Hae Ja Lim

A Meta-Analysis of Renal Function After Adult Cardiac Surgery With Pulsatile Perfusion

The aim of this meta-analysis was to determine whether pulsatile perfusion during cardiac surgery has a lesser effect on renal dysfunction than nonpulsatile perfusion after cardiac surgery in randomized controlled trials. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were used to identify available articles published before April 25, 2014. Meta-analysis was conducted to determine the effects of pulsatile perfusion on postoperative renal functions, as determined by creatinine clearance (CrCl), serum creatinine (Cr), urinary neutrophil gelatinase-associated lipocalin (NGAL), and the incidences of acute renal insufficiency (ARI) and acute renal failure (ARF). Nine studies involving 674 patients that received pulsatile perfusion and 698 patients that received nonpulsatile perfusion during cardiopulmonary bypass (CPB) were considered in the meta-analysis. Stratified analysis was performed according to effective pulsatility or unclear pulsatility of the pulsatile perfusion method in the presence of heterogeneity. NGAL levels were not significantly different between the pulsatile and nonpulsatile groups. However, patients in the pulsatile group had a significantly higher CrCl and lower Cr levels when the analysis was restricted to studies on effective pulsatile flow (P < 0.00001, respectively). The incidence of ARI was significantly lower in the pulsatile group (P < 0.00001), but incidences of ARF were similar. In conclusion, the meta-analysis suggests that the use of pulsatile flow during CPB results in better postoperative renal function.

Effect of propofol on cardiac function and gene expression after ischemic-reperfusion in isolated rat heart.

Background The aim of this study was to examine the cardiac function and transcriptional response of the heart to propofol after ischemia-reperfusion. Methods Rat hearts were Langendorff-perfused using the modified Krebs-Henseleit buffer, and took 20 min stabilizing periods, 40 min ischemia periods, and then 120 min reperfusion period. The hearts were divided into 5 groups; Control: 180 min perfusion after stabilization, Ischemic: 40 min global ischemia after stabilization, followed by 120 min reperfusion, Pre: 2 µM propofol treatment was preformed only before ischemia, Post: 2 µM propofol treatment was performed only during reperfusion after ischemia, Pre/Post: 2 µM propofol treatment was performed both before and after ischemia. The measurement for cardiac performances, such as left ventricular developed pressure (LVDP), rate of left ventricular pressure generation (dP/dt), heart rate, and coronary flow were obtained. The expression profiles of isolated mRNA were determined by using Agilent microarray and real time-polymerase chain reaction (RT-PCR) was used to confirm the microarray results for a subset of genes. Results The Post group showed better LVDP and dP/dt than the Ischemic group. But there were no significant differences in heart rate and coronary flow among the groups. On the results of RT-PCR, the expressions of Abcc9, Bard1, and Casp4 were increased, but the expressions of Lyz, Casp8, and Timp1 were decreased in the Post group compared with the Ischemic group. Conclusions This study suggests that 2 µM propofol may provide cardioprotective effect, and modulate gene expression such as apoptosis, and KATP ion channel related-genes during reperfusion in the isolated rat hearts.

A case of facial myofascial pain syndrome presenting as trigeminal neuralgia

Facial pain has many causes, including idiopathic factors, trigeminal neuralgia, dental problems, temporomandibular joint disorders, cranial abnormalities, and infections. However, the clinical diagnosis of facial pain is sometimes difficult to establish because clinical manifestations commonly overlap. The diagnosis of trigeminal neuralgia is based solely on clinical findings. Therefore, a careful evaluation of the patient history and a thorough physical examination are essential. This case describes a patient with facial myofascial pain syndrome involving the right zygomaticus, orbicularis oculi, and levator labii muscles, which presented as trigeminal neuralgia.

In-plane three-step needle insertion technique for ultrasound-guided continuous femoral nerve block after total knee arthroplasty: a retrospective review of 488 cases

Background Continuous femoral nerve block (CFNB) improves postoperative analgesia after total knee arthroplasty (TKA). The aim of this study was to investigate the clinical efficacy and complications of our in-plane three-step needle insertion technique that was devised to reduce the risk of direct femoral nerve injury during CFNB in anesthetized patients. Methods This retrospective study included 488 patients who had undergone TKA. Ultrasound (US)-guided CFNB was performed under general or spinal anesthesia using an in-plane, three-step needle insertion technique. The success rate and difficulties of catheter placement, clinical efficacy of analgesia, and complications were recorded. Results Femoral catheters were placed with a 100% success rate. In 488 patients, real-time US imaging revealed easy separation of the fascia iliaca and the femoral nerve following injection of local anesthetic through a Tuohy needle. Verbal numerical rating scale pain scores (0–10) were 2.0 ± 1.2, 3.5 ± 1.9, 3.2 ± 1.7, 2.9 ± 1.3, and 2.5 ± 1.1 at 1, 6, 12, 24 and 48 h postoperatively. No femoral hematoma, femoral abscess, or neurologic complications, including paresthesia or neurologic deficits, were observed during the 8-week follow-up period. Conclusions This retrospective study suggests that an in-plane three-step needle insertion technique for CFNB may reduce the risk of femoral nerve injury in anesthetized patients.

