Difficult intubation using intubating laryngeal mask airway in conjunction with a fiber optic bronchoscope

When anesthesiologists encounter conditions in which intubation is not possible using a conventional direct laryngoscope, they can consider using other available techniques and devices such as fiber optic bronchoscope (FOB)-guided intubation, a laryngeal mask airway (LMA), intubating LMA (ILMA), a light wand, and the Combitube. FOB-guided intubation is frequently utilized in predicted difficult airway cases and is generally performed when the patient is awake to enable easier access to the trachea. An LMA can be introduced to ventilate the patient with relative ease, while an ILMA can be used for definite endotracheal intubation. However, occasionally, an endotracheal tube (ETT) cannot pass through the larynx, despite successful introduction of a FOB into the trachea and placement of an ILMA by the anesthesiologist. Therefore, we initially introduced an ILMA for emergent ventilation, followed by successful insertion of an ETT under FOB guidance. In this report, we describe three cases of difficult intubation using a FOB and ILMA combination approach.

Difficult intubation using intubating laryngeal mask airway in conjunction with a fiber optic bronchoscope

When anesthesiologists encounter conditions in which intubation is not possible using a conventional direct laryngoscope, they can consider using other available techniques and devices such as fiber optic bronchoscope (FOB)-guided intubation, a laryngeal mask airway (LMA), intubating LMA (ILMA), a light wand, and the Combitube. FOB-guided intubation is frequently utilized in predicted difficult airway cases and is generally performed when the patient is awake to enable easier access to the trachea. An LMA can be introduced to ventilate the patient with relative ease, while an ILMA can be used for definite endotracheal intubation. However, occasionally, an endotracheal tube (ETT) cannot pass through the larynx, despite successful introduction of a FOB into the trachea and placement of an ILMA by the anesthesiologist. Therefore, we initially introduced an ILMA for emergent ventilation, followed by successful insertion of an ETT under FOB guidance. In this report, we describe three cases of difficult intubation using a FOB and ILMA combination approach.

Cerebral blood flow change during volatile induction in large-dose sevoflurane versus intravenous propofol induction: transcranial Doppler study / 대한마취과학회지

BACKGROUND: The impact of volatile induction using large-dose sevoflurane (VI-S) on cerebral blood flow has not been well investigated. The present study compared the changes in cerebral blood flow of middle cerebral artery using transcranial Doppler (TCD) during VI-S and conventional induction using propofol. METHODS: Patients undergoing elective lumbar discectomy were randomly allocated to receive either sevoflurane (8%, Group VI-S, n = 11) or target-controlled infusion of propofol (effect site concentration, 3.0 microg/ml; Group P, n = 11) for induction of anesthesia. The following data were recorded before and at 1, 2, and 3 min after commencement of anesthetic induction (T0, T1, T2, and T3, respectively): mean velocity of the middle cerebral artery (V(MCA)) by TCD, mean blood pressure (MBP), heart rate, bispectral index score (BIS) and end-tidal CO2 (ETCO2). Changes in V(MCA) and MBP from their values at T0 (DeltaV(MCA) and DeltaMBP) at T1, T2, and T3 were also determined. RESULTS: BISs at T1, T2 and T3 were significantly less than that at T0 in both groups (P < 0.05). DeltaVMCA in Group VI-S at T2 and T3 (18.1% and 12.4%, respectively) were significantly greater than those in Group P (-7.6% and -19.8%, P = 0.006 and P < 0.001, respectively), whereas ETCO2 and DeltaMBP showed no significant intergroup difference. CONCLUSIONS: VI-S using large-dose sevoflurane increases cerebral blood flow resulting in luxury cerebral flow-metabolism mismatch, while conventional propofol induction maintains cerebral flow-metabolism coupling. This mismatch in VI-S may have to be considered in clinical application of VI-S.

