Sung Uk Choi

Target-controlled propofol infusion for sedation in patients undergoing transrectal ultrasound-guided prostate biopsy.

The efficacy and safety of the routine use of target-controlled infusion of propofol for the sedation of patients undergoing transrectal ultrasound-guided prostate biopsy were assessed. The optimal level of sedation was also evaluated. A total of 250 patients were randomized into five groups according to sedation level determined by the Observers Assessment of Alertness/Sedation (OAA/S) scale. As the level of sedation was increased, the overall pain and discomfort score decreased and the satisfaction rate tended to increase, although hypoxia meant that intervention occurred more frequently at higher sedation levels. Target-controlled infusion of propofol provided safe and effective sedation during transrectal ultrasound-guided prostate biopsy, particularly if moderate sedation (OAA/S score of 3) was achieved. The effect-site concentration of propofol for this level of sedation was about 1.5 μg/ml.

Effect of propofol on cardiac function and gene expression after ischemic-reperfusion in isolated rat heart.

Background The aim of this study was to examine the cardiac function and transcriptional response of the heart to propofol after ischemia-reperfusion. Methods Rat hearts were Langendorff-perfused using the modified Krebs-Henseleit buffer, and took 20 min stabilizing periods, 40 min ischemia periods, and then 120 min reperfusion period. The hearts were divided into 5 groups; Control: 180 min perfusion after stabilization, Ischemic: 40 min global ischemia after stabilization, followed by 120 min reperfusion, Pre: 2 µM propofol treatment was preformed only before ischemia, Post: 2 µM propofol treatment was performed only during reperfusion after ischemia, Pre/Post: 2 µM propofol treatment was performed both before and after ischemia. The measurement for cardiac performances, such as left ventricular developed pressure (LVDP), rate of left ventricular pressure generation (dP/dt), heart rate, and coronary flow were obtained. The expression profiles of isolated mRNA were determined by using Agilent microarray and real time-polymerase chain reaction (RT-PCR) was used to confirm the microarray results for a subset of genes. Results The Post group showed better LVDP and dP/dt than the Ischemic group. But there were no significant differences in heart rate and coronary flow among the groups. On the results of RT-PCR, the expressions of Abcc9, Bard1, and Casp4 were increased, but the expressions of Lyz, Casp8, and Timp1 were decreased in the Post group compared with the Ischemic group. Conclusions This study suggests that 2 µM propofol may provide cardioprotective effect, and modulate gene expression such as apoptosis, and KATP ion channel related-genes during reperfusion in the isolated rat hearts.

A case of facial myofascial pain syndrome presenting as trigeminal neuralgia

Facial pain has many causes, including idiopathic factors, trigeminal neuralgia, dental problems, temporomandibular joint disorders, cranial abnormalities, and infections. However, the clinical diagnosis of facial pain is sometimes difficult to establish because clinical manifestations commonly overlap. The diagnosis of trigeminal neuralgia is based solely on clinical findings. Therefore, a careful evaluation of the patient history and a thorough physical examination are essential. This case describes a patient with facial myofascial pain syndrome involving the right zygomaticus, orbicularis oculi, and levator labii muscles, which presented as trigeminal neuralgia.

Epidural Dexamethasone Decreased Inflammatory Hyperalgesia and Spinal cPLA2 Expression in a Rat Formalin Test

Purpose The aim of this study was to investigate the effect of epidural dexamethasone on analgesia and cytosolic phospholipase A2 (cPLA2) expression in the spinal cord in a rat formalin test. Materials and Methods Epidural dexamethasone injection was performed to Sprague-Dawley rats with a 25 gauge needle under fluoroscopy. Following the epidural injection, a formalin induced pain behavior test was performed. Next, the spinal cords corresponding to L4 dorsal root ganglion was extracted to observe the cPLA2 expression. Results There were no differences in pain response during phase I among the groups. The phase II pain response in 300 µg of epidural dexamethasone group decreased as compared to control, 30 µg of epidural dexamethasone, 100 µg of epidural dexamethasone, and 300 µg of systemic dexamethasone groups. The expression of cPLA2 decreased in Rexed laminae I-II in 300 µg of the epidural dexamethasone group compared with the ones in the control group. Conclusion Taken together, these results suggest that 300 µg of epidural dexamethasone has an attenuating effect on the peripheral inflammatory tissue injury induced hyperalgesia and this effect is mediated through the inhibition of intraspinal cPLA2 expression and the primary site of action is the laminae I-II of the spinal cord.

