Seung Cheol Lee

Effect of remifentanil on oculocardiac reflex in paediatric strabismus surgery.

Background: Rapidly acting narcotics enhance the degree of bradycardia due to the oculocardiac reflex (OCR) elicited by extraocular muscle (EOM) tension during strabismus surgery. We evaluated and compared the effects of remifentanil and sevoflurane on OCR during paediatric strabismus surgery.

Effect of different anesthetic agents on oculocardiac reflex in pediatric strabismus surgery

PurposeThe oculocardiac reflex (OCR) occurs frequently during pediatric strabismus surgery. The aim of this study was to assess the effects of various anesthetic regimens on the incidence of OCR during the surgery.MethodsTwo hundred and eighty children, 1 to 9 years old, undergoing elective strabismus surgery, were randomly assigned to eight groups; ketamine-sevoflurane (KS), ketamine-desflurane (KD), ketamine-propofol (KP), ketamine-remifentanil (KR), midazolam-sevoflurane (MS), midazolam-desflurane (MD), midazolam-propofol (MP), and midazolam-remifentanil (MR). No premedication was given. Anesthesia was induced using ketamine 1 mg·kg−1 or midazolam 0.15 mg·kg−1 with 66% N2O in O2. Laryngeal mask airways (LMAs) were placed with rocuronium 0.5 mg·kg−1. Anesthesia was maintained with sevoflurane 2–3 vol. %, desflurane 5–6 vol. %, propofol 7–8 mg·kg−1·h−1, or remifentanil 0.75 µg·kg−1 over 1 min, followed by a continuous infusion of remifentanil 0.5 µg·kg−1·min−1 with 66% N2O in O2. Heart rate (HR) was recorded during extraocular muscle (EOM) manipulation. OCR was defined as a reduction in HR of more than 20% induced by the traction of an EOM.ResultsIn patients given ketamine, OCR occurred more frequently in the KP (65.7%) and KR (62.9%) groups than in the KD (29.4%) and KS (37.1%) groups (P < 0.05). In patients given midazolam, OCR occurred more frequently in the MP (54.3%) and MR (60.6%) groups than in the MD (36.4%) and MS (31.4%) groups (P < 0.05).ConclusionPropofol or remifentanil anesthesia was associated with a higher incidence of OCR during pediatric strabismus surgery than sevoflurane and desflurane anesthesia, when either ketamine or midazolam was used as an induction agent.

Spectral entropy monitoring allowed lower sevoflurane concentration and faster recovery in children

Background: Anesthetic titration using spectral entropy monitoring reduces anesthetic requirements and shortens recovery in adult surgical patients. This study was performed to evaluate the effect of entropy monitoring on end‐tidal sevoflurane concentration and recovery characteristics in pediatric patients undergoing sevoflurane anesthesia.

Comparison of effects of fentanyl and remifentanil on hemodynamic response to endotracheal intubation and myoclonus in elderly patients with etomidate induction

Background Etomidate has a stable hemodynamic profile after induction, but hypertension and tachycardia are frequent after intubation as well as myoclonus. We compared the effects of fentanyl and remifentanil on the hemodynamic response to intubation and myoclonus during etomidate induction in elderly patients. Methods Ninety ASA I or II patients aged over 65 were randomly assigned to 3 groups. Group C received normal saline 10 ml (n = 30), group F and R were pretreated with fentanyl 1.0 µg/kg (n = 30) or remifentanil 1.0 µg/kg with continuous infusion of 0.1 µg/kg/min (n = 30) 1 min before induction with etomidate 0.2 mg/kg. Endotracheal intubation was performed after administration of rocuronium 0.8 mg/kg. Systolic blood pressure (SBP), mean arterial pressure, diastolic blood pressure (DBP), heart rate (HR), and the incidence and intensity of myoclonus were recorded. Results After intubation, group R showed significant decreases compared with groups C and F for all of the hemodynamic variables measured. The incidences of increases in SBP and HR of more than 30% of the baseline levels, SBP of > 200 mmHg, and HR of > 120 beats/min were significantly lower in group R (0%, 10%, 0%, and 0%, respectively) compared with groups C (83%, 83%, 30%, and 13%, respectively) and F (63%, 77%, 13%, and 7%, respectively). The frequency and intensity of myoclonus were significantly decreased in both groups F and R compared with group C. Conclusions Pretreatment with remifentanil suppressed cardiovascular reactions to endotracheal intubation more effectively than that of fentanyl during etomidate induction. Both opioids reduced the incidence of myoclonus.

