Cyanide toxicity during cardiopulmonary bypass with small dose of nitroprusside: a case report / 대한마취과학회지

Sodium nitroprusside (SNP) is an anti-hypertensive drug, commonly used to decrease the systemic vascular resistance and lower the blood pressure. When the amount of cyanide generated by the SNP exceeds the metabolic capacity for detoxification, cyanide toxicity occurs. Under general anesthesia and cardiopulmonary bypass (CPB), it may be difficult to detect the development of cyanide toxicity. In cardiac surgical patients, hemolysis, hypothermia and decreased organ perfusion, which emphasize the risk of cyanide toxicity, may develop as a consequence of CPB. In particular, hemolysis during CPB may cause an unexpected overproduction of cyanide due to free hemoglobin release. We experienced a patient who demonstrated SNP tachyphylaxis and cyanide toxicity during CPB, even though the total amount of SNP administered was much lower than the recommended dose. We therefore report this case with a review of the relevant literature.

Comparison of 0.5% ropivacaine with fentanyl and 0.75% ropivacaine used in extension of a preexisting labor epidural for emergency cesarean section: retrospective study

BACKGROUND: Various regimens have been studied in extension of a preexisting labor epidural for emergency cesarean section. Lumbar epidural analgesia for delivery is safe and efficient. We compared retrospectively 0.5% ropivacaine with fentanyl and 0.75% ropivacaine in extension of a preexisting labor epidural for emergency cesarean section. METHODS: We investigated medical records of 61 parturients in extension of a preexisting labor epidural for emergency cesarean section. There were two regimens which was 0.5% ropivacaine with fentanyl (group 1) and 0.75% ropivacaine (group 2). We recorded demographic data, local anesthetic dose, surgical readiness time, maximum level of sensory block, surgery time, intravenous supplementation, number of hypotension and total dose of ephedrine between two groups. RESULTS: There were no differences between the study groups in demographic data, surgical readiness time, maximum sensory block level, intravenous supplementation, incidence of hypotension and total dose of ephedrine. Local anesthetic volume was larger in group 1 than group 2, but local anesthetic doses were lower in group 1 than group 2. CONCLUSIONS: 0.5% Ropivacaine with fentanyl regimen is as fast and efficacious as 0.75% ropivacaine in extension of a preexisting labor epidural for cesarean section and reduces the requiring total local anesthetic dose.

General anesthesia for cesarean section in a patient with multiple sclerosis: A case report

A 34-year-old female with multiple sclerosis (MS) was scheduled Cesarean section. She had been suffering from MS for 10 years and the symptoms of MS were paraplegia and urinary incontinence. After informed consent, anesthesia was induced with propofol and maintained with nitrous oxide, sevoflurane and fentanyl. Rocuronium was used for muscle relaxation and tracheal intubation. Train of four (TOF) ratio and bispectral index scale were monitored for adequate muscle relaxation and depth of anesthesia. She gave birth to a baby within 7 minutes after skin incision. When operation was over, TOF ratio was 0.8. She emerged from general anesthesia smoothly and was extubated. There was no febrile event or exacerbation of MS after Cesarean section under general anesthesia. We report a safe anesthetic management of the parturient with MS, using sevoflurane.

Comparison of clinical effects according to dosage of fentanyl added to 0.5% hyperbaric bupivacaine for spinal anesthesia in patients undergoing cesarean section

BACKGROUND: Spinal anesthesia for cesarean section is widely used technique for rapid induction, high success rate and excellent intraoperative and postoperative analgesia. Potentiating the effect of intrathecal local anesthetics by addition of opioid for cesarean section is well known. In this study, we compared the clinical effects when different doses of fentanyl were combined with intrathecal hyperbaric bupivacaine. METHODS: Ninety six healthy term parturients were randomly divided into four groups: Group C (control), : Group F10 (fentanyl 10 microg), : Group F15 (fentanyl 15 microg), F: Group F20 (fentanyl 20 microg). In every group, 0.5% heavy bupivacaine was added according to the adjusted dose regimen. We observed the maximal level of the sensory block and motor block, the quality of intraoperative analgesia, the duration of effective analgesia and the side effects. RESULTS: There were no significant differences between four groups in maximal level and recovery rate of sensory and motor block. Quality of intraopertive analgesia and muscle relaxation was increasing by increasing dosage of intrathecal opioids. Duration of effective analgesia was significantly prolonged in Group F15 and F20 than Group C and F10, but there were no differences between Group F15 and F20. And the frequencies of side effects such as hypotension, max sedation level were increasing by increasing dosage of intrathecal opioids. The Apgar scores were normal, and there were no differences between the four groups. CONCLUSIONS: The addition of fentanyl 15 microg for spinal anesthesia provides adequate intraoperative analgesia and good postoperative analgesia without significant adverse effects.

