Postoperative hypothermia in geriatric patients undergoing arthroscopic shoulder surgery

BACKGROUND: Hypothermia below 36℃ is a common problem during arthroscopic shoulder surgery. Geriatric patients are more vulnerable to perioperative hypothermia. The present study compared postoperative hypothermia between geriatric and young adult patients receiving arthroscopic shoulder surgery. METHODS: Data were collected retrospectively from a geriatric group (aged 65 or more, n = 29), and a control group (aged 19–64, n = 33) using the anesthesia records of patients who had undergone arthroscopic shoulder surgery. The primary outcome measure was the incidence of hypothermia upon arrival in the postanesthesia care unit (PACU). The secondary outcome measure was the decrease in body temperature from admission into the operating room to admission into the PACU. RESULTS: The incidence of hypothermia was 93.1% and 54.5% in the geriatric and control groups, respectively, demonstrating a significant difference between the groups (P < 0.001). Comparison between body temperature revealed a decrease of 1.5 ± 0.6℃ and 1.0 ± 0.4℃ in the geriatric and control groups, respectively, showing a significant difference between the groups (P < 0.001). The degree of hypothermia was significantly different between the groups (P = 0.027). No shivering was observed in either of the two groups, but the incidence of thermal discomfort was higher in the geriatric group than in the control group (P = 0.021). CONCLUSIONS: In geriatric patients undergoing arthroscopic shoulder surgery, both the incidence of postoperative hypothermia and the associated temperature drop are more prominent than those in young adult patients. Additional warming methods will be needed to prevent postoperative hypothermia in geriatric patients.

Endotracheal Intubation Using McGrath Videolaryngoscope in Klippel-Feil Syndrome / 이화의대지

Patients with Klippel-Feil syndrome require much attention during anesthesia because of congenital abnormalities in head and neck regions and the high probability of neurological damage from cervical spine instability during endotracheal intubation. We report a case of successful endotracheal intubation using a videolaryngoscope in a patient with Klippel-Feil syndrome who experienced difficult transnasal intubation.

A retrospective analysis of neurological complications after ultrasound guided interscalene block for arthroscopic shoulder surgery

BACKGROUND: Ultrasound-guided interscalene brachial plexus block (US-ISB) has been reported to be effective postoperative analgesia for arthroscopic shoulder surgery. Although considered rare, various neurological complications have been reported. We retrospectively evaluated 668 patients for post operation neurological symptoms including hemidiaphragmatic paresis and post-operative neurologic symptoms after US-ISB. METHODS: We performed a retrospective chart review of 668 patients undergoing shoulder surgery with single-shot US-ISB from January 2010 to May 2015. The general anesthesia prior to the US-guided ISB procedure was standardized by expert anesthesiologists. Neurological postoperative complications were evaluated at 48 hours, about 2 weeks, 1 month, 3 months, 6 months, and up to resolution after operation. RESULTS: Three patients (0.4%) developed hemidiaphragmatic paresis (HDP), which were likely US-ISB associated and improved within 1 day. Two patients developed sensory symptoms, also likely US-ISB associated; one was paresthesia at the tip of the thumb/index finger, which resolved within 2 weeks, and the other was hypoesthesia involving the posterior auricular nerve, which resolved within 6 months. Motor and sensory symptoms which were not likely associated with US-ISB were hypoesthesia and pain (n = 28, 4.6%) and motor weakness (n = 2, 0.3%). CONCLUSIONS: Incidence of HDP and neurological complications, respectively 0.4% and 0.3%, related to transient minor sensory symptoms occurred after US-ISB for arthroscopic shoulder surgery but the complications improved spontaneously. Therefore, we confirm that the US-ISB procedure with low volumes of local anesthetics is an acceptable technique with a low rate of HDP and neurological complications.

