Bispectral Index 감시장치로 경막외마취의 진정효과를 평가할 수 있는가?

신병철,이혜원,신혜원,조헌,임혜자,윤석민,장성호 대한마취과학회 2002 Korean Journal of Anesthesiology Vol.43 No.6

Background: Epidural anesthesia has been shown to a have direct sedative effect and to markedly reduce the amount of hypnotic agents required for sedation. A Bispectral Index (BIS) is a useful of the level of sedation and loss of consciousness for several anesthetics including propofol. In this study, we investigated whether BIS monitoring could detect the sedative effect of epidural anesthesia during propofol induction. Methods: Twenty patients scheduled for elective lower abdominal surgery were included. A Target controlled infusion (target effect concentration 5㎍/ml, induction time 3 min) of propofol was administered to the patients with or without epidural anesthesia (2% lidocaine 15 ml) at the L_2-3 level. The OAA/S scale and BIS were evaluated 20 min after epidural injection. Hypnotic requirements of propofol were determined using loss of eye opening in response to verbal command as an epidural. At the time of induction of hypnosis, the target concentration, target effect concentration and BIS were recorded. Results: Epidural lidocaine significantly decreased the hypnotic dose of propofol (1.0±0.2㎍/ml vs. 1.3±0.1㎍/ml; p=0.0008), hypnotic calculated concentration (3.3±0.6㎍/ml vs. 4.1±0.3㎍/ml; P=0.0007), and the hypnotic effect concentration (0.7±0.3㎍/ml vs. 1.1±0.1㎍/ml; P=0.0007). In the patients with epidural anesthesia, the OAA/S scale was decreased without a change of the BIS after epidural anesthesia and BIS recorded at the time of induction of hypnosis was much higher in patients with epidural anesthesia than in patients without in epidural anesthesia (92.7±2.2㎍/ml vs. 85.5±6.2㎍/ml; P=0.0029). Conclusions: Epidural anesthesia included a sedative effect without a change of the BIS and then induced the hypnosis with lesser dose of propofol. At the time of hypnosis, a higher BIS was noticed with epidural anesthesia. These results concluded that BIS monitoring could not detect the sedative effect induced with epidural anesthesia. (Korean J Anesthesiol 2002; 43: 698~703)

경막외 Lidocaine이 Bispectral Index로 측정한 적절한 마취깊이에 필요한 Desflurane 농도에 미치는 효과

최영균,신상우,이근무,정순호,김영재,신치만,박주열 白中央醫療院 2004 仁濟醫學 Vol.25 No.1

Background: Epidural anesthesia potentiates sedative drug effects and decreases minimum alveolar concentration (MAC) of inhalation anesthetics. The authors hypothesized that epidural anesthesia also decreases the general anesthetic requirements for adequate depth of anesthesia as measured by Bispectral Index(BIS) Methods: After premedication with 0.02 mg/kg midazolam, 30 patients aged 20-75 yr were randomized in a double-blinded fashion to receive general anesthesia with either intravenous saline placebo or intravenous lidocaine control (1-mg/kg bolus does; 25 ㎕·kg-1·min-1). A matched group was prospectively assigned to receive epidural lidocaine (15 ml; 2%) with intravenous saline placebo. All patients receive 1.5 mg/kg propofol and 1mg/kg rocuronium for tracheal intubation. After 10 min of equilibration period with 3% end-tidal desflurane concentration, BIS was measured at every 30 second. If BIS score was above 50, vaporizer dial was increased by 0.5 vol%. If BIS score was under 45, vaporizer dial was decreased by 0.5 vol%. When BIS score was maintained between 45-50 by 3minutes, we checked the end tidal desflurane concentration and defined as MACBIS50(Minimum alveolar concentration at BIS 50). MACBIS50, BIS score, and mean arterial pressure were recorded. Results: The MACBIS50 of desflurane (2.5 0.49%) was significantly decreased with lidocaine epidural anesthesia compared with general anesthesia alone (3.1 0.59%) or with intravenous lidocaine (3.0 0.51%)(p<0.05). Conclusions: Epidural anesthesia reduced by 19% the desflurane required for adequate depth of anesthesia. This effect was not a result of systemic lidocain absorption, but may have been caused by deafferentation by epidural anesthesia or direct rostral spread of local anesthetic within the cerebrospinal fluid. Lower-than-expected concentrations of volatile agents may be sufficient during combined epidural-general anesthesia.

