Ultrasound-guided Lateral Femoral Cutaneous Nerve Block in Meralgia Paresthetica

Meralgia paresthetica is a rarely encountered sensory mononeuropathy characterized by paresthesia, pain or sensory impairment along the distribution of the lateral femoral cutaneous nerve (LFCN) caused by entrapment or compression of the nerve as it crossed the anterior superior iliac spine and runs beneath the inguinal ligament. There is great variability regarding the area where the nerve pierces the inguinal ligament, which makes it difficult to perform blind anesthetic blocks. Ultrasound has developed into a powerful tool for the visualization of peripheral nerves including very small nerves such as accessory and sural nerves. The LFCN can be located successfully, and local anesthetic solution distribution around the nerve can be observed with ultrasound guidance. Our successfully performed ultrasound-guided blockade of the LFCN in meralgia paresthetica suggests that this technique is a safe way to increase the success rate.

Anesthetic experience of a patient with tracheomegaly: A case report / 대한마취과학회지

Tracheomegaly or tracheobronchomegaly is a rare syndrome that consists of marked dilatation of the trachea and the major bronchi, and this is usually due to a congenital defect of the elastic and muscle fibers of the tracheobroncheal tree. Physicians have had only limited experience with performing anesthesia in patients with this type of syndrome. This syndorme is diagnosed by roentenological investigation and this condition is frequently associated with chronic respiratory infection and partial airway obstruction. In this report, we present a case of performing tracheostomy for a patient with tracheomegaly, and this was probably secondary to mechanical ventilator therapy. The regular tracheostomy tube did not provided sufficient length to allow the cuff to lie properly in the trachea in this patient. Because of the peri-cuff air leakgae and hypercapnea after tracheostomy, we needed a longer tracheostomy tube. But we didn't have such a tube and we didn't know any other method, so we couldn't perform tracheostomy. Therefore, we introduced a method of reducing the length of the endotracheal tube to a suitable size until a longer tracheostomy tube can be obtained for those patients having tracheomegaly.

Anesthetic experience of a patient with tracheomegaly: A case report / 대한마취과학회지

Tracheomegaly or tracheobronchomegaly is a rare syndrome that consists of marked dilatation of the trachea and the major bronchi, and this is usually due to a congenital defect of the elastic and muscle fibers of the tracheobroncheal tree. Physicians have had only limited experience with performing anesthesia in patients with this type of syndrome. This syndorme is diagnosed by roentenological investigation and this condition is frequently associated with chronic respiratory infection and partial airway obstruction. In this report, we present a case of performing tracheostomy for a patient with tracheomegaly, and this was probably secondary to mechanical ventilator therapy. The regular tracheostomy tube did not provided sufficient length to allow the cuff to lie properly in the trachea in this patient. Because of the peri-cuff air leakgae and hypercapnea after tracheostomy, we needed a longer tracheostomy tube. But we didn't have such a tube and we didn't know any other method, so we couldn't perform tracheostomy. Therefore, we introduced a method of reducing the length of the endotracheal tube to a suitable size until a longer tracheostomy tube can be obtained for those patients having tracheomegaly.

Cardiac arrest in the prone position with the Andrews frame during lumbar spine surgery: A case report / 대한마취과학회지

The prone position during anesthesia sometimes causes hemodynamic changes such as a decrease in blood pressure. These changes are caused by a decrease in venous return from venous pooling in the legs, and decreased left ventricular compliance secondary to increased intrathoracic pressure, when patients are placed prone with an Andrews frame. We report on a patient who experienced cardiac arrest in the prone position with the Andrews frame during lumbar laminectomy and posterior lumbar interbody fusion. After 1.25 h in the prone position, bradycardia and hypotension occurred. Ephedrine, atropine and epinephrine were infused intravenously, but bradycardia and hypotension progressed to asystole. Cardioinhibitory reflex was likely triggered by decreased venous return and increased intrathoracic pressure, and the patient developed cardiac arrest as a result.

