The effects of direct hemoperfusion with polymyxin B immobilized fiber (PMX) treatment for septic shock have been recently reported. However, little evidence of a true benefit on clinical outcomes, including mortality, is available. Herein, we report three cases of intra-abdominal infection associated with refractory septic shock Case 1 was Escherichia coli peritonitis after a colectomy. PMX treatment improved the hemodynamic parameters and lactic acid levels of the patient. In case 2, secondary peritonitis was associated with septic or cardiogenic shock. Septic cardiomyopathy was assumed to be the cause of shock. 24 hours after the use of PMX, cardiac contractility assessed by echocardiography returned to baseline. In case 3, a patient with Burkitt's lymphoma and neutropenia was found to be gastroenteritis and Klebsiella pneumoniae bacteremia. Intravenous meropenem was administered for 3 days. Hemodynamic parameters improve after the twice use of PMXOverall, the change of serial sequential organ failure assessment score (SOFA) was more significant in surgical cases as compared to the medical case at 72 hours after PMX administration. All patients were discharged from the hospital. In addition to early resuscitation efforts and infection source control, PMX treatment may be beneficial to patients with refractory intra-abdominal infection associated with septic shock.
Bacteremia ; Burkitt Lymphoma ; Cardiomyopathies ; Colectomy ; Echocardiography ; Escherichia coli ; Gastroenteritis ; Hemodynamics ; Hemoperfusion* ; Humans ; Intraabdominal Infections ; Klebsiella pneumoniae ; Lactic Acid ; Mortality ; Neutropenia ; Peritonitis ; Polymyxin B* ; Resuscitation ; Shock ; Shock, Cardiogenic ; Shock, Septic*

BACKGROUND: Not many recent studies have shown that morphine antinociception may be directly expressed in forebrain structures. It is generally accepted that c-fos is a marker of neuronal activity and its expresson is correlated with nerve pathway activated by nociceptive stimuli. The aim of this study is to examine the effect of morphine on c-fos expression in the incisional pain rat brain. METHODS: A 1 cm longitudinal incision was made through the skin, fascia and muscle of the plantar aspect of the hindpaw in enflurane-anesthetized rats. 10 mg/kg of morphine was injected intraperitoneally 1 hour before (pre-morphine group; n = 15) and 30 minutes after surgery (post-morphine group; n = 15). The same amount of saline was injected 30 minutes after surgery (control group; n = 15). Two hours later c-fos protein expressions in the thalamus, hypothalamus, cerebral cortex and amygdala were examined by immunohistochemistry using a specific antibody. RESULTS: Numerous c-fos positive cells were observed in thalamus, hypothalamus, cerebral cortex, and amygdala in all groups. There were no significant differences in c-fos expression between pre-morphine, post-morphine and control group (P <0.05). CONCLUSIONS: In this study we expected to decreased c-fos expression in incisional pain rat brain by morphine injection. But no differences were observed compared to control group in thalamus and cortex which transmitting pain to CNS, also in hypothalamus and amygdale which transmitting emotional stress to CNS. These results suggests that intraperitoneal morphine can not protect the c-fos expression of ascending pathway to thalamus, hypothalmus, amygdala and cerebral cortex. Also we can not support the effect of morphine on the descending pathway of pain. So we thought for the more information, additional study, for example, behavior test, PCR (polymerase chain reaction)study, may be needed.
Amygdala ; Animals ; Brain* ; Cerebral Cortex ; Fascia ; Hypothalamus ; Immunohistochemistry ; Morphine* ; Neurons ; Polymerase Chain Reaction ; Prosencephalon ; Rats* ; Skin ; Stress, Psychological ; Thalamus

BACKGROUND: Rocuronium can cause pain on injection in awake patients. We compared the effect of ketamine at three different small doses (0.1 mg/kg, 0.2 mg/kg, 0.3 mg/kg) and saline (placebo) for reducing pain on injection in awake patients. METHODS: 80 patients (aged 19-63 yr) scheduled for elective surgery were randomized to four groups in double-blind manner. Patients received the study drug intravenously, with venous occlusion for 20 seconds, followed by rocuronium 0.6 mg/kg into the dorsal vein over 10 seconds. Patient's response torocuronium injection was graded by four-point verbal rating scale. RESULTS: The incidence of pain was significantly less in patients receiving ketamine 0.3 mg/kg (55%) than in patients receiving saline (85%)(P < 0.05). But, No difference was found between ketamine 0.1 mg/kg, 0.2 mg/kg and saline groups. The pain score was significantly less in patients receiving ketamine 0.2 mg/kg and 0.3 mg/kg than in patients receving saline (P < 0.05). CONCLUSIONS: We concluded that pretreatment of ketamine 0.3 mg/kg with venous occlu-sion for 20 seconds, effectively decreases the incidence of pain caused by rocuronium injection.
Humans ; Incidence ; Ketamine* ; Veins