Influence of Epidural Ropivacaine with or without Dexmedetomidine on Postoperative Analgesia and Patient Satisfaction after Thoraco-Lumbar Spine Instrumentation: A Randomized, Comparative, and Double-Blind Study

Qureshi Faisal,Meena Shyam Charan,Kumar Vishal,Jain Kajal,Chauhan Rajeev,Luthra Ankur 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.3

Study Design: This was a prospective, randomized, and double-blind study. Purpose: Thoraco-lumbar spine surgery is associated with severe postoperative pain and can cause chronic pain. We aimed to compare the impact of epidural ropivacaine with and without dexmedetomidine on postoperative analgesia after thoracolumbar spine instrumentation wherein an epidural catheter was placed by the surgeon intraoperatively. Overview of Literature: Very few studies have reported the use of epidural dexmedetomidine in spine surgeries. When used via the epidural route, dexmedetomidine is safe and efficacious and is associated with reduced rescue analgesia consumption, increased duration of analgesia, reduced pain scores, but not with major hemodynamic adverse effects. Methods: Total 60 American Society of Anesthesiologists I–III adult patients aged 18–65 years who were scheduled to undergo thoraco-lumbar spine instrumentation were randomly allocated into group RD (epidural ropivacaine+dexmedetomidine) or group R (epidural ropivacaine plus saline). We aimed to compare the total rescue analgesic consumption on postoperative day 0, 1, and 2. Moreover, we studied the time to first rescue analgesia with visual analogue scale score <4 and the overall patient satisfaction scores. Results: There was no difference between the demographic characteristics of the two groups. The mean value of total rescue analgesia consumption was 162.5±68.4 mg in the RD group and 247.5±48.8 mg in the R group. The mean time to first rescue analgesia was 594.6±83.0 minutes in the RD group and 103.6±53.2 minutes in the R group. The mean patient satisfaction score was 4.2±0.7 in the RD group and 3.2±0.6 in the R group. No patient had any respiratory depression or prolonged motor blockade during the postoperative period. Conclusions: This study demonstrated the superior efficacy, in terms of postoperative analgesia and patient satisfaction scores, of epidural ropivacaine plus dexmedetomidine over that of ropivacaine alone in patients undergoing surgery for thoraco-lumbar spine.

Is the Spinous Process of T7 Usually at the Same Level as the Inferior Tips of the Scapulae?

Mun Gyu Kim,Si Young Ok,Sang Ho Kim,Se Jin Lee,Sun Young Park,Eun Hyo Koh,Heon Yong Bae,Kyung Yul Hur 순천향대학교 순천향의학연구소 2012 Journal of Soonchunhyang Medical Science Vol.18 No.1

Objective: Appropriate placement of thoracic epidural catheter provides an adequate postoperative analgesia in chest and upper abdominal surgery. Usually, when thoracic epidural puncture is performed, both scapular lower tips and the thoracic (T)7 spinous process is assumed to be at the same horizontal level. The aim of this study is to identify the thoracic epidural puncture in the sitting position, with the neck flexed and arms crossed, may change the relationship between the thoracic vertebrae and the scapular lower tips. Methods: One hundred patients with postoperative patient controlled epidural analgesia using thoracic epidural catheters were enrolled. It is presumed that the both scapular lower tips and T7 spinous process is at the equal level when performing thoracic epidural puncture. The actual insertion level of the Tuohy needle was examined by radiography when the patient was in the sitting position. Results: Out of 100 patients, there were 62% that were in the same level as the scapular lower tips and T7 spinous process. However, 1% of the patients leveled at T4, 1% at T5, 25% at T6, 18% at T8, and 1% at T9. Conclusion: When performing the thoracic epidural puncture under the sitting position, the relationship of the T7 and the scapular lower tips may change. The change of position of scapular lower tips varied among T6.82±0.70. Therefore, to be precise, it is advised to utilize C-arm guide when epidural puncture is carried out.

