Po-Soon Kang

A comparison of infraclavicular and supraclavicular approaches to the brachial plexus using neurostimulation

Background A prospective, double blind study was performed to compare the clinical effect of vertical infraclavicular and supraclavicular brachial plexus block using a nerve stimulator for upper limb surgery. Methods One hundred patients receiving upper limb surgery under infraclavicular or supraclavicular brachial plexus block were enrolled in this study. The infraclavicular brachial plexus block was performed using the vertical technique with 30 ml of 0.5% ropivacaine. The supraclavicular brachial plexus block was performed using the plumb bob technique with 30 ml of 0.5% ropivacaine. The block performance-related pain was evaluated. This study observed which nerve type was stimulated, and scored the sensory and motor block. The quality of the block was assessed intra-operatively. The duration of the sensory and motor block as well as the complications were assessed. The patients satisfaction with the anesthetic technique was assessed after surgery. Results There were no significant differences in the block performance-related pain, frequency of the stimulated nerve type, evolution of sensory and motor block quality, or the success of the block. There were no significant differences in the duration of the sensory and motor block. There was a significant difference in the incidence of Horners syndrome. Two patients had a pneumothorax in the supraclavicular approach. There were no significant differences in the patients satisfaction. Conclusions Both infraclavicular and supraclavicular brachial plexus block had similar effects. The infraclavicular approach may be preferred to the supraclavicular approach when considering the complications.

Antinociceptive effect of phenyl N-tert-butylnitrone, a free radical scavenger, on the rat formalin test

Background Reactive oxygen species (ROS) such as superoxide radicals, hydrogen peroxide, nitric oxide, and nitroperoxide, cause oxidative stress which interferes with normal cell functioning, resulting in cell damage. It is reported to be associated with chronic pain, especially neuropathic pain, and inflammatory pain. ROS is also closely related to central sensitization. Therefore, this study was designed to explore the effects of Phenyl N-tert-butylnitrone (PBN), an ROS scavenger, in acute, continuous, and increasing pain caused by central sensitization. Methods Male Sprague-Dawley rats were divided into 2 groups, an intraperitoneal group (IP) and an intrathecal group (IT), and once again divided into an experimental group and a control group. The experimental group was injected with Phenyl N-tert-butylnitrone (PBN), a free radical scavenger, either intraperitoneally or intrathecally. After inducing pain by injecting formalin into the hind paw, pain behaviors were measured. Lumbar enlargement immmunohistochemistry was performed to assess nitrotyrosine, an oxidative stress marker, to identify the degree of protein nitration. Results Both experimental groups of IP and IT showed statistically significant decreases in the number of flinches compared to the control group in phase 1 and 2. Immunohistochemical evaluation in the control group revealed an increase in nitrated proteins in the gray matter of the lumbar spinal cord, but a significant decrease in nitrated proteins in the gray matter of lumbar spinal cord of the experimental group. Conclusions Intraperitoneal and intrathecal administration of PBN decreases analgesic behaviors, allowing us to believe that ROS is mainly responsible for acute pain and central sensitization.

Clinical effects of intrathecal fentanyl on shoulder tip pain in laparoscopic total extraperitoneal inguinal hernia repair under spinal anaesthesia: A double-blind, prospective, randomized controlled trial

Objective The study evaluated the clinical intraoperative effects of intrathecal administration of fentanyl on shoulder tip pain in patients undergoing laparoscopic total extraperitoneal inguinal hernia repair (TEP) under spinal anaesthesia. Methods Patients undergoing TEP were allocated in a double-blinded, prospective, randomized manner to two groups. Spinal anaesthesia was induced by intrathecal administration of 2.8u2009ml of 0.5% hyperbaric bupivacaine (14u2009mg) in the control group and with 2.6u2009ml of 0.5% hyperbaric bupivacaine (13u2009mg) and 10u2009µg fentanyl (0.2u2009ml) in the experimental group. Results The quality of muscle relaxation, adequacy of operative space and incidence of pneumoperitoneum were similar in the two groups (nu2009=u200936 per group). Compared with the control group, the experimental group had significantly fewer cases of hypotension (12 [33.3%]) versus 23 [63.9%]) and shoulder tip pain (nine [25%] versus 18 [50%]). Intraoperative shoulder tip pain was more severe in the control group than in the experimental group. Conclusions Addition of intrathecal fentanyl to local anaesthetic can relieve shoulder tip pain with no change in complications, especially hypotension, during TEP under spinal anaesthesia.

Predicted effect-site concentration of propofol and sufentanil for gynecological laparoscopic surgery.