Survey of Anxiety in Ordinary Workers and Doctors Regarding Sedative Use during Endoscopic Examination in the Seoul Metropolitan Area

BACKGROUND/AIMS: Sedative use is common in endoscopic examinations. The anxiety regarding sedative use may be different between doctors and nonmedical individuals. METHODS: A questionnaire survey was conducted by a research company (DOOIT Survey), and responses were collected from 649 doctors and 1,738 individuals who perform typical jobs in nonmedical fields. In this study, these ordinary workers are considered to represent nonmedical individuals. Anxiety was measured using a 5-point Likert scale. RESULTS: The nonmedical individuals exhibited more anxiety regarding the sedative use than the doctors. Age <40 years (odds ratio [OR], 2.27; p<0.001), female sex (OR, 1.62; p=0.002), experience of an adverse event (OR, 1.79; p=0.049), and insufficient explanation (OR, 2.05; p<0.001) were the significant factors that increased the anxiety of the nonmedical individuals. The doctors who experienced a sedative-related adverse event reported increased anxiety compared with the doctors who did not report this experience (OR, 1.73; p=0.031). CONCLUSIONS: Anxiety regarding sedative use during an endoscopic examination was significantly different between doctors and non-medical individuals. A younger age, female sex, an adverse event, and insufficient explanation affect the anxiety of nonmedical individuals. An adverse event also affects the anxiety of doctors.

Bilateral Vocal Cord Palsy after Thyroidectomy Detected by McGrath Videolaryngoscope / 대한내분비외과학회지

Bilateral vocal cord palsy (BVCP) is a rare complication of thyroid surgery, and it is confusing and frustrating for both patients and medical staff. We found postoperative vocal cord dysfunction using a McGrath videolaryngoscope from a patient with stridor and dyspnea after thyroidectomy performed with intraoperative recurrent laryngeal nerve monitoring. Soon after, the patient was diagnosed with BVCP by an ENT otolaryngologist using a laryngeal fiberscope. The patient underwent exploration and received a permanent tracheostoma. The possibility of false negative findings from intraoperative nerve monitoring should considered if there is suspicion of BVCP in a high risk patient after thyroidectomy. The McGrath video-laryngoscope can be useful for early discovery of postoperative vocal cord dysfunction.

Effect of Propofol and Desflurane on Immune Cell Populations in Breast Cancer Patients: A Randomized Trial

Several factors can affect the perioperative immune function. We evaluated the effect of propofol and desflurane anesthesia on the surgery-induced immune perturbation in patients undergoing breast cancer surgery. The patients were randomly assigned to receive propofol (n = 20) or desflurane (n = 20) anesthesia. The total and differential white blood cell counts were determined with lymphocyte subpopulations before and 1 hr after anesthesia induction and at 24 hr postoperatively. Plasma concentrations of interleukin (IL)-2 and IL-4 were also measured. Both propofol and desflurane anesthesia preserved the IL-2/IL-4 and CD4+/CD8+ T cell ratio. Leukocytes were lower in the propofol group than in the desflurane group at 1 hr after induction (median [quartiles], 4.98 [3.87-6.31] vs. 5.84 [5.18-7.94] 10(3)/microL) and 24 hr postoperatively (6.92 [5.54-6.86] vs. 7.62 [6.22-9.21] 10(3)/microL). NK cells significantly decreased 1 hr after induction in the propofol group (0.41 [0.34-0.53] to 0.25 [0.21-0.33] 10(3)/microL), but not in the desflurane group (0.33 [0.29-0.48] to 0.38 [0.30-0.56] 10(3)/microL). Our findings indicate that both propofol and desflurane anesthesia for breast cancer surgery induce a favorable immune response in terms of preservation of IL-2/IL-4 and CD4+/CD8+ T cell ratio in the perioperative period. With respect to leukocytes and NK cells, desflurane anesthesia is associated with less adverse immune responses than propofol anesthesia during surgery for breast cancer. (Clinical trial registration at https://cris.nih.go.kr/cris number: KCT0000939)

Anesthetic Management for Lung Adenocarcinoma Experienced Acute Neurocardiogenic Syncope and Cardiac Arrest / 이화의대지