Comparison of clinical effects according to the dosage of sufentanil added to 0.5% hyperbaric bupivacaine for spinal anesthesia in patients undergoing cesarean section / 대한마취과학회지

BACKGROUND: Subarachnoid block is a widely used technique for cesarean section. To improve the quality of analgesia and prolong the duration of analgesia, addition of intrathecal opioids to local anesthetics has been encouraged. We compared the effects of sufentanil 2.5 microg and 5 microg, which were added to intrathecal hyperbaric bupivacaine. METHODS: We enrolled 105 full term parturients were randomly divided into 3 groups: Group 1 (control), Group 2 (sufentanil 2.5 microg), and Group 3 (sufentanil 5 microg). In every group, 0.5% heavy bupivacaine was added according to the adjusted dose regimen. We determined the maximum level of sensory block and motor block, the quality of intraoperative analgesia, the duration of effective analgesia and side effects. RESULTS: There were no significant differences among the 3 groups in the maximum level of the sensory block and motor block. Recovery rate of the sensory block, however, was significantly slower in Group 3 than Group 1. Quality of intraopertive analgesia, muscle relaxation, and duration of effective analgesia were enhanced by increasing the dosage of intrathecal sufentanil. Frequencies of hypotension, maximum sedation level, and pruritus were directly related to the dosage of intrathecal sufentanil, whereas nausea and vomiting occurred only in the groups using sufentanil. CONCLUSIONS: The addition of sufentanil 2.5 microg for spinal anesthesia provides adequate intraoperative analgesia and good postoperative analgesia with minimal adverse effects on the mother.

Comparison of fentanyl and sufentanil added to 0.5% hyperbaric bupivacaine for spinal anesthesia in patients undergoing cesarean section / 대한마취과학회지

BACKGROUND: Subarachnoid block is widely used for cesarean section due to the rapid induction, the complete analgesia, the low failure rate and the prevention of aspiration pneumonia. The addition of intrathecal opioids to local anesthetics seems to improve the quality of analgesia & prolong the duration of analgesia. Therefore we compared the effects of fentanyl 20 microg and sufentanil 2.5 microg, which were added to intrathecal hyperbaric bupivacaine. METHODS: Seventy two healthy term parturients were randomly divided into three groups: Group C (control), Group F (fentanyl 20 microg) and Group S (sufentanil 2.5 microg). In every group, 0.5% heavy bupivacaine was added according to the adjusted dose regimen by Harten et al. We observed the maximal level of the sensory block and motor block, the quality of intraoperative analgesia, the duration of effective analgesia and the side effects. RESULTS: There were significant differences between the control and the fentanyl 20 microg and sufentanil 2.5 microg groups for the degree of muscle relaxation, the quality of intraoperative analgesia, the maximal sedation level and the duration of effective analgesia. The frequencies of side effects such as nausea and pruritis in the opioid groups were higher than those in the control group. But there were no differences between fentanyl 20 microg and sufentanil 2.5 microg for the frequencies of nausea and pruritis. CONCLUSIONS: The addition of fentanyl 20 microg or sufentanil 2.5 microg for spinal anesthesia provides adequate intraoperative analgesia without significant adverse effects on the mother and neonate.

Unexpected difficulty in ventilating the lungs after tracheal intubation: A case report / 대한마취과학회지

We experienced difficulty in ventilating the lungs of a patient after tracheal intubation. After intubation, an insufficient amount of tidal volume (VT) was delivered to the patient and the fiberoptic bronchoscopic examination identified partial abutment of the endotracheal tube (ETT) orifice against the tracheal wall. After various attempts to correctly place the ETT, a double-lumen endotracheal tube was placed to achieve a sufficient VT. It is important to notice that even an appropriately placed ETT may get obstructed due to the left sided bevel at its tip.

