Background: Cesarean section under spinal anesthesia may cause anxiety and hypotension. Administration of sedative drugs after delivery can diminish these side-effects, but may increase hemodynamic instability. We evaluated the effect of the administration of 0.7 μg/kg dexmedetomidine and compared it with that of 0.03 mg/kg midazolam for usefulness of sedation of the parturient after delivery during cesarean section. Methods: After obtaining written consent and the ethics board approval, 60 parturients aged 20–43 years who underwent elective cesarean delivery under spinal anesthesia were recruited. A total of 0.5% hyperbaric bupivacaine (8–10 mg) and intrathecal fentanyl (10 μg) was given to induce anesthesia. Parturients were then randomly allocated to receive either midazolam (0.03 mg/kg; group M) or dexmedetomidine 0.7 (μg/kg; group D) after delivery. The primary outcome measure was patient satisfaction score. Secondary outcomes included vital signs; vasopressor dosage; incidence of shivering, nausea, and vomiting; incidence of bradycardia; time to sensory and motor recovery; postoperative nausea and vomiting score; and postoperative pain visual analog scale at 6, 24, and 48 h. Results: Satisfaction scores for sedation were similar between the two groups. The systolic blood pressure, heart rate, oximetry saturation, and tympanic temperature were comparable between the two groups. The predicted mean systolic blood pressure of group D was 106.3 mmHg and that of group M was 107.5 mmHg. Both groups showed comparable adverse intraoperative and postoperative outcomes. Conclusions Dexmedetomidine and midazolam showed similar hemodynamic effects and patient satisfaction in parturients under spinal anesthesia.

Modern electroconvulsive therapy (ECT) is a non-pharmacological and biological treatment that is clinically effective and safe. ECT is used in the treatment of many psychiatric disorders, some neurological diseases, and psychiatric emergencies requiring a rapid and life-saving clinical response. Generalized seizures of the central nervous system induced by the electrical stimulation of ECT are an essential component of the therapeutic effects, which are attributed to the various neuronal responses of the brain. Modern ECT is conducted under general anesthesia, given to the extent of loss of consciousness, followed by administration of a muscle relaxant, and ECT with minimally appropriate electrical stimulation. ECT optimization has the main objective of ensuring maximum clinical efficacy and safety with minimal adverse events through adequate generalized seizures. Since its first introduction in clinical practice in 1938, many studies have been carried out and advances made to enhance the therapeutic effects of ECT and address the adverse events associated with it. As a result, there have been developments such as the use of a square wave instead of a sine wave, various electrode placements, dose titration methods, seizure thresholds, general anesthesia with muscle relaxation, session scheduling, monitoring of electroencephalograms (EEG) and electromyograms, etc. and these have been applied to actual clinical practice. Research on the clinical characteristics and the optimal ECT parameters to increase the efficacy of seizures is still ongoing. In this review, various factors associated with ECT such as EEG monitoring, motor seizures, electrode placements, stimulation dose and titration, seizure evaluation and adequacy, and the ECT algorithms are discussed to improve the efficacy of modern ECT as a useful treatment for psychiatric disorders.

Rivaroxaban, a factor Xa inhibitor, is one of the newly developed direct oral anticoagulants (DOAC). In recent times, it has been increasingly used in the prevention of pulmonary embolism in patients undergoing orthopedic surgery. This report describes a case of epidural hematoma in an elderly patient who underwent combined spinal epidural anesthesia for total knee arthroplasty; the patient received rivaroxaban postoperatively for 7 days to prevent pulmonary embolism. Additionally, the epidural hematomas developed on the 5th postoperative day but the patient recovered well with conservative treatment. Although rivaroxaban has a low need for monitoring and is easily administered, the guidelines should be carefully checked for the postoperative administration schedule in patients undergoing regional anesthesia. In addition, rivaroxaban should be used with caution, especially in elderly patients.
Aged ; Anesthesia, Conduction ; Anesthesia, Epidural ; Anticoagulants ; Appointments and Schedules ; Arthroplasty, Replacement, Knee* ; Factor Xa ; Hematoma* ; Hematoma, Epidural, Spinal ; Humans ; Orthopedics ; Pulmonary Embolism ; Rivaroxaban*

