Anesthesia for Fetal Surgery: Twin Reversed Arterial Perfusion Sequence

It is important to consider the fetal, uteroplacental, and maternal issues when choosing anesthetic technique for fetal surgery. The twin reversed arterial perfusion (TRAP) sequence, or the acardiac anomaly, occurs in 1：100 monozygous multiple pregnancies and in 1：35,000 births. The TRAP sequence is characterized by placental vascular arterio-arterial anastomosis between twin fetuses, one an acardiac/acephalic twin that receives its blood flow from the normal pumping twin, thereby endangering the normal twin by high output cardiac failure. The acardiac twin is nonviable, and perinatal mortality in the pump cotwin exceeds 50% because of cardiac failure and prematurity. This can be managed by fetal surgery. We report on a patient with a 26-wk gestation complicated by an acardiac/acephalic fetus anesthetized for surgical umbilical cord ligation.ope

The Analgesic Effects of Intercostal Nerve Block in Patients Undergoing Total Ear Reconstruction

BACKGROUND: Patients usually complain of severe postoperative pain at the rib cartilage recession site after total ear reconstruction surgery. We evaluated the postoperative analgesic effects of an intercostal nerve block (ICNB) in patients undergoing total ear reconstruction. METHODS: We injected normal saline (2 ml/rib space) in the control group (n = 15), and 0.75% ropivacaine (2 ml/rib space) in the ICNB group (n = 15) respectively into the 6th, 7th and 8th intercostal spaces following the induction of general anesthesia for surgery. Mean arterial pressures and heart rates were measured pre-ICNB, post-ICNB, pre-surgical incision, 10, 30 and 60 minutes after incision. Numerical rating scales (NRS: 0 = no pain, 10 = most severe pain) were measured at a postoperative 6, 12, 24, 36 and 48 hours by NRS-resting and NRS-coughing, respectively. RESULTS: Mean arterial pressures and heart rates were significantly more stable (P < 0.05) in the ICNB group at 10, 30 and 60 min after incision, than in the control group. NRS were low in all of the ICNB group throughout the postoperative period versus the control group. CONCLUSIONS: We conclude that ICNB induce stable vital signs during rib recession and has excellent postoperative analgesic effects. Thus, we recommend periop-ICNB for total ear reconstruction surgery for the management of anesthesia and postop-analgesia.ope

Can Ketamine Substitute for Fentanyl in Gynecologic Cone Biopsy Anesthesia?

Background: In a gynecologic cone biopsy, fentanyl is commonly used with propofol for its analgesic effect, but it has many side effects, such as bradycardia, respiratory depression and hypotension. A subanesthetic dose of ketamine has an analgesic effect and minimal cardiovascular effects. We wanted to know whether ketamine can be safely used with propofol in a gynecologic cone biopsy instead of fentanyl. Methods: Forty woman patients were randomly allocated to two groups. All patients were anesthesized with a propofol infusion. Fentanyl 1μg/kg IV was injected 2 minutes before LMA (laryngeal mask airway) insertion in group I, ketamine 0.25 mg/kg IV was injected also in group II. Blood pressure and heart rate were measured before fentanyl or ketamine injection, 1 minute, 3 minutes and 5 minutes after LMA insertion, and during the operation. A numerical rating scale (NRS) for pain and other side effects were checked for 24 hours after the operation. Results: There were no significant differences between the two groups in blood pressure, heart rate, NRS and side effects, but a more stable systolic blood pressure in the ketamine group occured. Conclusions: For a gynecologic cone biopsy, propofol anesthesia combined with fentanyl or ketamine was not different for stable cardiovascular results, postoperative pain relief and side effects. Therefore, ketamine as an analgesic combined with propofol could replace fentanyl in gynecologic cone biopsy anesthesia.ope

Effects of Ondansetron or Naloxone Patient-Controlled Analgesia on Postoperative Analgesia and Side Effects