Use of premolded armored tube for a patient with tracheal stenosis: A case report

It is essential to predict possibility of difficulties beforehand in ventilating or intubating the patient for the safe airway management and anesthetic maintenance. Even if there is no internal invasion, external compression of an enlarged neck mass can cause tracheal stenosis. The patient with nontoxic goitor had symptoms of dysphagia, exertional dyspnea and wheezing. There was difficulty in endotracheal passage of small bronchoscope through the compressed portion of the trachea during preoperative bronchoscopic examination. We premolded an armored endotracheal tube to fit the patient's trachea based on chest radiography, computed tomography and brochoscopic findings. Endotracheal intubation and thyroidectomy was successful and the patient discharged without any complication. We report a new method of intubation in patient with nontoxic goiter that obstructs the trachea by compression.

Respiratory insufficiency in a patient with preeclamsia and hypothyroidism developed after general anesthesia for emergency cesarean section: A case report / 대한마취과학회지

Anesthesia and surgery in a patients with undiagnosed or untreated hypothyroidism can carries the risk of potential complications such as prolonged unconsciousness, respiratory insufficiency, hypotension, hyponatremia, congestive heart failure, and even coma. A 33-year-old gravida was admitted at 36 weeks gestation with hypertension, proteinuria, generalized edema, and intrauterine fetal growth retardation. She had thyroidectomy for thyroid mass six years ago. Because of doubt of uterine abruption, emergency cesarean section was performed without result of thyroid function test. Preeclamsia and mild hypothyroidism show similar symptoms and it can make difficult to diagnose hypothyroidism. We experienced delayed recovery and respiratory insufficiency in a patient with preeclamsia and undetected hypothyroidism during emergence from general anesthesia. She was fully recovered after ventilatory care in intensive care unit.

Anesthetic managements for repair of atrial septal defect in a patient with Young-Simpson Syndrome: A case report / 대한마취과학회지

Young-Simpson Syndrome (YSS) is a rare malformation syndrome characterized by facial dysmorphism, congenital heart abnormalities, congenital hypothyroidism and severe growth retardation. A 5-month-old girl was scheduled to undergo patch closure of atrial septal defect. She had been diagnosed with YSS preoperatively. We report out clinical experience of a case of YSS patient with brief review of related literatures and relevant anesthetic problems.

The relationship of serum creatinine and cardiac troponin I after off-pump coronary artery bypass graft surgery

BACKGROUND: Renal dysfunction is an independent risk factor of cardiac dysfunction and one of common complications after cardiac surgery. This study was designed to evaluate the relationship between serum creatinine (s-Cr) and cardiac troponin I (cTnI) in off-pump coronary artery bypass graft surgery (OPCAB). METHODS: Data, from 13 patients underwent OPCAB, were analyzed in prospective fashion. The levels of s-Cr and cTnI were evaluated before and after OPCAB. The correlations of s-Cr and TnI were analyzed in the patients with cardiac dysfunction assessed by low cardiac output or stroke volume at end of surgery. RESULTS: Patients with preoperatively elevated s-Cr (female, > or =1.2 microg/L; male, > or =1.5microg/L) showed higher incidence of elevated s-Cr and elevated cTnI (> or =0.68microg/L) on arrival at intensive care unit (POD-0), postoperative 12 hours (POD-1) and postoperative 36 hours (POD-2) (P< 0.05). Patients with preoperatively elevated cTnI showed higher incidence of elevated cTnI at POD-0, POD-1 and POD-2 (P< 0.05). In 7 patients with low cardiac index (< 2.0 L/min/m2) or stroke volume index (<40 mL/beat/m2) at end of surgery, the increases of s-Cr and cTnI showed positive correlation at POD-0, POD-1 and POD-2 (correlation coefficient 0.818, 0.864 and 0.785, respectively). CONCLUSIONS: The increases of s-Cr and cTnI showed positive correlation in low cardiac output after OPCAB. The results suggested that elevated s-Cr may be an independent predictor of elevated cTnI representing perioperative myocardial injury.

