A Ram Doo, Jeongwoo Lee, Gwi Eun Yeo, Keun Hyeong Lee, Ye Sull Kim, Ju Han Mun, Young Jin Han, and Ji-Seon Son. Anesth Pain Med 2020;15:103-10. https://doi.org/10.17085/apm.2020.15.1.103

Neuroblastoma (NB) is the most common childhood cancer, with a very poor prognosis. More than 60% of children with NB die within five years; therefore, a more effective therapy for NB is required. Although ginsenoside has been shown to significantly inhibit the growth of various cancers, the effect of ginsenoside Rk1 on neuroblastoma has not been known yet. Hence, we examined the anticancer effects of highly pure Rk1 on neuroblastoma cell lines. The apoptotic effects of Rk1 on neuroblastoma cells were examined using cell viability assay, flow cytometry and cell staining assay, and the change in gene expression levels were analysed using RT-PCR, western blots, and immunohistochemistry. The metastatic effect of Rk1 was monitored by wound healing assay, invasion and migration with Matrigels. Rk1 inhibited neuroblastoma cell viability dose-dependently. Rk1-induced apoptosis was investigated through nuclear condensation and mitochondrial membrane potential loss, and it showed that Rk1 can induce cell cycle arrest at the G0/G1 phase but also inhibit the metastatic ability of neuroblastoma cells. Moreover, Rk1 (30 mg/kg) injections markedly inhibited xenograft tumor growth. These findings demonstrate that Rk1 might be valuable in the development of anti-cancer agents for neuroblastoma treatment.

Background: Hemodynamic instability is a frequent adverse effect following administration of dexmedetomidine (DMED). In this study, we evaluated the incidence of DMED-induced hemodynamic instability and its predictive factors in clinical regional anesthesia practice. Methods: One hundred sixteen patients who underwent orthopedic upper limb surgery under brachial plexus block with intravenous DMED administration were retrospectively identified. The primary outcome was the incidence of DMED-induced hemodynamic instability. The participants were allocated to a stable or unstable group by their hemodynamic instability status. Patients' characteristics were compared between the groups. The relationship between the potential risk factors and development of DMED-induced hemodynamic instability was analyzed with a logistic regression model. Results: DMED-induced hemodynamic instability was observed in 14.7% of patients (17/116). The unstable group had more women than the stable group (76.5% vs. 39.4%, P = 0.010). When patients were classified into four subgroup according to body mass index (underweight, normal weight, overweight, and obesity), there was significant difference in the composition of the subgroups in the two groups (P = 0.008). In univariate analysis, female sex, obesity, and pre-existing hypertension were significant predictors of DMED-induced hemodynamic instability. Multivariate analysis demonstrated that female sex (adjusted OR 3.86, CI 1.09; 13.59, P = 0.036) and obesity (adjusted OR 6.41, CI 1.22; 33.57, P = 0.028) were independent predictors of DMED-induced hemodynamic instability. Conclusions: Female and obese patients are more likely to have hemodynamic instability following intravenous DMED administration in clinical regional anesthesia practice. This study suggests that DMED dose may be diminished to prevent hypotensive risk in these populations.

Background: Retropharyngeal hematoma following cervical spine trauma may lead to life-threatening upper airway obstruction and difficult airway management. This retrospective study was performed to investigate whether the extension of retropharyngeal space (RPS) was associated with difficult intubation by direct laryngoscopy in traumatic cervical spine injury. Patients and methods: Sixty-two patients who had undergone direct endotracheal intubation under general anesthesia for cervical spine surgery were retrospectively identified. Laryngoscopic grade by Cormack–Lehane (C-L) classification was collected; grade 1 or 2 was categorized as easy laryngoscopy, whereas grade 3 or 4 was categorized as difficult laryngoscopy. In these patients, RPS thickness and the proportions of RPS to the vertebral bodies were measured at the 2nd, 5th and 7th cervical spine levels using magnetic resonance imaging (MRI) of the cervical spine. Measures of RPS were compared between easy and difficult laryngoscopy. Relationships between measures of RPS and difficult laryngoscopy were analyzed with logistic regression analysis. Results: RPS thickness at C2 was significantly greater in difficult laryngoscopy (median 14.29 mm, IQR: 9.75–18.04) than easy laryngoscopy (median 5.10, IQR: 4.33–5.94, p<0.001). Proportion of RPS to the C2 vertebral body were significantly higher in difficult laryngoscopy than in easy laryngoscopy (p<0.001). RPS thickness and the proportion of RPS to the vertebral body were significantly associated with difficult laryngoscopy (OR=2.13, 95% CI: 1.38–3.30; p<0.001 and OR=1.13, 95% CI: 1.05–1.21; p<0.001, respectively). Conclusion: RPS extension at the upper cervical spine level is associated with difficult direct laryngoscopy in traumatic cervical spine injury.

Rationale: Operative hysteroscopy intravascular absorption syndrome (OHIAS) results from systemic absorption of hypotonic solution during hysteroscopy, which may induce severe hyponatremia within hours. Depending on the serum sodium (Na⁺) level, this can be life-threatening and requires prompt and careful remedial treatment. Patient concerns and diagnoses: A 53-year-old woman underwent hysteroscopic myomectomy for submucosal leiomyoma. Approximately 3 hours postoperatively, the serum Na⁺ level decreased to 82 mM/L, accompanied by pulmonary edema and lactic acidosis. The patient was strongly suspicious of OHIAS. Interventions and outcomes: A rapid correction was made using 3% NaCl to prevent brain edema as an initial response. After the serum Na⁺ level reached 120 mM/L, gradual correction was performed considering osmotic demyelination syndrome, and desmopressin was administered to prevent overcorrection caused by excessive water diuresis. Serum Na⁺ level normalized in 4 days and the patient recovered without any specific sequelae. Lessons: The detection of OHIAS may be delayed under general anesthesia, and prior vigilance is important if the operation time is prolonged. In severe hyponatremia with an apparently rapid onset, such as OHIAS, a two-step correction process may be safe and useful: rapid correction followed by more gradual correction.

Lymphangiomyomatosis (LAM) is a rare lung disease that is characterized by the progressive proliferation of atypical smooth muscle-like cells, which leads to severe respiratory impairment and death. Dyspnea, cough, recurrent pneumothorax, and hemoptysis are the most common clinical symptoms of LAM. We report a 29-year-old female patient with massive hemoptysis during laparoscopic gynecologic surgery under general anesthesia, who was diagnosed with pulmonary LAM.