Accidental left atrial appendage thrombus detected by intraoperative transesophageal echocardiography during coronary artery bypass graft: A case report

A 77-year-old woman was scheduled for a coronary artery bypass graft. Her preoperative transthoracic echocardiographic (TTE) examination revealed an enlarged left atrium with reduced systolic dysfunction (ejection fraction: 38%), moderate global hypokinesia of the left ventricle, and moderate mitral and tricuspid regurgitation. No thrombus was visualized on the preoperative TTE. However, the intraoperative transesophageal echocardiography performed before the cardiopulmonary bypass revealed a thrombus of approximately 1.3 × 1.8 cm in the left atrial appendage (LAA). The LAA thrombus was removed, an internal suture was placed on the LAA before the coronary artery bypass grafting, and the main operation was performed successfully. The patient was transferred to the intensive care unit to receive postoperative care. She was extubated 4 h after the surgery and was transferred to the general ward on postoperative day 3 without any neurological sequelae.

Head Elevation in Spinal-Epidural Anesthesia Provides Improved Hemodynamics and Appropriate Sensory Block Height at Caesarean Section

PURPOSE: We aimed to determine whether head elevation during combined spinal-epidural anesthesia (CSE) and Caesarean section provided improved hemodynamics and appropriate sensory block height. MATERIALS AND METHODS: Forty-four parous women undergoing CSE for elective Caesarean section were randomly assigned to one of two groups: right lateral (group L) or right lateral and head elevated (group HE) position, for insertion of the block. Patients were positioned in the supine wedged position (group L) or the left lateral and head elevated position (group HE) until a block height of T5 to light touch was reached. Group HE was then turned to the supine wedged position with maintenance of head elevation until the end of surgery. Hemodynamics, including the incidence of hypotension, ephedrine dose required, and characteristics of the sensory blocks were analyzed. RESULTS: The incidence of hypotension (16 versus 7, p=0.0035) and the required dose of ephedrine [24 (0-40) versus 0 (0-20), p<0.0001] were greater in group L compared to group HE. In group L, the time to achieve maximal sensory block level (MSBL) was shorter (11.8+/-5.4 min versus 20.1+/-6.3 min, p<0.0001) and MSBL was also higher than in group HE [14 (T2) versus 12 (T4), p=0.0015]. CONCLUSION: Head elevation during CSE and Caesarean section is superior to positioning without head elevation in the lateral to supine position, as it is associated with a more gradual onset, appropriate block height, and improved hemodynamics.

Comparison of effects of intraoperative esmolol and ketamine infusion on acute postoperative pain after remifentanil-based anesthesia in patients undergoing laparoscopic cholecystectomy / 대한마취과학회지

BACKGROUND: Remifentanil is a short-acting drug with a rapid onset that is useful in general anesthesia. Recently, however, it has been suggested that the use of opioids during surgery may cause opioid-induced hyperalgesia (OIH). Researchers have recently reported that esmolol, an ultra-short-acing beta1 receptor antagonist, reduces the postoperative requirement for morphine and provides more effective analgesia than the administration of remifentanil and ketamine. Hence, this study was conducted to determine whether esmolol reduces early postoperative pain in patients who are continuously infused with remifentanil for anesthesia during laparoscopic cholecystectomy. METHODS: Sixty patients scheduled to undergo laparoscopic cholecystectomy were randomly divided into three groups. Anesthesia was maintained with sevoflurane and 4 ng/ml (target-controlled infusion) of remifentanil in all patients. Esmolol (0.5 mg/kg) was injected and followed with a continuous dosage of 10 microg/kg/min in the esmolol group (n = 20). Ketamine (0.3 mg/kg) was injected and followed with a continuous dosage of 3 microg/kg/min in the ketamine group (n = 20), while the control group was injected and infused with an equal amount of normal saline. Postoperative pain score (visual analog scale [VAS]) and analgesic requirements were compared for the first 6 hours of the postoperative period. RESULTS: The pain score (VAS) and fentanyl requirement for 15 minutes after surgery were lower in the esmolol and ketamine groups compared with the control group (P < 0.05). There were no differences between the esmolol and ketamine groups. CONCLUSIONS: Intraoperative esmolol infusion during laparoscopic cholecystectomy reduced opioid requirement and pain score (VAS) during the early postoperative period after remifentanil-based anesthesia.

