Mun Gyu Kim

Opioid sparing effect of low dose ketamine in patients with intravenous patient-controlled analgesia using fentanyl after lumbar spinal fusion surgery

Background The opioid sparing effect of low dose ketamine is influenced by bolus dose, infusion rate, duration of infusion, and differences in the intensity of postoperative pain. In this study, we investigated the opioid sparing effect of low dose ketamine in patients with intravenous patient-controlled analgesia (PCA) using fentanyl after lumbar spinal fusion surgery, which can cause severe postoperative pain. Methods Sixty patients scheduled for elective lumbar spinal fusion surgery were randomly assigned to receive one of three study medications (K1 group: ketamine infusion of 1 µg/kg/min following bolus 0.5 mg/kg, K2 group: ketamine infusion of 2 µg/kg/min following bolus 0.5 mg/kg, Control group: saline infusion following bolus of saline). Continuous infusion of ketamine began before skin incision intraoperatively, and continued until 48 h postoperatively. For postoperative pain control, patients were administered fentanyl using IV-PCA (bolus dose 15 µg of fentanyl, lockout interval of 5 min, no basal infusion). For 48 h postoperatively, the total amount of fentanyl consumption, postoperative pain score, adverse effects and patients satisfaction were evaluated. Results The total amount of fentanyl consumption was significantly lower in the K2 group (474 µg) compared to the control group (826 µg) and the K1 group (756 µg) during the 48 h after surgery. Pain scores at rest or with movement, the incidence of adverse events and patient satisfaction were not significantly different among the groups. Conclusions Low-dose ketamine at 2 µg/kg/min following bolus 0.5 mg/kg significantly reduced the total amount of fentanyl consumption during the 48 h after lumbar spinal fusion surgery without increasing adverse effects.

The analgesic effect of ultrasound-guided transverse abdominis plane block after laparoscopic totally extraperitoneal hernia repair

Background The ultrasound-guided transverse abdominis plane block (TAPB) reduces postoperative pain after laparoscopic abdominal surgery. But, its effect post laparoscopic totally extraperitoneal hernia repair (TEP) is not clear. In this study, we evaluated the analgesic effect of ultrasound-guided TAPB in TEP. Methods In this prospective, randomized study, forty adult patients (ASA I-II) scheduled for a TEP under general anesthesia were studied. In the TAPB group (n = 20), an ultrasound-guided bilateral TAPB was performed with 0.375% ropivacaine 15 ml on each side after the induction of general anesthesia. The control group (n = 20) did not have TAPB performed. Fentanyl 50 µg was repeatedly injected as per the patients request in the recovery room. Pain scores at rest and on coughing were assessed postoperatively in the recovery room (20 min, at discharge) and at 4, 8, and 24 hours after surgery. Results In the recovery room, pain scores (numeric rating scale, 0-10) at postoperative 20 min were lower in the TAPB group (3.9 ± 1.6, 4.9 ± 1.8) than the control group (6.9 ± 1.6, 8.0 ± 1.6) at rest and on coughing. Also, pain scores upon discharge from the recovery room were lower in the TAPB group (3.2 ± 1.2, 4.2 ± 1.5) than the control group (5.3 ± 1.6, 6.5 ± 1.8) at rest and on coughing. Conclusions The ultrasound-guided TAPB in patients that had undergone TEP reduced postoperative pain scores and the fentanyl requirement in the recovery room. Also, pain scores on coughing were reduced until postoperative 8 hours.

Suspected Anaphylactic Reaction Associated with Microemulsion Propofol during Anesthesia Induction

Although rare, intraoperative anaphylaxis can lead to significant morbidity and mortality. Aquafol® (Daewon Pharmaceutical Co. Ltd., Seoul, Korea), a microemulsion propofol, was developed to eliminate lipid solvent-related adverse events, and was used in clinical anesthesia since 2009 with little data about severe side effects such as anaphylaxis. A healthy 16-yr-old male patient who had past medical history with two previous operations of no complications developed cardiovascular shock with generalized erythema following administration of microemulsion propofol during anesthesia induction. Intravenous injection of epinephrine and steroid rescued him. He remained in a stable state without any problems postoperatively and was discharged. Clinicians should consider this rare but serious complication during induction of anesthesia with propofol.

