Jinseok Yeo

The Effect of Lavender Oil on Stress, Bispectral Index Values, and Needle Insertion Pain in Volunteers

OBJECTIVES The purpose of this study was to investigate whether lavender oil aromatherapy can reduce the bispectral index (BIS) values and stress and decrease the pain of needle insertion in 30 volunteers. SUBJECTS AND METHODS Thirty (30) healthy volunteers were randomly allocated to 2 groups: the experimental group received oxygen with a face mask coated with lavender oil for 5 minutes, and the control group received oxygen through a face mask with no lavender oil for 5 minutes. The stress level (0=no stress, 10=maximum stress), BIS value, and pain intensity of needle insertion (0=no pain, 10=worst pain imaginable) were measured. RESULTS There were no significant differences in age, sex, height, and weight between the two groups. Stress level, BIS value, and pain intensity of needle insertion before aromatherapy were similar between the two groups. However, the stress values (p<0.001) and BIS value (p<0.001) after aromatherapy were significantly reduced compared with the control. In addition, the pain intensity of needle insertion was significantly decreased after aromatherapy compared with the control (p<0.001). CONCLUSIONS Lavender aromatherapy in volunteers provided a significant decrease in the stress levels and in the BIS values. In addition, it significantly reduced the pain intensity of needle insertion.

Antiemetic efficacy of dexamethasone combined with midazolam after middle ear surgery.

OBJECTIVES: To evaluate the antiemetic efficacy of dexamethasone combined with midazolam after middle ear surgery. STUDY DESIGN: A prospective, randomized, double-blind, placebo-controlled study. SETTING: University hospital. SUBJECTS AND METHODS: The study population consisted of 120 American Society of Anesthesiologists physical status I or II, adult female patients undergoing middle ear surgery under general anesthesia. Patients were randomized into three groups of 40 each who received a dexamethasone dose of 10 mg/kg (group D), a combination of dexamethasone 10 mg and midazolam 0.075 mg/kg (group DM), and normal saline (group C) immediately after the induction of anesthesia. The incidence of nausea and vomiting, usage of rescue antiemetics, pain intensity, and side effects, such as headache and dizziness, were assessed during the first 24 hours after surgery. RESULTS: The overall incidence of nausea and vomiting was significantly lower in group D (35%, P < 0.05) and group DM (25%, P < 0.05) compared with that in group C (65%). The incidences of vomiting and usage of rescue antiemetic drugs in group DM were lower than those in group D (P < 0.05). There were no significant differences among groups in pain intensity and side effects, such as headache and dizziness. CONCLUSIONS: The combination of dexamethasone and midazolam was better than dexamethasone alone in reducing the incidence of vomiting and the rescue antiemetic requirements in women patients undergoing middle ear surgery. However, this combination treatment did not significantly decrease the overall incidence of nausea and vomiting compared with the use of dexamethasone alone.

Effect of pretreatment with acetaminophen on withdrawal movements associated with injection of rocuronium: a prospective, randomized, double-blind, placebo controlled study

Background Withdrawal movement during rocuronium injection is a common, unresolved adverse effect. We aimed to investigate the effect of IV acetaminophen pretreatment on withdrawal movement during rocuronium injection. Methods This study enrolled 120 American Society of Anesthesiologists (ASA) I-II patients undergoing general anesthesia. They were randomly assigned to three treatment groups. After occluding venous drainage using a tourniquet on the upper arm, the saline group received 5 ml of 0.9% sodium chloride solution, the lidocaine group received 40 mg of lidocaine, and the acetaminophen group received 50 mg of acetaminophen. During injection of pretreatment drug, pain was assessed on a four-point scale. The tourniquet was released after 120 seconds and anesthesia was performed using thiopental sodium 5 mg/kg followed by rocuronium 0.6 mg/kg. The withdrawal movement was graded on a four-point scale in a double-blind manner. Results The incidence of pain on pretreatment injection in saline, lidocaine, and acetaminophen groups was 7.7%, 5.1%, and 2.5%, respectively. The incidence of withdrawal movements was 77.5% in saline group, 32.5% in lidocaine group, and 37.5% in acetaminophen group (P < 0.05). Conclusions Acetaminophen and lidocaine reduced the incidence of withdrawal movement after rocuronium injection compared with saline.

