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.

Amniotic fluid embolism that took place during an emergent Cesarean section: A case report / 대한마취과학회지

Amniotic fluid embolism (AFE) is a rare but fatal obstetric emergency, characterized by sudden cardiovascular collapse, dyspnea or respiratory arrest and altered mentality, disseminated intravascular coagulation (DIC). It can lead to severe maternal morbidity and mortality, but the prediction of its occurrence and treatment are very difficult. We experienced a case of AFE during emergent Cesarean section in a 40(+6) weeks healthy pregnant woman, age 33. Sudden dyspnea, hypotension, signs of pulmonary edema and DIC were developed during Cesarean section, and cardiac arrest followed after these events. The course of these events was so rapid and catastrophic, which was consistent with AFE. Thus, we report this case precisely and review pathophysiology, diagnosis, treatment of AFE by referring to up-to-date literatures.

The effect of remifentanil for reducing myoclonus during induction of anesthesia with etomidate / 대한마취과학회지

BACKGROUND: Myoclonic movement is a common problem during induction of anesthesia with etomidate. We investigated the influences of pretreatment with remifentanil on etomidate induced myoclonus. METHODS: Ninety ASA class I patients were divided randomly into three groups. Group NS received normal saline 2 ml as placebo (n = 30), group R0.5 and group R1.0 were pretreated with remifentanil 0.5 microgram/kg (n = 30) or 1.0 microgram/kg (n = 30) 1 minute before induction with etomidate 0.3 mg/kg. Orotracheal intubation was performed after administration of rocuronium 0.5 mg/kg. We assessed the incidence, onset, duration and intensity of myoclonus. Mean arterial pressure (MAP), heart rate (HR) and bispectral index (BIS) were recorded during induction. RESULTS: Twenty five patients developed myoclonus in group NS (83.3%), 3 patients in group R0.5 developed myoclonus (10%), as did 5 patients in group R1.0 (16.7%). Moderate to severe myoclonus of grade 3 and 4 were found 66.7% of patients in group NS, whereas no patients in both remifentanil pretreated groups developed this grade of myoclonus. The duration of myoclonus was reduced significantly in the remifentanil groups: 93.8 +/- 59.5 sec in group NS, 49.3 +/- 34.9 sec in group R0.5, 36.0 +/- 27.0 sec in group R1.0 (P < 0.05). HR was decreased by pretreatment with remifentanil prior to induction, while MAP and HR were decreased after induction with etomidate (P < 0.05). BIS changes were not different among the three groups. The dose dependent differences between the two remifentanil doses were not noticed. CONCLUSIONS: Pretreatment with remifentanil significantly reduced the incidence, duration and intensity of etomidate induced myoclonus.

Interscalene brachial plexus block: depth and angle from the skin insertion point to the brachial plexus and to C6-7 intervertebral foramen / 대한마취과학회지

BACKGROUND: The angle and depth from the insertion point to the brachial plexus (BP) and C6-7 intervertebral foramen (IF) was examined to prevent critical complications of an interscalene brachial plexus block (ISBPB), such as an epidural or subdural injection of local anesthetics and spinal cord injury. METHODS: Thirty patients (female = 12, male = 18), aged 20-64 years, undergoing shoulder or upper limb surgery were examined. ISBPB was performed at the interscalene groove intersecting the extended transverse line from the cricoid cartilage. A needle was then advanced towards the C6 transverse process (TP) and C6-7 IF under the C-arm fluoroscopic guidance. The depth and angle of the needle path intersecting the sagittal plane from the skin insertion point to BP, transverse process (TP) and IF were measured. RESULTS: The mean depth of the needle from the insertion point to BP, TP and IF were 2.6 +/- 0.3 cm, 3.2 +/- 0.4 cm, 3.7 +/- 0.3 cm in the female patients, and 2.7 +/- 0.3 cm, 3.6 +/- 0.5 cm, 4.1 +/- 0.3 cm in the male patients. The mean angle of the needle path at the same point was 56.0 +/- 7.2o (range, 42.0-65.0degrees), 54.2 +/- 5.8degrees, 53.7 +/- 4.4degrees in the female patients, and 59.3 +/-8.3degrees (45.0-75.0degrees), 54.0 +/- 6.3degrees, 54.9 +/- 4.2degrees in male patients. There were significant differences in the depth from the skin to the TP and IF between males and females. CONCLUSIONS: These findings are expected to provide a guideline for more accurate needle placement and successful block during ISBPB.

