Rocuronium Injection Pain is Attenuated by NaHCO₃

Background: Rocuronium administration is associated with a severe burning pain during injection. However, the mechanistic cause of the pain has not been well established. The purpose of this study was to determine whether adjusting the pH of the rocuronium with NaHCO3 would ameliorate the pain. Methods: We examined mixtures using microscope after NaHCO3 was mixed with rocuronium to exam solubility. Sixty of 80 patients scheduled for elective gynecologic surgery were randomly allocated to one of three groups as follows: group 1 (rocuronium only, n = 20), group 2 (rocuronium 50 mg/5 ml mixed with 0.9% NaCl 3 ml, n = 20), group 3 (rocuronium 50 mg/5 ml mixed with NaHCO3 3 ml, n = 20). All patients received 0.6 mg/kg of rocuronium over 10 sec and were asked to assess pain using a visual analogue scale (VAS) followed by injection of propofol 1.5 mg/kg and fentanyl 100 mcg. The onset and duration of rocuronium were measured in three groups. Twitch responses to cumulative incremental doses of rocuronium were measured in another 20 patients, allocated to group A (rocuronium only, n = 10) or group B (rocuronium 50 mg/5 ml mixed with NaHCO3 3 ml, n = 10). Results: Over 24 hours, no precipitation or particles were found after mixing NaHCO3 with rocuronium. The VAS was significantly lower in group 3 (0.5 ± 0.9) than in group 1 (5.4 ± 3.2) or in group 2 (4.9 ± 2.1) (P < 0.05). Eighteen of 20 patients in group 3 had no pain and only 2 had mild pain, but all patients in groups 1 and 2 had mild to severe pain. There were no differences in onset or duration between the three groups and in twitch responses between group A and B. Conclusions: NaHCO3 mixed with rocuronium attenuates rocuronium injection pain, and there were no problems or complications.ope

‘경막외 통증자가조절 시 혼합되는 Alfentanil의 적정농도’에 관한 논문에 대하여

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The Current Status and Measures of Ever-increasing Geriatric Care Hospitals

Many health care hospitals for the elderly ("Geriatric care hospital") are being founded as a result the rapid increase in the elderly population in Korea. As the population in Korea ages, there is move toward a mass geriatric society with a corresponding increase in the number of and geriatric care hospitals beds. Accordingly, the government's health care policy, social ethics and medical care services must change in order to adapt to the aging society. In general, when the cost and quality grows hand in hand and quality improvements are needed to meet expectations, unnecessary expenses can be reduced. The government can be expected to take on the role to firmly secure this balance. In addition, medical institutions must be aware that an investment based solely on profit can have deleterious outcomes. In conclusion, geriatric care hospital should not be evaluated only by its expansion in size or need, but should be judged on the consistent improvement in the quality of medical services they provide. The government, a group of hospital administrators or a social-welfare groups cannot solve this task alone. The government must offer legal, institutional and financial support, while people of all fields must find some common ground in geriatric care. Moreover, the development of an appropriate and efficient supervising system for geriatric care, and greater efforts of the geriatric hospitals themselves are needed to improve medical care.ope

Anesthetic experience for orthopedic surgery on a patient with Glanzmann's thrombasthenia refractory to platelet transfusion: A case report

Glanzmann's thrombasthenia is an autosomal recessive bleeding disorder caused by qualitative or quantitative abnormalities of the platelet glycoprotein IIb/IIIa (GP IIb/IIIa), which can lead to excessive bleeding. Glanzmann thrombasthenia is associated with clinical variability, with some patients only having minimal bruising and others having frequent, severe and potentially fatal hemorrhages. Platelet transfusions, which used to be the standard treatment, may lead to the development of antibodies to HLA and/or GPIIb/IIIa, thereby rendering future transfusions ineffective. Glanzmann's thrombasthenia can be a severe hemorrhagic disease; however, the prognosis is excellent with careful supportive care. In this case, administering allogenic plateletpheresis to patients with Glanzmann's thrombasthenia who were refractory to platelet transfusions was found to be successful during bone surgeriesope

