Severe pancytopenia and coagulopathy discovered during anesthesia after pre-anesthetic evaluation – A report of two cases –

Pre-anesthetic evaluation is an important aspect of perioperative patient management. However, anesthesiologists often encounter challenges during anesthesia due toconditions that are not detected during pre-anesthetic evaluations.Case: Case 1 involved a 74-year-old female patient scheduled for cranioplasty and meningioma excision. Severe pancytopenia was detected during anesthesia. Cranioplasty was onlyperformed, the surgery was terminated, and drug-induced pancytopenia was diagnosed andtreated. The pre-anesthetic test results were normal, except for anemia. Case 2 involved a71-year-old male patient who discovered large ecchymosis during general anesthesia preparation in the operating room for choledochal cyst surgery. Surgery was canceled to evaluatethe bleeding tendency, and acquired coagulation factor VIII deficiency was diagnosed andtreated. The pre-anesthetic tests were normal, except for prolongation of the activated partial thromboplastin time.Conclusions: Abrupt hematologic and hemostatic changes may occur during anesthesiaeven though pre-anesthetic evaluation findings are normal.

Herpes zoster after COVID-19 vaccination, aspect of pain medicine: a retrospective, single-center study

Herpes zoster (HZ) is one of the most common cutaneous adverse reactionsassociated with the coronavirus disease 2019 (COVID-19) vaccine and has been widely reported. This study aimed to evaluate HZ following COVID-19 vaccination from the viewpointof pain management.Methods: A retrospective study was conducted on 42 patients with HZ who visited the painclinic between August 2021 and October 2021. Medical records were reviewed to comparepain severity, treatment methods, treatment duration, and incidence rate of postherpeticneuralgia (PHN) in patients who received COVID-19 vaccination within 6 weeks prior to developing symptoms compared with other patients with HZ.Results: Fourteen patients developed HZ within 6 weeks after vaccination and were significantly younger than the other HZ groups. There were no significant differences in the frequency of prodromal pain, location of pain, pain severity, treatment methods, treatmentduration, or incidence of PHN compared with the other HZ groups.Conclusions: COVID-19 vaccination-related HZ showed clinical features similar to those ofthe other HZ.

The effect of interscalene brachial plexus block with propofol sedation on preventing perioperative hypothermia during arthroscopic shoulder surgery / 대한마취과학회지

Background@#Interscalene brachial plexus block (ISBPB) is commonly used with general anesthesia for postoperative pain management in shoulder surgery. This study investigated the incidence of hypothermia and changes in the body temperature in patients undergoing arthroscopic shoulder surgery under ISBPB with propofol sedation. @*Methods@#This retrospective study enrolled 220 patients who underwent arthroscopic shoulder surgery. Patients were divided into general anesthesia (n = 34) and ISBPB with propofol sedation (n = 186) groups, and medical records were retrospectively compared. In addition, patients from the ISBPB group were further divided according to age (elderly, [≥ 65 years]; n = 98 vs. young, [< 65 years]; n = 88), and the incidence of hypothermia and changes in the body temperature were compared. @*Results@#Twenty-seven patients (12.3%) experienced perioperative hypothermia (range; 35.3–35.9℃). The incidence of perioperative hypothermia was 29.4% and 9.1% in the general anesthesia and ISBPB groups, respectively, and there was a significant difference between the two groups (P = 0.002). The incidence of perioperative hypothermia according to age in the ISBPB group was 9.2% and 9.1% in the elderly and young groups, respectively, and there was no significant difference between the two groups (P = 0.983). @*Conclusions@#The incidence of perioperative hypothermia during arthroscopic shoulder surgery under ISBPB with propofol sedation is lower than that under general anesthesia. Furthermore, when using ISBPB with propofol sedation, the incidence of perioperative hypothermia in elderly patients is similar to that in younger patients.

Invisible perforation during an endoscopic procedure of the esophagus under general anesthesia - A case report -

Background@#Endoscopic procedures of the esophagus are more complicated than those of other regions of the gastrointestinal tract. They have a relatively long procedure time and high risk of complications, such as perforation and bleeding. Perforations that occur during the procedure can accompany pneumoperitoneum and pneumomediastinum through leakage of insufflation air and cause severe ventilatory impairment.Case: A 58-year-old male patient underwent enucleation of leiomyoma in the esophagus using endoscopy under general anesthesia. Ventilatory impairment occurred 15 min after commencement of the procedure. Subsequently, subcutaneous emphysema and severe abdominal distension were observed. We suggested the possibility of microperforation during the procedure to the endoscopist, and he performed endoscopic clipping around the excision site of leiomyoma. @*Conclusions@#Providing anesthetic care by anesthesiologists during endoscopic procedures is considered necessary for patient safety. Complications of endoscopic procedures can be detected and managed early without sequelae during anesthetic care.

