Unilateral hypoglossal nerve palsy after endotracheal intubation for general anesthesia in a difficult airway patient: A case report

Hypoglossal nerve palsy after general anesthesia is an exceptionally rare complication, which has varied etiology. We present a case of unilateral hypoglossal nerve palsy resulting from repeated airway intervention for general anesthesia. A 57-year-old woman was scheduled to undergo modified radical mastectomy. During endotracheal intubation, the patient had Cormack's grade III-a severe airway condition. After the first intubation attempt failed, the intubation was attempted a second time using a stylet inside the endotracheal tube with cricoid pressure; this attempt was successful. In the evening of the operation day, the patient complained of dysarthria and dysphagia. Physical examination revealed deviation of the tongue to the right, which may have been caused by traumatic hypoglossal nerve injury. This case reviews the pathophysiology, prevention, and management of hypoglossal nerve palsy.

Relationship Between Pain Threshold and Postoperative Morphine Requirement / 대한마취과학회지

BACKGROUND: Variability in pain sensitivity is a well known phenomenon. The variability also extends to experimental stimuli and postoperative opioid requirement. But the report of the relationship between pain threshold and postoperative opioid requirement is very rare. METHODS: We investigated prospectively the association between pressure pain threshold and postoperative morphine requirement. We estimated pressure pain threshold by using pressure algometer and adopted PCA to treat postoperative pain. RESULTS: In this study the relationship between pain threshold and postoperative opioid requirement was significant. But the correlation was weak negative (Pearson r = -0.273, P < 0.05). CONCLUSIONS: Considering other associated factors which affect postoperative pain, although correlation between pain threshold and postoperative opioid requirement was significant but we concluded that clinical relevance of pain threshold is uncertain.

Unusual Presentation of Extralobar Pulmonary Sequestration: A Case Report

Extralobar pulmonary sequestration, a rare form of bronchopulmonary sequestration, is a congenital anomaly in which a portion of nonfunctioning lung tissue is surrounded by its own pleura and is supplied by a systemic artery. We describe a case of extralobar pulmonary sequestration with unusual features. CT scanning of the chest demonstrated a non-enhancing, hyperdense mass within the right major fissure, and thoracotomy revealed that the mass received blood from a branch of the right pulmonary artery and drained into the left atrium. The pathologic diagnosis was extralobar pulmonary sequestration.

Primary Non-Hodgkin ''s Lymphoma Involving the Third Ventricle: A Case Report

Non-Hodgkin's lymphoma of the primary central nervous system is a rare neoplasm. With the increased incidence of this tumor in both the immunocompetent and immunocompromised population, unusual locations and imaging manifestations are likely to be encountered. We report the radiologic findings of a case of primary lymphoma involving the third ventricle, confirmed by surgery and the pathologic findings.

Atretic Cephalocele: Report of Two Cases

In cases of meningoencephalocele, brain tissue, which is enveloped by the meninges and cerebrospinal fluid, herniates through the skull defect. Atretic cephalocele, on the other hand, is a congenital malformation in which small meningeal and vestigial glial tissue herniates through this defect; a benign nodular lesion is found near the midline of the scalp. Atretic cephalocele can occur in the parietal or occipital area; in cases involving the latter, the prognosis is poor. We report the radiologic findings of two cases of atretic cephalocele confirmed by surgery and pathologic findings.

Neuromuscular Blocking Effect of Vecuronium in Electric Burned Patients for Endotracheal Intubation / 대한마취과학회지

BACKGROUND: In inducing anesthesia for burn patients, nondepolarizing muscle relaxant (NDMR) is usually used, because succinylcholine, a widely used muscle relaxant may cause hyperkalemia. It is well known that because burn patients show resistance to NDMR, a high dose of NDMR is needed for them. In this study, we wanted to know whether there is significant difference of the relaxation effect between 0.1 mg/Kg and 0.15 mg/Kg dose's of vecuronium, and between burn and unburn patients. METHODS: Subjects are 40 male patients having 1 or 2 ASA physical status (20 are burn patients and the other 20 are unburn patients). We divided them into 4 groups; 1) Group BI (burn patients, vecuronium 0.1 mg/Kg) 2) Group BII (burn Pts, vecuronium 0.15 mg/Kg) 3) Group UBI (unburn Pts, vecuronium 0.1 mg/Kg) 4) Group UBII (unburn Pts, vecuronium 0.15 mg/Kg). Average onset times (time from injection of vecuronium to zero first twitch height (T1)) were measured and intubating condition were scored on 0 to 4 scale. RESULTS: The onset time of vecuronium and distribution of intubation scores didn't show statistical differences among 4 groups. CONCLUSION: The onset time of vecuronium and intubating condition in burn patients dosen't show a difference from unburn patient.