Effect of muscle relaxant on entropy during propofol anesthesia

BACKGROUND The purpose of this study was to investigate whether muscle relaxant affect the values of Entropy, response entropy (RE) or state entropy (SE) during propofol anesthesia. METHODS Eighty patients (ASA I) scheduled for elective surgery under general anesthesia were randomly assigned to four groups. Anesthesia was maintained at a SE value of 80 (80 +/- 2) using target controlled infusion (TCI) of propofol. After maintaining SE 80 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group I and same volume of normal saline was intravenously injected in group II. After maintaining SE 60 for 5 min, vecuronium 0.1 mg/kg was injected intravenously in group III and same volume of normal saline was injected intravenously in group IV. The mean arterial pressure, heart rate, SE and RE were measured before anesthetic induction and up to 5 min after vecuronium or normal saline injection in each group. RESULTS SE and RE were not changed in group II, but significantly decreased in group I (P < 0.05, respectively). In group III and IV, SE and RE were not changed in both groups. There were no significant hemodynamic changes among the four groups. CONCLUSIONS These results suggest that the effect of muscle relaxant on Entropy vary according to the baseline values of RE or SE during propofol anesthesia.

Thoracic Epidural Clonidine Attenuates Haemodynamic Responses Induced by Endobronchial Intubation

Laryngoscopy and endobronchial intubation usually cause transient hypertension and tachycardia. We investigated whether thoracic epidurally injected 3 μg/kg clonidine attenuates cardiovascular responses to intubation compared with 2 μg/kg fentanyl and 1 mg/kg lidocaine. Epidural catheterization was performed at the T6–T7 or T7–T8 intervertebral space, and saline or clonidine in saline was injected 20 min before anaesthetic induction. Anaesthesia was induced using 5 mg/kg thiopental sodium and 0.1 mg/kg vecuronium. Laryngoscopy and endobronchial intubation were performed 2 min later. Mean blood pressure and heart rate were measured throughout anaesthetic induction. In the control group and the fentanyl group, mean blood pressure and heart rate 3 min after endobronchial intubation were elevated significantly compared with baseline. In the clonidine group, however, mean blood pressure and heart rate did not increase compared with baseline. The control group had higher mean blood pressure and heart rate than the clonidine group 3 min after endobronchial intubation. Thoracic epidural clonidine may attenuate the haemodynamic response to endobronchial intubation.

Is postoperative nausea and vomiting still the big "little" problem?

Postoperative nausea and vomiting (PONV) is usually defined as any nausea, retching, or vomiting occurring within the first 24–48 hours of surgery. PONV can be extremely distressing to patients and is one of the most common causes of patient dissatisfaction and discomfort after anesthesia. The average incidence of PONV after general anesthesia is about 30% in all post-surgical patients but up to 80% in high-risk patients despite advances in anesthetics and anesthesia techniques [1,2,3]. In addition, PONV is rated highly in preoperative surveys, as the clinical anesthesia outcome that the patient would most like to avoid [4]. Therefore it is not surprising that patients express a high willingness-to-pay (

Severe bronchospasm in a premature infant during induction of anesthesia caused ventilation failure.

50–100) to avoid PONV [5,6]. While bleeding, wound dehiscence, pulmonary aspiration of gastric contents, esophageal perforation, and other serious complications associated with PONV are rare, nausea and vomiting is still an unpleasant, unwanted and all-too-common postoperative morbidity that can delay patient discharge from the postanesthesia care unit, require expanded levels of nursing care and increase unanticipated overnight hospital admissions in outpatients. The public now believes that anesthesia is extraordinarily safe from catastrophic outcomes, including major organ dysfunction or failure and even death. Therefore, many patients are more concerned about pain and PONV than surgical outcomes, such as whether the surgery would improve their condition. This is especially true for the majority of patients undergoing less invasive surgery. Moreover, minimally invasive surgery is now increasingly and routinely used across almost all surgical specializations. An important aspect of the quality of anesthetic care is the satisfaction of the patient with their care. Possible strategies to prevent the incidence of PONV include the prophylactic use of antiemetics such as dexamethasone or 5-HT3 antagonists, and avoiding use of emetic drugs such as inhalational anesthetics or opioids. However, no drug is completely effective at preventing PONV. If we can avoid drugs that cause PONV, all the better. The etiology of PONV remains unclear, but involves anesthetic, surgical and patient factors. Well-known risk factors are female gender, non-smoking status, a history of motion sickness or previous PONV, inhalational anesthetics, certain types of surgery, and opioid use [7]. Among the risk factors for PONV, the use of postoperative opioids is one of four major risk factors in the simplified risk-scoring system introduced by Apfel et al. [8]. In this months Korean Journal of Anesthesiology, Lim et al. [9] report a study focusing on the effects of intraoperative opioid use on the incidence and severity of PONV and the effects of a single bolus administration of fentanyl during anesthesia induction versus intraoperative infusion of remifentanil on PONV. In a previous randomized controlled trial in over 5000 patients, the use of a short-acting opioid, like remifentanil, instead of fentanyl did not decrease the incidence of PONV [10]. However, in that study, patients who had been assigned to receive intraoperative remifentanil were given 50 µg of morphine per kilogram or an equivalent opioid at the end of surgery. Therefore, the current study has meaningful results based on comparing only fentanyl versus remifentanil itself, without the other factors that affect PONV. They demonstrated that a single bolus administration of fentanyl during anesthesia induction increased the incidence of PONV, while an intraoperative remifentanil infusion did not affect the incidence and severity of PONV. These results should have a marked synergistic effect with antiemetic prophylaxis. It should be kept in mind that even a single bolus administration of fentanyl during anesthesia induction can increase the incidence of PONV in high-risk patients.