Comparison of chemical pregnancy rates according to the anesthetic method during ultrasound-guided transvaginal oocyte retrieval for in vitro fertilization: a retrospective study

Background@#Oocyte retrieval is the most important procedure in in vitro fertilization (IVF). Various anesthetic methods are used to control a patient’s anxiety and pain during IVF; however, there are no recommended anesthetic methods at present. In this study, we retrospectively investigated chemical pregnancy rates according to the anesthetic method used for oocyte retrieval. @*Methods@#We reviewed records of patients who underwent oocyte retrieval between January 1, 2012 and December 31, 2017. Patients were divided into the spinal anesthesia (SA) and monitored anesthesia care (MAC) groups. The primary outcome was chemical pregnancy rate after IVF. @*Results@#The study included 95 patients. SA was administered in 77 (81%) and MAC in 18 (19%). The overall chemical pregnancy rate was 32.6% (31/95). According to the anesthetic method, the pregnancy rate was 32.5% (25/77) in the SA group and 33.3% (6/18) in the MAC group. There was no statistical difference in the pregnancy rate between the groups (P = 0.575). The procedural time was significantly shorter in the SA group than in the MAC group (P < 0.001). @*Conclusions@#Chemical pregnancy rates were not significantly different between the SA and MAC groups. However, the procedure duration was shorter in the SA group than in the MAC group.

Herpes zoster in the ophthalmic branch of the trigeminal ganglia obscuring cavernous sinus thrombosis due to Streptococcus constellatus ssp. constellatus

Herpes zoster ophthalmicus (HZO) is an infectious disease that results from the reactivation of latent varicella zoster virus in the ophthalmic branch of the trigeminal ganglia. HZO manifests with herpes zoster-like symptoms such as rash with or without signs of ocular involvement. Cavernous sinus thrombosis (CST) is a life-threatening condition accompanied by signs and symptoms involving the eyes and the cranial nerves. Case: We report a case of septic cavernous sinus thrombosis (caused by Streptococcus constellatus ssp. constellatus) which was masked by the simultaneous occurrence of HZO in this patient, resulting in delayed diagnosis. Conclusions: CST may be obscured by HZO, prompt diagnosis and treatment is necessary when such case arrive.

Refractory intercostal neuralgia due to intercostal schwannoma: A case report

Intercostal neuralgia is neuropathic pain that develops in the thorax and abdomen. It usually occurs as a result of injury or inflammation associated with the intercostal nerve triggered by trauma, surgery, or herpes zoster. Primary intercostal neuroma is a rare cause of intercostal neuralgia. A 69-year-old male patient without a history of thoracic trauma or surgery underwent repeated testing and intermittent treatment for refractory pain in the right chest and abdomen for several years. However, the treatment had limited effect. Abdominal computed tomography performed to diagnose recent pain aggravation revealed schwannoma of the 11th intercostal nerve. The patient's pain was relieved following surgical excision of the tumor.

An anesthetic experience in severe preeclampsia patient suspected HELLP syndrome with an intraperitoneal hemorrhage caused by a rapidly progressed liver rupture: A case report

The diagnosis of HELLP syndrome associated with preeclampsia-eclampsia during pregnancy uses three test results, including hemolysis, elevated liver enzyme, low platelets and their related clinical symptoms. Liver rupture is a life-threatening and rare complication related to HELLP syndrome. Early diagnosis and rapid treatment are very important for protecting the life of the patient and the fetus. We are reporting an anesthetic experience a sudden-onset suspicious HELLP syndrome with an intraperitoneal hemorrhage caused by a rapidly progressed liver rupture in a severe preeclampsia patient without any abnormalities during gestation.

Postherpetic Neuralgia Aggravated by Upper Complete Denture / 이화의대지

Postherpetic neuralgia (PHN) is a chronic and refractory pain disease. It requires longterm treatment and follow-up. Comorbid diseases can change or aggravate the pain condition and responsiveness of patients to PHN treatment. In such cases, the cause of pain should be identified through proper testing, and appropriate treatment should be administered. Herein, we report the case of a 67-year-old man with PHN in the maxillary nerve. As the pain was being controlled with medication and infraorbital nerve block, the patient experienced deterioration of pain caused by a newly worn upper complete denture. The patient's pain was relieved following correction of the upper complete denture.

Abdominal muscle paresis due to herpes zoster with hiatal hernia: A case report

Herpes zoster is an infectious disease of the dorsal root ganglion and sensory nerve fibers. Motor nerve involvement is a rare complication. Hiatal hernia occurs when the stomach protrudes into the thoracic cavity through the esophageal hiatus of the diaphragm. Herein, we present the case of a 78-year-old man with abdominal wall muscle paresis caused by herpes zoster, which resulted in a hiatal hernia.