Interscalene brachial plexus block: depth and angle from the skin insertion point to the brachial plexus and to C6-7 intervertebral foramen / 대한마취과학회지

BACKGROUND: The angle and depth from the insertion point to the brachial plexus (BP) and C6-7 intervertebral foramen (IF) was examined to prevent critical complications of an interscalene brachial plexus block (ISBPB), such as an epidural or subdural injection of local anesthetics and spinal cord injury. METHODS: Thirty patients (female = 12, male = 18), aged 20-64 years, undergoing shoulder or upper limb surgery were examined. ISBPB was performed at the interscalene groove intersecting the extended transverse line from the cricoid cartilage. A needle was then advanced towards the C6 transverse process (TP) and C6-7 IF under the C-arm fluoroscopic guidance. The depth and angle of the needle path intersecting the sagittal plane from the skin insertion point to BP, transverse process (TP) and IF were measured. RESULTS: The mean depth of the needle from the insertion point to BP, TP and IF were 2.6 +/- 0.3 cm, 3.2 +/- 0.4 cm, 3.7 +/- 0.3 cm in the female patients, and 2.7 +/- 0.3 cm, 3.6 +/- 0.5 cm, 4.1 +/- 0.3 cm in the male patients. The mean angle of the needle path at the same point was 56.0 +/- 7.2o (range, 42.0-65.0degrees), 54.2 +/- 5.8degrees, 53.7 +/- 4.4degrees in the female patients, and 59.3 +/-8.3degrees (45.0-75.0degrees), 54.0 +/- 6.3degrees, 54.9 +/- 4.2degrees in male patients. There were significant differences in the depth from the skin to the TP and IF between males and females. CONCLUSIONS: These findings are expected to provide a guideline for more accurate needle placement and successful block during ISBPB.

Expiratory Valve Malfunction Detected Immediately after Endotracheal Intubation: A case report / 대한마취과학회지

The malfunction of an expiratory unidirectional valve (EV) can cause rebreath of expired gas, barotraumas, or ventilatory failure during the general anesthesia. The following is a report on a case of ventilatoryfailure caused by an EV that failed to open during the induction of anesthesia. A 57-year-old man was scheduled for the biopsy of a vocal cord polyp. After intubation, we could not detect the evidence of ventilation through the endotracheal tube. Suspecting the esophageal intubation, we administered extubation. The patient was still having difficulty in ventilating even after a retrial of intubation. Then we discovered the EV was failing to open properly with ventilation and thus not able to function properly. The common cause of ventilatory failure immediately after intubation is malposition of an endotracheal tube, like esophageal intubation, and equipment failure also has reported. Accordingly, we should remember possible causes of ventilatory failure after intubations and routine conscientious inspection of the ventilator.