Comparison of spread of subarachnoid sensory block and incidence of hypotension in early and late second trimester of pregnancy / 대한마취과학회지

BACKGROUND: Obstetric or non-obstetric surgery can be performed in pregnant women during the second trimester. We evaluated maximal sensory block level (MSBL), and other sensory block characteristics after spinal anesthesia in early and late second trimester pregnant women. METHODS: Forty-four pregnant women scheduled for cervical cerclage under spinal anesthesia in the early second trimester (Group E) or in the late second trimester (Group L) were enrolled in this study. Spinal anesthesia was performed at the L3/4 and 7 mg of 0.5% hyperbaric bupivacaine was injected into the subarachnoid space. Hemodynamic variables, incidence of nausea/vomiting, ephedrine dose, and sensory block were recorded every 2.5 min during the first 15 min and 20 min after the injection. The MSBL, the time at which MSBL was achieved, and the time to the two-segment regression of the sensory level were also recorded. RESULTS: The maximum number of segments blocked was significantly greater in the Group L than in the Group E. The incidence of nausea/vomiting and hypotension, and dose of administrated ephedrine were significantly higher in the Group L than in the Group E. The mean arterial pressure during the 15 min after subarachnoid injection was significantly lower compared to the baseline value in the Group L. CONCLUSIONS: The MSBL of spinal anesthesia with hyperbaric bupivacaine 7 mg were T9 in the early and T5 in the late second trimester groups. Pregnant women in the late second trimester exhibited increased incidence of hypotension and need for ephedrine than women in the early second trimester.

Motor Weakness after Caudal Epidural Injection Using the Air-acceptance Test

Air injected into the epidural space may spread along the nerves of the paravertebral space. Depending on the location of the air, neurologic complications such as multiradicular syndrome, lumbar root compression, and even paraplegia may occur. However, cases of motor weakness caused by air bubbles after caudal epidural injection are rare. A 44-year-old female patient received a caudal epidural injection after an air-acceptance test. Four hours later, she complained of motor weakness in the right lower extremity and numbness of the S1 dermatome. Magnetic resonance imaging showed no anomalies other than an air bubble measuring 13 mm in length and 0.337 ml in volume positioned near the right S1 root. Her symptoms completely regressed within 48 hours.

Anesthetic experience of Cesarean section in a patient with coexistence of Addison's disease with autoimmune thyroiditis: A case report

Addison's disease is a rare chronic endocrine disorder which results from progressive destruction of the adrenal glands. It is kind of autoimmune polyendocrine syndrome type 2 with autoimmune thyroiditis, and can lead to fatal outcomes when complicated in pregnancy. We report on an anesthetic experience with 38-year-old primigravida with Addison's disease and hypothyroidism who was followed up from the early stage of pregnancy to delivery by a multidisciplinary medical board. Great attention was given to steroid replacement therapy as well as fetal surveillance in order to lower the risk of maternal and fetal mortality. This report describes our experience of the spinal anesthetic management for Cesarean section of a patient with Addison's disease and hypothyroidism.

Anesthetic experience of Cesarean section in a patient with coexistence of Addison's disease with autoimmune thyroiditis: A case report

Addison's disease is a rare chronic endocrine disorder which results from progressive destruction of the adrenal glands. It is kind of autoimmune polyendocrine syndrome type 2 with autoimmune thyroiditis, and can lead to fatal outcomes when complicated in pregnancy. We report on an anesthetic experience with 38-year-old primigravida with Addison's disease and hypothyroidism who was followed up from the early stage of pregnancy to delivery by a multidisciplinary medical board. Great attention was given to steroid replacement therapy as well as fetal surveillance in order to lower the risk of maternal and fetal mortality. This report describes our experience of the spinal anesthetic management for Cesarean section of a patient with Addison's disease and hypothyroidism.

