Yoon Sook Lee

The effect of ketamine on the incidence of emergence agitation in children undergoing tonsillectomy and adenoidectomy under sevoflurane general anesthesia

Background The rapid emergence and recovery from general anesthesia afforded by sevoflurane is associated with a high incidence of emergence agitation in children. Small doses of ketamine reduce the incidence of emergence agitation. This study compared the effects of ketamine 0.25 mg/kg and 0.5 mg/kg on emergence agitation and postoperative pain. Methods The effects of added intravenous ketamine were evaluated in 93 children, ASA I-II, 2-14 years old, undergoing an adenotonsillectomy. The patients were allocated randomly to one of three groups receiving saline (group C), ketamine 0.25 mg/kg (group K0.25) or ketamine 0.5 mg/kg (group K0.5). The children in each group were administered the study drugs 10 minutes before the end of surgery. The recovery characteristics, including the time to extubation, delivery time from the PACU, postoperative nausea and vomiting, agitation and pain were assessed. Results There were no significant differences in the extubation time, delivery time and postoperative nausea and vomiting between the three groups. There were significant differences in modified CHEOPS (Childrens Hospital of Eastern Ontario Pain Scale) between the three groups. The incidence of emergence agitation was low in the K0.25 and K0.5 groups compared to the control group. However, there was no significant difference between the K0.25 and K0.5 groups. Conclusions There was no significant difference in the incidence of emergence agitation between K0.25 and K0.5 groups. However, K0.5 group showed a lower pain score than K0.25 group.

Lidocaine does not prevent bispectral index increases in response to endotracheal intubation

We investigated the effect of IV lidocaine on the hemodynamic and bispectral index responses to induction of general anesthesia and endotracheal intubation. Forty patients (ASA I) were randomly allocated into 2 groups of 20 to receive normal saline or lidocaine 1.5 mg/kg IV 30 s after induction. Ninety seconds later, endotracheal intubation was performed. Systolic blood pressure, heart rate, and bispectral index were measured at baseline, 1 min after induction, at preintubation, and every minute until 5 min after endotracheal intubation. Bispectral index at 1 min after induction and preintubation in the lidocaine group were significantly lower compared with the control group (P < 0.05). Systolic blood pressure increased significantly at 1 and 2 min after intubation in the control group compared with the baseline value (P < 0.05) but did not increase significantly in the lidocaine group. Heart rate increased at 1 to 3 min in both groups (P < 0.05), but there was no significant difference between the two groups. One patient in the control group had recall of the procedure. We conclude that the administration of IV lidocaine (1.5 mg/kg) does not suppress the hypnotic response to endotracheal intubation.

Effects of propofol target-controlled infusion on haemodynamic and respiratory changes with regard to safety

We investigated the haemodynamic and respiratory effects of propofol target-controlled infusion (TCI) during spontaneous ventilation. We studied 20 patients scheduled for elective orthopaedic surgery who were classified as American Society of Anesthesiologists physical status I. During spontaneous ventilation, haemodynamic, respiratory and electroencephalographic variables were measured. Oxygen flow was maintained at 5 1/min using a semi-closed system and a close-fitting face mask. All measurements were obtained before the propofol TCI and at each propofol effect-site concentration (0.5, 1.0, 1.5, 2.0, 2.5, 3.0, 3.5 and 4.0 μg/ml). Changes in Bispectral Index Score, systolic blood pressure, diastolic blood pressure, end tidal carbon dioxide tension and heart rate were negatively correlated with propofol effect-site concentrations. Despite maintaining oxygen saturation (> 99%), apnoea and blood pressure reductions were abruptly induced as the propofol effect-site concentration increased. We therefore recommend careful monitoring of haemodynamic and respiratory function during spontaneous ventilation using propofol TCI.