Broken inspiratory valve detected by capnographic waveforms during general anesthesia: A case report / 대한마취과학회지

Unidirectional valve malfunction causes re-breathing of expired gas during anesthesia. Capnography is a useful method for monitoring the integrity of anesthetic equipment such as the unidirectional valves in a circular system. We report, here a case in which the capnography did not sound any rebreathing alarm, but the capnogram showed a prolonged plateau, an apparently short inspiratory period and a gradually sloping descending limb that stopped just short of baseline. As a result, capnography helped to identify an inspiratory unidirectional valve malfunction during the course of anesthesia. This study emphasizes the need to analyze the capnogram during every procedure involving anesthesia, in addition to preoperative checking of the Unidirectional valve.

Cardiac arrest after position change in a morbidly obese patient: A case report / 대한마취과학회지

Morbid obesity presents many clinical problems. Especially, morbid obesity has a significant effect on airway management and pulmonary function. We experienced a cardiac arrest of a morbidly obese (Body Mass Index of about 62 kg/m2). 21-year-old male patient that necessitated cardiopulmonary resuscitation (CPR). The patient was scheduled for an emergency cystoscopy under local anesthesia. After change to supine position in the operation room, dyspnea, tachypnea, agitation, and, subsequently, cardiac arrest developed.

Anesthetic management in a pediatric patient with infantile phase Prader-Willi Syndrome: A case report / 대한마취과학회지

Prader-Willi syndrome is a genetic disorder characterized by infantile hypotonia, childhood obesity, characteristic facial appearance, mental retardation, hypogonadism and short stature. It is described as a 2-stage disorder with an infantile hypotonic phase, followed by a childhood obese phase. The first phase, during the newborn and infancy period, is characterized by marked hypotonia, poor sucking, swallowing, coughing, crying, and episodes of asphyxia. Since these signs of poor strength cause poor reversal in the postoperative period, muscle relaxants should be used cautiously, especially in patients in the first phase of the syndrome. We experienced the anesthetic management of a 5-month-old female patient with Prader-Willi syndrome under general anesthesia, without muscle relaxant for excision of BCG lymphadenitis and a preauricular mass.

Clinical experience of the percutaneous release for trigger fingers / 대한마취과학회지

BACKGROUND: Conservative management for the trigger fingers includes splinting, steroid injection and other adjuvant methods. If conservative treatment fails, a surgical release of the A1 pulley is offered. Although the success rate of the surgical intervention is high, the complications, for example, a digital nerve injury, bowstringing, infection and continued triggering, have been reported. Percutaneous release with an 18 guage needle has been reported as a safe and effective procedure for the trigger fingers. This study evaluates the safety and efficacy of the percutaneous release. METHODS: 33 patients received the percutaneous release of the A1 pulley with an 18 guage needle and steroid injection (Group A) and 36 patients did the only administration of steroid as a control group (Group B). Patients were examined with a clinical staging for the Watanabe stage (W stage) and 0-10 points verbal numerical rating scale (VNRS) score at 1 week, 3 months, 1 year after the initial treatment. RESULTS: After 1 year of the follow-up, 93.5% in the group A and 57.6% in the group B had complete release of the trigger fingers in the W stage. VNRS after the initial treatment demonstrated that the decrement of the pain score was more significant in the group A. CONCLUSIONS: We need to consider the percutaneous release with steroid injection at an early stage of the trigger fingers because of the more effective resolution of the symptoms and the better long-term prognosis than a steroid injection alone.

Occluded Espocan(R) needle and accidental dural puncture during combined spinal-epidural anesthesia: A case report / 대한마취과학회지

Here, we report a case of an occluded modified Tuohy needle (Espocan(R), B. Brown, Germany) due to the patient's own tissue. A 70-year-old female with left knee osteoarthritis was admitted for a total knee replacement arthroplasty under combined spinal-epidural anesthesia. Insertion of the Tuohy needle proceeded from the skin to 6 cm and then 6.5 cm, but there was no loss of resistance. We removed the needle from the patient and discovered a fibrous, white tissue inside the needle. We tried again and did the spinal-epidural anesthesia in another interspinous space. This time, we could feel the loss of resistance at 4 cm, but permanent leakage of clear fluid was seen in the epidural catheter so we removed the catheter. We observed the patient closely in the recovery room and ward, and no further complications were found. We present this case to remind the operator the importance of checking the epidural needle that possible may be occluded by a foreign body.

