A new local anesthetic, bupivacaine, is widely used for regional anesthesia because of its high potency and long duration of action. However, bupivacaine is reported to result in cardiovascular collapse associated with convulsion at a plasma concentration above the normal one, while other local anesthetics do not. Also resuscitation is very difficult. Although the mechanism of this action is not known, bupivacaine seems to have an influence on Ca2+ transport across cell membranes via various pathways. The present study was designed to evaluate the effects of bupivacaine on Ca2+ transport across cell membranes. The results are as follows: 1) Bupivacaine inhibites Ca2+ uptake by SR of skeletal muscle. 2) Bupivacaine suppressed the Bowditch and Woodworth staircase phenomena in a guines pig's left auricle, however this was reversible even at convulsant doses. 3) Bupivacaine also suppressed the Na+-Ca2+ exchange pump on guines pig's left auricle. 4) Bupivacaine increased the Ca2+-ATPase activity by SR of skeletal muscle. 5) At concentrations above 3ug/ml, bupivacaine induced cardiac arrhythmia. These findings suggest that bupivacaine-induced cardiotoxicity is possibly due to a Ca2+- channel blockade, depression of the Na+-Ca2+ pump, inhibition of Ca2+ uptake by SR and subsequent decrease of intracellular Ca2+ concentration.
Anesthesia, Conduction ; Anesthetics, Local ; Arrhythmias, Cardiac ; Bupivacaine* ; Calcium* ; Cell Membrane ; Depression ; Membranes* ; Muscle, Skeletal ; Plasma ; Resuscitation ; Seizures

The Taylor's approach is a special paramedian approach to enter the L5-S1 interspace. The L5-S1 interspace is the largest in vertebral column. This approach is particularly useful when the interspace has been narrowed by pathologic bone destruction such as rheumatoid arthritis or osteoarthritis. Surgery in geriatric patients is associated with a markedly higher incidence of perioperative complication or mortality rate. Optimal anesthetic management of geriatric patients depends on understanding of the normal anatomy and physiologic changes in response to drug in aging. We studied of 3-geriatric patients with Taylor's approach. These patients had problems with respiratory dysfunction and anatomic constraints, which make other approaches unfeasible.
Aging ; Arthritis, Rheumatoid ; Humans ; Incidence ; Mortality ; Osteoarthritis ; Spine

BACKGROUND: Epidural administration of local anesthetics and opiate or intravenous administration of opiate and ketorolac has proven to be effective in the treatment of postoperative pain. Studies that compare epidual morphine-bupivacaine vs intravenous nalbuphine-ketorolac administration showed conflicting results. We compared the ability and side effects of epidural (EPI-PCA) morphine-bupivacaine versus intravenous (IV-PCA) nalbuphine-ketorolac for postoperative pain relief after cesarean delivery. METHOD: Sixty healthy women were randomly assigned to receive an epidural bolus of morphine 3 mg mixed with 0.5% bupivacaine 10 ml, followed by a EPI-PCA with 0.0125% morphine and 0.125% bupivacaine (basal infusion 2 ml/hr, bolus 0.5 ml, lock-out interval 15 min) or intravenous bolus of nalbuphine 5 mg, followed by a IV-PCA with 0.05% nalbuphine and 0.15% ketorolac (basal infusion 2 ml/hr, bolus 0.5 ml, lock-out interval 30 min) for pain relief after cesarean delivery. The intensity of pain was assessed by the patient, who was unawared of the dose given, using a visual analog scale (VAS). To compare intensity of pain, VAS was used at 1, 6, 12, 24 and 40 hour after the end of surgery. RESULT : EPI-PCA group had significant lower visual analog scale (VAS) at immediate postoperative period, whereas no significant difference was observed when pain was assessed at other time sequence. Pruritus was more frequent with EPI-PCA group, although the incidence of other side effects were the same. CONCLUSION: We conclude that EPI-PCA or IV-PCA using morphine-bupivacaine or nalbuphine- ketorolac is relatively effective and safe method for the postoperative pain control. Although EPI-PCA with morphine-bupivacaine shows lower VAS at immediate postoperative period, IV-PCA with nalbuphine-ketorolac is a safe and effective alternative to EPI-PCA with morphine-bupivacaine for providing pain relief after cesarean delivery.
Administration, Intravenous ; Analgesia* ; Analgesia, Patient-Controlled* ; Anesthetics, Local ; Bupivacaine ; Female ; Humans ; Incidence ; Ketorolac ; Morphine ; Nalbuphine ; Pain, Postoperative ; Postoperative Period ; Pruritus ; Visual Analog Scale