Effect of Methylmethacrylate Monomer in Isolated Rat Tracheal Rings / 대한마취과학회지

BACKGROUND: Methylmethacrylate monomer (MN) bone cement is commonly employed in orthopedic procedures, particularly total hip and knee replacement, to anchor prosthetic devices to bone. Numerous cardiopulmonary complications can occur just after injection of MN. And MN produces direct relaxation of vascular smooth muscle in vitro. The purpose of this study was to determine if MN could have relaxation effect in tracheal smooth muscle too. METHODS: Each ring of rat trachea was suspended on wire supports in a bath with Tris Tyrode solution. Dose response curves of MN were recorded after contraction of tracheal ring with acethylcholine (Ach) 10(-5) M or cabachol (Cch) 10(-8) M. MN was administered in denuded tracheal rings and compared it's effect with intact tracheal rings to see the effect of epithelium for contraction. And MN dose response curves were recorded after pretreatment of nitric oxide synthase inactivator (L-NAME), muscarinic receptor blocker (atropine), beta-adrenaline receptor blocker (propranolol), adenylyl cyclase inhibitor (SQ22536) respectively. The effects of MN on cellular Ca2+ and K+ migration in rat tracheal preparations were studied. RESULTS: MN significantly inhibited acetylcholine or carbachol induced contractions of tracheal rings dose-dependently (P < 0.05). This relaxation effect of MN was not recovered in denuded tracheal rings. And pretreatment with L-NAME, propranolol, atropine, SQ22536 or tetraethylammonium respectively did not recover the relaxation effect of MN. MN inhibited both intracellular calcium release and extracelluar calcium influx. CONCLUSIONS: The relaxation effects of MN on rat tracheal rings are not related with epithelium, nitric oxide, muscarinic, or beta-adrenergic receptor. Methylmethacrylate monomer inhibits both intracellular calcium release and extracelluar calcium influx.

Delayed Cardiac Arrest after Brachial Plexus Block in a Patient Taking a beta-Adrenoreceptor Antagonist and Calcium Channel Blocker: A case report / 대한마취과학회지

A Bezold-Jarisch reflex (BJR) mediated vasovagal syncope is the most common neurally mediated reflex characterized by the sudden failure of the autonomic nervous system and have been reported in patients undergoing a peripheral nerve block. The concomitant administration of a beta-adrenoreceptor antagonist and calcium channel blocker have a synergistic suppressant effect on the autonomic nervous system and interact with the anesthetics significantly. We report a case of a 57-year-old female patient with essential hypertension controlled with lercanidipine and carvedilol. Cardiac arrest developed with spontaneous respiration 50 min after the brachial plexus block to remove a plate in the humerus. Epinephrine was administered and the pulse immediately returned to a normal sinus rhythm. This event might be vasovagal syncope mediated by BJR, and realted to the antihypertensive medication used.

Comparison of Emergence Agitation from Sevoflurane Anesthesia after Thiopental Sodium, Propofol or Ketamine Induction in Pediatric Inguinal Herniorrhaphy / 대한마취과학회지

BACKGROUND: This study compared the incidence of emergence agitation and the recovery profile from sevoflurane anesthesia after thiopental sodium, propofol or ketamine induction in pediatric inguinal herniorrhaphy. METHODS: Forty eight children aged 1-7 years undergoing high ligation due to an inguinal hernia were examined. All patients received a 0.004 mg/kg glycopyrrolate injection for premedication prior to induction and were randomly assigned to receive thiopental sodium 5 mg/kg (Group T, n = 16), propofol 2 mg/kg (Group P, n = 16) or ketamine 1 mg/kg (Group K, n = 16) for induction. The side effects during the induction time were checked. All patients received sevoflurane (2-2.5 vol%)-N2O (2 L/min)-O2 (2 L/min) for the maintenance of anesthesia. Ventilation was given to assist spontaneous ventilation using a facial mask. The agitation score, pain score, discharge score, incidence of emergence agitation and postoperative side effects in the three groups were assessed at the recovery room and compared. RESULTS: The emergence time in Group T (7.5 +/- 1.8 min) was significantly rapid. The agitation and pain scores were significantly low in Group P. The discharge score was more rapid in Groups P and K than in Group T. The incidence of emergence agitation was similar in all three groups. CONCLUSIONS: Although recovery was faster and emergence agitation was low in the propofol group, propofol induction was not smooth compared with thiopental or ketamine induction. The incidence of emergence agitation after sevoflurane anesthesia in pediatric inguinal herniorrhaphy was similar in the thiopental sodium, propofol or ketamine induction groups.