The relationship between symphysis-fundal height and intravenous ephedrine dose in spinal anesthesia for elective cesarean section / 대한마취과학회지

BACKGROUND: A decreased lumbosacral subarachnoidal space volume is a major factor in the cephalad intrathecal spread of local anesthetics in term parturients and their subarachnoidal space is decreased due to the compressive effect of huge uteri. Therefore, they show a higher level of sensory block and hypotensive episodes. The purpose of this study is to investigate whether the symphysis-fundal height (SFH) correlates with the highest sensory level and the amount of ephedrine administered under spinal anesthesia. METHODS: Fifty-two uncomplicated parturients who consented to spinal anesthesia for elective cesarean section were studied. The SFH of all parturients had been measured just before the spinal anesthesia administered by one person. Hyperbaric bupivacaine with fentanyl 20 microgram, was administered for spinal anesthesia. The amount of 0.5% bupivacaine was adjusted according to the patient's height and weight. The level of sensory block and the amounts of ephedrine to treat hypotension, nausea and vomiting were assessed. Linear regression and correlation analysis were applied to analyze the data. RESULTS: According to the results of correlation analysis, there was no significant correlation between the level of sensory block and SFH. There were statistically significant positive correlations between the amount of ephedrine administered due to hypotension and SFH. CONCLUSIONS: In term parturients choosing elective cesarean section, the SFH is not correlated with the sensory level of spinal anesthesia, but is correlated with the amount of ephedrine administered during spinal anesthesia.

Meralgia paresthetica affecting parturient women who underwent cesarean section: A case report / 대한마취과학회지

Meralgia paresthetica is commonly caused by a focal entrapment of lateral femoral cuteneous nerve while it passes the inguinal ligament. Common symptoms are paresthesias and numbness of the upper lateral thigh area. Pregnancy, tight cloths, obesity, position of surgery and the tumor in the retroperitoneal space could be causes of meralgia paresthetica. A 29-year-old female patient underwent an emergency cesarean section under spinal anesthesia without any problems. But two days after surgery, the patient complained numbness and paresthesia in anterolateral thigh area. Various neurological examinations and L-spine MRI images were all normal, but the symptoms persisted for a few days. Then, electromyogram and nerve conduction velocity test of the trunk and both legs were performed. Test results showed left lateral cutaneous nerve injury and meralgia paresthetica was diagnosed. Conservative treatment was implemented and the patient was free of symptoms after 1 month follow-up.

Intrathecal meperidine reduces intraoperative shivering during transurethral prostatectomy in elderly patients / 대한마취과학회지

BACKGROUND: Shivering is a frequent event during the perioperative period. We performed a prospective, randomized, double-blind study to determine whether intrathecal meperidine (0.2 mg/kg) decreases the incidence and intensity of shivering after spinal anesthesia for transurethral operations. METHODS: Fifty patients scheduled for elective transurethral resection operations under spinal anesthesia were randomly allocated to two groups. Spinal anesthesia consisted of 0.5% hyperbaric bupivacaine 8 mg and, mperidine (0.2 mg/kg) (meperidine group) or, normal saline (saline group). Data collection, including sensory block level (by pinprick), blood pressure, heart rate, sublingual temperature, incidence and intensity of shivering, pruritus, nausea, and vomiting was performed at 10 minute intervals. RESULTS: The incidence and intensity of shivering was significantly less in the meperidine group than saline group (P = 0.012 and P = 0.008, for incidence and intensity, respectively). However, pruritus was more common in the meperidine group compared with the saline group (16% vs. 0%, P < 0.05). CONCLUSIONS: The addition of meperidine 0.2 mg/kg to intrathecal bupivacaine lowers the incidence and severity of shivering during transurethral prostatectomy in elderly patients.

