Incidental Contralateral Retrograde Internal Jugular Venous Catheterization via a Right External Jugular Venous Route: A case report / 대한마취과학회지

We report of the occurrence of an incidental retrograde left internal jugular venous (IJV) catheterization during a right external jugular vein (EJV) approach.After induction of anesthesia, central venous catheterization was performed through the right EJV using the standard technique.There was no expected cardiac arrhythmia during guide wire insertion, and there was no atrial waveform on the CVP tracing.Therefore, we took a chest X-ray for confirmation of catheter placement, which revealed the tip was placed in the left IJV.We withdrew the catheter about 6-7 cm to prevent possible impairment of cerebral venous drainage by a retrograde-positioned catheter in the IJV.We think that the dilation of the left IJV due to Trendelenburg position, positive pressure ventilation, and the upward direction of the J-wire tip contributed to the contralateral retrograde IJV catheterization.We recommend that a chest X-ray always be taken if correct catheter tip placement is not confirmed during CVP catheterization.

Closed Reduction of Nasal Bone Fracture Under the Mask Ventilation Anesthesia Using Oral Airway

PURPOSE: The majority of nasal fractures have been treated by closed reduction. And they were manipulated under local anesthesia or general anesthesia. Under the local anesthesia, patients can feel the pain and fear, so general anesthesia through the endotracheal intubation became popularized recently to treat the nasal fracture. But it has still the drawbacks of postanesthetic complication. Therefore, under the mask ventilation anesthesia using oral airway, we tried to manipulate the nasal fracture. METHODS: From July 2007 to November 2007, we worked with fifty patients that were manipulated the nasal fracture. Fifty patients were divided into two groups, general anesthesia with the endotracheal intubation group(n=25) and the mask ventilation using oral airway group(n=25). We checked up the anesthesia time, postanesthetic complication, postoperative aesthetic & functional problem of nose in two groups. RESULTS: In total operation time and sore throat frequency among the postoperative anesthetic complications, there was statistically significant difference between the mask ventilation group and the endotracheal intubation group(p0.05). And no patients complained of postoperative nasal complication such as septal deviation, septal perforation, nasal obstruction and hump nose in two groups. CONCLUSION: Through the mask ventilation using oral airway, we could reach satisfactory results in the anesthetic time and postanesthetic complication.

Cardiovascular Effects of Free Movement of Abdominal Muscle in Prone Positioning during General Anesthesia / 영남의대학술지

BACKGROUND: The prone position is often used for operations involving the spine and provides excellent surgical access. The complications associated with the prone position include ocular and auricular injuries, and musculoskeletal injuries. In particular, the prone position during general anesthesia causes hemodynamic changes. To evaluate the cardiovascular effects of the prone position in surgical patients during general anesthesia, we investigated the effects on hemodynamic change of the prone position with the Jackson spinal surgery table. MATERIALS AND METHODS:Thirty patients undergoing spine surgery in the prone position were randomly selected. After induction of general anesthesia, intra-arterial and central venous pressures (CVP) were monitored and cardiac output was measured by NICO(R). We measured stroke volume, cardiac index, cardiac output, mean arterial pressure, heart rate, CVP and systemic vascular resistance (SVR) before changing the position. The same measurements were performed after changing to the prone position with the patient on the Jackson spinal surgery table. RESULTS: In the prone position, there was a significant reduction in stroke volume, cardiac index and cardiac output. The heart rate, mean arterial pressure and CVP were also decreased in the prone position but not significantly. However, the SVR was increased significantly. CONCLUSION: The degree of a reduced cardiac index was less on the Jackson spinal surgery table than other conditions of the prone position. The reduced epidural pressure caused by free abdominal movement may decrease intraoperative blood loss. Therefore, the Jackson spinal surgery table provides a convenient and stable method for maintaining patients in the prone position during spinal surgery.

