Airway management of a patient incidentally diagnosed with Mounier-Kuhn syndrome during general anesthesia

Mounier-Kuhn syndrome (MKS) is a disease characterized by dilation of the trachea and mainstem bronchi. Due to the risk of airway leakage, pulmonary aspiration, and tracheal damage, MKS can be fatal in patients undergoing tracheal intubation. Moreover, MKS may not be diagnosed preoperatively due to its rarity. In this case, a patient undergoing neurosurgery was incidentally diagnosed with MKS during general anesthesia. During anesthesia induction, difficulties in airway management led the anesthesiologist to suspect MKS. Airway leakage was resolved in this case using oropharyngeal gauze packing. Anesthesiologists should be aware of the possibility of MKS and appropriate management of the airways.

Left ventricular outflow tract obstruction with systolic anterior motion of the mitral valve in patient with pericardial effusion caused by ascending aortic dissection: A case report / 대한마취과학회지

Left ventricular outflow tract (LVOT) obstruction with systolic anterior motion (SAM) of mitral valve is not only limited to patients with hypertrophic cardiomyopathy. A diagnosis of LVOT obstruction with SAM is important because conventional inotropic support may potentially aggravate hemodynamic deterioration. We present a case of LVOT obstruction with SAM in a patient who underwent an emergent surgery for ascending aortic dissection with pericardial effusion. The patient showed refractory hypotension after standard pharmacologic interventions during induction of anesthesia. Transesophageal echocardiography (TEE) revealed LVOT obstruction with SAM and it was managed appropriately under the guidance of TEE. Intraoperative TEE can play an important role in diagnosis and management of LVOT obstruction with SAM caused by pericardial effusion.

Intravenous palonosetron increases the incidence of QTc prolongation during sevoflurane general anesthesia for laparotomy / 대한마취과학회지

BACKGROUND: Palonosetron is a recently introduced 5-hydroxytryptamine-3 (5-HT3) receptor antagonist useful for postoperative nausea and vomiting prophylaxis. However, 5-HT3 receptor antagonists increase the corrected QT (QTc) interval in patients who undergo general anesthesia. This retrospective study was performed to evaluate whether palonosetron would induce a QTc prolongation in patients undergoing general anesthesia with sevoflurane. METHODS: We reviewed a database of 81 patients who underwent general anesthesia with sevoflurane. We divided the records into palonosetron (n = 41) and control (n = 40) groups according to the use of intraoperative palonosetron, and analyzed the electrocardiographic data before anesthesia and 30, 60, 90, and 120 min after skin incision. Changes in the QTc interval from baseline, mean blood pressure, heart rate, body temperature, and sevoflurane concentrations at each time point were compared between the two groups. RESULTS: The QTc intervals at skin incision, and 30, 60, 90, and 120 min after the skin incision during general anesthesia were significantly longer than those at baseline in the two groups (P 500 ms 30 min after skin incision, whereas no patient did in the control group (P = 0.01). No significant differences were observed between the two groups in mean blood pressure, body temperature, heart rate, or sevoflurane concentrations. CONCLUSIONS: Palonosetron may induce QTc prolongation during the early general anesthesia period with sevoflurane.

Preoperative Aspirin Resistance does not Increase Myocardial Injury during Off-pump Coronary Artery Bypass Surgery

We performed a prospective cohort trial on 220 patients undergoing elective off-pump coronary artery bypass surgery and taking aspirin to evaluate the effect of aspirin resistance on myocardial injury. The patients were divided into aspirin responders and aspirin non-responders by the value of the aspirin reaction units obtained preoperatively using the VerifyNow(TM) Aspirin Assay. The serum levels of troponin I were measured before surgery and 1, 6, 24, 48 and 72 hr after surgery. In-hospital major adverse cardiac and cerebrovascular events, graft occlusion, the postoperative blood loss and reexploration for bleeding were recorded. Of the 220 patients, 181 aspirin responders (82.3%) and 39 aspirin non-responders (17.7%) were defined. There were no significant differences in troponin I levels (ng/mL) between aspirin responders and aspirin non-responders: preoperative (0.04 +/- 0.08 vs 0.03 +/- 0.06; P = 0.56), postoperative 1 hr (0.72 +/- 0.87 vs 0.86 +/- 1.10; P = 0.54), 6 hr (2.92 +/- 8.76 vs 1.50 +/- 2.40; P = 0.94), 24 hr (4.16 +/- 13.44 vs 1.25 +/- 1.95; P = 0.52), 48 hr (2.15 +/- 7.06 vs 0.65 +/- 0.95; P = 0.64) and 72 hr (1.20 +/- 4.63 vs 0.38 +/- 0.56; P = 0.47). Moreover, no significant differences were observed with regard to in-hospital outcomes. In conclusion, preoperative aspirin resistance does not increase myocardial injury in patients undergoing off-pump coronary artery bypass surgery. Postoperative dual antiplatelet therapy might have protected aspirin resistant patients.