The aim of this study was to examine the feasibility of the Smart dynamometer as a rehabilitation exercise device in a daily care by comparing with the existing medical devices. We used and analyzed clinical and measurement data of breast cancer survivors who have used Smart dynamometer during their rehabilitation after breast cancer surgery. The Smart dynamometer was compared with the two existing devices of Takei dynamometer and surface electromyography (sEMG) that were used in routine care, respectively. Three key components of the rehabilitation exercise devices were analyzed to validate the feasibility of the Smart dynamometer: grip strength, reaction time, and grip endurance time. Pearson's correlation analysis was performed to compare the statistical significance between the devices. The data of 12 and 15 female breast cancer patients were analyzed for comparing the Smart dynamometer with Takei dynamometer and sEMG, respectively. There was a very weak correlation between the maximum values from the Takei and the Smart dynamometers in the affected and non-affected arms of breast cancer patients (r = 0.5321, 0.4733). Comparisons of 3 features between the Smart dynamometer and sEMG showed that there were strong positive correlations for both reaction time and endurance time in the affected and non-affected arms (r > 0.9). The feasibility of the Smart dynamometer for the possible use in a daily rehabilitation exercise was partially verified. Moreover, since the Smart dynamometer was highly correlated with time-related variables, it was important and significant to measure both grip strength and time-related information.
Arm ; Breast Neoplasms ; Breast ; Electromyography ; Feasibility Studies ; Female ; Hand Strength ; Humans ; Reaction Time ; Rehabilitation ; Self Care ; Survivors

Although spinal anesthesia is one of the most reliable anesthetic techniques in clinical practice, failures may occur in daily practice at rare occasions. Their causes are diverse and they include anatomical structural variations. In particular, postoperative anatomical changes often occur in patients who have undergone spine surgery and may cause failures of spinal anesthesia. Postoperative pseudomeningocele constitutes extradural cerebrospinal fluid collected from a dural tear and it is considered a very rare complication of spine surgery. We describe the case where a patient with unexpected postoperative iatrogenic pseudomeningocele received lower extremity surgery under spinal anesthesia.
Anesthesia, Spinal ; Cerebrospinal Fluid ; Humans ; Lower Extremity ; Spine ; Tears

Many sedatives are used clinically and include benzodiazepines, barbiturates, antihistamines, propofol, and alpha-2-agonist. Benzodiazepines activate GABA neuronal receptors in the brain and present sedating, hypnotic, anxiolytic, amnestic, and anticonvulsant effects, but low analgesic effects. Propofol induce sedative, anxiolytic, and amnestic effects but no analgesic effects. However, risks such as cardiopulmonary instability and hypotension must be considered during administration. Dexmedetomidine is a high selective alpha-2 agonist and has many advantages as a sedative. Patients under dexmedetomidine sedation awaken easily and are more likely to be cooperative. Risk of respiratory depression and cardiopulmonary instability is low as well. Additionally, dexmedetomidine decreases amount of analgesic needed during and after surgery, presenting analgesic effects. Dexmedetomidine also decreases risk of delirium. However, bradycardia may occur and biphasic effects on blood pressure may be observed during beginning of administration. Because of lengthy symptom onset and offset time, physicians should carefully control administration at the beginning and end of dexmedetomidine administration. The purpose of this review is to evaluate the efficacy and availability of dexmedetomidine in various clinical fields including sedation for critically ill patients, regional anesthesia, monitored anesthesia care for some invasive procedures, stabilization of heart in cardiac surgery or endoscopic procedures.
Anesthesia* ; Anesthesia, Conduction ; Barbiturates ; Benzodiazepines ; Blood Pressure ; Bradycardia ; Brain ; Critical Illness ; Delirium ; Dexmedetomidine* ; GABAergic Neurons ; Heart ; Histamine Antagonists ; Humans ; Hypnotics and Sedatives ; Hypotension ; Propofol ; Respiratory Insufficiency ; Thoracic Surgery

Many sedatives are used clinically and include benzodiazepines, barbiturates, antihistamines, propofol, and alpha-2-agonist. Benzodiazepines activate GABA neuronal receptors in the brain and present sedating, hypnotic, anxiolytic, amnestic, and anticonvulsant effects, but low analgesic effects. Propofol induce sedative, anxiolytic, and amnestic effects but no analgesic effects. However, risks such as cardiopulmonary instability and hypotension must be considered during administration. Dexmedetomidine is a high selective alpha-2 agonist and has many advantages as a sedative. Patients under dexmedetomidine sedation awaken easily and are more likely to be cooperative. Risk of respiratory depression and cardiopulmonary instability is low as well. Additionally, dexmedetomidine decreases amount of analgesic needed during and after surgery, presenting analgesic effects. Dexmedetomidine also decreases risk of delirium. However, bradycardia may occur and biphasic effects on blood pressure may be observed during beginning of administration. Because of lengthy symptom onset and offset time, physicians should carefully control administration at the beginning and end of dexmedetomidine administration. The purpose of this review is to evaluate the efficacy and availability of dexmedetomidine in various clinical fields including sedation for critically ill patients, regional anesthesia, monitored anesthesia care for some invasive procedures, stabilization of heart in cardiac surgery or endoscopic procedures.
Anesthesia* ; Anesthesia, Conduction ; Barbiturates ; Benzodiazepines ; Blood Pressure ; Bradycardia ; Brain ; Critical Illness ; Delirium ; Dexmedetomidine* ; GABAergic Neurons ; Heart ; Histamine Antagonists ; Humans ; Hypnotics and Sedatives ; Hypotension ; Propofol ; Respiratory Insufficiency ; Thoracic Surgery

