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C-arm fluoroscopy is useful equipment in interventional pain management because it helps to guide correct needle targeting for the accurate injection and drug delivery. However, due to increased use of C-arm fluoroscopy in various pain procedures, the risk of radiation exposure is a significant concern for pain physicians. The harmful biological effects of ionizing radiation on the human body are well known. It is therefore necessary to strive to reduce radiation exposure. Lead aprons with thyroid shields are the most fundamental radiation protective devices for interventional procedures, and are very effective. However, the operator's radiation safety cannot be guaranteed because pain physicians seem to lack sufficient interest, knowledge, and awareness about radiation safety. Also, inappropriate care and use of radiation protective devices may result in a higher risk of radiation exposure. The purpose of this article was to review the literature on radiation safety with a focus on lead aprons and thyroid shields and present recommendations related to those devices during C-arm fluoroscopic-guided interventions by pain physicians.

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia. Magnesium has been reported to be effective in reducing the incidence or prophylaxis of AF. Magnesium is also an essential constituent of many enzyme systems and plays a physiological role in coagulation regulation. The aim of the present study was to examine the effects of magnesium, whether magnesium infusion might decrease the incidence of AF and induce hypocoagulable state in patients with AF, who were undergoing mitral valve annuloplasty. Methods: This prospective laboratory study was performed using blood from patients with AF undergoing mitral valve annuloplasty. The radial artery was punctured with a 20 gauge catheter and used for monitoring continuous arterial pressure and blood sampling. After anesthesia induction, 4 g of magnesium was mixed with 100 ml normal saline and infused for 5 minutes. Magnesium, calcium, activated clotting time (ACT) and thromboelastographic parameters were checked before and 60 minutes after the magnesium infusion. The electrocardiography changes after magnesium infusion were also checked before commencing cardiopulmonary bypass. Results: After magnesium infusion, the serum level of magnesium increased significantly but serum calcium did not change significantly. ACT did not change significantly before or after magnesium infusion. The thromboelastographic parameters showed no significant changes before or after magnesium infusion. None of the patients converted to sinus rhythm from AF after the magnesium infusion. Conclusions: A magnesium infusion did not influence the course of AF and coagulation in patients during prebypass period with AF undergoing mitral valve annuloplasty. (Korean J Anesthesiol 2011; 61: 210-215)

This randomised controlled trial compared the effect of equipotent anaesthetic doses of sevoflurane (S group) versus propofol (P group), during remifentanil-based anaesthesia for off-pump coronary artery bypass surgery, on myocardial injury. Either sevoflurane or propofol was titrated to maintain bispectral index values between 40 and 50. In both groups, a targeted concentration of remifentanil 20 ng.ml-1 was maintained during anaesthesia. The concentrations of creatine kinase MB and troponin I were measured before the start of surgery, on admission to the intensive care unit, and at 12 and 24 hours after intensive care unit admission. The postoperative values of creatine kinase MB (S group: 15.08±18.97, 20.78±20.92, 12.76±12.82 vs 2.09±1.54 ng.ml-1; P group: 10.99±13.15, 27.16±56.55, 11.88±18.80 vs 1.84±1.67 ng.ml-1) and troponin I (S group: 3.56±5.19, 5.66±7.89, 3.35±4.55 vs 0.52±1.90 ng.ml-1; P group: 2.42±3.33, 4.11±6.01, 3.04±5.31 vs 0.43±1.28 ng.ml-1) were significantly higher than preoperative values in both groups but there were no significant differences between the two groups. There were no significant differences in time to extubation (S group, 476±284 minutes; P group, 450±268 minutes) and intensive care unit length of stay (S group, 2775±1449 minutes; P group, 2797±1534 minutes) between the two groups. In conclusion, sevoflurane and propofol at equipotent doses guided by bispectral index with remifentanil 20 ng.ml-1 had similar creatine kinase MB and troponin I values.

Intraoperative formation of a thrombus in the right atrium and its management has occasionally been reported. However, spontaneous resolution of right atrial thrombi, without any event, is rare. We report a case of abrupt right atrial thrombus formation and spontaneous resolution, with no events, detected by transesophageal echocardiography during the replacement of an abdominal aortic aneurysm.

