Severe postoperative dyspnea caused by neglected massive intraperitoneal fluid collection during laser enucleation and morcellation of the prostate: a case report / 대한마취과학회지

Laser enucleation and morcellation of the prostate is an increasingly used surgical management of benign prostatic hyperplasia. However, it can cause several complications including capsular perforation, ureteral orifice injury, and bladder mucosal morcellation injury. Herein, we report a case of severe postoperative dyspnea caused by neglected massive intraperitoneal fluid collection during laser surgery of the prostate. The patient experienced massive abdominal distension and severe respiratory difficulty after the procedure. Although immediate postoperative cystogram showed no leakage of contrast dye, the computed tomography scan of the abdomen and pelvis showed massive fluid collection in the abdominal pelvic cavity suggesting bladder wall injury. After percutaneous drainage of intraperitoneal fluid, abdominal distention and dyspnea were relieved.

Effect of electrically heated humidifier on intraoperative core body temperature decrease in elderly patients: a prospective observational study

BACKGROUND: Core body temperature (TC) can decrease during general anesthesia. Particularly in elderly patients, more aggressive strategies to prevent intraoperative hypothermia may be required. Here, we investigated the effect of a heated humidifier on intraoperative TC decrease in the elderly. METHODS: Twenty-four elderly patients were randomly assigned into two groups: those who used a heated humidifier (group H) and those who used a conventional ventilator circuit with a heat moisture exchanger (group C). TC was measured continuously at the esophagus at several time-points during surgery. RESULTS: In group C, TC significantly decreased 90 minutes after skin incision (P < 0.001), while significant differences were not noted in group H during surgery. Comparing the two groups, TC decreased more in group C than in group H at 60, 90, 120, and 150 minutes after skin incision (group C vs. group H: -0.6℃ vs. -0.3℃, P = 0.025; -0.7℃ vs. -0.4℃, P = 0.012; -0.9℃ vs. -0.4℃, P = 0.006; and -1.0℃ vs. -0.5℃, P = 0.013, respectively). There were no significant differences between the two groups for any other parameters. CONCLUSIONS: A heated humidifier is more effective in preventing intraoperative TC decrease in elderly patients than a heat moisture exchanger. However, further studies with a larger population are required to substantiate its clinical use.

Palonosetron has superior prophylactic antiemetic efficacy compared with ondansetron or ramosetron in high-risk patients undergoing laparoscopic surgery: a prospective, randomized, double-blinded study / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) continues to be a major problem, because PONV is associated with delayed recovery and prolonged hospital stay. Although the PONV guidelines recommended the use of 5-hydroxy-tryptamine (5-HT3) receptor antagonists as the first-line prophylactic agents in patients categorized as high-risk, there are few studies comparing the efficacies of ondansetron, ramosetron, and palonosetron. The aim of present study was to compare the prophylactic antiemetic efficacies of three 5HT3 receptor antagonists in high-risk patients after laparoscopic surgery. METHODS: In this prospective, randomized, double-blinded trial, 109 female nonsmokers scheduled for elective laparoscopic surgery were randomized to receive intravenous 4 mg ondansetron (n = 35), 0.3 mg ramosetron (n = 38), or 75 microg palonosetron (n = 36) before anesthesia. Fentanyl-based intravenous patient-controlled analgesia was administered for 48 h after surgery. Primary antiemetic efficacy variables were the incidence and severity of nausea, the frequency of emetic episodes during the first 48 h after surgery, and the need to use a rescue antiemetic medication. RESULTS: The overall incidence of nausea/retching/vomiting was lower in the palonosetron (22.2%/11.1%/5.6%) than in the ondansetron (77.1%/48.6%/28.6%) and ramosetron (60.5%/28.9%/18.4%) groups. The rescue antiemetic therapy was required less frequently in the palonosetron group than the other groups (P < 0.001). Kaplan-Meier analysis showed that the order of prophylactic efficacy in delaying the interval to use of a rescue emetic was palonosetron, ramosetron, and ondansetron. CONCLUSIONS: Single-dose palonosetron is the prophylactic antiemetics of choice in high-risk patients undergoing laparoscopic surgery.

Arterial to end-tidal carbon dioxide pressure gradient increases with age in the steep Trendelenburg position with pneumoperitoneum / 대한마취과학회지