Is radial artery pressure waveform derived cardiac index is reliable during cardiac surgery with hypothermic cardiopulmonary bypass? / 대한마취과학회지

BACKGROUND: Discrepancy of central-peripheral arterial pressure after cardiopulmonary bypass may affect the reliability of arterial pressure waveform derived cardiac index (APCI) monitoring. METHODS: In 15 elective cardiac surgeries employing moderate hypothermic cardiopulmonary bypass (CPB), APCI from radial arterial cannula and pulmonary artery catheter derived cardiac index from thermodilution method (PACI) were measured 1) after anesthesia induction (T1), 2) before CPB (T2), 3) immediately after CPB (T3) and 4) 1 hour after CPB (T4). APCI and PACI were analyzed by using the Bland-Altman analysis. RESULTS: Biases of APCI and PACI at T1, T2, T3 and T4 were 0.093 L/min/m2, -0.053 L/min/m2, 0.485 L/min/m2 and -0.09 L/min/m2, respectively. The limits of agreement (2 SD) at T1, T2, T3 and T4 were from -2.285 to 2.471 L/min/m2, -2.475 to 2.369 L/min/m2, -2.255 to 3.225 L/min/m2 and -2.609 to 2.423 L/min/m2, respectively. Bias of APCI and PACI during entire period (T1-T4) was 0.095 L/min/m2 and 2 SD was from -2.387 to 2.557 L/min/m2. However, mean error % (2 SD/mean) of APCI at T1, T2, T3, and T4 were greater than 30%. CONCLUSIONS: Our results were not able to show that APCI measured from radial artery is comparable to PACI for hemodynamic monitoring during cardiac surgery employing moderate hypothermic CPB. Considering the limitations of PACI as a gold standard of hemodynamic monitoring in a certain clinical circumstance, further investigation employing other monitoring method than PACI may be followed to get more definitive conclusion.

Effect of the modality selected and the target concentration on the infusion rate and dosage of remifentanil during target controlled infusion of remifentanil: simulation study

BACKGROUND:Administration of a rapid or large dose of remifentanil (>1.0microg/kg for 30?60 s) should be avoided due to its association with side effects such as muscle rigidity. The present study determined the infusion rate and dosage of remifentanil administered using target-controlled infusion (TCI) varies with the modality selected and the target concentration. METHODS: Data including the age, sex, weight, and height of 10 patients undergoing elective surgery in a university hospital were randomly used for a 3-min simulation of TCI-remifentanil Minto model. In every simulation, TCI targeting both plasma (Cp) and the effect-site (Ce) was performed repeatedly with varying target concentrations (2, 3, 5, 10, and 20 ng/ml). The rate of administration and the cumulative dosages of remifentanil (per min) in all of the TCI simulations were recorded and analyzed. RESULTS: The rates of Ce TCI were significantly greater than those of Cp TCI using the same concentration. The cumulative dosage in the first-minute TCI simulation with Cp 20 ng/ml, and Ce 3, 5, 10, 20 ng/ml exceeded 1.0microg/kg/min. CONCLUSIONS: The target concentration and the infusion modality should be selected carefully to avoid rapid infusion and an overdose of remifentanil.

Effect of the modality selected and the target concentration on the infusion rate and dosage of remifentanil during target controlled infusion of remifentanil: simulation study

BACKGROUND:Administration of a rapid or large dose of remifentanil (>1.0microg/kg for 30?60 s) should be avoided due to its association with side effects such as muscle rigidity. The present study determined the infusion rate and dosage of remifentanil administered using target-controlled infusion (TCI) varies with the modality selected and the target concentration. METHODS: Data including the age, sex, weight, and height of 10 patients undergoing elective surgery in a university hospital were randomly used for a 3-min simulation of TCI-remifentanil Minto model. In every simulation, TCI targeting both plasma (Cp) and the effect-site (Ce) was performed repeatedly with varying target concentrations (2, 3, 5, 10, and 20 ng/ml). The rate of administration and the cumulative dosages of remifentanil (per min) in all of the TCI simulations were recorded and analyzed. RESULTS: The rates of Ce TCI were significantly greater than those of Cp TCI using the same concentration. The cumulative dosage in the first-minute TCI simulation with Cp 20 ng/ml, and Ce 3, 5, 10, 20 ng/ml exceeded 1.0microg/kg/min. CONCLUSIONS: The target concentration and the infusion modality should be selected carefully to avoid rapid infusion and an overdose of remifentanil.

