External Cephalic Version Attempted under Epidural Anesthesia : Case reports

Recently, the external cephalic version procedure has attracted attention as an alternative for the operative or vaginal delivery of a breech-presenting fetus. Although this procedure has many benefits, including its comparative safety and economical efficiency, it is not free from complications. We report two cases of external versions attempted under epidural anesthesia. These cases demonstrate that the use of a neuraxial blockade during a version attempt can provide the appropriate conditions necessary for this procedure, as well as the ability to deal with complications in a timely and safe manner.

Rupture of hepatic hemangioma during pregnancy : A case report

We report a case of hepatic hemangioma rupture in a 36-year-old woman with a 34-week twin pregnancy. Hemangiomas are the most common benign tumors of the liver and most of them are small and asymptomatic. However, they can induce severe abdominal pain or fatal hemorrhage when ruptured spontaneously during pregnancy. Because of non-specific symptoms and the presence of the large gravid uterus during pregnancy, it is difficult to reach this diagnosis. Under spinal anesthesia, a cesarean section for twin delivery and removal of the hematoma in the abdominal cavity were performed. However, the source of active bleeding was not found during the operation. The spontaneous rupture of hepatic hemangioma was diagnosed after postoperative hepatic angiography and treated successfully by embolization of the left hepatic artery.

Comparison of Ramosetron and Ondansetron for Preventing Nausea and Vomiting after Gynecologic Surgery / 대한마취과학회지

BACKGROUND: In this randomized, double-blinded study, we evaluated the efficacy of ramosetron and ondansetron for preventing postoperative nausea and vomiting (PONV) in gynecologic patients. METHODS: Sixty patients undergoing total abdominal hysterectomy or myomectomy, ASA physical status I or II, aged 30-65 yr, received IV ramosetron 0.3 mg (group R) or ondansetron 4 mg (group O) at the end of surgery (n = 30 each). A standard general inhalational anesthesia and postoperative IV patient-controlled analgesia were used. At postoperative 3, 24 and 48 hours, we assessed pain score (VAS), incidence of PONV, rescue drug consumption, adverse events associated with study medications and overall satisfaction scores. RESULTS: The incidence of PONV showed no difference between groups at each time points after surgery (overall incidence; 59% in group R, 69% in group O). There was no difference in the severity of nausea, pain score and analgesic drug usage. However, the consumption of rescue drug in the ramosetron group was markedly less than that of ondansetron group at postoperative 3 hrs (none vs. 8 patients). No clinically serious adverse events were observed in either of the groups. Overall satisfaction scores were also comparable in both groups (6.5 +/- 3.0 vs. 6.2 +/- 2.7). CONCLUSIONS: Prophylactic therapy with ramosetron is as effective and safe as conventional prophylactic therapy with ondansetron for preventing PONV in women undergoing general anesthesia for gynecologic surgery. Severity of PONV seems significantly less with ramosetron than with ondansetron in the early postoperative period.

Combined Spinal-epidural Anesthesia for Cesarean Section in a Patient with Peripartum Cardiomyopathy: A case report / 대한마취과학회지

Peripartum cardiomyopathy (PPCM) is a rare form of cardiomyopathy associated with a significant morbidity and mortality. The anesthetic management of a Cesarean section in patients with PPCM has not been well defined. Herein, our experience of a 31-year-old multipara, with recurrent PPCM and congestive heart failure, who presented for an elective cesarean section, is reported. Combined spinal-epidural anesthesia was successfully employed as the anesthetic technique for the procedure. The intra-arterial blood pressure and central venous pressure were monitored throughout the procedure. In addition, the patient's postoperative pain was markedly reduced with the use of epidural PCA. Combined spinal-epidural anesthesia is suggested to be a reliable technique, which provides minimal hemodynamic changes, and a lower failure rate than epidural anesthesia only, and is also highly effective with a low dose of local anesthetic drug.