Postoperative renal function in patients is unaltered after robotic-assisted radical prostatectomy

Background Pneumoperitoneum with an intra-abdominal pressure (IAP) of 14 mmHg is known to decrease renal function. Robotic-assisted radical prostatectomy (RARP) requires an IAP of more than 15 mmHg for operation. Therefore, we retrospectively investigated whether patients who underwent RARP experienced renal insufficiency during the postoperative period (at postoperative days 7 and 30). Methods One hundred patients who underwent RARP were enrolled in this study. Preoperative serum blood urea nitrogen (BUN) and serum creatinine (Cr) levels were measured. Creatinine clearance (CrCl) was calculated using the Cockcroft and Gault formula. CrCl was calculated at 1 day before surgery (baseline), 2 hr postoperatively, and at 1, 3, 7, and 30 days postoperatively (POD 1, POD 3, POP 7, and POD 30). Patients were assigned to abnormal CrCl (n = 52) or normal CrCl groups (n = 48) on the basis of these measurements. Results Significant inter-group differences in BUN, Cr, and CrCl were observed at all postoperative time points. BUN and Cr decreased significantly at postoperative 2 hr and POD 1, 3, and 7 versus baseline in both groups, whereas CrCl increased significantly at postoperative 2 hr and POD 1, 3, and 7 versus baseline in both groups. However, BUN, Cr, and CrCl were similar at POD 30 and preoperatively in the two groups. Conclusions RAPR, which requires an IAP of 15-20 mmHg for more than 4 hr, does not induce renal dysfunction during the postoperative period, and even in those patients with an abnormal CrCl.

Effect of muscle relaxant on entropy during propofol anesthesia

BACKGROUND The purpose of this study was to investigate whether muscle relaxant affect the values of Entropy, response entropy (RE) or state entropy (SE) during propofol anesthesia. METHODS Eighty patients (ASA I) scheduled for elective surgery under general anesthesia were randomly assigned to four groups. Anesthesia was maintained at a SE value of 80 (80 +/- 2) using target controlled infusion (TCI) of propofol. After maintaining SE 80 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group I and same volume of normal saline was intravenously injected in group II. After maintaining SE 60 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group III and same volume of normal saline was injected intravenously in group IV. The mean arterial pressure, heart rate, SE and RE were measured before anesthetic induction and up to 5 min after vecuronium or normal saline injection in each group. RESULTS SE and RE were not changed in group II, but significantly decreased in group I (P < 0.05, respectively). In group III and IV, SE and RE were not changed in both groups. There were no significant hemodynamic changes among the four groups. CONCLUSIONS These results suggest that the effect of muscle relaxant on Entropy vary according to the baseline values of RE or SE during propofol anesthesia.

An unexpected increase of entropy in a sleepwalking disorder patient during propofol and remifentanil anesthesia -a case report-

We report a case of increased values of entropy parameters Response Entropy (RE) and State Entropy (SE) during intravenous general anesthesia in a sleepwalking patient. An ASA class II, 64-year-old woman with stress incontinence underwent mid-urethral sling surgery. Prior to surgery, the patient had been administered paroxetine, valproic acid and clonazepam for the treatment of sleepwalking disorder. After 10 min of target-controlled infusion of propofol and remifentanil, entropy values increased up to 94 (RE) and 88 (SE) for 10 min. The target effect-site concentrations of anesthetics increased from 4 to 7 µg/ml propofol and 4 ng/ml remifentanil, at which point values fell back to adequate anesthesia levels. Episodes of recall or of explicit memories did not occur during the anesthesia. In conclusion, sleepwalking patients with long-term use medications may need increment of anesthetic dose caused by the anesthetic drug metabolism activation or impairment or immaturity of inhibitory circuits in brain.

Severe bronchospasm in a premature infant during induction of anesthesia caused ventilation failure.