BACKGROUND: Opioid delivered by PCA (patient-controlled analgesia) is effective at relieving pain after surgery, but it is associated with side effects, such as nausea, vomiting, pruritus, respiratory depression, and urinary retention. The purpose of this study was to compare fentanyl-related side effects and the quality of analgesia when naloxone or ondansetron was added to IV PCA regimen. METHODS: Ninety patients undergoing lumbar laminectomy were enrolled in this study. General anesthesia was maintained with 50% N2O and enflurane. In the recovery room patients received a 1 µg/kg bolus of fentanyl, and addition normal saline 2 ml (group C), ondansetron 4 mg (group O), or naloxone 0.04 mg (group N). Simultaneously intravenous fentanyl PCA with normal saline (group C), ondansetron 4 mg (group O), or naloxone 0.36 mg (group N) was commenced. Pain scores and side effects were assessed on postoperative days (PODs) 0, 1, and 2 using a VAS (visual analogue scale). RESULTS: The incidences of vomiting in the groups C, O, and N were 13.2%, 13.2%, and 3.3%, respectively. The VAS scores for nausea on PODs 0 and 1 in group N were significantly lower than in group C. The VAS scores for sedation on POD 0 in group N was lower than in group C, and on POD 2 lower than in group O. No differences in the VAS for pain and urinary retention were observed between the three groups. CONCLUSIONS: Low-dose naloxone with IV fentanyl PCA is effective at reducing opioid-related nausea and sedation without attenuating the quality of analgesia.ope

Comparison Between a Fentanyl and Clonidine Admixture to Lidocaine in a Brachial Plexus Block

Background: The admixture of clonidine or fentanyl to 1.5% lidocaine for brachial plexus block was studied with regard to onset and duration of anesthesia and postoperative analgesia after a brachial plexus blockade. Methods: Thirty patients (ASA I-II) undergoing surgery of the forearm and hand under an interscalene brachial plexus blockade (BPB) were included in this study. Patients were randomly divided into 3 groups. BPB was performed using 40 ml of 1.5% lidocaine added epinephrine 1：200,000 in group E, 1μg/kg of fentanyl in group F, and 2μg/kg of clonidine in group C, respectively. The onset times of blockade in the radial, ulnar, median and musculocutaneous nerve were recorded. Hemodynamic data and sedation scores were monitored. Finally, the duration of the sensory block was assessed. A value of P ＜ 0.05 was considered as statistically significant. Results: The clonidine group was shorter in onset time, decreased need for postoperative analgesia and increased analgesic duration than other groups but more sedated than group E. With the admixture of fentanyl, pain scores were lower at 180 and 210 min after the block (VAS: mean 2, 8) than with epinephrine (VAS: mean 27, 30 respectively). Hemodynamic changes were not significantly different in all groups. Conclusions: The addition of clonidine to 1.5% lidocaine causes a rapid onset of analgesia and prolonged duration of sensory blockade in the brachial plexus blockade when compared to the addition of epinephrine or fentanyl to 1.5% lidocaine.ope

Role of nuclear factor kappa B activation in ischemic injury of cerebral endothelial cells.

