Jong Bun Kim

Treatment for Postoperative Wound Pain in Gynecologic Laparoscopic Surgery: Topical Lidocaine Patches

BACKGROUND This article reports our early experience with the use of lidocaine patches for pain control in the immediate postoperative period after laparoscopic gynecologic surgery. SUBJECTS AND METHODS A prospective, double-blind, placebo-controlled clinical trial was conducted on 40 patients undergoing a gynecologic laparoscopy who were randomized to receive either topical patches of 700 mg of lidocaine (n=20) or placebo patches (n=20). The patch was divided evenly into four smaller patches, which were applied at the four port sites and changed every 12 hours for 36 hours after surgery. Postoperative pain was evaluated using the visual analog scale (VAS) score and the Prince Henry and 5-point verbal rating pain scale (VRS), and the analgesic requirement was also evaluated at 1, 6, 12, 24, and 36 hours after surgery. RESULTS The VAS score for wound pain was lower in the lidocaine patch group at 1 and 6 hours after surgery than the control group (P=.005 and <.0005, respectively). The VAS scores for postoperative pain were lower in the lidocaine patch group at rest 1 hour after surgery (P=.045). The 5-point VRS score for postoperative pain was lower in the lidocaine patch group at 6 and 12 hours after surgery (P=.015 and .035, respectively) than in the control group. CONCLUSIONS Topical lidocaine patches at the laparoscopic port sites reduced postoperative pain, particularly postoperative wound pain after gynecological laparoscopic procedures.

Effect of ketamine versus thiopental sodium anesthetic induction and a small dose of fentanyl on emergence agitation after sevoflurane anesthesia in children undergoing brief ophthalmic surgery

Background Emergence agitation (EA) in children after sevoflurane anesthesia is common. The purpose of this study was to compare the incidences of EA between ketamine and thiopental sodium induction in children underwent sevoflurane anesthesia. We also evaluated if a small dose of fentanyl could reduce the incidence of EA. Methods The patients who were scheduled for strabismus or entropion surgery were divided into 4 groups. The patients in Groups 1 and 2 were induced anesthesia with ketamine 1.5 mg/kg; those in Groups 3 and 4 were induced with thiopental sodium 5 mg/kg. The patients in Groups 1 and 3 received an injection of fentanyl 1.5 µg/kg, whereas the patients in Groups 2 and 4 received IV saline of the same volume. Anesthesia was maintained with sevoflurane. The recovery characteristics and EA in recovery room were assessed. Results The incidence of EA was significantly higher in Groups 2 and 4 and there was no difference between Groups 2 and 4. Group 2 had almost an eleven-fold higher risk of developing EA than did Group 1, and the incidence of EA in Group 4 was sixty-nine-fold higher than that of Group 1. The risk factor for EA was only the kind of medication. Preoperative anxiety had no significant correlation with EA. Conclusions The incidence of EA after sevoflurane anesthesia is similar between ketamine and thiopental sodium anesthetic induction in children undergoing pediatric ophthalmic surgery. Also, the addition of a small dose of fentanyl after anesthetic induction decreases the incidence of EA.

Postoperative Urinary Retention Following Anterior Cervical Spine Surgery for Degenerative Cervical Disc Diseases

Background Postoperative urinary retention (POUR) may cause bladder dysfunction, urinary tract infection, and catheter-related complications. It is important to be aware and to be able to identify patients at risk of developing POUR. However, there has been no study that has investigated the incidence and risk factors for the development of POUR following anterior cervical spine surgery for degenerative cervical disc disease. Methods We included 325 patients (164 male and 161 female), who underwent anterior cervical spine surgery for cervical radiculopathy or myelopathy due to primary cervical disc herniation and/or spondylosis, in the study. We did not perform en bloc catheterization in our patients before the operation. Results There were 36 patients (27 male and 9 female) that developed POUR with an overall incidence of 11.1%. The mean numbers of postoperative in-and-out catheterizations was 1.6 times and mean urine output was 717.7 mL. Thirteen out of 36 POUR patients (36%) underwent indwelling catheterization for a mean 4.3 days after catheterization for in-and-out surgery, because of persisting POUR. Seven out of 36 POUR patients (19%) were treated for voiding difficulty, urinary tract irritation, or infection. Chi-square test showed that patients who were male, had diabetes mellitus, benign prostate hypertrophy or myelopathy, or used Demerol were at higher risk of developing POUR. The mean age of POUR patients was higher than non-POUR patients (68.5 years vs. 50.8 years, p < 0.01). Conclusions To avoid POUR and related complications as a result of anterior cervical spine surgery for degenerative cervical disc disease, we recommend that a catheter be placed selectively before the operation in at-risk patients, the elderly in particular, male gender, diabetes mellitus, benign prostate hypertrophy, and myelopathy. We recommend that Demerol not be used for postoperative pain control.