Anesthetic management of a patient with Mounier-Kuhn syndrome undergoing off-pump coronary artery bypass graft surgery: A case report / 대한마취과학회지

Mounier-Kuhn-syndrome patients have markedly dilated trachea and main bronchi due to an atrophy or absence of elastic fibers and thinning of smooth muscle layers in the tracheobronchial tree. Although this syndrome is rare, airway management is challenging and general anesthesia may produce fatal results. However, only a few cases have been reported and this condition is not widely known among anesthesiologists. We present the case of a tracheobronchomegaly patient undergoing an emergency off-pump coronary artery bypass. Although the trachea was markedly dilated with numerous tracheal diverticuli, there was an undilated 2 cm portion below the vocal cords found on the preoperative CT. Under a preparation of extracorporeal membrane oxygenation, we intubated and placed the balloon of an endotracheal tube (I.D. 9 mm) at this portion, and maintained ventilation during the operation. This case showed that a precise preoperative evaluation and anesthetic plan is essential for successful anesthetic management.

Percutaneous Radiofrequency Thermocoagulation for Trigeminal Neuralgia / 대한마취과학회지

BACKGROUND: Percutaneous radiofrequency thermocoagulation (RFTC) at the trigeminal rootlets has been suggested as a safe and effective treatment for the trigeminal neuralgia.However, no clinical data of RFTC for the trigeminal neuralgia were reported in Korea.The objective of this study was to analyze the treatment efficacy and complications of the RFTC at the trigeminal rootlets for the relief of trigeminal neuralgia. METHODS: The data of RFTC performed in 22 consecutive trigeminal neuralgia patients from November 2004 to February 2007 were retrospectively collected both by the review of medical records and by the telephone interview using a questionnaire.Age, sex, side of the face, and division (s) of trigeminal nerve involved were recorded. Pain relief, recurrence requiring or not requiring reoperation, and type and rate of complications were also evaluated. RESULTS: Six men and 16 women were included in this study.The mean age were 61 +/- 15 years and mean duration of pain were 71.8 +/- 50.5 months.The 11-point-verbal numerical rating scale scores before and after RFTC were 8.4 +/- 2.0 and 1.5 +/- 2.3, respectively (P < 0.05).According to the Kaplan-Meier analysis, the probabilities of remaining pain relief at 6 and 12 months after the procedure were 90.7% and 55.3%, respectively.The overall satisfaction rate was 95% (21/22).Hypesthesia was the more common side effect (36%). CONCLUSIONS: We confirmed that RFTC at the trigeminal rootlets was a minimally invasive and low-risk technique with a high rate of efficacy.

The pain caused by a 2% propofol target-controlled infusion during anesthesia induction in adults / 대한마취과학회지