A case of displaced pulmonary artery catheter into hepatic vein in mitral insufficiency patient: A case report / 대한마취과학회지

A 47-year-old woman was scheduled for mitral valvoplasty. Before induction of anesthesia, a pulmonary artery catheter (PAC) was placed via right internal jugular vein. Central venous pressure or right atrial pressure was traced until about 60 cm of PAC insertion and right ventricular pressure curve appeared without arrhythmias. We withdrew and advanced the catheter several times, but pressure tracing showed the same pattern. And we could not obtain the pulmonary artery pressure. We decided to leave the PAC in the right ventricle. No ventricular arrhythmia was detected. Postoperative chest x-ray revealed that PAC traveled through inferior vena cava and looped in the hepatic vein with the tip of the catheter in the right ventricle. Under fluoroscopic guidance, PAC was inserted to the pulmonary artery. No sign of hepatic vein obstruction was detected.

Anesthetic management for emergent craniotomy in a patient with Eisenmenger's syndrome: A case report / 대한마취과학회지

Eisenmenger's syndrome describes the elevation of pulmonary arterial (PA) pressure to the systemic level caused by an increased pulmonary vascular resistance with reversed or bi-directional shunt through an intracardiac or aortopulmonary communication. We report a case of an emergent craniotomy for cerebellar abscess in a 21-year-old male patient with Eisenmenger syndrome secondary to Large VSD. A PA catheter was inserted via right femoral vein, but could not be advanced pass the pulmonic valve. After futile attempts to place the catheter tip in the right ventricle. Anesthesia was induced with etomidate, rocuronium, midazolam and fentanyl and maintained with only high dose fentanyl. Milinone and norepinephrine were infused continuously to decrease right to left shunt. He was transferred to the intensive care unit under intubated state and treated with antibiotics for a few days due to intermittent high fever. The operation ended without major complications and the patient was discharged 42 days later.

Anesthetic management for cesarean section in a patient with Budd-Chiari syndrome: A case report / 대한마취과학회지

Budd-Chiari syndrome (BCS) represents a spectrum of disease states resulting in hepatic venous outflow occlusion. Prothrombotic disorders, such as protein S deficiency may cause thrombosis of the portal and hepatic veins. We report the management of a 30-year-old BCS primigravida with protein S deficiency and destroyed lung by the pulmonary tuberculosis scheduled for Cesarean section. Moreover, patient's lungs were destroyed by the pulmonary tuberculosis. Spinal anesthesia was selected for the anesthetic management. The patient recovered without any complication and discharged from hospital on the fifth postoperative day.

Comparison of Emergence Agitation from Sevoflurane Anesthesia after Thiopental Sodium, Propofol or Ketamine Induction in Pediatric Inguinal Herniorrhaphy / 대한마취과학회지

BACKGROUND: This study compared the incidence of emergence agitation and the recovery profile from sevoflurane anesthesia after thiopental sodium, propofol or ketamine induction in pediatric inguinal herniorrhaphy. METHODS: Forty eight children aged 1-7 years undergoing high ligation due to an inguinal hernia were examined. All patients received a 0.004 mg/kg glycopyrrolate injection for premedication prior to induction and were randomly assigned to receive thiopental sodium 5 mg/kg (Group T, n = 16), propofol 2 mg/kg (Group P, n = 16) or ketamine 1 mg/kg (Group K, n = 16) for induction. The side effects during the induction time were checked. All patients received sevoflurane (2-2.5 vol%)-N2O (2 L/min)-O2 (2 L/min) for the maintenance of anesthesia. Ventilation was given to assist spontaneous ventilation using a facial mask. The agitation score, pain score, discharge score, incidence of emergence agitation and postoperative side effects in the three groups were assessed at the recovery room and compared. RESULTS: The emergence time in Group T (7.5 +/- 1.8 min) was significantly rapid. The agitation and pain scores were significantly low in Group P. The discharge score was more rapid in Groups P and K than in Group T. The incidence of emergence agitation was similar in all three groups. CONCLUSIONS: Although recovery was faster and emergence agitation was low in the propofol group, propofol induction was not smooth compared with thiopental or ketamine induction. The incidence of emergence agitation after sevoflurane anesthesia in pediatric inguinal herniorrhaphy was similar in the thiopental sodium, propofol or ketamine induction groups.