No abstract available.
Dislocations*

Acute massive pulmonary embolism after intracerebral hemorrhage (ICH) is rare but associated with a high mortality rate. A 44-year-old man presented with acute pulmonary embolism on 38th day after onset of ICH. We tried off-pump pulmonary embolectomy with CPB on stand-by. But, hemodynamic deterioration occurred when right pulmonary artery was clamped after removal of some clots, therefore CPB was rapidly instituted under normothermic beating heart with full heparinization. On pump beating, heart pulmonary embolectomy was performed successfully without adverse events. On postoperative 2nd day, the patient was started on anticoagulation therapy and recovered favorably without any neurologic sequelaes.
Adult ; Cerebral Hemorrhage ; Embolectomy ; Heart ; Hemodynamics ; Heparin ; Humans ; Pulmonary Artery ; Pulmonary Embolism

BACKGROUND: Patients undergoing liver transplantation may be a group predisposed to hypomagnesemia and bleeding tendency. There is evidence that magnesium is a crucial constituent of the blood coagulation cascade and has a pro-coagulant activity. The purpose of this study was to investigate the effect of magnesium therapy on thromboelastograph (TEG) findings and other clinical parameters in patients undergoing liver transplantation. METHODS: 27 patients scheduled for liver transplantation were included. 1.5 g of magnesium sulfate was diluted in 100 ml of normal saline and infused over a period of 5 minutes to all patients. TEG findings immediately before and after magnesium infusion were compared. Total blood transfused and CaCl2 requirements in these patients were compared with those of a group of patients who received liver transplantation without magnesium therapy. RESULTS: K time and coagulation time (r + k) showed significant reduction, and MA, A60 and TEG index showed significant increases after magnesium therapy (P < 0.05). R time reduced and alpha angle increased after magnesium therapy, but these were not statistically significant. Less blood and CaCl2 was required by these patients (P < 0.05). CONCLUSIONS: Magnesium therapy significantly improved TEG findings of general hypocoagulability in end stage liver disease. It was also associated with a reduced amount of total blood transfused and CaCl2 required during liver transplantation.
Blood Coagulation ; End Stage Liver Disease* ; Hemorrhage ; Humans ; Liver Transplantation ; Magnesium Sulfate ; Magnesium*

BACKGROUND: Monitored anesthetic care can provide patient safety and optimal surgical conditions. However, propofol and fentanyl decrease the hypoxic ventilatory response and heart rate. Ketamine has less respiratory depression and blocks bradycardia. Furthermore, ketamine can reduce the amount of opioid use but it delays discharge in the outpatient anesthesia. Therefore, this study retrospectively examined the effects of combined fentanyl and ketamine administered during monitored anesthetic care on the use of opioids, cardiorespiratory side effects, and patient discharge. METHODS: The anesthetic room, the recovery room and day surgery center records of ambulatory strabismus surgery with monitored anesthetic care was reviewed by anesthesiologists from Oct. 2004 to July 2005. The patients were classified as those receiving either fentanyl (F group: n = 32) or fentanyl and ketamine (FK group: n = 19) with a propofol infusion. The fentanyl dose used, the need for airway support, anticholinergics and naloxone were compared. The stay in the recovery room and the day surgery center was also examined. RESULTS: The FK group used significantly less fentanyl than the F group (P < 0.05). Although airway support was needed, there was less anticholinergics and naloxone used in the FK group, but this difference was not significant. The stay in recovery room and the day surgery center were similar. CONCLUSIONS: Co-administered ketamine reduces the amount of fentanyl-needed, but it does not reduce the need for airway support and anticholinergics. In addition, co-administered ketamine does not affect the number of days in the recovery room and day surgery center.
Ambulatory Surgical Procedures ; Analgesics, Opioid ; Anesthesia ; Bradycardia ; Cholinergic Antagonists ; Fentanyl* ; Heart Rate ; Humans ; Ketamine* ; Naloxone ; Outpatients ; Patient Discharge ; Patient Safety ; Propofol ; Recovery Room ; Respiratory Insufficiency ; Retrospective Studies ; Strabismus*

