Myoung Hoon Kong

Comparison of Surgical Pleth Index-guided Analgesia with Conventional Analgesia Practices in Children: A Randomized Controlled Trial.

Background:To compare surgical pleth index (SPI)-guided analgesia with conventional analgesia by evaluating intraoperative analgesic requirements, postoperative pain, and emergence agitation in children. Methods:This study was designed as a parallel, two-arm, double-blind, randomized controlled trial. Forty-five children undergoing elective adenotonsillectomy were randomly allocated to SPI-guided group (SPI-guided analgesia group, n = 21) or control group (conventional analgesia group, n = 24). Anesthesia was maintained with sevoflurane 2 to 3 vol% in 50% nitrous oxide and oxygen to achieve state entropy between 40 and 60. Intraoperative fentanyl 0.5 &mgr;g/kg was administered for the first event persisting 3 min and subsequent events persisting 5 min. An event was defined as an SPI over 50 (SPI-guided group) or a blood pressure or heart rate 20% above the baseline (control group). The primary outcome was intraoperative fentanyl requirement. Secondary outcomes included intraoperative sevoflurane consumption, postoperative emergence agitation and pain score, and postoperative rescue analgesic requirements. Results:Intraoperative fentanyl requirement was lower in SPI-guided group than in control group (0.43 ± 0.53 vs. 1.73 ± 0.59 &mgr;g/kg; P < 0.001). Intraoperative sevoflurane consumption was similar. The proportion of patients with high emergence agitation scores (4 to 5) was greater in SPI-guided group (61.9 vs. 25.0%; P = 0.01). The postoperative pain score and rescue fentanyl consumption were higher in SPI-guided group (7 [4.5; 9] vs. 3 [2; 6.75]; P = 0.002; 0.50 ± 0.34 vs. 0.29 ± 0.30 &mgr;g/kg; P = 0.04). Conclusions:As currently constructed, SPI does not appear to be valid in children. This may be due to both differences in blood vessel distensibility and baseline increased heart rates in children versus adults.

Antihistamine pretreatment to reduce incidence of withdrawal movement after rocuronium injection.

The purpose of this study was to determine the effectiveness of antihistamine therapy for withdrawal movements caused by rocuronium injection. One hundred seventy one ASA I-II adults undergoing elective surgery were randomly assigned to one of two groups. Patients in the control group (Group C) were premedicated with 2 mL normal saline, and those in the antihistamine group (Group A) were pre-medicated with 2 mL (45.5 mg) pheniramine maleate. After the administration of thiopental sodium 5 mg/kg, rocuronium 0.6 mg/kg was injected. Withdrawal movements were assessed using a four-grade scale. The administration of antihistamine reveals lower grade of withdrawal movement after rocuronium injection.

Reducing the Pain of Microemulsion Propofol Injections: A Double-Blind, Randomized Study of Three Methods of Tourniquet and Lidocaine

BACKGROUND Although the new formulation of lipid-free microemulsion propofol (MP) has some advantages over the lipid emulsion, it reportedly produces more injection pain than lipid-based propofol. Intravenous lidocaine with application of a rubber tourniquet before administration of propofol is considered to be the best method for reducing injection pain; however, this technique is not perfect. OBJECTIVE The goal of this study was to evaluate the effect of different methods of tourniquet application and lidocaine administration on MP injection pain. METHODS This single-center, randomized controlled clinical trial was conducted in 140 patients aged 18 to 65 years. Patients were randomly divided into 4 groups (n = 35 each). Group A received MP (2 mg/kg) after lidocaine (0.6 mg/kg) with a tourniquet with arm down (venous engorgement); group B received MP after lidocaine with a tourniquet with arm up (venous gravity drainage); group C received MP with a tourniquet with arm down; and group D (control group) received MP only (with no tourniquet). In groups A and C, the tourniquet was released after MP; in group B, the tourniquet was released before MP. Injection pain was evaluated by using a verbal pain score (VPS). The bispectral index, the time from the beginning of drug injection to the loss of eyelash reflex, and time to the lowest bispectral index value were recorded. RESULTS Group A showed significantly less incidence of pain than the control group when MP was injected. The mean VPS was significantly lower in groups A, B, and C than in group D (the control group). The VPS of group A was significantly lower than that in group B. Other observed values were not significantly different. CONCLUSIONS We concluded that intravenous retention of lidocaine with the application of a rubber tourniquet under venous engorgement of the arm reduces the incidence and intensity of MP injection pain. CLINICAL TRIAL REGISTRY UMIN000010725.

