Jin Young Chon

Sugammadex versus neostigmine reversal of moderate rocuronium-induced neuromuscular blockade in Korean patients

Background Rapid and complete reversal of neuromuscular blockade (NMB) is desirable at the end of surgery. Sugammadex reverses rocuronium-induced NMB by encapsulation. It is well tolerated in Caucasian patients, providing rapid reversal of moderate (reappearance of T2) rocuronium-induced NMB. We investigated the efficacy and safety of sugammadex versus neostigmine in Korean patients. Methods This randomized, safety assessor-blinded trial (NCT01050543) included Korean patients undergoing general anesthesia. Rocuronium 0.6 mg/kg was given prior to intubation with maintenance doses of 0.1-0.2 mg/kg as required. Patients received sugammadex 2.0 mg/kg or neostigmine 50 µg/kg with glycopyrrolate 10 µg/kg to reverse the NMB at the reappearance of T2, after the last rocuronium dose. The primary efficacy endpoint was the time from sugammadex or neostigmine administration to recovery of the train-of-four (TOF) ratio to 0.9. The safety of these medications was also assessed. Results Of 128 randomized patients, 118 had evaluable data (n = 59 in each group). The geometric mean (95% confidence interval) time to recovery of the TOF ratio to 0.9 was 1.8 (1.6, 2.0) minutes in the sugammadex group and 14.8 (12.4, 17.6) minutes in the neostigmine group (P < 0.0001). Sugammadex was generally well tolerated, with no evidence of residual or recurrence of NMB; four patients in the neostigmine group reported adverse events possibly indicative of inadequate NMB reversal. Conclusions Sugammadex was well tolerated and provided rapid reversal of moderate rocuronium-induced NMB in Korean patients, with a recovery time 8.1 times faster than neostigmine. These results are consistent with those reported for Caucasian patients.

The effect of ulinastatin on hemostasis in major orthopedic surgery

Background Ulinastatin, a urinary trypsin inhibitor, is widely used to treat acute systemic inflammatory disorders. However, the effects of ulinastatin, especially on the potential for hemostasis, have not been fully elucidated. This study examined whether ulinastatin had any beneficial effects on blood loss and blood transfusion requirements in patients undergoing major orthopedic surgery. Methods Eighty patients, aged 18 to 75 years, scheduled for major orthopedic surgery were enrolled in this study and were divided into the ulinastatin (n = 40) and control (n = 40) groups. Following the induction of general anesthesia, and immediately before the surgical incision, the patients in the ulinastatin group were given 5,000 units/kg of ulinastatin, which were mixed in 100 ml normal saline intravenously over 30 min, while those in the control group received the same volume of normal saline. The amounts of blood loss, infused fluid, and transfused blood products were measured throughout the study period. Blood samples for coagulation parameters were obtained before inducing anesthesia (T1), at the end of surgery (T2), and 12 h after surgery (T3). Results The amounts of blood loss and infused fluid during surgery were not significantly different between the two groups. However, 12 h postoperative blood loss was significantly less in the ulinastatin group than in the control group (255.0 ± 133.2 ml VS. 395.4 ± 338.4 ml, P < 0.05). Conclusions Our data suggest that a single infusion of ulinastatin in major orthopedic surgery is associated with decreased blood loss in the early postoperative period.

Amnesia and pain relief after cardiopulmonary resuscitation in a cancer pain patient: a case report.

The mechanism of chronic pain is very complicated. Memory, pain, and opioid dependence appear to share common mechanism, including synaptic plasticity, and anatomical structures. A 48-yr-old woman with severe pain caused by bone metastasis of breast cancer received epidural block. After local anesthetics were injected, she had a seizure and then went into cardiac arrest. Following cardiopulmonary resuscitation, her cardiac rhythm returned to normal, but her memory had disappeared. Also, her excruciating pain and opioid dependence had disappeared. This complication, although uncommon, gives us a lot to think about a role of memory for chronic pain and opioid dependence.

