Effect of Needle Tip Position on Contrast Media Dispersion Pattern in Transforaminal Epidural Injection Using Kambin's Triangle Approach

Purpose: Dispersion of contrast media into the anterior epidural space is correlated with better outcomes after transforaminal epidural injection (TFEI). Needle tip position is an important factor affecting the pattern of contrast media dispersion. It is difficult to advance the needle medially to the interpedicle line with a conventional approach, especially in a severe spinal stenosis. But, with Kambin's triangle approach, the needle can be advanced more medially even in the severe stenosis. We aimed to compare contrast media dispersion patterns according to the needle tip position in TFEI with Kambin's triangle approach. Patients and methods: This single-center retrospective study analyzed fluoroscopic data of patients who underwent TFEI from March 2019 to July 2019. Data on the history of lumbar spinal fusion surgery and MRI findings were collected. The needle tip position was evaluated in three positions on fluoroscopic images (final anteroposterior [AP] view): extraforaminal (EF), lateral foramen (LF), and medial foramen (MF). Contrast media dispersion into the epidural space (epidural pattern) in the AP view was evaluated as a dependent variable. The relationship between the contrast media dispersion pattern and needle tip position was analyzed, and other factors affecting the contrast media dispersion pattern were identified. Results: Ninety-eight TFEI cases were analyzed (51 LF, 35 MF, and 12 EF). An epidural pattern of dispersion was observed more frequently in the LF and MF groups than in the EF group. The LF and MF groups showed no significant difference in epidural pattern frequency. On logistic regression analysis, needle tip position emerged as a major factor influencing epidural pattern, while other factors including spine conditions had no significant effect. Conclusion: Positioning the needle tip medial to the pedicle helps in the spread of the contrast media into the epidural space during TFEI with Kambin's approach. Factors other than the needle tip position did not significantly affect the contrast media dispersion pattern.ope

A Study on the Effect of the Gap of Cultural Homogeneity and Onboard Working Tolerance between Korean and Foreign Crews on Organizational Commitment

The primary purpose of this study is to examine the cultural problem and working attitude in the Korean vessel of combined foreign crews who has increased. Different culture between Korean and foreign crews working together in the vessel bring on many misunderstanding and dissonance in working. So to solve these problems it is needed to accept and adapt other cultural characteristics. Also many characteristics of onboard working, such as isolated from home and society, limited workspace and violation of privacyhave a bad influence to vessel organization. This study make the research model and hypothesis through literature survey on the cultural and onboard working characteristics. ◁그림 삽입▷(원문을 참조하세요) The following hypotheses are set up for the research objectives. Hypothesis １: There will be the gap of cultural homogeneity between foreign crews and korean crews working together in the vessel. Hypothesis ２: There will be the gap of onboard working tolerance between foreign crews and korean crews working together in the vessel. Hypothesis 3: the group of high level in cultural homogeneity is higher than the group of low levels in organizational commitment in the Korean vessel of combined foreign crews. Hypothesis 4: the group of high level in onboard working tolerance is higher than the group of low levels in organizational commitment in the Korean vessel of combined foreign crews. According to the results, hypothesis 1 and 2, There is significant difference in the degree of other culture acceptance & acculturation and onboard working psychological & physiological tolerance between foreign crews and korean crews working together in the vessel. In conclusion studies on other culture acceptance & acculturation, the foreign crews more try to ensure cultural homogeneity than korean crews but onboard working psychological & physiological tolerance of the korean crews is higher than the foreign crews. According to the results of hypothesis 3, the high level group of other culture acceptance & acculturation is higher than the low level group in organizational commitment, but the significant relation between other culture acculturation and job satisfaction was not found. According to the results of hypothesis 4, the high level group of onboard working psychological tolerance is higher than the low level group in organizational commitment, but the difference between high physiological tolerance group and low group in organizational commitment was proved not to be significant. This study is meaningful as exploratory research about cultural homogeneity, onboard working tolerance and organization commitment for combined foreigner crews and the result of this study contributes on management of crew and vessel organization.Ⅰ. 서론 = 1 1. 연구의 필요성과 연구 목적 = 1 2. 연구방법과 범위 = 4 Ⅱ. 연구의 이론적 배경 = 6 1. 이문화 관리 = 6 2. 승선근무내성 = 19 3. 조직커미트먼트 = 23 Ⅲ. 연구의 설계 = 28 1. 연구 모형 = 28 2. 연구 가설 = 30 3. 변수의 조작적 정의 = 33 Ⅳ. 실증 분석 = 36 1. 조사개요 및 자료 분석 = 36 2. 신뢰성 및 타당성 분석 = 39 3. 가설 검정 = 44 Ⅴ. 결론 = 50 참고문헌 = 55 ABSTRACT = 62 부록(설문지) = 6