Subcutaneous Emphysema and Inflammation of the Neck after Tracheal Puncture by an Intubating Stylet / 영남의대학술지

Laryngo-tracheal perforation caused by the use of a stylet during tracheal intubation is a rare complication. We present a case of subcutaneous emphysema and connective tissue inflammation after tracheal intubation. The patient was a 41-year-old male undergoing general anesthesia for an appendectomy. The intubation was difficult during laryngoscopy (Cormack-Lehane Grade III). An assistant provided an endotracheal tube with a stylet inside while the laryngoscope was in place. During intubation, a short, dull sound was heard with a sudden loss of resistance after the distal tip of the endotracheal tube passed the rima glottis. A sonogram and computerized tomography revealed subcutaneous emphysema from the neck to the upper mediastinum and fluid collection between the trachea and the thyroid. This lesion appeared to have been caused by the protruded, loose stylet. Anesthesiologists should be aware of the damage a loose stylet protruding beyond the tip of the endotracheal tube can cause.

The Effect of Subtenons Lidocaine Injection and/or Preoperative Anxiety on Emergence Agitation after Sevoflurane Anesthesia in Pediatric Strabismus Surgery / 대한마취과학회지

< 0.05). The incidence of emergence agitation was 17% in the subtenons lidocaine injection group, which was significantly lower than in the control group (36%) (P < 0.05). CONCLUSIONS: A lidocaine injection into the subtenons space reduces emergence agitation after sevoflurane anesthesia in pediatric strabismus surgery.

Proper Respiratory Rate Determination during Controlled Ventilation in Infants under General Anesthesia / 대한마취과학회지

BACKGROUND:We experienced unintentional hyperventilation during mechanical ventilation in infants under general anesthesia. It is very difficult to decide upon respiratory rate or tidal volume for adequate ventilation without respiratory gas monitoring. During pulmonary ventilation using a Mapleson D circuit, the utilization of high fresh gas flow dilutes the expired gas and causes an underestimation of end-tidal CO2. We undertook to find a proper respiratory rate (RR) with a fixed tidal volume during controlled ventilation in infant general anesthesia. METHODS: We studied 50 infants weighing below 10 kg during general anesthesia. An uncuffed endotracheal tube was selected 3.5 or 4.0 mm (inner diameter). After intubation with midazolam, thiopental sodium and vecuronium, controlled ventilation was applied: total fresh gas flow 3 L/minute, peak inspiratory pressure 15-20 cmH2O, and RR 19 or 20/minute. Arterial blood gas analysis was done 20 minutes later. We calculated the RR for a PaCO2 of 36 mmHg according to the equation: RR (applied) = estimated RR x estimated PaCO2/ideal PaCO2. In addition, linear regression was performed to analyze the relation between age and RR. RESULTS: The estimated regression equation for RR using Pearson's correlation coefficient was as follows: RR = 22.835 - 0.415 x age (months). CONCLUSIONS: The equation (RR = 22.835 - 0.415 x age [months]) could be used as an index for safe ventilatory management without severe hyper- or hypo-carbia in infants during general anesthesia.

The Effect of Lesser Palatine Nerve Block on Pain after Elective Pediatric Tonsillectomy / 대한마취과학회지

BACKGROUND: This prospective, double-blind randomized study was performed to evaluate the analgesic effect of lesser palatine nerve block for postoperative pain control after a pediatric tonsillectomy, and to compare the analgesic effects of pre-emptive versus postoperative blocks. METHODS: Forty-eight ASA class 1 children, scheduled for an elective tonsillectomy were randomized into three groups. Patients received lesser palatine nerve blocks, using divided doses of 0.05 ml/kg of 0.2% ropivacaine, 5 min prior to the beginning of tonsillectomy (Pre-block group) or immediately after surgery (Post-block group). Patients allocated into the Control group did not receive any nerve block. Postoperative pain was measured immediately after surgery, 3, 6, 12 and 24 hours following operation using a 0 to 4 points pain scale, based on a facial expression of pain scale ruler. Side effects and the number of analgesic injections were observed for 24 hours postoperatively. RESULTS: No significant differences in the pain scores were observed immediately after surgery and at 3, 6, 12 and 24 hours after operation in the three groups (P > 0.05). The number of analgesic injections was similar in the groups. CONCLUSIONS: The results of this study reveal that the lesser palatine nerve block was not effective for postoperative pain control following pediatric tonsillectomy, and that the pre-emptive block offered no pain control benefit over the postoperative block. Therefore, we do not recommend lesser palatine nerve blocks for the management of postoperative pain after pediatric tonsillectomy.

