A clinical retrospective study comparing thoracic epidural catheterization between awake and anesthetized patients

BACKGROUND: The clinical outcomes and safety of thoracic epidural catheterization in anesthetized adult patients has not yet been established. The purpose of this study was to compare clinical differences between epidural catheterization performed before and after anesthesia for postoperative pain control. METHODS: The medical records of 549 patients who received thoracic epidural catheterization before (awake group, n = 303) or after (anesthetized group, n = 246) induction of anesthesia for major abdominal surgery were reviewed retrospectively. RESULTS: The catheter insertion time (1.6 ± 1.5 vs. 1.1 ± 1.2 min; 95% confidence interval [95% CI], 0.3–0.8; effect size, 0.368; P < 0.001) and number of attempts required for successful epidural catheterization (1 [1, 3] vs. 1 [1, 2], P = 0.003) were increased in the awake group. The incidence rates of dural puncture, vascular injury and postoperative paresthesia were similar between the two groups. The median surgical site numerical rating scale pain score (0 = no pain, 10 = worst pain imaginable) was lower in the awake group than in the anesthetized group (3 vs. 4 on postoperative day 1, P < 0.001; and 2 vs. 3 on postoperative day 3, P = 0.002). Serious complications, including meningitis, epidural abscess, epidural hematoma, spinal cord injury, and paraplegia, were not observed in either group. CONCLUSIONS: Successful epidural catheterization before induction of anesthesia required more attempts versus after anesthesia. Overall complication rates of thoracic epidural catheterization were similar regardless of the timing of the procedure.

Comparison of the clinical performance of airway management with the i-gel® and laryngeal mask airway Supremeâ„¢ in geriatric patients: a prospective and randomized study / 대한마취과학회지

BACKGROUND@#Geriatric patients are susceptible to respiratory and hemodynamic adverse events during endotracheal intubation and extubation due to anatomic and physiological changes with aging. Supraglottic airway devices (SADs) provide reduced airway morbidity and increased hemodynamic stability in adults. However, studies that have compared the clinical performance of SADs in geriatric patients are limited. Therefore, we evaluated the clinical performance of airway management with i-gel® and laryngeal mask airway Supreme (LMA Supreme™) in geriatric patients.@*METHODS@#The subjects were American Society of Anesthesiologists physical status classification I–III geriatric (65–85 years) patients who underwent elective surgery with general anesthesia and were randomly allocated into the i-gel® group and the LMA Supreme™ group. We compared the time for successful insertion on a first attempt as a primary outcome, and the secondary outcomes were success rate, ease of insertion, maneuver for successful ventilation, oropharyngeal leak pressure, gastric insufflation, fiberoptic view grades, ventilator problems, and adverse events.@*RESULTS@#Insertion time was significantly shorter for the i-gel® than the LMA Supreme™ (21.4 ± 6.8 vs. 29.3 ± 9.9 s; P = 0.011). The i-gel® was also easier to insert than the LMA Supreme™ (P = 0.014). Gastric insufflation was less frequent with the i-gel® than the LMA Supreme™ (0% vs. 31.3%; P = 0.013). Other measurements were comparable between groups.@*CONCLUSIONS@#Both devices can be safely applied to geriatric patients with similar success rates and oropharyngeal leak pressures. However, inserting the i-gel® was faster and easier compared to the LMA Supreme™ in geriatric patients.

Comparison of the clinical performance of airway management with the i-gel® and laryngeal mask airway Supreme™ in geriatric patients: a prospective and randomized study / 대한마취과학회지

BACKGROUND: Geriatric patients are susceptible to respiratory and hemodynamic adverse events during endotracheal intubation and extubation due to anatomic and physiological changes with aging. Supraglottic airway devices (SADs) provide reduced airway morbidity and increased hemodynamic stability in adults. However, studies that have compared the clinical performance of SADs in geriatric patients are limited. Therefore, we evaluated the clinical performance of airway management with i-gel® and laryngeal mask airway Supreme (LMA Supreme™) in geriatric patients. METHODS: The subjects were American Society of Anesthesiologists physical status classification I–III geriatric (65–85 years) patients who underwent elective surgery with general anesthesia and were randomly allocated into the i-gel® group and the LMA Supreme™ group. We compared the time for successful insertion on a first attempt as a primary outcome, and the secondary outcomes were success rate, ease of insertion, maneuver for successful ventilation, oropharyngeal leak pressure, gastric insufflation, fiberoptic view grades, ventilator problems, and adverse events. RESULTS: Insertion time was significantly shorter for the i-gel® than the LMA Supreme™ (21.4 ± 6.8 vs. 29.3 ± 9.9 s; P = 0.011). The i-gel® was also easier to insert than the LMA Supreme™ (P = 0.014). Gastric insufflation was less frequent with the i-gel® than the LMA Supreme™ (0% vs. 31.3%; P = 0.013). Other measurements were comparable between groups. CONCLUSIONS: Both devices can be safely applied to geriatric patients with similar success rates and oropharyngeal leak pressures. However, inserting the i-gel® was faster and easier compared to the LMA Supreme™ in geriatric patients.