The effect of sequential compression device on hypotension in the sitting position during shoulder arthroscopy; a comparison with elastic stocking

BACKGROUND: The sitting position under general anesthesia is associated with hemodynamic instability. The purpose of this study was to compare the efficacy of a sequential compression device (SCD) with that of elastic stockings (ES) in reducing the incidence of hypotension and other hemodynamic instability in the sitting position during shoulder arthroscopy. METHODS: Fifty-one patients undergoing shoulder arthroscopy were randomly assigned into one of three groups to receive no treatment (control group, n = 17), SCD (SCD group, n = 17) or ES (ES group, n = 17). Hemodynamic variables were measured 5 min after induction of anesthesia (baseline values), and every 1 min from 1 to 5 min after raising the patient to a 70degrees sitting position (T1-5) with the beach-chair. RESULTS: The incidences of hypotension (proportion, 95% CI) were 12/17 (0.71, 0.47-0.87), 5/16 (0.31, 0.14-0.56) and 7/15 (0.47, 0.25-0.70) in the control, SCD and ES group, respectively. The incidence was significantly lower in the SCD group than that in the control group (P = 0.038). At 1 min after sitting position, mean arterial pressure in the control group was significantly lower than that in the SCD group and it was significantly decreased from the baseline value. CONCLUSIONS: SCD could significantly reduce the incidence of hypotension with less hemodynamic instability in the sitting position during shoulder arthroscopy. Although the incidence of hypotension was decreased with the elastic stocking, there was no statistical significance.ope

The optimal exhaled concentration of sevoflurane for intubation without neuromuscular blockade using clinical bolus doses of remifentanil: A randomized controlled trial

BACKGROUND: The aim of this study was to investigate the optimal exhaled sevoflurane concentration that produces adequate endotracheal intubation conditions when sevoflurane is combined with the different bolus doses of remifentanil used in clinical practice. METHODS: The patients were randomized to 3 groups (groups 1.0, 1.5, and 2.0), receiving remifentanil bolus doses of 1.0, 1.5, and 2.0 μg/kg, respectively. For each group, the concentration of sevoflurane used for each consecutive patient was increased or decreased using the "up-and-down" method based on the success or failure to achieve adequate conditions for intubation in the previous patient. The remifentanil bolus dose was administered 90 s before intubation and after the target sevoflurane concentration was achieved. RESULTS: In groups 1.0, 1.5, and 2.0, the effective concentration in 50% (EC50) of the sevoflurane concentration required to perform successful intubation was 3.0, 2.0, and 1.29 vol% and the effective concentration in 95% was 3.45, 2.91, and 1.89 vol%, respectively. When sevoflurane was administered for the induction, the increase in heart rate (HR) of group 1.0 was the highest among the groups. The highest number of adverse events occurred in group 2.0, including vocal cord rigidity, hypotension, and bradycardia. DISCUSSION: The EC50 of the sevoflurane concentration was 3.0, 2.0, and 1.29 vol% when it was combined with a bolus dose of remifentanil of 1.0, 1.5, and 2.0 μg/kg, respectively. Of the 3 different bolus doses of remifentanil, the dose of 1.5 μg/kg was least associated with changes in the HR/mean blood pressure during intubation without increasing adverse effects.ope