Anesthetic experience using total intravenous anesthesia in a patient with Isaacs' syndrome: A case report / 대한마취과학회지

We report on an anesthetic experience with a 74-year-old female with Isaacs' syndrome, who underwent elective surgery for open rotator cuff repair. Isaacs' syndrome is a rare peripheral motor neuron disorder with clinical manifestations such as involuntary muscle twitching, cramps, mild weakness and increased sweating. To avoid prolonged neuromuscular blockade, the patient was observed with neuromuscular monitoring during total intravenous anesthesia with propofol, remifentanil, and atracurium. No adverse events were observed during the anesthetic management, and the patient recovered smoothly from the neuromuscular blockade. We describe the clinical characteristics of Isaacs' syndrome and its specific considerations in anesthesia.

Effect of warmed ropivacaine solution on onset and duration of axillary block / 대한마취과학회지

BACKGROUND: Bicarbonate, as an adjunct increasing the non-ionized form of local anesthetics, can reduce latency and prolong duration of regional nerve block. Warming of local anesthetics decreases pKa and also increases the non-ionized form of local anesthetics. We warmed ropivacaine to body temperature (37degrees C) and evaluated the sensory block onset time, motor block onset time and analgesic duration of axillary block. METHODS: Patients were consecutively allocated to two groups of 22 patients each. Ropivacaine 150 mg (30 ml) at 20degrees C (room temperature) and 150 mg (30 ml) at 37degrees C (body temperature) was injected in group 1 and group 2, respectively. Sensory block and motor block was assessed every 5 minutes, for 30 minutes after injection. The duration of analgesia was recorded after operation. RESULTS: In group 2, the onset times of both sensory and motor block of the radial, ulnar, median and musculocutaneous nerves were significantly reduced, compared to group 1. Also, the number of blocked nerves was increased in group 2, within 30 minutes after injection. Analgesia lasted for 2 hours longer in group 2, compared to group 1, but the difference was not statistically significant (P > 0.05). CONCLUSIONS: Warming of ropivacaine to 37degrees C can reduce the onset time of both sensory and motor block, during axillary block.

Comparison of loss of resistance technique between Epidrum(R) and conventional method for identifying the epidural space / 대한마취과학회지

BACKGROUND: Epidrum(R) is a recently developed, air operated, loss of resistance (LOR) device for identifying the epidural space. We investigated the usefulness of Epidrum(R) by comparing it with the conventional LOR technique for identifying the epidural space. METHODS: One hundred eight American Society of Anesthesiologists (ASA) physical status I or II patients between the ages of 17 and 68 years old and who were scheduled for elective surgery under combined spinal-epidural anesthesia were enrolled in this study. The patients were randomized into two groups: one group received epidural anesthesia by the conventional LOR technique (C group) and the second group received epidural anesthesia using Epidrum(R) (ED group). While performing epidural anesthesia, the values of variables were recorded, including the number of failures, more than 2 attempts, the incidence of dural puncture, the time needed to locate the epidural space, the distance from the skin to the epidural space and ease of performance, and the satisfaction scores. RESULTS: The ED group showed a lower failure rate, fewer cases of more than 2 attempts, a lesser time to identify the epidural space, and better ease and satisfaction scores of procedure than the C group, with statistical significance. CONCLUSIONS: Using Epidrum(R) compared to the conventional LOR technique is an easy, rapid, and reliable method for identifying the epidural space.

