Crush Syndrome Resulting from the Use of a Tourniquet: A case report / 대한마취과학회지

Although tourniquet application is a widely accepted adjuvant technique in the field of extremity surgery, its complication may be neglected. A 37-year-old healthy male underwent arthroscopic surgery for left posterior cruciate ligament reconstruction under a combination of spinal and epidural anesthesia. During the eleven hour operation, a tourniquet was applied four times in nine hours on the left thigh. The pressure reached 450 millimeters of mercury. Compartment syndrome developed with muscle ischemia and edema postoperatively. On the first day of the operation, a fasciotomy was performed to prevent the development of crush syndrome. However, bleeding due to vascular injury during the fasciotomy continued and crush syndrome including myoglobinemic renal failure, hyperkalemia, hypovolemic shock, and cardiac arrhythmia developed. On the second day, sudden cardiac arrest occurred during artery ligation. The patient was immediately resuscitated; he recovered, but his mental state was stuporous. Thereafter, the patient was cared intensively for eight days with fluid and electrolyte therapy, ventilatory care, hemodialysis, antibiotics for crush syndrome and renal failure, but the result was unsuccessful.

Efficacy of a Simulated Epidural Test Dose in Isoflurane-Anesthetized Adults / 대한마취과학회지

BACKGROUND: An epidural test dose containing epinephrine may be incomplete marker of incidental intravenous injection or migration of the epidural catheter in adult patients under general anesthesia. This study tests the hypothesis that the efficacy of simulated epidural test doses in anesthetized adult can be used to predict the adequacy of correct catheter placement. METHODS: Seventy-five healthy adult patients were randomly assigned to inject intravenously one of 5 solutions, either 2% lidocaine 3ml and epinephrine 15 microgram(Group E15, n=15) or epinephrine 20 microgram (Group E20. n=15) or isoproterenol 3microgram (Group I3, n=15) or isoproterenol 5microgram (Group I5, n=15) and 0.9% saline(Group NS, n=15), which was anesthetized with isoflurane and nitrous oxide. After the injection, a blinded observer recorded systolic blood pressure(SBP) and heart rate(HR) every 30seconds for 4minutes and the changes were analyzed. RESULTS: Although none in the saline group developed a HR increase> or20bpm, 6, 10, 12 and 15 patients elicited positive reponses in group E15, I3, E20, and I5(40%, 67%, 80% and 100% sensitivities), respectively. Meanwhile, none in the saline group developed a SBP increase> or15mmHg and 11, 1, 14 and 4 patients elicited positive reponses in E15, I3, E20, and I5(73%, 7%, 93% and 27% sensitivities), respectively. CONCLUSIONS: We conclude that under isoflurane anesthesia, (a) epinephrine 15 microgram or isoproterenol 3microgram is not reliable marker for incidental intravenous injection or migration of the epidural catheter, (b) epinephrine 20 microgram is applicable on SBP criterion and, (c) isoproterenol 5 microgram is applicable on HR criterion.

Facial Nerve Paralysis after General Anesthesia: A case report / 대한마취과학회지

A 42-year-old male was scheduled for left fronto-temporo-parietal craniotomy and subdural hematoma removal under general anesthesia. The past history was diabetes mellitus, hypertension, and chronic alcoholism. He was moderately obese, short neck, and deep drowsy. After rapid sequence induction with fentanyl, thiopental sodium and succinylcholine, anesthesia was maintained with nitrous oxide-oxygen-isoflurane. His head was fixed on horseshoe head rest with right side tilted. Throughout the 4 hours of anesthesia, cardiovascular and respiratory variables remained within normal limit. After extubation, upper respiratory obstruction developed, presumably as the result of the tongue's falling back against the posterior pharyngeal wall. This was only partly corrected by insertion of a rubber oral airway, but it was fully relieved when the lower jaw was lifted forward by bilateral digital pressure applied behind the angles of the mandible about ten minutes. At the intensive care unit, left partial facial nerve paresis developed with mild weakness of the right corner of the mouth, and striking right parotid swelling and tenderness. The parotid swelling receded over 2 weeks, and the paresis resolved over 3 weeks to complete recovery.

The Effects of Single Epidural Triamcinolone Injection on the Blood ACTH and Cortisol Level / 대한마취과학회지

BACKGROUND: Epidural steroids injections are often used for the treatment of low back pain but their effects on the endocrine system have not been determined. Few studies have quantified the degree or duration of the suppression of the hypothalamic-pituitary-adrenal (HPA) axis in humans given epidural triamcinolone injection (ETI) for low back pain. The evaluation of the blood adrenocorticotropic hormone (ACTH) and cortisol was undertaken to determine the extent of suppression of the HPA axis in patients given ETI. METHODS: Lumbar epidural triamcinolone injections were performed on the painful lumbar intervertebral space with patients in the lateral decubitus position. The injection consisted of 40 mg of triamcinolone acetonide diluted in 10 mL of 1% lidocaine. Patients remained in the lateral position for 10 min after the procedure. Basal blood sampling was performed at 30 min before ETI and tested blood sampling was obtained at 7 days, 10 days, and 14 days after ETI. RESULTS: The blood cortisol level was significantly decreased at 7 days and 10 days but at 14 days was not significantly decreased and the blood ACTH level was not significantly decreased at 7 days, 10 days, and 14 days. CONCLUSIONS: Above results demonstrate that blood ACTH and cortisol level normalize 7 days and 14 days, respectively, after epidural triamcinolone 40 mg injection.