Beneficial effects of adding ketamine to intravenous patient-controlled analgesia with fentanyl after the nuss procedure in pediatric patients

Purpose The aim of this prospective, double-blind, randomized study was to investigate the analgesic effects of low-dose ketamine on intravenous patient-controlled analgesia (IV-PCA) with fentanyl for pain control in pediatric patients following the Nuss procedure for pectus excavatum. Materials and Methods Sixty pediatric patients undergoing the Nuss procedure were randomly assigned to receive fentanyl (Group F, n=30) or fentanyl plus ketamine (Group FK, n=30). Ten minutes before the end of surgery, following the loading dose of each solution, 0.5 µg/kg/hr of fentanyl or 0.5 µg/kg/hr of fentanyl plus 0.15 mg/kg/hr of ketamine was infused via an IV-PCA pump (basal rate, 1 mL/hr; bolus, 0.5 mL; lock out interval, 30 min). Fentanyl consumption, pain score, ketorolac use, nausea/vomiting, ondansetron use, pruritus, respiratory depression, hallucination, dreaming, and parent satisfaction with pain control were measured throughout the 48 hours following surgery. Results The pain scores, ketorolac use, and fentanyl consumption of Group FK were significantly lower than in Group F (p<0.05). The incidence of nausea/vomiting and ondansetron use in Group FK was significantly lower than in Group F (p<0.05). There were no reports of respiratory depression, hallucination or dreaming. Parent satisfaction with pain control was similar between the two groups. Conclusion We concluded that low-dose ketamine added to IV-PCA with fentanyl after the Nuss procedure in pediatric patients can reduce pain scores, consumption of fentanyl, and incidence of nausea/vomiting without increasing side effects.

Effect of ketamine on intravenous patient-controlled analgesia using hydromorphone and ketorolac after the Nuss surgery in pediatric patients

Background Nuss surgery is preferred in pectus excavatum repair because this procedure produces excellent cosmetic results and prevents postoperative distressed pulmonary function. However, the procedure causes severe pain due to thoracic expansion. This study was designed to investigate the analgesic effect of small doses of ketamine on an intravenous patient-controlled analgesia (IV-PCA) using hydromorphone and ketorolac for pain control after Nuss surgery. Methods Forty-four patients undergoing elective Nuss surgery were randomly assigned to receive hydromorphone 3 µg/kg/hr, ketorolac 0.05 mg/kg/hr and ondansetron 0.1 mg/kg/day (Group HO, n = 22) or hydromorphone 3 µg/kg/hr, ketorolac 0.05 mg/kg/hr, ondansetron 0.1 mg/kg/day and ketamine 0.15 mg/kg/hr (Group HK, n = 22) via an IV-PCA pump after surgery. A blind observer evaluated each patient using the Modified Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS) for the assessment of pain control. The total administered PCA volume, side effects and parents satisfaction with pain control were assessed at postoperative 1, 4, 8, 12, 24, and 48 hours. Results There were no significant differences in Modified CHEOPS between the groups during postoperative 48 hours. The total PCA volume in group HK was significantly lower than that in group HO (P < 0.05). The side effects in both groups did not significantly differ except for pruritus. The levels of satisfaction from the parents were not significantly different between the groups. Conclusions A small dose of ketamine on IV-PCA reduced the total administered dose of IV-PCA with hydromorphone and ketorolac and reduced the incidence of pruritus after the Nuss procedure in pediatric patients.

Intrathecal hydromorphone added to hyperbaric bupivacaine for postoperative pain relief after knee arthroscopic surgery: a prospective, randomised, controlled trial.

Background and objective Adding opioid to spinal anaesthetic provides additional analgesia during the postoperative period. The purpose of this study was to determine the dose of intrathecal hydromorphone necessary to achieve postoperative pain relief after arthroscopic knee surgery. Methods In a prospective, double-blinded parallel, placebo-controlled manner, 60 patients who were undergoing unilateral knee arthroscopy randomly received unilateral spinal anaesthesia with 0.5% hyperbaric bupivacaine 6 mg combined with 0.0, 2.5, 5.0 or 10.0 &mgr;g per 0.05 ml hydromorphone. Fifteen patients were assigned to receive each dose. The visual analogue pain scores (VAPSs) were measured at 30 min and 2, 4, 6, 12 and 24 h postoperatively, and the side-effects of hydromorphone were recorded. Results The postoperative VAPSs at 4, 6 and 12 h for the 5 and 10 &mgr;g hydromorphone groups were significantly decreased, compared to the control group. The 2.5 &mgr;g hydromorphone group had lower VAPS only at 4 and 6 h postoperatively. Nausea was significantly increased in the 10 &mgr;g hydromorphone group (46.6%). Conclusion The analgesic effects of 5 and 10 &mgr;g intrathecal hydromorphone provided satisfactory pain relief for 12 h postoperatively and nausea increased significantly in a dose-dependent manner. Trial registration ClinicalTrials.gov. ID: NCT01172782.