A peroxynitrite decomposition catalyst prevents mechanical allodynia and NMDA receptor activation in the hind-paw ischemia reperfusion injury rats

The contributions of superoxide and nitric oxide to ischemia/reperfusion (I/R)-induced neuropathic pain have previously been demonstrated in an animal model that mimics the symptoms of complex regional pain syndrome type I (CRPS I). Targeting peroxynitrite, which is the product of their interaction, may provide effective treatments for I/R-induced neuropathic pain. In this study, the effect of the peroxynitrite decomposition catalyst FeTMPyP [5,10,15,20-tetrakis (N-methyl-4′-pyridyl)porphyrinato iron (III)], administered at doses of 1, 3 and 10 mg/kg via intraperitoneal injection 30 min prior to reperfusion, was evaluated in rats with chronic post-ischemic pain. The pain behavior of the rats was tested with a von Frey filament. Phosphorylation of N-methyl-D-aspartate (NMDA) receptors in the L4/6 section of the spinal cord was measured on the third day following reperfusion by western blotting. The rats treated with 3 or 10 mg/kg FeTMPyP demonstrated significant increases in their paw withdrawal thresholds and decreased levels of phosphorylated NMDA receptor subunit 1 compared with those of the vehicle group (all P<0.001). These findings suggest that nitrosative stress, specifically that associated with peroxynitrite, may be involved in the mechanical allodynia and central sensitization that are associated with CRPS I and may provide a rationale for CRPS I treatment strategies using peroxynitrite decomposition catalysts.

Effects of Allopurinol and Apocynin on Renal Ischemia-Reperfusion Injury in Rats

BACKGROUND This study evaluated the effects of allopurinol (ALP), a xanthine oxidase inhibitor, and apocynin (APC), a NADPH oxidase inhibitor, administered alone or together, on kidney damage caused by renal ischemia-reperfusion (IR) in rats. METHODS Thirty rats were randomly assigned to 5 groups. Group 1 was a sham group. Group 2 was the renal IR control group (30-min ischemia followed by 24-h reperfusion). In groups 3 and 4, ALP or APC, respectively, was administered 1 h before the ischemia. In group 5, ALP and APC were co-administered. Blood urea nitrogen (BUN) and serum creatinine (Cr), renal tissue malondialdehyde (MDA) and superoxide dismutase (SOD), and histological changes were evaluated. RESULTS A significant increase in BUN and Cr level, and histological damage was seen in the IR control group, indicating renal injury. Elevated MDA and decreased SOD levels in the IR control group demonstrated that renal damage occurred through oxidative stress. Pretreatment with ALP or APC alone or together prevented IR-induced renal damage. However, there was no significant difference between treatment with a single drug and co-administration of ALP and APC. CONCLUSIONS The use of ALP and/or APC before ischemia may be beneficial to ameliorate renal IR injury.

Can intravenous patient-controlled analgesia be omitted in patients undergoing laparoscopic surgery for colorectal cancer?

PURPOSE Opioid-based intravenous patient-controlled analgesia (IV-PCA) is a popular method of postoperative analgesia, but many patients suffer from PCA-related complications. We hypothesized that PCA was not essential in patients undergoing major abdominal surgery by minimal invasive approach. METHODS Between February 2013 and August 2013, 297 patients undergoing laparoscopic surgery for colorectal cancer were included in this retrospective comparative study. The PCA group received conventional opioid-based PCA postoperatively, and the non-PCA group received intravenous anti-inflammatory drugs (Tramadol) as necessary. Patients reported their postoperative pain using a subjective visual analogue scale (VAS). The PCA-related adverse effects and frequency of rescue analgesia were evaluated, and the recovery rates were measured. RESULTS Patients in the PCA group experienced less postoperative pain on days 4 and 5 after surgery than those in the non-PCA group (mean [SD] VAS: day 4, 6.2 [0.3] vs. 7.0 [0.3], P = 0.010; and day 5, 5.1 [0.2] vs. 5.5 [0.2], P = 0.030, respectively). Fewer patients in the non-PCA group required additional parenteral analgesia (41 of 93 patients vs. 53 of 75 patients, respectively), and none in the non-PCA group required rescue PCA postoperatively. The incidence of postoperative nausea and vomiting was significantly higher in the non-PCA group than in the PCA group (P < 0.001). The mean (range) length of hospital stay was shorter in the non-PCA group (7.9 [6-10] days vs. 8.7 [7-16] days, respectively, P = 0.03). CONCLUSION Our Results suggest that IV-PCA may not be necessary in selected patients those who underwent minimal invasive surgery for colorectal cancer.

