Guie Yong Lee

The analgesic effect of the ultrasound-guided transverse abdominis plane block after laparoscopic cholecystectomy

Background Several methods are performed to control the pain after a laparoscopic cholecystectomy. Recently, the transverse abdominis plane block has been proposed to compensate for the problems developed by preexisting methods. This study was designed to evaluate the effect of the ultrasound-guided transverse abdominis plane block (US-TAP block) and compare efficacy according to the concentration of local analgesics in patients undergoing laparoscopic cholecystectomy. Methods Fifty-four patients undergoing laparoscopic cholecystectomy were randomized into three groups. The patients in Group Control did not receive the US-TAP block. The patients in Group B0.25 and Group B0.5 received the US-TAP block with 0.25% and 0.5% levobupivacaine 30 ml respectively. After the general anesthesia, a bilateral US-TAP block was performed using an in-plane technique with 15 ml levobupivacaine on each side. Intraoperative use of remifentanil and postoperative demand of rescue analgesics in PACU were recorded. The postoperative verbal numerical rating scale (VNRS) was evaluated at 20, 30, and 60 min, and 6, 12, and 24 hr. Postoperative complications, including pneumoperitoneum, bleeding, infection, and sleep disturbance, were also checked. Results The intraoperative use of remifentanil, postoperative VNRS and the postoperative demand of rescue analgesics were lower in the groups receiving the US-TAP block (Group B0.25 and Group B0.5) than Group Control. There were no statistically or clinically significant differences between Group B0.25 and Group B0.5. No complications related to the US-TAP block were observed. Conclusions The US-TAP block with 0.25% or 0.5% levobupivacaine 30 ml (15 ml on each side) significantly reduced postoperative pain in patients undergoing laparoscopic cholecystectomy.

Dexamathasone added to levobupivacaine improves postoperative analgesia in ultrasound guided interscalene brachial plexus blockade for arthroscopic shoulder surgery

Background The purpose of this study was to evaluate the effect of the addition of 5 mg dexamethasone to 10 ml of 0.5% levobupivacaine on postoperative analgesic effects of ultrasound guided-interscalene brachial plexus block (ISBPB) in arthroscopic shoulder surgery under general anesthesia. Methods In 60 patients scheduled for arthroscopic shoulder surgery that underwent general anesthesia, ISBPB was preoperatively performed with 10 ml of 0.5% levobupivacaine under the guidance of ultrasound and a nerve stimulator. Patients were randomly allocated to receive the same volume of normal saline (Group I), 5 mg of dexamethasone (Group II), or 1 : 400,000 epinephrine (Group III) as an adjuvant to the mixture. A blind observer recorded total analgesic consumption, sleep quality, complication, and patient satisfaction using a verbal numerical rating scale (VNRS) at 0, 1, 6, 12, 24, 48 h after the operation. Results All patients had successful ISBPB and excellent analgesic effects less than VNRS 4 up to discharge time. VNRS in Group II at 12 h and 48 h was statistically much lower than in Group I and III. There were no differences in total analgesic consumption, sleep quality, complications, and patient satisfaction. Conclusions We conclude that the addition of 5 mg of dexamethasone to 10 ml of 0.5% levobupivacaine in ISBPB showed improvement of postoperative analgesia for arthroscopic shoulder operation without any specific complications.

Severe Hypocalcemia Caused by Absorption of Sorbitol-Mannitol Solution during Hysteroscopy

Hysteroscopic procedure can be complicated by intravascular absorption of irrigating fluid. The clinical features of this complication are similar to transurethral resection of the prostate (TURP) syndrome. There have been few reports on hypocalcemia during endoscopoic surgery and clinical implications of hypocalcemia in TURP syndrome have been underestimated. We report a case of TURP syndrome association with a decreased ionized calcium concentration of 0.53 mM/L after the absorption of a large amount of sorbitol-mannitol solution during hysteroscopy. The hypotension which occurred in TURP syndrome did not respond to vasopressor and inotropic agent but responded to the administration of calcium. This case was also accompanied by hyponatremia, hyperglycemia and lactic acidosis through the metabolism of sorbitol.

Antinociceptive synergy between the cannabinoid receptor agonist WIN 55,212-2 and bupivacaine in the rat formalin test.

