C-Arm Computed Tomography-Assisted Adrenal Venous Sampling Improved Right Adrenal Vein Cannulation and Sampling Quality in Primary Aldosteronism

BACKGROUND: Adrenal venous sampling (AVS) is a gold standard for subtype classification of primary aldosteronism (PA). However, this procedure has a high failure rate because of the anatomical difficulties in accessing the right adrenal vein. We investigated whether C-arm computed tomography-assisted AVS (C-AVS) could improve the success rate of adrenal sampling. METHODS: A total of 156 patients, diagnosed with PA who underwent AVS from May 2004 through April 2017, were included. Based on the medical records, we retrospectively compared the overall, left, and right catheterization success rates of adrenal veins during the periods without C-AVS (2004 to 2010, n=32) and with C-AVS (2011 to 2016, n=124). The primary outcome was adequate bilateral sampling defined as a selectivity index (SI) >5. RESULTS: With C-AVS, the rates of adequate bilateral AVS increased from 40.6% to 88.7% (P<0.001), with substantial decreases in failure rates (43.7% to 0.8%, P<0.001). There were significant increases in adequate sampling rates from right (43.7% to 91.9%, P<0.001) and left adrenal veins (53.1% to 95.9%, P<0.001) as well as decreases in catheterization failure from right adrenal vein (9.3% to 0.0%, P<0.001). Net improvement of SI on right side remained significant after adjustment for left side (adjusted SI, 1.1 to 9.0; P=0.038). C-AVS was an independent predictor of adequate bilateral sampling in the multivariate model (odds ratio, 9.01; P<0.001). CONCLUSION: C-AVS improved the overall success rate of AVS, possibly as a result of better catheterization of right adrenal vein.

Incidental ipsilateral subclavian vein catheterization via right internal jugular venous route: A case report

Central venous catheterization is frequently performed for perioperative management and intravenous access. However, the complications of central venous catheterization are numerous and include malposition, pneumothorax, hemothorax, chylothorax, thrombosis, extravasation of the infusate and infection. Although the malpositioning of the central venous catheter has been widely reported, there are few reports of ipsilateral subclavian vein catheterization via the right internal jugular venous route. In this case, we describe a misplacement of a right internal venous catheterization into the ipsilateral subclavian vein and suggest the possible causative factors.

Atrial Fibrillation during General Anesthesia Induction and Paroxysmal Supraventricular Tachycardia on Emergence / 이화의대지

A healthy 35-year-old man who was scheduled for closed reduction of nasal bone fracture developed atrial fibrillation during induction of general anesthesia after intravenous glycopyrrolate injection. During emergence of general anesthesia, atrial fibrillation was suddenly changed to paroxysmal supraventricular tachycardia with 200 beat per minute and lasted for about 10 seconds. Because blood pressure was stable, esmolol was used to reduce ventricular response. At recovery room, ventricular response reduction about 55 beat per minute was observed after intravenous injection of verapamil 5 mg. Thereafter, the rhythm was returned to normal sinus rhythm with bradycardia.

Monitored anesthesia care for unilateral inguinal herniorrhaphy in high risk patients: Two cases report

Remifentanil, an ultra-short acting opioid, exhibits at low doses distinct sedative properties that may be useful for supplementation of regional or local anesthesia. We described two patients suffered from serious underlying medical problems who underwent unilateral inguinal herniorrhaphy. One of them was 61 year-old male patient who had type B viral hepatitis, Child class B liver cirrhosis and rheumatoid arthritis with severe joint deformity including instability of cervical vertebrae. The other patient was 73 year-old man who had severe coronary artery occlusive disease which was recently managed with coronary stent and was underwent hemodialysis three times a week due to chronic renal failure. Monitored anesthesia care (MAC) with remifentanil through target controlled infusion (TCI) and local infiltration and ilioinguinal-hypogastric nerve block (IHNB) were done for herniorrhaphy. The operations were performed successfully without any complications such as respiratory depression or hypoxia and all patients and surgeon were very satisfied with MAC.