Fiberoptic intubation through a laryngeal mask airway as a management of difficult airwary due to the fusion of the entire cervical spine - A report of two cases -

Patients with cervical spine instability and limited range of motion are challenge to anesthesiologists. It is important to consider alternatetive methods for securing the airway while maintaining neutral position and minimizing neck motion, because these patients are at increased risk for tracheal intubation failure and neurologic injury during airway management or position change. We experienced two cases that patients had cervical spine instability and severe limited range of motion due to the fusion of the entire cervical spine. One patient was a 6-year-old girl weighing 12.7 kg and had Klippel-Feil syndrome with Arnold-Chiari malformation, the other was a 24-year-old female weighing 31 kg and had juvenile rheumatoid arthritis. We successfully performed the intubation by using the fiberoptic intubation though a laryngeal mask airway in these two cases.

Thoracic spinal cord stimulation for neuropathic pain after spinal meningioma removal: a case report.

Spinal cord stimulation (SCS) is highly successful for treating neuropathic pain but its effect is limited for central origin pain caused by cord injury. The authors describe a case in which pain was successfully controlled by SCS implantation in a patient with intractable chronic neuropathic pain after T5 meningioma removal. The authors tried lead insertion over the T5 level passing through postoperative adhesions to produce adequate stimulation to the patients painful areas fully enough without any complications. This case showed good response to SCS even though it was a central type of neuropathic pain by spinal cord injury.

Sugammadex for reversal of rocuronium-induced neuromuscular blockade in pediatric patients: A systematic review and meta-analysis.

Background:Previous studies have shown that sugammadex, a modified &ggr;-cyclodextrin, is a well-tolerated agent for the reversal of neuromuscular blockade (NMB) induced by a steroidal neuromuscular blocking drug in adult patients. However, its use has not been reviewed in pediatric patients. The aim of this meta-analysis was to evaluate the efficacy and safety of sugammadex in the reversal of rocuronium-induced NMB during surgery under general anesthesia in pediatric patients. Methods:A literature search was performed using the Pubmed, EMBASE: Drugs and pharmacology, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. Analysis was conducted using RevMan 5.3. Data collected from different trials were pooled; the weighted mean difference or the pooled risk ratio and the corresponding 95% confidence interval (CI) were used for analysis, and heterogeneity (I2) assessment was performed. Results:Six randomized controlled trials comparing 253 pediatric patients (age range, 2–18 years) were included in the final analysis. The mean time taken to reach a train-of-four ratio of ≥0.9 was significantly shorter in the sugammadex groups (2 and 4 mg/kg) than in the control group (neostigmine or placebo), although the heterogeneity was high. The weighted mean differences of the 2 and 4 mg/kg sugammadex groups were −7.15 (95% CI: −10.77 to −3.54; I2 = 96%; P = 0.0001) and −17.32 (95% CI: −29.31 to −5.32; I2 = 98%; P = 0.005), respectively. The extubation time in the sugammadex group was shorter than that in the control group; the weighted mean difference of the sugammadex group was −6.00 (95% CI: −11.46 to −0.53; I2 = 99%; P = 0.03). There was no significant difference between the groups in terms of the incidence of postanesthetic adverse events; the pooled risk ratio was 0.67 (95% CI: 0.27–1.71; I2 = 59%; P = 0.41). Conclusion:We suggest that sugammadex is fast and effective in reversing rocuronium-induced NMB in pediatric patients. Although there was no evidence of a higher incidence of adverse events with sugammadex compared to that with neostigmine or placebo, much more data regarding the safety of sugammadex in pediatric patients may be still required.