The Ventilatory and Cardiovascular Changes during Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: Laparoscopic cholecystectomy has emerged rapidly as a popular alternative to tradidonal laparotomy and cholecystectomy in the management of cholelithiasis. The advantages of shorter hospital stay, more rapid return to normal activities are combined with less pain associated with the small limited incisions. But it has some disadvantages related to insufflation of a large amount of carbon dioxide into peritoneal cavity. METHODS: To investigate ventilatory and hemodynamic changes during laparoscopic cholecystectomy, we observed the changes in blood pressure (systole, diastole, mean), heart rate, end-tidal carbon dioxide tension (PerCO2), arterial carbon dioxide tension(PaCO2), and arterial oxygen tension(PaO2) at intervals during general anesthesia with controlled ventilation (tidal volume: 10 mg/kg, ventilatory rate: 10 breaths/min). RESULTS: Mean arterial pressure was increased significantly until 30 minutes after carbon dioxide insufflation(p<0.05). Heart rate was not changed significantly throughout the operation. End-tidal carbon dioxide tension and arterial carbon dioxide tension were increased significantly during carbon dioxide insufflation(p<0.01), but arterial oxygen tension was not decreased significantly throughout the operation. CONCLUSIONS: This study described 19 patients who underwent laparoscopic cholecystectomy and analyzed the changes in hemodynamic and ventilatory parameters. It is important for anesthesiologist to monitor ventilation and hemodynamics carefully because the patients with cardiac or pulmonary diseases may be adversely affected by the hypercarbia associated with carbon dioxide insufflation.

Effect of Pre-vs. Post-incisional Lidocaine Infiltration on Postoperative Pain after Inguinal Herniorrhaphy / 대한마취과학회지

BACKGROUND: Recently many studies reported that the postoperative pain was prevented or decreased from preoperative regional anesthesia by preventing the establishment of central sensitization(pre-emptive analgesia). Therefore, we evaluated the efficacy of preincisional lidocaine infiltration on the postoperative pain. METHODS: We conducted a study to compare preinfiltrating group with 1% lidocaine (30 ml), postinfiltrating group with 1% lidocaine (30 ml) and non-infiltrating group in 45 patients scheduled for elective inguinal herniorrhaphy. During operation, all patients received a general anesthesia with thiopental, isoflurane and nitrous oxide in oxygen. Postoperatively, pain scores on visual analogue scale (VAS) and on verbal rating scale(VRS) at rest, coughing and movement from supine into sitting position were assessed. Also the time to first request for an on-demand postoperative analgesics and the total dose of postoperative analgesics were assessed. And the number of patients who didn't require any analgesics during postoperative period was assessed. RESULTS: The VAS and VRS at rest, coughing, movement were low in preinfiltrating group than in non-infiltrating group and postinfiltrating group postoperatively, but it was statistically significant only in early postoperative period. The time to first request for an on-demand postoperative analgesics occurred later in preinfiltrating group than in non-infiltrating group and in postinfiltrating group and the total dose of supplemental analgesics (ketorolac) was smaller in the preinfiltrating group than in non-infiltrating group and postinfiltrating group, and the patients without analgesic treatment was less in the preinfiltrating group than in non-infiltrating group and postinfiltrating group, but it was not statistically significant. CONCLUSIONS: In patients with inguinal herniorrhaphy, we can not support the pre-emptive analgesia clinically with preincisional lidocaine infiltration.

Anesthetic Experience of Adrenalectomy with Primary Aldosteronism / 대한마취과학회지

Primary aldosteronism is a clinical syndrome referring to increased and inappropriate production of aldosterone from adrenal gland due to a solitery adenoma, bilateral hyperplasia or an adrenal carcinoma and this syndrome is characterized by hypertension, hyporeninemia, and hypokalemia and its manifestations. Under the general anesthesia, operation was performed on a 34-year-old male, who was diagnosed as primary aldosteronism caused by aldosterone producing adenoma and we have experienced the anesthetic management of unilateral adrenalectomy during perioperative periods.

Retrograde Endotracheal Intubation Using Epidural Catheter / 대한마취과학회지

Since in 1963 Waters first described the techniques of guiede blind tracheal intubation to solve the problem of difficult in airway maintenance in patients who have deformity of the upper jaw, several methods are recommended to overcome a difficult intubation. We experienced successful retrograde endotracheal intubation without significant complications as follows. Using loca anethesia, 16G Tuohy needle was passed through the anterior wall of the trachea 1.5 to 2.0 cm below the cricoid cartilage in the midline. The needle was directd upward foward the larynx and the epidural catheter was insertedc through it and advanced retrograde between the vocal cords and into mouth or nose. The endotracheal tube was threaded over the catheter and the proximal end of the catheter was clamps by kelly forceps. By keeping the catheter taut and coincidently pulling back, the tube was adnvanced in to trachea.

Retrograde Endotracheal Intubation Using Epidural Catheter / 대한마취과학회지

Since in 1963 Waters first described the techniques of guiede blind tracheal intubation to solve the problem of difficult in airway maintenance in patients who have deformity of the upper jaw, several methods are recommended to overcome a difficult intubation. We experienced successful retrograde endotracheal intubation without significant complications as follows. Using loca anethesia, 16G Tuohy needle was passed through the anterior wall of the trachea 1.5 to 2.0 cm below the cricoid cartilage in the midline. The needle was directd upward foward the larynx and the epidural catheter was insertedc through it and advanced retrograde between the vocal cords and into mouth or nose. The endotracheal tube was threaded over the catheter and the proximal end of the catheter was clamps by kelly forceps. By keeping the catheter taut and coincidently pulling back, the tube was adnvanced in to trachea.