의학과/박사[한글] 뇌졸중은 사망률 1위를 차지하는 주요 질병이다. 뇌졸중은 뇌의 혈행 장애로 인한 허혈 (ischemia)에 의해 뇌신경세포가 사멸하여 그 신경학적 증상을 나타내며, 사망, 불구의 결과를 낳는다. 최근 뇌신경세포의 사멸 뿐 아니라 뇌혈관 내피세포도 뇌졸중의 중요한 병태 생리를 담당한다고 알려져 그 관심이 고조되고 있는 바, 뇌혈관 내피세포의 백혈구 부착 인자 (leukocyte adhesion molecule) 발현 및 이에 의한 뇌실질 염증, blood-brain barrier (BBB)의 손상에 의한 뇌 부종, 뇌혈관 내피세포 사멸에 의한 뇌 실질 츨혈 등으로 요약할 수 있다. Nuclear factor kappa B (NF-κB)는 염증, 세포 생존/사멸에 중요한 역할을 하는 전사인자이다. 본 실험에서는 허혈의 in vitro 모델인 oxygen glucose deprivation (OGD)을 이용하여, NF-κB가 허혈에 의한 뇌혈관 내피세포 사망에 미치는 영향을 연구하였다. 뇌혈관 내피세포주인 bEnd.3 세포에 OGD 처리하면, 그 기간에 비례하여 세포 사멸이 나타났으며, NF-κB가 활성화되었다. 이 때 OGD에 의한 세포 사멸은 있으나, 뒤따른 재관류에 의한 추가 손상은 없어, 이 후의 실험에서는 OGD에 의한 손상에 초점을 두었다. NF-κB 활성화는 electrophoretic mobility shift assay (EMSA)를 이용하여 확인하였고, 본 실험에서 활성화되는 NF-κB는 p65/p50 heterodimer와 p50/p50 homodimer였다. OGD에 의한 뇌혈관 내피세포의 NF-κB 활성화 기전은 대표적인 NF-κB 활성화인 TNFα에 의한 경우와는 그 기전이 다른 바, IκBα 32Ser의 인산화 및 proteasome에 의한 파괴 과정이 나타나지 않았으며, 허혈/재관류의 경우 나타난다는 IκBα 42Tyr의 인산화도 나타나지 않았다. OGD에 의해 활성화되는 NF-κB가 세포 생존인자인지, 사멸인자인지 혹은 이 경우의 세포 사멸에 관계 없는 인자인지 알아보기 위해 세 종류의 NF-κB 억제제인 pyrrolidine dithiocarbamate (PDTC) + zinc, sodium salicylate, caffeic acid phenethyl ester (CAPE)를 사용하였다. 이 세 약물은 공히 NF-κB를 억제하였으며, 세포 사멸을 증가 시켰다. 이러한 결과가 나타난 기전을 알기 위해 세포 생존/사멸 단백 중 NF-κB에 의해 조절되는 것으로서 p53, bax, bcl-2를 Western blot으로 측정하여 보았으나 이 단백들이 양적으로 변화하지 않아, 적어도 이 세 NF-κB 억제제의 효과는 이 세 가지 세포 생존/사멸 관련 단백을 경유하지 않았다. 결론적으로, OGD에 의한 뇌혈관 내피세포의 NF-κB 활성화는 세포 생존 인자로 판단된다. [영문] Stroke is a leading cause of sudden death. The major pathophysiology of stroke is cerebral ischemia causing neuronal death. There is increasing evidence that ischemia-induced vascular damage is an integral step in the cascade of the cellular and molecular events initiated by cerebral ischemia. In the present study, the role of nuclear factor kappa B (NF-κB) activation during ischemic injury was investigated in cerebral endothelial cells. A mouse brain endothelioma-derived cell line, bEnd.3 was used and oxygen-glucose deprivation (OGD) was applied for in vitro stroke model. OGD activated NF-κB through a quite different mechanism from that of TNFα-induced NF-κB activation; no phosphorylation of IκBα 32Ser, no degradation of IκBα, and no phosphorylation of IκBα 42Tyr. OGD induced bEnd.3 cell death in a time-dependent manner. The extent of cell death was 40%, 60% and 90% after 10, 12 and 14 hours of OGD respectively. Reperfusion following OGD did not cause additional cell death, which means there is no reperfusion injury in case of cerebral endothelial cells. Three chemicals, sodium salicylate, pyrrolidine dithiocarbamate (PDTC) and caffeic acid phenethyl ester (CAPE) known as NF-κB inhibitors, inhibited OGD-induced NF-κB activation and increased OGD-induced bEnd.3 cell death in a dose dependent manner. There was no changes in the protein levels of p53, bax and bcl-2 which can be modulated by NF-κB activity. These results suggest that NF-κB activation would be a protective mechanism for OGD-induced cell death in bEnd.3.ope