We report a case of abdominal compartment syndrome occurring due to uterine perforation while the patient was undergoing hysteroscopic uterine adhesiolysis for uterine synechia. The cause of the patient's abdominal compartment syndrome was irrigation fluid moving from the uterine cavity into the peritoneal space via defects in the uterus. Anesthesiologists must be alert for these complications during hysteroscopy procedures.

We hypothesised that relaxation of the serratus anterior muscle by long thoracic nerve (LTN) block could help pain relief after video-assisted thoracoscopic surgery. Patients undergoing thoracoscopic wedge resection for pneumothorax were randomly assigned to control or LTN block. LTN block was performed before induction of general anaesthesia. Pain was evaluated using a visual analogue scale before anaesthesia induction (T0), on arrival to the post-anaesthetic care unit (PACU) (T1), every ten minutes after arrival in the PACU for 30 minutes (T2, T3 and T4) and one hour and 24 hours after discharge from the PACU (T5 and T6). Visual analogue scale scores from T1 to T5 in the block group were lower than the control group (T1: 36±11 vs 48±14 [P=0001], T2: 36±11 vs 51±15 [P

Background: Although many clinicians know about the reducing effects of the pulsed and low-dose modes for fluoroscopic radiation when performing interventional procedures, few studies have quantified the reduction of radiation-absorbed doses (RADs). The aim of this study is to compare how much the RADs from a fluoroscopy are reduced according to the C-arm fluoroscopic modes used. Methods: We measured the RADs in the C-arm fluoroscopic modes including ‘conventional mode’, ‘pulsed mode’, ‘low-dose mode’, and ‘pulsed ＋ low-dose mode’. Clinical imaging conditions were simulated using a lead apron instead of a patient. According to each mode, one experimenter radiographed the lead apron, which was on the table, consecutively 5 times on the AP views. We regarded this as one set and a total of 10 sets were done according to each mode. Cumulative exposure time, RADs, peak X-ray energy, and current, which were viewed on the monitor, were recorded. Results: Pulsed, low-dose, and pulsed ＋ low-dose modes showed significantly decreased RADs by 32%, 57%, and 83% compared to the conventional mode. The mean cumulative exposure time was significantly lower in the pulsed and pulsed ＋ low-dose modes than in the conventional mode. All modes had pretty much the same peak X-ray energy. The mean current was significantly lower in the low-dose and pulsed ＋ low-dose modes than in the conventional mode. Conclusions: The use of the pulsed and low-dose modes together significantly reduced the RADs compared to the conventional mode. Therefore, the proper use of the fluoroscopy and its C-arm modes will reduce the radiation exposure of patients and clinicians. (Korean J Pain 2011; 24: 199-204)

Background: Third-generation hydroxyethyl starch (HES) solutions have been developed to minimize negative effects on hemostasis. In normal pregnancy, the coagulation activity increases, reaching a maximum around term. This study examined the effects of hemodilution with HES 130/0.4 (6%) on blood coagulation in parturients in vivo and in vitro. Methods: Forty parturients scheduled for cesarean sections were assigned randomly to receive either 500 or 1,000 ml of HES 130/0.4 (6%). Rotation thromboelastometry (ROTEM Ⓡ ) measurements were performed before and after administering HES 130/0.4 (6%). In addition, blood samples obtained from 20 randomly selected parturients were diluted 10% to 40% using HES 130/0.4 (6%), and ROTEM Ⓡ measurements were performed before and after dilution. The changes from baseline and the effects of dilution were analyzed by ROTEM Ⓡ parameters. Results: Infusions of 500 or 1,000 ml of HES 130/0.4 (6%) in the parturients altered the clot formation time, α angle, and maximal clot firmness, although all remained within normal ranges. HES 130/0.4 (6%) affected in vitro blood coagulation in parturients’ blood containing 10, 20, 30, and 40% HES. The clotting time was prolonged at each dilution percentage, but remained within the normal range. Other parameters showed an impairment of the coagulation system. Conclusions: Blood coagulation in parturients may be compromised at high dilution ratios of HES 130/0.4 (6%) to blood. Nevertheless, the infusion of 1,000 ml of HES 130/0.4 (6%) in normal parturients did not significantly affect blood coagulation. (Korean J Anesthesiol 2012; 62: 337-342)