Efficacy of Sufentanil during Laryngeal Microscopic Surgery / 대한마취과학회지

BACKGROUND: Various anesthetic agents have been used in laryngeal microscopic surgery, because the airway is shared with the surgeon, there is a short operation duration and intense cardiovascular stimulation occurs during the surgery. Sufentanil is superior than other anesthetic agents in blocking the cardiovascular response to the airway stimulation and a short duration of effects. METHODS: Thirty patients undergoing elective laryngeal microscopic surgery were randomized to receive sufentanil 0.125 microgram/kg (group 1, n = 10), sufentanil 0.25 microgram/kg (group 2, n = 10) or sufentanil 0.5 microgram/kg (group 3, n = 10). The bispectral index score, blood pressure, heart rate, recovery time from general anesthesia, the need for additional analgesics and naloxone and the postoperative complications associated with sufentanil were measured. RESULTS: The bispectral index, blood pressure and heart rate were similar in the three groups. Only four patients in group 3 required naloxone (P < 0.05). Three patients in group 1, one in group 2 and 0 in group 3 required an additional dose of sufentanil. Postoperative sore throat was detected in 6 patients in the immediate postoperative period and in 8 patients 6 hours after the end of anesthesia in group 1 (P < 0.05). CONCLUSIONS: Sufentanil is an effective analgesic for attenuating the cardiovascular responses of airway stimulation in laryngeal microscopic surgery. In addition, sufentanil 0.25 microgram/kg is an appropriate dose for the rapid recovery and attenuation of the cardiovascular response in laryngeal microscopic surgery.

Respiratory Depression Induced by Intraarticular Morphine under Total Knee Replacement: A case report / 대한마취과학회지

Intraarticular administration of morphine has good analgesic effect and satisfactory duration. It also shows less adverse effect of morphine than subarachnoid or epidural administration. However, high dose of morphine can cause long lasting respiratory depression. Although naloxone is effective in treatment of adverse effects of morphine, it has short duration of action. So repeating intravenous injections or continuous administration following bolus injection are recommended. We experienced a case of low dose continuous naloxone infusion for treatment of respiratory depression caused by iatraarticular morphine administration in total knee replacement surgery patient without affecting analgesic effect.

Respiratory Depression Induced by Intraarticular Morphine under Total Knee Replacement: A case report / 대한마취과학회지

Intraarticular administration of morphine has good analgesic effect and satisfactory duration. It also shows less adverse effect of morphine than subarachnoid or epidural administration. However, high dose of morphine can cause long lasting respiratory depression. Although naloxone is effective in treatment of adverse effects of morphine, it has short duration of action. So repeating intravenous injections or continuous administration following bolus injection are recommended. We experienced a case of low dose continuous naloxone infusion for treatment of respiratory depression caused by iatraarticular morphine administration in total knee replacement surgery patient without affecting analgesic effect.

Succinylcholine-Induced Fasciculation is Prevented by Mivacurium-Precurarization / 대한구급학회지

BACKGOUND: Succinylcholine (SCC) injection may be associated with adverse effects including elevated serum potassium (K ) and creatinine phosphokinase (CPK) level, and postoperative myalgia. Many studies have been made to prevent these adverse effects such as pretreatment with non-depolarizing muscle relaxants. The effects of the pretreatment with vecuronium or mivacurium, a new non-depolarizing neuromuscular blocker, on SCC-induced fasciculation, serum K and CPK level was investigated in this study. METHODS: ASA physical status I or II, 40 patients were allocated randomly into 4 groups. Group I as a control group received SCC 1 mg/kg only, while the other groups were pretreated with vecuronium 0.02 mg/kg (0.4 x ED95) (group II), mivacurium 0.02 mg/kg (0.25 x ED95) (group III) and 0.03 mg/kg (0.4 x ED95) (group IV) before the SCC 1.5 mg/kg injection, respectively. Serum K concentration was measured just before anesthetic induction and 5 minute after SCC injection, and serum CPK was estimated before induction and at 24~36 hours postoperatively. And the fasciculation after SCC injection was graded by Cullen's suggestion. RESULTS: Serum K concentration was increased in group I and decreased in pretreated groups, but the difference was not significant within each group and between the groups. Serum CPK level was increased in group I, II and IV but these changes were also insignificant between all groups. The grade of SCC-induced fasciculation was attenuated in group II and IV (p<0.05). CONCLUSIONS: Like vecuronium, mivacurium 0.03 mg/kg is effective to reduce fasciculation after SCC injection, but 0.02 mg/kg is not. However, any complication does not occur in the two dosages.