The synergistic effect of gentamicin and clindamycin on rocuronium-induced neuromuscular blockade

Background Gentamicin reduces acetylcholine release and clindamycin causes end-plate ion channel blockade. Because of these reasons, two drugs show muscular relaxant effect and potentiate the action of nondepolarizing neuromuscular agents. This study was intended to evaluate the effect of gentamicin and clindamycin on rocuronium-induced neuromuscular blockade and the interaction between these drugs. Methods Male Sprague-Dawley rats phrenic nerves and diaphragms were installed in a bath containing Krebs solution. They were divided into three study groups. The first group was pre-treated with 0.1 (n = 3), 0.2 (n = 4) or 0.5 (n = 3) mM gentamicin and the tension was measured as the concentration of rocuronium was increased. The second group was experimented by increasing gentamicin on 0.25 (n = 5), 0.5 (n = 6) or 1.0 (n = 6) mM clindamycin. The final group was pre-treated with various combinations of gentamicin and clindamycin. The drug concentration was gradually increased until single twitch tension decreased by around 80%. Effective concentration was calculated using a probit model and interaction indices derived the Loewe additivity. Results The administration of gentamicin and the combination of gentamicin and clindamycin enhanced rocuronium-induced neuromuscular blockade. At 0.2 and 0.5 mM gentamicin, synergistic interactions with rocuronium were observed. Likewise, at 0.5 and 1.0 mM clindamycin, synergistic interactions with gentamicin appeared. When all three drugs were combined, in the tetanic fade, all the groups except for those administered with 0.01 mM gentamicin and 0.25 mM clindamycin showed synergistic interactions. Conclusions This study demonstrate that gentamicin and clindamycin potentiated rocuronium induced neuromuscular blockade. Moreover, it was found that these drugs interacted synergistically.

Procedural sedation with dexmedetomidine for pediatric endoscopic retrograde cholangiopancreatography guided stone retraction