Consideration on Application of Modified Monitored Anesthetic Care in Plastic Surgery

PURPOSE: Many patients have fear for surgery owing to the injection of lidocaine and the possible pain in the course of the operation. To resolve such a problem the cases to do plastic surgery with monitored anesthetic care are increasing, in which something like sedatives is injected into vein without endotracheal intubation and under voluntary respiration, but the usage is now under the controversy. METHODS: There were 25 patients who had surgery with local anesthesia, and another 25 patients who had surgery with monitored anesthetic care which belongs to ASA class 1 and 2 from January to April, 2009. Their anesthesia records were collected and surveys were given before and after the surgery and the surgery staff recorded OAA/S during the surgery. The postoperative surveys included the awakening during the surgery, pain, anxiety, and the degree of patient's satisfaction through visual analogue scale to identify the difference between the two methods. RESULTS: The OAA/S results according to time lapse show that it is possible to lead a fast effective sedation and recovery with monitored anesthetic care, and monitored anesthetic care enhances both surgeon's convenience level and patient's satisfaction level, and reduces awakening, pain, and anxiety, compared to local anesthesia. CONCLUSION: The current paper shows about the plastic surgery, particularly the outpatient surgery, when monitored anesthetic care method is applied, it could gain a fast sedation and recovery or an effective sedation of patients. The method also has some affirmative effects in regard with surgeon's convenience and the patients' satisfaction degree and the reduction of their awakening, pain, and anxiety. With careful and adequate watch on the measures about vital signs like electrocardiogram, the degree of oxygen saturation, and blood pressure, it could clinically be very useful.

Anesthetic management for child with idiopathic ketotic hypoglycemia: A case report

Idiopathic ketotic hypoglycemia (IKH) is the common cause of clinically significant non-diabetic hypoglycemia among children. The cause of IKH is decrease in endogenous glucose production after a prolonged fasting. We report the experience of perioperative management for a six-year-old female child undergoing strabismus surgery with a history of IKH. This patient experienced two episodes of severe hypoglycemia and loss of consciousness caused by prolonged fasting at the age of 31 and 41 months. For elective general anesthesia, children should be restricted from fluid and foods to prevent pulmonary aspiration. Because of higher metabolic rate and larger body surface area-to-weight ratio than adult, pediatric patient are more prone to hypovolemia and hypoglycemia during preoperative fasting period. When the preoperative fasting is inevitable in the child with IKH, anesthesiologist should start the parenteral infusion with dextrose-containing fluid and periodically check blood glucose level during perioperative period.

Left mainstem bronchial rupture during one-lung ventilation with Robertshaw double lumen endobronchial tube: A case report / 대한마취과학회지

Lung separation using a double-lumen endobronchial tube is necessary for video assisted thoracoscopy (VATs). Bronchial rupture after intubation with a double-lumen endobronchial tube has been rarely reported. We report a case of a 70-year-old man who had solitary pulmonary nodule in his right upper lobe. He was intubated with a left-sided Robertshaw double-lumen endobronchial tube. He underwent a VATs right upper lobectomy with the one-lung ventilation of left lung. During the operation, the rupture of the left mainstem bronchus was detected. Immediately, the thoracotomy was performed and the ruptured left mainstem bronchus was repaired with absorbable sutures (vicryl). Seven days later he had a bronchoscopy to examine the left mainstem bronchus. There was no evidence of the bleeding, leakage and inflammation. Subsequent course was uneventful. Tracheobronchial injuries related to the double-lumen endobronchial tube are discussed.

Acute low back pain revealed as pyogenic spondylitis: A report of 2 cases

Many people suffer from low back pain and that has caused much socioeconomic cost. As a non specific cause of low back pain, an increase in the incidence of pyogenic spondylitis has been noticed. Early radiological diagnosis is of great importance for prompt treatment and prevention of clinically significant consequences which include neurological deficit and secondary spine deformity. We describe two cases of pyogenic spondylitis with epidural abscess. The former case, we could not make an early diagnosis and proper management was delayed. Fortunately, no neurologic deficits were remained. On contrast, the latter was promptly diagnosed as a pyogenic spondylitis and proper treatment was established. Most of all, careful preliminary evaluation, especially laboratory data and analysis of radiologic findings are important prognostic factor in treatment patient for pyogenic spondylitis.