Background: This study was to estimate the predicted effect‐site concentration of propofol administered by a target‐controlled infusion (TCI) for maintenance of anesthesia based on the bispectral (BIS) index as a measure of hypnosis in laparoscopic surgery.

Laparoscopic appendectomy under spinal anesthesia with dexmedetomidine infusion

Background Laparoscopic appendectomy (LA) is rarely performed under regional anesthesia because of pneumoperitoneum-related problems. We expected that dexmedetomidine would compensate for the problems arising from spinal anesthesia alone. Thus, we performed a feasibility study of spinal anesthesia with intravenous dexmedetomidine infusion. Methods Twenty-six patients undergoing LA received spinal anesthesia with intravenous dexmedetomidine infusion. During surgery, the patients pain or discomfort was controlled by supplemental fentanyl or ketamine injection, and all adverse effects were evaluated. Results No patient required conversion to general anesthesia, and all operations were completed laparoscopically without conversion to open surgery. Seventeen (65.4%) patients required supplemental injection of fentanyl or ketamine. Bradycardia occurred in seven (26.9%) patients. Conclusions Spinal anesthesia with dexmedetomidine infusion may be feasible for LA. However, additional analgesia, sedation, and careful attention to the potential development of bradycardia are needed for a successful anesthetic outcome.

Anesthesia in a child with adrenoleukodystrophy

X-linked adrenoleukodystrophy (ALD) is rare genetic disorder, and children with ALD are at an increased risk of anesthetic mortality and morbidity [1]. Therefore, they require an individual anesthetic protocol based on their clinical condition. Herein we report the case of a male with childhood-onset X-linked ALD who required general anesthesia for a dental operation. An 11-year-old male (height 143 cm, weight 30 kg) was scheduled for scaling and multiple deciduous tooth extractions under general anesthesia due to his failure to cooperate willingly. He had been diagnosed with childhood-onset X-linked ALD 3 years previously. Other history included an episode of status epilepticus, adrenal insufficiency, aspiration pneumonia, pressure sores and blindness. He was bed-ridden and maintained on a positive-pressure home ventilator via tracheostomy. Physical examination revealed spastic tetraparesis, unresponsiveness to the environment, and cushingoid facies due to chronic steroid supplementation. Preoperative medications including topiramate, divalproex, prednisolone were continued until the morning of the operation. On arrival at the operating room, standard monitoring commenced. For anesthetic induction, 75 mg of pentothal sodium were injected. Anesthesia was maintained using N2O at 2 L/min, O2 at 2 L/min, and sevoflurane. About 5 min after the start of maintenance inhalational anesthesia, the surgeon was unable to open the patient’s mouth so rocuronium 10 mg was injected, after which the mouth could be opened and the surgery commenced. The operation lasted 30 min and was uneventful. Residual neuromuscular blockade was reversed with pyridostigmine 10 mg and glycopyrrolate 0.2 mg, and 15 min after administration of reversal agents, we placed the patient’s home ventilator in pressure-support ventilation (PSV) mode, as it was preoperatively. The patient was observed closely for over 1 h by an anesthesiologist and a pediatrician in the post-anesthesia care unit (PACU). The home ventilator with PSV mode was well tolerated, so we then transferred the patient to the general ward under monitoring with pulse oximetry. X-linked ALD is a progressive neurodegenerative disorder characterized by demyelination of cerebral white matter, axonopathy of the spinal cord, and reduced adrenal response to adrenocorticotropic hormone. The onset age of the condition is between 3 and 10 years, and the patients initially present with behavioral problems and deficits in memory and language. As the disease progresses, vision loss, auditory impairment, hemiparesis and spastic tetraparesis may occur. In the later stages, seizures begin and the patient becomes bedridden, blind, and unable to interact with the environment. Death usually ensues within 2 to 4 years after the onset of symptoms [1]. There are several considerations in anesthetic management for these patients. The anesthetic plan should be formulated based on each individual patient’s condition according to their disease progression. In our case, the anesthetic plan focused on the prevention of seizures and early return to the preoperative condition without any anesthesia-related complications. In an ALD patient with seizure disorders, anticonvulsants should be continued throughout the perioperative period, including the day of surgery, and the anesthesiologist should consider the altered pharmacokinetics of anesthetics due to hepatic microsomal enzyme induction secondary to chronic antiseizure

