Yeon-Dong Kim

Antihyperalgesic effects of dexmedetomidine on high-dose remifentanil-induced hyperalgesia.

Background Dexmedetomidine is a highly selective α2 adrenergic agonist that has been shown to decrease the intensity of opioid-induced hyperalgesia (OIH). We aimed to investigate the antihyperalgesic effects of dexmedetomidine on high-dose remifentanil-induced hyperalgesia. Methods Ninety American Society of Anesthesiologists physical status I-II patients undergoing laparoscopically assisted vaginal hysterectomy (LAVH) were randomly assigned to one of the following three groups, each of which received either dexmedetomidine (an initial dose of 1.0 µg/kg for 10 min, followed by a continuous infusion of 0.7 µg/kg/hr) or placebo saline 15 min before the induction of anesthesia and intraoperative remifentanil infusion: group C received a placebo and 0.05 µg/kg/min remifentanil; group RH received a placebo and 0.3 µg/kg/min remifentanil; and group DRH received dexmedetomidine and 0.3 µg/kg/min remifentanil. Results The mechanical hyperalgesia threshold 24 hr after surgery was significantly lower in group RH than in the other two groups. Postoperative pain intensity using visual analog scale (VAS) and cumulative volume of a patient-controlled analgesia (PCA) containing morphine over 24 hr were significantly greater in group RH than in group DRH. The time to the first postoperative analgesic requirement was significantly shorter in group RH than in the other two groups. The desflurane requirement was significantly greater in group C than in the other groups. The frequency of hypotension and bradycardia was significantly higher, but shivering and postoperative nausea and vomiting were significantly lower in group DRH than in the other two groups. Conclusions High-doses of remifentanil induced hyperalgesia, which presented a decreased mechanical hyperalgesia threshold, enhanced pain intensity, a shorter time to first postoperative analgesic requirement, and greater morphine consumption, but dexmedetomidine efficiently alleviated those symptoms. Dexmedetomidine may be a novel and effective treatment option for preventing or attenuating OIH.

Acute septic arthritis of the acromioclavicular joint caused by Haemophilus parainfluenzae: a rare causative origin

Septic arthritis of the acromioclavicular (AC) joint is a rare entity with symptoms that include erythema, swelling, and tenderness over the AC joint, fever, and limitation of shoulder motion with pain. In previous reports, Staphylococcus and Streptococcus species have been mentioned as common causative organisms. Haemophilus parainfluenzae is a normal inhabitant of the oral cavity, respiratory tract, gastrointestinal tract, and urogenital tract. However, it sometimes causes opportunistic infections leading to septic arthritis and osteomyelitis. AC joint infection associated with H.parainfluenzae is very rare, and only one case has been reported in the literature. Moreover, septic arthritis in immunocompetent patients is also very rare. Here, we report the case of a healthy patient with H. parainfluenzae-related septic arthritis of the AC joint.

Duloxetine in the treatment of burning mouth syndrome refractory to conventional treatment: A case report

Patients with burning mouth syndrome (BMS) report burning sensation and pain involving the tongue and oral mucosa without any apparent medical or dental cause. The pathogenesis of this syndrome remains unclear and there is currently no standard treatment. BMS is, therefore, often misdiagnosed and its management is complex. This lack of clinical expertise may result in decreased health-related quality of life and increased psychological distress among patients with BMS. The present case report involves a 77-year-old female patient with BMS refractory to conventional treatment with nerve block and medication, who was successfully treated with duloxetine. Duloxetine may become a new therapeutic option in the management of BMS.

Epidemiology of Postherpetic Neuralgia in Korea: An Electronic Population Health Insurance System Based Study.

AbstractPostherpetic neuralgia (PHN) is a disease entity defined as persistent pain after the acute pain of herpes zoster gradually resolves. It is associated with impaired daily activities, resulting in reduced quality of life. General epidemiological data on PHN is necessary for the effective management. However, data on the epidemiology of PHN in Korea is lacking. The aim of this study was to evaluate the epidemiological features of PHN in the general population.We used population-based medical data for 51,448,491 subscribers to the Health Insurance Service in the year of 2013 to analyze of PHN epidemiology in Korea, such as the incidence, regional distribution, seasonal variation, and healthcare resource utilization. Total number of patients and medical cost on PHN were analyzed from 2009 to 2013.Findings indicate that the incidence of PHN in Korea was 2.5 per 1000 person-years, which was strongly correlated with age and sex. There were no differences in seasonal variation or regional distribution. The medical cost increased steadily over the study period. When admitted to general hospitals, patients with PHN were mainly managed in the dermatology and anesthesiology departments.The incidence and prevalence rates of PHN in Koreans appear to be considerably higher compared to those in western populations, while the sex and age predisposition was similar. Considering that the pain associated with PHN can have a marked impact on a patients quality of life resulting in a medicosocial economic burden, anesthesiology physicians have an important role in primary care in Korea. Future research on the cost-effectiveness of the management of PHN is needed.