A case of spinal myoclonus with radiculopathy following spine surgery: A case report / 대한마취과학회지

Despite adequate surgery, a number of patients have a return of back pain and radiculopathy of the legs following their operation. We present here a case of spinal myoclonus with radiculopathy after spine surgery. A 51 year old woman with bilateral radiculopathy and urinary incontinence was diagnosed with a cauda equina syndrome along with spinal stenosis. The patient underwent emergency operation for posterior decompression and internal fixation from the L2 to S1 levels. Immediately after surgery, the patient continued to experience intermittent myoclonic movement with severe shooting pain in her legs despite being given pharmacological treatments such as benzodiazepines, opioids, NSAIDs and gabapentin. The patient was found to have sudden, brief, bilateral involuntary muscle contraction on the lower extremities. The patient was referred to our pain clinic. She underwent a caudal block 2 times in 4 days. However, she reported only limited pain relief for 3 to 4 hours. She was then prescribed phenytoin 300 mg intravenously in a day; her myoclonic movement gradually subsided after 1 week of receiving phenytoin. Sixty days later, she was discharged without any long term sequelae.

Acute Posthypoxic Myoclonus in Recovery Room: A case report / 대한마취과학회지

Acute posthypoxic myoclonus is not an uncommon complication of cardiopulmonary arrest. The presence of myoclonus early after hypoxia or anoxia has been reported as a poor prognostic factor. Especially posthypoxic myoclonus status epilepticus was defined as continuous myoclonic seizure activity lasting 30 minutes or more which is thought to reflect irreversible neocortical damage, but there have been very rarely reported complete recovery. We report a case of the patient who developed posthypoxic myoclonus status epilepticus and completely recovered without any complications.

Neuromuscular Pharmacodynamics of Mivacurium in Patients with Major Burns / 대한마취과학회지

BACKGROUND: Burned patients sometimes require rapid onset of neuromuscular paralysis to secure the airway in full stomach patients or to treat laryngospasm. Because of poor lung function and hypermetabolic state, they desaturate quite rapidly. Burned patients are usually resistant to the effects of nondepolarizing relaxants. Mivacurium can be potentially a good alternative for rapid onset of paralysis, since it is metabolized by plasma cholinesterase, an enzyme often decreased in subject with major burns. This prospective study was conducted to define the neuromuscular pharmacodynamic profile of a single bolus dose of mivacurium in adult patients with major burns. METHODS: Adults (M/F = 22/8), aged 44.0 +/- 10.2 years, with total body surface area (TBSA) burn of 35.0 +/- 12.5% were studied at 39.8 +/- 28.9 post burn days. Age and sex matched 30 non-burned patients served as controls. Anesthesia was consisted of propofol and fentanyl infusion with nitrous oxide and oxygen. Mivacurium 0.2 mg/kg was administered as a bolus. Using TOF Watch, neuromuscular block was monitored with T1 response after the initial tetanic stimulation to recruit all muscle fibers. Onset time was defined as the interval from the beginning of drug administration to maximal twitch suppression. Intubation was attempted at 1 minute after the drug administration to simulate the rapid sequence induction with recording of either failure or success of intubation. By allowing spontaneous recovery without reversal drug, recovery profiles of neuromuscular paralysis were also measured. RESULTS: Patients demographics were similar in both groups except for the burn. Onset times and all recovery profiles were significantly prolonged in the burned versus non-burned groups. Attempts at intubation at 1 minute after the drug administration were successful with difficulty in approximately 70% of patients in both groups. CONCLUSIONS: Mivacurium 0.2 mg/kg demonstrated the conflicting dual responses in the burned patients. The prolonged onset time suggests resistance to neuromuscular effects. The prolonged recovery suggests increased sensitivity. This can be partially explained by the acetylcholine receptor proliferation and decreased level of plasma pseudocholinesterase. In view of the prolonged onset time of almost two minutes for maximal paralysis, mivacurium does not appear to be a good drug for rapid onset of paralysis in burns.

