Difficult Airway and Failed Tracheal Intubation in a Patient with Mucopolaysaccharidoses Type II: A Case Report

Mucopolysaccharidoses are rare lysosomal storage diseases resulting from defects in lysosomal enzymes involved in degradation of glycosaminoglycans. Different mucopolysaccharidoses are caused by different enzyme deficiencies The anesthetic complications are related to the organs involved. Patients with mucopolysaccharidoses are rare, and few anesthetists encounter such patients. We experienced a case of mucopolysaccharidoses type II. Several endotracheal intubation attempts were tried, but we experienced failed endotracheal intubation. And we decided to proceed with surgery under bag-mask ventilation because of the short operation time. There’s no desaturation time. And the patient’s spontaneous ventilation was recovered and awakened. We have also briefly discussed the pathophysiology, clinical features, and possible airway management options for patients with mucopolysaccharidoses type II.

A Case of Expiratory Limb Filter Obstruction in Heated Circuit Kit

Antimicrobial filters that prevent cross-contamination through anesthesia equipment are commonly used in operating rooms. Occlusion of this filter leads to the patient’s airway obstruction, which may lead to fatal outcomes. We report a case of the airway obstruction by antimicrobial filter occlusion during general anesthesia, and symptoms recovered immediately after removal of the filter.

Incidentally Detected Hypopharyngeal Mass during Endotracheal Intubation

Hypopharyngeal mass is an uncommon condition in the aerodigestive tract. There were only a few cases have been published in the medical literature. We experienced a case of incidentally detected hypopharyngeal mass during endotracheal intubation. Hypopharyngeal mass was located at the right posterior pharyngeal wall. The hypopharyngeal mass was small and not obstruct the glottis, and endotracheal intubation was performed successfully. We have also briefly discussed symptoms, diagnosis, and related problems during general anesthesia of hypopharyngeal mass.

Sustained erroneous near-infrared cerebral oxygen saturation in alert icteric patient with vanishing bile duct syndrome during and after liver transplantation: A case report

Monitoring cerebral oxygenation using a near infrared spectroscopy (NIRS) device is useful for estimating cerebral hypoperfusion and is available during liver transplantation (LT). However, high serum bilirubin concentration can interfere with NIRS because bilirubin absorbs near infrared light. We report a patient who underwent LT with a diagnosis of vanishing bile duct syndrome, whose regional cerebral oxygen saturation (rSO₂) remained below 15% even with alert mental status and SpO2₂ value of 99%. The rSO₂ values were almost fixed at the lowest measurable level throughout the intra- and postoperative period. We report a case of erroneously low rSO₂ values during the perioperative period in a liver transplant recipient which might be attributable to skin pigmentation rather than higher serum bilirubin concentration.

Anesthetic Experience of Cesarean Section in Evans Syndrome

Evans syndrome is an uncommon condition defined by the combination of immune thrombocytopenia and autoimmune hemolytic anemia in the absence of known underlying cause. Association of Evans syndrome with pregnancy is very rare, and only a few cases have been published in the medical literature. We experienced a case of Evans syndrome in pregnancy. Cesarean section was performed under general anesthesia without hemorrhagic complications at the 37th week of pregnancy following treatment with steroid, intravenous immunoglobulin, and transfusion of platelet concentrates. We have also briefly discussed the pathophysiology, the possible treatment options during pregnancy and prenatal outcome of Evans syndrome.

Prediction of midline depth from skin to cervical epidural space by lateral cervical spine X-ray

