Successful Balloon Angioplasty with Low-pressure Balloon on Early Transplant Renal Artery Stenosis at Postoperative Day 7 / 대한이식학회지

Transplant renal artery stenosis (TRAS) is an important cause of hypertension, allograft dysfunction, and graft loss. Patient and allograft survival rates are lower in patients with TRAS. Causes of TRAS include acute rejection, cytomegalovirus infection, calcineurin inhibitor toxicity, atherosclerosis of recipient, and/or donor. Technical problems due to surgery are a common cause of early TRAS. A 62-year-old male in end stage renal disease received kidney transplant surgery. There was 5/6 mismatch of human leukocyte antigen and the panel reactive antibody of patient was class I 0% and class II 0%. End to side anastomosis was done between the graft's renal artery and the patient's common iliac artery. His serum creatinine was measured at 6.4 mg/dL before transplantation but his serum creatinine level did not fall below 2.6 mg/dL at 5 days postoperative. His blood pressures was 160/90~180/100 mmHg. There was a significant TRAS (about 80% luminal narrowing) at the arterial anastomosis site on the renal magnetic resonance angiography. We performed percutaneous transluminal angioplasty (PTA) for the stenotic lesion. The balloon angioplasty was done with a 5 mm balloon and low pressure (8 mmHg, nominal pressure was 10 mmHg) at the stenotic lesion. The arterial pressure gradient was 8 mmHg (recipient's common iliac arterial pressure, 147/73 mmHg; poststenotic segmental renal arterial pressure, 139/70 mmHg) just before the balloon angioplasty. After PTA, the arterial pressure gradient became 3 mmHg (recipient's common iliac arterial pressure, 157/66 mmHg; poststenotic segmental renal arterial pressure, 154/65 mmHg). The arterial size and blood flow recovered to within normal range and serum creatinine level was normal after PTA. PTA using low pressure and a small balloon was safe and effective modality in treating early TRAS.

Late Onset Infection of Pneumocystis jirovecii Infection in a Renal Transplant Recipient / 대한이식학회지

Pneumocystis jirovecii pneumonia (PCP) can be a life-threatening opportunistic infection after kidney transplantation, occurring most frequently in the first 12 months with the symptoms of dyspnea, cough, fever, and hypoxia. Prophylaxis for PCP is usually applied during the first 3 months to 1 year after transplantation, but late onset incidence of PCP can be detected. We report on a patient who developed PCP 9 years after renal transplantation. The patient showed indolent onset of acute respiratory distress and was treated with trimethoprim-sulfamethoxazole and corticosteroid therapy. Previous rescue treatment of acute cellular rejection with ongoing maintenance of an elevated level of immunosuppressants may have predisposed the patient to PCP.

Accuracy of Live Fluoroscopy to Detect Intravascular Injection During Lumbar Transforaminal Epidural Injections

BACKGROUND: Complications following lumbar transforaminal epidural injection are frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection. The generally accepted technique during epidural steroid injection is intermittent fluoroscopy. In fact, this technique may miss vascular uptake due to rapid washout. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. However, when vascular contrast patterns are overlapped by expected epidural patterns, it is hard to distinguish them even on live fluoroscopy. METHODS: During 87 lumbar transforaminal epidural injections, dynamic contrast flows were observed under live fluoroscopy with using digital subtraction enhancement. Two dynamic fluoroscopy fluoroscopic images were saved from each injection. These injections were performed by five physicians with experience independently. Accuracy of live fluoroscopy was determined by comparing the interpretation of the digital subtraction fluoroscopic images. RESULTS: Using digital subtraction guidance with contrast confirmation, the twenty cases of intravascular injection were found (the rate of incidence was 23%). There was no significant difference in incidence of intravascular injections based either on gender or diagnosis. Only five cases of intravascular injections were predicted with either flash or aspiration of blood (sensitivity = 25%). Under live fluoroscopic guidance with contrast confirmation to predict intravascular injection, twelve cases were predicted (sensitivity = 60%). CONCLUSION: This finding demonstrate that digital subtraction fluoroscopic imaging is superior to blood aspiration or live fluoroscopy in detecting intravascular injections with lumbar transforaminal epidural injection.

