In-Suk Kwak

The relationship between bispectral index and targeted propofol concentration is biphasic in patients with major burns

Background:  Many pathophysiologic alterations in major burns can cause changes in the distribution of, and perhaps response to, drugs commonly used in anesthesia practice. This study was conducted to assess changes in bispectral index (BIS) caused by increasing the target propofol effect‐site concentration during a target‐controlled infusion (TCI) in major burns.

Clinical and Histological Correlation in Post-Burn Hypertrophic Scar for Pain and Itching Sensation

Background Hypertrophic scar following a burn is caused by the excessive deposit of collagen resulting in an exaggerated wound healing response. The burn patient complains of pain and itching over the scar, which can give rise to cosmetic and functional problems. Objective The aim of this study was to investigate the clinical and histological correlation of a hypertrophic burn scar for itching and pain sensations. Methods Thirty-eight patients underwent a scar release and skin graft. the modified Vancouver scar scale and the verbal numerical rating scale were recorded. All biopsies were taken from scar tissue (scar) and normal tissue (normal). Histologically, tissues were observed in the epidermis, the monocytes around the vessels, the collagen fiber, elastic fiber, and the mast cells. Results The mean total score of MVSS was 8.4±2.7 (pliability 2.0±0.9; thickness 1.8±0.9; vascularity 2.0± 0.9; and pigmentation 2.1±0.9). Pain and itching were 2.4±2.0 and 2.9±3.0. Epidermis were 7.9±2.8 layers (scar) and 4.0±0.8 layers (normal). The collagen fibers were thin and dense (scar) and thicker and loose (normal). The elastic fibers were thin and nonexistent (scar) and thin and loose (normal). Mast cells were 11.2±5.8/high power field (scar) and 7.4±4.1 (normal). Conclusion As the scar tissue thickens, the itching becomes more severe. The stiffness of the scar with the pain appeared to be associated with the condition of the tissue. The correlation between clinical and histological post-burn hypertrophic scars will help further studies on the scar. This helped with the development of the base material for therapeutic strategies.

Improvement of burn pain management through routine pain monitoring and pain management protocol

INTRODUCTION Pain management is an important aspect of burn management. We developed a routine pain monitoring system and pain management protocol for burn patients. The purpose of this study is to evaluate the effectiveness of our new pain management system. METHODS From May 2011 to November 2011, the prospective study was performed with 107 burn patients. We performed control group (n=58) data analysis and then developed the pain management protocol and monitoring system. Next, we applied our protocol to patients and performed protocol group (n=49) data analysis, and compared this to control group data. Data analysis was performed using the Numeric Rating Scale (NRS) of background pain and procedural pain, Clinician-Administered PTSD Scale (CAPS), Hamilton Depression Rating Scale (HDRS), State-Trait Anxiety Inventory Scale (STAIS), and Holmes and Rahe Stress Scale (HRSS). RESULTS The NRS of background pain for the protocol group was significantly decreased compared to the control group (2.8±2.0 versus 3.9±1.9), and the NRS of procedural pain of the protocol group was significantly decreased compared to the control group (4.8±2.8 versus 3.7±2.5). CAPS and HDRS were decreased in the protocol group, but did not have statistical significance. STAIS and HRSS were decreased in the protocol group, but only the STAIS had statistical significance. CONCLUSION Our new pain management system was effective in burn pain management. However, adequate pain management can only be accomplished by a continuous and thorough effort. Therefore, pain control protocol and pain monitoring systems need to be under constant revision and improvement using creative ideas and approaches.

The effect of heated breathing circuit on body temperature and humidity of anesthetic gas in major burns

Background Cold and dry gas mixtures during general anesthesia cause the impairment of cilliary function and hypothermia. Hypothermia and pulmonary complications are critical for the patients with major burn. We examined the effect of heated breathing circuit (HBC) about temperature and humidity with major burned patients. Methods Sixty patients with major burn over total body surface area 25% scheduled for escharectomy and skin graft were enrolled. We randomly assigned patients to receiving HBC (HBC group) or conventional breathing circuit (control group) during general anesthesia. The esophageal temperature of the patients and the temperature and the absolute humidity of the circuit were recorded every 15 min after endotracheal intubation up to 180 min. Results There was no significant difference of the core temperature between two groups during anesthesia. The relative humidity of HBC group was significantly greater compared to control group (98% vs. 48%, P < 0.01). In both groups, all measured temperatures were significantly lower than that after intubation. Conclusions The use of HBC helped maintain airway humidity, however it did not have the effect to minimize a body temperature drop in major burns.