BACKGROUND:The analgesic interaction between cannabinoids and local anesthetics has not been investigated. We sought to determine the nature of the interaction between the intrathecal cannabinoid receptor agonist (WIN 55,212-2) and bupivacaine using the formalin test. METHODS:Lumbar intrathecal catheters were implanted in male Sprague-Dawley rats. After intrathecal administration of WIN 55,212-2, bupivacaine, or their combination, 50 &mgr;L of 5% formalin was injected subcutaneously into the hindpaw. Dose–response curves were established and the respective ED50 (50% effective dose) values were determined for each agent alone. Fixed-ratio combinations of WIN 55,212-2 and bupivacaine were tested for combined antinociceptive effects in the formalin test and an isobolographic analysis was performed to characterize the pharmacologic interaction of both drugs. RESULTS:Intrathecally administered WIN 55,212-2, bupivacaine, or their combination produced a dose-dependent decrease in the number of flinches during Phase 1 and 2 of the formalin test. Isobolographic analysis revealed a synergistic interaction between intrathecal WIN 55,212-2 and bupivacaine in both phases of the formalin test. In combination, the ED50 value was significantly smaller than the theoretical additive value (P < 0.05). CONCLUSIONS:These results demonstrate that intrathecally coadministered WIN 55,212-2 and bupivacaine provide synergistic antinociceptive interaction in both phases of the formalin test.

Effect of intraoperative infusion of ketamine on remifentanil-induced hyperalgesia.

Background Opioid induced hyperalgesia (OIH) is related with high opioid dosage, a long duration of opioid administration, and abrupt discontinuation of infused opioids in anesthetic settings. Ketamine is known to attenuate OIH efficiently, but methods of administration and methods to quantify and assess a decrease in OIH vary. We demonstrated the existence of remifentanil-induced hyperalgesia and investigated the ability of ketamine to attenuate OIH. Methods Seventy-five patients undergoing laparoscopic gynecologic surgery under remifentanil-based anesthesia were assigned to one of the following groups: (1) group RL (remifentanil 0.05 µg/kg/min), (2) group RH (remifentanil 0.3 µg/kg/min), or (3) group KRH (remifentanil 0.3 µg/kg/min + ketamine 0.5 mg/kg bolus with 5 µg/kg/min infusion intraoperatively). Desflurane was administered for maintenance of anesthesia to target bispectral index scores (40-60) and hemodynamic parameters (heart rate and blood pressure < ± 20% of baseline values). All parameters related to OIH and its attenuation induced by ketamine were investigated. Results There was no significant difference among the three groups related to demographic and anesthetic parameters except the end-tidal concentration of desflurane. Additional analgesic consumption, numerical rating scale scores at 6 and 24 h, and cumulative fentanyl dose were significantly higher in group RH than in the other two groups. The value difference of the Touch-Test sensory evaluation was significantly higher negative in group RH than in the other two groups. Conclusions Remifentanil-induced hyperalgesia is significantly attenuated by intraoperative bolus and infusion of ketamine. Ketamine also decreased tactile sensitization, as measured by Touch-Test sensory evaluation.

Effect of flumazenil on recovery from anesthesia and the bispectral index after sevoflurane/fentanyl general anesthesia in unpremedicated patients

Background Benzodiazepines have a hypnotic/sedative effect through the inhibitory action of γ-aminobutyric acid type A receptor. Flumazenil antagonizes these effects via competitive inhibition, so it has been used to reverse the effect of benzodiazepines. Recently, flumazenil has been reported to expedite recovery from propofol/remifentanil and sevoflurane/remifentanil anesthesia without benzodiazepines. Endogenous benzodiazepine ligands (endozepines) were isolated in several tissues of individuals who had not received benzodiazepines. Methods Forty-five healthy unpremedicated patients were randomly allocated to either flumazenil or a control groups. Each patient received either a single dose of 0.3 mg of flumazenil (n = 24) or placebo (n = 21). After drug administration, various recovery parameters and bispectral index (BIS) values in the flumazenil and control groups were compared. Results Mean time to spontaneous respiration, eye opening on verbal command, hand squeezing on verbal command, extubation and time to date of birth recollection were significantly shorter in the flumazenil group than in the control group (P = 0.004, 0.007, 0.005, 0.042, and 0.016, respectively). The BIS value was significantly higher in flumazenil group than in the control group beginning 6 min after flumazenil administration. Conclusions Administration of a single dose of 0.3 mg of flumazenil to healthy, unpremedicated patients at the end of sevoflurane/fentanyl anesthesia without benzodiazepines resulted in earlier emergence from anesthesia and an increase in the BIS value. This may indicate that flumazenil could have an antagonistic effect on sevoflurane or an analeptic effect through endozepine-dependent mechanisms.