Pulsed radiofrequency under ultrasound guidance for the tarsal tunnel syndrome: two case reports

Tarsal tunnel syndrome (TTS) is a compression neuropathy that results from entrapment of the posterior tibial nerve or its branches. TTS may be treated either by conservative measures, including physical therapy, medications, and steroid injections, or by surgical decompression. Despite a variety of treatments, a few cases of TTS will relapse, and many cases of recurrent TTS will require re-operation. Pulsed radiofrequency (PRF) is known to have a number of advantages for pain management, particularly as this technique does not cause neural compromise such as motor weakness. Here, we report a new application of ultrasound-guided PRF in two cases of intractable TTS. Both patients had a long duration of severe foot pain and had been treated with various therapeutic modalities without lasting relief. We applied ultrasound-guided PRF to the affected posterior tibial nerve in each patient, and both had significantly reduced pain intensity scores and analgesic requirements without any complications. Ultrasound-guided PRF for intractable TTS relieved severe foot pain. It may supersede surgery as a reliable treatment for intractable TTS.

Long-term Results of Stellate Ganglion Block in Patients with Olfactory Dysfunction.

Background Olfactory dysfunction, including anosmia and hyposmia is difficult to treat. Although the mechanism is not well known, stellate ganglion block (SGB) is used to treat olfactory dysfunction. There are no prior studies on the long-term effects of SGB on olfactory dysfunction. The purpose of this study was to evaluate the continuity of therapeutic effects and patient satisfaction with SGB treatment. Methods This was a follow-up study carried out via a telephonic survey. The olfactory function of the patient was evaluated using a visual analog scale (VAS). We checked VAS three times: VAS-I (pre-treatment VAS), VAS-A (post-treatment VAS), and VAS-C (VAS at follow up telephone survey). We divided the subjects into 2 groups according to their responsiveness to SGB: the responsive (R group) and the unresponsive groups (UR group). Patient satisfaction was evaluated using a Likert scale. Results Out of the 40 subjects, 37 responded to the telephone survey. In the UR group, there was difference in the olfactory function. However, in the R group, there were significant VAS differences; VAS-I was 9.6 ± 0.7, VAS-A was 5.1 ± 4.2, and VAS-C was 2.7 ± 2.7 (P < 0.05). On the Likert scale, patient satisfaction was as follows: grade 1, 17 patients (45.9%); grade 2, 6 patients (16.2%); grade 3, 6 patients (16.2%); and grade 4, 8 patients (21.6%). Conclusions SGB is a safe, long-lasting, and effective therapeutic modality for olfactory dysfunction treatment.

Air-Q®sp-assisted awake fiberoptic bronchoscopic intubation in a patient with Ludwig's angina

A drastic, progressive gangrenous cellulitis of the soft tissues of the deep neck and mouth floor was described in 1836 by the German surgeon Karl Friedrich Wilhelm von Ludwig [1]. Current medical care practices have meant that Ludwig’s angina is rarely seen. However, once the disease process is underway, there is a serious risk of sudden death due to airway obstruction. We describe the successful management of a case of Ludwig’s angina and provide details of awake fiberoptic bronchoscope (FOB) intubation using the Air-Q Ⓡ sp as a conduit. A 57-year-old, 80 kg man presented complaining of a 3 day history of mouth and neck pain, dyspnea, and dysphagia. The patient had no recent history of dental treatment, but had a medical history of gout, hypertension for 10 years, and a mild cerebral stroke 8 years previously. Laboratory tests revealed acute kidney injury combined with severe dehydration. Despite the hospitalized treatment for 2 days, his symptoms worsened and he began to exhibit the features of Ludwig’s angina. Neck computed tomography (CT) showed severe swelling of the left peritonsilar region with parapharyngeal space-occupying lesions, the aryepiglottic folds with obstruction of the left pyriform sinus were suggestive of a deep neck infection. The patient was scheduled to undergo emergency intubation ahead of surgery. The patient underwent hemodialysis to correct his renal and hemodynamic conditions prior to the procedure. He was febrile (a tympanic temperature of 39 o C), a heart rate of 115 bpm, a respiratory rate of 25, and blood pressure of 150/90 mmHg. The extent of mouth opening was slightly restricted with an inter-incisor gap of 2.5 cm. Tracheostomy was considered, but it was rejected because of concerns over the reduction in the patient’s cricothyroid space caused by the swelling, the limited extension and shortness of the neck with vague landmarks. Awake FOB intubation was selected as the safest option. The necessity of the procedure was explained to the patient and written informed consent was obtained. Because of the patient’s status, no premedication was administered. It was difficult to effectively administer nebulized drugs, so topical 4% lidocaine drops and a 10% lignocaine spray puff was used. The FOB (outer diameter of 3.5 mm) was fitted with a size 7.0 endotracheal tube (ET). After preoxygenation (SpO2 was 98%) and meticulous suction of oral secretions, the FOB tip was gently introduced into the oral cavity with the full cooperation. The vocal cords were visible, but it was hard to move past them because of their swollen and distorted anatomy, and moving the tongue disturbed the progress, thereby stopping the FOB tip. For the second attempt, a lubricated Air-Q Ⓡ sp size 3.5 (Cookgas LLC, St. Louis, USA) was gently inserted without hindrance, and a bite block was inserted through the tube of the Air-Q Ⓡ sp after removing the red-color coded connector. The prepared FOB and ET were inserted using the Air-Q Ⓡ sp as a conduit; the FOB tip was able to easily pass over the vocal cords and into the trachea. There were no difficulties in removing the Air-Q Ⓡ sp after intubation. Successful tracheal intubation had been achieved while maintaining spontaneous ventilation. The patient was admitted to the ICU for intensive medical care. The following morning, the patient was stable but neck CT showed the deep neck regions were aggravated. Elective surgery to incise and drain the lesions was performed. Surgery and postextubation recovery was uneventful. Clinical recovery was slow, with a persistent fever that lasted until the fifth day of