Analgesia after Arthroscopic Shoulder Surgery: Study of Effective Concentration of Continuous Patient-Controlled Subacromial Ropivacaine Infusion / 대한마취과학회지

BACKGROUND: The aim of this study was to estimate the effective concentration of subacromial ropivacaine for the control of postoperative pain after arthroscopic shoulder surgery. METHODS: In a prospective, randomized double-blind trial, 60 patients were divided equally into 3 groups; Groups I, II, and III. At the end of surgery, a bolus dose (0.75% ropivacaine 150 mg, depomedrol 40 mg) was injected via the trocar and a continuous subacromial infusion catheter was inserted into all patients. The drugs were administered for 48 hours after surgery. Group I was given 0.11% ropivacaine in 96 ml of normal saline, which consisted of 0.75% ropivacaine (15 ml), and fentanyl (10 microgram/kg). Group II received 0.15% ropivacaine in 96 ml saline consisting of 0.75% ropivacaine (20 ml) and fentanyl, (10 microgram/kg). Group III received 0.23% ropivacaine in saline consisting of 0.75% ropivacaine (30 ml) and fentanyl (10 microgram/kg). The rate of continuous infusion was, 2 ml/hr. The VAS for pain at rest and the range of motion (ROM) exercise, the amounts of supplemental analgesics and side effects were assessed postoperative 3, 9, 24 and 48 hours. RESULTS: There was no significant difference in the VAS for pain at rest and ROM exercise as well as in the amounts of supplemental analgesics between the three groups. CONCLUSIONS: 0.11% ropivacaine with 10 microgram/kg fentanyl provides effective postoperative analgesia at rest and during ROM exercise after arthroscopic shoulder surgery.

A Study on the Effect of Dosage Increase and Methods of Ondansetron Administration on the Prevention of Postoperative Nausea and Vomiting of Vaginal Total Hysterectomy Patients during IV Patient-Controlled Analgesia / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting are a 'Big Little Problem' during IV-PCA after vaginal total hysterectomy. This study was designed to determine the effect of dosage and the method of ondansetron administration on the incidence of postoperative nausea and vomiting in patients that received intravenous patient-controlled analgesia (IV-PCA). METHODS: Sixty ASA I-II patients that underwent elective total vaginal hysterectomy and received postoperative IV-PCA were randomly divided into three groups according to dosage and the timing of ondansetron administration. These patients were given ondansetron; twice, (4 mg each) after induction and 5 minutes before the end of the operation (group 1); 8 mg 5 minutes before the end of the operation (group 2); and twice, (8 mg each) after induction and 5 minutes before the end of the operation (group 3). The incidences of nausea and vomiting and pain scores by visual analogue scale (VAS) were checked and recorded in recovery rooms and wards at 1, 6, 24, and 48 hours after operation, respectively. RESULTS: The three groups showed no significant differences in terms of the incidences of nausea and vomiting and had similar VAS pain scores. CONCLUSIONS: Our findings suggest that ondansetron dosage and methods of its administration are not effective at reducing the incidence of postoperative nausea and vomiting.

Acute Pulmonary Edema following Failed Intubation: A Case Report / 대한구급학회지

Pulmonary edema that follows upper airway obstruction may occur in a variety of clinical situations. Post anesthetic laryngospasm has been implicated as the most frequent cause of this syndrome. Risk factors for development of post laryngospasm pulmonary edema include difficult intubation; nasal, oral, or pharyngeal surgical site; and obesity with obstructive apnea. We report a case that developed acute bilateral pulmonary edema after laryngospasm induced by failed intubation.