Macintosh laryngoscope vs. Pentax-AWS video laryngoscope: comparison of efficacy and cardiovascular responses to tracheal intubation in major burn patients / 대한마취과학회지

BACKGROUND: Patients with major burns accompanied with airway edema need more attention for airway management. Although the Pentax-AWS has an advantage in managing endotracheal intubation more easily, its usefulness cannot be assured if it does not maintain hemodynamic stability in burn patients. The aim of this study was to compare cardiovascular responses and general efficacy of the Pentax-AWS and Macintosh laryngoscopes in burn patients. METHODS: American Society of Anesthesiologists physical status 2 or 3 adult patients with major burn injury were randomly assigned to group P (AWS, n = 50) or group M (Macintosh, n = 50). Fifty-nine patients assigned to the Macintosh group and no patient to AWS group were excluded because of failure to first intubation. Hemodynamic data at baseline, just before and after intubation as well as 3, 5 and 10 minutes after intubation and grade of sore throat were recorded in two groups. Intubation time, success rate of intubation, number of intubation attempts and the percentage of glottic opening (POGO) scores were also observed and analyzed in all patients. RESULTS: A statistically significant increase in heart rate just after laryngoscopy was seen in group M. The success rate of the first attempt in group P (100%) was greater than with the group M (46%). POGO scores were higher in group P (97 +/- 4%) than in group M (48 +/- 29%) CONCLUSIONS: The use of Pentax-AWS offers a reduced degree of heart rate elevation compared with the Macintosh laryngoscope and better intubation environments in major burn patients.

The BIS and hemodynamic changes in major burn patients according to a slow infusion of propofol for induction / 대한마취과학회지

BACKGROUND: Many pathophysiologic alterations in patients with major burns can cause changes in the response of propofol. The aim of this study is to determine the appropriate induction dose of propofol using a slow infusion rate for major burn patients to obtain desirable sedation and hypnotic conditions with minimal hemodynamic changes. METHODS: 45 adults with major burns and who were electively scheduled for escharectomy less than a week after injury were recruited. For induction with propofol, the patients were randomly allocated to one of two groups (group 1: 1.5 mg/kg, n = 20 and group 2: 2.0 mg/kg, n = 25). The infusion rate was 20 mg/kg/hr. The systolic and diastolic blood pressure (SBP, DBP), the heart rate, the bispectral index and the modified observers' assessment of the alertness/sedation scale (OAA/S) were measured before the induction and after the propofol infusion, as well as immediately, 3 and 5 minutes after intubation. RESULTS: The SBP and DBP were significantly decreased after the propofol infusion in both group, but there were no significant differences between the two groups. The BIS values after the propofol infusion and intubation were 44.2 +/- 16.1 and 43.5 +/- 13.8 in group 1, and 45.6 +/- 10.3 and 46.5 +/- 11.4 in group 2, respectively, and there were no differences between the 2 groups. CONCLUSIONS: When propofol is administrated to major burn patients, an induction dose of 1.5 mg/kg is appropriate and a slow infusion rate of 20 mg/kg/hr is safe for maintaining the desired hypnotic conditions and this dose and rate cause no significant hemodynamic problems.

Neurogenic-stunned Myocardium and Pulmonary Edema Following a Ruptured Cerebral Aneurysm: A Case Report / 대한구급학회지

We report a case of neurogenic cardiopulmonary instability with pulmonary edema occurring after an aneurysmal subarachnoid hemorrhage. The patient's pre-operative Glasgow coma scale score was 6 and the PA chest radiograph showed increased diffuse haziness in the right lung field. The patient presented with severe hypotension and low oxygen saturation during surgery. Cardiac damage was documented by increased CK-MB troponin-T levels, and ischemic ECG findings. Reversible cardiac failure associated with subarachnoid hemorrhage may be due to a neurogenic-stunned myocardium. The patient underwent clipping of the aneurysm and recovered with minimal neurologic impairment and normal cardiac function.