BACKGROUND: Several factors affect the end-tidal carbon dioxide pressure (PETCO2) and increase the arterial to end-tidal carbon dioxide pressure gradient (Pa-ETCO2) during general anesthesia. We evaluated the relationship between age and Pa-ETCO2 during pneumoperitoneum in the steep Trendelenburg position in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). METHODS: Ninety-two consecutive patients undergoing RALP were divided by age into a middle-aged (45-65 years) and an elderly (> 65 years) group. Anesthesia was standardized. Heart rate, mean arterial pressure, peak inspiratory pressure, lung compliance, minute ventilation, PaO2, PETCO2, PaCO2, and Pa-ETCO2 were measured 10 min after intubation in the supine position without pneumoperitoneum (T0); and 10 (T1), 60 (T2), and 120 (T3) min after pneumoperitoneum in the Trendelenburg position. RESULTS: Although PETCO2 did not change significantly during surgery, PaCO2 and Pa-ETCO2 increased gradually with time during pneumoperitoneum in the Trendelenburg position, and both parameters showed greater increases in the elderly than in the middle-aged group. Simple linear regression analyses revealed significant correlations between age and Pa-ETCO2 at T0 (P = 0.018), T1 (P = 0.006), T2 (P < 0.001), and T3 (P = 0.001). Linear mixed model analysis showed that Pa-ETCO2 was associated statistically significantly with age and duration of pneumoperitoneum in the Trendelenburg position, but age and duration of pneumoperitoneum in the Trendelenburg position were not associated (P = 0.090). CONCLUSIONS: The magnitude of Pa-ETCO2 during pneumoperitoneum in the steep Trendelenburg position increased with age, which could be attributed to age-related respiratory physiological changes.

Hypotension in patients administered indigo carmine containing impurities: A case report / 대한마취과학회지

Indigo carmine has been used for eight decades with few adverse effects. Several of our patients, however, experienced severe hypotensive episodes after indigo carmine administration within a period of one month. Analysis of the raw materials used to formulate the preparation of indigo carmine we used showed that they contained impurities. Following recall of these impure materials, none of our patients experienced further hypotensive episodes.

Anesthetic management of renal cell carcinoma that extended into the right atrium through the inferior vena cava: A case report

Renal cell carcinoma (RCC) rarely extends to the cardiac chambers, and the presence of an extension of tumor thrombus to the inferior vena cava or the right atrium has not been shown to determine the survival of patients with RCC.Although an aggressive surgical approach remains the primary treatment for RCC, the anesthetic management remains a difficult intraoperative challenge.We report here on a case of performing cavoatrial tumor thrombectomy and radical nephrectomy in a patient with RCC with an intracardiac extension, and we used cardiopulmonary bypass and intraoperative trans-esophageal echocardiography to assess and treat this tumor.

The interaction of intrathecal neostigmine and N(6)-cyclohexyladenosine on anti-allodynic effects in rats with a nerve ligation injury / 대한마취과학회지

BACKGROUND: Nerve ligation injury in rats produces a pain syndrome that includes mechanical allodynia. Intrathecal administration of cholinesterase inhibitors or adenosine receptor agonists have anti-allodynic effects in this model. Therefore, we tested the interaction between intrathecal neostigmine and N(6)-cyclohexyladenosine (CHA) in a rat behavioral model of neuropathic pain. METHODS: Male Sprague-Dawley rats were prepared with tight ligation of the spinal nerves for producing allodynia and with a lumbar intrathecal catheter for drug administration. Allodynia thresholds for hindpaw withdrawal against mechanical stimuli were assessed and converted to percent maximal possible effect. Neostigmine (0.3-10 microgram) and CHA (0.03-3 microgram) were administered to obtain the dose-response curves and the 50% effective dose (ED(50)). Equal fractions (1/2, 1/4 and 1/8 ED(50)s) of the two drugs were administered to establish the ED(50) of neostigmine-CHA combination. Side effects were also assessed. The drug interaction was evaluated by isobolographic and fractional analyses. RESULTS: Neostigmine, CHA, and the neostigmine-CHA combination dose-dependently produced anti-allodynia effects. Side effects such as sedation and motor weakness were similar in the three groups. In the isobolographic analysis, the experimental ED(50) for the combination of neostigmine-CHA lay far below and to the left of the theoretical additive line. Fractional analysis indicated that the total combination fraction of the two drugs was 0.39. CONCLUSIONS: Intrathecal co-administration of neostigmine and CHA showed a synergistic anti-allodynia effect.

Comparison of antiallodynic effect of intrathecal morphine, brimonidine and rilmenidine between neuritis and ligation injury induced neuropathic pain / 대한마취과학회지

BACKGROUND: Mechanical allodynia is generally resulted from nerve damage by direct injury or inflammation. Thus, this study was designed to compare the antiallodynic effect of morphine, brimonidine and rilmenidine in two models of neuropathic pain, that is, induced by nerve ligation and neuritis. METHODS: Rats were prepared with tight ligation of the L5/L6 spinal nerves (SNL group) or with Freund's complete adjuvant (FCA) administration evoked sciatic inflammatory neuritis (SIN group). Antiallodynic effects by intrathecal morphine, brimonidine and rilmenidine were measured by applying von Frey filaments to the lesioned hind paw. Thresholds for withdrawal response were assessed and converted to % MPE to obtain an effective dose 50% (ED 50) and a dose response curve. RESULTS: Either SNL group or SIN group showed marked mechanical allodynia in the lesioned hind paw. Antiallodynic effects of morphine were different between two groups. That is ED 50 was 0.16 microgram (SIN) and 8.12 microgram (SNL), and dose response curve of the SIN group shifted left from that of the SNL group. The difference between SIN and SNL groups was statistically significant (P < 0.05). With the brimonidine or rilmenidine administration, ED 50 s were 0.12 microgram (SNL) and 0.37 microgram (SIN) and 2.16 microgram (SIN) and 11.46 microgram (SNL), respectively. And the shift to left of dose response curve from the SNL group is more prominent with rilmenidine administration. CONCLUSIONS: These results suggest morphine and rilmenidine showed a better effect on reducing the mechanical allodynia induced by FCA administration.

