080 minutes, 117.5 minutes) compared with I.V. dexamethasone (810 minutes, 48.1 minutes) (P = 0.02). There were no significant differences in side effects, neurological symptoms, or changes in blood glucose values between the 2 groups. Our results show that perineural dexamethasone 5 mg is more effective than I.V. dexamethasone 5 mg with regard to analgesic duration of SISB for arthroscopic shoulder surgery.

Effect of Propofol and Desflurane on Immune Cell Populations in Breast Cancer Patients: A Randomized Trial

Several factors can affect the perioperative immune function. We evaluated the effect of propofol and desflurane anesthesia on the surgery-induced immune perturbation in patients undergoing breast cancer surgery. The patients were randomly assigned to receive propofol (n = 20) or desflurane (n = 20) anesthesia. The total and differential white blood cell counts were determined with lymphocyte subpopulations before and 1 hr after anesthesia induction and at 24 hr postoperatively. Plasma concentrations of interleukin (IL)-2 and IL-4 were also measured. Both propofol and desflurane anesthesia preserved the IL-2/IL-4 and CD4+/CD8+ T cell ratio. Leukocytes were lower in the propofol group than in the desflurane group at 1 hr after induction (median [quartiles], 4.98 [3.87-6.31] vs. 5.84 [5.18-7.94] 103/µL) and 24 hr postoperatively (6.92 [5.54-6.86] vs. 7.62 [6.22-9.21] 103/µL). NK cells significantly decreased 1 hr after induction in the propofol group (0.41 [0.34-0.53] to 0.25 [0.21-0.33] 103/µL), but not in the desflurane group (0.33 [0.29-0.48] to 0.38 [0.30-0.56] 103/µL). Our findings indicate that both propofol and desflurane anesthesia for breast cancer surgery induce a favorable immune response in terms of preservation of IL-2/IL-4 and CD4+/CD8+ T cell ratio in the perioperative period. With respect to leukocytes and NK cells, desflurane anesthesia is associated with less adverse immune responses than propofol anesthesia during surgery for breast cancer. (Clinical trial registration at https://cris.nih.go.kr/cris number: KCT0000939) Graphical Abstract

A Modified Approach of Percutaneous Endoscopic Lumbar Discectomy (PELD) for Far Lateral Disc Herniation at L5-S1 with Foot Drop

Foraminal or extraforaminal Far Lateral Disc Herniations (FLDH) extending into or beyond the foraminal zone have been recognized as between 7-12% of all lumbosacral disc herniations. Conventional posterior laminectomy may not provide good access to a herniation that lies far lateral to the lateral margin of the pedicle. Use of the endoscopic technique through a percutaneous approach to treat such FLDH patients can decrease the surgical morbidity while achieving better outcomes. We made an effort to utilize the advantages of percutaneous endoscopic lumbar discectomy (PELD) and to determine the appropriate approach for FLDH at the level between the 5th Lumbar and first Sacral vertebrae(L5-S1). The authors present a case of an endoscopically resected lumbar extruded disc of the left extraforaminal zone with superior foraminal migration at the level of L5-S1, which had led to foot drop, while placing the endoscope in the anterior epidural space without facetectomy.

Airway management in patients with deep neck infections: A retrospective analysis.

AbstractSecuring the airway in patients undergoing surgical intervention to control a deep neck infection (DNI) is challenging for anesthesiologists due to the distorted airway anatomy, limited mouth opening, tissue edema, and immobility. It is critical to assess the risk of a potential difficult airway and prepare the most appropriate airway management method.We reviewed our anesthetic experiences managing patients with DNIs, focusing on the need for video-laryngoscope or awake fiberoptic intubation beyond a standard intubation from the anesthesiologists perspective.When patients had infections in the masticatory space, mouth of floor, oropharyngeal mucosal space, or laryngopharynx, their airways tended to be managed using methods requiring more effort by the anesthesiologists, and more extensive equipment preparation, compared with use of a standard laryngoscope. The degree to which the main lesion influenced the airway anatomy, especially at the level of epiglottis and aryepiglottic fold was related to the airway management method selected.When managing the airways of patients undergoing surgery for DNIs under general anesthesia, anesthesiologists should use imaging with computed tomography to evaluate the preoperative airway status and a comprehensive understanding of radiological findings, comorbidities, and patients’ symptoms is needed.

Monitored anesthesia care for great saphenous vein stripping surgery with target controlled infusion of propofol and remifentanil: a prospective study

Background The aim of this study was to determine the appropriate target concentrations at the effect site of propofol and remifentanil when deep sedation was achieved by monitored anesthesia care (MAC) anesthesia and related respiratory depression during vein stripping surgery for varicose veins. Methods In total, 51 adult patients who were scheduled for varicose vein stripping surgery were sedated with propofol and remifentanil during the surgery, after administration of midazolam. Target concentrations at the effect site of the two drugs were changed based on the patients status. Respiratory support was applied in the order of oxygen supply, chin lift, and assisted mask ventilation. Target concentrations at the effect site of propofol and remifentanil, the need for respiratory support, and a six-point rating scale satisfaction score were the outcome measurements. Results Only one patient did not require oxygen, eight patients needed oxygen alone, 22 patients required use of the chin lift technique, and 20 patients were assisted with mask ventilation. There was no significant difference in the target concentration of propofol or remifentanil between the patients who required mask ventilation and those who did not. Fifty of the 51 patients reported a satisfaction score of 6. Conclusions Although MAC using low target concentrations of propofol and remifentanil during vein stripping surgery was satisfactory to patients, close observation regarding the need for respiratory assistance was necessary.