BACKGROUND: Previous studies have shown that measuring the distance from the skin to the ligamentum flavum by ultrasound preceding cervical epidural block can be beneficial in excluding false loss of resistance. However, the measurement value using ultrasound may vary depending on the degree of operator experience. Therefore, we aimed to determine the depth from skin to cervical epidural space by using lateral cervical spine X-ray, which is a more intuitive method. METHODS: We enrolled 102 adult patients who were scheduled to undergo cervical epidural anesthesia for vascular bypass surgery of upper arm. After attaching a steel rod on the needle insertion site, lateral cervical spine X-ray was taken before the epidural procedure. We measured the distance from the steel rod to the midpoint of interlaminar space on the spinolaminar line. The X-ray depth was compared with needle depth. RESULTS: Of the 102 enrolled patients, 18 patients including 13 in whom we were unable to measure X-ray depth were excluded from the analysis. In total, 84 patients were included in the analysis. Concordance correlation coefficient between the X-ray-measured depth and needle depth was 0.925. Bland-Altman analysis indicated a mean difference of ± 1.96 SD with 0.06 ± 0.56 cm. CONCLUSIONS: Lateral cervical spine X-ray can be useful for prediction of the midline depth from skin to epidural space, particularly for operators who are not skilled at spine ultrasound or the use the C-arm fluoroscopy.

Comparison of eye protection methods for corneal abrasion during general anesthesia

BACKGROUND: Corneal abrasion is one of the most common ophthalmic complications that occurs after general anesthesia. Although they can occur by direct contact with surgical drapes or masks, most occur as a result of the drying of the cornea exposed during general anesthesia due to a reduced amount of tear secretions, the loss of light reflex, or the loss of recognition of pain during the procedure. Thus, to prevent corneal abrasions during general anesthesia, proper eye protection is required. METHODS: Seventy-two patients (144 eyes) were divided into four groups as follows: 1) control group: careful manual eye closure; 2) adhesive tape group: a bandage attached over the eyelid; 3) ointment group: eye ointment placed into the eye followed by eye closure; and 4) ointment and tape group: eye ointment placed into the eye followed by a bandage attached over the eyelid, with the patient subjected to both methods for each eye. The National Eye Institute (NEI) scale, conjunctiva hyperemia scale, tear break-up time, and Schmer test were conducted before and after operation. RESULTS: No statistically significant difference was noted between groups regarding the NEI scale, conjunctiva hyperemia scale, tear break-up time, or Schirmer test. CONCLUSIONS: To prevent corneal abrasions in normal patients undergoing general anesthesia, eye taping, eye ointment application, or taping after eye ointment application will not significantly reduce the degree of corneal epithelial damage compared to manual eye closure.

The Use of Total Intravenous Anesthesia Without Muscle Relaxation in Amyotrophic Lateral Sclerosis Patient

66-year-old woman with amyotrophic lateral sclerosis was scheduled for closed reduction and external fixation of left tibio-fibula. Total intravenous anesthesia using 2% propofol and remifentanil was done without muscle relaxant to avoid possible postoperative respiratory complication and pulmonary aspiration. The surgery had done without difficulty and she recovered from anesthesia promptly without respiratory complication and pulmonary aspitation. She discharged satisfactorily 15 days after surgery.

Effects of Thoracic Epidural Anesthesia on Hemodynamic Changes Induced by Hypercapnia during Sevoflurane Anesthesia

OBJECTIVE: Many studies have demonstrated that carbon dioxide has direct depressive effects on the myocardium and dilates the vascular bed. However, it leads to an increase in arterial blood pressure and cardiac output because of sympathetic stimulating effect. Extensive epidural block may impair the sympathetic innervation to the heart as well as to the adrenal gland. The present study was set up in order to investigate how an extensive epidural block would affect the hemodynamic response to sympathetic stimulation induced by hypercapnia. METHODS: Twenty patients were mechanically ventilated under general anesthesia after epidural catheter insertion on T6–T7 intervertebral space. Hypercapnia was obtained by CO2 breathing. PaCO2 (partial pressure of CO2, arterial) was adjusted to 30, 45, and 60 mm Hg with each concentration being maintained for 10 minutes. In each period, hemodynamic variables were monitored by pulmonary artery catheter. After returning to normocarbia for 15 minutes, 20 mL of 0.375% ropivacaine was injected epidurally and PaCO2 was adjusted in the same manner, and then, the hemodynamic variables of each period were checked. RESULTS: There were no changes in mean arterial pressure and heart rate by hypercapnia after combined epidural anesthesia compared with general anesthesia only. Hypercapnia increased cardiac output and cardiac index. Systemic vascular resistance was decreased significantly. Pulmonary artery pressure was increased but not significantly. The degrees of hemodynamic changes were similar between in general anesthesia alone and in combined epidural anesthesia. CONCLUSION: In spite of an extensive epidural block, hemodynamic changes induced by hypercarbnia were not changed. There are some ‘escaped’ sympathetic nerve fibers.