Clinical Experience with Recombinant Activated Factor VII in a Surgical Patient with Coagulation Factor VII Deficiency: A case report / 대한마취과학회지

A 33-yr old female patient with coagulation factor VII deficiency was scheduled for laparoscopic oophorectomy under the diagnosis of ovarian teratoma. Plasma concentration of factor VII of this patient was 9 IU/dl (normal range; 60-140 IU/dl) and the prothrombin time INR (International Normalization Ratio) was 1.79 (normal range; 0.8-1.2) on the day before the operation. Total 1,200microgram (30microgram/kg) of recombinant activated factor VII (rFVIIa) was administered just before the start of the laparoscopic procedure, which was accomplished safely without severe hemorrhage or other complications. Postoperative course was uneventful. In addition, this article provides the clinical implication of rFVIIa in terms of hemostasis management in hemophiliacs and surgical patients.

Rupture of Unscarred Uterus Detected during a Cesarean Section : A case report

Uterine rupture is usually associated with previous uterine scar. Although intrapartum rupture of unscarred uterus is very rare, it may cause catastrophic outcomes to both the mother and the newborn infant compared with that of a scarred uterus. The present case describes our experience of anesthesia for an emergency cesarean section due to the arrest of fetal descent in a 36-year-old parturient who had undergone external cephalic version for the breech presentation of her fetus. We detected the rupture of her unscarred uterus during the operation under epidural anesthesia, which was changed to general anesthesia. Despite the uterine rupture the newborn infant survived uneventfully. At the postoperative twelfth day she was discharged from hospital with her baby.

Epidural Analgesia in the Parturient with Spinal Cord Injury: A case report / 대한마취과학회지

Autonomic dysreflexia is a syndrome of uninhibited sympathetic spinal reflexes in response to stimuli below the level of injury in the patients with high spinal lesions. During labor, it can cause uteroplacental vasoconstriction resulting in fetal distress or devastating maternal complications including retinal hemorrhage, cerebrovascular accident and hypertensive encephalopathy. Neuraxial blockade has proven to be an effective method to attenuate or prevent it. We present a case detailing the use of epidural analgesia in managing the delivery of a quadriplegic parturient with a history of autonomic dysreflexia.

Comparison of General Anesthesia using Propofol-Remifentanil and Propofol-Nitrous Oxide / 대한마취과학회지

BACKGROUND: Remifentanil is a novel, ultra-short acting opioid. This study was performed to compare the hemodynamic responses of remifentanil and nitrous oxide under propofol-based anesthesia during the intraoperative period. METHODS: Forty patients undergoing gynecologic surgery were randomly allocated to either remifentanil (R group) or N2O group (N group). In the R group, remfentanil was continuously infused from the induction of anesthesia (0.5 microgram/kg/min) to the end of surgery (0.1-0.5 microgram/kg/min). In the N group, fentanyl (2 microgram/kg) was injected intravenously and N2O was used thereafter. In both groups, target-concentration infusion of propofol was applied. We compared mean arterial pressure (MAP) and heart rate (HR) before and after tracheal intubation and during the rest of anesthetic time between the two groups. Postoperative parameters such as nausea/vomiting, consciousness level and pain at 2 and 24 hours were also compared. RESULTS: The magnitude of MAP and HR after tracheal intubation were significantly smaller and more stable in the R group than in the N group. Hypertensive (systolic blood pressure > 140 mmHg) episodes were significantly less frequent in the R group (3.0%) than in the N group (12.4%) during the operation. R group showed less MAP (76+/-12 mmHg) and HR (61+/-10 bpm) compared with those of N group (86+/-17 mmHg, 63+/-8 bpm, P < 0.05 respectively). Other postoperative measures were comparable between the two groups. CONCLUSIONS: We conclude that the continuous infusion of remifentanil can provide more stable hemodynamic status than N2O without significant adverse effects, in propofol-based general anesthesia.