Clinical Evaluation of General and Caudal Anesthesia for Inguinal Herniorrhaphy in Children / 대한마취과학회지

BACKGROUND: Caudal block has proved to be a satisfactory method of providing perioperative analgesia for pediatric surgery in the inguinal and perineal areas. The object of this study was to compare the general (n=55) with caudal anesthesia (n=41) in pediatric inguinal herniorrhaphy during surgery and postoperative 24 hours in their changes of behaviors in the recovery room, and other complications. METHODS: Ninety six children who underwent to inguinal herniorrhaphy were devided into two groups. Group I was given general anesthesia as usual methods using endotracheal intubation. Group II was given caudal block using 1% lidocaine 1 ml/kg or 0.25% bupivacaine 1 ml/kg, or a mixture of both of them at the ratio of 1:1, 1 ml/kg. All caudal blocks were carried out in left lateral position after ketamine 1-1.5 mg/kg intravenous injection. The side effects during and after operation and postoperative behavior in the recovery room, neurologic complications and postoperative fever incidence were observed and compared with the two groups. RESULTS: In group I (n=55), 13 cases (23.6%) showed hoarseness after extubation. 78.2% of 55 patients were irritable and cryng in the recovery room. Postoperative fever incidence was over 69%. In group II (n=41), almost all patients were calm and stayed quiet in the recovery room. However there were 3 cases of bradycardia and 2 cases of hypotension during operation. Postoperative complications were rare and the mumber of patients with fever was 36.6% which was significantly low compared to group I. CONCLUSIONS: As the results of this study, we report that caudal anesthesia is a safe, simple practical method with few complications for inguinal herniorraphy in children compared with general anesthesia. We also recommend that the caudal block can be used safely in pediatric outpatient surgery.

Volume Changes under Isotonic Condition Containing Thiopental in Brain Astrocytoma Cells / 대한구급학회지

BACKGOUND: Cell volume regulation is especially important in the brain because the brain is confined within a non-compliant vault and cannot tolerate significant perturbations in cell size. Cerebral cell volume regulation mechanisms are activated by sustained disturbances in plasma osmolality. The constancy of cell volume under physiological conditions is generally thought to reflex a balance between influx and efflux of solute and is therefore critically dependent on the properties of the plasma membrane. Cell volume regulation have not been described under isoosmotic solution. The object of the study was to know the effects of thiopental on cell volume change in isoosmotic condition. METHODS: We made isoosmotic solution without thiopental (Group 1) and isoosmotic solution with 22.9 mM (Group 2), 16.8 mM (Group 3), 13.3 mM (Group 4) thiopental, separately, in order to study changes in cell volume under isoosmotic solution. We put cultured human brain astrocytoma cells into isoosmotic solution for each group and calculated cell volume using Coulter Counter after 30 minutes. RESULTS: Cell volume was shown to be 5084+/-8580 (micrometer3)in Group 1, 501+/-854 (micrometer3) in Group 2, 1183+/-3839 (micrometer3) in Group 3, and 624+/-1100 (micrometer3) in Group 4. We discovered that cells in Group 2,3,4 were shrunk relative to cells in Group 1 (p<0.01). And there were significant differences in cell volume among thiopental groups. CONCLUSIONS: Thiopental may has an effect on cell membrane properties and decrease cell volume under isoosmotic solution in brain astrocytoma cell.

Effectiveness of Left Infrascapular Skin Temperature Monitoring in the ICU / 대한구급학회지

