A case involving anesthesia for cesarean section followed by resection of ruptured cavernous malformation of pons :A case report

Cavernous malformation is an important cause of cerebral hemorrhage in pregnant women. We experienced a case of cesarean section followed by neurosurgery for resection of ruptured cavernous malformation of pons in a 24-year-old pregnant woman. Establishing integrated treatment strategy for pregnant women with cavernous malformation is difficult because of the small number of cases. Therefore, the cooperation between the brain surgeon, anesthesiologist and obstetrician is essential when surgical intervention is needed. Despite aspiration pneumonia, the patient successfully underwent surgery. We reported this case along with a brief literature review.

Comparison of Transesophageal Doppler Monitor vs. Pulmonary Artery Catheter in the Hemodynamic Indices of Major Burn Patients Undergoing an Extensive Escharectomy / 대한마취과학회지

BACKGROUND: In major burn patients, many invasive monitors including a pulmonary artery catheter (PAC) are often required to assess hemodynamic status. An esophageal Doppler monitor (EDM), as a noninvasive method of measuring hemodynamic parameters, may be a substitute for a PAC in this clinical circumstance. This study was conducted to evaluate the validity of Doppler derived hemodynamic indices in comparison to that of a PAC. METHODS: A total of 20 critically ill, severe burn patients, scheduled for an elective escharectomy and application of artificial dermis, were enrolled for the placement of a PAC and EDM. Simultaneous data was collected in regular intervals and the various parameters were compared between the two methods. RESULTS: A total of 158 pairs of data in 20 patients were gathered. Among all the parameters, cardiac output (CO) and stroke volume (SV) showed consistently 20% less in EDM. Correlation coefficients of heart rate (HR), CO, SV and systemic vascular resistance (SVR) were 0.97, 0.54, 0.62, and 0.68 respectively. Corrected flow time (FTc) had poor correlations with central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP). In the mean time, significant, but very weak correlations with FTc vs. CO and SV were demonstrated. CONCLUSIONS: EDM may be a substitute for a thermodilution (TD) PAC technique, it can be used with usefulness for hemodynamic and preload assessment in major burn patients.

Psoas Abscess and Discitis after Intradiscal Nucleoplasty / 대한마취과학회지

Nucleoplasty is a newly developed minimal invasive spinal surgery using a coblation technique. The complications of this new spinal surgery are trauma to retroperitoneal organs involving the kidney, discitis, menigitis, and epidural abscess. Recently, postoperative psoas abscess and discitis appears to have increased in frequency, in part because procedures performed on the spine have been more frequent and improvements in diagnostic capabilities have been made. Antibiotic therapy, abscess drainage, or a surgical procedure is required to treat discitis and psoas abscess. We encountered one case of postoperative psoas abscess and discitis after a nucleoplasty that had not responded to antibiotics but which responded successfully to treatment by spinal surgery.

Evaluation of Safety and Usability of Low Pressure Carbon Dioxide Insufflation in Endoscopic Thyroidectomy / 대한마취과학회지

BACKGROUND: Carbon dioxide insufflation during an endoscopic thyroidectomy may cause an adverse effects on blood gas and hemodynamic status. This study was conducted to evaluate the safety of low pressure carbon dioxide insufflation during an endoscopic thyroidectomy. METHODS: Patients in ASA physical status I or II, scheduled for an endoscopic thyroidectomy (n = 70) were gathered for the evaluation. During the operative procedure, minute ventilation at a tidal volume 10 ml/kg and respiratory rate 10/minute was maintained. End-tidal carbon dioxide tension, blood pressure and heart rate were measured and compared before and at 10, 20, 30, 60 and 90 minutes after CO2 insufflation. RESULTS: End tidal carbon dioxide tension significantly increased up to 30 minutes and plateaued thereafter. Mean blood pressure significantly increased up to 30 minutes but there was no change in heart rate after CO2 insufflation. Complications were not reported. CONCLUSIONS: We concluded that low pressure carbon dioxide insufflation during an endoscopic thyroidectomy was safe and useful.

The Changes of Plasma Potassium Concentrations during Anesthesia Induction with Etomidate in Patients with Major Burns / 대한마취과학회지

BACKGROUND: Etomidate, an anesthetic induction agent, has dose-dependent involuntary myoclonic movement. This prospective, randomized study was conducted to determine the safety of etomidate in patients with major burn injury. METHODS: Twenty ASA physical status II or III adult patients, scheduled for an elective early escharectomy, were studied. These patients had varying degrees of myoclonic activity at the time of anesthesia induction with etomidate (0.3 mg/kg). The plasma concentrations of potassium before and after myoclonus were measured and compared. RESULTS: Incidence of myoclonus after the injection of etomidate induction dose was 31.7%. No significant changes in plasma concentrations of the potassium level before or after myoclonus were found in this study group. CONCLUSIONS: Myoclonus during induction of anesthesia with etomidate did not cause any change in the plasma concentration of potassium. It appears to be a safe anesthetic induction agent in patients with major burns, threatened by hemodynamic and pulmonary insufficiency.