Proper Respiratory Rate during Mechanical Ventilation in Pediatric General Anesthesia / 대한마취과학회지

BACKGROUND: We experienced unintentional hyperventilation during mechanical ventilation in pediatric general anesthesia. It is very difficult to decide respiratory rate or tidal volume with a patient's condition for adequate ventilation while respiratory gas monitoring is unavailable in many cases. Therefore, we studied to find a proper respiratory rate (RR) with a fixed tidal volume during mechanical ventilation in general anesthesia. METHODS: We studied 70 children weighing 10-30 kg during general anesthesia. An endotracheal tube was selected according to 3.5+age (yrs)/4. After intubation with midazolam, thiopental sodium and succinylcholine, mechanical ventilation was applied: tidal volume 8-10 ml/kg, peak inspiratory pressure 15-20 mmHg, RR 20 (infant), 18 (under 3 yrs), 16 (under 5 yrs), 14 (above 5 yrs) breaths/min. We adjusted the RR for a PetCO2 30 33 mmHg and arterial blood gas analysis was done 30 minutes each change. We calculated the RR for a PaCO2 of 36 mmHg according to the equation: RR (applied) = estimated RR estimated PaCO2/ideal PaCO2. In addition, the linear regression was analyzed between the age and RR. RESULTS: The estimated regression for RR using Pearson's correlation coefficient was as follows: RR = 19.25-0.07Xage (month). CONCLUSIONS: The equation (RR = 19.25-0.07Xage [month]) could be an index for safe ventilatory management without severe hyper- or hypo-carbia in the pediatric general anesthesia.

Anesthetic Consideration Concerning a Congenital Diaphragmatic Hernia in a Patient with a Single Ventricle: A case report / 대한마취과학회지

A congenital diaphragmatic hernia is a life threatening condition. It causes pulmonary hypertension with right to left shunting that contributes to severe hypoxemia in neonates. A particulary poor prognosis is predicted if a congenital diaphragmatic hernia is associated with cardiac deformities and pulmonary hypoplasia. We experienced a case of a 3,500 gm female infant with a congenital diaphragmatic hernia and a single ventricle with left pulmonary atresia. Of prime concern was the maintenance of pulmonary vascular resistance, and this was achieved by altering ventilation, inspired oxygen concentration and blood pH. Also postoperative management of pulmonary hypertension is as important as surgical correction of the congenital diaphragmatic hernia. We performed general anesthesia with O2-fentanyl-isoflurane for correction of diaphragmatic hernia. The fentanyl infusion continued after the operation for blunting of stress responses in the pulmonary circulation. The patient was given a Blalock-Taussig shunt at postoperative day 12.

Pediatric Outpatient Anesthesia / 영남의대학술지

In recent years, health care cost containment concerns have resulted in an increase in outpatient (or same-day) surgery. Many procedures previously performed on an inpatient surgery basis have been shifted to outpatient settings. Anesthesia for outpatient surgery is exactly the same as inpatient anesthesia, except that the primary concern is the selection of patients who can be discharged safely on the day of surgery. The anesthesiologist should have a sound rational basis for choice of pharmacologic agents that are geared to expeditious patient discharge from the hospital. Cost concerns aside, outpatient surgery has many additional advantages in the pediatric setting. It minimizes the length of time the child is hospitalized, decreases separation anxiety, promotes parental involvement in the child's postoperative care in the more congenial environment of home, and decreases risk of nosocomial infection and iatrogenic illness.

On the Usefulness of Intravenous Anesthesia for Patients Undergoing Postoperative Radiologic Examination / 대한마취과학회지

