Unilateral postoperative visual loss in a patient undergoing hip arthroscopy in the supine position: a case report / 대한마취과학회지

Micro-emboli have been reported to occur commonly during arthroscopic surgery, which is frequently performed as an orthopedic surgical procedure. We here report a patient who experienced unilateral postoperative visual loss after a hip arthroscopy using irrigation fluid in the supine position without any evidence of external compression to either eye throughout the surgical procedure. Retinal fundoscopy suggested that the patient had central retinal artery occlusion, one of the causes of the postoperative visual loss. This case suggests that arthroscopic surgery may pose a substantial risk for paradoxical air embolism, such as central retinal artery occlusion, and suggests the need to prevent the entry of micro-air bubbles during such a type of surgery.

Relationship between Serum Uric Acid Concentration and Acute Kidney Injury after Coronary Artery Bypass Surgery

An elevated serum concentration of uric acid may be associated with an increased risk of acute kidney injury (AKI). The aim of this study was to investigate the impact of preoperative uric acid concentration on the risk of AKI after coronary artery bypass surgery (CABG). Perioperative data were evaluated from patients who underwent CABG. AKI was defined by the AKI Network criteria based on serum creatinine changes within the first 48 hr after CABG. Multivariate logistic regression was utilized to evaluate the association between preoperative uric acid and postoperative AKI. We evaluated changes in C statistic, the net reclassification improvement, and the integrated discrimination improvement to determine whether the addition of preoperative uric acid improved prediction of AKI. Of the 2,185 patients, 787 (36.0%) developed AKI. Preoperative uric acid was significantly associated with postoperative AKI (odds ratio, 1.18; 95% confidence interval, 1.10-1.26; P<0.001). Adding uric acid levels improved the C statistic and had significant impact on risk reclassification and integrated discrimination for AKI. Preoperative uric acid is related to postoperative AKI and improves the predictive ability of AKI. This finding suggests that preoperative measurement of uric acid may help stratify risks for AKI in in patients undergoing CABG.

Cardiovascular collapse due to right heart failure following ethanol sclerotherapy: a case report / 대한마취과학회지

Ethanol sclerotherapy for the treatment of low-flow vascular malformations can cause catastrophic cardiopulmonary complications, including pulmonary embolism and pulmonary hypertension, that can result in right heart failure and fatal arrhythmias, leading to death. We here report a case of abrupt cardiovascular collapse that developed immediately following ethanol sclerotherapy in 31-year-old female patient who had a large arteriovenous malformation in her leg. Anesthesiologists should be aware of the fatal cardiopulmonary complications that are associated with ethanol sclerotherapy and consider the use of invasive hemodynamic monitoring, such as pulmonary artery pressure monitoring, when large doses of ethanol are required.

Effect of remote ischemic preconditioning on cognitive function after off-pump coronary artery bypass graft: a pilot study / 대한마취과학회지

BACKGROUND: Several studies have shown in animal models that remote ischemic preconditioning (rIPC) has a neuroprotective effect. However, a randomized controlled trial in human subjects to investigate the neuroprotective effect of rIPC after cardiac surgery has not yet been reported. Therefore, we performed this pilot study to determine whether rIPC reduced the occurrence of postoperative cognitive dysfunction in patients who underwent off-pump coronary artery bypass graft (OPCAB) surgery. METHODS: Seventy patients who underwent OPCAB surgery were assigned to either the control or the rIPC group using a computer-generated randomization table. The application of rIPC consisted of four cycles of 5 min ischemia and 5 min reperfusion on an upper limb using a blood pressure cuff inflating 200 mmHg before coronary artery anastomosis. The cognitive function tests were performed one day before surgery and again on postoperative day 7. We defined postoperative cognitive dysfunction as decreased postoperative test values more than 20% of the baseline values in more than two of the six cognitive function tests that were performed. RESULTS: In the cognitive function tests, there were no significant differences in the results obtained during the preoperative and postoperative periods for all tests and there were no mean differences observed in the preoperative and postoperative scores. The incidences of postoperative cognitive dysfunction in the control and rIPC groups were 28.6% (10 patients) and 31.4% (11 patients), respectively. CONCLUSIONS: rIPC did not reduce the incidence of postoperative cognitive dysfunction after OPCAB surgery during the immediate postoperative period.

Anesthetic considerations of percutaneous transcatheter aortic valve implantation: first attempt in Korea: A report of 2 cases / 대한마취과학회지

Conventional aortic valve replacement for severe aortic stenosis is associated with a high operative mortality in the elderly patients with significant comorbidities, including severe respiratory dysfunction, renal insufficiency, and compromised cardiac function. Human transcatheter aortic valve implantation was first reported in 2002 and has become a valid alternative in selected high-risk patients in Europe and North America. This article describes the first attempt of transfemoral transcatheter aortic valve implantation in Korea. The procedure was applied in two consecutive patients with severe aortic stenosis. Despite several intra-operative complications during procedure, the post-operative outcomes were good for both patients. At post-operative 30 days there was satisfactory prosthetic valve function and hemodynamic stability.