The Change of Cervical Epidural Pressure according to Infused Normal Saline in Epiduroscopy / 대한마취과학회지

BACKGROUND: Normal saline is used to dilate the epidural space to provide a focal length for the lens and to wash the epidural adhesive neural tissue in an epiduroscopy. Saline infusion into the epidural space during an epiduroscopy might affect pressure-volume compliance of the CSF which has a high compliance; therefore, it might cause neurological sequelaes. The purpose of this study was to investigate the change of cervical epidural pressure according to the volume of infused saline during epiduroscopy. METHODS: Twenty-one patients who complained of low back pain with radiculopathy that did not respond to conservative pain management and underwent an epiduroscopy were included in this study. The epidural catheter was placed between the 5th and 6th cervical epidural space under fluoroscopic guidance and cervical epidural pressure was monitored. Next, an epiduroscopy via caudal route was performed and cervical epidural pressure was measured after each 10 ml of infused saline. We also checked neurological sequelaes that might be resulted from increased epidural pressure. RESULTS: All patients except two showed no difference in basal cervical epidural pressure. One patient who had failed back surgery syndrome complained of a headache and dizziness when the cervical epidural pressure was rapidly increased from 90 mmHg to 5 mmHg following an infusion of 27 ml of saline. One patient who had a herniated disc showed posterior nuchal pain and stiffness following an infusion of 48 ml of saline despite a stable cervical epidural pressure (range: 0 - 3 mmHg) during the procedure. There were no residual neurological sequelaes in this study. CONCLUSIONS: There are variable patterns in cervical epidural pressure according to the volume of infused saline. Close monitoring of intracranial pressure is therefore neccessary during an epiduroscopy.

Clinical Study of the Changes in End tidal PCO2 Arterial Blood Gas and Vital Signs by Increased Minute Ventilation After Deflation of Tourniquet / 대한마취과학회지

Tourniquets are often used for surgery on the extremities to provide a bloodless surgical field. However, tourniquets may cause nerve and other tissue injuries.While the tourniquet is inflated, metabolic changes occur in the ischemic limb, chages that include increased PaCO2, lactic acid and pottasium, and decreased levels of PaO2 and pH. Deflation of the tourniquet results in the release of these products of ischemia into the general circulation. The resultant decreases in arterial pH and PaO2 and increased in arterial lactic acid, potassium, PaCO2 and P(ET)CO2 are associated with significant decrease in mean arterial and central venous pressure and increase in heart rate. Since Pa is one of the important factor to control the cerebral blood flow and intracranial pressure, a sudden increase in PaCO2 immediately after toumiquet deflation may cause detrimental effects in head injured patients with elevated intracranial pressure. The purpose of this study was investigate the effect of the degree of hyperventilation by means of increased minute ventilation by 25%, 50% and 75% respectively, after deflation of toumiquets to keep P(ET)CO2 at former levels, for twenty minutes period, with arterial blood gas analysis, endtidal PaCO2 and vital signs was monitored serially. We compared normal minute ventilation group I with increased minute ventilation groups(II, III and IV) before and after deflation of tourniquet. In summary, we calculated from our data that increasing minute ventilation by more than 50% for 5 minutes following tourniquet deflation could prevent P(ET)CO2 from increasing more than 1.5-6.5 mmHg in all patients.

Effect of Propranolol on Changes in Sereum K+ Induced by brachial Plexus Block / 대한마취과학회지

When we perform the regional blockade, we usually addit epinephrine to the local anesthetics for the purpose of lengthening anesthesia time and preventing the systemic reaction of local anesthetics. In that situation, epinephrine produces decrease in serum potassium concentration and changes in electrocardiogram. We investigated the influence of propranolol on changes in serum potassium and ECG induced by brachial plexus block with 30ml of mixture of local anesthetic (2% lidocaine +0.5% bupivacaine) which contains 1:200,000 epinephrine. The subjects classified as following two groups: Group l : Brachial plexus block with mixture of local anesthetic and 1:200,000 epinephrine(n=20). Group ll : Pretreated with 2 mg of propranolol(slow intravenous injection for 5 min. before block) and performed as Group l. The results were as follows: 1) Group l showed statistically significant decrease of serum potassium after 10, 20, 30 min. of block(p<0.05). Group ll did not show any significant change. 2) Group l showed progressive flattening of T wave and appearance of U wave (25% of pts) in ECG as the serum-potassium decreased progressively, but Group ll did not sho any significant change. 3) The epinephrine mediated beta-adrenergic stimulation may be considered as the cause of epinephrine induced hypokalemia during brachial plexus block.