Suspected anaphylactic reaction associated with sugammadex: a case report / 대한마취과학회지

We describe a case of a 35-year-old male patient who was scheduled for laparoscopic cholecystectomy and developed a life-threatening anaphylactic reaction 2 min after the administration of sugammadex. He manifested erythematous wheals on the entire body, dyspnea, hypotension, and tachycardia. These symptoms disappeared after the administration of epinephrine. The patient recovered and was discharged at postoperative day 5 without any complications. After 7 weeks, we performed a skin prick test, and there was a weakly positive reaction for sugammadex. This case is suspected anaphylaxis associated with sugammadex, and we need to be aware that the use of sugammadex is associated with a serious risk of anaphylaxis.

The effect of dexmedetomidine sedation on patient and surgeon satisfaction during retinal surgery under sub-tenon's anesthesia: a randomized controlled trial / 대한마취과학회지

BACKGROUND: The purpose of this study was to evaluate the effect of intraoperative dexmedetomidine sedation on patient's and surgeon's satisfaction during retinal surgery under sub-tenon's anesthesia. METHODS: Forty-four patients scheduled for elective retinal surgery under sub-tenon's anesthesia were enrolled in this randomized controlled trial. The patients were divided into Dexmedetomidine (n = 22) and Control (n = 22) groups. Intravenous dexmedetomidine or 0.9% saline via infusion pump were administered continuously to the dexmedetomidine or control group, respectively. Ramsay sedation scale with a target level of 3-4 was used to assess adequacy of sedation. Perioperative pain, hemodynamic and respiratory data were collected, while satisfaction from patients and surgeon were assessed post-surgery using a 5-point satisfaction scale. RESULTS: Patient and surgeon satisfaction was higher in the dexmedetomidine group (P < 0.001, P = 0.002, respectively). The pain associated with sub-tenon's anesthesia and peripheral vitrectomy was lesser in the dexmedetomidine group than in the control group (P = 0.020). There was significant reduction of heart rate in the dexmedetomidine group (P = 0.001), but only one patient needed treatment with atropine. There was no respiratory effect on both groups. CONCLUSIONS: Dexmedetomidine sedation during retinal surgery improved satisfaction from both patient and surgeon without respiratory complication. It is a safe and preferable choice of sedation for retinal surgery.

Is transverse abdominis plane block effective following local anesthetic infiltration in laparoscopic totally extraperitoneal hernia repair? / 대한마취과학회지

BACKGROUND: Transverse abdominis plane (TAP) block can be recommended as a multimodal method to reduce postoperative pain in laparoscopic abdominal surgery. However, it is unclear whether TAP block following local anesthetic infiltration is effective. We planned this study to evaluate the effectiveness of the latter technique in laparoscopic totally extraperitoneal hernia repair (TEP). METHODS: We randomly divided patients into two groups: the control group (n = 37) and TAP group (n = 37). Following the induction of general anesthesia, as a preemptive method, all of the patients were subjected to local anesthetic infiltration at the trocar sites, and the TAP group was subjected to ultrasound-guided bilateral TAP block with 30 ml of 0.375% ropivacaine in addition before TEP. Pain was assessed in the recovery room and post-surgery at 4, 8, and 24 h. Additionally, during the postoperative 24 h, the total injected dose of analgesics and incidence of nausea were recorded. RESULTS:: On arrival in the recovery room, the pain score of the TAP group (4.33 +/- 1.83) was found to be significantly lower than that of the control group (5.73 +/- 2.04). However, the pain score was not significantly different between the TAP group and control group at 4, 8, and 24 h post-surgery. The total amounts of analgesics used in the TAP group were significantly less than in the control group. No significant difference was found in the incidence of nausea between the two groups. CONCLUSIONS: TAP block following local infiltration had a clinical advantage only in the recovery room.