Effects of Hydralazine Pretreatment on Esmolol-induced Controlled Hypotension during Spine Surgery / 대한마취과학회지

BACKGROUND: Controlled hypotension improves surgical field and decreases transfusion requirement in surgical patients and can be induced with various kinds of drugs including esmolol and hydralazine. METHODS: This study examined the effect of a combination of esmolol and hydralazine as hypotensive agents in spine surgery. In the esmolol group (n = 15), after boluses of esmolol (0.5 mg/kg) injection, esmolol was infused to maintain the mean arterial pressure of 55-65 mmHg. In the hydralazine-esmolol group (n = 15), hydralazine (0.3 mg/kg) was administered 15 minutes before esmolol injection which was done in the same way as that of the esmolol group. RESULTS: The mean arterial pressure decreased to the target range more rapidly in the hydralazine-esmolol group. The heart rate was increased by hydralazine, but reduced by esmolol. The cardiac output remained elevated after hydralazine injection in the hydralazine-esmolol group, and decreased significantly by esmolol in the esmolol group. The administered dose of esmolol was much less in the hydralazine-esmolol group than in the esmolol group. CONCLUSIONS: Our data suggest that hydralazine can enhance the efficacy of esmolol-induced controlled hypotension. It can reduce the requirement of esmolol and maintain a higher cardiac output during hypotension.

A Comparison of Epidural Morphine-Bupivacaine with Intravenous Morphine-Ketorolac in Patient-Controlled Analgesia after Gynecologic Operation / 대한마취과학회지

BACKGROUND: Postoperative pain control is provided for humanitarian reasons and to alleviate nociception-induced responses, such as endocrine metabolic responses, autonomic reflexes, which have adverse effects on organ function, and other undesirable results. Of the various methods of treatment, patient-controlled analgesia (PCA) is considered the gold standard for the of control postoperative pain. PCA can be administered via intraveous, epidural, or subcutaneous routes. Although patient-controlled epidural analgesia (PCEA) has been compared to IV-PCA, there is no optimal administrative route for the treatment of postoperative pain. This randomized study compared the effectiveness of PCEA and IV-PCA on postoperative pain and the side-effects after gynecologic surgery. METHODS: Ninety-seven patients undergoing gynecologic surgery were randomly assigned to receive either IV-PCA using a mixture of morphine and ketorolac or PCEA using 0.1% bupivacaine and morphine. Pain intensity was tested using a visual analog scale (VAS) until postoperative day 2. Nausea, vomiting, sedation, and pruritus were also measured. RESULTS: Among the 97 patients, 12 patients were excluded during study. Pain relief was better at rest and after coughing in the PCEA group during the 2 postoperative days, except at the first visit. Additional analgesics were used significantly less in the PCEA group, whilst the incidence of other complications was comparable in the IV-PCA and PCEA groups. CONCLUSIONS: After gynecologic surgery, PCEA using bupivacaine and morphine provides better pain relief than IV-PCA using morphine and ketorolac.

Replacement of Uterine Inversion by the Induction of General Anesthesia: A case report / 대한마취과학회지

Uterine inversion is a rare but a potentially fatal complication of labor, and may occur in the third stage of labor. Because it can lead to shock and hemorrhage, immediate management should be attempted to replace the inverted uterus. We report a case in which uterine inversion was not replaced by manual manipulation, but which was successfully replaced by the induction of general anesthesia.

The Perioperative Management of Diabetic Patients: A Retrospective Study / 대한마취과학회지

BACKGROUND: Diabetic patients have more chance of requiring surgery than non-diabetic population. Glycemic and metabolic controls are key points in the perioperative diabetic management. A variety of methods have been proposed for the management of diabetics perioperatively, but their effectiveness is still controversial. This study was done to investigate whether diabetic patients are managed appropriately in perioperative period. METHODS: Among diabetic patients referred to anesthesiologic outpatient clinic from August 1997 to September 2002, 85 patients were randomly selected Diabetic duration, medication for diabetic control, concurrent illness and referral surgical department was recorded. In preoperative routine laboratory findings, HbA1c, fasting glucose and postprandial glucose were checked Perioperative glucose control protocols applied to patients were investigated RESULTS: Patients received 1.32 operation per person. Diabetic duration was 12.2 +/- 7.2 years, thirty nine patients had take oral hypoglycemic agent and thirty one patients had received insulin. Mean HbA1c was 8.0 +/- 1.6%, thirty four patients showed above 8.0%. Alberti's regimen was used in fifty five patients and insulin was omitted in fifty six patients. Two patients received insulin of half of usual dose in the morning. Alberti's regimen in major surgery and no insulin in minor surgery were preferred. The composition of Alberti's regimen and target blood glucose level varied. During operation, blood glucose was checked only in fourty four cases. Five of seven postoperative hypoglycemic patients were not checked glucose level during operation. Mortality rate was 7% and major cause of death was sepsis. All of the mortality cases had diabetic cardiovascular and nephrologic complications. CONCLUSIONS: We concluded there is a pitfall in managing diabetic patients requiring surgery. There must be a consensus between surgeon and anesthesiologist about perioperative management of diabetics. Perioperative glucose level should be checked as often as feasible, and insulin supply be continued during operation.

