BACKGROUND: Thoracic epidural analgesia is the mainstay of postoperative pain control after thoracotomy. Usually the epidural catheter is blindly inserted and secured without confirming the tip position. The purpose of this study was to determine the influence of epidural approach angle on the position of the thoracic epidural catheter tip. METHODS: 129 patients scheduled for thoracotomy were enrolled. Patients were randomized into two groups: narrow angle group and wide angle group. The epidural needle was inserted at the skin of T8-9 level in both groups. In the narrow angle group the epidural space was approached at T7-8, whereas in the wide angle group the epidural space was approached at T6-7. After epidural space confirmation, a B-D nylon multi-hole epidural catheter was threaded 8cm into the epidural space. The epidural catheter tip position was assessed using a small amount of radiocontrast dye under fluoroscopy. RESULTS: The mean (95% confidence interval) position of the catheter tip was the mid-body of T5 (T5-6 - T5 upper body) in the narrow angle group and T3-4 (mid-body of T4-T3 lower body) in the wide angle group (P = 0.037). CONCLUSIONS: When approaching the thoracic epidural space by a wide angle, we can place the epidural catheters at a higher level because of a straighter threading.
Analgesia ; Analgesia, Epidural ; Catheterization* ; Catheters* ; Epidural Space ; Fluoroscopy ; Humans ; Needles ; Nylons ; Pain, Postoperative ; Skin ; Thoracic Surgery ; Thoracotomy

No abstract available.
Fractures, Compression* ; Vertebroplasty*

BACKGROUND: In liver transplantation, an increase of serum potassium [K+] after reperfusion is related to components of the preservation solution. However, the histidine-tryptophan-ketoglutarate (HTK) solution, which is now popularly used, has a twelve times lower [K+] as compared to the UW solution. This retrospective study was performed to compare the use of the UW solution with the HTK solution for changes in the serum [K+] during the early reperfusion period in liver transplantation recipients. METHODS: Anesthesia medical records of 366 liver transplant patients were reviewed and patients were enrolled in one of the two groups; recipients who received a transplanted liver preserved with the UW solution (UW group), and recipients received a liver preserved with the HTK solution (HTK group). Serum [K+] changes 5 min before, 5 min after, and 20 min after reperfusion for recipients in each group were compared. RESULTS: In the UW group, [K+] increased 5 min after reperfusion and decreased 20 min after reperfusion as compared to [K+] 5 min before reperfusion (3.93, 4.07, and 3.76 mM in 5 min before, 5 min after, and 20 min after reperfusion respectively; P < 0.001). In the HTK group, [K+] significantly decreased 5 min and 20 min after reperfusion as compared to [K+] 5 min before reperfusion (4.12, 3.79, and 3.75 mM; P < 0.001). CONCLUSIONS: When the HTK solution was used, the serum [K+] 5 min after reperfusion decreased as compared to the [K+] before reperfusion and didn't further decrease until 20 min after reperfusion.
Adenosine ; Allopurinol ; Anesthesia ; Glucose ; Glutathione ; Humans ; Insulin ; Liver ; Liver Transplantation ; Mannitol ; Medical Records ; Organ Preservation Solutions ; Potassium ; Potassium Chloride ; Procaine ; Raffinose ; Reperfusion ; Retrospective Studies ; Transplants

We tried to determine the significance of invasion to the muscularis mucosae on the progression and recurrence of the superficial bladder cancer. Muscularis mucosae was composed of the smooth muscle bundles around relatively large vessels and found in the lamina propria approximately midway between the surface mucosa and the true muscular layer, lying parallel to the mucosa. Between January 1984 and December 1993, 81 patients with diagnosed superficial bladder cancer showing lamina propria invasion (pTl) were treated by transurethral resection (TUR) at our hospital. The mean age was 59.4 years ( range, 31-86 years), the mean follow-up period was 35.3 months ( range, 13-120 months) and the male : female ratio was 69 : 12. We subclassified superficial bladder cancer showing lamina propria invasion into two groups with ( pT1b) or without ( pT1a) cancer invasion to the muscularis mucosae. The muscularis mucosae was identified in 58 (71.6%) of 81 cases. In the other cases ( 28.4% ), relatively large vessels were used as the landmark instead of the muscularis mucosae. Of 81 bladder cancers, 52 (64.2%) were diagnosed as pT1a and 29 (35.8%) as pTlb. The progression rate of pT1b cancer (41.4% ) was significantly higher than that of pT1a cancer (3.8% ) (p= 0.001). And the recurrence rate of pT1b cancer (55.2% ) was significantly higher than that of pT1a cancer ( 26.9 %)(p= 0.024). In conclusion, superficial bladder cancer invading to the muscularis mucosae has a high risk for disease progression after TUR. Careful follow-up examination and aggressive therapy should be recommended in patients with these tumors.
Deception ; Disease Progression ; Female ; Follow-Up Studies ; Humans ; Male ; Mucous Membrane* ; Muscle, Smooth ; Recurrence ; Urinary Bladder Neoplasms* ; Urinary Bladder*

