Clinical Experience with Buttonhole Needling in a Single Hemodialysis Center / 대한내과학회지

BACKGROUND/AIMS: The buttonhole technique, in which needle insertion during cannulation is always into the same site, confers advantages including ease of cannulation, ease of achieving hemostasis, and reduced pain compared with rope-ladder needling. We introduced the buttonhole technique in hemodialysis patients experiencing pain during needling. None of the disadvantages associated with the buttonhole technique, such as infection or access events, were observed, due to the short duration of the study. METHODS: Patients undergoing buttonhole needling were observed prospectively. Data were collected on the following parameters: infectious complications, hospitalizations and access events. We compared buttonhole and rope-ladder needling using baseline data. RESULTS: A total of 48 patients (34 males; mean age = 49.4 +/- 13.8 years) were enrolled. Seven patients were excluded: in three patients, the buttonhole technique failed to form a tract, three others underwent kidney transplantation, and one was lost to follow-up. The remaining 41 patients were followed for 15.7 +/- 4.7 months. Thirteen patients suffered infections, as follows: local infections (n = 5), pneumonia (n = 3), bacteremia (n = 2), cellulitis (n = 1), osteomyelitis (n = 1), and liver abscess (n = 1). There were no significant differences between the rope-ladder and buttonhole needling techniques in rates of infection, hospitalization or vascular access events. CONCLUSIONS: The infection rate and access event frequency associated with buttonhole needling did not differ in relation to that of rope-ladder needling.

Clinical Experience with Buttonhole Needling in a Single Hemodialysis Center / 대한내과학회지

BACKGROUND/AIMS: The buttonhole technique, in which needle insertion during cannulation is always into the same site, confers advantages including ease of cannulation, ease of achieving hemostasis, and reduced pain compared with rope-ladder needling. We introduced the buttonhole technique in hemodialysis patients experiencing pain during needling. None of the disadvantages associated with the buttonhole technique, such as infection or access events, were observed, due to the short duration of the study. METHODS: Patients undergoing buttonhole needling were observed prospectively. Data were collected on the following parameters: infectious complications, hospitalizations and access events. We compared buttonhole and rope-ladder needling using baseline data. RESULTS: A total of 48 patients (34 males; mean age = 49.4 +/- 13.8 years) were enrolled. Seven patients were excluded: in three patients, the buttonhole technique failed to form a tract, three others underwent kidney transplantation, and one was lost to follow-up. The remaining 41 patients were followed for 15.7 +/- 4.7 months. Thirteen patients suffered infections, as follows: local infections (n = 5), pneumonia (n = 3), bacteremia (n = 2), cellulitis (n = 1), osteomyelitis (n = 1), and liver abscess (n = 1). There were no significant differences between the rope-ladder and buttonhole needling techniques in rates of infection, hospitalization or vascular access events. CONCLUSIONS: The infection rate and access event frequency associated with buttonhole needling did not differ in relation to that of rope-ladder needling.

Unexpected tracheal narrowing during general anesthesia in the prone position of Duchenne muscular dystrophy patient: A report of two cases / 대한마취과학회지

Unexpected tracheal narrowing was observed in a patient with Duchenne muscular dystrophy during a corrective operation for thoracolumbar scoliosis. As the operating time progressed, peak airway pressure and end-tidal CO2 increased gradually in the prone position. We found a floppy portion of the trachea using fiberoptic bronchoscopy (FB) in the prone position. We advanced a wire-reinforced tube toward the carina beyond the lesion. This allowed correction of the ventilatory abnormalities. We encountered another patient scheduled for the same operation. We performed FB in advance before the position change and observed a narrowed portion of trachea. We advanced the tracheal tube under FB beyond the pathologic portion and then moved the patient into the prone position. The operation was done successfully without any problems.

Clinical Utility of the Buttonhole Technique Using Biohole(TM) in Hemodialysis Patients / 대한내과학회지

BACKGROUND/AIMS: Buttonhole cannulation has been popular because it provides an easy puncture, is less painful, and requires less time for hemostasis. However, the technique requires a skilled staff and a long time to form the tract. A new buttonhole technique using Biohole(TM), which shortens the time needed for tract formation, has been introduced in Europe, North America, and Japan. METHODS: We prepared a cannulation tract using the buttonhole technique and Biohole(TM) over a two-week period and compared the 12-week outcomes between patients who underwent the rope-ladder versus buttonhole techniques. RESULTS: The 40 patients (27 males) had a mean age of 49.1 +/- 14.2 years. Thirteen and 27 patients were cannulated with the rope-ladder and buttonhole techniques, respectively. Patients who underwent the buttonhole technique had more initial pain than did those who received the rope-ladder technique (p = 0.044). The Biohole(TM) procedure improved puncture pain (5.6 vs. 3.4, p = 0.003) and shortened hemostasis time (1.8 vs. 1.3, p = 0.001). Over a two-week period, patients using Biohole(TM) experienced dislocation (20.8%), bleeding at peg sites (8.6%), and pain during peg change (2.4%). Over the 12 week study period, patients who underwent the buttonhole technique had insignificantly less pain than did those who received the rope-ladder technique (p = 0.088), but the former had less bleeding time than the latter (p = 0.000). One patient who received the buttonhole technique experienced one episode of infection (p = 0.327). CONCLUSIONS: The new buttonhole technique using Biohole(TM) is safe and useful in the short term. A long-term, larger, multicenter study is required to confirm these results.