Objective Endoscopic vein harvest (EVH) for coronary artery bypass grafting surgery is performed with carbon dioxide (CO 2 ) insufflation for visualization and dissection. The insufflated CO 2 is rapidly absorbed into the body and may influence haemodynamics. However, the haemodynamic changes during EVH have not been clearly defined. This study evaluated the haemodynamic effects during EVH of the saphenous vein for off-pump coronary artery bypass grafting surgery (OPCAB). Methods After fixing the position for harvesting of the left internal mammary artery, EVH of the saphenous vein was performed at a maximum CO 2 pressure of 12 mmHg and a flow of 3 l/min. The haemodynamic parameters were measured before and just after the end of endoscopic vein harvest. Results One hundred patients were studied. The end-tidal CO 2 pressure (P ET CO 2 , 35.0 ± 2.7 vs. 52.0 ± 6.2 mmHg), partial pressure of arterial CO 2 (PaCO 2 , 35.1 ± 3.1 vs. 52.5 ± 4.3 mmHg), mixed venous oxygen saturation (SvO 2 , 75.6 ± 4.1 vs. 82.0 ± 1.6%), cardiac index (2.7 ± 0.6 vs. 3.3 ± 0.6 l/min/m 2 ), and cerebral oxygen saturation (ScO 2 , left: 63.5 ± 7.9 vs. 73.3 ± 8.4; right: 62.2 ± 8.0 vs. 72.3 ± 6.3%) differed significantly between before and after CO 2 insufflation, whereas mean systemic blood pressure, mean pulmonary artery blood pressure, central venous pressure, heart rate, partial pressure of arterial oxygen, and peak inspiratory pressure did not differ significantly between before and after CO 2 insufflation. Conclusions EVH, at a maximum CO 2 pressure of 12 mmHg and a flow of 3 l/min, of the saphenous vein for OPCAB was associated with hypercarbia and a tolerable range of hypercarbia (PaCO 2

Spinal glutamate transporters (GT) have been implicated in the mechanisms of neuropathic pain; however, how spinal GT uptake activity is regulated remains unclear. Here we show that alteration of spinal arachidonic acid (AA) turnover after peripheral nerve injury regulated regional GT uptake activity and glutamate homeostasis. Chronic constriction nerve injury (CCI) in rats significantly reduced spinal GT uptake activity ((3)H-glutamate uptake) with an associated increase in extracellular AA and glutamate concentration from spinal microdialysates on postoperative day 8. AACOCF3 (a cytosolic phospholipase A2 inhibitor, 30mug) given intrathecally twice a day for postoperative day 1-7 reversed this CCI-induced spinal AA production, prevented the reduced spinal GT uptake activity and increased extracellular glutamate concentration. Conversely, alteration of spinal AA metabolism by diclofenac (a cyclooxygenase 1/2 inhibitor, 200mug) further reduced spinal GT uptake activity and increased extracellular glutamate concentration in CCI rats. GT uptake activity was also attenuated when AA (10 or 100nM) was directly added into spinal samples of naive rats in an in vitro(3)H-glutamate uptake assay, indicating a direct inhibitory effect of AA on GT uptake activity. Consistent with these findings, AACOCF3 reduced the development of both thermal hyperalgesia and mechanical allodynia, whereas diclofenac exacerbated thermal hyperalgesia, in CCI rats. Thus, spinal AA turnover may serve as a regulator in CCI-induced changes in regional GT uptake activity, glutamate homeostasis, and neuropathic pain behaviors. These data suggest that regulating spinal AA turnover may be a useful approach to improving the clinical management of neuropathic pain.

Loeys-Dietz Syndrome (LDS) is a recently described autosomal dominant aortic aneurysm syndrome with widespread systemic involvement. It is characterized by the triad of 1) arterial tortuosity and aneurysms, 2) hypertelorism, and 3) bifid uvula or cleft palate. A 12-year-old boy with LDS was scheduled to undergo correction of aortic valve regurgitation due to aortic annuloectasia. We report our clinical experiences of a case of LDS patient with brief review of related literatures and relevant anesthetic problems.

