BACKGROUND: Spinal anesthesia is a anesthetic technique that can be easily used and practically applied according to patient's preference and physiologic status, surgical procedures and so forth. The purpose of the present study is to analyze factors related to patient refusal of spinal anesthesia, arising from the previous spinal anesthesia experience associated with side effects or unsatisfactory senses after spinal anesthesia. METHODS: One hundred ninety four patients undergoing various surgical procedures under spinal anesthesia were enrolled. We made a questionnaire that consisted of examination items and question items, and checked it during spinal anesthesia and about 24 hours after spinal anesthesia. Factors related to patient refusal of spinal anesthesia were analyzed with multiple logistic regression. RESULTS: Thirty one out of 194 patients (16%) rejected to receive spinal anesthesia if they would have chance to have it again. Significant factors associated with refusal of spinal anesthesia were low back pain (P = 0.005), needle type (Quincke) (P = 0.025) and tingling sensation in the lower extremities immediately after spinal anesthesia induction (P = 0.003). Low back pain was significantly associated with the number of attempts of spinal block (P = 0.023). CONCLUSIONS: Factors related to patient refusal of spinal anesthesia are low back pain, needle type and tingling sensation. Low back pain is related to the number of attempts of spinal block. Practitioners should give patients appropriate information about spinal anesthesia preoperatively and consider using Whitacre needle and avoid multiple attempts of spinal block so as to increase patient's compliance with spinal anesthesia.
Anesthesia, Spinal ; Compliance ; Disulfiram ; Humans ; Logistic Models ; Low Back Pain ; Lower Extremity ; Needles ; Surveys and Questionnaires ; Sensation

Background and Objectives: Steroids have strong anti-inflammatory, anti-edema, and antipyretic effects. Since there are few studies on the use of steroids in the treatment of peritonsillar abscess in Korea, we aimed at this study to investigate the effects of steroids along with antibiotics in the treatment of peritonsillar abscess.Subjects and Method A retrospective study was conducted on 75 patients who were admitted from 2014 to 2019. Between 2014 and 2017, only antibiotics were administrated after incisional drainage (no-use group), but between 2018 and 2019, antibiotics and adjunctive steroids were administrated after incisional drainage (steroids group). Symptoms of patients, blood tests, diets available, and hospitalization period were compared between the two groups. Results: The length of hospital stay for the steroids group (n=24) and the no-use group (n=51) was 4.2±1.3 days and of 5.1±1.8 days (p=0.046), respectively, showing significantly shortened time for the steroids group. The rate of change in 48-hour C-reactive protein was 53.3% and 20% for the steroid group and no-use group (p=0.013), respectively. However, there was no differences between the two groups in the rate of change in body temperature at 12 hours of treatment, the diet available at 12 hours, and rate of change in the number of white blood cells after 48 hours of treatment. Conclusion Adjunctive steroids for peritonsillar abscess can be a useful treatment that shows rapid improvement of symptoms and C-reactive protein, and shorter hospitalization periods.

Sugammadex is a specific antagonist of aminosteroidal neuromuscular blocking agents with 1:1 binding to guest molecules. Sugammadex can also bind to other drugs having a steroid component in its chemical structure. In this in vivo experiment, we investigated the differences in the recovery of rocuronium-induced neuromuscular blockade using sugammadex pre-exposed with two different concentrations of hydrocortisone. Methods: The sciatic nerves and tibialis anterior muscles of 30 adult Sprague–Dawley rats were prepared for the experiment. The sciatic nerves were stimulated using a train-of-four (TOF) pattern with indirect supramaximal stimulation at 20 s intervals. After 15 min of stabilization, a 250 μg loading dose and 125 μg booster doses of rocuronium were serially administered until > 95% depression of the first twitch tension of TOF stimulation (T1) was confirmed. The study drugs were prepared by mixing sugamadex with the same volume of three different stock solutions (0.9% normal saline, 10 mg/ml hydrocortisone, and 100 mg/ ml hydrocortisone). The recovery of rats from neuromuscular blockade was monitored by assessing T1 and the TOF ratio (TOFR) simultaneously until T1 was recovered to > 95% and TOFR to > 0.9. Results: In the group injected with sugammadex premixed with a high concentration of hydrocortisone, statistically significant intergroup differences were observed in the recovery progression of T1 and TOFR (P < 0.050). Conclusions: When sugammadex was pre-exposed to a high dose of hydrocortisone only, recovery from neuromuscular blockade was delayed. Delayed recovery from neuromuscular blockade is not always plausible when sugammadex is pre-exposed to steroidal drugs.