Cervical Spinal Cord Stimulation in a Patient with Complex Regional Pain Syndrome Type 2 at the Middle Finger: A case report / 대한마취과학회지

Complex regional pain syndrome (CRPS) is quite difficult to comprehend and manage, of which etiology and pathophysiological mechanisms have not been fully understood. CRPS is classified as either type 1 (without any known nerve injury) or type 2 (with apparent nerve or tissue injury). Spinal cord stimulation is a restorative therapy that currently offers the best chances of obtaining long-term pain relief in CRPS patients with pain that has not responded to other treatments such as physical therapy or analgesic medications. A 45 years old male patient referred to our pain clinic due to uncontrolled pain at the middle finger for 4 years after crushing injury. He was diagnosed with CRPS type 2 and treated with medication, stellate ganglion block, thoracic sympathetic block, and pulsed radiofrequency therapy, but their effects were transient and not satisfactory. A percutaneous spinal cord stimulation (SCS) with a single quadripolar electrode was tried and the patient's finger pain was improved significantly (from VAS 10 to 2). SCS is an effective treatment for CRPS type 2 which results from crushing injury when alternative therapies fail.

Pulmonary Edema after Staging Exicision of Bilateral Carotid Body Tumor: A case report / 대한마취과학회지

We report a case of pulmonary edema developed in a 33-year-old female who underwent two-stage bilateral carotid body tumor excision. About 1 month ago, she had undergone a left carotid body tumor excision. After the operation, her tongue was deviated to left side. Bilateral hypoglossal nerve injury was suspected. These injuries should be carefully monitored in patients who will undergo a similar procedure on both sides because a bilateral deficit of the hypoglossal nerve is poorly tolerated, resulting potentially serious pulmonary edema. In recovery room, she became pale and SpO2 was fall down. We reintubated her immediately and the pulmonary edema was treated using a supportive management. She was discharged without any signs of dyspnea or airway obstruction, but hypoglossal nerve injury remained. We discuss the possible etiology of the upper airway obstruction after the neck surgery and review the literatures associated with the pulmonary edema following upper airway obstruction.

The Abdominal Pain Caused by a Trigger Point in the Rectus Abdominis: A case report / 대한마취과학회지

Three cases of the abdominal pain, which are derived from the rectus abdominis, were presented. The abdominal pains of unknown origin are frequently misdiagnosed as arisen from visceral sources. That brings inappropriate diagnostic tests and unsatisfactory treatments. If patients have no intraabdominal cause, we must pay attention to the possibility that patients with abdominal pain may suffer from this presumed nerve entrapment syndrome or myofacial pain syndrome. Rectus abdominis syndrome is causes by entrapment of an anterior cutaneous branch of one or more thoracic intercostal nerves. Myofacial pain syndrome is defined as the sensory, motor and autonomic symptoms caused by the myofacial trigger points. The authors report three cases of abdominal pain caused by trigger point in the rectus abdominis muscle. On physical examination, trigger points in the rectus abdominis muscle were found, and abdominal pain was successfully treated by trigger point injections.

Comparison of Total Intravenous Anesthesia and Sevoflurane-Alfentanil Anesthesia for Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: The aim of this prospective, double-blind randomized study was to compare the clinical properties of sevoflurane-alfentanil with propofol-remifentanil anesthesia in patients undergoing a laparoscopic cholecystectomy. METHODS: Forty patients (ASA physical status 1, 2) scheduled for elective surgery received total intravenous anesthesia (TIVA group) with remifentanil and propofol or sevoflurane-alfentanil. The TIVA group was induced with propofol 5 microgram/ml and remifentanil 4.5 ng/ml. The anesthesia was maintained with a continuous infusions of propofol 2.5 microgram/ml and remifentanil 3 ng/ml. The sevoflurane-alfentanil group was induced with alfentanil 15 microgram/kg and propofol 1.5 mg/kg IV. Maintenance was obtained with 2.0 vol% sevoflurane and a bolus of alfentanil 10microgram/kg IV where needed. RESULTS: There were no significant differences in the systolic and diastolic blood pressure and heart rate between the two groups. There were no significant differences in the time to eye opening, the time to extubation, post-anesthetic recovery room stay time and the incidence of postoperative nausea and vomiting between the two groups. CONCLUSIONS: Propofol-remifentanil (TIVA) and sevoflurane-alfentanil both provided satisfactory anesthesia for a laparoscopic cholecystectomy.