수술 후 통증조절을 위한 지속적 경막외제통 및 정맥내 자가조절법 2,510예에 대한 임상분석

배상철,곽수달,강규식 순천향의학연구소 1998 Journal of Soonchunhyang Medical Science Vol.4 No.2

Background: The efficacy and safety of continuous epidural analgesia(CEA) and intravenous patient-controlled analgesia(IV-PCA) for postoperative analgesia on hospital wards was studied. And then we started postoperateve pain management service using a continuous epidural analgesia and intravenous patient-controlled analgesia. Method: A retrospective study was performed to evaluate the effects of continuous epidural analgesia(CEA): 0.125% bupivacaine 100ml + morphine 5~7mg or clonidine 1800㎍ and intravenous patient-controlled analgesia(IV-PCA): normal saline 20ml + fentanyl 800~1000㎍ or nalbuphine 80~100mg, for postoperative pain relief of 2,510 surgical patients who received general-epidural or epidural-regional anesthesia. Anesthesia records, patients charts, and pain control records were received and classified according to: age, sex, department, operation site, degree of pain relief by CEA and IV-PCA, and side effects(including nausea, vomiting, pururitis, urinary retention and respiratory depression). Results: 1) The study included CEA were 1,022(40.7%) patients and IV-PCA were 1,488(59.3%) patients. 2) From the total of 2,510 patients, there were 2,253(89.8%) female patients; 2,078(82.8%) patients were from Obstetrics and Gyneco]ogy. 3) In the operation site, lower abdomen were 2,053(81.8%), lower extremity were 206(8.2%), upper abdomen 136(5.4%) were order of decreasing frequency. 4) Ninety one percent of the patients experienced mild or no pain in the postoperative course. 5) There were most common complication is the nausea and vomiting. 6) There were eight cases of respiratory depression. The course of treatment consisted of: cesation of infusion, and then administration of oxygen and intravenous naloxone. Conclusions: According to our experiences, we conclude that CEA and IV-PCA is an effective, relatevely safe and highly satisfactory method for postoperative pain management.

The Neurological Safety of Epidural Pamidronate in Rats

Lee, Pyung-Bok,Kim, Yong-Chul,Lee, Chul-Joong,Shin, Hye-Young,Lee, Seung-Yun,Park, Jong-Cook,Choi, Yun-Suk,Kim, Chong-Soo,Park, Sang-Hyun The Korean Pain Society 2010 The Korean Journal of Pain Vol.23 No.2

Background: Pamidronate is a potent inhibitor of osteoclast-mediated bone resorption. Recently, the drug has been known to relieve bone pain. We hypothesized that direct epidural administration of pamidronate could have various advantages over oral administration with respect to dosage, side effects, and efficacy. Therefore, we evaluated the neuronal safety of epidurally-administered pamidronate. Methods: Twenty-seven rats weighing 250-350 g were equally divided into 3 groups. Each group received an epidural administration with either 0.3 ml (3.75 mg) of pamidronate (group P), 0.3 ml of 40% alcohol (group A), or 0.3 ml of normal saline (group N). A Pinch-toe test, motor function evaluation, and histopathologic examination of the spinal cord to detect conditions such as chromatolysis, meningeal inflammation, and neuritis, were performed on the 2nd, 7th, and 21st day following administration of each drug. Results: All rats in group A showed an abnormal response to the pinch-toe test and decreased motor function during the entire evaluation period. Abnormal histopathologic findings, including neuritis and meningeal inflammation were observed only in group A rats. Rats in group P, with the exception of 1, and group N showed no significant sensory/motor dysfunction over a 3-week observation period. No histopathologic changes were observed in groups P and N. Conclusions: Direct epidural injection of pamidronate (about 12.5 mg/kg) showed no neurotoxic evidence in terms of sensory/motor function evaluation and histopathologic examination.