In the hour of Sugammadex

Sugammadex is a modified gamma-cyclodextrin which is showing favorable outcomes regarding reversal of neuromuscular blockade, especially by rocuronium. It is designed to encapsulate rocuronium and being considered a new class of drugs as selective relaxant binding agents. It has given countless benefits to the patients at risk of incomplete or delayed recovery after neuromuscular block and has renown for another milestone in anesthesia practice. Recurrence of neuromuscular block has not been reported to be associated with the provided doses of sugammadex that are adequate for selected for reversal. Acceptable profiles are brought to light telling safety of sugammadex. However, some questions related to the twitch characteristics those resembled succinylcholine when reversal, the application for rocuronium anaphylaxis, and the hypersensitivity or anaphylaxis to sugammadex remain and are need of further investigation. It is imperative that potential problems that we need attention may include the patients history of pulmonary disease and allergic disease for using sugammadex.

Lead fracture of peripheral nerve stimulator for brachial plexopathy -a case report-

Peripheral nerve stimulation (PNS) is a useful treatment for chronic pain, but it can cause damage depending on its application site. Here, we describe the case of a 54-year-old man who underwent PNS for brachial plexopathy in 2015. One lead was implanted on the left medial cord to stimulate the medial antebrachial cutaneous nerve, and the other was implanted on the radial nerve to stimulate the posterior antebrachial cutaneous nerve. Both leads were inserted near the shoulder joint but did not cross it. Before PNS, the patient did not move his shoulder and elbow because of severe pain, but the treatment greatly alleviated this pain. Twenty months after the operation, both leads were fractured, and the severe pain returned. Repetitive motion near the joint was closely related to the lead fractures. In conclusion, large joints as the insertion sites of PNS leads should be avoided to prevent lead fractures.