BACKGROUND: To determine if positive pressure pneumoperitoneum has adverse effects on autonomic nervous system function, we examined baroreflex sensitivity (BRS) during carbon dioxide pneumoperitoneum in patients undergoing laparoscopic surgery. METHODS: Twenty adult patients scheduled for laparoscopic gynecologic surgery were selected for the study. After general anesthesia was induced with sevoflurane, continuous electrocardiography and blood pressure were monitored. Spontaneous BRS was achieved using sequence method immediately before, and 5 minutes after, pneumoperitoneum. Heart rate variability (HRV) was also determined. RESULTS: After pneumoperitoneum, BRS decreased from 12.9 +/- 1.8 ms/mmHg to 8.1 +/- 1.1 ms/mmHg (P < 0.05), and the power of the high frequency band decreased from 237.8 ms2/Hz to 49.6 ms2/Hz (P < 0.05). CONCLUSIONS: Compared to recordings obtained before pneumoperitoneum, BRS was decreased during pneumoperitoneum. This may predispose patients undergoing laparoscopic surgery to hemodynamic instability in addition to pneumoperitoneum itself.
Adult ; Anesthesia, General ; Autonomic Nervous System ; Baroreflex ; Blood Pressure ; Carbon ; Carbon Dioxide ; Electrocardiography ; Female ; Gynecologic Surgical Procedures ; Heart Rate ; Hemodynamics ; Humans ; Laparoscopy ; Methyl Ethers ; Pneumoperitoneum

An epiglottic cyst is a common form of laryngeal cysts which are rare causes of upper airway obstruction. A congenital laryngeal cyst always causes neonatal respiratory distress, but an acquired cyst shows very wide spectrum of symptoms such as no specific complaints, dysphagia, respiratory difficulty, or even death according to its size, location, or age. From anesthesiologists' point of view, an asymptomatic undiagnosed laryngeal cyst is a major concern. Unexpectedly, it can cause difficult airway such as 'cannnot intubate' or 'cannot intubate and cannot ventilate' situation during anesthesia. Recently we discovered an undiagnosed epiglottic cyst obscuring laryngeal inlet, leading to difficult intubation during general anesthesia for decompression and fusion of lumbar vertebrae. Fortunately, mask ventilation was possible, and after failed attempts of direct laryngoscopy, we could perform oral fiberoptic bronchoscope-aided intubation. He was discharged 10 days later with no harmful events.
Airway Obstruction ; Anesthesia ; Anesthesia, General ; Bays ; Bronchoscopes ; Decompression ; Deglutition Disorders ; Intubation ; Intubation, Intratracheal ; Laryngoscopy ; Lumbar Vertebrae ; Masks ; Ventilation

Purpose: Appropriate preclinical mouse models are needed to evaluate the response to immunotherapeutic agents. Immunocompetent mouse models have rarely been reported for gastric cancer. Thus, we investigated immunophenotypes and responses to immune checkpoint inhibitor (ICI) in immunocompetent mouse models using various murine gastric cancer cell lines. Materials and Methods: We constructed subcutaneous syngeneic tumors with murine gastric cancer cell lines, YTN3 and YTN16, in C57BL/6J mice. Mice were intraperitoneally treated with IgG isotype control or an anti–programmed death-ligand 1 (PD-L1) neutralizing antibody. We used immunohistochemistry to evaluate the tumor-infiltrating immune cells of formalin-fixed paraffin-embedded mouse tumor tissues. We compared the protein and RNA expression between YTN3 and YTN16 cell lines using a mouse cytokine array and RNA sequencing. Results: The mouse tumors revealed distinct histological and molecular characteristics. YTN16 cells showed upregulation of genes and proteins related to immunosuppression, such as Ccl2 (CCL2) and Csf1 (M-CSF). Macrophages and exhausted T cells were more enriched in YTN16 tumors than in YTN3 tumors. Several YTN3 tumors were completely regressed by the PD-L1 inhibitor, whereas YTN16 tumors were unaffected. Although treatment with a PD-L1 inhibitor increased infiltration of T cells in both the tumors, the proportion of exhausted immune cells did not decrease in the non-responder group. Conclusion We confirmed the histological and molecular features of cancer cells with various responses to ICI. Our models can be used in preclinical research on ICI resistance mechanisms to enhance clinical efficacy.

Background: Chronic glucocorticoid exposure is associated with resistance to nondepolarizing neuromuscular blocking agents. Therefore, we hypothesized that sugammadex-induced recovery would occur more rapidly in subjects exposed to chronic dexamethasone compared to those who were not exposed. This study evaluated the sugammadex-induced recovery profile after neuromuscular blockade (NMB) in rats exposed to chronic dexamethasone. Methods: Sprague–Dawley rats were allocated to three groups (dexamethasone, control, and pair-fed group) for the in vivo study. The mice received daily intraperitoneal dexamethasone injections (500 μg/kg) or 0.9% saline for 15 days. To achieve complete NMB, 3.5 mg/kg rocuronium was administered on the sixteenth day. The recovery time to a train-of-four ratio ≥ 0.9 was measured to evaluate the complete recovery following the sugammadex injection. Results: Among the groups, no significant differences were observed in the recovery time to a train-of-four ratio ≥ 0.9 following sugammadex administration (P = 0.531). The time to the second twitch of the train-of-four recovery following rocuronium administration indicated that the duration of NMB was significantly shorter in Group D than that in Groups C and P (P = 0.001). Conclusions Chronic exposure to dexamethasone did not shorten the recovery time of sugammadex-induced NMB reversal. However, the findings of this study indicated that no adjustments to sugammadex dosage or route of administration is required, even in patients undergoing long-term steroid treatment.