BACKGOUND: Many sites are used to measure the body temperature and each site has different physiologic and practical importance. Several types of skin temperature monitoring have been used as simple, inexpensive and viable alternatives in many settings. In the operating area, it is difficult to insert a temperature probe during operation. The object of this study was to compare the difference and the correlation between the temperature of the left infrascapular skin region and temperatures of axilla, nasopharynx and rectum, METHODS: Forty-two adult patients who were admitted at surgical ICU were studied. After covering the bed with insulator and sheets, patients were placed in supine position. Temperature monitoring was done at the same time using four temperature probes from two bedside patient monitors in the same patient. The temperatures were measured twice at 30 minutes after application of the temperature probe at 10 minute intervals and the average temperature was recorded. RESULTS: The differences between skin temperature and rectal, nasopharyngeal, and axillary temperatures were -0.64+/-0.21degrees C (p<0.05), -0.40+/-0.21degrees C, and 0.24+/-0.21degrees C respectively. The lineal correlation between skin temperature and rectal, nasopharyngeal, and axillary temperatures were 0.839, 0.854, and 0.819, respectively (p<0.001). CONCLUSION: This study suggests that the monitoring of the skin temperature at the left infrascapular skin region is well correlated with the nasopharyngeal, rectal and axillary temperatures. And it will be an easy, simple and safe method which can be used for the patients who are alert but need continuous temperature monitoring in the intensive care unit and as well as for the patients who are in the middle of operation.

Statistical Analysis of the Patients in the ICU by Using the APACHE II Scoring System / 대한구급학회지

Introduction: The APACHE II scoring system has been promulgated as a useful tool in the assessment of the severity of disease and prognosis for patients with acute-on-chronic medical conditions. The purpose of this study was to assess the statistical association of APACHE II score and multiple variables in ICU patients. METHODS: Prospective data on 803 ICU patients for validation of the APACHE II system were analysed. We evaluated the relationship between APACHE II scores within the first 24 hours of ICU admission and multiple variables that included days in the ICU, mortality rate and age. The patients were classified as operation and nonoperation, survival and nonsurvival groups. RESULT: 1) The APACHE II score was significantly higher in the 153 nonsurvivals (23.97+/-10.98) than in the 651 survivals (11.51+/-6.14) (p<0.05). 2) The mean APACHE II score of the nonoperation group (14.52+/-9.29) was significantly higher than operation group (12.40+/-7.30) (p<0.05). 3) The overall mortality rate was 17.8%. 4) All patients with an APACHE II score over 40 died. CONCLUSION: The APACHE II score is statistically related with the mortality of critically ill patients.

Anesthesia forPatients with Wolff-Parkinson-White Syndrome / 대한마취과학회지

Since it was first described in 1930 by Wolff, Parkinson and White (W-P-W), the W-P-W syndrome, in its clinical significance, is the occurrence of tachyarrythmia by accessory conduction which may result in chest pain, hypotesion, congestive failure, syncope or sudden death. It still remains one of the most difficult cardiac arrythinias to treat. We experience the successful anesthetic management of 10 patients with W-P-W syndrome for non-cardiac and cardiac surgery from January, 1971 to April, 1987 at Severance hospital. With adequate preoperative management, in spite of their syndrome, all 10 patients tolerated general anesthesia fairly well, and we did not notice any significant changes in their vital signs during the perioperative period, Among the 10 patients, one recently experienced serious case is presented. In the selection of drugs for general anesthesia in cases of W-P-W syndrome, careful consideration should be given to all drugs which affect the conduction system of the heart.

Anesthesia forPatients with Wolff-Parkinson-White Syndrome / 대한마취과학회지

Since it was first described in 1930 by Wolff, Parkinson and White (W-P-W), the W-P-W syndrome, in its clinical significance, is the occurrence of tachyarrythmia by accessory conduction which may result in chest pain, hypotesion, congestive failure, syncope or sudden death. It still remains one of the most difficult cardiac arrythinias to treat. We experience the successful anesthetic management of 10 patients with W-P-W syndrome for non-cardiac and cardiac surgery from January, 1971 to April, 1987 at Severance hospital. With adequate preoperative management, in spite of their syndrome, all 10 patients tolerated general anesthesia fairly well, and we did not notice any significant changes in their vital signs during the perioperative period, Among the 10 patients, one recently experienced serious case is presented. In the selection of drugs for general anesthesia in cases of W-P-W syndrome, careful consideration should be given to all drugs which affect the conduction system of the heart.