“Spray-as-you-go” medical technique for awake intubation using a combination of an epidural catheter and the OptiScope in a patient with Ludwig's angina: A case report

A 73-year-old woman presented to the emergency department with submandibular pain and swelling. The patient was diagnosed to have Ludwig's angina, and she was planned to undergo urgent incision and drainage under general anesthesia. However, her physical examination revealed severe diffuse swelling extending from the bilateral submandibular spaces to the submental space and further down to the neck. As our view was blocked by the patient's neck swelling, we did not perform a regional anesthesia of the airway or a transtracheal block. Several non-invasive alternatives were considered. The “spray-as-you-go” technique was chosen, and it was performed using the OptiScope®. However, the OptiScope did not have a working channel or syringe adaptor for the administration of the local anesthetic solution. To solve this problem, we combined the OptiScope with a 27-G tunneled epidural catheter (100 cm) for the administration of lidocaine and this combination made the awake intubation successful.

A Comparison of the Effects of Remifentanil and Alfentanil on Hemodynamic Responses to Endotracheal Intubation in Hypertensive Patients

BACKGROUND: Laryngoscopy and endotracheal intubation often provoke an undesirable increase in blood pressure and heart rate. This response may be exaggerated in patients with essential hypertension. We compared the effect of administration of remifentanil and alfentanil on the hemodynamic responses to endotracheal intubation in patients with essential hypertension. METHODS: Forty patients with essential hypertension were allocated into two groups. The remifentanil group received 0.5micro g/kg remifentanil followed by an infusion of 0.25microg/kg/min remifentanil. The alfentanil group received 10microg/kg alfentanil intravenously. Anesthesia was induced with thiopental and vecuronium, and was maintained with 2 vol% sevoflurane with 100% oxygen. Laryngoscopy and tracheal intubation were performed 3 min after vecuronium administration. Arterial blood pressure and heart rate were measured in patients after arrival at the operating room and before and after intubation. RESULTS: The systolic and mean blood pressure after intubation showed significantly higher values in the alfentanil group of patients than in the remifentanil group of patients. There was no significant difference in blood pressure measured at baseline and after intubation in the remifentanil group of patients, but blood pressure showed significantly higher values after intubation in the alfentanil group of patients. Heart rate showed significantly higher values after intubation than at baseline in each group of patients. CONCLUSIONS: These results show that the administration of 0.5micro g/kg remifentanil followed by an infusion of 0.25microg/kg/min remifentanil attenuated the pressor response to endotracheal intubation more significantly than the administration of 10microg/kg alfentanil in patients with essential hypertension.

Control of Postinguinal Herniorrhaphy Pain in Children / 대한마취과학회지

BACKGROUND: Postoperative pain control in children is an important problem for management but it was treated negligently. In the past, the pain was undertreated in children, even more in infant. In recent years, the importance of the pain control in children was emphasized but not enough, yet. This study was designed to evaluate the propriety of intraoperative intravenous medication technique and effectiveness of the fentanyl, ketorolac and ketamine for pain control following inguinal herniorrhaphy in pediatric patients. METHODS: Eighty children for inguinal herniorrhaphy under general anesthesia were divided into four groups. Group I received no analgesics as a control. Group II, III and IV were received intravenous fentanyl 1microgram/kg, ketorolac 1 mg/kg and ketamine 1 mg/kg respectively. Fentanyl and ketolorac were injected intravenously during the induction of anesthesia and ketamine was injected at the entrance of operating room. Emergence time and the degree of pain was evaluated. RESULTS: Our result showed that group II and group III had a lower pain score than that of the control group at the 5 min, 10 min, 20 min and 30 min in the recovery room (P <0.05), but no significant differences were found between the group I and group IV. The time interval from the end of operation to extubation was prolonged in the group II compared to the control group (P <0.05). But no significant differences were found between the three groups. CONCLUSIONS: We suggest that intravenous administration of analgesics has the propriety of the control of postinguinal herniorraphy pain in children. Intravenous administration of fentanyl 1microgram/kg and ketorolac 1 mg/kg during induction would be an easy, simple and effective means for relieving postinguinal herniorrhaphy pain in recovery room.

The Comparison of Ropivacaine and Bupivacaine in Epidural Patient Controlled Analgesia (PCA) / 대한마취과학회지