Epidural Cavernous Hemangioma with Foraminal Extension

하진경,배채완,강신광,임승철 대한척추신경외과학회 2011 Neurospine Vol.8 No.3

The increased use of magnetic resonance imaging (MRI) has increased the frequency of diagnosis of cavernous hemangioma, but its presentation of an epidural lesion with foraminal extension without intramedullary involvement is very rare. We describe a 31-year-old woman admitted to our department with pain in the left side of her neck and shoulder. Gadolinium enhanced cervical MRI revealed a brightly enhanced, extradural mass (1×1×2 cm sized) with widened neural foramen; after surgical excision, it was histologically confirmed as a cavernous hemangioma. Postoperatively, the patient has no neurological deficit or specific complication. Although this lesion mimicked an epidural- neurogenic tumor, its enhancement pattern indicated a cavernous hemangioma. Accurate preoperative diagnosis is necessary for treatment planning. Cavernous hemangioma must be included in the differential diagnosis of a brightly enhanced, extradural tumors.

Safety of epidural steroids: a review

Lee Min Soo,문호식 대한마취통증의학회 2021 Anesthesia and pain medicine Vol.16 No.1

Spine disease is one of the most common musculoskeletal diseases, especially in an aging society. An epidural steroid injection (ESI) is a highly effective treatment that can be used to bridge the gap between physical therapy and surgery. Recently, it has been increasingly used clinically. The purpose of this article is to review the complications of corticosteroids administered epidurally. Common complications include: hypothalamic-pituitary-adrenal (HPA) axis suppression, adrenal insufficiency, iatrogenic Cushing's syndrome, hyperglycemia, osteoporosis, and immunological or infectious diseases. Other less common complications include psychiatric problems and ocular ailments. However, the incidence of complications related to epidural steroids is not high, and most of them are not serious. The use of nonparticulate steroids is recommended to minimize the complications associated with epidural steroids. The appropriate interval and dosage of ESI are disputed. We recommend that the selection of appropriate ESI protocol should be based on the suppression of HPA axis, which reflects the systemic absorption of the corticosteroid.

급성 자발성 척수 경막외 출혈 2례

강보승,이정훈,송형곤,송근정,정연권,김병철 대한응급의학회 2000 대한응급의학회지 Vol.11 No.2

Spontaneous spinal epidural hemorrhage(SSEH) represent 0.3%∼0.9% of spinal epidural-space-occupying lesions. The therapeutic outcome seems to be determined by the accuracy of the diagnosis and by the time interval between the onset of symptom and surgical decompression. Thus, SSEH is a rare spinal emergency and a diagnostic challenge. We experienced two such cases. In one case, the symptoms were confused with those for a ureter stone, aortic aneurysm, spinal cord infarction. That patient completely recovered spontaneously within 2 hours. In the other case, which was initially diagnosed incorrectly as a cerebral infarction, surgical decompression was performed. That patient recovered completely within 1 month.

Age-related requisite concentration of sevoflurane for adequate sedation with combined epidural-general anesthesia

Yoshihito Fujita,Asuka Kondo,Hiroki Yamauchi,Eisuke Kako,Kazuya Sobue 대한마취통증의학회 2013 Korean Journal of Anesthesiology Vol.64 No.6

Background: The requisite anesthetic concentration of sevoflurane required to obtain adequate sedation when sufficient analgesics are supplied has not been determined. The purpose of this study was to determine the requisite age-associated concentration of sevoflurane to obtain an adequate level of anesthesia during combined epidural-general anesthesia by bispectral index (BIS) monitoring. Methods: Twenty-seven elective abdominal surgery patients (American Society of Anesthesiologists physical status I-II) were enrolled. The patients were divided into two groups of more or less than 60 years of age. We investigated the concentration of sevoflurane required to obtain an adequate sedation level during combined epidural-general anesthesia, maintaining the BIS value between 40 and 60. Results: The requisite sevoflurane concentration required to keep the BIS value at 40-60 was not stable during surgery. In the younger group, the maximum concentration of sevoflurane needed during surgery was 1.95 ± 0.14 (95% confidence interval: 1.87-2.10) vol%, while it was 1.54 ± 0.44 (95% confidence interval: 1.27-1.80) vol% in the older group (P < 0.01). Conclusions: The requisite concentration of sevoflurane required with combined epidural-general anesthesia was 2.5 vol% for the younger group and 2.0 vol% for the older group as determined by BIS monitoring. We believe that these percentages are sufficient to avoid awareness during surgery with adequate analgesia.