Vasovagal syncope is one of the most common causes of transient syncope during anesthesia for elective surgery in patients with a history of syncope and requires special attention and management of anesthetics. The causes and pathophysiological mechanism of this condition are poorly understood, but it has a benign clinical course and recovers spontaneously. However, in some cases, this condition may cause cardiovascular collapse resulting in major ischemic organ injury and be life threatening. Herein we report a case and review literature, regarding completing anesthesia safely during an elective surgery of a 59-year-old female patient with history of loss of consciousness due to suspected vasovagal syncope followed by cardiovascular collapse and cardiac arrest, which required cardiopulmonary resuscitation and insertion of a temporary pacemaker and intra-aortic balloon pump immediately after a fine-needle aspiration biopsy of a lung nodule located in the right middle lobe.

Topographic pattern of the brachial plexus at the axillary fossa through real-time ultrasonography in Koreans / 대한마취과학회지

BACKGROUND: The ability to explore the anatomy has improved our appreciation of the brachial anatomy and the quality of regional anesthesia. Using real-time ultrasonography, we investigated the cross-sectional anatomy of the brachial plexus and of vessels at the axillary fossa in Koreans. METHODS: One hundred and thirty-one patients scheduled to undergo surgery in the region below the elbow were enrolled after giving their informed written consent. Using the 5-12 MHz linear probe of an ultrasound system, we examined cross-sectional images of the brachial plexus in the supine position with the arm abducted by 90degrees, the shoulder externally rotated, and the forearm flexed by 90degrees at the axillary fossa. The results of the nerve positions were expressed on a 12-section pie chart and the numbers of arteries and veins were reported. RESULTS: Applying gentle pressure to prevent vein collapse, the positions of the nerves changed easily and showed a clockwise order around the axillary artery (AA). The most frequent positions were observed in the 10-11 section (79.2%) for the median, 1-2 section (79.3%) for the ulnar, 3-5 section (78.4%) for the radial, and 8-9 section (86.9%) for the musculocutaneous nerve. We also noted anatomical variations consisting of double arteries (9.2%) and multiple axillary veins (87%). CONCLUSIONS: Using real-time ultrasonography, we found that the anatomical pattern of the major nerves in Koreans was about 80% of the frequent position of individual nerves, 90.8% of the single AA, and 87% of multiple veins around the AA.

Polyuria during Sevoflurane Anesthesia for Parotidectomy Patient / 이화의대지

Polyuria is occasionally observed during general anesthesia. Usually urine output during general anesthesia is decreased because of anesthetic agents. The authors came across with a case of polyruia during sevoflurane anesthesia which occurred after induction of anesthesia. Polyuria is a nonspecific symptom, but can cause many serious complications. Therefore, it is very important to investigate the cause thoroughly and treat patient appropriately.

The analgesic efficacy of ultrasound-guided transversus abdominis plane block with 2% lidocaine in early postoperative period after lower abdominal surgery

BACKGROUND: Transversus abdominis plane (TAP) block is a new regional anesthetic technique for postoperative pain control after lower abdominal surgery. We evaluated the analgesic efficacy of ultrasound-guided (US-) TAP block in patients undergoing lower abdominal surgery. METHODS: Thirty American Society of Anesthesiologists physical status I or II patients between 20-80 years of age undergoing lower abdominal surgery were randomized to receive standard care (n = 15) including intravenous patient-controlled analgesia (IV-PCA), or to undergo bilateral US-TAP block adjunctively (n = 15). A standard general anesthetic technique was used. After induction of anesthesia, bilateral US-TAP block was performed using total 30 ml of 2% lidocaine. Each patient was assessed postoperatively at 20, 30, and 60 min in postanesthesia care unit (PACU) and at 6, 12, and 24 h in ward for pain scores using verbal numerical rating scale (VNRS), analgesic requirements, quality of sleep, and complications. RESULTS: US-TAP block significantly reduced VNRS pain scores at 20, 30, and 60 min postoperatively (P < 0.001). The US-TAP block group required significantly fewer remifentanil intraoperatively (P < 0.05). Additional analgesic requirements were significantly lower in both PACU and ward (P < 0.05) in the US-TAP block group. There were no statistically significant between-group differences in total infused volume of IV-PCA, time to first requirement of analgesics in ward, and quality of sleep. CONCLUSIONS: US-TAP block with 2% lidocaine provided superior analgesia after lower abdominal surgery especially in the first 60 postoperative min when used as a component of a multimodal analgesic regimen.

