Fluoroscopy and Sonographic Guided Injection of Obliquus Capitis Inferior Muscle in an Intractable Occipital Neuralgia

Occipital neuralgia is a form of headache that involves the posterior occiput in the greater or lesser occipital nerve distribution. Pain can be severe and persistent with conservative treatment. We present a case of intractable occipital neuralgia that conventional therapeutic modalities failed to ameliorate. We speculate that, in this case, the cause of headache could be the greater occipital nerve entrapment by the obliquus capitis inferior muscle. After steroid and local anesthetic injection into obliquus capitis inferior muscles under fluoroscopic and sonographic guidance, the visual analogue scale was decreased from 9-10/10 to 1-2/10 for 2-3 weeks. The patient eventually got both greater occipital neurectomy and partial resection of obliquus capitis inferior muscles due to the short term effect of the injection. The successful steroid and local anesthetic injection for this occipital neuralgia shows that the refractory headache was caused by entrapment of greater occipital nerves by obliquus capitis inferior muscles.

Anesthetic Management of Embolization for a Cerebral Aneurysm in Patient with Portal-systemic Encephalopathy: A case report / 대한마취과학회지

The clinical syndrome of hyperammonemic encephalopathy is often encountered in the context of decompensated liver disease. Although it is rare in patients without hepatic disease, non-hepatic causes cannot be excluded. Anesthesiologists should be careful in choosing the anesthetic agent and perioperative management for hyperammonemic patients in order to avoid acute hyperammonemia and encephalopathy. We report successful general anesthesia during GDC (Guglielmi detachable coil) embolization for a large unruptured aneurysm in the right distal internal carotid artery in a female patient with hyperammonemic encephalopathy that was caused by a portal-systemic shunt.

Spinal Anesthesia for a Formerly Premature Infant with Unilateral Vocal Cord Paralysis Undergoing Inguinal Herniorrhaphy: A case report / 대한마취과학회지

In premature infants, the incidence of inguinal hernia has been reported to be 14-30%. It is generally accepted that inguinal hernia should be repaired as soon as possible, as the incidence of incarceration is higher in infant than in children. However, the risk of life-threatening apnea after surgery is significant in this age group. Spinal anesthesia in premature infants offer a safe alternative to general anesthesia, especially if intubation should be avoid because of coexisting disease. We present a case of successful spinal anesthesia for inguinal herniorraphy in a premature female infant at a postconceptual age 44 + 6 weeks weighing 2,620 g with coexisting unilateral vocal cord paralysis to illustrate technical details and feasibility of this technique even in very low birth weight (birth weight < 1,500 g) infants.

Anesthetic Management of Premature Infant with Severe Respiratory Distress Syndrome Who Underwent Surgical Closure of Patent Ductus Arteriosus: A case report / 대한마취과학회지

Premature infants with respiratory distress syndrome may have clinically significant shunting through a patent ductus arteriosus (PDA). Left-to-right shunting through the PDA may lead to left ventricular volume overload and pulmonary edema. We present a case of perioperative management for severe respiratory distress syndrome in a premature infant who underwent surgical closure of PDA. Under general anesthesia, the infant was successfully managed by inhaled nitric oxide, high frequency oscillation ventilation with intermittent mandatory ventilation despite intermittent hypoxia. The operation was performed safely in the neonatal intensive care unit.

Low Pressure (8 mmHg) Pneumoperitoneum does not Reduce the Incidence and Severity of Postoperative Nausea and Vomiting (PONV) following Gynecologic Laparoscopy / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) is distressing complication of anesthesia and surgery, with a relatively high incidence in women undergoing gynecologic laparoscopy. Therefore, this study aimed to investigate occurrence and severity of PONV of low pressure (LP [8 mmHg]) in comparison to standard pressure (SP [13 mmHg]) pneumoperitoneum. METHODS: 46 consecutive patients qualified for elective gynecologic laparoscopy were randomly allocated to either SP group (n = 23) or LP group (n = 23). All the patients were separately evaluated at three intervals of 0-2 h, 2-6 h and 6-24 h during the first postoperative 24 hours with regard to emetic symptoms. Additionally, the degree of surgical exposure in LP group was rated in 4-point scale by surgeon. RESULTS: The overall incidence of PONV during the initial 24 postoperative hours did not differ between the groups (65.2% in LP group vs 82.6% in SP group, P = 0.314). There was also no difference between the groups in regard to the incidence and severity of PONV and postoperative nausea, consumption of analgesics and the need for rescue ondansetron at any separate observation periods. However, some degrees of surgical difficulties were rated in 12 patients (52.1%) from LP group. Furthermore, mean estimated blood loss in LP group was significantly increased than in SP group (P < 0.05). CONCLUSIONS: We conclude that lowering of the insufflation pressure to 8 mmHg can not reduce the incidence and severity of PONV after gynecologic laparoscopy and even increase the noticeable surgical difficulties and risks in some cases.