Effect of 1 mg of prophylactic haloperidol for postoperative nausea and vomiting after gynecological laparoscopic surgery using IV patient controlled analgesia

BACKGROUND: Haloperidol, a major tranquilizer similar to droperidol, has been found to have a potent antiemetic effect on postoperative nausea and vomiting (PONV), but the supporting evidence was incomplete, especially in Korea.Therefore we evaluated the prophylactic effect of haloperidol on opioid-based IV patient-controlled analgesia (PCA) related PONV in susceptible patients after gynecological laparoscopic surgery. METHODS: Ninety-six adult women scheduled gynecological laparoscopic surgery were enrolled in a randomized, double-blinded and placebo study.Patients received haloperidol 1 mg (Group H) or saline (Group C) 30 min before the end of surgery.Fentanyl-based IV PCA was administered after surgery.The incidences and severity of nausea, vomiting, rescue antiemetic administration, pain, and adverse effects (cardiac arrhythmias and extrapyramidal effects) were assessed for 24 h after surgery.The sedation score was recorded in the post-anesthesia care unit for 2 h. RESULTS: The incidences and severity of nausea and the number of antiemetic administration were significantly lower in Group H than Group C (P < 0.05). But the sedation and pain score were similar. There was no QTc prolongation or extrapyramidal symptom in both groups. CONCLUSIONS: Prophylactic haloperidol 1 mg is effective in preventing PONV related to fentanyl-based IV PCA, with less adverse effects, in patients undergoing gynecological laparoscopic surgery.

Effects of the modified blade on reducing the risk of dental trauma by novice laryngoscopists in anticipated difficult airway / 대한마취과학회지

BACKGROUND: Dental trauma is one of the most common complications during laryngoscopy, especially by novice. As the chance of making direct contact with the teeth is decreased during laryngoscopy, the chance of applying direct pressure to the teeth is decreased, thus the injury by the blade also can be decreased. The purpose of this study was to determine the effectiveness of a modified Macintosh blade on reducing dental contact and the risk of dental trauma by novice laryngoscopists in anticipated difficult airway. METHODS: Sixty-six patients scheduled for elective surgery were divided into Easy group and Difficult group according to Wilson's risk sum score. Laryngoscopy was performed twice on each patient by novice, once with a regular Macintosh 3 blade and once with a blade in which the flange was partially removed (Callander modification). The distance between the flange of the blade and the upper incisors at glottic exposure was measured. We compared the blade-tooth distances and the chance of directly contacting the tooth between two blades. RESULTS: The modified blade provided more distance than the regular Macintosh blade in both group (P < 0.001). It is also associated with decreased chance of directly contacting the teeth, especially in Difficult group (73.7% with regular blade vs 10.6% with the modified blade) (P < 0.001). CONCLUSIONS: The modified Macintosh blade used in this study proved to be an effective device for novice laryngoscopists in reducing likelihood of dental injuries in anticipated difficult intubation.

Effects of the modified blade on reducing the risk of dental trauma by novice laryngoscopists in anticipated difficult airway / 대한마취과학회지

BACKGROUND: Dental trauma is one of the most common complications during laryngoscopy, especially by novice. As the chance of making direct contact with the teeth is decreased during laryngoscopy, the chance of applying direct pressure to the teeth is decreased, thus the injury by the blade also can be decreased. The purpose of this study was to determine the effectiveness of a modified Macintosh blade on reducing dental contact and the risk of dental trauma by novice laryngoscopists in anticipated difficult airway. METHODS: Sixty-six patients scheduled for elective surgery were divided into Easy group and Difficult group according to Wilson's risk sum score. Laryngoscopy was performed twice on each patient by novice, once with a regular Macintosh 3 blade and once with a blade in which the flange was partially removed (Callander modification). The distance between the flange of the blade and the upper incisors at glottic exposure was measured. We compared the blade-tooth distances and the chance of directly contacting the tooth between two blades. RESULTS: The modified blade provided more distance than the regular Macintosh blade in both group (P < 0.001). It is also associated with decreased chance of directly contacting the teeth, especially in Difficult group (73.7% with regular blade vs 10.6% with the modified blade) (P < 0.001). CONCLUSIONS: The modified Macintosh blade used in this study proved to be an effective device for novice laryngoscopists in reducing likelihood of dental injuries in anticipated difficult intubation.