BACKGROUND: Manual manipulation under anesthesia in primary frozen shoulder is recommended for restoring range of motion and improving function. Usually, manipulation is performed briefly under general anesthesia, which accompanies some anesthesia- related risks for outpatients. METHODS: 12 patients suffered from primary frozen shoulder were received manipulation under monitored anesthesia care (MAC) with propofol (1 mg/kg) and remifentanil (25microgram) as an initial dose. And then we injected additional bolus dose (propofol 20 mg, remifentanil 10microgram) in case of inadequate sedation. After manipulation, sodium hyaluronate 20 mg, 0.75% ropivacaine 22.5 mg and ketorolac 30 mg were injected into the glenohumeral joint. Clinical data were gathered at baseline and at 4 weeks after manipulation. RESULTS: The procedure was carried out successfully under MAC. Clinical results including improvements of visual analogue scale of pain and range of motion were comparable to previous studies. 2 patients who received relatively large doses of anesthetics have required triple airway maneuver and manual mask ventilation for 1 to 2 minutes respectively because of desaturation below 90%. There are not any serious adverse effects. CONCLUSIONS: MAC with propofol and remifentanil makes it possible to get adequate level of sedation for shoulder manipulation and to reduce recovery time from anesthesia at the same time. MAC, therefore, is the adequate outpatient anesthetic method for shoulder manipulation.
Amides ; Anesthesia ; Anesthesia, General ; Anesthetics ; Bursitis ; Humans ; Hyaluronic Acid ; Ketorolac ; Masks ; Outpatients ; Piperidines ; Propofol ; Range of Motion, Articular ; Shoulder ; Shoulder Joint ; Ventilation

PURPOSE: The present visual and electromyographic study was designed to evaluate muscle fasciculations caused by succinylcholine in adults pretreated with either remifentanil 1.5 microgram/kg or saline. MATERIALS AND METHODS: The effect of remifentanil on succinylcholine-induced muscle fasciculations was studied using a double-blind method in 40 adults. After i.v. pretreatment with either remifentanil 1.5 microgram/kg (remifentanil group, n = 20) or an equivalent volume of i.v. saline (saline group, n = 20), patients were anaesthetized with a 2.0 mg/kg of i.v. propofol followed by i.v. succinylcholine 1.0 mg/kg. Intensity and duration of muscle fasciculation following i.v. succinylcholine administration were recorded. Electromyography (EMG) was used to quantify the extent of muscle fasciculation following i.v. succinylcholine injection. Myalgia was evaluated 24 hours after induction time. Serum potassium levels were measured five minutes after i.v. succinylcholine administration and creatine kinase (CK) levels 24 hours after induction time. RESULTS: Compared to saline treated controls, remifentanil decreased the intensity of muscle fasciculations caused by i.v. succinylcholine [fasciculation severity scores (grade 0 to 3) were 2/1/12/5 and 3/13/4/0 (patients numbers) in the saline group and the remifentanil group, respectively, p < 0.001]. The mean (SD) maximum amplitude of muscle action potential (MAP) by EMG was smaller in the remifentanil group [283.0 (74.4) microV] than in the saline group [1480.4 (161.3) microV] (p = 0.003). Postoperative serum CK levels were lower in the remifentanil group (p < 0.001). Postoperative myalgia was not different between the two groups. CONCLUSION: Remifentanil 1.5 microgram/kg attenuated intensity of muscle fasciculations by succinylcholine.