BACKGROUND: An increasing number of cases of target-controlled infusion (TCI) of propofol have substituted 2% propofol for 1% due to the concerns about lipid deposition and the practical convenience. However, 2% propofol may possess a higher proportion of free aqueous propofol because of the relatively decreased lipid-solvent ratio as compared to that for 1% propofol. We performed a prospective, randomized, double-blind trial to evaluate the pain of 1% and 2% propofol TCI. The efficacy of lidocaine pretreatment to abolish the pain was also tested for each concentration of propofol. METHODS: Two hundred adult patients were randomly allocated to 4 groups according to the pretreatment drugs and propofol concentrations; placebo (normal saline) and 1% propofol group (group 1), placebo and 2% propofol group (group 2), lidocaine and 1% propofol group (group 1L), and lidocaine and 2% propofol group (group 2L). Administration of pretreatment drug was followed by TCI with using each concentration of propofol. Pain was assessed using a four-point scale during propofol infusion. RESULTS: Propofol pain was more frequent (82% vs. 63%, respectively, P = 0.026), and severe (P = 0.002) for the group 2 than for group 1. Pain was significantly reduced by lidocaine pretreatment in the group 2L (48%) and group 1L (19%), as compared with group 2 (82%) and group 1 (63%), respectively (P < 0.001, both). However, group 2L still showed considerable pain that was similar to the pain of group 1. CONCLUSIONS: TCI of 2% propofol caused more frequent and severe pain despite of lidocaine pretreatment.

Redundant Nerve Roots of the Cauda Equina: MR Findings

PURPOSE: To evaluate MR findings of redundant nerve roots (RNR) of the cauda equina. MATERIALS AND METHODS: 17 patients with RNR were studied; eight were men and nine were women, and their ages ranged from 46 to 82 (mean63) years. Diagnoses were established on the basis of T2-weighted sagittal and coronal MRI, which showed a tortuous or coiled configuration of the nerve roots of the cauda equina. MR findings were reviewed for location, magnitude, and signal intensity of redundant nerve roots, and the relationship between magnitude of redundancy and severity of lumbar spinal canal stenosis (LSCS) was evaluated. RESULTS: In all 17 patients, MR showed moderate or severe LSCS caused by herniation or bulging of an intervertebral disc, osteophyte from the vertebral body or facet joint, thickening of the ligamentum flavum, degenerative spondylolisthesis, or a combination of these. T2-weighted sagittal and coronal MR images well clearly showed the location of RNR of the cauda equina; in 16 patients (94%), these were seen above the level of constriction of the spinal canal, and in one case, they were observed below the level of constriction. T2-weighted axial images showed the thecal sac filled with numerous nerve roots. The magnitude of RNR was mild in six cases (35%), moderate in five cases (30%), and severe in six cases (35%). Compared with normal nerve roots, the RNR signal on T2-weighted images was iso-intense. All patients with severe redundancy showed severe LSCS, but not all cases with severe LSCS showed severe redundancy. CONCLUSION: Redundant nerve roots of cauda equina were seen in relatively older patients with moderate or severe LSCS and T2-weighted MR images were accurate in identifying redundancy of nerve roots and evaluating their magnitude and location.

Imaging of the Jaw Cysts with a Dental CT Software Program: Distinction of Odontogenic Keratocysts from Other Cysts

PURPOSE: To evaluate the usefulness of a dental CT software program in the assessment of jaw cysts and in the differentiation of odontogenic keratocysts and other cysts. MATERIALS AND METHODS: Seventeen patients with proven jaw cysts (8 maxillae & 9 mandibles) were evaluated with a dental CT software program for location, locularity, the presence or absence of marginal scalloping, and height to length ratio. For the delineation of involvement or displacement of neurovascular bundles, cortical erosion, perforation or expansion, and tooth root resorption by the jaw cysts, images from this program were compared to conventional images. RESULTS: Seventeen lesions icomprised 15 odontogenic cysts (five odontogenic keratocysts, five radicular, three residual and two dentigerous cysts) and two non-odontogenic cysts (one nasopalatine duct cyst and one postoperative maxillary cyst). Images of jaw cysts obtained with the dental CT software program delineated much more clearly than conventional images the status of neurovascular bundle and cortical bone, but there was no clear difference between the two modalities in delineating tooth root erosion. Dental CT findings of five mandibular odontogenic keratocysts were scalloped margin in all, mandibular ramus involvement in four, height to length ratio below 60% in four, and multilocularity in two. The findings of the other 12 cysts (eight maxillae and four mandibles) were unilocularity in all, smooth inner margin in ten, height to length ratio below 60% in only two, and ramus involvement in none. CONCLUSION: Adental CT software program is an improved imaging modality for assessing jaw cysts ; and findings which tend to indicate odontogenic keratocysts are marginal scalloping, mandibular ramus involvement, prominent spread along the marrow space and multilocularity.