(The) effects of magnesium-pretreatment on the neuromuscular blocking actions of cis-atracurium in the cat

의학과/석사[한글] Cis-atracurium은 benzylisoquinolinium계 비탈분극성 근이완제로 atracurium의 10가지 광학이성체들 중 R-cis와 R'-cis 형태의 두 가지 이성체 만을 분리한 것으로서 atracurium에 비해 역가가 높고 histamine 분비가 적어 자율신경계 및 심혈관계에 미치는 영향도 훨씬 적다. 또한 대부분 Hofmann elimination에 의해 대사되며 제1대사 물질로 중추신경 흥분 작용이 있는 laudanosine의 생성이 atracurium보다 아주 적어 근래에 임상에 도입된 약제이다. 하지만 다른 이온과의 상호 작용 특히 임신 중독중의 치료제로 사용되는 magn esium에 의한 근이완 작용의 구체적인 효능 변화에 대해서는 알려진 바가 없다. 본 연구는 고양이를 대상으로 실험적으로 cis-atracurium을 단계적으로 투여하면서 전경골근-좌골신경 표본을 이용하여 0.1 Hz의 등척성 장력(isometric tension)을 기록하여 축적 효과 유무를 확인하였고, 그후 sis-atracurium의 용량-반응 실험을 시행하여 magnesium을 투여하지 않은 군 (Ⅱ)과 투여한 군 (Ⅲ)에서 누적 용량-반응 실험을 통하여 역가와 작용 지속 시간을 비교하였으며, 이후 90 % 정도의 연축 억제가 이루어지는 cia-atracurium의 적정 주입 속도를 20 분간 유지한 후 그 반에서는 자연회복을 시켰고 나머지 반은 주입속도를 유지하면서 neostigmine 10 ㎍/kg를 투여하여 가역시켰으며 적응에 따라 발현 시간, 작용 지속 시간, 회복 지수 및 최대 가역 효과 등을 관찰하였다. 그 결과, sis-atracurium 100 ㎍/kg를 4회 연속 정주하여 근연축이 100 % 회복될 때까지의 각각의 작용 지속 시간은 유의한 차이를 보이지 않았으므로 축적 효과는 없었다. ED^^50 및 ED^^95 를 비교할 때 Ⅲ군이 각각 103±18 및 173±28 ㎍/kg로, Ⅱ군의 234±82 및 399±123 ㎍/kg에 비해 44 및 43 % 로써 의의있게 감소하여 근이완 역가가 항진되었으며, 작용 지속 시간은 143±29 초에서 190±52 초로 33% 정도 유의하게 증가되었다. 또한 90% 정도의 연축 억제를 20 분간 일정하게 유지하는 데에 필요한 cis-atracurium의 주입 속도는 Ⅱ군의 6.63±2.37 ㎍/kg/min에 비하여 4.47±1.58 ㎍/kg/min로 유의하게 감소되었으나 자연 회복시 회복 지수는 유의한 차이를 보이지 않았다. Neostigmine 의 가역효과를 관찰하기 위하여, 90% 정도의 연축 억제를 20 분간 일정하게 유지하는 데에 필요한 cis-atracurium의 주입속도는 Ⅱ군의 7.88±1.14 ㎍/kg/min에 비하여 Ⅲ군에서 4.27±1.49 ㎍/kg/min로 유의하게 역시 감소되었으며, 각 주입속도를 유지하면서 neostgmine을 투여하였을 때 발현 시간, 작용 지속 시간 및 최대 가역 효과는 양군간에 유의한 차이를 보이지 않았다. 결론적으로 cis-atracurium은 축적 효과가 없고, magnesium에 의하여 cis-atracurium의 역가가 증강되고 근이완 작용은 연장되나 neostigmine에 의한 가역 효과에는 영향이 없다. [영문] The cia-atracurium, composed of two types (R-cis & R'-cis form) of the ten isomers of atracurium, is the benzylisoquinolinium derivative non-depolarizing muscle relaxant. It is more potent, and less likely to release histamine and has better autonomic and cardiovascular stability, compared with atracurium. It is eliminated mainly by Hofmann reaction and produces less amounts of laudanosine, the first metabolite which has the CNS stimulating property. However, drug interactions with several ions, such as magnesium that is popular in treating eclampsia have not yet to be known. Using sciatic nerve-anterior tibialis preparation in the cat, we tried to find out whether cia-atracurium has the cumulation effect by administering four consecutive 100 μg/kg of cis-atracurium. After confirming that the cis-atracurium had no cumulation effect, we proceeded the dose-response study to find out the ED^^50, ED^^95 and action duration of cis-atracurium in control group (Ⅱ) and magnesium-pretreated group (Ⅲ). After cumulative dose-response study, in the half of the group Ⅱ and Ⅲ, the infusion rate to maintain 90 % twitch depression at least for 20 minutes was obtained, and afterwards, the recovery index was measured after the discontinuation of infusion. In the other half of the group Ⅱ and Ⅲ, while maintaining 90% twitch depression at least for 20 minutes through continuous infusion of cis-atracurium, we administered the 10 μg/kg of neostigmine to measure the onset time, action duration and antagonism effect of the drug. The cis-atracurium did not have the cumulation effect and in group Ⅲ, ED^^50 and ED^^95 were decreased significantly from 234±82 μg/kg to 103±18 μg/kg and from 399±123 μg/kg to 173±28 μg/kg, respectively, compared with group Ⅱ. The action duration of cis-atracurium ED^^95 in group Ⅲ (190±52 sec) was significantly longer than in group Ⅱ (143±29 sec). The infusion rate of cis-atracurium to maintain 90% twitch depression was significantly higher in group Ⅱ in the spontaneous recovery and the neostigmine-induced antagonism (6.63±2.37 and 4.47±1.58 μg/kg/min, respectively), However, there was no significant difference in recovery time between group Ⅱ and Ⅲ. There was no significant difference in the onset time, the action duration and the antagonism effect of neostigmine between group Ⅱ and Ⅲ. In conclusion, the cis-atracurium do not have the cumulation effect. And, the magnesium potentiates the neuromuscular blocking actions of cis-atracurium. However, it has no effect on the antagonism action of neostigmine.restrictio