Delayed Pneumocephalus Following Fluoroscopy Guided Cervical Interlaminar Epidural Steroid Injection : A Rare Complication and Anatomical Considerations

Cervical epidural steroid injection is indicated for radicular symptoms with or without axial neck pain. Complications are rare but can be serious. Here, we report the case of a 54-year-old man with cervical radicular pain who was treated with cervical epidural steroid injection. Injection was administered twice under fluoroscopic guidance with the loss-of-resistance technique using air to confirm the epidural space. After the second procedure, the patient complained of severe persistent headache and was diagnosed with pneumocephalus on brain computed tomography. The patient returned home without any neurological complication, after a few days of conservative treatment. Though, a fluoroscopic guidance cervical epidural injection is also known to diminish the risk of complications. Physicians should always keep in mind that it does not guarantee safety, particularly in the cervical region, related to its anatomical considerations.

Clinical usefulness of pectoral nerve block for the management of zoster-associated pain: case reports and technical description

The recently introduced pectoral nerve (Pecs) block is a simple alterative to the conventional thoracic paravertebral block or epidural block for breast surgery. It produces excellent analgesia and can be used to provide balanced anesthesia and as a rescue block in cases where performing a neuraxial blockade is not possible. In the thoracic region, a neuraxial blockade is often used to manage zoster-associated pain. However, this can be challenging for physicians due to the increased risk of hemodynamic instability in the upper thoracic level, and comorbid and contraindicated medical conditions such as coagulopathy. Here, we introduce an ultrasound-guided Pecs block for the management of herpes zoster-associated pain, which could be an effective alternative to other interventional options in the thoracic region.

Management of pudendal neuralgia using ultrasound-guided pulsed radiofrequency: a report of two cases and discussion of pudendal nerve block techniques

Pudendal neuralgia is characterized by chronic pain or discomfort in the area innervated by the pudendal nerve, with no obvious cause. A successful pudendal nerve block is crucial for the diagnosis of pudendal neuralgia. Blind or fluoroscopy-guided pudendal nerve blocks have been conventionally used for diagnosis and treatment; however, ultrasound-guided pudendal nerve blocks were also reported recently. With regard to the achievement of long-term effects, although pulsed radiofrequency performed under fluoroscopic guidance has been reported, that performed under ultrasound guidance is not well reported. This report describes two cases of pudendal neuralgia that were successfully managed using ultrasound-guided pulsed radiofrequency and presents a literature review of pudendal nerve block techniques. However, in the management of chronic neuropathic pain, physicians should keep in mind that the placebo effect related to invasive approaches must not be neglected.

Conversion of supraventricular tachycardia to normal sinus rhythm by dexmedetomidine treatment.

Cardiac dysrhythmias are an important cause of morbidity and mortality in the perioperative period, and they are more common after thoracic surgery and are most often supraventricular in origin [1]. Dexmedetomidine, a highly selective α-2 adrenoceptor agonist, is increasingly being used in anesthesia and critical care because it not only produces sedation and analgesia but also decreases sympathetic tone and attenuates stress responses to surgery leading to potential antiarrhythmic effects [2]. Here, we present a case of dexmedetomidine treatment of paroxysmal supraventricular tachycardia (PSVT) that occurred during thoracic surgery. A 72-year-old man, 168 cm tall and weighing 63 kg, was scheduled for right lower lobectomy suspicious of non-smallcell lung cancer. He has medical history of diabetes mellitus and hypertension for 10 years, which were both well controlled with medications. Preoperative electrocardiography (ECG) and chest radiography was unremarkable. Moreover, laboratory data were within normal limits. The patient was monitored with pulse oximetry, ECG, invasive radial arterial blood pressure, capnography, bispectral index (BIS), esophageal temperature probe. Induction of anesthesia was commenced with a slow (60 second) intravenous bolus dose of remifentanil (1 μg/kg), followed by propofol (1 mg/kg) tracheal intubation was facilitated with rocuronium (0.9 mg/kg). Anesthesia was maintained With O2 1.5 L/min, N2O 1.5 L/min and desflurane. Single-lung ventilation using a double-lumen endotracheal tube was the mode of anesthesia. After one-lung ventilation, arterial blood gas analysis showed normal findings. During retraction of the right lung apex, blood pressure abruptly decreased to 70/45 mmHg and heart rate increased to 185 beats/min. ECG findings showed PSVT. After notifying the surgeon, the surgery was stopped, and sinus rhythm and blood pressure returned to normal within 2030 seconds after carotid sinus massage. Right lower lobectomy was performed, and during lung retraction for hemostasis, PSVT accompanying a low blood pressure of 70/40 mmHg and high heart rate of 180-190 beats/min occurred again. The dopamine dose (5-10 μg/kg/min) was titrated to stabilize vital signs, and carotid sinus massage was performed to terminate the PSVT. However, the PSVT did not revert to normal sinus rhythm even after adenosine was administered using the standard two-stage protocol, i.e., 0.1 mg/kg (6 mg) followed by 0.2 mg/kg (12 mg). The PSVT disappeared temporarily and reappeared later. At that time, arterial blood gas analysis showed the following results: pH, 7.25; PaCO2, 53 mmHg; PaO2, 139 mmHg; Na + , 140 mEq/L;