The prophylactic use of recombinant factor VIIa in a patient with DeBakey type III aortic dissection: A case report / 대한마취과학회지

Little is known about the prophylactic use of recombinant factor VIIa (rFVIIa) in patients undergoing surgery for a bleeding aorta employing cardiopulmonary bypass. We report the successful use of rFVIIa in a patient undergoing hypothermic circulatory arrest and prolonged cardiopulmonary bypass for repair of a DeBakey type III aortic dissection.

Temporary bilateral sensorineural hearing loss following cardiopulmonary bypass: A case report / 대한마취과학회지

Sudden sensorineural hearing loss has been reported to occur following anesthesia and various non-otologic surgeries, mostly after procedures involving cardiopulmonary bypass. Unilateral sensorineural hearing loss resulting from microembolism is an infrequent complication of cardiopulmonary bypass surgery that has long been acknowledged. Moreover, there are few reports on the occurrence of bilateral sensorineural hearing loss without other neurologic deficits and its etiology has also not been determined. We describe here a rare case of bilateral hearing loss without other neurologic deficits in an otherwise healthy 27-year-old woman who underwent cardiopulmonary bypass surgery for repair of severe mitral valve stenosis. The patient suffered from profound sensorineural hearing loss in both ears that was recognized immediately upon extubation, and audiometry tests confirmed the diagnosis. Without any treatment, her hearing recovered almost completely by the time of her discharge one week after surgery.

High Frequency Jet Ventilation of One Lung using a Bronchial Blocker of Univent during Carinal Resection

Airway management during carinal resection should provide adequate ventilation and oxygenation as well as a good surgical field, but without complications such as barotraumas or aspiration. One method of airway management is high frequency jet ventilation (HFJV) of one lung or both lungs. We describe a patient undergoing carinal resection, who was managed with HFJV of one lung, using a de-ballooned bronchial blocker of a Univent tube without cardiopulmonary compromise. HFJV of one lung using a bronchial blocker of a Univent tube is a simple and safe method which does not need additional catheters to perform HFJV and enables the position of the stiffer bronchial blocker more stable in airway when employed during carinal resection.

Amplatzer septal occluder found in the thoracic descending aorta by transesophageal echocardiography: A case report / 대한마취과학회지

Percutaneous device closure of atrial septal defect (ASD) has proven to be safe and effective, and become a widely accepted option to the surgical repair. However, the embolization of Amplatzer septal occluder (ASO) occurs in about 0.55% to 3.5% of cases, regardless of ASD size, device size, or the physician's expertise. We report a case of embolization of an ASO into the thoracic descending aorta, successfully removed through a surgical approach.

The Relationship between Arterial Carbon Dioxide Tension and Oxygenator Exhausted Carbon Dioxide Tension during Cardiopulmonary Bypass

BACKGROUND: The neurologic deficit is one of the most serious complications after cardiopulmonary bypass (CPB). This complication has reported to be closely associated with arterial partial pressure of carbon dioxide tension (PaCO2). The traditional way to measure PaCO2 is by intermittent arterial gas analysis during CPB. We tested the relationship between PaCO2 and CPB exhausted partial pressure of carbon dioxide tension (exPCO2) which can be monitored continuously during CPB. METHODS: The total 46 patients who underwent cardiac surgery under CPB were studied. Capnography sampling line was connected to CPB exhausted port to monitor exPCO2. We sampled arterial blood from CPB for gas analysis at cooling, stable hypothermia, and rewarming phase and recorded exPCO2 simultaneously at each phase. RESULTS: We found out that exPCO2 was associated with temperature corrected PaCO2 (cPaCO2) at all 3 phases(r = 0.73, 0.70, 0.84, P < 0.05) and with temperature uncorrected PaCO2 (ucPaCO2) at cooling (r = 0.64, P < 0.05) and rewarming phases (r = 0.81, P < 0.05). CONCLUSIONS: We concluded that exPCO2 could be used to monitor either ucPaCO2 or cPaCO2 at cooling and rewarming phase and cPaCO2 at hypothermia during CPB.

Inadvertent Breakage of the Spinal Needle during the Obturator Nerve Block for the Transurethral Resection of Bladder Tumor: A case report / 대한마취과학회지

Obturator nerve block is occasionally performed during transurethral resection of lateral bladder wall tumors to prevent the violent contraction of the adductor muscle of the thigh. Rare complications including intravascular injection of the local anesthetics and hematoma formation may occur during the obturator nerve block. We report a case of the unintentional breakage of the spinal needle during the obturator nerve block with successful removal of the broken spinal needle by an orthopedic surgeon.