Does Trendelenburg Position or Reverse Trendelenburg Position affect Changes of Peak Inspiratory Pressure and Arterial Blood Gas in Laparoscopic Surgery

Background: Laparoscopic surgery has increased in popularity due to its small skin incision, reduced postoperative pain and short hospital day. But increased abdominal pressure caused by CO2 insufflation and Trendelenburg position or reverse Trendelenburg position affects cardiovascular function and pulmonary ventilation. Some studies suggested that Trendelenburg position affect more serious results on pulmonary ventilation than reverse Trendelenburg position, but others do not. So we designed this study to compare the difference of peak inspiratory pressures and arterial blood gases between Trendelenburg position and reverse Trendelenburg position in laparoscopic surgery. Methods: Twenty patients undergoing laparoscopic operation were randomized into two groups. Group Ⅰ (n=10) was laparoscopic gynecological surgery under Trendelenburg position, and group Ⅱ (n=10) was laparoscopic cholecystectomy under reverse Trendelenburg position. All patients were mechanically ventilated (a tidal volume of 12 ㎖/㎏ at a respiratory rate of 12 breaths/minute) with 50% nitrous oxide and 50% oxygen with enflurane. We measured peak inspiratory pressure, PaO2 and PaCO2 at pre-CO2 insufflation, 10 minute after CO2 insufflation, 30 minute after CO2 insufflation and 10 minute after CO2 deflation, respectively. Results: There were no significant differences between the two groups in peak inspiratory pressure, PaCO2 and PaO2. Conclusions: We suggest that there are no changes in pulmonary ventilation between Trendelenburg and reverse Trendelenburg position in patients undergoing laparoscopic surgery.ope