BACKGROUND: In most brain operations, the endotracheal tube is kept in postoperatively for airway maintenance during radiologic examinations. But the endotracheal tube causes tracheal irritation and hemodynamic changes. Inhalation anesthetics can not be administered during transport, and minimal concentration is exhaled for several hours after the end of inhalation. The present study was designed : (1) to determine the end tidal isoflurane concentration after the end of administration ; (2) to investigate the effects of intravenous anesthetics in patients with tracheal intubation during radiologic examination postoperatively. METHODS: We selected forty adult patients who were scheduled for elective neurosurgical operation with postoperative brain CT (computerized tomography). The study was performed in 2 steps; in the step 1 (n = 10), end tidal isoflurane concentration was checked after ending inhalation. In the step 2 (n = 30), patients were divided into one of three groups according to anesthesia method; group I (using isoflurane), group P (change from isoflurane to propofol about an hour before operation end), group M (using midazolam instead of propofol, compared to group P). In each group, the frequency of bucking and incidence of hypertension were checked during postoperative radiologic examinations. RESULTS: Minimal concentrations of isoflurane were detected in exhaled gas for about 2 hours after the end of isoflurane inhalation. The frequency of bucking was significantly lower in the group P and M than in group I (P = 0.002). In group P, the incidence of hypertension was significantly reduced compared to group M and I (P = 0.031). CONCLUSIONS: These results suggest that the change of anesthetic technique (from inhalation to intravenous) in the late period of operation, provides postoperative hemodynamic stability, a more comfortable state and minimal environmental pollution in comparison to inhalation anesthesia only.

On the Usefulness of Intravenous Anesthesia for Patients Undergoing Postoperative Radiologic Examination / 대한마취과학회지

BACKGROUND: In most brain operations, the endotracheal tube is kept in postoperatively for airway maintenance during radiologic examinations. But the endotracheal tube causes tracheal irritation and hemodynamic changes. Inhalation anesthetics can not be administered during transport, and minimal concentration is exhaled for several hours after the end of inhalation. The present study was designed : (1) to determine the end tidal isoflurane concentration after the end of administration ; (2) to investigate the effects of intravenous anesthetics in patients with tracheal intubation during radiologic examination postoperatively. METHODS: We selected forty adult patients who were scheduled for elective neurosurgical operation with postoperative brain CT (computerized tomography). The study was performed in 2 steps; in the step 1 (n = 10), end tidal isoflurane concentration was checked after ending inhalation. In the step 2 (n = 30), patients were divided into one of three groups according to anesthesia method; group I (using isoflurane), group P (change from isoflurane to propofol about an hour before operation end), group M (using midazolam instead of propofol, compared to group P). In each group, the frequency of bucking and incidence of hypertension were checked during postoperative radiologic examinations. RESULTS: Minimal concentrations of isoflurane were detected in exhaled gas for about 2 hours after the end of isoflurane inhalation. The frequency of bucking was significantly lower in the group P and M than in group I (P = 0.002). In group P, the incidence of hypertension was significantly reduced compared to group M and I (P = 0.031). CONCLUSIONS: These results suggest that the change of anesthetic technique (from inhalation to intravenous) in the late period of operation, provides postoperative hemodynamic stability, a more comfortable state and minimal environmental pollution in comparison to inhalation anesthesia only.

The Appropriate Inflow Rates of Oxygen and Nitrous Oxide in Adult General Anesthesia / 대한마취과학회지

BACKGROUND: During adult general anesthesia, we used 3~5 L/min of fresh gas flow(FGF) but low FGF are employed, the amount of anesthetic consumption and air contamination can be reduced. The aim of this study was to determine the minimal appropriate inflow rate of oxygen and nitrous oxide during semiclosed circle technique. METHODS: We selected 40 patients, ASA group 1 or 2, scheduled for elective, nonabdominal surgery under general anesthesia with semiclosed circle system. Anesthesia was maintained with 50% oxygen, nitrous oxide and enflurane, controlled ventilation was used; rate of 10/min, tidal volume of 10 ml/kg. After induction and vital signs stabilized, FGF was changed to 4 L, 3 L, 2 L and 1L/min at interval of 30 minutes. We observed mean airway pressure and arterial blood gas tensions. RESULTS: The changes of mean airway pressure did not correlated with fresh gas inflow rate. In arterial blood gas analysis, PaO2 showed a decreasing tendency significantly according to decreasing fresh gas inflow rate(p<0.01) but there were no clinical hypoxemia in all patients. There were no significant changes in pH, PaCO2 and base excess. CONCLUSIONS: We consider that FGF of 1~2 L/min is appropriate during adult general anesthesia because of economic and ecological advantages. Also, we consider low flow technique with below 1L/min can be used safely and effectively under proper gas monitoring such as oxygen analyzer, capnometer.

