Masui. The Japanese journal of anesthesiology
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Much evidence has been accumulated on the cerebral mechanisms of pain perception owing to rapid and diverse development in magnetic resonance imaging and its analysis techniques over the last decades. In addition to pain-evoked cerebral activities, our knowledge now extends into chronic pain-associated alterations in cerebral connectivity over networks and in gray matter density, which characterize cerebral steady-state pathological properties underlying chronic pain conditions. A dynamic cerebral model for chronification of pain is presented, in which a bottom-up nociception via the lateral system leads to a reactive, top-down hyperactivity of the medial system, and eventually to both functional and anatomical degeneration of pain modulatory mechanisms and reward systems. All such biomarkers of "chronic pain brain" revealed by neuroimaging will hopefully help us in diagnosis of chronic pain and evaluation of therapeutics for each patient on an outpatient basis.
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Case Reports
[Awake insertion of i-gel under dexmedetomidine sedation in a patient with severe obstructive sleep apnea syndrome].
We report a successful awake insertion of the i-gel supraglottic airway device under dexmedetomidine (DEX) sedation in a patient with severe obstructive sleep apnea syndrome and symptomatic angina. A 71-year-old man was scheduled for open stoma closure under general anesthesia. Given the patient's history of difficult mask ventilation during anesthesia for resection of rectal cancer, we decided to perform awake i-gel insertion under DEX sedation and regional anesthesia with lidocaine. ⋯ We also performed transversus abdominis plane block and rectus sheath block with ropivacaine, as severe respiratory suppression due to continuous intravenous fentanyl infusion had been observed in the previous operation. No vital sign change or respiratory suppression was noted upon recovery from general anesthesia. Awake insertion of a supraglottic airway device, such as i-gel, under DEX sedation can be effective for airway management in patients with severe obstructive sleep apnea syndrome.
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Case Reports
[The use of dexmedetomidine and Airwayscope in airway management of a child with Cornelia de Lange syndrome].
We report anesthetic management of a 22-month-old child with Cornelia de Lange syndrome scheduled for palatoplasty because of cleft palate. Micrognathia and short neck of the patient suggested difficult airway management. For anesthetic induction, 1 microg x kg(-1) dexmedetomidine was loaded intravenously, followed by infusion at a rate of 0.7 microg x kg(-1) x hr(-1) with incremental inhalation of sevoflurane. ⋯ During the Airwayscope operation, pharyngeal reflex, laryngeal reflex and saliva increase were inhibited resulting in good view of the larynx and the lowest Spo2 was 94% temporarily. After intubation, anesthesia was maintained with sevoflurane, remifentanil and fentanyl. Dexmedetomidine infusion was also useful to maintain adequate spontaneous breathing and to achieve awaking before extubation.
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This article introduces the equipment used for epiduroscopy and describes its indications, procedures for use, treatment outcomes, the potential complications and future developments. Epiduroscopy is used in the treatment and diagnosis of intractable low back and leg pain in patients in whom nerve block is not efficacious and when pain recurs after operation. The characteristics of epiduroscopy are that it is: 1) safe and less invasive; 2) used for endoscopic washing of the epidural space and fluoroscopic X-ray; 3) it allows injection of an agent into the lesion; and 4) it results in no change in the normal lumbar structure after operation. Epiduroscopy is expected to provide successful outcomes for many patients with intractable low back and leg pain through further improvements in equipment related to epiduroscopy, advances in technology, the accumulation of data regarding its efficacy and safety, and the coverage of treatment by insurance.
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As scoliosis surgery in children is a large invasive surgery, postoperative pain control is difficult. ⋯ The amount of fentanyl required for postoperative analgesia was decreased by combining DEX. In addition, it is thought that side effects of fentanyl are reduced in low dose fentanyl administration cases. As a result, it may bring early postoperative recovery. The IV-PCA using fentanyl with DEX may be useful for postoperative analgesia in scoliosis surgery. We will recommend using DEX (0.25 microg x kg(-1) x hr(-1)) together with fentanyl (0.5 microg x kg(-1) x hr(-1)) for this purpose.