Risk of Encountering Dorsal Scapular and Long Thoracic Nerves during Ultrasound-guided Interscalene Brachial Plexus Block with Nerve Stimulator

BACKGROUND: Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach. METHODS: A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded. RESULTS: Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). Neither was encountered in 21 cases (30.4%). The average current measured immediately before the disappearance of muscle twitches was 0.44 mA and 0.50 mA at DSN and LTN, respectively. CONCLUSIONS: Physicians should be cautious on the risk of injury related to the anatomical structures of nerves, including DSN and LTN, during ultrasound-guided IBPB by posterior approach. Nerve stimulator could be another option for a safer intervention. Moreover, if there is a motor response, it is recommended to select another way to secure better safety.

Severe Hypocalcemia Caused by Absorption of Sorbitol-Mannitol Solution during Hysteroscopy

Hysteroscopic procedure can be complicated by intravascular absorption of irrigating fluid. The clinical features of this complication are similar to transurethral resection of the prostate (TURP) syndrome. There have been few reports on hypocalcemia during endoscopoic surgery and clinical implications of hypocalcemia in TURP syndrome have been underestimated. We report a case of TURP syndrome association with a decreased ionized calcium concentration of 0.53 mM/L after the absorption of a large amount of sorbitol-mannitol solution during hysteroscopy. The hypotension which occurred in TURP syndrome did not respond to vasopressor and inotropic agent but responded to the administration of calcium. This case was also accompanied by hyponatremia, hyperglycemia and lactic acidosis through the metabolism of sorbitol.

The Prevention of Propofol-induced Pain in the Pediatric Patients: Comparison among the Effects of Remifentanil, Lidocaine, and the Combination of Remifentanil and Lidocaine / 대한마취과학회지

BACKGROUND: There is a high incidence of pain following injection of propofol, and many studies have been conducted to find a way of reducing this. The administration of lidocaine and recently, remifentanil has also been used for this purpose in adults, but has been only partially effective. Thus, the purpose of this study was to investigate the analgesic effect of remifentanil alone, the premixture of lidocaine and both remifentanil and lidocaine and to compare either treatment alone during propofol injection in dorsal hand-veins in the pediatric patients. METHODS: In a randomized, double-blind, prospective trial, 120 pediatric patients were allocated to one of four groups (each n = 30) receiving normal saline, remifentanil (0.5microgram/kg), lidocaine (0.3 mg/kg) and remifentanil (0.5microgram/kg) plus lidocaine (0.3 mg/kg) as pretreatment, followed by injection of 2% propofol (3 mg/kg). Pain was assessed on a four-point scale (none, mild, moderate, severe) during propofol injection. Mean arterial blood pressure and heart rates were measured before and after propofol injection. RESULTS: The remifentanil, lidocaine and remifentanil plus lidocaine groups showed significantly less frequent and intense pain than the normal saline group. There are no significant change of mean arterial blood pressure and heart rate except normal saline group. The remifentanil and remifentanil plus lidocaine groups provided more pain relief than the lidocaine group. CONCLUSIONS: The combination of remifentanil and premixture of lidocaine with propofol is the most effective method to prevent propofol-induced pain with hemodynamic stability in the pediatric patients.

Optimal Infusion Rates of Remifentanil during Propofol Anesthesia for Monitored Anesthesia Care in Patient Undergoing Varicose Vein Endovenous Laser Therapy / 대한마취과학회지

BACKGROUND: Propofol and remifentanil are both rapid and short-acting drugs that can be used for sedation and analgesia during monitored anesthesia care (MAC). This study was designed to determine the optimal infusion rates of remifentanil during propofol anesthesia in patient undergoing the varicose vein endovenous laser therapy. METHODS: In this randomized, double-blind study, we evaluated the effects of different remifentanil infusion rates on the requirement doses of propofol, level of sedation, intraoperative recall, respiratory and cardiovascular variables, and recovery. Forty consenting ASA physical status I or II patients undergoing endovenous laser therapy with 1% lidocaine skin infiltration were randomly assigned to one of two treatment groups. All patients received midazolam 0.05 mg/kg intravenously for premedication. Remifentanil was infused at 0.05 or 0.10microgram/kg/min during the anesthesia. Sedation was evaluated using the Observer's Assessment of Alertness/Sedation (OAA/S) scale at 5 min intervals by a blinded observer and continuous BIS monitor. The propofol infusion was started from the rate, 3 mg/kg/hr, and subsequently varied to maintain patient comfort, sedation, stable cardiovascular and respiratory function. RESULTS: Higher infusion rates of remifentanil (0.10microgram/kg/min) produced significant respiratory depression (P < 0.05). The infused total doses of propofol were not different from each other significantly. CONCLUSIONS: This study demonstrated that administration of propofol at 3.4 +/- 1.3 mg/kg/hr with a remifentanil infusion at 0.05microgram/kg/min is the optimal dosing regimen to provide sedation, analgesia and amnesia with a low incidence of side effects, such as respiratory depression in the patients premedicated with midazolam undergoing varicose vein endovenous laser therapy.