Combined spinal-epidural analgesia for labor and delivery in a patient with known dilated cardiomyopathy: A case report

Dilated cardiomyopathy (DCM) is a multifactorial disease with enlargement and systolic dysfunction of one or both ventricles. Most of parturients having DCM would be advised to avoid or terminate her pregnancy owing to the high risk of cardiac overload that is likely associated with pregnancy. When maternal cardiac disease is observed, effective neuraxial analgesia may play an important role because a pain induced activation of the sympathetic nervous system during labor is associated with cardiovascular adverse effects, which may endanger the maternal and/or fetal well-being. Herein we report a case of a parturient with known DCM who received combined spinal-epidural anesthesia for labor and vaginal delivery. The maternal cardiac function and the effect of analgesia were evaluated by echocardiography during labor.

Pneumocephalus during labor analgesia using the combined spinal-epidural technique / 대한마취과학회지

No abstract available.

The effect of colloid co-hydration on the use of phenylephrine and hemodynamics during low-dose combined spinal-epidural anesthesia for cesarean delivery / 대한마취과학회지

BACKGROUND: Ephedrine has been recommended as the best vasopressor in obstetrics. But, recent clinical evidences show the possibility that phenylephrine has become more pertinent as a primary vasopressor. We think a phenylephrine infusion with colloid co-hydration will be more useful in maintaining baseline blood pressure in combined spinal-epidural anesthesia (CSEA) for cesarean section. METHODS: CSEA was performed using 6 mg bupivacaine and 20microgram fentanyl as a spinal and 10 ml of 0.25% levobupivacaine as an epidural in randomized, colloid co-hydration (hydroxyethl starch, HES 500 ml) (group C, n = 34) or no colloid co-hydration (group N, n=34) parturients scheduled to undergo cesarean delivery. After an infusion of 100microgram phenylephrine following the spinal injection, phenylephrine was intermittently infused using a PCA-pump to maintain the baseline blood pressure (BP). Systolic BP and heart rate (HR) were checked and total phenylephrine amount was measured. Nausea and vomiting and fetal umbilical pH/base excess (BE) were also investigated. RESULTS: There was a lower incidence of bradycardia in the C group compared with the N group (5.9% vs. 32.4%, p = 0.014), and total phenylephrine consumption was less in the C group (400microgram vs. 500microgram, p = 0.019). The incidence of reactive hypertension (11.8% vs. 55.9%, p < 0.001), and the hypotension (0% vs. 11.8%, p = 0.114) were lower in the C group, too. The others were comparable in both groups. CONCLUSIONS: Colloid co-hydration was effective in reducing the phenylephrine use and the incidences of abnormal hemodynamics such as hypotension, bradycardia and hypertension in low-dose CSEA for cesarean delivery.

Effects of Naloxone Mixed with Patient-Controlled Epidural Analgesia Solution after Total Knee Replacement Surgery / 대한통증학회지

BACKGROUND: Patient-controlled epidural analgesia (PCEA), using a local anesthetic-opioid mixture, has been effectively applied after total knee replacement (TKR) surgery, which is associated with intense postoperative pain that requires postoperative analgesia for both rehabilitation and the pain itself. However, adverse opioid-related effects, such as nausea, vomiting and pruritus, are commonly encountered. It was our hypothesis that the adverse opioid-related effects could be reduced by the addition of naloxone, an opioid antagonist, to a mixture of fentanyl-ropivacaine PCEA. METHODS: In 120 patients undergoing elective TKR surgery, epidural or combined spinal-epidural (CSE) anesthesia was performed and PCEA applied. In the control group (n = 65), 0.16% ropivacaine and 3microgram/ml fentanyl (2.4microgram/ml for those older than 65 yrs) were administered. In the naloxone group (n = 55), naloxone (2microgram/ml) was coadministered with the above regimen. The incidence and severity of postoperative nausea and vomiting, and the frequency of pruritus, the visual analog score (VAS) and the PCEA volume used were assessed 6 and 24 hrs after surgery. RESULTS: The incidence of nausea and vomiting during the early postoperative period, and those of pruritus during the late postoperative period were significantly lower in the naloxone group. The VAS pain scores, the PCEA volume used and amount of rescue IV meperidine were similar in the two groups. CONCLUSIONS: A small dose of naloxone mixed with an opioid significantly reduces the incidence and severity of adverse opioid-related effects in PCEA, without reducing the analgesic effect

