Sang Yoon Jeon

Influence of Ketamine on Early Postoperative Cognitive Function After Orthopedic Surgery in Elderly Patients.

Background: Postoperative cognitive dysfunction (POCD) is a serious and frequent complication after surgery, especially in elderly patients. Ketamine is an N-methyl D-aspartic acid receptor antagonist with demonstrated neuroprotective effects. An intravenous bolus of a sub-anesthetic dose (0.5 mg/kg) of ketamine can reduce postoperative delirium (POD) and POCD after cardiac surgery. But, the influence of ketamine on early POCD after non-cardiac surgery is unclear. Objectives: The current study aimed to evaluate the influence of ketamine on early postoperative cognitive function after orthopedic surgery in elderly patients. Patients and Methods: Fifty six elderly patients (> 60-years-old), scheduled for elective orthopedic surgery during general anesthesia (duration of anesthesia > two hours) were enrolled. Patients received intravenous bolus, a total of 3 mL mixed with 0.9% normal saline and 0.5 mg/kg ketamine (K group) or 3 mL of 0.9% normal saline (N group). Three neurocognitive function tests (mini-mental status examination, trail-making test, digit substitution test), and c-reactive protein (CRP) concentration were determined before surgery and on postoperative day one (POD 1) and postoperative day six (POD 6). Results: The two groups had similar demographic characteristics except for the gender. Surgical and anesthetic data were not significantly different. A statistically significant difference was observed in comparison of trail-making test score. Trail-making test score increased more in the N group (52.5 points) than the K group (13 points) at POD 1 (P = 0.047) compared with baseline scores. There were no significant differences in the mini-mental status examination, digit substitution test and CRP concentration at POD 1 and POD 6 between the two groups. POCD (the two Z-scores in more than two tests or the combined Z-score was 1.96 or more) was present in one patient (4%) in the K group at POD 6 (P = 0.98). Conclusions: The incidence of POCD was not significantly influenced by a bolus dose of ketamine (0.5 mg/kg) after orthopedic surgery in elderly patients. There were no negative effects of ketamine on early POCD.

The development of efficient X-ray conversion material for digital mammography

In this study, an experimental method based on theory is used to develop photoconductor that can replace the a-Se currently used as X-ray conversion layer in digital mammography. This is necessary because a-Se produced by the commercial fabrication method, of physical vapor deposition, has exhibited several problems when applied to digital mammography: instability due to crystallization and defect expansion due to high operating voltages, which is called the aging effect. Therefore, our work focused on developing a method of fabricating X-ray conversion films that do not suffer from crystallization and X-ray damage and optimizing the factors affecting the properties of the candidate photoconductors in order to acquire sufficient electrical signals to detect minute calcifications. The photoconductors were initially selected after the requirements for X-ray conversion materials, such as high atomic absorption, density, band-gap energy, work function, and resistivity, were examined. We selected HgI2, PbI2, and PbO because of their basic properties. Next, we experimentally investigated the performance of film samples fabricated by sedimentation and screen printing instead of physical vapor deposition. The structure of the X-ray conversion films (e.g., the thickness, electrodes, and blocking layer) were optimized for the application of a relatively low voltage to the X-ray conversion layer. The performance of the films were morphologically and electrically evaluated under mammography X-ray exposure conditions, and compared with those of a-Se films produced by physical vapor deposition. PbO appeared to be the most suitable alternative material because its electrical properties, such as the dark current, sensitivity, and signal-to-noise ratio (SNR), did not reveal the X-ray damage problem, and thus were maintained after repeated exposure to X-rays. Although PbO showed low sensitivity to X-ray exposure, its SNR was superior to that of the other materials, which is expected to improve its detective quantum efficiency, one of the factors used in evaluating images acquired by digital mammography.