Anesthetic experience in a patient with Gorham's disease : A case report

Gorham's disease is a very rare non-familial disorder of uncertain etiology characterized by uncontrolled non-neoplastic proliferation of vascular or lymphatic channels within bone, leading to resorption and replacement of osseous matrix with angiomatous tissue. Spinal cord compression due to cervical spine osteolysis can lead to respiratory problems due to chylous pleural effusion or cardiac dysfunction due to chylous pericardial effusion, which can be life threatening and cause high morbidity and mortality. We present a 32-year-old female patient complicated by chylothorax who underwent general anesthesia for a bone biopsy.

Three-dimensional Transesophageal Echocardiography for Mitral Valve Repair Surgery: A case report / 대한마취과학회지

Although several reports have showed the application of 3-dimensional (3D) echocardiography, it is hard to find a report regarding the intraoperative use of real time 3D transesophageal echocardiography (TEE) in mitral valve repair surgery. In the present case, real time 3D TEE the one from the one TEE probe position as well as their rotated and cropped images showed detailed spatial images enough for immediate assessment of the mitral valve deformity and the characteristics of mitral regurgitation flow. Under cardiopulmonary bypass (CPB) employing moderate hypothermia, the prolapsed mital leaflet was excised, the ruptured cord was repaired and an annuloplasty ring was inserted to reinforce the mitral valve and to close up the defect. The 2D and 3D TEE images after CPB showed effective repair providing complete closure of the mitral leaflets and absence of residual regurgitation flow. Considering that the conventional 2D TEE requires examiner's ability to gather the various 2D TEE images and experience essential for intergrating the 2D images for full understanding of spatial structure of valvular deformity and dysfunction, 3D TEE's ability for making a comprehensive spatial image from a limited number of 2D images seems to have an additional clinical efficacy in intraoperative TEE monitoring for cardiac value surgery.

Retrohepatic Inferior Vena Cava Injury by Gunshot: A case report / 대한흉부외과학회지

Injury to the inferior vena cava (IVC) is associated with a high mortality rate, and little progress has been made for improving the treatment for this since the 1970s. Injury to the retrohepatic IVC, in particular, has been associated with up to a 75% mortality rate due to the difficulty in gaining adequate exposure and controlling the bleeding. Both the severity of injury and anatomic accessibility has been directly correlated with survival in IVC injury. We have experienced a patient with retrohepatic IVC that was ruptured by a penetrating gunshot injury and we managed to save this patient's life.

An Anesthetic Experience in a Patient with Tay-Sachs Disease : A case report / 대한마취과학회지

Tay-Sachs Disease (TSD), the most common form of GM(2) gangliosidosis, is an autosomal recessive inborn lysosomal glycosphingolipid storage disease which is resulted from the mutations that affect the alpha-subunit locus on chromosome 15 and cause a severe deficiency of hexosaminidase A. It is characterized by normal motor development in the first few months of life, followed by progressive weakness and loss of motor skills beginning around 6 months of life. Neurodegeneration is relentless and manifested as relentless motor and mental deterioration, beginning with motor incoordination, mental obtundation leading to muscular flaccidity, blindness, and increasing dementia, with death occurring by the age of 4 or 5 years. We report a successful anesthetic management in a patient with Tay-Sachs Diseases for tracheostomy and feeding gastrostomy.