Effects of Dexamethasone on Neuromuscular Transmission in a Phrenic Nerve-Hemidiaphragm Preparation in the Rat

Background: MacFarlane and Rosenthal reported a case of acute quadriplegia after nondepolarizing muscular blocking agents in status asthmaticus patient treated with high doses of corticosteroid. Reports regarding the reactions of glucocorticoid treated muscles to neuromuscular blocking agents are sparse and inconsistent. The aims of this study were to examine the degree of muscle atrophy and its effects on sensitivity to neuromuscular blocking agents in relation to the dose and duration of dexamethasone. Methods: Sixty Sprague-Dawley rats were divided into six groups. They were treated daily with dexamethasone 0.4 mg/kg and 4 mg/kg daily for 1 week or 3 weeks. The two control groups were treated with normal saline. The day after treatment, the dose-response curves of vecuronium were measured using a phrenic nerve-hemidiaphragm preparation. To classify muscle fiber, the diaphragm was stained for myofibrillar adenosine triphosphatase after alkaline and acid preincubation, and a morphometric examination was carried out. Results: The diaphragmatic muscle in rats treated with long term, high dose dexamethasone showed significant atrophy. For the short term, low dose dexamethasone group, the ED50 and ED95 of vecuronium decreased 41.5% and 26.8% compared to those of the control group, respectively (P ＜ 0.05). However, the ED50 of vecuronium in the long term, high dose dexamethasone group increased 22.2% compared to that of the control group (P ＜ 0.05). Conclusion: This study suggests that sensitiviy to vecuronium was not modulated by dexamethasone-induced muscle atrophy. Quantitative changes of receptors at the neuromuscular junction or some anoother process might be responsible for this change.ope

A Model of Accreditation System for Medical Subspecialty Board Certification in Korea

Subspecialty board certification is a post-graduate program in which clinicians can acquire the qualifications for special areas or techniques, after they have received a board certification in a specialty in clinical medicine. Considering the trend of increasingly sub-classified and professionalized medicine and the higher demand on specialized medical services, introduction of subspecialty board certification is inevitable. However, given the characteristics of the medical environment in Korea, such as the medical payment system, a possibility of undesirable outcomes should not be overlooked. An imprudent administration of the specialty board system would cause conflict and split within communities of medical professionals and also produce confusion among medical consumers. Accordingly, the establishment of subspecialty board system should proceed based on academic communications as well as organic collaboration with the parent academic society and/or the relevant academic societies. Individuals can submit an application for a subspecialty board qualification under the agreement of specialized academic societies which have already been authorized, but the authorization of the societies is determined following a rigorous assessment by the Korean Academy of Medical Sciences (KAMS). An active intervention by KAMS is essential for maintaining the quality of specialty board system and preventing imprudent administration. KAMS will make the best effort to prevent distribution of unauthorized certificates and to rectify rational implementation of the subspecialty board certification systemope

Rocuronium onset at the adductor pollicis and masseter muscles for endotracheal intubation in children

Background: Masseter muscle is a better predictor of good intubating conditions than adductor pollicis after the administration of rocuronium in adults. We compared the onset of rocuronium at the masseter muscle to that at the adductor pollicis to determine which is the more suitable predictor of good intubaring conditions using rocuronium in children. Methods: Fifty children aged from 1 to 6 years old, were anesthetized with thiopental sodium and sevoflurane. The ulnar nerve was stiumlated to monitor the relaxation of the adductor pollicis, and the mandibular nerve for monitoring masseter muscle relaxation. Rocuronium 0.6 ㎎/㎏ was administered. We measured the time to maximal blckade of the masseter muscle (M-0%). We recorded the percentage of relaxation of the adductor pollicis (AP-%) at M0)% and the time of the maximal blockade of the adductor pollicis (AP-0%), from the administration of rocuronium. Endotracheal intubation was started when the masseter muscle contraciton was maximally blocked. Results: M-0% occurred at 37.4% ± 15.4 s, and AP-% was 32.4 ± 32.2% at M-0%. AP-0% occurred at 54.8% ± 19.0 s. The time gap between M-0% and AP-0% was 16.8 ±18.3 s. Intubation was at 64.4 ± 19.4 s from the administration of rocuronium. conclusions: The time gap between M-0% and AP-0% was very short in children. Therefore, the monitoring of muscle relaxation on masseter muscle is not straightfoward, and therefore, not advised.ope