Is transverse abdominis plane block effective following local anesthetic infiltration in laparoscopic totally extraperitoneal hernia repair

Background Transverse abdominis plane (TAP) block can be recommended as a multimodal method to reduce postoperative pain in laparoscopic abdominal surgery. However, it is unclear whether TAP block following local anesthetic infiltration is effective. We planned this study to evaluate the effectiveness of the latter technique in laparoscopic totally extraperitoneal hernia repair (TEP). Methods We randomly divided patients into two groups: the control group (n = 37) and TAP group (n = 37). Following the induction of general anesthesia, as a preemptive method, all of the patients were subjected to local anesthetic infiltration at the trocar sites, and the TAP group was subjected to ultrasound-guided bilateral TAP block with 30 ml of 0.375% ropivacaine in addition before TEP. Pain was assessed in the recovery room and post-surgery at 4, 8, and 24 h. Additionally, during the postoperative 24 h, the total injected dose of analgesics and incidence of nausea were recorded. Results: On arrival in the recovery room, the pain score of the TAP group (4.33 ± 1.83) was found to be significantly lower than that of the control group (5.73 ± 2.04). However, the pain score was not significantly different between the TAP group and control group at 4, 8, and 24 h post-surgery. The total amounts of analgesics used in the TAP group were significantly less than in the control group. No significant difference was found in the incidence of nausea between the two groups. Conclusions TAP block following local infiltration had a clinical advantage only in the recovery room.

Transient Horner’s syndrome following thoracic epidural anesthesia for mastectomy: a prospective observational study

PurposeTransient Horner’s syndrome is an uncommon complication of epidural anesthesia, though its exact incidence in thoracic epidural anesthesia is not clear. Therefore, this study prospectively evaluated the incidence of Horner’s syndrome after thoracic epidural anesthesia for mastectomy.MethodsPatients scheduled for mastectomy, with or without breast reconstruction, were enrolled in this prospective observational study from September 2010 to December 2013. Intraoperative thoracic epidural anesthesia was established using 0.375% or 0.5% ropivacaine 15 mL with thoracic epidural analgesia continued postoperatively with a continuous infusion of 0.15% ropivacaine 2xa0mL·hr−1 with fentanyl 8xa0μg·hr−1. Signs of Horner’s syndrome (miosis, ptosis, and hyperemia) were assessed at one and two hours as well as one, two, and three days postoperatively.ResultsThoracic epidural anesthesia was successful in 439 patients, with six (1.4%) of these patients acquiring Horner’s syndrome. All signs of Horner’s syndrome resolved gradually within 180 min of discontinuing the epidural infusion. In one patient with Horner’s syndrome, a radiographic contrast injection confirmed that the drug had spread to the cervical epidural level.ConclusionThe incidence of Horner’s syndrome following thoracic epidural anesthesia and continuous thoracic epidural analgesia for mastectomy was 1.4%. The mechanism was consistent with cephalic spread of the epidural local anesthetic. This trial was registered at: Clinicaltrials.gov, number: NCT02130739.RésuméObjectifLe syndrome de Horner transitoire est une complication rare de l’anesthésie péridurale, bien qu’on n’en connaisse pas précisément l’incidence dans l’anesthésie péridurale thoracique. Cette étude a donc évalué de manière prospective l’incidence du syndrome de Horner après anesthésie péridurale thoracique pour mastectomie.MéthodesDes patientes devant subir une mastectomie programmée, avec ou sans reconstruction du sein, ont été recrutées dans cette étude observationnelle prospective de septembrexa02010 à décembrexa02013. L’anesthésie péridurale thoracique peropératoire a été obtenue avec 15xa0ml de ropivacaïne à 0,375xa0% ou 0,5xa0% et l’analgésie péridurale thoracique a été poursuivie en postopératoire avec une perfusion continue de ropivacaïne à 0,15xa0% à raison de 2xa0ml·h−1 plus fentanyl 8xa0μg·h−1. Des signes du syndrome de Horner (myosis, ptose, et hyperhémie) ont été recherchés en postopératoire une et deux heures après l’intervention, puis un, deux et trois jours en post opératoire.RésultatsL’anesthésie péridurale thoracique a été un succès chez 439 patientes, parmi lesquelles 6xa0(1,4xa0%) ont éprouvé un syndrome de Horner. Tous les signes du syndrome de Horner ont progressivement disparu dans les 180xa0minutes suivant l’arrêt de la perfusion péridurale. Une radiographie avec injection de produit de contraste a confirmé chez une patiente présentant le syndrome de Horner que le médicament s’était étendu au niveau péridural cervical.ConclusionL’incidence du syndrome de Horner après anesthésie péridurale thoracique et analgésie péridurale thoracique continue pour mastectomie a été de 1,4xa0%. Son mécanisme était compatible avec la propagation céphalique de l’anesthésique local en péridural. Cette étude a été enregistrée sur le site ClinicalTrials.gov sous le numéro: NCT02130739.