Anesthetic Experience of Percutaneous Nephrolithotomy for Renal Calculi in a Patient with Lesch-Nyhan Syndrome: A case report / 대한마취과학회지

Lesch-Nyhan syndrome (LNS) is a rare, X-linked recessive inherited disorder caused by a deficiency of the enzyme hypoxanthine-guanine-phophoribosyltransferase, leading to excessive purine production and elevation of uric acid. Clinical manifestations include mental retardation, spasticity, choreathetosis, compulsive self-mutilation, renal calculi followed by obstructive nephropathy, and arthritis. Patient with LNS may have increased risk of aspiration pneumonia, acute renal failure and unexpected sudden death. We accomplished successful general anesthesia in a case of LNS requiring percutaneous nephrolithotomy due to renal calculi.

Asymptomatic Severe Dilutional Hyponatremia during Transurethral Resection of the Prostate: A case report / 대한마취과학회지

The transurethral resection of the prostate (TURP) syndrome is caused by intravascular absorption of an electrolyte-free irrigating fluid during TURP for benign prostatic hypertrophy or prostatic carcinoma. The clinical symptoms and signs include hypertension, bradycardia, respiratory distress, hypotension, nausea, vomiting, confusion, blindness, seizure, coma, hyponatremina, and hypoosmolality. In this case, we incidentally detected very severe dilutional hyponatremia (99 mmol/L) without any symptoms during TURP and immediately took measures to treat TURP syndrome. On the third postoperative day, the hyponatremia had resolved within the normal range.

The Reliability and Validity of the Rhodes Index of Nausea, Vomiting and Retching in Postoperative Nausea and Vomiting / 대한마취과학회지

BACKGROUND: The Rhodes index of nausea, vomiting and retching (RINVR) is a patient self-report instrument to assess the objective and subjective factors of nausea and vomiting. The aim of this study is to evaluate the reliability and validity of the RINVR in postoperative nausea and vomiting (PONV). METHODS: The RINVR, VAS for nausea and incidence of emetic episodes were administered to 150 patients approximately 30 minutes apart at 6 hours and 24 hours after surgery. The validity was evaluated by Spearman's correlation and internal consistency of reliability was determined using Cronbach's alpha. To determine test-retest reliability, second administration of the RINVR was done 2 hours after the first. The test-retest reliability was evaluated by Spearman's correlation and agreement. RESULTS: Cronbach's alpha of nausea, vomiting, retching and total experience scores of the RINVR ranged from 0.912 to 0.968. Test-retest scores of all items were strongly correlated (Spearman's coefficients: 0.962-1.000, P< 0.0001) and highly agreed (weighted kappa: 0.932-1.000). Coefficients of construct validity for nausea components (vs VAS for nausea) and emetic components (vs incidence of emetic episodes) of the RINVR were 0.860-0.928 and 0.724-0.811, respectively (P<0.0001). The overall weighted kappa between the incidences of PONV assessed by the RINVR and by patient self-assessment of VAS for nausea and incidence of emetic episodes was 0.917-0.945. The number of patients in "great" total experience category was 1.33% or less. There was no significant difference of VAS for nausea between "severe" and "great" nausea experience categories. CONCLUSIONS: The RINVR was a reliable and valid instrument to assess PONV.

The Effect of Sevoflurane Anesthesia on the Phase Relationship between Systolic Blood Pressure and Heart Rate / 대한마취과학회지

BACKGROUND: The phase relationship indicates the time delay between the input signal (systolic blood pressure, SBP) and output signal (R-R interval, RRI). In contrast to the awake state, little is known about the effects of general anesthesia on the phase shift. In the present study, we tested the hypothesis that sevoflurane anesthesia causes a phase change between the two signals. METHODS: We assessed changes in phase, coherence, and baroreflex sensitivity between SBP and RRI by the use of transfer function analysis in 50 ASA 1 patients during the awake state and during end-tidal 2% sevoflurane-50% N2O anesthesia. RESULTS: SBP and RRI decreased significantly during sevoflurane anesthesia (P < 0.001). The phase in the low frequency (LF) region remained unchanged, but the phase in the high frequency (HF) region changed significantly from -29.52 +/- 50.70 to 27.28 +/- 80.22 degrees during sevoflurane anesthesia (P < 0.001). Coherence and baroreflex sensitivity between the two signals in the LF and HF regions decreased significantly during sevoflurane anesthesia (P < 0.001, respectively). CONCLUSIONS: We found that in the HF region and not in the LF region, sevoflurane anesthesia provokes the shift of the SBP-RRI phase relationship, suggesting that this change is inconsistent with a vagally mediated response.