The effect of intermittent levator massage with caudal block on management of levator ani syndrome - A case report -

A 3-month-old (39 weeks postconceptual age) male infant weighing 2.9 kg was scheduled for laser photocoagulation with a diagnosis of retinopathy of prematurity. He was born at 27 weeks gestation with a birth weight of 970 g. He had been mechanically ventilated from birth for 20 days for respiratory insufficiency due to respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD). A chest X-ray performed before the sub sequent ligation of the patent ductus arteriosus showed bilateral haziness in the entire lung field due to the RDS and BPD during tracheal intubation. The infant required ventilation with a high concentration of oxygen and received surfactant therapy. Twenty days after birth, patent ductus arteriosus (PDA) liga tion was done under general anesthesia in which induction was achieved with inhalation of sevoflurane and 1 mg of rocuroni um. The operation proceeded uneventfully and the extubation was performed five days after the surgery. After extubation, the infant was able to breathe spontaneously with an incubator oxygen supply, and the oxygen saturation was maintained above 90%. After PDA ligation, the infant was diagnosed with retinopa thy of prematurity, and he was then scheduled for laser photocoagulation. On the chest X-ray, improvement of haziness was observed from five days before the operation. After consultation with pediatrics, the decision was made to operate. Upon arrival in the operating room, electrocardiography, pulse oximetry, and noninvasive blood pressure were monitored, and the patient’s vital signs were stable. Induction of anesthesia was achieved with thiopental (15 mg), rocuronium (2 mg), and sevoflurane. The tracheal intubation was performed with an uncuffed 3.5 mm internal diameter endotracheal tube, but there was no capnogram trace after three breaths. At this time, the oxygen saturation rapidly dropped to below 80%. The endotra cheal tube was removed because the anesthesiologist suspected esophageal intubation and the patient was ventilated with 100% oxygen via face mask. Mask ventilation was not performed well, and peak inspiratory pressure was revealed to be above 25 mmHg. The anesthesiologist suspected stiff lungs, which suggested bronchospasm. Hydrocortisone sodium succinate (SoluCortef Ⓡ , Pfizer Inc., New York, NY, USA) 20 mg was intravenously injected. Five minutes later, oxygen saturation slowly increased up to 99% and reintubation was attempted. Although it was confirmed by direct laryngoscopy that the tube had passed between the vocal cords, proper ventilation of the lungs was not achieved. No expired carbon dioxide was noted on the capnograph, and chest auscultation was equivocal. The oxygen saturation was then in the low sixties. After sevoflurane was administered by inhalation, a slight chest movement was noted, and oxygen saturation increased up to 80%. During that time, a portable chest radiograph was taken which revealed severe consolidation with air bronchograms (Fig. 1A). Despite ventilatory support for 10 minutes, the oxygen saturation failed to increase beyond 80%. Hydrocortisone sodium succinate 20 mg was then intravenously injected once more. Afterwards, SaO 2 was maintained at 88-93%. The surgery was cancelled, and glycopyrrolate

Tracheal laceration detected by high end-tidal CO2 during endoscopic thyroidectomy

Levator ani syndrome (LAS) is a functional disorder of the pelvic floor muscles in which recurrent and persistent distressing pain is felt in the anus without detectable organic pathology. Eighty one percent of coccygodynia was alleviated by the levator massage when the massage motion was repeated 10 to 15 times on each side of the pelvis daily for 5 or 6 days. The authors encountered the LAS patient for whom successive visit to pain clinic was economic burden. Therefore, the authors managed the patient by intermittent levator massage with caudal block, once a week for 3 times, resulting in two years of pain free status. Intermittent levator massage with caudal block may be as effective as successive levator massage and induce longer painless period in the management of LAS.