Polymorphisms in neuropeptide genes and bone mineral density in Korean postmenopausal women

Objective:The purpose of this study was to investigate the association between single nucleotide polymorphisms in neuropeptide genes and bone mineral density (BMD) in Korean postmenopausal women. Methods:Twenty polymorphisms in NMU (neuromedin U; two polymorphisms), NMU2R (NMU receptor 2; six polymorphisms), CART (cocaine- and amphetamine-regulated transcript; three polymorphisms), NPY (neuropeptide Y; four polymorphisms), NPY2R (NPY type 2 receptor; two polymorphisms), NOS1 (neuronal nitric oxide synthase; two polymorphisms), and MC4R (melanocortin 4 receptor; one polymorphism) genes were analyzed in 482 Korean postmenopausal women. BMD at the lumbar spine and femoral neck was also examined. Effects of polymorphisms on BMD were evaluated after adjusting for potential confounding factors using analysis of covariance. Odds ratios and 95% CIs for osteoporosis were estimated using &khgr;2 test or Fishers exact test. Results:Among the polymorphisms measured, the AG genotype of CART rs2239670 had the highest BMD at the lumbar spine. Furthermore, osteoporosis at the lumbar spine was more frequently observed in the GG genotype of NPY rs17149106 polymorphism and in the CC genotype of NPY rs16123 polymorphism and was less frequently observed in the TT-TT genotype identified by a combined polymorphism in the NPY2R gene, compared with the other genotypes. The AA genotype of NOS1 rs1279104 polymorphism was found to have a 3.68-fold higher prevalence of osteoporosis at the femoral neck compared with the GG genotype (95% CI, 1.29-10.50; P = 0.02). Conclusions:Results suggest that CART rs2239670 polymorphism may be one of the genetic factors affecting lumbar spine BMD in Korean postmenopausal women and that NPY rs17149106, NPY rs16123, NOS1 rs1279104, and combined (rs2880415 and rs6857715) polymorphisms in the NPY2R gene may be useful in identifying women at risk for osteoporosis.

Arytenoid cartilage dislocation mimicking bilateral vocal cord paralysis: A case report

Rationale: Arytenoid dislocation is very rare and may be misdiagnosed as vocal cord paralysis or a self-limiting sore throat. Patient Concerns: A 70-year-old male (70 kg, 156 cm) was scheduled for transurethral resection of bladder tumors. A McGrath videolaryngoscope, with a basic cuffed Mallinckrodt oral tracheal tube of 7.5 mm internal diameter, was used to successfully intubate his trachea. The duration of surgery was 25 minutes. In the recovery room, he complained of sore throat and dyspnea with inspiratory stridor, which were not resolved after intravenous injection of 10 mg of dexamethasone. Diagnoses: The otolaryngological examination revealed midline fixation of the bilateral vocal folds, suggestive of bilateral arytenoid dislocation or bilateral vocal cord palsy. The latter was ruled out because there was no evidence of recurrent laryngeal nerve injury. Interventions: Under general anesthesia, a closed reduction was performed using laryngoscopic forceps to apply posterolateral pressure on the arytenoid joints on both sides. Only the dislocation of the left cricoarytenoid joint could be easily reduced, whereas reduction of the right joint was not possible. Outcomes: On postoperative day 7, examination with a rigid laryngoscope showed a medially fixed right vocal fold, with full compensation by the left vocal fold. Computed tomography of the neck showed no pathologic findings. Six weeks after surgery, the patient had regained his normal voice with no complications. Lessons: Although arytenoid dislocation is a rare complication, it should be considered even in patients with uncomplicated tracheal intubation. Early diagnosis and the optimal therapeutic approach are critical for restoration of the patients original vocal cord function.

Ultrasound measurement of the vertebral level of Tuffier's line in elderly women

Background It would be imprecise to generalize the vertebral level determined by palpation to patients of all ages. The purpose of this study was to compare the vertebral level passed by Tuffiers line in elderly women with that passed in adult women using ultrasound in the left lateral decubitus flexed position. Methods We enrolled 50 female patients over the age of 65 (elderly group) and 50 female patients between ages 20 and 50 (control group) who had been scheduled to undergo spinal anesthesia. Using ultrasound, we marked the L2–5 lumbar spinous processes and intervertebral spaces. The most cephalad part was labeled 1 and the most caudal part was labeled 11. We then identified which line of these vertebral levels Tuffiers line crossed. Results The median value of the numbers signifying the vertebral level of Tuffiers line was 3 (the L2–3 intervertebral space) in the elderly group, while it was 8 (the lower part of the L4 vertebra) in the control group. The vertebral level of Tuffiers line had statistically significant correlations with age, body mass index, and weight in the elderly group (P < 0.001). Conclusions The vertebral level of Tuffiers line determined with ultrasound measurement in the left lateral decubitus flexed position was more cephalad in the elderly women than in those of the control group. Therefore, we should consider that the needle could be inserted at a higher level than expected, and use care in determining the level of needle insertion during spinal anesthesia in elderly women.