Meralgia paresthetica affecting parturient women who underwent cesarean section: A case report / 대한마취과학회지

Meralgia paresthetica is commonly caused by a focal entrapment of lateral femoral cuteneous nerve while it passes the inguinal ligament. Common symptoms are paresthesias and numbness of the upper lateral thigh area. Pregnancy, tight cloths, obesity, position of surgery and the tumor in the retroperitoneal space could be causes of meralgia paresthetica. A 29-year-old female patient underwent an emergency cesarean section under spinal anesthesia without any problems. But two days after surgery, the patient complained numbness and paresthesia in anterolateral thigh area. Various neurological examinations and L-spine MRI images were all normal, but the symptoms persisted for a few days. Then, electromyogram and nerve conduction velocity test of the trunk and both legs were performed. Test results showed left lateral cutaneous nerve injury and meralgia paresthetica was diagnosed. Conservative treatment was implemented and the patient was free of symptoms after 1 month follow-up.

Anesthetic management for emergent craniotomy in a patient with Eisenmenger's syndrome: A case report / 대한마취과학회지

Eisenmenger's syndrome describes the elevation of pulmonary arterial (PA) pressure to the systemic level caused by an increased pulmonary vascular resistance with reversed or bi-directional shunt through an intracardiac or aortopulmonary communication. We report a case of an emergent craniotomy for cerebellar abscess in a 21-year-old male patient with Eisenmenger syndrome secondary to Large VSD. A PA catheter was inserted via right femoral vein, but could not be advanced pass the pulmonic valve. After futile attempts to place the catheter tip in the right ventricle. Anesthesia was induced with etomidate, rocuronium, midazolam and fentanyl and maintained with only high dose fentanyl. Milinone and norepinephrine were infused continuously to decrease right to left shunt. He was transferred to the intensive care unit under intubated state and treated with antibiotics for a few days due to intermittent high fever. The operation ended without major complications and the patient was discharged 42 days later.

Detection of Carbon Dioxide Embolism Using Transesophageal Echocardiography during Thoracoscopic Sympathicotomy / 대한마취과학회지

BACKGROUND: Thoracoscopic Sympathicotomy (TS) is widely accepted as an effective method for the treatment of palmar hyperhidrosis. Single lumen endotracheal tube using CO2 insufflation is a simple and safe method for thoracoscopic surgery. However, there are chances of CO2 embolism during CO2 insufflation and nerve dissection. The object of this study were to assess the incidence of embolic events using transesophageal echocardiography (TEE) and to evaluate the related cardiorespiratory consequence during TS. METHODS: Thirty-two patients undergoing TS were studied. The long axis four chamber view was obtained continuously, except for predetermined intervals (after induction, CO2 insufflation in left thoracic cavity, left sympathicotomy, CO2 insufflation in right thoracic cavity, and right sympathicotomy) where the transgastric short axis view was obtained to derive ejection fraction (EF). Heart rate, mean arterial pressure (MAP), O2 saturation, and end tidal CO2 were monitored. Statistical analysis was performed using multivariated ANOVA and unpaired Student's t-test. P < 0.05 was considered significant. RESULTS: We observed CO2 embolism in 28/32 patients during CO2 insufflation (left or right) and in 32/32 patients during nerve dissection (left or right). There was no significant difference in cardiorespiratory variables between patients who presented embolism and who did not, during four distinct periods of events. Meanwhile, MAP decrease (P = 0.002) and EF increased significantly (P = 0.007) after sympathicotomy. This can be explained by decrease in systemic vascular resistance (SVR) by sympathicotomy. CONCLUSIONS: Embolic events commonly occur during CO2 insufflation and nerve dissection without cardiorespiratory instability during TS. However, we should pay attention when administrating N2O.