Heparin resistance during cardiopulmonary bypass.

The hemostatic system is activated during cardiopulmonary bypass (CPB) procedures, and the use of heparin attenuates the coagulation. However, heparin resistance occurs in between 4 and 22% of patients undergoing cardiac surgery, and the preoperative use of heparin is usually responsible for this. Sometimes, critically ill patients are referred for intra-aortic balloon pump (IABP) insertion, and anticoagulation therapy with heparin is recommended to prevent thrombosis and embolization. The author experienced heparin resistance in patients who underwent percutaneous coronary intervention (PCI) and IABP insertion.

CHIP-mediated degradation of transglutaminase 2 negatively regulates tumor growth and angiogenesis in renal cancer

The multifunctional enzyme transglutaminase 2 (TG2) primarily catalyzes cross-linking reactions of proteins via (γ-glutamyl) lysine bonds. Several recent findings indicate that altered regulation of intracellular TG2 levels affects renal cancer. Elevated TG2 expression is observed in renal cancer. However, the molecular mechanism underlying TG2 degradation is not completely understood. Carboxyl-terminus of Hsp70-interacting protein (CHIP) functions as an ubiquitin E3 ligase. Previous studies reveal that CHIP deficiency mice displayed a reduced life span with accelerated aging in kidney tissues. Here we show that CHIP promotes polyubiquitination of TG2 and its subsequent proteasomal degradation. In addition, TG2 upregulation contributes to enhanced kidney tumorigenesis. Furthermore, CHIP-mediated TG2 downregulation is critical for the suppression of kidney tumor growth and angiogenesis. Notably, our findings are further supported by decreased CHIP expression in human renal cancer tissues and renal cancer cells. The present work reveals that CHIP-mediated TG2 ubiquitination and proteasomal degradation represent a novel regulatory mechanism that controls intracellular TG2 levels. Alterations in this pathway result in TG2 hyperexpression and consequently contribute to renal cancer.

Operating room fire using an alcohol-based skin preparation but without electrocautery

To the Editor, An operating room fire is rare but a well-known hazard that can result in significant patient morbidity. Due to their well-established antimicrobial properties, alcohol-based skin preparations are commonly used in the operating room despite their known flammability. The risk of an operating room fire with alcohol-based prep solutions is greatest in an oxygen-enriched atmosphere and the use of electrocautery as the ignition source. We report the occurrence of an operating room fire while using an alcohol-based skin preparation but without the use of electrocautery. An otherwise healthy 46-yr-old female patient was admitted to our institution for adhesiolysis of a flexion in her right third finger. She preferred general anesthesia. After routine monitors were applied and prior to induction of anesthesia, the patient’s lungs were preoxygenated with 100% oxygen at a flow rate of 5 L min. Anesthesia was induced with propofol 100 mg iv, lidocaine 40 mg iv, fentanyl 100 lg iv, and rocuronium 30 mg iv, followed by tracheal intubation. Anesthesia was maintained with 1-2 vol% of sevoflurane, with an oxygen to nitrous oxide ratio of 1:1 administered at a fresh gas flow rate of 3.0 L min. The patient was positioned supine on an operating room table with the affected hand placed on a hand surgery table that was well padded to prevent pressure sores or contusion to the ulnar nerve. An 18-in pneumatic tourniquet was applied to the patient’s right upper arm and a cotton drape was placed on the hand surgery table. The patient’s right arm was then prepped with an 83% ethyl alcohol solution (Green Ethyl Alcohol Solution 0.83ml/ml , Green Pharm, Korea). At this point, a fire suddenly ignited over the patient’s right arm. The fire was extinguished immediately with a wet cotton drape, and water and ice water were used to cool the wound. The patient’s right forearm became slightly swollen and red, and two small-sized blisters formed. The Safety Incident Management Committee investigated the cause of the fire. The surgeon explained the burn incident to the patient’s family, obtained their informed consent, and then performed the adhesiolysis using the finger tourniquet. During the investigation into the cause of the fire, no electrical short circuit was found around the patient or in the patient monitoring devices. The fire was considered to have been caused by pooling of the alcohol-based skin preparation fluid underneath the cotton drape on the hand surgery table. This produced alcohol vapour that was ignited by a static spark. Operating room fires from alcohol-based skin preparations usually occur in an oxygen-enriched atmosphere and are mainly associated with the use of electrocautery; however, ethyl alcohol is known to ignite and burn in room air (21% oxygen). A surface wiped down with alcohol requires only a single spark at room air oxygen concentrations to ignite. In this case, the operating room fire occurred during alcoholbased skin preparation without the use of electrocautery. Therefore, special precautions are necessary when alcoholbased skin preparations are used. The Emergency Care Research Institute has recommended that alcohol-based skin preparation solutions should not be allowed to pool and should be dry or dried before using electrocautery. In conclusion, the likelihood of fire can be reduced with awareness of the risk and by using simple prevention measures in every case. Anesthesiologists have a role to J. B. Kim, MD H. J. Jung, MD K. S. Im, MD (&) Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Uijeongbu St Mary’s Hospital, Uijeungbu-City, Gyeonggi-do, Korea e-mail: idonga@catholic.ac.kr