Spinal Cord Stimulation for Intractable Visceral Pain Due to Sphincter of Oddi Dysfunction

Sphincter of Oddi dysfunction (SOD) is a syndrome of chronic biliary pain or recurrent pancreatitis due to the functional obstruction of the pancreaticobiliary flow. We report a case of spinal cord stimulation (SCS) for chronic abdominal pain due to SOD. The patient had a history of cholecystectomy and had suffered from chronic right upper quadrant abdominal pain. The patient had been diagnosed as having SOD. The patient was treated with opioid analgesics and nerve blocks, including a splanchnic nerve block. However, two years later, the pain became intractable. We implanted percutaneous SCS at the T5-7 level for this patient. Visual analog scale (VAS) scores for pain and the amount of opioid intake decreased. The patient was tracked for more than six months without significant complications. From our clinical case, SCS is an effective and alternative treatment option for SOD. Further studies and long-term follow-up are necessary to understand the effectiveness and the limitations of SCS on SOD.

Cardiac Tamponade Following Ultrasonography-Guided Trigger Point Injection

Abstract Background: Trigger point injection [TPI] is generally considered a safe and easy procedure. Findings: We describe a case of cardiac tamponade after ultrasonography [US]-guided TPI in a thin patient. The symptoms progressively appeared directly after the injection, and the patient experienced cardiogenic shock 3 h later. Cardiac tamponade was diagnosed with difficulty when US was performed near the injection site, and then pericardiocentesis was performed immediately. Conclusions: When US-guided TPI is performed near the neck and chest, the authors suggest that the entire shaft and tip of the needle be identified to prevent any critical complications during an US-guided procedure.

Successful use of caudal anesthesia and light sevoflurane mask ventilation for inguinal hernia repair in an infant with multiple large intrapulmonary cysts.

