Who are at high risk of mortality and morbidity among children with congenital heart disease undergoing noncardiac surgery?

With advances in the development of surgical and medical treatments for congenital heart disease (CHD), the population of children and adults with CHD is growing. This population requires multiple surgical and diagnostic imaging procedures. Therefore, general anesthesia is inevitable. In many studies, it has been reported that children with CHD have increased anesthesia risks when undergoing noncardiac surgeries compared to children without CHD. The highest risk group included patients with functional single ventricle, suprasystemic pulmonary hypertension, left ventricular outflow obstruction, and cardiomyopathy. In this review, we provide an overview of perioperative risks in children with CHD undergoing noncardiac surgeries and anesthetic considerations in patients classified as having the highest risk.

Comparison of pulse pressure variation and pleth variability index in the prone position in pediatric patients under 2 years old / 대한마취과학회지

BACKGROUND@#The assessment of intravascular volume status is very important especially in children during anesthesia. Pulse pressure variation (PPV) and pleth variability index (PVI) are well known parameters for assessing intravascular volume status and fluid responsiveness. We compared PPV and PVI for children aged less than two years who underwent surgery in the prone position.@*METHODS@#A total of 27 children were enrolled. We measured PPV and PVI at the same limb during surgery before and after changing the patients’ position from supine to prone. We then compared PPV and PVI at each period using Bland-Altman plot for bias between the two parameters and for any correlation. We also examined the difference between before and after the position change for each parameter, along with peak inspiratory pressure, heart rate and mean blood pressure.@*RESULTS@#The bias between PPV and PVI was −2.2% with a 95% limits of agreement of −18.8% to 14.5%, not showing significant correlation at any period. Both PPV and PVI showed no significant difference before and after the position change.@*CONCLUSIONS@#No significant correlation between PVI and PPV was observed in children undergoing surgery in the prone position. Further studies relating PVI, PPV, and fluid responsiveness via adequate cardiac output estimation in children aged less than 2 years are required.

Comparison of pulse pressure variation and pleth variability index in the prone position in pediatric patients under 2 years old / 대한마취과학회지

BACKGROUND: The assessment of intravascular volume status is very important especially in children during anesthesia. Pulse pressure variation (PPV) and pleth variability index (PVI) are well known parameters for assessing intravascular volume status and fluid responsiveness. We compared PPV and PVI for children aged less than two years who underwent surgery in the prone position. METHODS: A total of 27 children were enrolled. We measured PPV and PVI at the same limb during surgery before and after changing the patients’ position from supine to prone. We then compared PPV and PVI at each period using Bland-Altman plot for bias between the two parameters and for any correlation. We also examined the difference between before and after the position change for each parameter, along with peak inspiratory pressure, heart rate and mean blood pressure. RESULTS: The bias between PPV and PVI was −2.2% with a 95% limits of agreement of −18.8% to 14.5%, not showing significant correlation at any period. Both PPV and PVI showed no significant difference before and after the position change. CONCLUSIONS: No significant correlation between PVI and PPV was observed in children undergoing surgery in the prone position. Further studies relating PVI, PPV, and fluid responsiveness via adequate cardiac output estimation in children aged less than 2 years are required.

Heart rate variability may be more useful than pulse transit time for confirming successful caudal block under general anesthesia in children

BACKGROUND: Confirming a successful caudal block is challenging in the pediatric population. Pulse transit time (PTT) may reflect the decrease in arterial resistance and may act as a potential indicator for confirming successful peripheral nerve or axial block. Heart rate variability (HRV) is also a possible candidate because it may be influenced by variation in sympathetic tone. We expected an increasing PTT pattern and change in HRV parameters after caudal block. METHODS: We enrolled 27 male patients (range, 1–4 years old) who were scheduled for urological surgeries. Caudal block was performed with 1 ml/kg of 0.25% ropivacaine and 1 : 200,000 epinephrine under sevoflurane anesthesia after the surgery. Successful block was confirmed by auscultation and ultrasonography. PTT and HRV parameters, such as standard deviation of normal-to-normal intervals, root mean square of successive differences, very low-frequency power, low-frequency power (LF), high-frequency power (HF), LF/HF ratio, approximate entropy (ApEn) were calculated based on electrocardiography from 1 min before to 5 min after the block. Those variables were analyzed by repeated measures analysis of variance. RESULTS: No significant change was found in PTT with time interval after caudal block. Heart rate and ApEn of the R-R interval decreased with time interval (P = 0.001, 0.033, respectively). Some HRV parameters showed notable changes, although statistically insignificant. CONCLUSIONS: The PTT pattern may not be an indicator for successful caudal block. However, heart rate with parameters of HRV analysis may be alternatives.