Macintosh laryngoscope vs. Pentax-AWS video laryngoscope: comparison of efficacy and cardiovascular responses to tracheal intubation in major burn patients

Background Patients with major burns accompanied with airway edema need more attention for airway management. Although the Pentax-AWS has an advantage in managing endotracheal intubation more easily, its usefulness cannot be assured if it does not maintain hemodynamic stability in burn patients. The aim of this study was to compare cardiovascular responses and general efficacy of the Pentax-AWS and Macintosh laryngoscopes in burn patients. Methods American Society of Anesthesiologists physical status 2 or 3 adult patients with major burn injury were randomly assigned to group P (AWS, n = 50) or group M (Macintosh, n = 50). Fifty-nine patients assigned to the Macintosh group and no patient to AWS group were excluded because of failure to first intubation. Hemodynamic data at baseline, just before and after intubation as well as 3, 5 and 10 minutes after intubation and grade of sore throat were recorded in two groups. Intubation time, success rate of intubation, number of intubation attempts and the percentage of glottic opening (POGO) scores were also observed and analyzed in all patients. Results A statistically significant increase in heart rate just after laryngoscopy was seen in group M. The success rate of the first attempt in group P (100%) was greater than with the group M (46%). POGO scores were higher in group P (97 ± 4%) than in group M (48 ± 29%) Conclusions The use of Pentax-AWS offers a reduced degree of heart rate elevation compared with the Macintosh laryngoscope and better intubation environments in major burn patients.

The prevalence of human endogenous retroviruses in the plasma of major burn patients

BACKGROUND Approximately 8% of the human genome is composed of retroviral sequences, which are known as human endogenous retroviruses (HERVs) and, have been implicated in both health status and disease. Recently, indirect evidence for a possible role of retroviral elements in the systemic response to stress signals has been provided by several studies. In the present study, we sought to evaluate the relationship between HERVs and major burn in humans. METHOD We investigated the prevalence of HERV families by reverse transcriptase PCR (RT-PCR) in cell-free plasma samples from patients with burns and from normal individuals. RESULTS Different prevalences of HERV families were observed in the plasma samples from the burn patient group and normal group. Compared with the prevalences of HERV-W and HERV-K in the normal group, in the burn patient group, the prevalence of HERV-W was significantly lower (P<0.001), but the prevalence of HERV-K was higher (P=0.059). CONCLUSIONS Our study of the prevalences of HERVs revealed that the activation of certain HERV families may be influenced not only by burns but also by the initial treatments that were used to address these injuries.

Cardiovascular crisis after small dose local infiltration of epinephrine in patient with asymptomatic subarachnoid hemorrhage -A case report-.

The infiltration of dilute epinephrine solution has been used for many years to provide hemostasis. However, epinephrine has adverse cardiovascular effects, such as arrhythmia, pulmonary edema, and even cardiac arrest. We have experienced epinephrine-induced cardiovascular crisis, with severe hypertension, tachycardia, and cardiac arrest after subcutaneous infiltration of a 2% lidocaine and 1 : 200,000 epinephrine solution in a patient with an asymptomatic subarachnoid hemorrhage. We provided successfully advanced cardiac life support in the operating room and cardioverted the patient back into a sinus rhythm with no untoward effects. The patient recovered without any apparent sequelae after intensive care.

Serial Changes of Heat Shock Protein 70 and Interleukin-8 in Burn Blister Fluid

Background It has been reported that heat shock protein 70 (HSP70) and interleukin-8 (IL-8) play an important role in cells during the wound healing process. However, there has been no report on the effect of HSP70 and IL-8 on the blisters of burn patients. Objective This study aimed to evaluate the serial quantitative changes of HSP70 and IL-8 in burn blisters. Methods Twenty-five burn patients were included, for a total of 36 cases: twenty cases on the first day, six cases on the second, five cases on the third, three cases on the fourth, and two cases on the fifth. A correlation analysis was performed to determine the relationship between the concentration of HSP70 and IL-8 and the length of the treatment period. Results The HSP70 concentration was the highest on the first day, after which it decreased down to near zero. Most HSP70 was generated during the first 12 hours after the burn accident. There was no correlation between the concentration of HSP70 on the first day and the length of the treatment period. No measurable concentration of IL-8 was detected before 5 hours, but the concentration started to increase after 11 hours. The peak value was measured on the fourth day. Conclusion While HSP70 increased in the first few hours and decreased afterwards, IL-8 was produced after 11 hours and increased afterward in burn blister fluid. These findings provide new evidence on serial changes of inflammatory mediators in burn blister fluid.

Pericardial tamponade caused by massive fluid resuscitation in a patient with pericardial effusion and end-stage renal disease -A case report-

Pericardial tamponade can lead to significant hemodynamic derangement including cardiac arrest. We experienced a case of pericardial tamponade in a patient with end-stage renal disease. Hemodynamic changes occurred by unexpectedly aggravated pericardial effusion during surgery for iatrogenic hemothorax. We quickly administered a large amount of fluids and blood products for massive bleeding and fluid deficit due to hemothorax. Pericardial effusion was worsened by massive fluid resuscitation, and thereby resulted in pericardial tamponade. Hemodynamic parameters improved just after pericardiocentesis, and the patient was transferred to the intensive care unit.