Effect of Intravenous High Dose Vitamin C on Postoperative Pain and Morphine Use after Laparoscopic Colectomy: A Randomized Controlled Trial

Background and Objective. Vitamin C has antioxidant, neuroprotective, and neuromodulating effects. Recently, it showed antinociceptive effect as a result of the antioxidant properties. Therefore, we designed this study to assess the effect of intravenous vitamin C on opiate consumption and pain in patients undergoing laparoscopic colectomy. Methods. A total of 100 patients were enrolled and allocated to receive 50 mg/kg vitamin C or placebo by intravenous infusion immediately after induction of anesthesia. Morphine consumption and scores of pain were assessed at 2, 6, and 24 h after completion of surgery. Results. There were 97 patients included in the analysis. Patients who received vitamin C had higher plasma concentrations of vitamin C at the end of surgery, significantly lower morphine consumption at the 2 h after end of surgery, and significantly lower pain scores at rest during first 24 h postoperatively. There was no significant difference between groups in side effects, fatigue score, or pain score during cough. Conclusion. This study shows high dose vitamin C infusion decreased postoperative pain during the first 24 h and reduced morphine consumption in the early postoperative period. Additional research needed to examine whether higher doses of vitamin C and longer infusion times can amplify these effects.

Effects of Glutathione on Mechanical Allodynia and Central Sensitization in Chronic Postischemic Pain Rats

Background The chronic postischemia pain (CPIP) model is an animal model using ischemia/reperfusion injury that mimics the symptoms of complex regional pain syndrome type I. Glutathione (GSH) prevents ischemia/reperfusion injury by scavenging free radicals. We conducted this study to investigate the protective effect of GSH in CPIP rats via changes of mechanical allodynia and phospholyration of the N-methyl-D-aspartate receptor subunit GluN1. Methods We divided 45 rats into 5 groups: sham, CPIP, CPIP + GSH 100 mg/kg, CPIP + GSH 200 mg/kg, and CPIP + GSH 500 mg/kg. Rats in the sham and CPIP groups received normal saline and rats in the other groups received GSH at the designated doses thirty minutes prior to reperfusion. Withdrawal thresholds were evaluated before sugery as well as 1, 3, and 7 days after surgery. pGluN1 level in the spinal cord was also measured. Results GSH treated rats show a significant increase in the withdrawal thresholds of both hind paws as compared with the CPIP group dose-dependently. The expression of pGluN1 in the GSH treated rats significantly decreased as compared to the CPIP group (all P < 0.05). Conclusion These findings suggest that GSH inhibited the development of mechanical allodynia and central sensitization in CPIP rats.

Refractory status epilepticus occurred at the end of sevoflurane anesthesia in patient with epilepsy