Epidural naloxone reduces postoperative nausea and vomiting in patients receiving epidural sufentanil for postoperative analgesia

BACKGROUND: Epidural opioids have excellent analgesic properties, but their side-effects limit their use in patient-controlled epidural analgesia. This study was designed to evaluate the effect of epidural naloxone on the side-effects of sufentanil, focusing on postoperative nausea and vomiting (PONV) in patients undergoing total knee replacement (TKR). METHODS: After obtaining Institutional Review Board approval and informed consent, 50 patients undergoing unilateral TKR were randomly assigned to receive either sufentanil in ropivacaine alone (Group C, n = 25) or the same solution with naloxone (Group N, n = 25) for their postoperative epidural analgesia. Episodes of PONV and five-point-scaled nausea scores were evaluated at 6, 12, and 24 h after epidural analgesia was started. Visual analogue scale (VAS) score for pain and the incidence of sedation, pruritus, hypotension, and respiratory depression were also evaluated at each of three time points. RESULTS: The nausea score in Group N was significantly lower than that in Group C. The VAS pain score at rest and on movement were significantly lower in Group N than in Group C at 24 h. Other opioid-induced side-effects were not significantly different. CONCLUSIONS: Epidural naloxone was effective in reducing PONV induced by epidural sufentanil and additionally enhanced the analgesic effect. Therefore, concomitant infusion of a small dose of epidural naloxone should be considered to reduce PONV, especially in patients at greater risk for PONV.ope

Motor Weakness on Lower Extremities after the Combined Spinal-epidural Anesthesia and Analgesia

The spinal-epidural nerve block is widely used for anesthesia or postoperative pain control. The incidence of neurological complications after spinal and epidural anesthesia is increased although it is usually transient. Such complications may be caused by various mechanical, chemical, and ischemic factors. We experienced a case of motor weakness following combined spinal-epidural anesthesia and analgesia. The motor weakness and hypoesthesia were reversible on right leg, but persistent on left leg.ope

Optimal Dose of Rocuronium for Rapid Tracheal Intubation under Sevoflurane Anesthesia

Background : There are situations in anesthesia in which it may be desirable to achieve rapid tracheal intubation. Rapid tracheal intubation with rocuronium has been studied using a probability-based approach. But these studies used intravenous anesthetics for anesthetic induction. Therefore, we aimed to predict doses of rocuronium giving 90% and 95% probabilities of intubation within 60 seconds and to estimate their action durations using sevoflurane for anesthetic induction. Methods : Anesthesia was induced in sixty patients with sevoflurane. Patients received randomly rocuronium, 0.0, 0.3, 0.6, 0.9 or 1.2 mg/kg (n = 12/dose). Laryngoscopy began 40 seconds later, aiming for intubation at 60 seconds, and conditions were graded as either perfect, acceptable of unacceptable, with the first two conditions being taken as successful intubation. Duration of action was accepted as time until a twitch height recovery of 15%. The dose versus the fraction of patients showing successful intubation was analyzed by logistic regression. Doses giving 90% and 95% (D90 and D95) probabilities of successful intubation were calculated. Results : Of the 12 patients in each group (0.0, 0.3, 0.6, 0.9 or 1.2 mg/kg), intubation was successful in 4, 10, 12, 12 and 12 patients, respectively. The D90 and D95 doses were determined to be 0.34 and 0.43 mg/kg, respectively. Conclusions : After induction with sevoflurane, rocuronium at 0.43 mg/kg, gives a 95% probability of successful intubation at 60 seconds.ope