Myocardial bridge detected by changes in ECG before induction: A case report

Myocardial bridge, in which some of the epicardial coronary arterial segments are embedded in the muscle, has clinical significance because serious cardiac diseases such as angina, cardiac ischemia, myocardial infarction, and sudden cardiac death can occur. However, anesthetic management for the perioperative period for patients with myocardial bridge has remained controversial. We present a case of anesthetic management for total gastrectomy in a previously healthy 56-year-old male patient, who exhibited T-wave inversion and ST-segment depression in ECG monitoring on arrival to the operating room. While delaying the operation for further study, he was diagnosed as having myocardial bridge on a 3D-coronary CT. After confirmation of the normal coronary angiography, the patient underwent total gastrectomy uneventfully. There is no substitute for vigilance regarding the anesthesiologist.

Dexamathasone added to levobupivacaine improves postoperative analgesia in ultrasound guided interscalene brachial plexus blockade for arthroscopic shoulder surgery / 대한마취과학회지

BACKGROUND: The purpose of this study was to evaluate the effect of the addition of 5 mg dexamethasone to 10 ml of 0.5% levobupivacaine on postoperative analgesic effects of ultrasound guided-interscalene brachial plexus block (ISBPB) in arthroscopic shoulder surgery under general anesthesia. METHODS: In 60 patients scheduled for arthroscopic shoulder surgery that underwent general anesthesia, ISBPB was preoperatively performed with 10 ml of 0.5% levobupivacaine under the guidance of ultrasound and a nerve stimulator. Patients were randomly allocated to receive the same volume of normal saline (Group I), 5 mg of dexamethasone (Group II), or 1 : 400,000 epinephrine (Group III) as an adjuvant to the mixture. A blind observer recorded total analgesic consumption, sleep quality, complication, and patient satisfaction using a verbal numerical rating scale (VNRS) at 0, 1, 6, 12, 24, 48 h after the operation. RESULTS: All patients had successful ISBPB and excellent analgesic effects less than VNRS 4 up to discharge time. VNRS in Group II at 12 h and 48 h was statistically much lower than in Group I and III. There were no differences in total analgesic consumption, sleep quality, complications, and patient satisfaction. CONCLUSIONS: We conclude that the addition of 5 mg of dexamethasone to 10 ml of 0.5% levobupivacaine in ISBPB showed improvement of postoperative analgesia for arthroscopic shoulder operation without any specific complications.

Effect of flumazenil on recovery from anesthesia and the bispectral index after sevoflurane/fentanyl general anesthesia in unpremedicated patients / 대한마취과학회지

BACKGROUND: Benzodiazepines have a hypnotic/sedative effect through the inhibitory action of gamma-aminobutyric acid type A receptor. Flumazenil antagonizes these effects via competitive inhibition, so it has been used to reverse the effect of benzodiazepines. Recently, flumazenil has been reported to expedite recovery from propofol/remifentanil and sevoflurane/remifentanil anesthesia without benzodiazepines. Endogenous benzodiazepine ligands (endozepines) were isolated in several tissues of individuals who had not received benzodiazepines. METHODS: Forty-five healthy unpremedicated patients were randomly allocated to either flumazenil or a control groups. Each patient received either a single dose of 0.3 mg of flumazenil (n = 24) or placebo (n = 21). After drug administration, various recovery parameters and bispectral index (BIS) values in the flumazenil and control groups were compared. RESULTS: Mean time to spontaneous respiration, eye opening on verbal command, hand squeezing on verbal command, extubation and time to date of birth recollection were significantly shorter in the flumazenil group than in the control group (P = 0.004, 0.007, 0.005, 0.042, and 0.016, respectively). The BIS value was significantly higher in flumazenil group than in the control group beginning 6 min after flumazenil administration. CONCLUSIONS: Administration of a single dose of 0.3 mg of flumazenil to healthy, unpremedicated patients at the end of sevoflurane/fentanyl anesthesia without benzodiazepines resulted in earlier emergence from anesthesia and an increase in the BIS value. This may indicate that flumazenil could have an antagonistic effect on sevoflurane or an analeptic effect through endozepine-dependent mechanisms.