Background: Propofol is the extensively used general anesthetic-sedative agent. Although propofol is known to be involved in migration of various cells, migration response to it in vascular smooth muscle cells is not investigated. This study was carried out to determine the role of propofol in migration of rat aortic smooth muscle cells (RASMCs). Methods: A7r5 RASMCs were used. Cell migration was examined by the analysis of 5 ng/ml of platelet-derived growth factor (PDGF)-induced RASMC response after treatment of cells with propofol (1−100μM) in the Boyden chamber. The activity of cofilin by propofol in RASMCs was measured by the Western blot analysis for the change of cofilin dephosphorylaton in cells treated with 10μM propofol for 5, 10, 15 and 20 min, for the effect of propofol (1, 10 and 100μM) on cofilin phosphorylation, and for the effects of ethylene glycol-bis (β-aminoethyl ether)-N,N,N',N'-tetra acetic acid (2 mM; EGTA), Na3VO4 (200μM), and calyculin A (10 nM) on 10μM propofol-induced cofilin dephosphorylation. Results: PDGF increased RASMC migration and this response was dose-dependently inhibited by treatment with propofol. Propofol attenuated the cofilin phosphorylation in RASMCs in a dose- and time-dependent manner. Propofol-induced dephosphorylation of cofilin in RASMCs was abolished by calyculin A, a protein phosphatase 2A inhibitor, but not by EGTA, a Ca 2+ chelating agent, or Na3VO4, a protein tyrosine phosphatase inhibitor. Conclusions: The present results suggest that propofol induces the diminution of PDGF-stimulated RASMC migration and this response may be associated with dephosphorylation of cofilin mediated by the protein phosphatase 2A-dependent pathway. (Korean J Anesthesiol 2008; 54: S 22∼8)

Moderate to severe pulmonary hypertension, mean pulmonary arterial pressure (mPAP) ＞ 35 mmHg, in cirrhotic patients is usually considered an absolute contraindication to orthotopic liver transplantation (OLT) because of unacceptably high mortality. We present the case of successful OLT in a cirrhotic patient with a mPAP of 42 mmHg and a pulmonary vascular resistance (PVR) of 298 dyneㆍsecㆍcm−5 preoperatively. He was treated with oral sildenafil (ViagraⓇ) and inhaled iloprost (VentavisⓇ) for 45 days and then his mPAP and PVR were reduced to 33 mmHg and 206 dyneㆍsecㆍcm−5 at the time of transplantation. During OLT, his mPAP was stable of 28−38 mmHg with the combined use of sildenafil via a nasogastric tube and iloprost via a nebulizer. His hemodynamic parameters were stable and significant postoperative bleeding was not noticed throughout his stay in the intensive care unit. Thereafter, he was transferred to general ward without any cardio-respiratory problems on 7th postoperative days.

Renal failure frequently accompanies advanced hepatic failure. Even if adequate renal function is not considered as a prerequisite for transplant candidacy, impaired renal function prior to liver transplantation has been regarded as an independent risk factor of graft dysfunction and mortality. Liver transplantation in such a patient also presents a number of challenges to the anesthesiologists. Optimal fluid therapy, prompt and aggressive correction of electrolytes and metabolic disturbances, careful selection of anesthetic techniques and agents, and close monitoring of cardio-respiratory function help reduce the graft failure and perioperative mortality. In such cases, continuous renal replacement therapy (CRRT) is used with increasing frequency during or after the surgery. So, anesthesiologists need to understand the basic principles, potential applications, and anesthetic implications of several CRRT options. We therefore present the anesthetic experience in a patient with hepatic failure combined with primary renal failure, successfully managed during or after liver transplantation. (Korean J Anesthesiol 2007; 53: 547∼553)

We present a case of an anesthetic gas leak through the valve of the Selectatec back bar during a surgical procedure. The Selectatec Vaporizing System is a quick-change system consisting of anesthetic vaporizers of the 'Tec models' of the Ohmeda machine that are seated on a compatibility manifold block located on the back bar of the anesthetic machine. In order to prevent a leak and a failure of vapor delivery, the 'Tec models series' can only be turned 'on' when the locking lever is turned to the 'lock' position. However in this case, the control knob was rotated despite the back bar locking mechanism not being engaged, and a gas leak developed through the unlocked valves in Selectatec back bar. The Penlon Sigma Delta Anesthetic Vaporizer (sevoflurane) in a Datex-Ohmeda Aestiva/5 anesthesia machine can be turned 'on' when the locking lever is maintained at the 'unlock' position.

