Amniotic Fluid Embolism during Dilatation and Curettage in a Second Trimesteric Missed Aborted Pregnant Patient / 대한마취과학회지

Amniotic fluid embolism (AFE) is a rare but devasting obstetric emergency. We experienced a case of AFE during dilatation and curettage (D & C) in a 15 2/7 weeks pregnant woman, age 30, who was diagnosed as having a missed abortion. Sudden rapid hypoxemia, low SpO2, hypotension, low PETCO2, high CVP, and tachycardia, right axis deviation and right bundle branch block in 12 leads ECG were developed during D &C under general anesthesia, and signs of disseminated intravascular coagulation (DIC) followed after the operation, which are consistent with the findings of AFE. Even though there was no definite pathologic and radiologic confirmation of AFE, laboratory findings showed 100 times higher level of alpha-fetoprotein in her central venous blood than same weeks of missed abortion woman's blood. Though it is rare, the anesthesiologist should always suspect the possibility of AFE, when the patient shows an unexplained collapse, cyanosis, low PETCO2, high CVP, low SpO2, ECG change and DIC during any kind of obstetric procedure.

Cervical Subcutaneous Emphysema Occured by Unexpected Difficult Endotracheal Intubation: A case report / 대한마취과학회지

Subcutaneous emphysema is one of the rare complication of tracheal intubation and it's mechanism has been known as airleakage to subcutaneous tissue from the perforated site of larynx, trachea and esophagus by the trauma of laryngoscopic blade, stylet and endotracheal tube. We experienced a case of subcutaneous emphysema during unexpected difficult endotracheal intubation. At the initial laparoscopic examination, the patient's laryngeal view was grade IV of Cormack and Lehane's calssification. After several trial of the intubation, cervical subcutaneous emphysema developed by the trauma of laryngoscopic blade, stylet and endotracheal tube, even though failed to confirm the perforated site at postanesthesia one day.

Effect of Single Epidural Saline on Spinal Sensory Blockade Level during Combined Spinal Epidural Anesthesia / 대한마취과학회지

BACKGROUND: Combined spinal epidural anesthesia (CSE) is used for obtaining adventages of both spinal and epidural anesthesia. But it might be suspected that epidural volume load affect spinal sensory blockade level during CSE. METHODS: Eighty patients undergoing lower abdominal and lower extremity operation were involved in our study. Subarachnoid block with 12mg of tetracaine was established in all patients. Four groups were studied. Group 1 (n=20), the control, received only spinal anesthesia. Group 2 (n=20), group 3 (n=20) and group 4 (n=20) received 10, 15 and 20 ml of epidural saline immediately after spinal anesthetic administration. Sensory blockade level was checked by pinprick test at 5, 10, 15, 20, 25, 30, 40, 60 and 90 minutes. Blood pressure, heart rate and incidence of complications such as hypotension, bradycardia, nausea and high block were measured. RESULTS: The sensory blockade level of groups 3 and 4 was higher than group 1 (p<0.05). Blood pressure and heart rate were not different compared with each other. The incidence of complications, except that higher block above T4 in group 4 was more than in group 1 (p<0.05), were not different when compared with each other. CONCLUSIONS: Epidural saline above 15 ml may affect sensory blockade level of spinal anesthesia during CSE.

Effects of Alkalinization of Local Anesthetics on Anesthetic Action in Epidural Anesthesia for Cesarean Section / 대한마취과학회지

Several studies have indicated that the addition of sodium bicarbonate and opioid to soiutions of locl anesthetics shortens the onset time,increases the intensity and prolongs the duration of neural blockade. This study was performed to compare onset times and duration of neural blockade in each groups. Eighty-two parturients scheduled for cesarean section at term under epidural anesthesia were assigned to three groups. Group 1 (n=19) received 1.5% lidocaine hydrochloride (pH 6.32+/-0.01), group 2 (n=26) received 1.5% lidocaine hydrochloride plus fentanyl 50 mcg (pH 6.27+/-0.02) and group 3 (n=37) received l.5% lidocaine hydrochloride plus fentanyl 50 mcg plus 8.4% sodium bicarbonate (sodium bicarbonate l mEq/lidocaine 10 ml)(pH 7.32+/-0.03). All groups were given 22-28 ml of local anesthetic solutions according to their height. Onsei times and duration of sensory blockade were evaluated using pin prick test at two minutes interval after epidural injection at L2, 76, T4 dermatomes. Onset timcs (time between the completion of anesthetic injection and loss of pin prick sensation at each dermatome) of sensory blockade at L2 dermatome were 3.1+/-0.2 minutes in Group 3, which were shorter than 5.0+/-0.3 minutes in Group l and 4.7+/-0.4 minutes in Group 2 (p<0.05). At T6 dermatome, onset times of sensory blockade were 6.9+/-0.6 minutes in Group 3, which were shorter than 15.4+/-1.2 minutes in Group l and 12.9+/-1.0 in Group 2 (p<0.05). At T4 dermatome, onset times of sensory blockade were 10.l+/-0.2 minutes in Group 3, which were shorter than 22.3+/-1.2 minutes in Group 1 and 18.8+/-1.1 in Group 2 (p<0.05). The duration (time between loss of pin prick sensation and complete recovery of pain at each dermatome) of sensory blockade at T4 dermatome in Group 3 were 74.0+/-3.8 min, which were longer than 52.9+/-2.4 minutes in Group 1 and 52.7+/-1.4 minutes in Group 2 (p<0.05). The duration of sensory blockade at L2 dermatome in Group 3 were 119.6+/-4.4 minutes,which were longer than 78.6+/-4.8 minutes in Group 1 and 81.6+/-2.5 minutes in Group 2 (p<0.05). The above results suggested that alkalinization of lidocaine solution is an effective way to shorten the latency and to prolong the duration of epidural block for cesarean section.

A Case of Suspicious Subdural Block During Epidural Anesthesia for Cesarean Section / 대한마취과학회지

Accidental subdural block is one of the rare complications of epidural anesthesia and can lead to a life threatening condition. A healthy 40 year old woman underwent cesarean section under the diagnosis of placenta previa. Single epidural puncture was performed at L3-4 interspace without difficulty. A test dose of 3ml of 1.5% lidocaine was injected without adverse effects. However, hypotension(80/40) and loss of pain sensation up to the level of C4 were devloped in 5 min. after injection of 25 ml of 1.5% lidocaine with 50ug fentanyl and 2.5ml of 8.4% sodium bicarbonate. She complained of dyspnea without change of SpO2 and difficulty of phonation about 15min. after injetion. And then, She was lethargic, but was able to open eyes with verbal communication. She was fully recovered in 180 minutes after epidural injection. Such extensive block might be caused by subdural administration of the drugs even if it was not confirmed radiologically.