The Sedative Effect of Propofol and Midazolam in Pediatric Caudal Anesthesia / 대한마취과학회지

Pediatric patients often could not be cooperated with physician during various procedures. So, many agents such as inbalation anesthetics and intravenous anesthetics have been used to decrease pain, anxiety and awareness during regional anesthesia in children. The purpose of this study was to compare propofol with midazolam and inhalation anesthetics for emergence time from sedation in caudal anesthesia of children. Forty five patients were randomly divided three groups. In propofol group(Group P, n=15), induction dose of 1.0 mg/kg propofol(Diprivan) was received followed by continuous infusion of 3~5 mg/kg/hr. In midazolam group(Group M, n=15), induction dose of 0.15 mg/kg midazolam(Dormicum) was received followed by continuous infusion of 0.06~0.08 mg/kg/hr. In inhalation anesthetic group(Group E, n=15), O2-NO2-Enflurane(3L/min, 3L/min, 0.6~1.0 vo1% respectively) inhalated through face mask by non-rebreathing system for sedation. The blood pressure, heart rate, arterial oxygen saturation during anesthesia and emergence time, complications were measured. The results were as follows: 1) The blood pressure was significantly decreased in group M and E. Heart rate was also significantly increased in group M and E. 2) The arterial oxygen saturation was not significantly changed in each three groups. 3) In the group P and E, emergence time was shorter than in the group M. From the above results, we conclude that propofol is more excellent intravenous anesthetics than midazolam in respect to emergence time and hemodynamic changes in pediatric caudal anesthesia.

Changes of Oxygen Saturation Depend on the Tracheal Extubation Methods in Pediatric Patients / 대한마취과학회지

This study was performed to observe the changes of oxygen saturation after tracheal extubation, which depends on the following tracheal extubation methods of the group 1. 2A. 2B, has done. One hundred twenty-five healthy patients that had been selected out of 1~15 year-old at random were divided as follows; Group 1; extubation performed in being awake (n=49) Group 2; anesthetized extubation (n=76) 2A: extubation done in 5 min after discontinuing N2O (n=38) 2B: extubation under anesthesia (GOE or GOF) (n=38) The grouping, which has at random been assigned to the patients, was done just before the end of operation. Oxygen saturation was measured continuously by pulse-oximeter (Minolta Pulsox TS-7, Japan) and was recorded in the process of operation, immediately after extubation and at 1.2.4.6.8.10.20.30 min after extubation while they were spontaneously breathng room air. In case oxygen saturation were less than 90%, supplementary oxygen was administered to them. The frequency of hypoxemia was higher in Group 2 (19.7%) than in Group 1 (10.2%). In group 2B, 2 patients developed severe hypoxemia and 1 patient developed PVC immediately after extubation. Changes of oxygen saturation were as follows; Oxygen saturation in Group 2B was higher than that in Group 1 at each 2 min and 4 min and was also higher than that in Group 2A at 4 min after extubation. As a result, Group 1 is the safest extubation method because of its low risk of hypoxemia. If anestltized extubation must be needed, Group 2A would be preferable to Group 2B method because the frequency of hypoxemia was higher in Group 2B than in Group 2A.In addition, It is suggested that monitoring oxygen saturation continuously by the patients should be safe.

Analgesic Effects of Lumbar Epidural Narcotics for Relief of Upper Abdominal Post-operative Pain / 영남의대학술지

To assess the effect of postoperative pain control of upper abdominal surgery through lumbar epidural narcotic injection, the 3rd or 4th lumbar epidural puncture was done, and were injected 1 mg of morphine (Group I) or 10 mg of demerol (Group II) mixed with 10 ml of normal saline into the epidural space, after operation of the cholecystectomy in 10 patients and antrectomy and vagotomy, subtotal or total gastrectomy in 10 patients. Time interval of the postoperative analgesic effect between morphine and demerol groups were compared. The results of this study were as follows: 1. In the group I, average analgesic duration was 29.4 hours. 2. In the group II, average analgesic duration was 4.0 hours. It is concluded that postoperative pain control of upper abdominal surgery through the lumbar epidural narcotic injection was effective, and morphine injection was more effective than demerol.