One-lung Ventilation using Wire-guided Endobronchial Blocker and Single Lumen Endotracheal Tube: A Case Report / 대한구급학회지

We had done one-lung ventilation using 9 Fr wire-guided endobronchial blocker and outer diameter 41-mm flexible fiberoptic bronchoscope in ruptured esophageal patient who expected difficult tracheal intubation and in esophageal cancer patient who was in need of mechanical ventilation during and after the operation.

Comparison of the Myocardial Protective Effects of Desflurane and Sevoflurane against Global Ischemia and Reperfusion Injury in Isolated Rat Heart / 대한마취과학회지

BACKGROUND: Desflurane and sevoflurane have been shown to induce pharmacologic preconditioning in experimental studies. The present study was aimed at comparing the myocardial protective effects of these two halogenated anesthetics in terms preconditioning induction. METHODS: Three groups of Sprague-Dawley rat hearts (n = 10 each) were perfused with oxygenated modified Kreb's solution using a Langendorff perfusion device. All groups underwent 30 minutes of global ischemia and 60 minutes of reperfusion after a stabilization period of 30 minutes. Before ischemia, hearts underwent a preconditioning period consisting of either no inhalation for 20 minutes (control group), or 15 minutes of either MAC desflurane or sevoflurane followed by 5 minutes of washout. Left ventricular end systolic pressure (LVESP), left ventricular end diastolic pressure (LVEDP), heart rate (HR) and maximal rate of change of ventricular pressure (dP/dt) were measured at after inhalation, before ischemia, and 5 minutes, 30 minutes and 60 minutes after reperfusion. Coronary sinus effluent also was measured. Infarct size was measured by triphenyl tetrazolium staining. RESULTS: LVESP and dP/dt were decreased in the control group, but remained unchanged in the desflurane and sevoflurane groups during the reperfusion period. LVEDP was increased in all groups, but the magnitude of the increase was smaller in the desflurane and sevoflurane groups than in the control group during the reperfusion period. HR was increased in the control group, but remained unchanged in the desflurane and sevoflurane groups during the reperfusion period. Coronary blood flow was decreased in all groups. Infarct size for the two anesthetics were smaller than in the control group. Differences in hemodynamics was observed between the desflurane and sevoflurane group at any time. CONCLUSIONS: Desflurane and sevoflurane had similar myocardial preconditioning effects in isolated rat heart.

A Clinical Study of Geriatric Anesthesia / 대한마취과학회지

In contrast to younger patients, geriatric patients are generally considered to be a poor risk for anesthesia and surgery and greater care should be taken in anesthetic management, because many have chronic systemic diseases in addition to a decrease in physiologic function. To evaluate geriatric anesthetic experiences, we received clinical records of 1,062 patients aged over 65 out of 21,656 surgical cases performed at Korea University Hye-Wha Hospital from January 1980 to December 1986. The cases were analysed according to age, sex, department, preoperative physical status, anesthetic techniques and agents, duration of anesthesia, operation site, length of hospital stay, laboratory data(Chest X-ray, EKG), associated diseases, postoperative complications and mortality. The results are as follows: 1) Of the 1,062 geriatric surgical patients, 516 cases(48.6%) were 65~69 years of age. 2) The number of geriatric surgical cases was 1,062 of which 672(63.3%) were male and 390(36.7%) were female. 3) Most surgical cases were general surgery(401 cases, 37.8%). 4) The rate of elective and emergency surgery was 78.0%(829 cases) and 22.0%(233 cases), respectively. The ratio of insurance patients (737 cases, 69.4%) versus noninsurance patients(325 cases, 30.6%) was approximately 2:1. 5) The number of general anesthesia cases was 777 (73.2%), spinal anesthesia 244( 23.0%), epidural anesthesia, 21(.20%), and brachial plexus block, 5( 0.5%). The anesthetics were thalamonal and meperidine hydrochloride(238 cases, 22.4%), halothane(204 cases, 19.2%) and tetracaine(244 cases, 23.0%). 6) The duraion of anesthesia was within 1hour in 88 cases( 8.3%), 1~2 hours in 421 cases(39.6%), and 2~3 hours in 291 cases(27.4%). 7) The number of lower abdominal surgery cases was 497 (46.8%) and the number of upper abdominal surgery cases was 188(17.7%). 8) Preoperative laboratory findings were as follows: The findings of preoperative chest X-rays revealed that 219 cases(21.4%) were within normal mits. 182 cases(17.8%) had hypertensive heart, and 208 cases(20.4%) had atherosclerosis. The EKG, which was done on 90.8% of the patients, revealed that 333 cases (34.5%) were within normal limits, 77 cases(8.0%) showed left ventricular hypertrophy, 65 cases(6.7%) showed sinus bradycardia, and 27 cases(2.8%) showed myocardial ischemia. 9) Hypertension(88cases, 49.4%) was the most commonly associated disease. 10) The total number of postoperative complication cases was 73(6.9%). Seventeen cases showed wound infection and delayed skin closure, 19 cases showed pneumonia, and 7 cases showed atelectasis. 11) The total number of postoperative deaths was 18 cases(1.7%).