Aspiration of a sponge during conscious sedation

Conscious sedation under monitored anesthesia care is used for a wide range of operations including dacryocystorhinostomy. The most common side effects are this respiratory depression and apnea [1], which require constant care from anesthesiologists. Recently, we experienced an uncommon case of aspiration of a small surgical sponge from the nasal cavity during dacryocystorhinostomy performed on the patient under conscious sedation using the total intravenous anesthesia (TIVA) technique. This is a rare but potentially serious complication [2]. Anesthesiologists need to be cautious about maintaining adequate sedation levels to prevent adverse events from occurring. Additionally, surgeons need to ensure that surgical materials are not unintentionally misplaced or lost. A 68-year-old woman was admitted for surgery to treat a nasolacrimal duct obstruction. After the patient arrived at the operating room, we initiated standard monitoring with bispectral index (BIS). For oxygen supplementation, a nasal cannula was placed between the lips of the patient with O2 3 L/min. After confirming that all monitored parameters were normal, we infused 1000 mg propofol (Fresopol MCT inj 2% Ⓡ , Fresenius Kabi, Graz, Austria) and remifentanil (ULTIVA Ⓡ , GlaxoSmithKline, Brentford, Middlesex, UK) using an Orchestra TM module (Fresenius Vial, Brezins, France). By regulating the plasma remifentanil concentration to 2.0 ng/ml, the BIS value of the patient fell to 85. Next, we set the target concentration of propofol at 1.5 mcg/ml and her BIS values were maintained at approximately 80. Under these conditions, the patient breathed spontaneously and responded to our orders. The surgeon started the operation and we maintained a stable anesthetic depth. After 30 minutes, the patient intermittently stopped breath ing, but responded when we attempted to reawaken her. Her BIS value was not changed between 80 to 85 in this period. We reduced the target concentration of propofol to 1.0 mcg/ml and remifentanilto 0.5 ng/ml, but the patient continued to snore and took a deep breath in response to our order. About 45 minutes later, she suddenly became apneic and failed to respond to our stimuli. Her oxygen saturation decreased from 96 to 90%. Even though we raised the patient’s chin, her saturation decreased to 75% momently after one deep breath with BIS value also fell to 60. We stopped the operation, and started mask ventilation with 100% O2. Her saturation increased rapidly to 95% and the BIS value returned to 80. After consulting with the surgeon about continuing the operation, we intubated the patient without administering a muscle relaxant. The patient was still unresponsive despite hav ing a BIS value of 80. Surgeons went on operation and finished without special event. The patient fully awoke near the end of operation, she couldn’t stand intubation. Therfore, we extubated unwillingly. After then, we noticed that a small sponge (Petipad TM Neurosurgical Sponges Pollak Int., Euroband, France) was missing. It had been packed into a deep nasal cavity to control bleeding but could not find it in the nasal or oral cavity. We suspected that the sponge had been swallowed rather than aspirated because the patient’s vital signs remained stable with 100% oxygen saturation. We examined the chest X-ray to determine the location of the gauze. We discovered that the radio-opaque thread dangling from the sponge was located in the midline of the chest (Fig. 1A). It followed the shape of the trachea and main bronchus. Since we had already extubated the trachea, we decided to re