Epiduroscopic Removal of a Lumbar Facet Joint Cyst

Facet joint synovial cysts are usually associated with osteoarthritis of the adjacent facet joint and/or spondylolisthesis. In between the conservative and operative ends of the treatment spectrum lie minimally invasive techniques such as cyst rupture using epiduroscopy. In this report, we describe an 82-year-old male patient presenting with low back pain radiating to his lower left extremity and associated paresthesia. Magnetic resonance imaging of the lumbar spine revealed a synovial cyst at left L4/5 facet joint. Using epiduroscopy, the cyst was mechanically ruptured by popping it with the tip of the scope. The patient remained symptom-free at his successive visits until 12 months after the procedure, and was opened for desired follow up.

Anesthetic management in patients suspected of Creutzfeldt-Jakob disease -A case report- / 대한마취과학회지

Creutzfeldt-Jakob disease (CJD) is a fatal neurodegenerative disorder in which accumulation of the pathogenic prion protein induces neuronal damage and results in distinct pathologic features. This abnormal prion is an infectious protein and resistant to methods of sterilization currently being used. Therefore, management of definite, or suspected CJD patients requires additional precautions. We report our experience of a patient who had undergone brain biopsy for suspected of CJD. The patient was confirmed to have sporadic CJD.

Inappropriate elevation of bispectral index values in robot assisted thyroidectomy with electromyographic endotracheal tube: A case report / 대한마취과학회지

We report a case of an erroneously elevated bispectral index (BIS) during robot assisted thyroidectomy using an electromyographic endotracheal tube (EMG tube), which is safe and useful for laryngeal electromyographic monitoring. Ten minutes after start of the operation, a sudden increase of BIS value up to 98 was noticed. The BIS values were not decreased to < 65 with supplemental anesthetics. The anesthetic method was changed from total intravenous anesthesia to balanced anesthesia. The BIS sensor and monitor were changed and other models were used. These interventions did not alter BIS values. BIS levels remained between 60 and 70 throughout the main procedure and intermittently increased to the mid-90s without any trace of poor signal quality. At the end of the surgery, the BIS values returned to normal range. The patient did not complain of intraoperative recall. Knowledge of potential interference from the use of an EMG tube must be considered when interpreting BIS.

Hypocalcemia and hypokalemia due to hyperventilation syndrome in spinal anesthesia: A case report / 대한마취과학회지

Hyperventilation syndrome (HVS) often occurs under stressful conditions, and has been reported during or after anesthesia and operation. HVS, characterized by multiple somatic symptoms and electrolyte imbalances induced by inappropriate hyperventilation, should be managed as an emergency. We report a rare case of HVS during spinal anesthesia. The patient was a previously healthy 51-year-old female without psychogenic conditions. During spinal anesthesia for lower extremity surgery, the patient complained of nausea, headache, paresthesia in the upper extremities and perioral numbness. We found carpal spasm in both hands and flattening of T wave on electrocardiogram (ECG). Emergent arterial blood gas analysis (ABGA) revealed markedly decreased PaCO2, hypocalcemia and hypokalemia. We managed the patient with verbal sedation, electrolytes replacement therapy and closed mask inhalation. HVS subsided gradually. We conclude that monitoring for possible HVS during anesthesia is very important for patient safety.

The effect of nitroglycerin on hemodynamic changes during laparoscopic low anterior resection / 대한마취과학회지

BACKGROUND: More laparoscopic low anterior resections (LAR) are being performed in recent years. There has been controversy around the hemodynamic changes affected by the Trendelenburg position and pneumoperitoneum during LAR. The goal of this study was to analyze the effect of nitroglycerin (NTG) on hemodynamic changes during LAR. METHODS: Forty ASA physical status I-II patients undergoing LAR were randomized into two groups: the NTG infused group (N group, n = 20) and the control group (C group, n = 20). Anesthesia was maintained with sevoflurane at 1-3 vol%, air/oxygen (50%/50%) and continuous infusion with remifentanil. The N group patients were given 0.5 microg/kg/min of NTG during anesthesia. Mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), cardiac index (CI), stroke volume (SV) and systemic vascular resistance (SVR) were assessed 10 min after induction (T1), 5 min after pneumoperitoneum in the supine position (T2), 10 min after pneumoperitoneum in the Trendelenburg position (T3), 30 min after pneumoperitoneum in the Trendelenburg position (T4), 1 hr after pneumoperitoneum in the Trendelenburg position (T5) in addition to 5 (T6), 10 (T7) and 30 min (T8) after removal of the pneumoperitoneum in the supine position. RESULTS: The increases of MAP were milder in the N group (22.6-7.3%) than the C group (32.3-17.7%) during pneumoperitoneum and while in the Trendelenburg position. The significant decreases of HR were maintained in the C group, but the changes in HR were not significant in N group during the operation. The increases in CVP were less in N group than C group. The increases of SVR were milder in N group (19.4-1.4%) than C group (41.7-16.6%) during pneumoperitoneum in the Trendelenburg position. CONCLUSIONS: Intraoperative NTG infusions were effective to some degree in reducing the hemodynamic changes during pneumoperitoneum with Trendelenburg positioning for LAR.