Cystic lung diseases of infants include congenital cystic adenoid malformation, pulmonary sequestration, bronchogenic cyst, and bronchial atresia. The progressions of cystic lung disease vary from spontaneous regression to severe respiratory difficulty [1]. Infants with cystic lung disease can suffer variable degrees of respiratory symptoms which can result in recurrent infection and pulmonary hypoplasia [2]. Therefore, perioperative management of patients with cystic lung disease can be a challenge for anesthesiologists. We report our experience with a 2-month-old female patient with multiple large intrapulmonary cysts. The 2-month-old-female patient was scheduled for surgery for a right-side inguinal hernia. The baby was born prematurely at 36 weeks, weighing 3.4 kg. She was admitted to the neonatal intensive care unit for 4 days right after birth. She was asymptomatic at birth and doing well after discharge. The patient was diagnosed with inguinal hernia and scheduled for surgery. In the preoperative evaluation, chest X-rays showed a unilocular air-containing cystic lesion of 4.8 × 3.3 cm in size occupying the left upper lung region (Fig. 1A). She was checked via a computed tomography (CT) scan. The CT scan revealed a large air-containing cyst in left upper lung and several small cysts in right upper lobe, right middle lobe, and both lower lobes (Fig. 1B). Fig. 1 Preoperative infantogram. An unilocular air-containg cystic lesion (4.8 × 3.3 cm) in left upper lung (A). CT scan represented large air-containing cyst in the left upper lung and several small cysts in multiple lobes (B). In the operating room, she was monitored through pulse oximetry, non-invasive arterial pressure and electrocardiographic monitoring. She received 1 mg/kg ketamine intravenously. The patient was placed in the right lateral position. After local anesthesia with 1% lidocaine, we used 0.25% bupivacaine 1 ml/kg for the caudal block with 22-gauge angiocatheter using an ultrasound machine (Philips CX50, Philips ultrasound, Bothell, WA, USA). She turned into the supine position right after the injection. After 10 minutes, we confirmed motor block of the lower extremities. There was no lower extremity movement during the operation. Blood pressure and heart rate were maintained within baseline values. During the operation, we used spontaneous breathing light sevoflurane for sedation via a face mask. The total operation time was 20 minutes. She was transferred to the postanesthetic care unit with intact self-respiration. She was discharged the next day uneventfully. A caudal block is a commonly performed technique during anesthesia of pediatric patients. It is known to be used as the sole form of anesthesia instead of as general anesthesia for high-risk neonate patients. Our institution usually performs general anesthesia in infants for inguinal hernia repair. However, in this case, we considered the use of regional anesthesia to avoid unintentional complications. A variety of congenital cystic lung lesions may appear in the neonatal period. The development of prenatal care has made frequent the detection of congenital cystic lung disease via fetal ultrasonography [1]. The cystic lesion in her CT scan represented large air-containing cyst in the left upper lung and several small cysts in multiple lobes. There are few reports of the anesthetic management of cases of inguinal hernia repair in infants with multiple intrapulmonary cysts. Our anesthetic concern was to prevent barotraumas due to positive pressure ventilation. Large cystic lesions can induce tension pneumothorax and can further cause cardiovascular collapse. Therefore we decided to utilize regional anesthesia with spontaneous mask ventilation. Another concern was the risk of postoperative apnea. Before reaching the postconceptional age of 60 weeks, ex-premature infants are at risk of postoperative apnea [3]. Our patients postconceptional age was 44 weeks so the risk of apnea still remained. There are several anesthtetic techniques to avoid postoperative apnea including caudal or spinal anesthesia. Caudal anesthesia has considerably easier technical requirements and for that reason is performed widely. It is known to a safe and effective procedure for pediatric patients undergoing subumbilical surgery. However, there remain some problems such as the presence of pain and the possibility of an inadequate anesthetic level. Geze et al. [4] reported a successful case of caudal anesthesia during inguinal hernia repair of a low-birth-weight neonate while awake. However, we used ketamine during caudal block for relief in patients with stressful conditions. During the operation, we established light sevoflurane mask ventilation and maintained self-respiration without any adverse events. The epidural space of infants is different from that of adults due to increased vascularity, less fat, and a smaller absorptive surface for local anesthetics [5]. So, we used ultrasonography to ensure safety and accuracy of the regional block. It provided the advantage of detecting sacral anatomy and of visualing the spread of local anesthetics. Therefore, the side effects of a caudal block, such as an inadvertent vascular or dural injection, can be minimized. The combination of sevoflurane and caudal anesthesia may prevent movement and pain during surgery in accordance with a stable hemodynamic condition. In conclusion, the anesthesic care of infants with cystic lesions can be challenging for anesthesiologists. We report a successful single-shot caudal block under light sevoflurane sedation. It can be used effectively for performing a procedure on a high-risk infant.

Parathyroidectomy under superficial cervical plexus block in a patient with severe kyphoscoliosis

355 Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014 approximately 60° to the left and leg pain in this patient prompted us to order an MR scan, which showed all the typical features of this anomaly. Scoliosis with these features or a rapidly progressive curve point to a possible intraspinal abnormality.[1] There are case reports of associated systemic anomalies in the gastrointestinal, pulmonary, craniofacial and cardiovascular systems, but these are infrequent.[2]

Dexmedetomidine and remifentanil in the perioperative management of an adolescent undergoing resection of pheochromocytoma -A case report-

A 15-year-old adolescent with unilateral multiple adrenal pheochromocytoma had an episode of subcortical intracerebral hemorrhage and seizure 6 weeks before the surgery. He was pretreated with terazosin, losartan, atenolol and levetiracetam for 2 weeks. Dexmedetomidine was started in the preoperative waiting area, and a combination of dexmedetomidine and remifentanil was continuously infused for most of anesthetic time. To control blood pressure, bolus injection of remifentanil and low-dose infusion of sodium nitroprusside, nicardipine, and esmolol were administered during three adrenergic crises. There was minimal post-resection hypotension, and his trachea was extubated safely 20 min after the surgery. He was discharged without noticeable complication. His catecholamine levels showed the steadily decreasing pattern during the operation in this case. Though a combination of dexmedetomidine and remifentanil may not prevent the hemodynamic instability impeccably during the tumor manipulation, this combination seems to be the way of interrupting release of catecholamines and minimizing hemodynamic fluctuations.