BACKGROUND: Caudal injection of local anesthetics with morphine is the most common anesthetic technique for perianal operation and postoperative analgesia. This study was purposed to compare the onset time of caudal analgesia, postoperative analgesic effect and side effects. METHOD: Sixty healthy patients scheduled for perianal operation were divided into 2 groups randomly. Group I was given 2 mg of morphine in 20 ml of 2% mepivacaine via sacral hiatus. Group II was also given 2 mg of morphine in 20 ml of 0.5% bupivacaine caudally. We measured the onset time of caudal block, time to the first request of analgesics, the number of analgesics within 24 hours and the incidence of postoperative side effects. Analgesic effect was evaluated by visual analogue scales (VAS) at 1, 2, 6, 12 and 24 hours postoperatively. RESULT : The onset time of caudal block for operation and the first request time of analgesic for postoperative pain was significantly shorter in group I than group II. The analgesic use in the first 24 hours was significantly more in group I than group II. The side effects were similar in both groups. CONCLUSION: We concluded that the combined use of morphine and bupivacaine provided better postoperative analgesia than the combined use of morphine and mepivacaine.
Analgesia ; Analgesics ; Anesthetics, Local ; Bupivacaine* ; Humans ; Incidence ; Mepivacaine* ; Morphine* ; Pain, Postoperative ; Weights and Measures

BACKGROUND: The development of postdural puncture headache is related to a patient's age, size, pregnancy, sex, type of dural puncture needle and direction of the needle bevel. We studied the effect of the needle size and type of dural puncture on postdural puncture headache after spinal anesthesia in the 40 patients. METHODS: Forty patients, belonging to ASA classes 1 and 2, were divided into 2 groups, one using the lumbar paramedian approach (n = 20, Group 1) on L4-5 interspinous space with a 24 G spinal needle and the the other using Taylor's approach (n = 20, Group 2) through S2 foramen with a 22G spinal needle. All patients received an infusion of lactated Ringer's solution (1,000 ml). After spinal anesthesia, we measured the incidence, onset, duration and severity of postdural puncture headache in the 40 patients. RESULTS: The incidence of postdural puncture headache is lower in Group 2 (0%) than in Group 1 (15%). The onset of postdural puncture headache occured within 24 hours in 100% of the patients in Group 1 and the duration of postdural puncture headache occured within 48 hours in 66.7% of the patients in Group 1. The severity of postdural puncture headache was mild and moderate in 3 cases of all the 3 cases with postdural puncture headache of Group 1. The location of postdural puncture headache was frontal in 2 cases and occipital in 1 case. CONCLUSIONS: The incidence of postdural puncture headache is zero in Taylor's approach group in 20 patients. Therefore we think that spinal anesthesia using Taylor's approach is safer than spinal anesthesia with the lumar approach for postdural puncture headache.
Anesthesia, Spinal* ; Humans ; Incidence* ; Needles ; Post-Dural Puncture Headache* ; Pregnancy ; Punctures