Clinical comparisons of 0.5% and 0.375% levobupivacaine for ultrasound-guided axillary brachial plexus block with nerve stimulation / 대한마취과학회지

BACKGROUND: In an axillary brachial plexus block (ABPB), where relatively large doses of local anesthetics are administered, levobupivacaine is preferred due to a greater margin of safety. However, the efficacy of levobupivacaine in ABPB has not been studied much. We performed a prospective, double-blinded study to compare the clinical effect of 0.375% levobupivacaine with 0.5% levobupivacaine for ultrasound (US)-guided ABPB with nerve stimulation. METHODS: Forty patients undergoing elective upper limb surgery were randomized into two groups: Group I (0.375% levobupivacaine) and Group II (0.5% levobupivacaine). All four main terminal nerves of the brachial plexus were blocked separately with 7 ml of levobupivacaine using US guidance with nerve stimulation according to study group. A blinded observer recorded the onset time for sensory and motor block, elapsed time to be ready for surgery, recovery time for sensory and motor block, quality of anesthesia, patient satisfaction and complications. RESULTS: There were no significant differences in the time to find nerve locations, time to perform block and number of skin punctures between groups. Insufficient block was reported in one patient of Group I, but no failed block was reported in either group. There were no differences in the onset time for sensory and motor block, elapsed time to be ready for surgery, patient satisfaction and complications. CONCLUSIONS: 0.375% levobupivacaine produced adequate anesthesia for ABPB using US guidance with nerve stimulation, without any clinically significant differences compared to 0.5% levobupivacaine.

Fulminant neurogenic pulmonary edema developed after spontaneous cerebellar hemorrhage: A case report

Neurogenic pulmonary edema (NPE) was first reported in the literature in 1874. NPE has been described following head injury, subarachnoid hemorrhage (SAH), intracerebral hemorrhage, seizures, brain stem tumor and cervical spinal cord injury. According to the reports in the literature since 1990, the most frequent underlying factor for NPE has been subarachnoid hemorrhage and aneurysm rupture is following. The incidence of NPE was reported to be 6% in a series of 457 patients with SAH. We present here a case of NPE arising from cerebellar hemorrhage, which is a very rare cause of NPE.

Airway obstruction by dislodgement of an endobronchial tumor fragment during right lung lobectomy using a bronchial blocker: A case report

Dislodgement of tumor fragment with airway obstruction in a dependent bronchus can be a cause of severe hypoxemia, which is a rare but very serious complication of lung surgery. We describe a case of airway obstruction following deflation of a balloon of a bronchial blocker of a Univent tube during right bilobectomy. Following reintubation with a single lumen tube, the patient was simultaneously extubated with the biopsy forceps holding the mass. This report underlines that anesthesiologist should be alert to a possibility of airway obstruction following deflation a balloon of a bronchial blocker.

Negative Pressure Pulmonary Edema and Hemorrhage after Extubation: A Case Report / 대한구급학회지

Negative pressure pulmonary edema (NPPE) is a rare complication of acute airway obstruction which develops after endotracheal extubation. The proposed mechanism is generation of very low negative pressure during laryngospasm by inspiratory efforts, which leads to alveolar exudation and hemorrhage. The diagnosis of NPPE is confirmed by clinical findings of tachypnea, pink prothy sputum in the endotracheal tube, hypoxemia on arterial blood gas analysis, and distinctive radiologic findings. NPPE is usually self-limited within 48 hours when diagnosed early and treated appropriately. We report three patients who recovered from NPPE without complications.