A 3-month-old (39 weeks postconceptual age) male infant weighing 2.9 kg was scheduled for laser photocoagulation with a diagnosis of retinopathy of prematurity. He was born at 27 weeks gestation with a birth weight of 970 g. He had been mechanically ventilated from birth for 20 days for respiratory insufficiency due to respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD). A chest X-ray performed before the sub sequent ligation of the patent ductus arteriosus showed bilateral haziness in the entire lung field due to the RDS and BPD during tracheal intubation. The infant required ventilation with a high concentration of oxygen and received surfactant therapy. Twenty days after birth, patent ductus arteriosus (PDA) liga tion was done under general anesthesia in which induction was achieved with inhalation of sevoflurane and 1 mg of rocuroni um. The operation proceeded uneventfully and the extubation was performed five days after the surgery. After extubation, the infant was able to breathe spontaneously with an incubator oxygen supply, and the oxygen saturation was maintained above 90%. After PDA ligation, the infant was diagnosed with retinopa thy of prematurity, and he was then scheduled for laser photocoagulation. On the chest X-ray, improvement of haziness was observed from five days before the operation. After consultation with pediatrics, the decision was made to operate. Upon arrival in the operating room, electrocardiography, pulse oximetry, and noninvasive blood pressure were monitored, and the patient’s vital signs were stable. Induction of anesthesia was achieved with thiopental (15 mg), rocuronium (2 mg), and sevoflurane. The tracheal intubation was performed with an uncuffed 3.5 mm internal diameter endotracheal tube, but there was no capnogram trace after three breaths. At this time, the oxygen saturation rapidly dropped to below 80%. The endotra cheal tube was removed because the anesthesiologist suspected esophageal intubation and the patient was ventilated with 100% oxygen via face mask. Mask ventilation was not performed well, and peak inspiratory pressure was revealed to be above 25 mmHg. The anesthesiologist suspected stiff lungs, which suggested bronchospasm. Hydrocortisone sodium succinate (SoluCortef Ⓡ , Pfizer Inc., New York, NY, USA) 20 mg was intravenously injected. Five minutes later, oxygen saturation slowly increased up to 99% and reintubation was attempted. Although it was confirmed by direct laryngoscopy that the tube had passed between the vocal cords, proper ventilation of the lungs was not achieved. No expired carbon dioxide was noted on the capnograph, and chest auscultation was equivocal. The oxygen saturation was then in the low sixties. After sevoflurane was administered by inhalation, a slight chest movement was noted, and oxygen saturation increased up to 80%. During that time, a portable chest radiograph was taken which revealed severe consolidation with air bronchograms (Fig. 1A). Despite ventilatory support for 10 minutes, the oxygen saturation failed to increase beyond 80%. Hydrocortisone sodium succinate 20 mg was then intravenously injected once more. Afterwards, SaO 2 was maintained at 88-93%. The surgery was cancelled, and glycopyrrolate

Feasibility of ultrasound-guided posterior approach for interscalene catheter placement during arthroscopic shoulder surgery

Background Continuous interscalene block has been known to improve postoperative analgesia after arthroscopic shoulder surgery. This was a prospective study investigating the ultrasound-guided posterior approach for placement of an interscalene catheter, clinical efficacy and complications after placement of the catheter. Methods Forty-two patients undergoing elective arthroscopic shoulder surgery were included in this study and an interscalene catheter was inserted under the guidance of ultrasound with posterior approach. With the inplane approach, the 17 G Tuohy needle was advanced until the tip was placed between the C5 and C6 nerve roots. After a bolus injection of 20 ml of 0.2% ropivacaine, a catheter was threaded and secured. A continuous infusion of ropivacaine 0.2% 4 ml/hr with patient-controlled 5 ml boluses every hour was used over 2 days. Difficulties in placement of the catheter, clinical efficacy of analgesia and complications were recorded. All patients were monitored for 48 hours and examined by the surgeon for complications within 2 weeks of hospital discharge. Results Easy placement of the catheter was achieved in 100% of the patients and the success rate of catheter placement during the 48 hr period was 92.9%. Postoperative analgesia was effective in 88.1% of the patients in the post anesthetic care unit. The major complications included nausea (7.1%), vomiting (4.8%), dyspnea (4.8%) and unintended vascular punctures (2.4%). Other complications such as neurologic deficits and local infection around the puncture site did not occur. Conclusions The ultrasound-guided interscalene block with a posterior approach is associated with a success high rate in placement of the interscalene catheter and a low rate of complications. However, the small sample size limits us to draw definite conclusions. Therefore, a well-designed randomized controlled trial is required to confirm our preliminary study.

The effect of intermittent levator massage with caudal block on management of levator ani syndrome - A case report -

Levator ani syndrome (LAS) is a functional disorder of the pelvic floor muscles in which recurrent and persistent distressing pain is felt in the anus without detectable organic pathology. Eighty one percent of coccygodynia was alleviated by the levator massage when the massage motion was repeated 10 to 15 times on each side of the pelvis daily for 5 or 6 days. The authors encountered the LAS patient for whom successive visit to pain clinic was economic burden. Therefore, the authors managed the patient by intermittent levator massage with caudal block, once a week for 3 times, resulting in two years of pain free status. Intermittent levator massage with caudal block may be as effective as successive levator massage and induce longer painless period in the management of LAS.