The Effect of Angiotensin II on Hypoxic Pulmonary Vasoconstriction in Isolated Rabbit Lung / 대한마취과학회지

BACKGROUND: The isolated lung model is a very useful model in investigation of hypoxic pulmonary vasoconstriction (HPV), and angiotensin II is extensively used in this model. But the exact role of angiotensin II in HPV is not clear in the isolated rabbit lung. Thus we were concerned about the role of angiotensin II in the blood-perfused rabbit lung. METHODS: New Zealand white rabbits (n = 28) lungs were isolated and perfused with a constant pulmonary perfusate flow; acid-base status and temperature were maintained at constant levels. Deoxyglucose (DOG group, n = 7), angiotension II and deoxyglucose (AG-DOG group, n = 7), calcium (CA group, n = 7), angiotensin II and calcium (AG-CA group, n = 7) were administered, and then hypoxic responses were measured. Three ratios were calculated and compared (P alpha: ratio of hypoxic response to pulmonary arterial pressure at normoxia, P beta: ratio of hypoxic response to baseline hypoxic response, P gamma: ratio of pulmonary arterial pressure at hypoxia to pulmonary arterial pressure at baseline). RESULTS: Angiotensin II increased the pulmonary arterial pressure by 14%, and increased HPV. Baseline pulmonary pressure was increased in the AG-DOG group and in the AG-CA group (P<0.05). P gamma significantly increased in the AG-DOG and AG-CA groups (P<0.05). The first HPV increased but the second HPV decreased in the AG-DOG group (P alpha: P<0.05) and in the AG-CA group. P beta showed no difference between groups. CONCLUSIONS: Angiotensin II resulted in an increase of pulmonary arterial pressure in the isolated rabbit lung. One may misinterpret this as an potentiation of HPV, but HPV was not changed by angiotensin II. Therefore we deny the necessity for angiotensin II in the isolated rabbit lung model.

Change of Tumor Necrosis Factor-alpha Concentration after Pediatric Cardiopulmonary Bypass and Its Relationship with Postoperative Course / 대한마취과학회지

BACKGROUND: Systemic inflammatory response after open heart surgery has an adverse effect on the postoperative course of patient, and results from the release of cytokines by leukocytes activated by cardiopulmonary bypass (CPB). TNF-alpha has an important role in inflammatory response-it has clinical effects such as fever, tachycardia, and hypotension, and also induces other cytokines. However studies about the change of blood concentration of TNF-alpha after CPB show differing results, and so have been up to now inconclusive, we have therefore endeavored to investigate the change of TNF-alpha level after CPB and its relationship with the postoperative course of patients. METHODS: We studied 20 children undergoing open heart surgery. Serum TNF-alpha was detected after induction (control), 5 minutes after onset of CPB (T1), 5 minutes after release of aortic cross clamp (T2), and 30 minutes after CPB (T3) by enzyme-linked immunosorbent assay. We compared the concentration of TNF-alpha and the duration that patients stayed in intensive care unit (ICU) and were supported by mechanical ventilator in group I (CPB time 60 minutes, n = 10). RESULTS: TNF-alpha levels of S2 and S3 were significantly lower than those of S1 and S4 (P = 0.001), but no difference was detected between group I and II. No statistical relationship was found linking TNF-alpha levels with the duration in ICU, or time supported by mechanical ventilator. Three children with postoperative complications showed higher level of TNF-alpha than others (P = 0.002). CONCLUSIONS: We concluded that TNF-alpha levels decreased during CPB, did not increased after CPB, and had no relationship to such postoperative courses as postoperative ICU time and intubation time, but there was a correlation with postoperative complications.