A Clinical Study to Evaluate the Safety and Efficacy of a Patient-controlled Analgesia Pump in Post-surgical Patients / 대한마취과학회지

BACKGROUND: The disposable patient-controlled analgesia (PCA) devices are convenient for portability and management. An ideal PCA can be developed as an electronic device with various functions of safety and control. Recently, Accumate 1000(R) was developed as an electronic pump in Korea, and has passed the relevant laboratory criteria of safety and efficacy. We conducted a clinical study on the safety and efficacy when the device is applied to patients. METHODS: Fentanyl 1,500microgram, ketorolac 180 mg, and ondansetron 8 mg were used for PCA. Continuous infusion rate, bolus dose, and lockout time were set at 1 ml/h, 1 ml, and 15 min, respectively. Fifty patients were monitored for 48 h. The safety of Accumate 1000(R) was evaluated by backflow and siphonage, auto-clamp function, and lockout time intraoperatively. The efficacy was evaluated by the accuracy of bolus and total infused dose, and the satisfaction rates of patients and users. RESULTS: Backflow and siphonage did not occur, and the auto-clamp function was excellent. There was no bolus infusion during lockout time, and the bolus dose was infused accurately after lockout time. For the accuracy of the total infused dose, the mean and median value of performance error between the infused and target doses were -0.55%, and -0.29%, respectively. Noise, button sense, and convenience of cable were rated as satisfactory by 90%, 78%, and 84%, of patients respectively. CONCLUSIONS: The safety and efficacy of Accumate 1000(R) were established by clinical trial. We can provide patients with the more precise and optimal analgesia. The history of drug infusion can be used as research data.

Fatal Cardiac and Pulmonary Embolisms during Radical Nephrectomy and Inferior Vena Cava Thrombectomy: A case report / 대한마취과학회지

Intraoperative pulmonary embolism can result in severe hemodynamic instability, including cardiac arrest. Therefore, immediate diagnosis and proper treatment are required. We report a case of the acute cardiac and pulmonary embolisms during radical nephrectomy and inferior vena cava (IVC) thrombectomy in a patient with renal cell carcinoma with thrombus in the IVC. We diagnosed the cardiac embolism intraoperatively using the transesophageal echocardiogram, and performed emergent cardiac and pulmonary embolectomies immediately. After the surgery, the patient was discharged without any complication.

Inguinal Hernia following Lumbar Spinal Surgery in the Prone Position: A case report / 대한마취과학회지

An inguinal hernia shows that the protruding viscus exits from the endoabdominal fascial sac through the internal inguinal ring. Because an inguinal hernia is usually associated with incarceration, obstruction and even strangulation, it must be quickly treated whenever observed. Although there are several predisposing factors of the development of inguinal hernia, relatively little is a case report of the inguinal hernia developed by the increased intra-abdominal pressure during general anesthesia. In this case, we report a patient who developed the unexpected recurrence of left inguinal hernia following lumbar spinal surgery in prone position by increasing intra-abdominal pressure. After manual reduction was performed promptly by general surgeon, the patient was discharged without any complication on the eighth postoperative day.

Effects of Patients' Position on Blood Pressure and Heart Rate during Spinal Anesthesia for Axillo-femoral Bypass Surgery / 대한마취과학회지

BACKGROUND: Hypotension is one of the most common complications from the spinal anesthesia frequently used for surgery on the lower abdomen or extremities. It might be important in prognostic improvements to maintain cardiovascular homeostasis in elderly or patients with cardiovascular diseases. This study evaluated the effect of the patients' position on the preservation of cardiovascular stability when elderly patients suffering from hypertension undergo surgery for an axillo-femoral arterial bypass. METHODS: 24 patients with hypertension undergoing an elective axillo-femoral bypass surgery were examined. The patients were randomly allocated into two groups (Lateral 20 min group: patients with lateral position for 20 min after spinal anesthesia; Supine group: patients with the supine position immediately after spinal anesthesia). The observers recorded the hemodynamic variables, as well as the loss of sensation on both sides. RESULTS: Considering the changes in the arterial blood pressure and heart rate from the baseline values, patients in the supine group showed a greater decrease in arterial blood pressure and heart rate (P < 0.05). In the lateral 20 min group, there was a lower block level of cold sensation that reflected the sympathetic blockade at the non-operated site (P < 0.05). CONCLUSIONS: The lateral decubitus position for 20 min after spinal anesthesia can contribute to the maintenance of cardiovascular stability during unilateral axillo-femoral bypass surgery in elderly patients with hypertension.