Intraoperative Thermoregulation in Laparoscopic Gynecologic Surgery with Conventional and Low Insufflation: A Comparison with Open Surgery / 대한마취과학회지

BACKGROUND: It has been suspected that laparoscopic surgery exacerbates hypothermia to a greater extent than open surgery. Thus, this study was designed to compare the intraoperative thermoregulatory profiles of three different operative techniques: open surgery, low pressure (LP: 8 mmHg) or conventional pressure (CP: 13 mmHg) laparoscopic surgery. METHODS: Forty five patients who were scheduled for radical hysterectomy were allocated to three groups, 15 in each group: group O (open surgery), group LP and group CP. Anesthesia was maintained with 2.5% sevoflurane. Intraoperative core temperature and forearm minus fingertip skin temperature gradients were measured at 15-min intervals during the first three hours. Vasoconstriction threshold was defined by the esophageal temperature at which the skin temperature gradient equalled 0 degree C. RESULTS: All groups were comparable in terms of the characteristics of patients and preoperative body temperatures. Core temperatures and forearm minus fingertip skin temperature gradients were not significantly different among the three groups at all measurements. Thermoregulatory vasoconstrictions were observed in 6 of group O and 6 of laparoscopic surgical patients (4 patients from group LP and 2 patients from group CP). These 12 patients were divided into open (n = 6) and laparoscopic (n = 6) surgery group. There were no significant difference between the groups with regard to the vasoconstriction threshold and threshold time. CONCLUSIONS: Laparoscopic procedures with conventional insufflation pressure have similar profiles in terms of intraoperative thermoregulation, when compared to open surgery. Lowering insufflation pressure to 8 mmHg can not reduce the risk of intraoperative hypothermia.

Sedation with Propofol-Midazolam Combination versus Propofol alone during Spinal Anesthesia: Prospective, Randomized Study / 대한마취과학회지

BACKGROUND: Propofol can produce a dose-dependent reduction in blood pressure by providing titratable sedation and rapid recovery. It has been reported that a combination of midazolam and propofol resulted in the significant reduction in the total dose of propofol needed. It was hypothesized that the addition of low-dose midazolam to propofol may provide sufficient sedation without compromising the hemodynamic stability. METHODS: A total of 40 consecutive patients were randomly assigned to one of two groups (n = 20 each). Group M-P received a bolus of 0.02 mg/kg of midazolam, followed by a propofol infusion with a fixed target concentration of 1.0microgram/ml. Group P received only a propofol infusion with an initial target plasma concentration of 2.5microgram/ml. Subsequent titration of the infusion rates in Group P or the additional midazolam boluses in Group M-P were made in order to maintain a predetermined sedation level. RESULTS: In Group P, a mean dose of 5.4 +/- 0.7 mg/kg/h propofol was used compared with 2.7 +/- 0.5 mg/kg/h in Group M-P (P<0.0001, plus additional 2.96 +/- 1.8 mg of midazolam). Ephedrine was administered to 15 patients in Group M-P and 17 patients in Group P. Recovery was significantly fast (Group P, 6.8 +/- 2.9 min vs. Group M-P, 9.8 +/- 4.4 min, P<0.05). CONCLUSIONS: Sedation with propofol plus midazolam requires a lower total dose of propofol compared with propofol alone but has no superior hemodynamic stability. A further study using younger patients and combinations of different doses of each drug will be needed.

Bronchospasm Caused by N-Acetylcysteine Intratracheal Instillation in a Patient with Bronchial Asthma: A Case Report / 대한마취과학회지

We report of a successfully treated case of fatal bronchospasm, which developed after N-acetylcysteine bolus intratracheal instillation in a 49-year-old female patient with bronchial asthma undergoing laparoscopic cholecystectomy. N-acetylcysteine has been widely used as a potent mucolytic agent since 1963, with few reported adverse reactions. Its mucolytic action is due to the breakage of disulfide bonds in mucus mucoproteins. Most adverse reactions to N-acetylcysteine are usually mild and respond to the termination of the medication and symptomatic treatment with antihistamine. However, several cases of fatal bronchospasm have been reported in asthmatic patients after inhaled or intravenous N-acetylcysteine. N-acetylcysteine induced bronchospasm could be avoided in most asthmatic patients if its concentration is not allowed to exceed 10%, and concomitant beta2-selective bronchodilators are utilized. Nevertheless, asthma is still a potent risk factor and requires special precautions, including careful risk-versus-benefit assessment, close observation and the immediate availability of resuscitation equipment and staff in the event of life-threatening bronchospasm.