Pediatric endoscopic retrograde cholangiopancreatography (ERCP) is currently used as a diagnostic and therapeutic procedure [1]. Compared to adults, pediatric patients experience different physiological effects with respect to discomfort, anxiety, and pain responses. Therefore, appropriate analgesia and amnesia are more frequently required for pediatric patients. Various methods of sedation, including general anesthesia, can be used for pediatric ERCP [2]. n nAlthough the use of dexmedetomidine for sedation in pediatric patients in various circumstances is reported, few studies have reported its use in pediatric ERCP. Here, we report our experience with dexmedetomidine for ERCP-guided stone retraction in a pediatric patient. n nA 10-year-old boy weighing 29 kg was referred to our department for deep sedation. He presented with obstructive jaundice, and a CT scan revealed a small stone at the distal common bile duct. Five days earlier, ERCP-guided stone retraction was performed under intravenous midazolam (3 doses of 0.1 mg/kg) sedation by a gastroenterologist. Stone retraction failed because of inadequate sedation, but the duct was successfully visualized using fluoroscopy. n nERCP-guided stone retraction was therefore rescheduled. Before the second procedure, informed consent was obtained from the patients parents. After arrival at the ERCP suite, the patient was monitored using electrocardiography and pulse oximetry, and his noninvasive blood pressure (BP) and bispectral index (BIS) were checked. He was calm and cooperative. His vital signs, BIS values and Observers Assessment of Alertness/Sedation scores were closely monitored and recorded (Table 1) during sedation. n n n nTable 1 n nValues During the Procedure n n n nThe patient was positioned in the prone position with his head turned toward the operator. A 0.7 µg/kg loading dose of dexmedetomidine was intravenously administered over 10 minutes followed by a maintenance infusion of 0.5 µg/kg/h. Just prior to the procedure, 0.5 mg/kg ketamine and 0.5 µg/kg fentanyl were intravenously administered consecutively. His oxygen saturation (SpO2) decreased to 85% for a second. When the scope was inserted, his SpO2 recovered to 100%. He breathed spontaneously with oxygen supplementation via nasal prongs. The procedure was completed with minimal reductions in BP and heart rate. n nAfter completing of the procedure, dexmedetomidine infusion was discontinued. The patient was then positioned in the supine position. He remained in the ERCP suite for 15 minutes, after which he was then discharged to the general ward, where his complete recovery was confirmed by anesthesiologists. The patient did not complain of postoperative nausea or vomiting and did not exhibit emergence agitation/delirium. n nDexmedetomidine is a highly selective α2 adrenoceptor agonist that has many advantages over other sedatives. In addition to producing sedative, analgesic, and anxiolytic effects, it provides respiratory stability [3]. It was first used as a sedative for patients being intubated in the intensive care unit. It was then used for sedation during many medical and surgical procedures without intubation. In addition, many studies have reported the use of dexmedetomidine in pediatric patients despite the lack of Food and Drug Administration approval [3]. Among pediatric patients, dexmedetomidine has been used for procedural sedation, particularly in diagnostic radiology. n nAs a sedative, dexmedetomidine maintains spontaneous respiration and preserves oxygenation and ventilation even at deep sedation. However, it is neither a complete anesthetic nor a complete analgesic [4]. Therefore, adjunctive analgesics are required during painful procedures. n nBecause the half-life of dexmedetomidine is relatively long, its use as a sedative is limited. Small doses and brief exposures may reduce the risk of prolonged recovery and delayed discharge from the recovery room and hospital [4]. n nIn the present case, the total procedural and infusion times were short, and the patient recovered completely from the sedation within 30 minutes with no adverse events. n nSedation with topical pharyngeal anesthesia has developed into a safe and common alternative to general anesthesia in pediatric endoscopy because of short-acting opioids and specific narcotic and benzodiazepine medications. General anesthesia is still used in younger patients, particularly when intolerance in anticipated and after considering the higher complexity of procedures in patients with smaller anatomies [1]. n nIn the present case, the stone was located in the distal common bile duct. Therefore, positional changes and other complicated situations were not required. Possible pain due to stone retraction was prevented with ketamine and fentanyl. Furthermore, visualization of the duct was previously performed during the first procedure; the stone removal was therefore fast and gentle. When patients are treated with appropriate analgesics, sedation with dexmedetomidine for pediatric ERCP would be safe and associated with better outcomes than sedation with other sedatives.

Effective doses of cisatracurium in the adult and the elderly

Background There are few information about the differences of the effective dose (ED) of cisatracurium between the adult and the elderly. We investigated the ED and the onset time of cisatracurium in the adults and the elderly. Methods We studied two hundred patients of the adults aged 20 through 64 years and the elderly aged ≥ 65 years, with American Society of Anesthesiologists physical status I or II. Each 100 patients with 20 patients of each dose group, randomly selected from 30, 40, 50, 60 or 70 µg/kg of cisatracurium, were randomly allocated to the adults and the elderly groups. We recorded the 0.1 Hz single twitch responses of the adductor pollicis and the onset times to maximal blockade. The magnitude of muscle relaxation was recorded by using an acceleromyography. The effect of cisatracurium on single twitch was calculated as percent reduction. After converting each drug dose into logarithm and percent reduction of the muscle reduction into probit, the EDs representing the muscle relaxation effects of 5%, 25%, 50%, 75% and 95% were estimated using the linear regression analysis. Results No significant differences were found in age, weight, height, or body mass index within or between the groups. The ED50 and ED95 of the adult group were 35.39 and 59.58 µg/kg. The ED50 and ED95 of the elderly group were 34.89 and 55.50 µg/kg, respectively. The onset times were 375.4 ± 76.9 seconds in the adult group and 369.1 ± 70.0 seconds in the elderly group. Conclusions The ED and the onset time were not significantly different between the adult and the elderly.