Optimal transducer levels for central venous pressure and pulmonary artery occlusion pressure monitoring in supine and prone positions in pediatric patients

BACKGROUND: This study was performed to investigate optimal central venous pressure (CVP) or pulmonary artery occlusion pressure (PAOP) transducer levels in supine and prone positions in pediatric patients. METHODS: Chest tomography images of 213 children aged ≤ 10 years were reviewed. Distances from the back to the uppermost blood level of both atria and their ratios to the largest anteroposterior (AP) diameter of the thorax were calculated for the supine position. For the prone position, same distances and ratios were calculated from the anterior chest. Subgroup analysis was performed to evaluate if there were significant differences in each ratio according to age. RESULTS: In the supine position, the ratio of the uppermost blood level of the right atrium (RA) and left atrium (LA) to the largest AP diameter of the thorax was 80–85% and 60–65%, respectively. The ratio of the most posterior blood level of the RA and LA to largest AP diameter of thorax was 45–50% and 55–60%, respectively, from the anterior chest in the prone position. Subgroup differences in each ratio were within the range of 5%. CONCLUSIONS: In pediatric patients, CVP and PAOP transducers should be differently placed according to supine and prone positions. The influence of age was minimal on the level of each transducer.

Polyuria during Sevoflurane Anesthesia for Parotidectomy Patient / 이화의대지

Polyuria is occasionally observed during general anesthesia. Usually urine output during general anesthesia is decreased because of anesthetic agents. The authors came across with a case of polyruia during sevoflurane anesthesia which occurred after induction of anesthesia. Polyuria is a nonspecific symptom, but can cause many serious complications. Therefore, it is very important to investigate the cause thoroughly and treat patient appropriately.

The analgesic efficacy of ultrasound-guided transversus abdominis plane block with 2% lidocaine in early postoperative period after lower abdominal surgery

BACKGROUND: Transversus abdominis plane (TAP) block is a new regional anesthetic technique for postoperative pain control after lower abdominal surgery. We evaluated the analgesic efficacy of ultrasound-guided (US-) TAP block in patients undergoing lower abdominal surgery. METHODS: Thirty American Society of Anesthesiologists physical status I or II patients between 20-80 years of age undergoing lower abdominal surgery were randomized to receive standard care (n = 15) including intravenous patient-controlled analgesia (IV-PCA), or to undergo bilateral US-TAP block adjunctively (n = 15). A standard general anesthetic technique was used. After induction of anesthesia, bilateral US-TAP block was performed using total 30 ml of 2% lidocaine. Each patient was assessed postoperatively at 20, 30, and 60 min in postanesthesia care unit (PACU) and at 6, 12, and 24 h in ward for pain scores using verbal numerical rating scale (VNRS), analgesic requirements, quality of sleep, and complications. RESULTS: US-TAP block significantly reduced VNRS pain scores at 20, 30, and 60 min postoperatively (P < 0.001). The US-TAP block group required significantly fewer remifentanil intraoperatively (P < 0.05). Additional analgesic requirements were significantly lower in both PACU and ward (P < 0.05) in the US-TAP block group. There were no statistically significant between-group differences in total infused volume of IV-PCA, time to first requirement of analgesics in ward, and quality of sleep. CONCLUSIONS: US-TAP block with 2% lidocaine provided superior analgesia after lower abdominal surgery especially in the first 60 postoperative min when used as a component of a multimodal analgesic regimen.

Keratectasia after Laser in Situ Keratomileusis: Clinicopathologic Case Report

PURPOSE: To describe the morphological features of a prominent ectasia of the cornea after laser in situ keratomileusis (LASIK). METHODS: The morphology of the ectatic corneas were examined using corneal topography, optical microscopy and transmission electron microcopy in 2 cases who had undergone penetrating keratoplasty due to a poor visual acuity induced by progressive corneal ectasia after LASIK. RESULTS: On a topographic examination, the apex of the corneal surface was observed within the central 3 mm zone and the smallest thickness was 116 micrometer and 271 micrometer in each case. The histological examination showed that the epithelial layer had become thinner and detached easily. The Bowman's membrane was broken down and folded. An irregular arrangement of the stromal lamellae with the fibroblastic keratocytes was found. Scar tissue was observed between the epithelium and the Bowman's layer in the central region. In contrast, the corneal endothelium was intact and no abnormality was found in both cases. CONCLUSIONS: The morphologic examination of 2 cases with corneal ectasia revealed a forward protrusion of both the anterior and posterior corneal surface. In addition epithelial detachment, breakage and folding of the Bowman's membrane and irregular lamellae were found. The 2 cases had greatly thinned and protruding corneas, yet there was no abnormality in the corneal endothelium.