Cardiovascular crisis after small dose local infiltration of epinephrine in patient with asymptomatic subarachnoid hemorrhage: A case report / 대한마취과학회지

The infiltration of dilute epinephrine solution has been used for many years to provide hemostasis. However, epinephrine has adverse cardiovascular effects, such as arrhythmia, pulmonary edema, and even cardiac arrest. We have experienced epinephrine-induced cardiovascular crisis, with severe hypertension, tachycardia, and cardiac arrest after subcutaneous infiltration of a 2% lidocaine and 1 : 200,000 epinephrine solution in a patient with an asymptomatic subarachnoid hemorrhage. We provided successfully advanced cardiac life support in the operating room and cardioverted the patient back into a sinus rhythm with no untoward effects. The patient recovered without any apparent sequelae after intensive care.

Prediction of difficult intubation in patients with postburn sternomental contractures: modified onah class / 대한마취과학회지

BACKGROUND: Postburn sternomental contractures cause various changes in mouth, oral cavity, pharynx, larynx and related structures. Although there are many methods to predict difficult intubation, the modified Mallampati test (mMT) and the El-Ganzouri multivariate risk index (EGRI) are popular tests. The authors wanted to compare modified Onah class with these 2 tests and also explored the possibility that Onah class could be an adequate independent predictor for difficult intubation. METHODS: One hundred and nine patients, aged 18 to 60 years of age, scheduled for elective surgery for reconstruction of postburn sternomental contractures were divided according to the modified Onah class. We made assessments prior to general anesthesia with respect to mouth opening, thyromental distance, mMT, neck movement, ability to prognath, body weight, and history of difficult tracheal intubation. The accuracy, specificity, positive and negative predictive values were calculated from the data of the 3 tests, and as the 3 tests were compared with patient's laryngoscopic view grade according to Cormack and Lehane criteria by using the Chi-square test. RESULTS: The incidence of Cormack and Lehane grade III, IV was 39.4%. Onah class showed significantly higher accuracy, specificity, and positive predictive value than mMT and EGRI. There were significant correlations between modified Onah class 2b, 3 and the Cormack and Lehane grade III, IV. CONCLUSIONS: Application of modified Onah class for preoperative prediction of the degree of difficulty with laryngeal visualization can reduce the frequency of both an unanticipated failure to visualize laryngeal structures as well as potential unnecessary interventions related to over-prediction of airway difficulty in patients with postburn sternomental contractures.

Remifentanil for postoperative patient-controlled analgesia after laparoscopic-assisted vaginal hysterectomy: dose-finding study / 대한마취과학회지

BACKGROUND: This randomized, double-blinded clinical study was designed to compare the efficacy and safety of three regimens of intravenous (IV) patient-controlled analgesia (PCA) with remifentanil for postoperative analgesia after laparoscopic-assisted vaginal hysterectomy during the first 24 postoperative hours. METHODS: Thirty-four patients were randomly allocated into three groups. The first group received IV remifentanil PCA at a basal rate of 0.02 microgram/kg/min, a bolus of 0.3 microgram/kg, and a lockout time of 15 min. The second group received IV-PCA at a basal rate of 0.025 microgram/kg/min, a bolus of 0.375 microgram/kg, and a lockout time of 15 min. The third group received IV-PCA at a basal rate of 0.03 microgram/kg/min, a bolus of 0.45 microgram/kg, and a lockout time of 15 min. Age, weight, height, and duration of surgery and anesthesia were recorded. Heart rate, systolic and diastolic blood pressure (BP) and oxygen saturation by pulse oxymetry were recorded in the recovery room as a base line after the operation. Heart rate, systolic and diastolic BP, sedation score, visual analogue scale (VAS), and postoperative nausea and vomiting (PONV) scores were recorded at 1 h, 3 h, 6 h, 12 h, and 24 h after the initiation of IV-PCA. RESULTS: Thirty two patients were evaluated. The VAS in group 1 at 1, 3 and 6 hours after surgery was significantly higher than in other groups (P < 0.05). There were no clinically relevant differences between the groups in PONV, sedation scores, or hemodynamic parameters. CONCLUSIONS: This study suggests that IV remifentanil PCA with at a basal rate of 0.025 microgramram/kg/min (group 2) provided efficacious analgesia after laparoscopic-assisted vaginal hysterectomy. Special attention must be given to respiratory depression during establishment of PCA with remifentanil.