Use of sugammadex in lung cancer patients undergoing video-assisted thoracoscopic lobectomy

Background This study aimed to retrospectively evaluate the use of sugammadex in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy. Methods Data were obtained from medical record review of patients who underwent VATS lobectomy from January 2013 to November 2014. Fifty patients were divided into two groups: the sugammadex group (group S, n = 19) was administered sugammadex 2 mg/kg, while the pyridostigmine group (group P, n = 31) received pyridostigmine 20 mg with glycopyrrolate 0.2 mg or atropine 0.5 mg. The primary endpoint measure was the overall incidence of postoperative pulmonary complications including prolonged air leak, pneumonia, and atelectasis. The secondary endpoint measures were the length of postoperative hospital stay and duration of chest tube insertion. Results The overall incidence of postoperative pulmonary complications in patients in group S was significantly lower compared with that of group P (5 [26.3%] vs. 17 [54.8%]; P = 0.049). Also, the durations of chest tube insertion (5.0 [4.0–7.0] vs. 7.0 [6.0–8.0] days; P = 0.014) and postoperative hospital stay (8.0 [8.0–10.0] vs. 10.0 [9.0–11.0] days; P = 0.019) were shorter in group S compared with group P. Administration of sugammadex was associated reduced with postoperative pulmonary complications (OR: 0.22; 95% CI: 0.05–0.87; P = 0.031). Conclusions The use of sugammadex, compared with pyridostigmine, showed a significantly reduced overall incidence of postoperative pulmonary complications and decreased duration of chest tube use and postoperative hospital stay in patients undergoing VATS lobectomy, suggesting that sugammadex might be helpful in improving clinical outcomes in such patients.

The prophylactic effect of dexamethasone on postoperative sore throat in prone position surgery

Background Sore throat and hoarseness are common complications after general anesthesia with tracheal intubation. The position for patients can affect the incidence of postoperative sore throat (POST) by causing displacement of the endotracheal tube. This study investigated the prophylactic effect of dexamethasone in prone position surgeries. Methods One hundred-fifty patients undergoing lumbar spine surgery (18-75 yr) were randomly allocated into the normal saline group (group P, n = 50), dexamethasone 0.1 mg/kg group (group D1, n = 50) or dexamethasone 0.2 mg/kg group (group D2, n = 50). The incidence and severity of POST, hoarseness, and cough were measured using direct interview at 1, 6, and 24 h after tracheal extubation. The severity of POST, hoarseness, and cough were graded using a 4-point scale. Results At 1, 6, and 24 h after extubation, the incidence of sore throat was significantly lower in group D1 (1 h; P = 0.015, 6 h; P < 0.001, 24 h; P = 0.038) and group D2 (1 h; P < 0.001, 6 h; P < 0.001, 24 h; P = 0.017) compared to group P. There were less number of patients in the groups D1 and D2 than group P suffering from moderate grade of POST at 1, 24 h after extubation. The incidence of hoarseness at 1, 6, and 24 h after extubation was significantly lower in groups D2 than group P (P < 0.001). There were no significant differences in the incidence of cough among the three groups. Conclusions The prophylactic use of dexamethasone 0.1 mg/kg and 0.2 mg/kg in prone surgery reduces the incidence of postoperative sore throat and dexamethasone 0.2 mg/kg decreases the incidence of hoarseness.