The Report for Genetic Analysis of Korean Families with Congenital Cataract

PURPOSE: To describe the clinical phenotype of congenital cataract in Korean families and to determine whether the cataract is causally related to other congenital cataract with known gene. METHODS: We examined total 21 patients with congenital cataract and their families. Peripheral blood samples were obtained from congenital cataract patients and their families who visited clinics. The phenotypes were characterized by slit lamp examination and photographs of digital camera. And genetic traits were discriminated by family pedigree analysis. And we performed known mutation specific enzyme digestion, cold - SSCP and sequencing analysis for identification of genetic defects. RESULTS: We found nuclear (42.8%), anterior polar (4.8%), cortical (4.8%), sutural (4.8%) cataract. And the families affected with coexisting cortical and posterior polar opacity, posterior polar and post-subcapsular opacity were two cases (9.4%) respectively. We identified and examined a three-generation family affected with coexisting autosomal dominant zonular cataract and sutural opacity (CCZS, 4.8%: Family Yun). Previously the CCZS had mapped to chromosome 17q11-q12 and reported mutation of the beta A3A1-crystallin (CRYBA1) gene. We had not identified any mutation in CRYAB1 gene. CONCLUSIONS: In conclusion, we reported that nuclear type is very frequent in Korean patients with congenital cataract. And we had not identified any defects in CRYAB1 gene. These results demonstrated another gene caused this congenital cataract with same phenotype. Furthermore it will be necessary to perform the linkage analysis with microsatellite marker.

The Change of Cornea after 20% Ethanol Treatment in LASEK

PURPOSE: Recently, 20% ethanol has been used to make a corneal epithelial flap effectively. We investigated the toxicity of ethanol using the corneal epithelial cell line and rat cornea. METHODS: Cultured corneal epithelial cells were exposed to different concentrations (5~60%) of ethanol for different exposure time (20~120 seconds). And then cell viability was measured with MTT assay. In vivo, rat central corneas (3mm in diameter) were exposed to 20% ethanol for 30 seconds. The eyes were enucleated, fixed and processed for light microscopy (LM) and transmission electron microscopy (TEM) at indicated interval (0, 4, 8 and 12hours, 1, 3 and 7 days). TUNEL assay was used to detect apoptotic cells. RESULTS: Cultured epithelial cells showed survival rate of over 50% in ethanol concentration of below 20% (76.2 +/- 7.4%) and exposure time of below 1 minute (54.8 +/- 6.5%). In vivo experiment, after 20% ethanol exposure for 30 seconds, vacuoles were detected in the nuclei of epithelial cells and gradually disappeared. Hemidesmosomes were detected in the basement membrane at all times. TUNEL positive cells were detected in the epithelial layer and anterior stroma at the edge until 8hrs. CONCLUSIONS: Our results showed 20% ethanol exposure for 30 seconds did not seems to induce significant damage to the cornea. Corneal epithelial damage could occur by physical force during epithelial flap making.

Genetic Analysis of Korean Patients with Corneal Dystrophy

PURPOSE: We collected genomic DNAs of Korean patients with inherited corneal disorders, and identified mutations of the BIGH3 gene related corneal dystrophies in Korean patients: Lattice type I (CDLI), Avellino (ACD), Reis-Buckler's (CDRB). METHODS: Slit-lamp examination of 75 patients and their relatives was carried out to confirm the diagnosis of the disorders. We composed pedigree and extracted genomic DNAs from members of the CDaffected family and individual patients. Genomic DNAs of the patients with mutation in BIGH3 gene were identified using Polymerase chain reaction (PCR) and sequencing. RESULTS: The number of patients was ranked as follows: 30 patients (40.0%) with ACD, 24 patients (32.0%) with keratoconus, 7 patients (9.3%) with CDLI, 5 patients (6.7%) with Fuchs' dystrophy, 3 patients (4.0%) with CDRB. In the genetic examination, we identified R124H mutation in ACD, R124C mutation in CDLI and R555Q mutation in CDRB. During this study, we also identified a polymorphism (F540F) in exon 12. CONCLUSIONS: ACD associated with R124H mutation is the most common form of inherited corneal disorder in Korea. And in Korean patients with CDRB, this study is the first report about mutation R555Q.

Proliferation of Corneal Endothelial Cells by Delivery of SV40 Large T Antigen

PURPOSE: To determine whether the delivery of the SV40 large T-antigen is a feasible method for transiently inducing proliferation of corneal endothelial cells, we delivered liposome-protein complex into bovine corneal endothelial cells(BCEC). METHOD: SV40 large T-antigen protein was introduced into BCEC and positive cells were identified by immunohistochemistry. Quiescent BCECs were double-labeled using BrdU as a measure of de novo DNA synthesis and the Ki-67 was detected by standard immunohistochemical methods. RESULT: The treatment of quiescent BCECs with large T antigen caused an increase in BrdU incorporation and Ki-67 expression. It was tested by time-course study. CONCLUSION: This finding suggests that liposome-mediated delivery of transforming proteins could be a method to transiently induce corneal endothelial cell proliferation.

One Case of Tachycardia-Bradycardia Syndrome

One case of Tachycardia-Bradycardia Syndrome was reported with brief review. A 42 year old woman was admitted to Seoul national University Hospital because of palpitation and dizziness. She had had the intermittent episodes of such attacks for 4 years. The electrocardiogram checked 3 days prior to admission showed atrial fibrillation but the electrocardiogram at admission revealed irregular bradycardia with wandering pacemaker. The patient had complained palpitation and dizziness throughout the hospital days, but only one attack of Adams-Stokes Syndrome was developed. She was improved symptomatically by isoproterenol infusion during the hospital course.