Tracheal intubation without the use of muscle relaxant in severe burn patients using propofol and varying doses of remifentanil / 대한마취과학회지

BACKGROUND: Severe burn patients often have a difficult airway. Tracheal intubation can be conducted safely in patients in a stable hemodynamic condition using a propofol in conjunction with remifentanil without employing muscle relaxant. However, no studies have been conducted to date to evaluate intubation of severe burn patients. Therefore, this study was conducted to evaluate the condition of tracheal intubation with propofol and varying doses of remifentanil without muscle relaxants in severe burn patients. METHODS: Eighty severe burn patients were divided into four groups at random. Anesthesia was intravenously induced by continuous infusion of propofol (4 microgram/ml of effect site concentration)and slowly injected remifentanil. Groups 1, 2, 3, and 4 received 1, 1.5, 2, and 2.5 microgram/kg of remifentanil, respectively. Ninety seconds after the administration of remifentanil, tracheal intubation was attempted. We used a scoring system in which jaw relaxation, the state when laryngoscopy was inserted, vocal cord opening, cough, limb movement, and difficulty with laryngoscopy were divided into or = 3 (not acceptable). In addition, the hemodynamic changes were measured at baseline, before intubation, and 1, 2, 3, 4, and 5 min after intubation. RESULTS: Clinically acceptable intubating conditions were observed in 35%, 40%, 55%, and 70% of the patients in groups 1-4, respectively. The mean arterial pressure and heart rate decreased immediately before intubation in all groups. One patient was treated for bradycardia however, no patients manifested hypotension. CONCLUSIONS: Propofol and slowly injected remifentanil (2.5 microgram/kg) without muscle relaxant can provide clinically acceptable intubating conditions and stable hemodynamic conditions in major burn patients. However, further studies should be conducted to evaluate the effects of increased doses of remifentanil.

The changes of heart rate, blood pressure and cardiac index in burn surgery under propofol-remifentanil anesthesia and desflurane anesthesia

BACKGROUND: Major burns can alter the hemodynamic effect caused by anesthesia. Total intravenous anesthesia induces little hemodynamic change and desflurane has a rapid induction advantage among the different kinds of inhalation anesthesia. The study compared propofol and remifentanil anesthesia with desflurane anesthesia during induction and maintenance anesthesia. METHODS: Forty patients, who were scheduled for burn surgery, were randomly assigned to either Group 1 (n = 20) or Group 2 (n = 20). Group 1 was induced and maintained with an infusion of propofol and remifentanil. After inducing anesthesia with propofol and rocuromium, group 2 was maintained with desflurane. The heart rate and mean arterial pressure, and cardiac index were measured in the operation room, after induction (AI), after intubation (AT) and at 5, 10, 15 and 20 minutes after intubation. RESULTS: There was a significantly lower heart rate in group 1 than in group 2. The heart rate of group 2 showed a significant increase at AI, AT, 5, 10, 15 and 20 minutes after intubation. There was no significant difference in the mean arterial blood pressure and cardiac index between the two groups. CONCLUSIONS: During burn surgery, total intravenous anesthesia was effective in attenuating the hemodynamic effects.