Cardiac Arrest after Complete Intratracheal Obstruction by an Aspirated Blood Clot in a Patient with Upper G-I Bleeding: A case report / 대한마취과학회지

Fatal airway obstruction due to the presence of blood clot occurs in a variety of clinical settings. Initial efforts to remove an airway clot, if warranted, involve suctioning, lavage, and forceps extraction through a flexible bronchoscope. If unsuccessful, further management options include rigid bronchoscopy, balloon-tip embolectomy catheter dislodgement, and the application of topical thrombolytic agents. We report a case of complete airway obstruction that developed after the aspiration of a blood clot during emergency operative vessel ligation in a 86-year-old female patient with gastric ulcer bleeding. Initial conventional suctioning was unsuccessful, in this case, due to a large firmly adherent clot. Therefore we peformed the alternative suctioning technique using suction attached directly to the existing tracheal tube in situ, with the cuff deflated. However, repeated direct tracheal suctioning alone failed to prevent cardiac arrest. Thereafter, simultaneously with several CPR chest compressions, large cylindrical clots were sucked up by direct tracheal suctioning. Presumably simultaneous chest compression has the potential advantage of creating higher airway pressures that provide effective kinetic energy to obstructing object.

The Effect of Injection Direction during Hyperbaric Tetracaine Spinal Anesthesia with Pencil-Point Needle / 대한마취과학회지

BACKGROUND: Pencil-point needle currently are used for spinal anesthesia because of an alleged lowered incidence of postdural puncture headache. Although the direction of the side hole is one of the important factors that might affect the level and the duration of anesthesia, those data are not readily available. The aim of this study was to assess if the side hole direction of pencil-point needle during hyperbaric tetracaine injection affects the level and the duration of anesthesia. METHODS: We induced spinal anesthesia in 80 young men presenting for elective orthopedic surgery. Patients were allocated randomly with the side hole direction of the 25 gauge pencil-point needle in one of the four directions; cephalad, caudad, left lateral, right lateral. Hyperbaric 0.5% tetracaine 15~17 mg (3 to 3.4 ml) was injected with the speed of 0.75 ml/sec. Maximum sensory block level, time to maximum sensory block level, duration of sensory block (2 segments regression time) were assessed by a blinded observer with the pin-prick test and degree of motor block were measured by Bromage motor scale. Data were analysed using the Kruskal-Wallis test followed by the Mann-Whitney U test and chi-square test as appropriate (SAS v. 6.04). RESULTS: Time to maximum sensory block level was significantly fast in group 'cephalad'. Other values have no statistical differences. Post-spinal headache was observed in one case in group 'caudad'. CONCLUSIONS: Using the pencil-point needle, the time to maximum sensory block level was fast in group cephalad but there were no differences in the maximum sensory block level and the duration of sensory block among the four groups.

Anesthetic Management of Patient with Renal Cell Carcinoma Extending into the Right Atrium Using Adjunctive Deep Hypothermic Circulatory Arrest: A case report / 대한마취과학회지

Renal cell carcinoma is associated with inferior vena cava tumor spread in 4~10% of cases and with extension of the tumor thrombus into the right atrium in less than 1% of cases. Because inferior vena caval involvement does not affect the ultimate survival in patients with nonmetastatic renal cell carcinoma, aggressive surgical resection is indicated. We experienced a case of complete tumor excision with radical nephrectomy and inferior vena caval and right atrial thrombectomy using adjunctive cardiopulmonary bypass(CPB) and deep hypothermic circulatory arrest(DHCA). During total circulatory arrest(TCA), we protected brain from ischemic insult using deep hypothermia, retrograde cerebral perfusion, thiopental, and high dose steroid. The patient recovered uneventfully except minor neuropsychiatric symptom for 3 weeks after operation.

Anesthetic Management of an Infant with Nesidioblastosis: A case report / 대한마취과학회지

Nesidioblastosis, persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is a disorder characterized by diffuse pancreatic islet cell hyperplasia arising from the ductal epithelium. Patients usually present during the neonatal or infantile period with apnea, hypotonia, poor feeding, lethargy, or seizure. Despite of greater awareness, one in three has some degree of mental retardation by the time the diagnosis is made. The diagnosis is established by demonstrating high plasma insulin concentration during an episode of hypoglycemia. This hypoglycemia is initially managed medically, but these medical treatment modalities are failed in more than half of nesidioblastosis. Patient who failed to respond to optimal medical treatment should be referred for surgery early, if permanent neurologic damage is to be avoided. The surgical procedure of choice is near total pancreatectomy (95~98% resection). We herein discuss the anesthetic management of a patient with nesidioblastosis who presented for near total pancreatectomy.