Transesophageal Echocardiographic Assessment of Venous Carbondioxide Embolism during Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: Although major CO2 gas embolism has occurred rarely during laparoscopic cholecystectomy (LC), the incidence of less severe episodes of CO2 embolism is unknown. It is also possible that such gas embolism, if present, could affect to cardiorespiratory variables. This study was designed to assess the incidence of subclinical embolic events using transesophageal echocardiography (TEE) and to evaluate the related hemodynamic consequence during LC. METHODS: With IRB approval, 20 patients undergoing LC were studied. The long axis four chamber view was obtained continuously, except for predetermined intervals where the transgastric short axis view was obtained to derive ejection fraction (EF). Heart rate, mean arterial pressure, O2 saturation, and end-tidal CO2 were monitored. Statistical analysis was performed using multivariated ANOVA and unpaired Student's t-test. P<0.05 was considered significant. RESULTS: We observed gas embolism in 4/20 patients during CO2 insufflation and 20/20 patients during gallbladder (GB) dissection. There was no significant difference in cardiorespiratory variables between embolic and nonembolic patients during insufflation. Also there was no significant difference in cardiorespiratory variation in all patients with embolism between before and after GB dissection. EF decreased significantly after insufflation (P = 0.002) and was recovered after exsufflation (P = 0.001). This can be explained by increase in systemic vascular resistance (SVR). CONCLUSIONS: Embolic events commonly occur during CO2 insufflation and GB dissection without cardiorespiratory instability. Although embolic event itself didn't affect the hemodynamic variables, peritoneal insufflation increased SVR and decreased EF. We should pay attention to patients undergoing LC who have decreased cardiac function and also prepare for serious CO2 embolic event.

Respiratory Depression Induced by Intraarticular Morphine under Total Knee Replacement: A case report / 대한마취과학회지

Intraarticular administration of morphine has good analgesic effect and satisfactory duration. It also shows less adverse effect of morphine than subarachnoid or epidural administration. However, high dose of morphine can cause long lasting respiratory depression. Although naloxone is effective in treatment of adverse effects of morphine, it has short duration of action. So repeating intravenous injections or continuous administration following bolus injection are recommended. We experienced a case of low dose continuous naloxone infusion for treatment of respiratory depression caused by iatraarticular morphine administration in total knee replacement surgery patient without affecting analgesic effect.

Respiratory Depression Induced by Intraarticular Morphine under Total Knee Replacement: A case report / 대한마취과학회지

Intraarticular administration of morphine has good analgesic effect and satisfactory duration. It also shows less adverse effect of morphine than subarachnoid or epidural administration. However, high dose of morphine can cause long lasting respiratory depression. Although naloxone is effective in treatment of adverse effects of morphine, it has short duration of action. So repeating intravenous injections or continuous administration following bolus injection are recommended. We experienced a case of low dose continuous naloxone infusion for treatment of respiratory depression caused by iatraarticular morphine administration in total knee replacement surgery patient without affecting analgesic effect.

Management with High Frequency Ventilation of Acute Idiopathic Pulmonary Hemorrhage in Infants / 대한마취과학회지

Acute idiopathic pulmonary hemorrhage in infants (AIPHI) is characterized by a sudden onset of pulmonary hemorrhage in previous healthy infants. Evidence of pulmonary hemorrhage may present as hemoptysis or a finding of blood in the nose or airway with no evidence of upper respiratory or gastrointestinal bleeding. Patients presenting with acute, severe respiratory distress or failure, and those requiring mechanical ventilation and often demonstrate bilateral infiltrates by chest radiography. We report a case of AIPHI which developed during the induction of anesthesia. A 3-month-old male infant received right herniorraphy under general endotracheal anesthesia. After intubation, blood tinged fluid was aspirated using an endotracheal tube during operation. Chest radiography showed bilateral ground glass opacity. We transferred the patient to the ICU and applied conventional mechanical ventilation. However hypoxemia and respiratory acidosis were persisted. We then switched to a high frequency ventilator (HFV), the hypoxemia and respiratory acidosis were corrected. The patient was transferred to the general ward on the 7th postoperative day.