Anesthetic management of a neonate with congenital laryngeal cyst

Congenital laryngeal cysts are rare, with an incidence of 1.82 per 100,000 live births [1]. They arise from the glottic area (58.2%), ventricular fold (18.3%), vallecula (10.5%), epiglottis (10.1%), and the aryepiglottic fold, as an order of frequency [2]. A congenital laryngeal cyst may easily obstruct the smaller airway of a neonate [3]. During anesthesia for patients with laryngeal cysts, anesthesiolosists can face the risk of obscured views of the larynx, loss of the airway, risk of rupturing the cyst, and potential aspiration of cyst contents. A 3.83 kg-weighed, 21-day-old female neonate was scheduled for an elective operation on a laryngeal cyst. She was born at 39 weeks and two days of gestation by cesarean section at 3.7 kg body weight. She started to cough at 7 days after birth, exacerbated by feeding. Her chest x-ray was normal. The otolaryngologist heard stridor, and confirmed a laryngeal cyst by flexible fiberoptic laryngoscopy. They confirmed a 1.2 × 0.9 cm - sized large fluid attenuation mass at the right oropharyngeal region immediately below the vallecula by CT (Fig. 1). Her weight gain was only 130 gm during the 3 weeks after birth. She was inactive and cried very weakly. Fig. 1 Neck CT sagittal view shows a 1.2 × 0.9 cm - sized cyst (arrow) just below the vallecula, protruding into the airway. The major concern in anesthesia was how to intubate the trachea of the neonate. Our flexible endoscope has an outer diameter of 3.1 mm, unusable through 3.0 mm and 3.5 mm inner diameter endotracheal tubes. We decided to attempt an awake intubation. When the neonate arrived at the operating suite, her blood pressure was 75/40 mmHg, heart rate was 135 beats/min, and SpO2 was 97%. We injected glycopyrrolate 0.04 mg intravenously. After sufficient preoxygenation at right-side down decubitus position, we attempted a direct laryngoscopy with a Macintosh #1 blade. However, while the attempted intubation failed, her SpO2 did not decrease. From a brief observation during the first attempt, the laryngeal cyst completely blocked our view of the larynx. It appeared that she did not need sedative or anesthetics for further intubation procedure because she was inactive and her struggling was very weak during laryngoscopy. After the second trial of laryngoscopy that brought the same result, we decided to aspirate the cystic contents. We punctured the cyst with a 22 gauge needle and aspirated about 1 ml of the viscous fluid under the laryngoscopy at decubitus position, while an assistant suctioned the leaking fluid simultaneously. The cyst was decompressed and we intubated the trachea with a 3.0 mm inner diameter uncuffed endotracheal tube under the view of the entire glottis while the patient breathed spontaneously. We used 2% sevoflurane-O2 1 L/min-N2O 1 L/min through a semiclosed circuit and injected 0.5 mg of vecuronium bromide. Excision of the cyst under a microscope by the otolaryngologist took 40 minutes. The neonate recovered spontaneous ventilation and her trachea was extubated after an injection of glycopyrrolate 0.04 mg and pyridostigmine 1 mg. Her recovery process was unremarkable. At the follow-up to 4 months after surgery, her body weight had increased to 7.7 kg, and stridor no longer occurred during feeding. The presenting symptoms of laryngeal cysts can vary with age of the patient, and the size and location of the cyst. Laryngeal cysts in adults can either be asymptomatic until it is detected incidentally such as during intubation, or symptoms are similar to other space occupying lesions of the airway. In neonates and infants, they produce clinical presentations of upper airway obstruction, such as dyspnea, inspiratory stridor, and feeding difficulty soon after birth or during the first weeks of life [1-3]. In the series of pediatric vallecular cysts, the most common symptoms were stridor and feeding problems [3], causing our patient to fail to thrive. These conditions of the patient and the degree of airway obstruction influenced our plan to give her only minimal drugs during anesthesia. In diagnosis of a laryngeal cyst, flexible fiberoptic laryngoscopy is essential, as well as CT, MRI, or ultrasonography [4]. When we planned anesthesia, airway management was the most problematic aspect. There was the possibility of airway loss by sedation and paralysis. Through the first trial of direct laryngoscopy at awaken state, we judged that the neonate was tolerable for laryngoscopy and the airway was very difficult to intubate. Several reports have described the method of intubation in pediatric patients with laryngeal cysts. Ahrens et al. [4] intubated bronchoscopically through the laryngeal mask airway (LMA) in a 3-month-old infant with a vallecular cyst, using a 2.2 mm diameter very thin bronchoscope. In pediatric airway emergencies on children with vallecular cysts, emergency cyst puncture or tracheotomy have been performed [3]. The surgeons should be asked to be on standby for emergency tracheotomy. We considered which laryngoscopy blade would be useful. Any blade could compress the cyst, increasing the risk of rupture and aspiration. However, Kalra et al. [5] reported successful intubation in a neonate using a right paraglossal straight blade laryngoscopy (Miller size 0 blade) with the aid of an intubating stylet. It was considered appropriate to try the paraglossal approach in our case. The success of puncture and aspiration depends on the characteristics of the cystic contents. Very thick cystic content cannot be aspirated. For this reason, the authors recommended the use of a wide-bore needle to aspirate [1]. Fortunately in our case, the cystic contents were slightly turbid but aspirated well through a 22G needle. We kept in mind the possibility of pulmonary aspiration and suctioned the leaking contents at immediately below the decubitus position under laryngoscopic view. Congenital laryngeal cysts in pediatric patients are challenging cases for anesthesiologists. When we planned anesthesia, we thoroughly evaluated the general condition of the patient and the endoscopic and radiologic results of the epiglottic cyst. We could intubate successfully after aspiration of the cyst contents while the neonate breathed spontaneously. Also, alternative methods could be to use fiberoptic intubation with an ultrathin bronchoscope, intubating LMA, or paraglossal straight blade laryngoscopic technique. Whatever intubation methods are chosen, anesthesiologists should always be reminded of the potentially life-threatening nature of congenital laryngeal cysts.