Background and Objectives: In this study, we investigated the effects of hearing loss on mental health and quality of life (QoL) using survey data in adults aged >40 years. Subjects and Methods: We obtained data from 10,921 individuals who responded to the fifth Korean National Health and Nutrition Examination Survey. Primary outcomes were measured using questionnaires that recorded stress perception, depressive mood, and suicidal ideation to evaluate mental health and motor ability, self-management, activities of daily living, pain or discomfort, and anxiety or depression to evaluate QoL. Results: On multivariate analysis, suicidal ideation was more prevalent among older adults with hearing loss than in older adults without hearing loss. Motor ability was lower in individuals with hearing loss of >20 dB than in older adults with normal hearing. Categorization of the EuroQol-5 Dimension (EQ-5D) health state into upper and lower groups showed that the EQ-5D values were lower in the moderate-tosevere hearing loss group than in the mild hearing loss group. Conclusions Among adults aged >40 years, those with hearing loss experienced more suicidal ideation, had lower motor ability, and lower overall QoL compared with these variables in older adults with normal hearing. Additionally, QoL scores were low in individuals with poor hearing.

Background: In this study, we used an ex-vivo model to investigate the recovery pattern of both the train-of-four (TOF) ratio and first twitch tension of TOF (T1), and determined their relationship during recovery from rocuronium-induced neuromuscular blockade at various concentrations of sugammadex. Methods: Tissue specimens of the phrenic nerve-hemidiaphragm were obtained from 60 adult Sprague-Dawley rats. Each specimen was immersed in an organ bath filled with Krebs buffer solution and stimulated with the TOF pattern using indirect supramaximal stimulation at 20-second intervals. After a 30-minute stabilization period, rocuronium loading and booster doses were serially administered at 10-minute intervals in each sample until > 95% depression of T1 was confirmed. Specimens were randomly allocated to either the control group (washout) or to one of five sugammadex concentration groups (0.75, 1, 2, 4, or 8 times equimolar doses of rocuronium to produce >95% T1 depressions; SGX0.75, SGX1, SGX2, SGX4, and SGX8, respectively). Recovery from neuromuscular blockade was monitored using T1 and the TOF ratio simultaneously until the recovery of T1 to > 95% and the TOF ratio to > 0.9. Results: Statistically significant intergroup differences were observed between the recovery patterns of T1 and the TOF ratio (TOFR, p<0.050), except between SGX2 and SGX4 groups. TOFR/T1 values were maintained at nearly 1 in the control, SGX0.75, and SGX1 groups; however, they were exponentially decayed in the SGX2, SGX4, and SGX8 groups. Conclusions Recovery of the TOF ratio may be influenced by the sugammadex dose, and a TOF ratio of 1.0 may be achieved before full T1 recovery if administration of sugammadex exceeds that of rocuronium.

BACKGROUND: Ventilation is a major determinant of the alveolar concentration of inhaled anesthetics. Hyperventilation accelerates the equilibration of anesthetic in the lungs, but decelerates it in the brain. We evaluated this phenomenon for desflurane. METHODS: Twenty healthy subjects were enrolled after IRB approval. End-tidal concentrations of desflurane (P.DESF) were recorded during 10 minutes of mask induction with 8% desflurane. P.DESF was modeled with time and end-tidal concentrations of CO2 (P.ETCO2) using a two-exponential pharmacokinetic equation. Bispectral index (BIS) values were also measured to find out the component reflecting the cerebral concentration of desflurane. RESULTS: During induction, the rise of P.DESF could be separated into two components: early and late rises. Individual BIS values showed a higher correlation with the late component of P.DESF (P = 0.000). P.ETCO2 had two different effects on the rise of P.DESF. CONCLUSIONS: Hyperventilation hastened the early rise and delayed the late rise of P.DESF (P = 0.00, P = 0.00). Hyperventilation should be avoided to obtain rapid anesthesia induction with desflurane.
Anesthesia ; Anesthesia, Inhalation ; Anesthetics ; Brain ; Ethics Committees, Research ; Hyperventilation ; Isoflurane ; Lung ; Masks ; Nonlinear Dynamics ; Ventilation