Anesthesiologic considerations in a pediatric patient with cornelia de lange syndrome: A case report / 대한마취과학회지

Cornelia de Lange syndrome (CdLS) is a relatively uncommon, multiple malformation syndrome involving neurodevelopmental, craniofacial, cardiac, musculoskeletal and gastrointestinal systems. Anesthetic management of a patient with CdLS may pose a serious problem mainly from difficult tracheal intubation, aspiration complications and cardiac malformation. We report our successful experience in anesthetic management of a 15-month-old male patient with CdLS who underwent orchiopexy for bilateral cryptochidism.

Anesthetic experience in a pediatric patient with pyruvate dehydrogenase complex (PDHC) deficiency: A case report / 대한마취과학회지

Mitochondrial dysfunction represents a biochemically and clinically diverse group of conditions that can affect any organs with high energy requirement such as brain and muscle being particularly vulnerable. Pyruvate dehydrogenase complex (PDHC) deficiency is one type of mitochondrial dysfuntion that is anesthetically associated with lactic acidosis, muscle hypotonia, malignant hyperthermia, and postoperative respiratory failure. We report a case of general anesthetic management during ventriculoperitoneal shunt in a pediatric patient with PDHC deficiency and its possible considerations.

Anesthetic experience in a pediatric patient with pyruvate dehydrogenase complex (PDHC) deficiency: A case report / 대한마취과학회지

Mitochondrial dysfunction represents a biochemically and clinically diverse group of conditions that can affect any organs with high energy requirement such as brain and muscle being particularly vulnerable. Pyruvate dehydrogenase complex (PDHC) deficiency is one type of mitochondrial dysfuntion that is anesthetically associated with lactic acidosis, muscle hypotonia, malignant hyperthermia, and postoperative respiratory failure. We report a case of general anesthetic management during ventriculoperitoneal shunt in a pediatric patient with PDHC deficiency and its possible considerations.

Anesthetic management of a patient with amyotrophic lateral sclerosis (ALS): A case report / 대한마취과학회지

Amyotrophic lateral sclerosis (ALS) is a progressive, neurodegenerative disorder involving primarily motor neurons in the cerebral cortex, brain stem and spinal cord, which leads to respiratory failure and death. The impairment of respiratory function, together with weakened upper airway muscles, may affect anesthetic management. The response to muscle relaxants, either depolarizing or nondepolarizing, is also altered in patients with ALS. Patients with ALS require special care throughout the perioperative period. We experienced the anesthetic management of a 63-year-old female patient with ALS under general anesthesia without the use of muscle relaxants for closed reduction with percutaneous screw fixation to treat a right femur neck fracture.

Anesthetic management of a patient with amyotrophic lateral sclerosis (ALS): A case report / 대한마취과학회지

Amyotrophic lateral sclerosis (ALS) is a progressive, neurodegenerative disorder involving primarily motor neurons in the cerebral cortex, brain stem and spinal cord, which leads to respiratory failure and death. The impairment of respiratory function, together with weakened upper airway muscles, may affect anesthetic management. The response to muscle relaxants, either depolarizing or nondepolarizing, is also altered in patients with ALS. Patients with ALS require special care throughout the perioperative period. We experienced the anesthetic management of a 63-year-old female patient with ALS under general anesthesia without the use of muscle relaxants for closed reduction with percutaneous screw fixation to treat a right femur neck fracture.

Pneumocephalus after an autologous blood patch procedure to treat a postdural puncture headache: A case report / 대한마취과학회지

Postdural puncture headache is the most common complication of unintentional dural puncture with an epidural needle. We present here the case of a 44-year-old woman who developed a severe headache from pneumocephalus, which was the result of an epidural blood patch procedure being performed to treat a PDPH. Both the epidural block and the autologous blood patch procedure were done at the L4-5 interspinous space with the loss of resistance technique and using air. After the epidural blood patch procedure, the headache was not relieved at the supine position and the computerized tomographic brain scan revealed the presence of air within the intracranial cavities. After conservative treatment, she was discharged from the hospital on the fourth-day without any neurologic sequelae.