Endotracheal intubation-related vocal cord ulcer following general anesthesia

Post-intubation throat pain is a common complaint that is caused by focal ischemia, damage to the laryngeal mucosa, or edema. However, if the laryngeal symptoms persist after 72 h, vocal cord paralysis, the formation of granulation tissue, or ulcers can occur [1]. Most vocal cord ulcers that are caused by intubation are found after progression to granuloma. However, we recently observed a patient in whom the ulcer was detected before progression, and was successfully treated with conservative interventions. n nA 39-year-old male (167 cm, 66 kg) was scheduled for elective Guyons tunnel release surgery. The patient had no significant medical history, except for septoplasty surgery 6 years ago using general anesthesia with endotracheal intubation. Pre-operatively, he exhibited no laryngopharyngeal symptoms such as sore throat, hoarseness, or stridor. Anesthesia was induced using 130 mg propofol, and endotracheal intubation was performed with 35 mg rocuronium. An endotracheal tube with an internal diameter of 8.0 mm, and a high volume/low pressure cuff was used. Laryngoscopy was performed using a standard 3 Macintosh metal blade, a stylet, and external laryngeal pressure, and was characterized as Cormack-Lehane laryngoscopy grade III. There was slight friction when going through the vocal cord during intubation, but the process was otherwise successful. The duration of intubation was 65 min, and anesthesia was completed without any specific hemodynamic instability. Emergence was smooth, and extubation was completed without any coughing or vigorous movement. n nAfter surgery, the patient persistently complained of throat pain during the hospitalization period. However, the attending physician and nurse overlooked his complaints because throat pain was considered to be a normal side effect of intubation. He was therefore discharged 4 days after the operation without any further examination. The day after discharge, the patient was concerned that his sore throat persisted, unlike his previous experience with general anesthesia and intubation, and visited an otolaryngology outpatient clinic. Laryngeal endoscopic examination showed an ulcer in the posterior of the vocal cord (Fig. 1A). Prednisolone (5 mg, BID) and esomeprazole (40 mg, QD) were prescribed, and voice rest was recommended. His sore throat improved after 1 week, and laryngoscope examination revealed partial cure of the vocal cord ulcer (Fig. 1B). After subsequent visits, the ulcer had completely healed without progressing to granuloma. n n n nFig. 1 n n(A) Five days after surgery, a vocal cord ulcer was observed in the rightsided posterior of the vocal cord. (B) Twelve days after surgery, the vocal cord ulcer had decreased in size after medical therapy and voice rest. n n n nVocal cord ulcers are non-neoplastic lesions of the posterior glottis, and represent an early stage in the progression of vocal cord granulomas [2]. Generally, vocal cord ulcers occur due to mechanical or chemical damage, such as the overuse of voice, chronic coughing, throat clearing, or gastroesophageal reflux disease [3]. The common symptoms of vocal cord ulcers and granulomas are throat pain, hoarseness, and coughing [4]. n nThe causes of vocal cord ulcers related to endotracheal intubation are vocal cord mucosa damage during intubation and extubation, clasping movements between the vocal cords and the tube, continuous pressure of the tube during anesthesia, use of a tube that is too large, or infection. During endotracheal intubation, inflammation can occur on the mucous membrane of the vocal process area of arytenoid cartilage, and its severity tends to increase with longer intubation times or increased pressure [5]. n nIn the current case, the duration of intubation was short, and there was little or no movement of the head and neck during the surgery or extubation. It is therefore likely that the vocal cord ulcer was caused by friction with the tube during intubation, damaging the vocal cord mucosa. It is also possible that the endotracheal tube used was too large, or that the pressure exerted by the external cricoids led to backward and lateral tilt, making the vocal process more prominent and vulnerable to injury [5]. n nMost vocal cord ulcers can be cured with conservative treatment such as voice therapy, or medical interventions including steroids, antibiotics, proton pump inhibitors, or histamine-2 receptor blockers. However, if the cause of ulcer is iatrogenic or the ulcer has progressed to granuloma, it may lead to aspiration and respiratory distress, and so long-term treatment or even surgical excision may be required [1,4]. n nTo prevent post-intubation vocal cord ulcers from occurring, using an appropriately sized tube, adequate sedation and muscle relaxation, performing smooth intubation, stabilization of the tube, and extubation without laryngeal reflexes are recommended [4,5]. n nIn conclusion, anesthesiologists should recognize that vocal cord ulcers could occur as a complication of intubation following endotracheal anesthesia. Persistent post-operative laryngopharyngeal symptoms should not be overlooked, and appropriate examinations will help identify complications, such as ulcers, before they progress to granuloma.