Background: Diabetes mellitus is the most common endocrinopathy encountered in the perioperative period and has long been assumed to increase perioperative risk. However, when diabetes mellitus was segregated from old age and the complications of it, it was questioned that diabetes mellitus itself increased perioperative risk. In this study, we investigated the influence of hyperglycemia on the length of postoperative hospital stay. Methods: We studied 100 patients undergone intra-abdominal operations with general anesthesia. These patients were divided into the hyperglycemic group (n = 20) with postoperative blood glucose level higher than 10 mM and the non-hyperglycemic group (n = 80) with glucose level lower than 10 mM and we investigated the length of postoperative hospital stay, serum electrolyte, serum chemistry, arterial blood gas values, and base excess by unmeasured anions. We also divided these patients into the diabetic patients group (n = 15) and the non-diabetic patients group (n = 85) and compared the same variables. Results: The length of postoperative hospital stay was significantly prolonged in the hyperglycemic group ( days) compared with the non-hyperglycemic group ( days), and the cumulative postoperative hospital stay curves based on Kaplan-Meier method also showed significant difference between the two groups. When we compared the length of postoperative hospital stay between the diabetic and the non-diabetic patients, there was no significant difference. Conclusions: This study demonstrated that hyperglycemia prolonged the length of postoperative hospital stay. This finding suggests that the patient´s glucose level should be monitored and controlled within an adequate range perioperatively.

Background: Ropivacaine is a long acting, amide-type local anesthetic with a chemical structure similar to that of bupivacaine. In this study we investigated the efficacies of 18 ml of 0.5% bupivacaine, and of 0.5% and 0.75% ropivacaine to provide caudal anesthesia. Methods: Sixty ASA physical status 1 or 2 patients undergoing hemorrhoidectomy were randomly allocated to 3 parallel treatment groups to receive either 18 ml of 0.5% bupivacaine, or 0.5% or 0.75% ropivacaine. Caudal anesthesia was performed using the loss of resistance method via sacral hiatus. Soft touch testing around the anal sphincter muscle, the pin prick method at the S3 dermatome, onset time of loss of anal sphincter reflex, and sensory block were checked following local anesthetic injection. Duration of sensory block was assessed at 30 minute intervals through out block duration. Quality of muscle relaxation was assessed by the surgeon at the end of each operation. Blood pressures were measured and the incidences of nausea, vomiting and dizziness were recorded. Results: Significant differences were observed between the 0.5% ropivacaine and 0.75% ropivacaine groups (P

Background: Music is widely used to help a patient relax, and divert their attention from unpleasant and stressful situations. In addition, it eliminates the noise in the operating room. A light level of general anesthesia for a cesarean section is usually applied to the mother to improve the fetal safety. Therefore, there is an increased incidence of maternal explicit and implicit memory with the bispectral index (BIS) monitoring. Methods: Fifty patients undergoing a cesarean section under general anesthesia were allocated randomly to either a control group(group 1) or a music group (group 2). Patients in group 2 listened to music with a headphone during the procedure. The blood pressure, heart rate, intraoperative awareness, postoperative explicit and implicit memory and the plasma cortisol level were assessed. Results: The systolic blood pressure and heart rate were significantly lower in group 2 than group 1 at 1 minute before intubation and 5 minutes after extubation (P 0.7) than in group 1 (1.6 0.4) (P

Background: Post-dural puncture headache (PDPH) is one of the well-known complication of spinal anesthesia. Epidural blood patch is the treatment of choice for PDPH but is rarely used for the prevention of PDPH after spinal anesthesia. The purpose of this study is to observe the effectiveness of epidural blood patch for prevention of PDPH and to evaluate the complications after epidural blood injection. Methods: Three hundred patients (ASA I or II) receiving spinal anesthesia were studied. They were randomly devided into two groups. Patients in Group I, the control group, were maintained in a supine position for 24 hour after spinal anesthesia. Patients in Group II, the study group, received 3 ml of autologous blood in the epidural space after spinal anesthesia. PDPH was evaluated for 5 days. The incidence, location, onset, and duration of headache in the patients presenting with PDPH were measured for 5 days, and the complications following epidural blood patch in Group II were observed for 2 weeks. Results: The incidence of PDPH in group I was 11%, but 0% in group II. There were no specific complications following epidural blood patch in Group II. Conclusions: This study suggest that the 3 ml epidural autologous blood patch is an useful method for the prevention of PDPH in patients with spinal anesthesia. (Korean J Anesthesiol 1998; 35: 933∼938)