Effects of cranial electrotherapy stimulation on preoperative anxiety, pain and endocrine response

Objectives Cranial electrotherapy stimulation (CES) is used as a treatment for depression and anxiety, and as an adjunctive intervention for pain management. This prospective study investigated whether CES could decrease preoperative anxiety, the injection pain of rocuronium, postoperative pain and stress hormone levels. Methods Female patients undergoing thyroidectomy were randomly assigned to two groups, to receive either no pretreatment (control group) or CES pretreatment. Anxiety score, withdrawal response on rocuronium injection, and pain scores at 1, 4, 12 and 24 h post surgery were evaluated. Adrenocorticotrophic hormone (ACTH), cortisol and glucose levels were measured. Patients were blinded to the treatment condition. Results Fifty patients entered the study (n = 25 per group). Anxiety score and withdrawal responses during rocuronium injection were significantly reduced in the CES group compared with the control group. Pain score was significantly lower in the CES group than in the control group, 1 h and 4 h post surgery. There were no significant differences in ACTH, cortisol and glucose levels. Conclusions CES pretreatment appears to reduce the level of preoperative anxiety, injection pain of rocuronium and postoperative pain. However, CES pretreatment did not affect stress hormone responses.

Morphine attenuates endothelial cell adhesion molecules induced by the supernatant of LPS-stimulated colon cancer cells.

A large reservoir of bacterial lipopolysaccharide (LPS) is available in the colon and this could promote colon cancer metastasis by enhancing tumor cell adhesion, intravasation, and extravasation. Furthermore, adhesion molecules like ICAM-1, VCAM-1, and E-selectin play important roles in the adhesion of tumor cells to endothelium. This study was designed to determine whether morphine can attenuate the expressions of adhesion molecules up-regulated by the supernatant of LPS-stimulated HCT 116 colon cancer cells (LPS-Sup). In this study, we divided to three groups by cell-growth medium of human umbilical vascular endothelial cells (HUVECs): the control group was incubated in growth factor-free endothelial medium, the Sup group was incubated in the supernatant of HCT 116 cells (Sup), and the LPS-Sup group was incubated in LPS-Sup. To observe effect of morphine to the adhesion molecules expressions in the LPS-Sup group, we co-treated morphine with LPS or added it to LPS-Sup. Adhesion molecule expressions on HUVECs in all three groups were measured during incubation period. Consquentially, ICAM-1, VCAM-1, and E-selectin expressions on HUVECs were significantly lower when morphine was co-treated with LPS than not co-treated. Thus, we suggest that morphine affects the expressions of adhesion molecules primarily by attenuating LPS stimuli on tumor cells.

Anaphylaxis with angioedema by rocuronium during induction of general anesthesia -A case report-

Perioperative anaphylaxis is characterized by severe respiratory and cardiovascular manifestations. Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anesthesiologist. A 34-year-old woman was scheduled to undergo endo venous laser therapy of varicose veins. She had no history of allergies and had never undergone general anesthesia. General anesthesia was induced with propofol and rocuronium bromide. Approximately three minutes after rocuronium administration, hypotension and tachycardia developed and angioedema around the eyelids and skin rashes and urticaria appeared. The patient received ephedrine and hydrocortisone with hydration. After achieving stable vital signs and symptom relief, surgery was performed without complications. A postoperative skin dermal test performed to identify the agent responsible revealed a positive skin test for rocuronium.

Anesthetic experience using total intra-venous anesthesia for a patient with Wolf-Hirschhorn syndrome -A case report-

We present here the case of a 33-month-old male patient with Wolf-Hirschhorn syndrome (WHS) and who underwent tympanoplasty and myringotomy. WHS is caused by a rare chromosomal abnormality, which is the deletion of the short arm of chromosome number 4. The typical craniofacial features of WHS patients such as micrognathia, microcephaly and the muscular weakness can make using neuromuscular blocking agents and performing intubation difficult. Moreover, there are a few previous case reports showing that malignant hyperthermia occurred during and after an operation in which the anesthesia was done with inhalation agents, so special anesthetic care is needed when operating on a WHS patient. By carefully intubating the patient and using total intravenous anesthesia, we performed successful anesthesia without any complications. We describe here the anesthetic management of a WHS patient and we review the relevant literature.