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

The frequency of fentanyl-induced cough in children and its effects on tracheal intubation

STUDY OBJECTIVE To determine if fentanyl-induced cough was dose-dependent in children and whether it could affect tracheal intubation. DESIGN Prospective, randomized, double-blinded study. SETTING Operating room of a university-affiliated hospital. PATIENTS 160 ASA physical status I pediatric patients, aged two to 14 years, scheduled for elective surgery during general anesthesia and requiring orotracheal intubation. INTERVENTIONS Patients were divided into two groups. Group 1 patients were given fentanyl at a dosage of one microg/kg; Group 2 patients received two microg/kg of fentanyl. Induction of anesthesia was conducted immediately following cough cessation or one minute after the end of injection with propofol 2.5 mg/kg. At loss of eyelash reflex, rocuronium 0.6 mg/kg was given intravenously (IV). Two minutes later, tracheal intubation was started. MEASUREMENTS Onset and degree of cough and intubating conditions were observed and recorded. MAIN RESULTS No statistically significant differences in frequency of coughing or in intubating conditions between the two groups were noted. Cough severity in Group 1 was statistically lower than that of Group 2 (P < 0.05). Onset of cough in Group 2 (12.2 +/- 3.4 sec) was statistically shorter than in Group 1 (16.9 +/- 7.6 sec, P < 0.05). CONCLUSION Fentanyl at doses of one and two microg/kg may induce coughing in pediatric patients.

Impending compartment syndrome of the forearm and hand after a pressurized infusion in a patient under general anesthesia -A case report-

A 74-year-old woman underwent posterior lumbar decompressive fusion at L4-5 for treating spondylolisthesis, with the patient under general anesthesia and she was in the prone position. Following attempts to transfuse blood using a pressurized bag, the intravenous infusion site of the left hand along with the noninvasive blood pressure cuff was changed. Swelling and several bullae on the left forearm and hand were visible. Removal of intravenous catheter, hyaluronidase injection, wet dressing were subsequently performed. In postanesthesia recovery unit, the patient did not complain of pain, and the radial pulse and oxygen saturation of the left appeared normal. Three days after the incident, the edema on the patients forearm and hand subsided, and the patient was discharged without any complications two weeks afterwards. Impending compartment syndrome should be given close attention, and particularly when performing pressurized infusion in patients who are unable to express pain because they are under general anesthesia.

Topographic pattern of the brachial plexus at the axillary fossa through real-time ultrasonography in Koreans

Background The ability to explore the anatomy has improved our appreciation of the brachial anatomy and the quality of regional anesthesia. Using real-time ultrasonography, we investigated the cross-sectional anatomy of the brachial plexus and of vessels at the axillary fossa in Koreans. Methods One hundred and thirty-one patients scheduled to undergo surgery in the region below the elbow were enrolled after giving their informed written consent. Using the 5-12 MHz linear probe of an ultrasound system, we examined cross-sectional images of the brachial plexus in the supine position with the arm abducted by 90°, the shoulder externally rotated, and the forearm flexed by 90° at the axillary fossa. The results of the nerve positions were expressed on a 12-section pie chart and the numbers of arteries and veins were reported. Results Applying gentle pressure to prevent vein collapse, the positions of the nerves changed easily and showed a clockwise order around the axillary artery (AA). The most frequent positions were observed in the 10-11 section (79.2%) for the median, 1-2 section (79.3%) for the ulnar, 3-5 section (78.4%) for the radial, and 8-9 section (86.9%) for the musculocutaneous nerve. We also noted anatomical variations consisting of double arteries (9.2%) and multiple axillary veins (87%). Conclusions Using real-time ultrasonography, we found that the anatomical pattern of the major nerves in Koreans was about 80% of the frequent position of individual nerves, 90.8% of the single AA, and 87% of multiple veins around the AA.