Hemidiaphragmatic paralysis and hemohydrothorax following right internal jugular vein catheterization

21 year-old female patient (167 cm, 80 kg) has decided to undergo radical free flap in the left leg. After anesthetic induction, the needle was inserted by an anterior approach for central venous catheterization in right internal jugular vein. Good aspiration of blood into the syringe was seen at second venipuncture. One milliliter of blood was aspirated out and intravenous (IV) fluids were injected through a 14 gauge (G) main catheter after insertion of the catheter. After confirming the position of the patient over two steps (from supine to prone and right lateral decubitus) aspiration of blood through side catheter (18 G) was not done well and only injection of IV fluids was possible. We connected 500 ml 6% hydroxyethyl starch (Voluven, Fresenius Kabi, Germany) to each central venous catheter (CVC), because ineffective back flow was thought to be caused by obesity and right lateral decubitus position of the patient. The central venous pressure was measured (8 mmHg) and a wave pattern was seen. Three hours in the surgery, the patient again exhibited spontaneous respiration so 10 mg of rocuronium was injected through 18 G catheter of the central venous catheter. However, spontaneous respiration continued so another 10 mg of rocuronium was injected. Still, spontaneous respiration did not disappear and another 20 mg of rocuronium was injected but it had no effects. So we suspected the CVC was not placed in the vessel. Aspiration via CVC was immediately done and 2,400 ml of IV fluids were drained. The position of the CVC was to be checked after the operation and the surgery was continued after securing IV fluid supply line by the peripheral vessels. The postoperative CT of the neck and chest showed collapse of the right internal jugular vein, and the CVC running lateral to the vein, and the tip of the catheter was found in the pleural cavity (Fig. 1). Fig. 1 Chest and neck CT with enhancement. Right internal jugular vein is collapsed and the edematous anterior scalene muscle contains the catheter. The catheter is in the pleural cavity. IJV: internal jugular vein, SCM: sternocleidomastoid muscle. The endotracheal tube was removed on postoperative day 2 and the chest tube was removed after 9 days. Elevation of right diaphragm was found in the chest x-ray after 2 weeks but the patient was asymptomatic. The patient was under observation for 1 week but the paralysis did not improve. Fluoroscopy of diaphragm was done and it showed no movement of right diaphragm so the right diaphragmatic paralysis was diagnosed. The progress of the paralysis was observed because the patient did not have any complaining symptoms. The patient was discharged on post-op day 32. The elevated right diaphragm still remained in the chest x-ray before the discharge but it improved after 6 months. Because it is uncommon to find hydrohemothorax with diaphgragmatic paralysis among the complications associated with a CVC, a similar case could not be found. In addition, there are two points in this case that must be carefully looked at. First, that insertion of catheter outside the vessel could not be detected during insertion process even though there was about 1 ml of blood regurgitation. Second, the causes of the diaphragmatic paralysis was not clear. Hydrohemothorax or hydromediastinum can occur when IV fluids are injected without detecting malposition of the CVC. The following examples have been reported: when the catheter is placed outside the vessel as the vessel is expanded by a guidewire or dilator during the process of inserting the CVC [1]; when the vein ruptures due to excess IV fluids after the catheter was inserted in the external jugular vein or bracheocephalic vein rather than the targetted central vein [2]; and when the catheter deviates outside the vessel due to change of vessel wall or because the catheter is not fixed well in place even after placement of the catheter within the targetted vein [3]. The chest CT of the patient showed the CVC passed down outside the internal jugular vein into the pleural cavity. So primary malposition with initial intrapleural placement seems to be more likely. During catheterization, we confirmed aspiration of blood into the transparent part of large bore lumen and easy flushing indicated correct intrvascluar catheter placment. However, Hohlrieder et al. [4] mentioned that the blood regurgitated up to the transparent part of the 12 Fr catheter even though the CVC malposition, and described that 0.1 ml of blood can fill about 1 cm of the transparent part of 12 G catheter. The CVC used in the case that the authors read had volume less than 1 ml within the catheter. In this patient, hemorrhage occurred because the wall of vein was perforated by the guidewire or dilator. If the catheter was filled with the blood due to more than 2 ml hemorrhage and the tip of the catheter was sunk where the blood was collected, about 1 ml of blood could have been aspirated. The possible causes of the right diaphragmatic paralysis are phrenic nerve injury due to needle puncture in the neck, and phrenic nerve compression due to edema in the muscles and soft tissues around the catheter placed outside the vein. Also, inflammation due to injection of excess IV fluids may have caused the delayed diaphragmatic paralysis. No clinical reports of inflammation of colloids or crystalloids within the pleural cavity were found, but Hydroxyethyl starch solution mixed with blood was described to activate neutrophils and increase their adhesion ex vivo [5]. In order to reduce these complications, presence of catheter outside the vein needs to be detected immediately by aspirating enough blood through all catheters as well as the main catheter even with a successful venipuncture. And the additional control aspiration needs to be checked frequently during surgery before starting the infusions.