Anesthetic Management of Myotonic Dystrophy: A case report / 대한마취과학회지

Myotonic dystrophy is a muscle disorder characterized by progressive muscle wasting and weakness associated with myotonia. It is a systemic disease transmitted in an autosomal dominant pattern. Myotonia may be precipitated by hypothermia, shivering, and mechanical or electrical stimulation. Furthermore, sensitivity to sedative, anesthetic and neuromusclular blocking agents may result in intraoperative and early postoperative cardiovascular and respiratory complications, as well as prolonged recovery from anesthesia. Therefore, a patient with myotonic dystrophy is at high risk for complications from anesthetic management. We report the successful anesthetic management of such a patient undergoing a total abdominal hysterectomy, in which we used an epidural technique for intraoperative anesthesia and postoperative analgesia.

Effect of Rilmenidine and Clonidine Premedication on the Cardiovascular Action of Phenylephrine and Nitroprusside in Rats / 대한마취과학회지

BACKGROUND: Patients premedicated with clonidine often present with hypotension and bradycardia. The hypotensive patient premedicated with clonidine should be given a vasopressor to treat hypotension. In these patients, an augmented vasopressor response would be shown. Rilmenidine as an allied drug of clonidine is an antihypertensive agent with selectivity for the imidazoline receptor that acts centrally by reducing sympathetic overactivity. This study was designed to evaluate the effect of clonidine and rilmenidine on changes in mean blood pressure and baroreflex sensitivity following phenylephrine and nitroprusside administration. METHODS: Sixty Sprague-Dawley rats were assigned randomly into one of three groups, control group (n = 20), clonidine group (n = 20) or rilmenidine group (n = 20). Saline (control group), clonidine 30ng/kg (clonidine group) or rilmenidine 300ng/kg (rilmenidine group) were intraperitoneally injected respectively. Following the injection, a phenylephrine and nitroprusside test were performed. RESULTS: The percent change in mean blood perssure from the baseline values in the control group, clonidine group and rilmenidine group were 35 +/- 18%, 54 +/- 17% and 62 +/- 38%, respectively. There was no difference between the baroreflex sensitivity in the pressure (phenylephrine) test (0.94 +/- 0.43, vs 1.05 +/- 0.62, vs 1.13 +/- 0.59 msec/mmHg). In contrast, the slopes of the depressor (nitroprusside) test were decreased in rats receiving clonidine and rilmenidine (0.51 +/- 0.34, vs 0.12 +/- 0.08, vs 0.18 +/- 0.09 msec/mmHg, P < 0.05). CONCLUSIONS: It is concluded that the rilmenidine and clonidine groups showed a more augmented pressure response to vasopressors than the control group. Therefore, the decreased dosage of vasopressors is recommended to treat hypotension in rilmenidine premedicated patients.

Relation between Symptom Duration and Abnormal Spontaneous Activity in S1 Radiculopathy

OBJECTIVE: It is a widely accepted belief that paraspinal muscles tend to show spontaneous activity on needle electromyography early on in a radiculopathy and distal muscles become abnormal later on. But most studies have shown the limitations of using symptom duration when interpreting electrodiagnostic findings in radiculopathy. The purpose of this study was to determine the relationship between symptom duration and abnormal spontaneous activity in S1 radiculopathy confined to abnormal H-reflex. METHOD: A retrospective study that collected the informations on symptom duration and spontaneous activity in paraspinal muscle and gastrocnemius for 112 patients with S1 radiculopathy diagnosed by unilateral H-reflex abnormality was undertaken. RESULTS: Abnormal spontaneous activity in paraspinal muscle had shown a significant negative correlation with symptom duration, that is a tendency to decrease its expression over symptom duration. On the contrary abnormal spontaneous activity in gastrocnemius muscle was rare at first a few weeks and became to show after 7 weeks. Patients with symptom duration over 1 year had higher incidence of having no abnormal spontaneous activities both in paraspinal and gastrocnemius muscle. CONCLUSION: These results suggested that symptom duration had a potential role in the diagnosis of S1 radiculopathy when H-reflex were abnormal unilaterally.