PURPOSE: Opioids may affect changes in the corrected QT interval (QTc) during anesthetic induction. This study examine whether a single bolus of remifentanil would prolong QTc after laryngeal mask airway (LMA) insertion during sevoflurane induction. MATERIALS AND METHODS: Forty women of American Society of Anesthesiologists physical status 1 (ASA PS1) undergoing gynecological surgery were studied. All patients were induced using three vital capacity inhalation inductions with 5% sevoflurane. Two minutes after induction, the inspiratory concentration of sevoflurane was reduced to 2%. Using double-blinded randomization, patients were allocated into one of two groups, receiving either saline (placebo group, n = 20) or 0.25 microg.kg-1 remifentanil (remifentanil group, n = 20) over a period of thirty seconds. Sixty seconds later, LMA insertion was performed. Recordings were taken with a 12-lead electrocardiogram at baseline, 2 min after induction and 1 and 3 min after LMA insertion. QTc was calculated by Bazett's formula. The mean arterial pressure (MAP) and heart rate (HR) were also measured at each time point. RESULTS: The QTc interval was significantly prolonged in the placebo group as compared to the remifentanil group at 1 min after LMA insertion (467.8 +/- 16.5 vs. 442.7 +/- 21.3 ms, p < 0.001). However, there was no significant difference in QTc at 3 min after LMA insertion between the two groups. MAP and HR were significantly higher in the placebo group (p < 0.001). CONCLUSION: A single bolus of remifentanil is safe method to attenuate prolonged QTc associated with insertion of LMA.
Adult ; Anesthetics, Inhalation/adverse effects/*pharmacology ; Anesthetics, Intravenous/administration & dosage/*pharmacology ; Electrocardiography/drug effects ; Female ; Gynecologic Surgical Procedures/adverse effects ; Heart Rate/*drug effects ; Humans ; Methyl Ethers/adverse effects/*pharmacology ; Middle Aged ; Piperidines/*pharmacology

BACKGROUND: Cytokines are important mediators of immune response to surgery and pain.The aim of the study was to investigate the effect of remifentanil on serum levels of cytokines, tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6), in patients undergoing laparoscopic hysterectomy. METHODS: Twenty four patients scheduled for laparoscopic hysterectomy were randomly assigned to control or remifentanil group.Both groups received 1.5-2.5% end tidal concentration of sevoflurane and air in 50% oxygen.Remifentanil group received a bolus of remifentanil 1microgram/kg over 1 min and an infusion of remifentanil at a rate of 0.1microgram/kg/min.Control group received 10 ml saline (placebo) and an infusion of saline at the same rate. Venous blood samples for measurement of serum cytokine concentrations were taken before anesthesia (T1), at 2 h after infusion (T2), and at the 1 hour after surgery (T3). RESULTS: Serum TNF-alpha concentration did not differ significantly over time in both groups.Serum TNF-alpha concentration was higher in remifentanil group at T3 (9.76 +/- 1.19 pg/ml vs.8.53 +/- 0.71 pg/ml) than in control group (P < 0.05). In both groups, serum IL-6 concentrations were significantly higher at T3, when compared to those at T1 and T2 (P < 0.05). CONCLUSIONS: Remifentanil did not attenuate early postoperative change of serum TNF-alpha and IL-6 concentrations in patients undergoing laparoscopic hysterectomy. Serum IL-6 level increased at postoperative 1 h, regardless of remifentanil use.
Anesthesia ; Cytokines ; Humans ; Hysterectomy ; Interleukin-6 ; Methyl Ethers ; Piperidines ; Tumor Necrosis Factor-alpha

A 35-year old woman was scheduled to undergo a total hystectomy due to uterine myoma. She had been diagnosed with Charcot-Marie-Tooth disease 2 years ago. In addition, she had previously received a Cesarean section under epidural anesthesia 10 years ago and reported a prolonged motor blockade at that time. General anesthesia was induced with propofol 120 mg in a divided dose and the intubating condition was achieved with vecuronium 3 mg. Anesthesia was maintained with 1.5-2.5% enflurane with air and O2. During surgery, the body temperature and end tidal concentration of CO2 were maintained within the normal range. Despite the continuous monitoring of the train-of-four (TOF) response, no more muscle relaxants were required during surgery and the patient recovered without a delay in awakening. In the management of patients with Charcot-Marie-Tooth disease, it is desirable to evaluate the patient carefully, select the appropriate anesthetics and adjust the dosage of the drug according to the patients requirements.
Adult ; Anesthesia ; Anesthesia, Epidural ; Anesthesia, General ; Anesthetics ; Body Temperature ; Cesarean Section ; Charcot-Marie-Tooth Disease* ; Enflurane ; Female ; Humans ; Leiomyoma ; Pregnancy ; Propofol ; Reference Values ; Vecuronium Bromide