Epidural Catheter Malposition in a Failed Epidural Anesthesia Confirmed by Computed Tomography

We report a case of failed epidural anesthesia despite successful identification of the epidural space, loss of resistance technique, hanging drop method and drip infusion. This case evaluated the use of computed tomography to confirm epidural catheter position, which showed the catheter accidentally positioned at the T2 lamina. Because epidural anesthesia can even after successful procedure using standardized techniques such as loss of resistance, we recommend performing the procedure under fluoroscopic guidance to improve success rate and patient safety.

Incidental left main bronchus obstruction during left-sided double-lumen tube intubation of a patient with an unrecognized tracheal bronchus: A case report

Introduction:Tracheal bronchus is a right-sided anomalous bronchus arising from the trachea above the main carina and occurs in 0.1% to 2% of the general population. Case presentation:We present a case of left main bronchus obstruction during a left-sided double-lumen tube intubation in a patient with an unrecognized tracheal bronchus. After the intubation, to confirm the position of the tube, we observed what we believed was the carina with a fiberoptic bronchoscope, but it was a site between the tracheal bronchus and the right main bronchus. Thus, a right-sided intubation was performed, and the left main bronchus was obstructed with a bronchial cuff. As a result of the inappropriate ventilation, peak inspiratory pressure was elevated and arterial oxygen saturation decreased. Conclusion:Anesthesiologists should keep in mind the possibility of anatomical variation in the large airways, and bronchoscopy should be accompanied by cautious auscultation and confirmation of the division of the bronchus.

Radiological analysis of the position of epidural catheters in the thoracic epidural space.

Thoracic epidural catheterization is used widely for anesthesia and postoperative pain control in thoracic and abdominal surgery. Generally, an epidural catheter is inserted only 4–5 cm into the epidural space, as excessive catheter insertion causes complications like vascular injury and paresthesias [1]. Nevertheless, a catheter can often be inserted quite a distance as a consequence of the catheter becoming dislodged outside the epidural space with changes in the patient’s position. Most studies of the amount of epidural catheter insertion have focused on the lumbar level [2,3]. Therefore, we examined catheter advancement at the thoracic level. This study enrolled 72 mastectomy patients graded as American Society of Anesthesiologists class I or II and treated under general or epidural anesthesia. A thoracic epidural catheter was inserted for post-surgical pain control. Patients with coagulopathy, infection at the needle puncture site, a history of spine surgery, or scoliosis were excluded. The aims of the study were explained to the patients and the study was approved by the Institutional Review Board. In a sitting position, the patient’s neck was flexed as much as possible while the patient held the opposite knee with both hands, and the inferior tips of both scapulas were palpated to find the seventh thoracic spinous process. Then, an epidural puncture was made in the largest interspinous space out of T3–4, T4–5, or T5–6. Using a midline approach, with the bevel of a 17-gauge Tuohy needle facing cephalad, the needle was inserted and the epidural space was confirmed by the loss-ofresistance method using air. Then, a 19-gauge end-hole epidural catheter (Flextip Plus TM Epidural Catheter; Arrow International

A rare case of nonresterilized reinforced ETT obstruction caused by a structural defect: A case report

Rationale: Various factors can cause ventilatory failure after endotracheal tube (ETT) intubation, which is associated with increased patient morbidity and mortality. Patient concerns: A 76-year-old woman who was diagnosed with a hemopericardium and suspicion of a major-vessel injury due to dislocation of the clavicular fracture fixation screw. Diagnosis: Non-resterilized reinforced ETT obstruction caused by a structural defect. Intervention: Endotracheal tube was exchanged. Outcomes: The ventilator profile showed rapid improvement. Lessons: Anesthesiologists should consider that a non-resterilized reinforced ETT may be defective. An ETT defect can cause high PIP and ETT obstruction without kinking or foreign materials.