BACKGROUND: Marcaine is a recently introduced hyperbaric bupivacaine. The aim of this study was to compare the difference in hemodynamic change and sensory or motor block between 0.5% hyperbaric bupivacaine and 0.5% hyperbaric tetracaine in spinal anesthesia. METHODS: Thirty patients belonging to ASA classes I and II were divided into either a tetracaine (Group I) or bupivacaine (Group II). All patients received an infusion of lactated Ringer's solution (1,000 ml). We standardized techniques and injected equal doses (12 mg) in equal volume (2.4 ml) intrathecally for spinal anesthesia. After intrathecal injection of the agents, we measured the blood pressure, heart rate, change of sensory block level according to pinprick test and motor block by the modified Bromage score until fixation was achived. RESULTS: The onset time of sensory block was more rapid in Group I than in Group II. There was no difference in the level of sensory block between Group I and Group II. The time for maximum motor block was significantly shorter in Group I than in Group II (p < 0.05). The change in systolic and mean blood pressure in Group II was less than the change in Group I. CONCLUSIONS: Bupivacaine has a longer sensory block duration, a weaker intensity and shorter duration of motor block and yields less change in blood pressure than tetracaine in spinal anesthesia. Therefore, we concluded that spinal anesthesia with hyperbaric bupivacaine may be used more safely in comparision with hyperbaric tetracaine in hemodynamically troublesome cases.
Anesthesia, Spinal* ; Blood Pressure ; Bupivacaine* ; Heart Rate ; Hemodynamics ; Humans ; Injections, Spinal ; Tetracaine*

Gastric adenocarcinoma is the second most common cause of cancer death worldwide, but there are some geographical differences in its incidence. Gastointestinal stromal tumor (GIST) is an uncommon disease with a wide spectrum of aggressive behavior. These two tumors have a distinct pathogenesis. GIST is frequently identified as an incidental lesion found by routine endoscopy or in resection specimens that are removed for other reasons. We report a case of a gastric adenocarcinoma mimicking GIST in a 79-year-old woman. GIST was suggested by endoscopic ultrasonography and computed tomography scanning, but gastric adenocarcinoma was confirmed by gastroduodenoscopic biopsy. We performed a subtotal gastrectomy with Billroth I, lymph node dissection and transverse colon segmentectomy, and a 15.0x7.5x5.5 cm-sized gastric tumor was confirmed pathologically. Immunohistochemistry was positive for carcinoembryonic antigen and focal weakly positive for cytokeratin7 and cytokeratin20.
Adenocarcinoma ; Aged ; Biopsy ; Carcinoembryonic Antigen ; Colon, Transverse ; Endoscopy ; Endosonography ; Female ; Gastrectomy ; Gastroenterostomy ; Gastrointestinal Stromal Tumors ; Humans ; Immunohistochemistry ; Incidence ; Lymph Node Excision ; Mastectomy, Segmental

OBJECTIVE: The purpose of this study was to investigate the efficacy and safety of risperidone in the treatment of Korean schizophrenic patients. METHOD: This multicenter open study included 377 schizophrenic patients drawn from 39 university hospitals. After a wash-out period of 1 week, the schizophrenic patients were treated with risperidone for 8 weeks and evaluated at 5 points: at baseline, and 1,2,4 and 8 weeks of treatment. The dose was increased from 2mg/day(1mg twice daily) to 6mg/day(3mg twice daily) during the first week and adjusted to a maximum of 16mg/day over the next 7 weeks according to the patient's clinical response. Medication to control extrapyramidal symptoms was permitted. The psychiatric and neurological status of the patients was assessed by PANSS, CGI, and ESRS scales. RESULTS: 343(91%) of 377 patients completed the 8-week trial period. Clinical improvement, as defined by a 20% or more reduction in total PANSS score at end point, was shown by 81.3% of patients. The predictors of response to risperidone were associated older age, shorter duration of illness, fewer previous hospitalization. Risperidone had rapid onset of action: a significant decrease of the total PANSS and three PANSS factor(positive, negative, general), and CGI was already noticed at the end of first week. For the ESRS, parkinsonism rating scores were significantly increased until week 4 comparing with baseline. Dystonia rating scores were significantly increased until week 1, and dyskinesia rating scores were not significantly changed during the study. Laboratory parameters including vital sign, EKG, hematological, and biochemical values showed no significant changes during the trial. CONCLUSIONS: This study suggests that risperidone is generally safe and effective against both the positive and negative symptoms in our group of patients.
Dyskinesias ; Dystonia ; Electrocardiography ; Hospitalization ; Hospitals, University ; Humans ; Parkinsonian Disorders ; Risperidone* ; Schizophrenia* ; Vital Signs ; Weights and Measures