Pneumocephalus after an autologous blood patch procedure to treat a postdural puncture headache: A case report / 대한마취과학회지

Postdural puncture headache is the most common complication of unintentional dural puncture with an epidural needle. We present here the case of a 44-year-old woman who developed a severe headache from pneumocephalus, which was the result of an epidural blood patch procedure being performed to treat a PDPH. Both the epidural block and the autologous blood patch procedure were done at the L4-5 interspinous space with the loss of resistance technique and using air. After the epidural blood patch procedure, the headache was not relieved at the supine position and the computerized tomographic brain scan revealed the presence of air within the intracranial cavities. After conservative treatment, she was discharged from the hospital on the fourth-day without any neurologic sequelae.

Propriospinal myoclonus after cervical epidural blockade: A case report / 대한마취과학회지

Myoclonus is one of the rare complications after the neuroaxial blockade. We report a patient who developed propriospinal myoclonus following cervical epidural steroid injection. An outpatient, 73-years-old man, complaining of a tingling sensation from the right shoulder of supraspinatous region to the ipsilateral hand, particularly along the C6 dermatome, visited our pain clinic center. In cervical magnetic resonance imaging scan, the disc between 6th and 7th cervical vertebrae was herniated and pressed the nerves to the right side. We performed cervical epidural steroid injection, using triamcinolone acetonide 40 mg with 0.25% bupivacaine HCL 5 ml. After the first injection, he had no problem, but following the second injection, myoclonic movements were developed and lasted for 6 hours along only the right side of the whole body without other neurologic complications. The myoclonic movement improved by intravenous injection of clonazepam 0.5 mg and the patient completely recovered without any neurologic sequelae on that day.

Propriospinal myoclonus after cervical epidural blockade: A case report / 대한마취과학회지

Myoclonus is one of the rare complications after the neuroaxial blockade. We report a patient who developed propriospinal myoclonus following cervical epidural steroid injection. An outpatient, 73-years-old man, complaining of a tingling sensation from the right shoulder of supraspinatous region to the ipsilateral hand, particularly along the C6 dermatome, visited our pain clinic center. In cervical magnetic resonance imaging scan, the disc between 6th and 7th cervical vertebrae was herniated and pressed the nerves to the right side. We performed cervical epidural steroid injection, using triamcinolone acetonide 40 mg with 0.25% bupivacaine HCL 5 ml. After the first injection, he had no problem, but following the second injection, myoclonic movements were developed and lasted for 6 hours along only the right side of the whole body without other neurologic complications. The myoclonic movement improved by intravenous injection of clonazepam 0.5 mg and the patient completely recovered without any neurologic sequelae on that day.

Airway Management in a Patient with Goldenhar's Syndrome: A case report / 대한마취과학회지

Goldenhar's syndrome is a rare form of a hemifacial microsomia in which the facial and vertebral anomalies are frequently associated with cardiac, pulmonary and renal defects. Infants with Goldenhar's syndrome commonly have an airway that is difficulty to manage. A difficult tracheal intubation may be due to a combination of mandibular hypoplasia, macrognathia, palatal defects and vertebral anomalies. We report the successful anesthetic management of a 10-month-old girl with Goldenhar's syndrome for the excision of conjunctival lipodermoid. The use of remifentanil followed with an anesthetic induction dose of propofol provides adequate conditions for tracheal intubation without the use of neuromuscluar blocking agents in a patient with Goldenhar's syndrome.

Lumbar Paraspinal Myonecrosis Following Combined Spinal Epidural Anesthesia: A case report / 대한마취과학회지

A 55-year-old woman received a combined spinal epidural anesthesia for total replacement surgery of the left knee. After surgery, the epidural patient controlled analgesia (PCA) device was activated. After the first post-operative day, the patient complained of severe back pain rather than left knee pain in spite of the bolus dose of analgesics via epidural catheter. The epidural catheter was removed and intravenous PCA was initiated. On the 16th post-operative day, the patient's back and knee pain improved; however, the fever did not subside. A blood test revealed increased inflammatory markers in spite of antibiotic therapy. Under the suspicion of epidural abscess, a lumbar magnetic resonance imaging scan was performed and revealed an increase in the signal within left lumbar paraspinal muscle. A prompt debridement and irrigation of the necrotic tissues was performed. The histologic diagnosis was lumbar paraspinal myonecrosis. Subsequent to this corrective procedure, the patient's fever subsided and the inflammatory markers were normalized, except for mild back pain after the surgical repair.