The Depth of Insertion for Left-Sided Double-Lumen Endotracheal Tube is Correlated with the Height and the Length of Sternocleidomastoid Muscle / 대한마취과학회지

BACKGREOUND: When a double-lumen endotracheal tube (DLT) is used for one-lung ventilation, its position should be accurate. But only a few studies has been performed about how to predict the depth of insertion for DLT preoperatively. The purpose of this study is to investigate which physical measurements are correlated with the depth of insertion for left-sided DLT and how the depth of insertion for DLT can be explained with these physical measurements. METHODS: After placing a 5 cm-high pillow under the patient's head, we intubated left-sided disposable DLT (BronchocathTM, Mallinckrodt medical Ltd, USA) in 65 adults. We tape-measured sternocleidomastoid muscle (SCM) length and sternal length. We positioned the proximal margin of the bronchial cuff of DLT just below carinal bifurcation through fiberoptic bronchoscope, and recorded the depth of insertion for DLT at the upper incisor level. RESULTS: The depth of insertion for DLT was correlated with both height (y=3.96+0.15x, r2=0.51, p=0.0001) and SCM length (y=16.73+0.82x, r2=0.49, p=0.0001). Sternal length (r2=0.11, p=0.0081) was weakly correlated with the depth of insertion for DLT. The best regression model was depth of insertion for DLT (cm)=6.88+0.09 height (cm)x0.46 SCM length (cm). CONCLUSIONS: The depth of insertion for DLT is correlated with SCM length as well as height. So we may use them in predicting the depth of insertion for DLT.

Total Intravenous Anesthesia with Sufentanil and Midazolam for Open Heart Surgery / 대한마취과학회지

BACKGROUND: This study was conducted to evaluate the hemodynamic effects, the time to arousal and the postoperative recall with the continuous infusion technique of sufentanil and midazolam used for induction and maintenance of anesthesia in patients undergoing open heart surgery. METHODS: Forty patients with good ventricular function undergoing elective open heart surgery were evaluated. They received midazolam 0.1 mg/kg, pancuronium 0.15 mg/kg and sufentanil 2.5 mcg/kg, followed by infusions of midazolam 0.1 mg/kg/hr, pancuronium 0.02 mg/kg/hr and sufentanil 1.5 mcg/kg/hr until the end of operation. We observed the mean arterial pressure, heart rate and central venous pressure before the initiation of cardiopulmonary bypass(CPB) and recorded the time to arousal after the end of operation and asked about awareness of any intraoperative events on the third postoperative day. RESULTS: The mean arterial pressures during prebypass period were lower than preinduction value but there were no severe hypotension with mean arterial pressures less than 60 mmHg. The mean arousal time of eye opening was 119 minutes and there was no postoperative recall case. CONCLUSIONS: The results show that the infusion of sufentanil with midazolam to patients with good ventricular function provides a stable and safe anesthesia hemodynamically and neurologically and a rapid recovery from anesthesia without postoperative recall.

The Application of Cryoneurolysis in Patients with Intercostal Neuralgia: A Case report / 대한마취과학회지

Cryoneurolysis to peripheral neuralgia has been tried in selected postoperative pain and chronic pain patient; post-thoracotomy pain, post-herniorrhapy pain and trigeminal neuralgia. Here we report first two cases those were effectively controlled by percutaneous cryoneurolysis. Intercostal neuralgia was confirmed by intercostal nerve block with 1% mepivacaine and then we applied cryoneurolysis. Those pains could be relieved for more than two or three months. We suggest that cryoneurolysis can be an useful, simple and safe neurolytic method to intercostal neuralgia in outpatient pain clinic.