The analgesic effect of nefopam combined with low dose remifentanil in patients undergoing middle ear surgery under desflurane anesthesia: a randomized controlled trial

Background We investigated the effects of the combined administration of nefopam, a N-methyl-D-aspartate receptor antagonist and low dose remifentanil, on early postoperative pain and analgesic requirement. Methods Fifty patients scheduled to undergo mastoidectomy and tympanoplasty were randomized to be given either nefopam 40 mg mixed with normal saline 100 ml (Group N) or an equal amount of normal saline (Group C) before anesthesia induction. Anesthesia was maintained with 5-6 vol% desflurane and remifentanil 0.05-0.15 µg/kg/min during the surgery. Postoperative pain was controlled by titration of ketorolac in the postanesthesia care unit (PACU) and ward. We evaluated the intraoperative remifentanil dose, recovery profiles, ketorolac demand in the PACU and ward, numeric rating scale (NRS) for pain at time intervals of every 10 min for 1 h in the PACU, 6, 12, 18 and 24 h in a ward, as well as the time to first analgesic requirement in the PACU and ward. Results Ketorolac demand and NRS in the PACU were significantly lower in Group N than Group C (P = 0.002, P = 0.005, respectively). The time to first analgesic requirement in the PACU in Group N were significantly longer than Group C (P = 0.046). There were no significant differences in intraoperative remifentanil dose, ketorolac demand, NRS, and the time to first analgesic requirement in the ward between the groups. Conclusions Nefopam administration combined with low dose remifentanil infusion reduces pain and analgesic consumption during the immediate postoperative period in patients undergoing middle ear surgery under desflurane anesthesia.

Comparison of relative oxycodone consumption in surgical pleth index-guided analgesia versus conventional analgesia during sevoflurane anesthesia: A randomized controlled trial.

Background:The surgical pleth index (SPI) is proposed for titration of analgesic drugs during general anesthesia. Several reports have investigated the effect of SPI on the consumption of opioids including remifentanil, fentanyl, and sufentanil during anesthesia, but there are no reports about oxycodone. We aimed to investigate intravenous oxycodone consumption between SPI-guided analgesia and conventional analgesia practices during sevoflurane anesthesia in patients undergoing thyroidectomy. Methods:Forty-five patients undergoing elective thyroidectomy were randomly assigned to an SPI group (SPI-guided analgesia group, n = 23) or a control group (conventional analgesia group, n = 22). Anesthesia was maintained with sevoflurane to achieve bispectral index values between 40 and 60. In the SPI group, oxycodone 1 mg was administered intravenously at SPI values over 50; in the control group, oxycodone 1 mg was administered intravenously at the occurrence of tachycardia or hypertension event. Intraoperative oxycodone consumption and extubation time were recorded. The number of hemodynamic and somatic movement events was recorded, as were postoperative pain and recovery scores. Results:Patients’ characteristics were comparable between the groups. Intraoperative oxycodone consumption in the SPI group was significantly lower than the control group (3.5 ± 2.4 vs 5.1 ± 2.4 mg; P = 0.012). Extubation time was significantly shorter in the SPI group (10.6 ± 3.5 vs 13.4 ± 4.6 min; P = 0.026). Hemodynamic and somatic movement events during anesthesia were comparable between the groups, as were numeric rating scales for pain and modified Aldrete scores at postanesthesia care unit. Conclusions:SPI-guided analgesia reduces intravenous oxycodone consumption and extubation time compared with conventional analgesia based on clinical parameters during sevoflurane anesthesia in patients undergoing thyroidectomy.