Septated de Quervain's Disease with MRI Images: A case report

De Quervain's disease is the most common form of tenosynovitis, which causes disability in daily living and occupational activity. Anatomical variations in the first extensor compartment including separate comparment influenced the effects of treatment. A 45-year-old woman had severe pain on wrist and suffered in activity of daily living after motor vehicle accident. She had swelling and tenderness upon the radial styloid process, and more aggravated pain by Finkelstein's maneuver test. The magnetic resonance imaging (MRI) scans showed severe peritendinous edema within the synovial sheath, increased signal intensity within the tendons. Also, the images revealed a thickened septum between abductor pollicis longus and extensor pollicis brevis. Corticosteroid was injected on both sides of the septum. We report a case of definite septum of de Quervain's disease via MRI scans.

The Protective Effect of Ischemic and Hypoxic Preconditioning on Hypoxic-ischemic Brain Injury in the Neonatal Rat: 1H Magnetic Resonance Spectroscopic Study / 대한마취과학회지

BACKGROUND: A brief episode of cerebral ischemia confers transient ischemic tolerance to a subsequent ischemic challenge. We examined the effect of ischemic and hypoxic preconditioning in the neonatal rat. METHODS: Seven-day old Sprague-Dawley rat pups were divided into three groups:control (n = 53), ischemic preconditioning (n = 51), and hypoxic preconditioning (n = 48). For ischemic preconditioning, the right common carotid artery was occluded for 10 min. Rats in the hypoxic preconditioning group were kept under hypoxic (8% oxygen/92% nitrogen) conditions for 4h. Twenty-four hours after the preconditioning, rats from all groups were exposed to the right common carotid artery ligature, followed by 2.5 h of hypoxia. Lipid/N-acetyl aspartate (Lip/NAA) and lipid/creatine (Lip/Cr) ratios from 1H MR spectroscopy and terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) were evaluated as measures of apoptosis 1 and 7 days after hypoxic-ischemic injury. RESULTS: In the ischemic and hypoxic preconditioning groups, the Lip/NAA and Lip/Cr ratios and the numbers of TUNEL-positive cells were significantly lower than those in the control group (P < 0.05), but there were no significant differences between the two preconditioning groups. CONCLUSIONS: These results suggest that ischemic and hypoxic preconditioning in the neonatal rat attenuate the apoptosis that is caused by hypoxic-ischemic brain injury.

The Usage Pattern of Neuromuscular Blocker at Intensive Care Unit / 대한구급학회지

BACKGROUND: The neuromuscular blocker is helpful to intubate the patients and reduce the amount of anesthetic agent. It also used at intensive care unit (ICU) to maintain airway patency, to achieve proper ventilatory care, etc. This survey is to determine the neuromuscular blocker usage patterns in ICU settings. METHODS: Three hundred general hospitals with ICU settings were chosen. We designed a 10 itemed questionnaire which has several subquestions with multiple choices and sent it to them. After three months, forty seven hospitals returned the questionnaire and we made careful analysis with it. RESULTS: The most frequent indication of neuromuscular blocker was to facilitate the mechanical ventilation (80.9%). Vecuronium was the most common neuromuscular blocker used (97.9%). Only 6.4% of them used peripheral nerve stimulator and the rest of them (89.4%) used clinical information to determine the degree of neuromuscular blocker. The respondents reported that recovery from muscle relaxation was needed on a periodic basis for regular neurological examinations (59.6%) in ICU settings. All respondents used the sedatives or narcotics with neuromuscular blocker and only 6.4% used reversal agents. CONCLUSIONS: Although the rate of reply was not much (15.7%), we could get the current usage pattern of neuromuscular blocker at ICU. We recommend using short to intermediate acting neuromuscular blocker than long acting agents. Continuous infusion with careful dosage titration by peripheral nerve stimulator would be helpful to achieve rapid recovery. Additional sedatives and narcotics are beneficial to reduce the amount of neuromuscular blocker and to make patients comfortable as well.