The use of Pentax-Aws(R) for difficult intubation due to postburn contracture: Two cases report / 대한마취과학회지

The causes of difficult intubation associated with post-burn contracture from the face to the upper torso include the limitations of neck movement and opening the mouth. Fiberoptic oral intubation can be the final alternative technique that overcomes those difficulties. However, a small inter-incisor gap about 2 cm, a fixed head or neck position and the large tongue in these cases makes fiberoptic intubation difficult. The Pentax-AWS video display unit (Pentax-AWS(R), Pentax, Japan) (Pentax-AWS) allows indirect visualization of the glottis without a straightened line of orophalyngolaryngeal axis and its attached tracheal tube and this makes the intubation easier. We experienced rapid, easy intubation with Pentax-AWS following multiple attempts of fiberoptic intubation or confirming a bad glottic view with a Macintosh laryngoscope. Further study is needed on the availibility of Pentax-AWS and comparing it with fiberoptic intubation for the management of a difficult airway.

The Hemodynamic Effect of the Local Epinephrine Injection to a Burn Scar

BACKGROUND: As a method for reducing bleeding, epinephrine local infiltration is used in hypertrophic scar release. However, this can induce unexpected increased absorption and increase the cardiovascular risk. Therefore we evaluated the hemodynamic effects of epinephrine local infiltration. METHODS: Sixty patients underwent hypertropic scar release under general anesthesia. Thirty patients who do not have a history of hypertension were classified as group 1, and thirty patients who had a history of hypertension were classified as group 2. The heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were observed before injection of epinephrine and every minute up to six minutes after injection of epinephrine. RESULTS: Even though the HR significantly increased at 1 and 2 minutes in each group, the difference between the two groups was not significant. The SBP, DBP and MAP were significantly increased in group 2 compared to group 1. The SBP of group 2 significantly increased at every minute up to six minutes and group 1 had a significant increased for 2 minutes. The DBP of group 2 significantly increased for 3 minutes and group 1 significantly increased for 2 minutes. The MAP of group 2 significantly increased for 2 minutes and group 1 significantly increased for 2 minutes (P < 0.05). CONCLUSIONS: Local infiltration of epinephrine in hypertrophic scar temporarily increases the heart rate and blood pressure. Therefore, the patient with hypertension can have an increased the cardiovascular risk and this should be carefully considered.

Hemoptysis and obstruction of the endotracheal tube by blood clot in a pediatric patient: A case report / 대한마취과학회지

Hemoptysis leading to airway obstruction by blood clot is a serious and potentially lethal condition in pediatric patients because of the unpredictable course and technical difficulty of managing small airways. An 11-month-old male patient with a contact burn on his left foot was intubated uneventfully during induction for general anesthesia. After 15 minutes, we noted blood in his endotracheal tube along with high airway pressure and desaturation. Immediate suction was performed, and the oxygen saturation recovered, but the airway pressure and small exhaled tidal volume were unchanged. We had difficulty differentiating endotracheal tube obstruction from bronchial spasm at that time. We successfully managed the endotracheal obstruction by extubation with removal of the blood clot and reintubation after the diagnosis was made using fiberoptic bronchoscopy. We review the etiology and management of airway obstruction and hemoptysis in the operating room.

Effect of Inhaled Sevoflurane and Intravenous Propofol with Remifentanil on the Core Body Temperature in Burn Patients

BACKGROUND: The ability of the body to maintain its temperature is evidently decreased in patients with thermal injury. The aim of this study is was to evaluate the effect of inhaled sevoflurane and intravenous propofol with remifentanil on core body temperature in burn patients. METHODS: Sixty patients scheduled for burn surgery were divided into 4 groups. Within the major burn patients, intravenous propofol and remifentanil group (group I) followed by a continuous infusion of propofol and remifentanil. In inhaled sevoflurane group (group II), propofol 2mg/kg was given intravenously over 10 seconds as a single bolus and was maintained with nitrous oxide and oxygen and 2-2.5% sevoflurane. In minor burn patients, the intravenous propofol and remifentanil group (group III) and inhaled sevoflurane group (group IV) were treated in the same manner. After induction of anesthesia, esophageal stethoscope was placed to monitor the core temperature every five minutes in all patients. RESULTS: During operation, the core temperature of major burn patients was about 0.7-1.0 degreesC greater than that of minor burn patients. Until 95 minutes after induction of anesthesia, this difference showed statistical significant. However, there was no statistical significance after 100 minutes (P < 0.05). There were no statistically significant differences between group I and group II and group III and group IV for burn patients as well. CONCLUSIONS: Compared to minor burn patients, the core temperature of major burn patients was greater, and anesthetics type and administration route during operation had no effect on the core temperature in these patients.