BACKGROUND: Local anesthetics combined with an opiate are frequently used as a postoperative epidural PCA regimen. Ropivacaine is known to have a selective blockade of the sensory nerve without motor blockade. This study is designed to show advantages of ropivacaine over bupivacaine. METHODS: Patients undergoing elective abdominal and orthopedic surgeries were randomly selected and divided into two groups, B and R. The patients in group B and R received 0.2% bupivacaine and 0.2% ropivacaine respectively through an epidural catheter using a PCA pump. Both local anesthetic solutions were mixed with 4 microgram/ml of fentanyl. The PCA pumps of both groups were set in the same manner. A basal rate of 2 ml/hr was infused from 1hour after the onset of surgery. This basal rate was continued postoperatively. A bolus dose and lock out time were set at 2 ml and 20 minutes respectively. The Visual analogue pain scale (VAS), demand dose, complication and additional intramuscular analgesic requirements were checked up to 24 hours after surgery in 6-hour interval. RESULTS: The VAS was significantly lower in group R than in group B at 6, 12, 18 and 24 hours after the surgery (P < 0.05). Total additional bolus doses of the PCA pump were not significantly different in either group at 6, 12, 18 and 24 hours after surgery. The patients in group R showed more satisfaction and less additional intramuscular injections. CONCLUSIONS: 0.2% Ropivacaine, mixed with 4microgram/ml of fentanyl, was more effective than bupivacaine, mixed with the same concentration of fentanyl, in controlling postoperative pain using an epidural PCA pump.

The Effect of Preoperative Pulmonary Arterial Pressure and Right Ventricular Function on the Changes in Right Ventricular Function after Mitral Valve Replacement / 대한마취과학회지

BACKGROUND: In patients with mitral valvular disease with pulmonary hypertension (PHT) accompanying right ventricular (RV) dysfunction, mitral valve replacement (MVR) improves RV function and other hemodynamic variables in long term follow-up. However, there are controversies in improvement of RV function in the immediate postoperative period. We compared the RV function immediately after a MVR with a pulmonary artery catheter (PAC) between patients with normal and decreased RV function with PHT preoperatively. METHODS: Twenty nine patients undergoing a MVR were included in the study. The patients (n = 14) with mean pulmonary arterial pressure (PAP) < or = 25 mmHg were assigned to group I and the patients (n = 15) with mean PAP 25 mmHg were assigned to group II. A PAC with rapid response-thermistors which enables us to determine right ventricular ejection fraction (RVEF) was inserted in all patients and hemodynamic variables were measured before and after cardiopulmonary bypass (CPB). RESULTS: After CPB, PAP, pulmonary vascular resistance index (PVRI), and RV end-diastolc volume (RVEDV) were significantly decreased and RVEF was significantly increased in group II compared with group I in which no hemodynamic variables were changed. CONCLUSIONS: A MVR decreased RV afterload and increased RV function more significantly in patients with preoperative PHT accompanying RV dysfunction than in patients with normal PAP preoperatively.

Is Central to Peripheral Arterial Pressure Gradient Influenced by Cardiac Output and Vasoactive Drugs in Canines Undergoing Cardiopulmonary Bypass? / 대한마취과학회지

BACKGROUND: It has been known that radial arterial pressure sometimes underestimates central pressure after cardiopulmonary bypass (CPB) and status of circulatory volume, vascular tone, hemodilution or rewarming were explained as the major causes of this phenomenon. We evaluated the effects of these variables on blood pressure and flow in radial and femoral arteries in dogs undergoing CPB. METHODS: Both radial and femoral arteries were cannulated for pressure monitoring and the opposite side arteries were exposed for the measurement of blood flow in 9 dogs. Radial arterial pressure (RBP), femoral arterial pressure (FBP), aortic pressure (ABP), radial blood flow (RBF), and femoral blood flow (FBF) were measured before and just after the initiation of CPB. All values were also recorded when pump flow or ABP were changed during hypothermic CPB and after rewarming. RESULTS: Unlike patients with cardiac disease, RBP, FBP and ABP were almost the same and changes in pump flow and vasoactive drugs didn't make any clinically significant pressure difference between RBP and ABP during hypothermic CPB or after rewarming in the normal condition of dogs. RBF was constantly maintained when the ABP increased with phenylephrine or decreased with sodium nitroprusside (SNP). However, FBF markedly increased during SNP infusion. CONCLUSIONS: Cardiac output, vasoactive drugs and even CPB didn't exert any effect on RBP and FBP in dogs with a normal cardiovascular system. Cardiovascular abnormalities and vascular change or hemodynamic instability itself may induce a large discrepancy between RBP and ABP in cardiac patients undergoing CPB.

Electrmyographic Responses Evoked by Electrocortical Stimulations under Various Anesthetics: A case report / 대한마취과학회지

Motor evoked potentials(MEP) have been recently introduced as intraoperative monitoring of descending motor pathways. Transcranial electrical or magnetic MEP have been using clinically, but there are still some limitations of using in operating room. Furthermore, according to anesthetic regimens, MEP responses vary significantly. The authors observed the effects of the various anesthetics (thiopental, fentanyl, ketamine, nitrous oxide and isoflurane) on electocortical MEP in a patient who had been previously undertaken electrocortico-graphic grid insertion operation for seizure monitoring. Electromyographic responses were recorded from contralateral arm flexor and extensor using needle type electrode. Most anesthetics except ketamine decreased the amplitude of MEPs reversibly and there were differences in electromyographic responses according to measuring compound muscles.