Status epilepticus (SE) is a single seizure or recurrent seizures lasting for more than 30 minutes, in which the consciousness is not regained. Refractory status epilepticus (RSE) is defined as status epilepticus that continues despite treatment with benzodiazepines and one antiepileptic drug [1]. The incidence of seizure activity in patients with epilepsy associated with anesthesia is 3.4% [2], but RSE is rarely reported during emergence of anesthesia. We describe a patient with epilepsy who developed RSE during and after emergence from anesthesia. A 5-year-old, 22 kg, female patient was presented for ventilating tube insertion. She had a history of traumatic subarachnoid hemorrhage, diffuse brain injury and basal skull fracture 2 years ago. She was diagnosed with simple partial seizure 14 months ago and had been treated with valproic acid 240 mg/day. She did not show seizure activity for 1 year. Preoperative valproic acid concentration was 53.9 ug/ml and electroencephalogram (EEG) was normal. Other preoperative evaluations were within normal value, but she showed rhinorrhea. On the day of surgery, she received valproic acid 10 mg/kg IV during nil per os (NPO). The patient was taken to the operation room. The heart rate, noninvasive blood pressure, oxygen saturation and BIS (A-2000, Asepct Medical Systems Inc, Natick, MA, USA) were continuously monitored. After preoxygenation, induction of anesthesia was performed using thiopental sodium 110 mg iv and rocuronium bromide 10 mg iv. After intubation, anesthesia was maintained with sevoflurane in an air-oxygen mixture (fraction inspired oxygen concentration = 0.5). Arterial oxygen saturation remained greater than 98% during the intraoperative course. No episodes of hypoxia occurred during the procedure. As the patient began to emerge from anesthesia (BIS value was approximately 70), focal clonic movement of the right face and right arm was occurred. We suspected seizure and gave her midazolam 4 mg iv, but focal clonic movement did not stop. Therefore, we gave her phenytoin 20 mg/kg iv for 20 minutes and started desflurane inhalation (end-tidal concentration was 8%). Her seizure activity ceased and BIS was below 10. We discontinued desflurane and tried to emerge her from anesthesia. After 10 minutes, she started focal seizure again (BIS values was 65). We started phenobarbital infusion 20 mg/kg for 20 minutes. Her seizure activity did not stop after phenobarbital infusion. We planned to move her to the intensive care unit. In the intensive care unit, we checked for complete blood count, electrolyte, arterial blood gas, urine analysis, liver function test, EEG and serum valproic acid level. EEG showed rhythmic or periodic spikes in the left occipital region and was suggestive of SE (Fig. 1). Serum valproic acid level was 36.2 ug/ml. Other laboratory values were within normal limit. We infused valproic acid 10 mg/kg for 1 hour. Focal seizure was stopped and she regained consciousness. She was discharged 2 days after without any other complication. Fig. 1 Electroencephalogram in the intensive care unit shows rhythmic or periodic spikes in the left occipital region. Arrows are spike. General anesthesia may increase seizure activity, such as withholding antiepileptic drugs while maintaining NPO status prior to surgery, sleep deprivation, and use of proconvulsant medications. Sevoflurane anesthesia causes epileptiform EEG activity and produce clinical evidence of seizures in patients with or without a history of epilepsy. Hypercarbia and hypoventilation during emergence from anesthesia may increase seizure susceptibility and prolong seizure duration [3]. Lowered antiepileptic drug level is a common cause of status epilepticus. In this case, postoperative serum valproic acid concentration was lower than preoperative level, despite of preoperative iv administration. There are two possible causes of lowered valproic acid level. First, the patient missed one or two dose of antiepileptic drugs after admission without notifying the medical staff. Second, phenobarbital and phenytoin are potent hepatic enzyme inducers. They may increase valproic acid metabolism and decrease plasma concentration [4]. Treatment of RSE starts immediately with additional agents. Most often recommended drugs for use as a continuous infusion are midazolam, propofol, pentobarbital and thiopental. Continuous drug infusion in RSE is titrated to achieve an EEG burst suppression pattern. If continuous EEG monitoring is not available, BIS monitor can be used to guide titration of anesthetics in RSE [5]. In conclusion, we report a case of RSE during emergence of general anesthesia that may be caused by sevoflurane anesthesia and lowered antiepileptic drug concentration.

Comparison of effect of premixed lidocaine in propofol with or without ketorolac pretreatment with placebo on reducing pain on injection of propofol: A prospective, randomized, double-blind, placebo-controlled study in adult Korean surgical patients.

BACKGROUND Pain on injection of propofol is a common adverse event. OBJECTIVE The aim of this study was to investigate the effect of a combination of ketorolac pretreatment and premixed lidocaine in propofol compared with placebo on propofol injection pain. METHODS In this prospective, randomized, double-blind, placebo-controlled study, Korean patients scheduled for elective plastic surgery were randomized to 1 of 3 groups. Group A received 15 mg ketorolac in saline IV as pretreatment. Groups B and C received 3 mL saline IV as pretreatment. Sixty seconds after pretreatment, groups A and B received a mixture of lidocaine 1% in propofol 1% at a 1:10 ratio and group C received propofol 1% alone. Pain during propofol injection was assessed on a 4-point scale (0 = none, 1 = mild, 2 = moderate, 3 = severe). RESULTS Ninety patients (41 men, 49 vvomen; mean age, 41.7 years; mean weight, 63 kg) completed the study. The overall incidence of pain on propofol injection was significantly lower in groups A (16.7%) and B (36.7%) than in group C (83.3%; both, P < 0.001). There was no significant difference in the incidence of pain between groups A and B. However, the patients in group A reported a significantly lower incidence of moderate (0% vs 33.3%; P < 0.001) and severe pain (0% vs 20%; P = 0.024) compared with those in group C. There were no significant differences in the incidences of moderate and severe pain between the B and C groups. CONCLUSIONS In this Korean population, premixed lidocaine in propofol with or without ketorolac pretreatment was associated with significantly less pain when compared with placebo. The combination of ketorolac pretreatment and premixed lidocaine in propofol was more effective in decreasing the incidence of moderate or severe pain compared with placebo.