The Validity of Intraoperative Brainstem Auditory Evoked Potentials (BAEPs) for the Postoperative Hearing Impairments in Microvascular Decompression (MVD)

BACKGROUND: Intraoperative brainstem auditory evoked potentials reduced the sensorineural hearing loss (SNHL) after microvascular decompression (MVD) This study was performed to evaluate the validity of BAEP parameters of latency or amplitude to SNHL. METHODS: 557 patients out of 930 hemifacial spasm patients performed MVD, who were free from hearing impairment preoperatively, were enrolled in this study. Maximal changes of BAEPs wave V latency and amplitude during MVD were retrospectively sought according to postoperative SNHL. Sensitivity, specificity and positive predictability of wave V latency and amplitude were also sought according to the postoperative SNHL with a critical value of 1.0 msec prolongation and 40% decrease, respectively. RESULTS: Wave V latency of BAEPs prolonged less in patients with normal hearing outcome (0.44 ± 0.63 msec) than in the patients with temporary or permanent SNHL (1.23 ± 0.56 msec, 1.33 ± 0.33 msec). Wave V amplitude also decreased less in the patients with normal hearing outcome (5.4 ± 15.8%) than in the patients with transient or permanent SNHL (42.8 ± 31.7%, 60.0 ± 34.7%). While sensitivity, specificity and predictability of prolongation of wave V latency at a value of 1.0 msec for SNHL, were 52.5%, 76.4% and 14.7%, respectively, those of decrease in the amplitude of wave V for SNHL at a value of 40% were 35.0%, 93.6% and 29.8%, respectively. CONCLUSIONS: Decrease of the amplitude of wave V seems to have higher specificity, predictability and lower sensitivity for SNHL than the prolongation of wave V latency.ope

Anesthesia for Fetal Surgery: Twin Reversed Arterial Perfusion Sequence

It is important to consider the fetal, uteroplacental, and maternal issues when choosing anesthetic technique for fetal surgery. The twin reversed arterial perfusion (TRAP) sequence, or the acardiac anomaly, occurs in 1：100 monozygous multiple pregnancies and in 1：35,000 births. The TRAP sequence is characterized by placental vascular arterio-arterial anastomosis between twin fetuses, one an acardiac/acephalic twin that receives its blood flow from the normal pumping twin, thereby endangering the normal twin by high output cardiac failure. The acardiac twin is nonviable, and perinatal mortality in the pump cotwin exceeds 50% because of cardiac failure and prematurity. This can be managed by fetal surgery. We report on a patient with a 26-wk gestation complicated by an acardiac/acephalic fetus anesthetized for surgical umbilical cord ligation.ope

Comparison of the laryngeal view during intubation using Airtraq and Macintosh laryngoscopes in patients with cervical spine immobilization and mouth opening limitation

BACKGROUND: For patients suspicious of cervical spine injury, a Philadelphia cervical collar is usually applied. Application of Philadelphia cervical collar may cause difficult airway. The aim of this study was to evaluate the laryngeal view and the success rate at first intubation attempt of the Airtraq and conventional laryngoscopy in patients with simulated cervical spine injury after application of a Philadelphia cervical collar. METHODS: Anesthesia was induced with propofol, remifentanil, and rocuronium. After a Philadelphia cervical collar applied, patients were randomly assigned to tracheal intubation with an Airtraq (Group A, n = 25) or with conventional laryngoscopy (Group L, n = 25). Measurements included intubation time, success rate of first intubation attempt, number of intubation attempts, and percentage of glottic opening (POGO) score. Mean blood pressure and heart rate were also recorded at baseline, just before and after intubation. RESULTS: The success rate of the first attempt in Group A (96%) was significantly greater than with the Group L (40%). POGO score was significantly greater in Group A (84 ± 20%) than in Group L (6 ± 11%). The duration of successful intubation at first tracheal intubation attempt and hemodynamic changes were not significantly different between the two groups. CONCLUSIONS: The Airtraq offers a better laryngeal view and higher success rate at first intubation attempt in patients who are applied with a Philadelphia cervical collar due to suspicion of cervical spine injuryope