BACKGROUND: The old age population, including the very old aged (> or = 85 years), is rapidly increasing, and femur neck fracture from accidents is commonly seen in the elderly. Use of bone cement during bipolar hemiarthroplasty can cause bone cement implantation syndrome. METHODS: This study was prospectively conducted on the elderly who were scheduled to undergo elective cemented bipolar hemiarthroplasty under spinal anesthesia. Patients were divided into 2 groups: the old age (65-84 years) and very old age groups (> or = 85 years). Hemodynamic parameters were recorded at the following time points: the start of the operation, femoral reaming, cement insertion, every 2 minutes after cement insertion for 10 minutes, femoral joint reduction, and the end of operation. When hypotension occurred, ephedrine was given. RESULTS: Sixty-five patients in the old age group and 32 patients in the very old age group were enrolled. Mean ages were 78.9 and 89.4 years, respectively, in the old age and very old age groups. The very old age group showed constantly decreased levels of cardiac index and stroke volume from cementing until the end of the operation compared to the old age group. To maintain hemodynamic stability after cement insertion, the requirement of ephedrine was higher in the very old age group than in the old age group (13.52 +/- 7.76 vs 8.65 +/- 6.38 mg, P = 0.001). CONCLUSIONS: Bone cement implantation during bipolar hemiarthroplasty may cause more prominent hemodynamic changes in very elderly patients. Careful hemodynamic monitoring and management are warranted in very elderly patients undergoing cemented bipolar hemiarthroplasty.
Aged ; Anesthesia, Spinal* ; Bone Cements ; Ephedrine ; Femoral Neck Fractures ; Hemiarthroplasty* ; Hemodynamics* ; Humans ; Hypotension ; Joints ; Prospective Studies ; Stroke Volume

BACKGROUND: Postoperative cognitive dysfunction (POCD) is a common perioperative complication. The definitive causes of POCD have not been identified, but depth of anesthesia or sedation has been reported to influence POCD. The purpose of the present study was to assess the possible effect of the level of sedation on POCD at 1 week after surgery under spinal anesthesia in elderly patients. METHODS: We included 48 patients aged over 60 years, who were scheduled for elective knee and hip joint surgery under spinal anesthesia. Those patients were randomly allocated to one of the 2 groups: deep sedation group and light sedation group. The depth of sedation was monitored by entropy and observer's assessment of alertness/sedation (OAA/S) score. Cognitive function was assessed by 5 neurocognitive tests before and at 1 week after surgery. A postoperative deficit was defined as a postoperative decrement to preoperative score greater than 1 standard deviation on any test. A patient whose postoperative performance deteriorated by 1 or more standard deviations on 2 or more tests was classified as having experienced POCD. RESULTS: POCD occurred in 7 patients (28%) in the deep sedation group and in 4 patients (17.4%) in the light sedation group. The incidence of the POCD was not significantly different between the 2 groups. CONCLUSIONS: We were unable to detect a significant association between the depth of sedation and the presence of POCD at 1 week after surgery under spinal anesthesia.
Aged* ; Anesthesia ; Anesthesia, Spinal* ; Deep Sedation ; Entropy ; Hip Joint ; Humans ; Incidence ; Knee ; Propofol*

BACKGROUND: This study was designed to determine the optimal dose of remifentanil single bolus for the prevention of cardiovascular disturbance due to both a rapid increase in desflurane concentration and stimulation by intubation. METHODS: One hundred three adult patients were enrolled in this prospective, double-blind, randomized study. Before anesthesia induction, all patients received normal saline (control) or one of the following 3 doses of remifentanil: 1.0 microg/kg of remifentanil (remifentanil 1.0), 1.5 microg/kg of remifentanil (remifentanil 1.5), and 2.0 microg/kg of remifentanil (remifentanil 2.0). After induction with propofol and rocuronium, 1.3 minimal alveolar concentration of desflurane with oxygen was administered via a face mask. Heart rate (HR) and mean blood pressure (MBP) were recorded before remifentanil administration, and 1, 2, and 3 min after inhalation of desflurane, as well as 0, 1, 2, and 3 min after intubation. The proportions of patients with hemodynamics that maintained within +/- 25% of preinduction values (MBP and HR proportion) were calculated. RESULTS: MBP and HR were lower in the 3 remifentanil groups than in the control group throughout the study period. The MBP proportion was higher in remifentanil 1.0 group than in control group. The HR proportion was higher in the 3 remifentanil groups than in control group. CONCLUSIONS: A single bolus injection of remifentanil (1.0-2.0 microg/kg) may be effective in alleviating adverse hemodynamic changes induced by both desflurane inhalation and tracheal intubation. Especially, administration of remifentanil 1.0 microg/kg maintained more stable blood pressure compared to the control group throughout the study period.
Adult ; Anesthesia* ; Blood Pressure ; Heart Rate ; Hemodynamics* ; Humans ; Hypertension ; Inhalation ; Intubation ; Masks ; Oxygen ; Propofol ; Prospective Studies ; Tachycardia