Effects of Ondansetron and Granisetron on Rocuronium-induced Neuromuscular Blockade in a Rat Phrenic Nerve-hemidiaphragm Preparation / 대한마취과학회지

BACKGROUND: Both ondansetron and granisetron exert their antiemetic effects via a blockade of the 5-hydroxytryptamine 3 receptor (5-HT(3)R). Because the 5-HT(3)R is a member of a superfamily of ligand-gated ion channels and has structural similarities to the nicotinic acetylcholine receptor (nAChR), a 5-HT(3)R antagonist may also inhibit the nAChR. This study examined the effects of 5-HT(3)R antagonists, ondansetron and granisetron, on rocuronium-induced neuromuscular blockade in vitro. METHODS: Rat phrenic nerve-hemidiaphragm preparations were isolated and allocated randomly into seven groups (control, 1, 10, 100 microgram/ml of ondansetron, 0.1, 1, 10 microgram/ml of granisetron). Two studies were carried out using single twitch responses. In the cumulative dose-response study, rocuronium 1 microgram/ml and each doses of ondansetron or granisetron were administered simultaneously, and incremental 0.5 microgram/ml doses of rocuronium were added to obtain more than 95% neuromuscular twitch inhibition. ED(5), ED(50), ED(90), and ED(95) of rocuronium in each group were calculated using a logistic model. In the partial curarization study, the twitch heights were measured after administering ondansetron or granisetron (10 minutes after administering 3 microgram/ml rocuronium) and were measured 10 minutes later. The 2 twitch heights were then compared. RESULTS: In the cumulative dose-response study, ondansetron 100 microgram/ml and granisetron 10 microgram/ml significantly reduced the ED50 of rocuronium (P < 0.05). There were no intergroup differences in the partial curarization study. CONCLUSIONS: High concentration of ondansetron and granisetron enhanced the neuromuscular blockade of rocuronium. Granisetron enhanced the neuromuscular blockade of rocuronium more potently than ondansetron.

Percutaneous Treatment with Steroid Injections and Distension of Facet Synovial Cyst: A case report / 대한통증학회지

Facet joint synovial cysts are uncommon intraspinal abnormalities, which appear to be secondary to degenerative changes of the joints. They can cause chronic back pain and radiculopathy, as shown in spinal stenosis. When symptomatic cysts fail to respond to conservative measurements, surgical decompression is known as the standard treatment. Percutaneous steroid injections, and distension of the cysts under fluoroscopic guidance, may be a minimally invasive treatment option. Here, the case of a patient with a symptomatic L5-S1 facet joint synovial cyst and left S1 radiculopathy, who responded satisfactorily to percutaneous treatment, is presented.

Action Duration of Atracurium and Vecuronium in Patients with Renal Failure / 대한마취과학회지

BACKGROUND: Atracurium is eliminated by Hofmann elimination and ester hydrolysis, with minimal renal and hepatic excretion. It's action duration is not affected by renal function. Although metabolism of vecuronium is less dependent on the renal function than other steroid type neuromuscular blockers, the action duration of vecuronium is prolonged in renal failure. The purpose of this study is to compare the differences of the action duration of atracurium and vecuronium in patients with renal failure. METHODS: Forty patients with normal renal function and 40 patients with chronic renal failure were assigned to one of four groups: atracurium-normal (n=20, AC group), atracurium-renal failure (n=20, AK group), vecuronium-normal (n=20, VC group), vecuronium-renal failure (n=20, VK group). Anesthesia was induced with thiopental and maintained with the inhalation of nitrous oxide (50%) and isoflurane (0.5~1.5 vol%). Atracurium (0.5 mg/kg) or vecuronium (0.1 mg/kg) was given and endotracheal intubation was performed after twitch response was depressed more than 80%. Neuromuscular blockade was assessed by train-of-four at the adductor pollicis with supramaximal stimulation of ulnar nerve of 2 Hz every 12 sec. The onset time, duration of 5, 25, 50, 75% recovery time and recovery index were checked. RESULTS: Onset of block was not significantly different among four gorups. Recovery time of 5, 25, 50, 75% and recovery index were longer in the both renal failure groups. Action durations in renal failure were not significantly different between AK and VK groups. CONCLUSION: It is concluded that action duration of atracurium and vecuronium are affected by renal function. We would better monitor muscle relaxation and titrate dose of muscle relaxant.