Topographical study of the trapezius muscle, greater occipital nerve, and occipital artery for facilitating blockade of the greater occipital nerve

The aim of this study was to clarify the topographical relationships between the greater occipital nerve and the trapezius muscle and between the greater occipital nerve and the occipital artery in the occiput in order to increase the success rate of greater occipital nerve blockade. Fifty-six halved heads of 28 cadavers were used in this study. The piercing points and the courses of the greater occipital nerve and occipital artery were analyzed by dividing a line connecting between the external occipital protuberance and mastoid process into three equal parts. A circle with a radius of 2 cm drawn at the medial trisection point of this line was divided into four equal sectors. The greater occipital nerve simply passed the lateral border of the trapezius muscle and then pierced the fascia connecting the cranial attachment of the trapezius muscle with the sternocleidomastoid muscle in 62.5% of the specimens, whereas it pierced the muscle itself in the other 37.5%. The greater occipital nerve and occipital artery pierced the fascia within the 2-cm-radius circle in 85.7% and 98.2% of the specimens, respectively. The piercing points of the greater occipital nerve and occipital artery were observed most frequently in the inferomedial (42.9%) and inferolateral (37.5%) sectors of the circle, respectively. The greater occipital nerve and occipital artery pierced the same sector of the circle and accompanied each other in 51.8% of the specimens. These results are expected to improve the understanding of the topographical relationships between the greater occipital nerve and trapezius muscle and between the greater occipital nerve and occipital artery in the occiput, and thus provide helpful information for the management of occipital neuralgia.

Epidemiology of complex regional pain syndrome in Korea: An electronic population health data study

Chronic regional pain syndrome (CRPS) is an inflammatory and neuropathic pain disorder characterized by the involvement of the autonomic nervous system with sensory, autonomic, motor, skin, and bone changes. At present, universally accepted consensus criteria for CRPS are not yet established, despite the diagnostic criteria proposed by the International Association for the Study of Pain (IASP). Various hypotheses for the pathophysiology of CRPS have been proposed; as a result, current therapeutic modalities are varied. General epidemiological data on CRPS are necessary for effective management. However, recent data on the epidemiology of CRPS in Korea are scarce. The aim of this study was to evaluate the incidence and other epidemiological features of CRPS in the general population in Korea. In this study on the epidemiology of CRPS in Korea, population-based medical data acquired from 51,448,491 subscribers to the National Health Insurance Service (NHIS) from 2011 to 2015 were analyzed, including the incidence, distribution by the CRPS type, regional distribution, monthly distribution, medical costs, and healthcare resource-utilization. The findings indicated that the incidence of CRPS in Korea was 29.0 per 100,000 person-years in 2015 and was correlated with patient age and sex. CRPS types included type I (63%) and type II (37%); moreover, the number of individuals with CRPS I have shown a growing trend since 2011. There was no monthly distribution, but there was regional variation according to the province. The medical departments managing CRPS I the most were orthopedics, internal medicine, anesthesiology and pain medicine, in order; however, patients with CRPS spent more money per visit in the departments of rehabilitation medicine, and anesthesiology and pain medicine. The incidence rate of CRPS in Korea was 29.0 per 100,000 person-years with an increasing trend, which was correlated with patient age in the 70s and female sex. CRPS type I was more common than CRPS type II; in addition, constant increase in medical expenses, regional imbalance, and differences in medical expense among medical specialties should be considered for early management of patients to reduce the disease burden in Korea. Sharing of knowledge about the diagnostic criteria of CRPS are also needed.