Aspiration Pneumonia in Esophageal Achalasia Patient during Anesthesia for Cesarian Section / 대한마취과학회지

Achalasia is a motility disorder of the esophagus characterized by aperistalsis, incomplete lower esophageal sphincter (LES) relaxation, and increased LES tension. Obstruction at the esophageal hiatus results in dilatation of the thoracic esophagus, which can cause coughing and dyspnea by compression of the trachea and main-stem bronchi, and predisposes the patient to regurgitation and pulmonary aspiration of stagnant esophageal contents. We report a case of slight aspiration pneumonia during anesthesia in a pregnant woman who had achalasia of the esophagus. Epidural anesthesia was performed for a cesarian section uneventfully. She had a regurgitation of the gastroesophageal contents after a thiopental 225 mg IV because she wanted to sleep due to anxiety. We performed endotracheal intubation with Sellick's maneuver immediately followed by suction. We regret not to have recognized that she had achalasia of the esophagus. Therefore, we did not remove the esophageal contents with a nasogastric tube. The result was that she had slight aspiration pneumonia.

What is the Minimum Effective Dose of Propofol in Relieving Epidural Morphine Induced Pruritus? / 대한마취과학회지

BACKGROUND: Mu-receptor antagonists are considered effective for the treatment of epidural morphine induced pruritus (EMIP). However, they have been associated in certain cases with a concomitant reduction in analgesia. It is noteworthy that propofol has been shown to produce marked spinal depression, in particular of the dorsal and ventral horn. Recently it was reported that subhypnotic doses of propofol were efficient in relieving EMIP. This study was designed to investigate an effective minimum dose of propofol. METHODS: After obtaining informed consent from patients and with IRB approval, 155 patients having cesarean section received an epidural morphine 3 mg bolus, and 4 mg/day with continuous infusion for 2 days via a Baxter infusor(R). Patients who had pruritus with scratching were allocated randomly to one of the three groups. Patients received 10 mg propofol intravenously in group I (n = 25), 20 mg in group II (n = 25) and 30 mg in group III (n = 25). Pruritus and the level of sedation were assessed 5 minutes later using 5 points pruritus rating scale (PRS) and 4 points sedation rating scale (SRS). Statistical analysis was performed using chi-square test, one-way ANOVA and paired t-test. P or = 3). The success rate was significantly greater in the group II (76%) and group III (80%) than in the group I (48%) (P < 0.05). Seven patients had an increase in sedation in the group III versus none in the group I and group II (P < 0.05). The beneficial effect of treatment was longer than 60 minutes in 100% of patients in group I, II and III. CONCLUSION: These results suggest that 20 mg propofol and 30 mg propofol intravenously are equally effective in treating EMIP than 10 mg propofol. However the level of sedation is significantly less in 20 mg propofol group than 30 mg propofol group.

Effect of Midazolam Premedication on Postanesthetic Recovery and Postanesthetic Recovery Room Discharge Time for Outpatient Surgery / 대한마취과학회지

BACKGROUND: Midazolam is often used as an anxiolytic premedication before surgery. But preoperatively administered midazolam may contribute to postopertive sedation and delayed recovery from general anesthesia. This study was undertaken to evaluate the effect of midazolam premedication on postoperative recovery and discharge-readiness after brief outpatient surgery. METHODS: Sixty healthy ASA physical status I women scheduled for outpatient diagnostic laparoscopic surgery were considered for the study. They were randomly allocated to one of two groups. Group one received normal saline (N/S) 5 ml intravenously (IV), while group two received IV midazolam 0.04 mg/kg. The study drug was prepared in 5 ml of saline and administered 10 minutes before the induction of general anesthesia. General anesthesia was induced with fentanyl, propofol and vecuronium and was maintained with N2O and enflurane. Postanesthetic recovery (PAR) scores were recorded after the arrival of the patients in the postanesthetic recovery room. Sedation was quantified before and after premedication and 60, 120 minutes after arriving in the postanesthetic recovery room, using the symbol-digit-modalities test (SDMT) and trail-making test (TMT). RESULTS: There were no significant differences between the two groups with respect to age, weight and anesthesia time. There were no significant differences in PAR scores or PAR-stay time between two groups. SDMT and TMT scores were significantly different 5 minutes after the study's drug administration, and 60 minutes after arrival in the postanesthetic recovery room between the two groups. The incidence of side effects was similar in both groups. CONCLUSIONS: Midazolam premedication proved effective in sedation and anxiolysis without prolonging postanesthetic recovery and discharge times for outpatient general anesthesia.