Cerebral fat embolism after bilateral total knee replacement arthroplasty: A case report / 대한마취과학회지

Fat embolism syndrome is a rare and potentially lethal complication most commonly seen in long bone fractures and intramedullary manipulation. The clinical triad of fat embolism syndrome consists of mental confusion, respiratory distress, and petechiae. This study reports a case of cerebral fat embolism syndrome following elective bilateral total knee replacement. After an uneventful anesthesia and initial recovery, the patient developed neurologic symptoms nine hours postoperatively.

The analgesic effect of the ultrasound-guided transverse abdominis plane block after laparoscopic cholecystectomy / 대한마취과학회지

BACKGROUND: Several methods are performed to control the pain after a laparoscopic cholecystectomy. Recently, the transverse abdominis plane block has been proposed to compensate for the problems developed by preexisting methods. This study was designed to evaluate the effect of the ultrasound-guided transverse abdominis plane block (US-TAP block) and compare efficacy according to the concentration of local analgesics in patients undergoing laparoscopic cholecystectomy. METHODS: Fifty-four patients undergoing laparoscopic cholecystectomy were randomized into three groups. The patients in Group Control did not receive the US-TAP block. The patients in Group B(0.25) and Group B(0.5) received the US-TAP block with 0.25% and 0.5% levobupivacaine 30 ml respectively. After the general anesthesia, a bilateral US-TAP block was performed using an in-plane technique with 15 ml levobupivacaine on each side. Intraoperative use of remifentanil and postoperative demand of rescue analgesics in PACU were recorded. The postoperative verbal numerical rating scale (VNRS) was evaluated at 20, 30, and 60 min, and 6, 12, and 24 hr. Postoperative complications, including pneumoperitoneum, bleeding, infection, and sleep disturbance, were also checked. RESULTS: The intraoperative use of remifentanil, postoperative VNRS and the postoperative demand of rescue analgesics were lower in the groups receiving the US-TAP block (Group B(0.25) and Group B(0.5)) than Group Control. There were no statistically or clinically significant differences between Group B(0.25) and Group B(0.5). No complications related to the US-TAP block were observed. CONCLUSIONS: The US-TAP block with 0.25% or 0.5% levobupivacaine 30 ml (15 ml on each side) significantly reduced postoperative pain in patients undergoing laparoscopic cholecystectomy.

Analgesic effect of low-dose levobupivacaine for ultrasound-guided interscalene brachial plexus block for arthroscopic shoulder surgery / 대한마취과학회지

BACKGROUND: Ultrasound guided-interscalene brachial plexus block (US-ISBPB) becomes more popular and has higher success rate. The aim of this study was to assess the analgesic effectiveness of US-ISBPB with low dose levobupivacaine for arthroscopic shoulder surgery. METHODS: The thirty patients undergoing elective arthroscopic shoulder surgery were randomly assigned to two groups: Group B(0.5), and Group B(0.25) received ultrasound-guided ISBPB using same volume 10 ml of 0.5% levobupivacaine and 0.25% levobupivacaine, respectively. General anesthesia was standardized. All patients received continuous intra-articular infusion of a local anesthetic. Remifentanil consumption during operation, verbal numerical rating scales (VNRS) after operation were assessed. The need for rescue analgesics in post-anesthesia care unit (PACU), sleep quality, and complications were documented. RESULTS: There were no significant differences in VNRS at 20 min, 30 min, 60 min, 120 min, 8 h, 24 h after surgery, remifentanil consumption during operation, the number of patients required rescue analgesics in the PACU, sleep quality, and complication up to 24 h after surgery. CONCLUSIONS: Ultrasound-guided interscalene brachial plexus block with levobupivacaine, 10 ml of 0.5% and 0.25%, provides effective analgesia after arthroscopic shoulder surgery.