The Effect of Tumor Manipulation on Serum Carcinoembryonic Antigen Levels in Colorectal Cancer Patients

PURPOSE:Tumor cells can be shed into a venous blood stream by manipulation of tumor during surgery, resulting metastasis to distant organs from the primary tumor. In order to elucidate the effect of early lymphovascular dissection prior to tumor mobilization, we studied the difference in carcinoembryonic antigen (CEA) values of tumor draining veins before and after tumor mobilization. METHODS:Blood samples were taken from the tumor draining veins of sixteen patients during operations. The lymphovascular dissection was performed before the tumor mobilization, and the main draining vein from the tumor was isolated and the proximal end was ligated and blood samples were taken, then the tumor mobilization was made. Just before the removal of the tumor, we took the second sets of blood samples from the same sites. RESULTS:There were no significant differences in CEA values between peripheral blood (1.8+/-1.2 ng/mL) and tumor draining veins before the tumor mobilization. The mean CEA value of draining veins after the tumor mobilization (14.3+/-11.9 ng/mL) was significantly higher than that of draining veins before the mobilization (2.2+/-2.1 ng/mL)(P<0.001). CONCLUSIONS:Theses results suggest that early lymphovascular dissection procedures before tumor mobilization can reduce the opportunity of tumor cell dissemination into draining vein.

Clinical Review and Surgical Treatment of Intrahepatic Stones / 한국간담췌외과학회지

BACKGROUND: Intrahepatic stones are common in East Asia and pose serious complications such as biliary stricture, liver atrophy, liver abscess, sepsis and sometimes cholangiocarcinoma. The management of primary intrahepatic stones is difficult and it is also difficult to remove all stones during operation. METHODS: Eighty seven patients with hepatolithiasis were admitted to the department of surgery, Keimyung University Dongsan Medical Center during 4 year period between 1994 and 1997. We reviewed medical records retrospectively for these patients. RESULTS: The peak incidence of age was 50's and the male to female ratio was 1:1.2. Intrahepatic stones were located in the left lobe in 62.1%, right lobe 17.2% and both lobe 20.7%. Stones were found only within the liver (I type) in 34.5% and both inside and outside the liver (IE type) in 65.5%. Analysis of the composition of intrahepatic stones revealed calcium bilirubinate as the most common compound (over 75%) and E. coli was the most common organism in bile culture. We classified intrahepatic stones as four types. Type I (45.9%) is cases with liver atrophy on abdominal CT, type II (20.6%) is cases without liver atrophy as IE type, type III (16.0%) is cases with dilatation of extrahepatic bile duct as I type, and type IV (17.2%) is cases without liver atrophy nor extrahepatic bile duct dilatation. Of the 72 operated patients, liver resection was done in 43 (59.7%) and 9 patients (20.0%) had residual stones. Cholangiocarcinoma was found in 3 (7.0%) of the total 43 patients who underwent liver resection. CONCLUSION: Hepatic resection should be performed in selected patients with intrahepatic stones because of lowest presence of residual stones and no difference of postoprative complications compared with drainage procedure.

Solid and Papillary Epithelial Neoplasms of the Pancreas / 한국간담췌외과학회지

BACKGROUND: Solid and papillary epithelial neoplasm(SPEN) of the pancreas is a rare tumor with low grade malignant potential and usually found in young female patients. The prognosis of this lesion is reported to be much more favorable than other pancreatic neoplasms. METHODS: We report four cases of SPENs of the pancreas treated at the department of surgery, Keimyung University Dongsan Medical Center. Three were women and one was a man and their mean age at the time of surgery was 19 years with the ranges between 11 and 29 years of age. Two patients were admitted with a palpable abdominal mass and another two patients with abdominal pain. Results of laboratory studies including serum amylases and tumor markers were all within normal limits. Diagnosis was made preoperatively in three patients by MRI and needle biopsies. Tumors were located in the head portion in three patients and in the body of the pancreas in one patient. RESULTS: All patients underwent complete resection which involved three enucleations and one pancreaticoduodenectomy. All patients are alive at the time of this report with mean follow up period of 69.5 month (the ranges between 8 and 105 months) without evidence of recurrence. CONCLUSION: In our experience, complete resection of this neoplasm is the treatment of choice and the prognosis is excellent.