Retropharyngeal Laceration during Nasotracheal Intubation: A case report / 대한마취과학회지

Nasotracheal intubation is a useful airway management technique for head, neck, and dental surgery. However, the risks associated with this technique include the possibility of damaging the nasal mucosa and related structures including the epistaxis, pharyngolaryngeal mucosal injury, bleeding, avulsion of the turbinate, nasal polyps, sinusitis, and bacteremia. Some of these symptoms occasionally result in fatal complications. A 26-year-old male, was scheduled to undergo surgery for malocclusion type 3 under general anesthesia with nasotracheal intubation. During the nasotracheal intubation, the tip of nasotracheal tube entered into the retropharyngeal space through the nasopharyngeal wall instead of oropharyngeal space, however no blood aspiration and retropharyngeal swelling occured. After surgery, the patient was treated with broad spectrum antibiotics and conservative management, and was completely cured without further complications.

Characteristics of Chronic Sensory Abnormalities in Korean Burn Patients / 대한통증학회지

BACKGROUND: After burn patients are discharged from the hospital, they may continue to feel pain and paresthetic sensations at the site of a healed burn and these problems may persist for years. This study was designed to describe the characteristics of these symptoms in terms of intensity, frequency, and influencing factors. METHODS: Patients that developed paresthetic sensations at sites of a healed burn were recruited from the pain management center from January 2003 to April 2006. Data was collected using a structured interview protocol. RESULTS: Fifty one adults, with a total body surface area burned (TBSA) of 21.1 +/- 16.3% aged 42.0 +/- 12.9 years were studied. A paresthetic sensation was reported to be present every day in 52.9% (27/51) of the subjects. A variation in the intensity was most commonly related to changes in the weather. A tight sensation and itching types of sensations were significantly more frequent in patients with more extensive injuries. CONCLUSIONS: Recognition and understanding of the chronic paresthetic sensation that many burn patients continue to experience at sites of a healed burn deserve further attention. Not only do clinicians need to be aware of these problems but also strategies for prevention and alleviation shoul\d be explored.

General Anesthesia for Cesarean Section in a Patient with Moyamoya Disease and Sick Sinus Syndrome: A case report / 대한마취과학회지

Moyamoya disease is a rare progressive occlusive disease of the internal carotid arteries. We experienced a case of general anesthesia in a patient with Moyamoya disease and sick sinus syndrome who underwent a cesarean section. General anesthesia was performed using laryngeal mask airway ProSeal(TM) in order to avoid the hemodynamic response to tracheal intubation. INVOS(R) 5100 was used to monitor the level of cerebral oxygenation. The patient was kept stable hemodynamically and her level of cerebral oxygenation was kept at the optimal level during the operation.

Glossodynia as an Unusual Manifestation of Vitamin B12 Deficiency: A case report / 대한통증학회지

A 58-year old male patient, with a history of gastrectomy, came to our department for recently aggravated glossodynia. A delicate physical examination revealed gait ataxia and a positive Rhomberg test. He was diagnosed as having vitamin B12 deficiency using a combination of the laboratory results, such as macrocytic anemia. It was thought that the tongue pain might have been a main clinical manifestation of vitamin B12 deficiency.