Acid-Base Regulation during Hypothermia in Dogs / 대한마취과학회지

BACKGROUND: Controversy exists regarding acid-base management during hypothermia. Two different concepts of arterial blood gas (ABG) management during hypothermia have been proposed to date; pH-stat and alpha-stat. There has been no consistency about physiological benefit provided by one protocol over the other. Most of previous studies have investigated the effects of two different strategies during cardiopulmonary bypass or controlled ventilation. We studied the actual acid-base regulation during acute hypothermia in anesthetized dogs with spontaneous ventilation. METHODS: With institutional review board approval, 10 mongrel dogs were anesthetized with intravenous pentobarbital 25 mg/kg. The dogs were kept to have spontaneous ventilation with trachea intubated. After monitoring devices were placed, the rectal temperature was lowered to 32oC with wet towel, cold solution, and ice cubes. ABG analyses were performed at each degree drop of body temperature from 37oC to 32oC. The pH and arterial carbon dioxide tension (PaCO2) were measured at 37oC and were corrected to the actual body temperature. [OH- ]/[H- ] was also calculated. RESULTS: Non-corrected pH values tended to decrease and PaCO2 values tended to increase as the temperature dropped. The temperature corrected pH and PaCO2 values were almost constant through 37oC to 32oC. [OH- ]/[H-] was declined with a drop of temperature. CONCLUSIONS: The acid-base regulation during acute hypothermia in anesthetized dogs with spontaneous ventilation is considered to be the pattern close to "pH-stat" regulation.

Reliability of Pulse Oximetry in Severe Hypoxemic Children with Congenital Heart Disease / 대한구급학회지

Introduction: Oxygen delivery to tissue is of major clinical interest in patients with cyanotic congenital heart disease (CHD). The use of pulse oximeter to monitor arterial oxygen saturation (SaO2) is considered accurate and reliable in the range of 90% to 100%. However with desaturation, the accuracy remains controversial below 90%. The aim of this study was to evaluate the accuracy of pulse oximetry in severe hypoxemia. METHOD: In 110 children with cyanotic CHD, pulse oximeter (N-200, Nellcor, USA) readings were compared with the direct measurement of SaO2 by blood gas analyser (Profile10, Stat, USA). All measurements were carried out after induction of anesthesia and devided into 4 groups according to saturation measured by pulse oximeter (SpO2). SpO2 in group I was higher than 90% (n=90), in group II between 80% and 89% (n=75), in group III between 70% and 79% (n=41), in group IV lower than 69% (n=18). Statistical analysis of paired SpO2 and SaO2 values was performed using correlation analysis and paired t-test. The other comparisons were perfomed with ANOVA. p<0.05 was considered statistically significant. RESULTS: Correlation coefficient of group I was 0.89 (p<0.01), group II was 0.67 (p<0.01), group III was 0.63 (p<0.01) and group IV was 0.41. The study demonstrate that SpO2 seems to have good correlation with SaO2 when SpO2 is higher than 70%. This results are contrary to other studies which show that SpO2 is not reliable when SpO2 is below 90%. However, the correlation value r seems to decrease with desaturation. CONCLUSION: The use of pulse oximeter in severe hypoxemic children with CHD is efficient in monitoring oxygenation, even though there is decrease in accuracy of the SpO2.

Subvalvular Aortic Stenosis Developed after Patch Closure of VSD in A Child: Case Report / 대한흉부외과학회지

Subvalvular aortic stenosis developed after patch closure of perimembranous VSD is rarely reported. A 18-month-old, 8 kg child with this complication after VSD closure 8 months ago in other hospital has been treated medically and was admitted to this hospital because of severe cardiomegaly and sign of heart failure. Cardiac catheterization revealed 55 mmHg of pressure gradient between aorta and LV cavity. We report one successful redo case of surgically relieved subvalvular aortic stenosis in a child after patch closure of perimembranous VSD.