Dobutamine, not dopttmine, improves gastric intmmucostd pH during resuscitation from hemorrhagic shock in dogs

To the Editor: Preservation of splanchnic perfusion is considered an important goal of resuscitation because the derangement of gastrointestinal mucosal perfusion is the main cause of the progression of hemorrhagic shock into an irreversible state.1 When measuring systemic oxygenation only, the possibility of overlooking serious gastrointestinal mucosal ischemia is high, hence the need to monitor mucosal oxygenation selectively.2 We examined the effects of dopamine or dobutamine on the recovery of mucosal perfusion in a canine model of hemorrhagic shock. Thirty dogs were bled to a mean arterial pressure of 40 mmHg and maintained in this state for 90 min. After volume resuscitation, dogs were randomized to receive dopamine (DP, 4 μg·kg–1·min–1, n=10 ), dobutamine (DB, 7 μg·kg–1·min– 1, n=10 ), or no drug (C, n=10 ) and followed up for 180 min. The gastric intramucosal PCO2 and pH (pHi) were measured with a Trip® NGS catheter (Datex, Engstrom, Finland). The cardiac index was maintained higher with DP than with DB or C after resuscitation. However, the pHi was maintained higher with DB than with DP or C, while DP was not significantly different from C (Figure). We conclude that low-dose dopamine has little effect on the restoration of gastrointestinal mucosal oxygenation despite a significant improvement of cardiac index, and that dobutamine is effective to improve gastrointestinal mucosal oxygenation after volume resuscitation from hemorrhagic shock. This result may be explained by the dopamineinduced redistribution of perfusion away from the mucosal area3 and an increase in oxygen requirements greater than supply.4 Dobutamine may selectively dilate the intramucosal vessels to direct perfusion towards the mucosal and/or increase oxygen delivery more than oxygen requirements.5

Cardiopulmonary bypass weaning difficulty due to anomalous origin of coronary artery -A case report-

We report a case of hemodynamic instability after aortic valve replacement, due to the anomalous origin of the right coronary artery. During the cardiopulmonary bypass weaning process, hemodynamic instability occurred. The cause was not identified at first, and compression of the anomalous right coronary artery was thought to be the culprit, thereafter.

Barotrauma developed during intra-hospital transfer -A case report-

A 74-year-old male patient receiving ventilatory support due to aspiration pneumonia developed bilateral pneumothorax, pneumopericardium, pneumomediastinum, pneumo-retroperitoneum, and subcutaneous emphysema, after manual ventilation while being transferred from the intensive care unit (ICU) to the operating room (OR). These complications were assumed to be secondary to inappropriate manual ventilation of the intubated patient. In addition, it is likely that the possible migration of an already marginally acceptable endotracheal tube (ETT) position during transport was the cause of these complications. Finally, aggravation of a latent pneumothorax might have contributed to these complications.

Subclavian artery penetration involving central line access treated with a self-expanding stent

Fig. 2. (A) Angiogram shows the leakage of contrast media in the right subclavian artery (white arrow). (B) The angiogram following the insertion of the self-expanding stent shows no leakage of contrast media in the right subclavian artery (black arrow). Fig. 1. Chest computed tomography scan shows the central venous catheter penetrating the right subclavian artery and within the pleural space (white arrow). The large amount of pleural effusion with a passive atelectasis of the right lung, subsegmental atelectasis in the left lung, and a left mediastinal shift are shown. Left nephrectomy state and postoperative pneumoperitoneum can be seen.