Comparison of Single and Double Fusions in Transverse Tarsal Joint

Purpose: The purpose of this study was to compare the clinical and radiological results of single and double fusions in the transverse tarsal joint. Materials and Methods: Between December 2000 and April 2009, 16 patients (16 feet) who had been treated by fusion of transverse tarsal joint were included in this study. In 8 patients, only talonavicular joint was fused and in the other 8 patients, both talonavicular and calcaneocuboid joints were fused simultaneously. We have measured talo-first metatarsal angle, calcaneal pitch angle, talonavicular coverage angle and presence of adjacent joint arthritis for radiological assessment at both preoperative and last visit. Furthermore, we have evaluated Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score and patient's satisfaction. Results: In a single fusion group, VAS was improved from $6.4{\pm}1.4$ to $0.8{\pm}1.0$ (p=0.0011) and AOFAS score was improved from $63.8{\pm}6.2$ to $89.4{\pm}9.8$ (p=0.0012). In a double fusion group, VAS was improved from $8.0{\pm}0.75$ to $2.0{\pm}1.8$ (p=0.0011) and AOFAS score was improved from $60.5{\pm}11.2$ to $89.5{\pm}6.0$ (p=0.0012). In the difference of talo-first metatarsal angle between two groups, a single fused group was more improved than a double fused group (p=0.04). Conclusion: Both single and double fusions are useful and attractive treatment for the transverse tarsal joint arthritis. Furthermore, a single fusion has advantages of less invasiveness and preserving some degree of hindfoot motion and could be an effective alternative to a double fusion if patient meets appropriate criteria through careful preoperative evaluationope

Undiagnosed light chain systemic amyloidosis: does it matter to anesthesiologists? -a case report-

Light chain systemic amyloidosis is rare but may accompany laryngeal or pulmonary involvement, which may increase the risk in airway management. We present a case of a patient planned for resection of cervical epidural mass. The patient had face and neck ecchymoses and purpuras with an unknown cause. Mask ventilation and intubation were successful, but the operation was cancelled to evaluate bleeding from facial skin lesions. A diagnosis of light chain systemic amyloidosis prompted evaluation of involvement of other organs and treatment. This case shows the importance of preoperative evaluation and careful airway management in patients with systemic amyloidosis.ope

Effects of steep head-down position on pulse pressure variation

Background:The effects of head-down position on dynamic hemodynamic variables remain without full understanding. We evaluated the effects of steep head-down position on the pulse pressure variation (PPV).Methods:Forty patients were positioned at 30o head-down position after anesthesia induction. We measured the heart rate (HR), arterial blood pressure (BP) and PPV before and 2 minutes after the position change.Results:PPV and HR decreased (9.3 ± 3.2% to 4.6 ± 1.8%, 67.2 ± 11.4 to 62.4 ± 7.8, respectively) after steep head-down position, whereas the BP increased. Baseline PPV was related with decreases of PPV (r2 = −0.83, P ＜ 0.0001). An 8% PPV threshold discriminated the patients with more than 5% decreases of absolute PPV value. The area under the receiver operating characteristic curve was 0.98 (95% CI = 0.88 to 1.00, P ＜ 0001). Conclusions:Steep head-down position caused decreases in PPV. Higher PPV at the supine position decreased more after the position change. Further investigations are required to assess the significance, the duration and the relationship with fluid responsi-veness of this change.ope