The Experiences of Airway Management for Anesthesia of Patients with Postburn Mentosternal Contractures: 10 cases report / 대한마취과학회지

Postburn sternomental contractures (PBSMC) of the neck can cause difficulties in endotracheal intubation when the cervical hyperextension and lifting of the mandible are impaired. Ten patients with a healed burn of the neck were assessed prior to surgery using the modified Mallampati test, and by measuring the sternomental distance, interincisor gap with their mouth fully open, and using Onah's classification system for PBSMC. Difficult endotracheal intubation was predicted. The patients were intubated successfully with a fiberoptic bronchoscope. The fiberoptic bronchoscope was found to be a useful device for managing patients with PBSMC. Moreover, Onah's classification system can be used for assessing postburn contractures.

Lung Injury Induced by Major Burns does not Affect Fentanyl Clearance / 대한마취과학회지

BACKGROUND: Major burns can alter the pharmacokinetics of opiate analgesics, which are commonly used perioperatively. Fentanyl undergoes a significant amount of pulmonary pharmacokinetic transition. This study was conducted to compare the pharmacokinetics of fentanyl in major burns, with and without lung injury, during the subacute hyperdynamic phase of recovery. METHODS: Twelve adults, with total body surface area (TBSA) 51.0 +/- 11.8% burns, aged 34.9 +/- 9.6 years, with a lung injury related to the burn, were studied at 15.4 +/- 9.4 days after the injury. Another 8 patients, aged 39.8 +/- 10.5 years, with TBSA 46.3 +/- 19.4%, at 19.3 +/- 10.9 days, without lung injury, served as controls. Fentanyl 200microgram was given intravenously over 10 seconds. Blood samples (n = 20) were collected at predetermined intervals. A two-compartment model was used for pharmacokinetic analyses of the fentanyl concentrations, as determined by LC/MS. The cardiac index (CI) was also measured using an esophageal Doppler monitor. RESULTS: There were no differences in the patient characteristics between the two groups. Those with burns had a significantly higher cardiac index (4.1 +/- 2.4 L/min/m2), clearance (Cl), central (V1) and total volume of distribution (Vd), but there were no differences between those with and without lung injury (30.2 +/- 14.3 vs. 30.1 +/- 5.8 ml/min/kg, 0.8 +/- 0.3 vs. 0.6 +/- 0.2 L/kg, 5.8 +/- 1.7 vs. 5.2 +/- 2.1 L/kg, respectively). Prolonged distribution (t1/2alpha) and elimination half-lives (t1/2beta) were noted in those with burns, but there were no differences between the two groups (3.2 +/- 1.3 vs. 3.3 +/- 1.3 minutes, 2.6 +/- 1.4 vs. 2.0 +/- 0.7 hours, respectively). CONCLUSIONS: The increased Cl of fentanyl in those with burns is primarily dependent upon the resultant increased hepatic blood flow. The pulmonary kinetics is a saturable process, which is not affected by a single bolus of fentanyl. The lung injury induced by major burns would have no influence on the elimination kinetics of fentanyl.

Tearing of the Lingual Frenulum Caused by Insertion of the LMA-ProSeal by the Introducer: A case report / 대한마취과학회지

The LMA (laryngeal mask airway)-ProSeal introducer was developed for easy insertion and fewer PLMA related complications. We experienced tearing of the lingual frenulum incidentally caused by insertion of the PLMA with the introducer. We believe that the introducer may have some advantages concerning insertion PLMA but some disadvantages because it hinder patient tongue control.

Pseudoaneurysm in the Superficial Femoral Artery Following Removal of a Femoral Vein Catheter: A case report / 대한마취과학회지

Central venous catheterization allows the measurement of hemodynamic variables, the delivery of medications, and nutritional support. The placement of central venous catheterization is associated with adverse events, such as, arterial puncture, hematoma, A-V fistula, pseudoaneurysm, etc. We report a case of a superficial femoral artery pseudoaneurysm after removing a femoral vein catheter in a 48-year-old female patient undergoing cervical spinal fusion. An insidious arterial puncture not noticed during femoral vein catheterization may produce complications immediately after catheter removal. Whenever a central venous catheter is removed, the importance of firm and even compression for a sufficient length of time cannot be overemphasized.