The Pulmonary Hemodynamic Effects of Nitric Oxide Inhalation on Hypoxic Pulmonary Vasoconstriction / 대한마취과학회지

BACKGROUND: Nitric Oxide (NO) has been discovered to be an important endothelium-derived relaxing factor. The exogenous inhaled NO may diffuse from the alveoli to pulmonary vascular smooth muscle and produce pulmonary vasodilation, but any NO that diffuses into blood will be inactivated before it can produce systemic effects. To examine the effects of NO on pulmonary and systemic hemodynamics, NO was inhaled by experimental dogs in an attempt to reduce the increase in pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) induced by hypoxia in dogs. METHODS: Eight mongrel dogs were studied while inhaling 1)50% O2 (baseline), 2)12% O2 in N2 (hypoxia), 3)followed by the same hypoxic gas mixture of O2 and N2 containing 20, 40 and 80 ppm of NO, respectively. RESULTS: Breathing at FIO2 0.12 nearly doubled the pulmonary vascular resistance from 173 56dyn sec cm-5 to 407 139dyn sec cm-5 and significantly increased the mean pulmonary artery pressure from 16 3mmHg to 22 4mmHg. After adding 20~80 ppm NO to the inspired gas while maintaining the FIO2 at 0.12, the mean pulmonary artery pressure decreased (p<0.05) to the level when breathing oxygen at FIO2 0.5 while the PaO2 and PaCO2 were unchanged. The pulmonary vascular resistance decreased significantly and the right ventricular stroke work index returned to a level similar to breathing at FIO2 0.5 by addition of NO into the breathing circuit. Pulmonary hypertension resumed within 3~5 minutes of ceasing NO inhalation. In none of our studies did inhaling NO produce systemic hypotension and elevate methemoglobin levels. CONCLUSIONS: Inhalation of 20~80 ppm NO selectively induced pulmonary vasodilation and reversed hypoxic pulmonary vasoconstriction without causing systemic vasodilation and bronchodilation. Methemoglobin and NO2 were within normal limit during the study.

Comparison of Intranasal and Sublingual Midazolam as a Preanesthetic Medication in Pediatric Patients / 대한마취과학회지

BACKGROUND: The perfect preanesthetic medication and its ideal route of administration are still debated. Transmucosal administration of midazolam has been of interest because of the rapid, reliable onset of action, predictable effects and avoidance of injections. Because many medications are well absorbed from the mucosa, we conducted a randomized, prospective, blinded study to compare acceptance and efficacy of intranasal and sublingual administration of midazolam as a preanesthetic medication in children. METHODS: One hundred twenty eight patients aged 0.5-12year were stratified by age: 38 infants and toddlers, 0.5-3yr; 48 preschoolers, 3.1-7yr; and 42 school age, 7.1-12yr. They were randomized to received 0.2 mg/kg of midazolam in the nose or under the tongue. Hemoglobin oxygen saturation by pulse oximetry and sedation score were recorded before drug administration, at 2.5min intervals for 15min, at separation from parents and during induction with enflurane in O2. Retention time of sublingual drug and duration of crying were recorded. RESULTS: The incidence of crying at the time of administration of midazolam was greater following intranasal compared with sublingual administration(60% vs 17%, p<0.05). Within age groups, only infants and toddlers showed a significant difference in the incidence of crying between treatment groups. Significant changes in sedation occured in both groups from 2.5min after administration. CONCLUSIONS: Sublingual midazolam is better accepted than intranasal midazolam as a preanesthetic sedative in children.

Evaluation of Esmolol and Fentanyl in Controlling Increase in Heart Rate and Blood Pressure during Endotracheal Intubation / 대한마취과학회지

Laryngoscopy and intubation cause an adrenergic response manifested by tachycardia and hypertension. Various phamacological agents have been administered prior to induction in an attempt to attenuate the adrenergic response but they all have limitations. The objective of our study was to determine if esmolol would be equally effective when adrninistered in a bolus with and without fentanyl. A double-blind, randomized trial was conducted in sixty ASA physical status 1 patients undergoing elective surgery. All patients were premedicated with 0.2 mg/kg diazepam orally and glycopyrrolate 0.04 mg/kg intramuseularyly 1 hour beforehand. Induction of anesthesia was accomplished with 4 mg/kg thiopental intravenously foUowed immediately by 0.15-0.2 mg/kg vecuronium and study drug (placebo, esmolol 150 mg, esmolol 150 mg and fentanyl 100 mcg). Endotracheal intubation was performed at 2 minutes after study drug adrninistration. Anesthesia was maintained with 1 MAC (+/-10%) isoflurane in 60% nitrous oxide in oxygen at a 5 L/min flow for 6 minutes. Heart rate and blood pressure were measured every minute by an automatic recording device. After laryngoscopy and intubation, maximum increase in stolic blood pressure above awake levels was 33 mmHg (p<0.05) and 14 mmHg (p<0.05) in esmolol 150 mg, esmolol 150 mg with fentanyl 100 mcg respectively, whereas systolic blood pressure increased 62 mmHg after tracheal intubation in patients with placebo. In six patients with esmolol 150 mg, rate-pressure product reached a level considered potentially dangerous to patients with coronary artery disease. However, when used with fentanyl, esmolol provides effectvie protection against the adrenergic response and increase of the rate-pressure product to laryngoscopy and intubation.