Comparison of emergence agitation between sevoflurane/nitrous oxide administration and sevoflurane administration alone in children undergoing adenotonsillectomy with preemptive ketorolac

Background Sevoflurane anesthesia commonly causes emergence agitation (EA) in children. One previous study has reported that the use of nitrous oxide (N2O) during the washout of sevoflurane may reduce EA by decreasing the residual sevoflurane concentration, while many animal studies suggest that N2O poses a potential risk to children. The present study was designed to compare EA in children assigned to receive sevoflurane with N2O (group N) or sevoflurane alone (group S). Methods We enrolled 80 children aged 3-10 years. Anesthesia was induced with 5 mg/kg thiopental sodium, 0.6 mg/kg rocuronium and 0.5 mg/kg ketorolac, and was maintained with 50% N2O and sevoflurane in group N or with sevoflurane alone in group S. The sevoflurane concentration was adjusted with a bispectral index (BIS) of 40-60. After completion of the surgery, N2O and sevoflurane were simultaneously discontinued and replaced with oxygen (O2) at 6 L/min. End-tidal sevoflurane concentration (Et Sevo) (%), BIS at the end of surgery, Et Sevo at recovery of self-respiration and emergence profiles were recorded. EA occurrence, pain score and rescue fentanyl consumption were assessed in the postanesthesia care unit. Results Et Sevo was significantly lower in group N (1.9%) than in group S (2.3%) at the end of surgery. However, there were no differences in Et Sevo at recovery of self-respiration, emergence times, the incidence of EA, pain score or dose of rescue fentanyl between the groups. Conclusions In children undergoing adenotonsillectomy with preemptive ketorolac, anesthetic maintenance using sevoflurane alone does not affect the incidence of EA or emergence profiles compared to anesthetic maintenance using sevoflurane with N2O.

Possible role of GABAergic depolarization in neocortical neurons in generating hyperexcitatory behaviors during emergence from sevoflurane anesthesia in the rat

Hyperexcitatory behaviors occurring after sevoflurane anesthesia are of serious clinical concern, but the underlying mechanism is unknown. These behaviors may result from the potentiation by sevoflurane of GABAergic depolarization/excitation in neocortical neurons, cells implicated in the genesis of consciousness and arousal. The current study sought to provide evidence for this hypothesis with rats, the neocortical neurons of which are known to respond to GABA (γ-aminobutyric acid) with depolarization/excitation at early stages of development (i.e., until the second postnatal week) and with hyperpolarization/inhibition during adulthood. Employing behavioral tests and electrophysiological recordings in neocortical slice preparations, we found: (1) sevoflurane produced PAHBs (post-anesthetic hyperexcitatory behaviors) in postnatal day (P)1–15 rats, whereas it failed to elicit PAHBs in P16 or older rats; (2) GABAergic PSPs (postsynaptic potentials) were depolarizing/excitatory in the neocortical neurons of P5 and P10 rats, whereas mostly hyperpolarizing/inhibitory in the cells of adult rats; (3) at P14–15, <50% of rats had PAHBs and, in general, the cells of the animals with PAHBs exhibited strongly depolarizing GABAergic PSPs, whereas those without PAHBs showed hyperpolarizing or weakly depolarizing GABAergic PSPs; (4) bumetanide [inhibitor of the Cl− importer NKCC (Na+–K+–2Cl− cotransporter)] treatment at P5 suppressed PAHBs and depolarizing GABAergic responses; and (5) sevoflurane at 1% (i.e., concentration <1 minimum alveolar concentration) potentiated depolarizing GABAergic PSPs in the neurons of P5 and P10 rats and of P14–15 animals with PAHBs, evoking action potentials in ≥50% of these cells. On the basis of these results, we conclude that sevoflurane may produce PAHBs by potentiating GABAergic depolarization/excitation in neocortical neurons.