The airway management for patients with critical airway problems continues to be a challenge to the anesthesiologist. In general cases, conventional ventilation techniques have been used successfully. These include fiberoptic bronchoscope guided intubation, supraglottic airway, endotracheal or endobronchial intubation at operative field, high frequency jet ventilation, etc. However, patients with near-fatal airway obstruction or severely depressed pulmonary function that is refractory to conventional ventilation methods also present. In these cases, cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO) can be used. Although these situations are uncommon indications for ECMO, ECMO can be a potential option for these life threatening conditions. Especially, venovenous (VV) ECMO can be used for pure pulmonary support. We describe three cases of airway surgery requiring ECMO. VV ECMO was established in all cases. ECMO provided adequate temporary pulmonary support and all patients weaned from ECMO successfully without any complication.
Airway Management ; Airway Obstruction ; Anesthesia ; Bronchoscopes ; Cardiopulmonary Bypass ; Extracorporeal Membrane Oxygenation ; High-Frequency Jet Ventilation ; Humans ; Intubation ; Membranes ; Ventilation

BACKGROUND: In the case of bilateral total knee replacement arthroplasty (TKA), surgery is performed either simultaneously or in a staged manner. We tried to investigate the differences of blood loss and transfusion practice between the use of simultaneous and staged operations. METHODS: We analyzed retrospectively the medical records of 20 patients undergoing simultaneous TKA (simultaneous group), who received autologous blood via a reinfusion system, and 20 patients undergoing staged TKA (staged group), of which the interval is about three weeks. We compared the amount of blood loss, and the number of transfusions and transfusion-related complications between the two groups of patients. RESULTS: Postoperative total blood loss was 2,174 +/- 460 ml in the simultaneous group and 1,850 +/- 461 ml in the staged group. There was no significant difference for transfusion (simultaneous group 3.5 +/- 1.1 units, staged group 3.9 +/- 1.4 units; P > 0.05). In the simultaneous group, the volume of autologous transfusion was 985 +/- 326 ml, corresponding to 2.5 +/- 0.8 units. The total number of transfused RBC units including autologous blood was 6.1 +/- 1.5 units in the simultaneous group and 3.9 +/- 1.4 units in the staged group. In the staged group, the amount of postoperative drained blood was significantly less in the second knee operation than that in the first knee operation (first knee surgery, 992 +/- 265 ml; second knee surgery, 868 +/- 260 ml: P < 0.05). CONCLUSIONS: Postoperative blood loss and total transfusion were less in the staged TKA group of patients as compared with the simultaneous TKA group of patients. Postoperative blood salvage and reinfusion appear to be safe and effective for patients undergoing simultaneous TKA.
Arthroplasty ; Arthroplasty, Replacement, Knee ; Blood Transfusion ; Costs and Cost Analysis ; Humans ; Knee ; Medical Records ; Operative Blood Salvage ; Postoperative Hemorrhage ; Retrospective Studies

BACKGROUND: The adductor canal block (ACB) is an effective intervention for postoperative analgesia following total knee arthroplasty (TKA). However, the ideal ACB regimen has not yet been established. We compared the analgesic effects between a continuous ACB group and fentanyl-based intravenous patient-controlled analgesia (IV-PCA) with a single-shot ACB group. METHODS: Patients who underwent TKA were randomly allocated to either a continuous ACB group (Group CACB) or IV-PCA with a single-shot ACB group (Group IVACB). Before the surgery, ultrasound guided ACB with 0.5% ropivacaine 20 cc was provided to all patients. Before skin incision, the infusion system (0.2% ropivacaine through an adductor canal catheter in group CACB vs. intravenous fentanyl in group IVACB) was connected. The postoperative pain severity; the side effects of local anesthetics and opioids; administration of rescue analgesics and anti-emetics; and sensorimotor deficits were measured. RESULTS: Postoperative pain severity was significantly higher in the IVACB group at 30 min, 4 h, 24 h, and 48 h after surgery. The averages and standard deviations (SD) of the NRS score of postoperative pain were 0.14 ± 0.37, 4.57 ± 2.37, 6.00 ± 1.63, and 4.28 ± 1.49, respectively in the IVACB group. Rescue analgesic requirements and quadriceps muscle strength were not statistically different between the groups throughout the postoperative period. Moreover, rescue antiemetic requirements were higher in group IVACB than group CACB. CONCLUSIONS: In this study, the continuous ACB provided superior analgesia and fewer side effects without any significant motor deficit than the IV-PCA with a single-shot ACB.
Analgesia ; Analgesia, Patient-Controlled ; Analgesics ; Analgesics, Opioid ; Anesthetics, Local ; Antiemetics ; Arthroplasty, Replacement, Knee ; Catheters ; Fentanyl ; Humans ; Nausea ; Pain Management ; Pain, Postoperative ; Postoperative Period ; Quadriceps Muscle ; Skin ; Ultrasonography ; Vomiting