Continuous epidural analgesia versus continuous intravenous analgesia with peri-articular infiltration following total knee arthroplasty in geriatric patients

BACKGROUNDnPostoperative continuous intravenous analgesia may not provide effective postoperative analgesia following total knee arthroplasty. This study was conducted to determine if combined continuous intravenous analgesia and peri-articular infiltration provided a better quality of analgesia following total knee arthroplasty than epidural analgesia.nnnMETHODSnA prospective, double-blind study involving 50 patients who had undergone total knee arthroplasty was conducted. Patients were divided into control group and an experimental group. Patients in the control group (n = 25) received peri-articular infiltration with 47 mL normal saline prior to closure of the wound and postoperative epidural analgesia for 48 hours. Patients in the experimental group (n = 25) received a mixture of peri-articular infiltration of 16 mL of 0.75% ropivacaine, 6 mg morphine, 0.2 mg of epinephrine and 25 mL normal saline prior to closure of the wound and postoperative continuous intravenous analgesia for 48 hours. The analgesic efficacy was then evaluated using the verbal numeric rating scale at 1, 2, 6, 12, 24, and 48 hours postoperatively. The side effects and the dosage of rescue analgesics were then recorded.nnnRESULTSnThe experimental group showed a significantly higher pain score than the control group 2 and, 6 hours postoperatively at rest and 2 hours postoperatively following passive knee movement (P < 0.05). In addition, the rescue analgesic requirement was higher for the experimental group during the first 24 hours following surgery than for the control group (P < 0.05).nnnCONCLUSIONSnWe found that combined continuous intravenous analgesia and peri-articular infiltration of a mixture of ropivacaine and, morphine injected into the peri-articular tissue provided minimal benefits for pain control during the early postoperative period when compared to epidural analgesia after total knee arthroplasty.

Comparison of the expression of cluster of differentiation (CD)39 and CD73 between propofol- and sevoflurane-based anaesthesia during open heart surgery

High expression of cluster of differentiation (CD)39 and CD73 has cardio-protective effects. We hypothesised that the expression of CD39 and CD73 would differ between propofol- and volatile anaesthetic-based anaesthesia in patients undergoing open heart surgery (OHS). The objective of this prospective randomized trial was to compare the changes in CD39 and CD73 levels in CD4+ T cells between propofol- and sevoflurane-based anaesthesia during OHS. The study randomly allocated 156 patients undergoing OHS to a propofol or sevoflurane group. Blood was obtained preoperatively and up to 48u2009hours after weaning from cardiopulmonary bypass (CPB). The expression levels of CD39 and CD73 in circulating CD4+ T cells, serum cytokines and other laboratory parameters were analysed. The primary outcome was the expression of CD39 and CD73 on CD4+ T cells. Demographic data and perioperative haemodynamic changes did not show significant differences between the two groups. The expression of CD39 and CD73 in the sevoflurane group was significantly lower than in the propofol group (Pu2009<u20090.001). Other laboratory findings including cardiac enzymes and cytokine levels, did not show significant intergroup differences. Propofol attenuated the decrease in CD39 and CD73 in circulating CD4+ T cells compared to sevoflurane-based anaesthesia during OHS.

Optimal propofol dosage for i-gel® insertion in healthy paralyzed patients

Background Propofol is used for supraglottic airway device insertion, often with the i-gel. However, the propofol requirement for i-gel insertion has not been explored in paralyzed patients. This study was performed to explore hemodynamic changes and sedation level with different propofol doses in healthy paralyzed patients when the i-gel was inserted. Methods A total of 141 patients undergoing a urologic operation were randomly allocated to three groups depending on the propofol dose (1.5, 2, and 2.5 mg/kg; Groups P1.5, P2, and P2.5, respectively). After patients had been administered each propofol dose and rocuronium, the i-gel was inserted and changes in hemodynamic parameters and bispectral index were evaluated. Results Group P2 showed a lower incidence of complications (17%) such as hemodynamic instability and inadequate sedation than Group P1.5 (55.3%, P < 0.001) or Group P2.5 (40.4%, P = 0.012). The incidence and dose of additional propofol increased in Group P1.5 (51%, median [range]; 20 [0–50]) compared with those in the other groups (0%, 0 [0–0] in Group P2 and 8.5%, 0 [0–50] in Group P2.5, all P < 0.001), and the incidence and dose of additional ephedrine were significantly higher in Group P2.5 (31.9%; 0 [0–20]) than in Group P1.5 (10.6%, P = 0.012; 0 [0–5], P = 0.007, respectively). Conclusions For the stable maintenance of hemodynamic parameters and proper sedation level during i-gel insertion, 2 mg/kg propofol has an advantage over 1.5 mg/kg or 2.5 mg/kg propofol in healthy paralyzed patients.