Pneumomediastinum due to inadvertent bladder perforation during transurethral resection of the prostate : A case report / 대한마취과학회지

Transurethral resection of the prostate (TURP) is a common procedure for managing benign prostatic hyperplasia (BPH), and this procedure is associated with low complication rates. Bladder perforation is an unusual complication of TURP, and it may create an air leak into the retroperitoneal space. Here we describe a case of pneumomediastinum, pneumoretroperitoneum and subcutaneous emphysema that were all due to a bladder perforation that occurred during performing TURP in a 74-year-old male patient with BPH.

Anesthetic experience of a pediatric patient with Seckel syndrome associated with pneumonia : A case report / 대한마취과학회지

Seckel syndrome, also called bird-headed dwarfism, is an extremely rare, inherited, autosomal recessive disorder. The patients with Seckel syndrome are characterized by growth retardation, microcephaly with mental retardation, proportional dwarfism, bird like faces, and beak-like triangular nose. A literature review reveals that they have multiple anesthetic problems such as difficult airway management, difficult venous cannulation and concomitant medical diseases. We describe our experience in anesthetic management of a 21-month-old male patient with Seckel syndrome associated with pneumonia who underwent orchiopexy for bilateral cryptochidism.

Anesthetic management of a patient with prune-belly syndrome : A case report

Prune-belly syndrome is characterized by absent abdominal wall musculature with wrinkled overlying skin, urinary tract dilatation and cryptorchidism. Prune-belly syndrome is also associated with diseases of the respiratory, cardiovascular, skeletal, gastrointestinal and central nervous system. Because the congenital disease is uncommon, it is difficult to collect the information of anesthetic management of prune-belly syndrome. We report a case of 4 year-old-boy with prune-belly syndrome who underwent abdominoplasty and Mitrofanoff operation under general anesthesia.

Unexpected cardiac tamponade during robot-assisted permanent pacemaker insertion: A case report / 대한마취과학회지

Cardiac tamponade can result in severe hemodymanic instability, including cardiac arrest. We experienced one case of unexpected cardiac tamponade during permanent pacemaker insertion using da Vinci(TM) Surgical System (Intuitive Surgical Inc., Mountain View, USA) in 76-year-old male patient with complete atrioventricular block. Soon after the port insertion for robotic arm, sudden-onset electromechanical dissociation was developed. Prompt cardiopulmonary resuscitation was performed. Rapid left thoracotomy revealed the cardiac tamponade caused by the injury of right ventricle. Hemodynamic parameter was immediately improved after pericardiocentesis and primary repair of right ventricle. Permanent pacemaker was inserted uneventfully through the left thoracotomy. The patient was discharged 10 days after operation without any other complication.

A Questionnaire Survey of Domestic Anesthesiologists on the Ethics of Publishing / 대한마취과학회지

BACKGROUND: The importance of publication ethics has recently been emphasized.Therefore, inquiries regarding dual publications were analyzed to obtain basic data on whether domestic anesthetists recognized its importance and understood its practicalities. METHODS: The data for the questionnaire was collected from doctors who participated in a review workshop with full consent. A total of 15 questions were classified into 3 categories:a general interest regarding the ethics of publication, personal objective opinions and reactivity toward an illegal act in this regard. RESULTS: Thirty-eight participants responded spontaneously to the questionnaire.Thirty-six participants were aware of the principle of dual publications and 35 participants were aware of the contents in the home page.Twenty participants had contact with lectures or other media related to redundant publishing.Fourteen participants answered 'yes' regarding their colleague in an illegal action.However, 25 participants said that they were prepared to report an illegal act to the department or society.Only 5 participants tried to take into consideration ethical issues of dual publication while 15 participants were tempted regarding dual publication while writing a paper.Twenty-seven participants agreed with the principle of duplicate or illegal publication.Thirty participants were prepared to have a consistent attitude toward any individual that committed a violation against publication ethics.Nineteen participants worried about the possibility of exposure of an illegal publication. CONCLUSIONS: According to the development of a watch system, dual publication can easily be detected. Regular education regarding publication ethics and notification to members to prevent an illegal act is necessary.

Fatal Renal Rupture as a Rare Complication of Percutaneous Nephrolithotomy / 대한마취과학회지

Percutaneous nephrolithotomy (PNL) is a safe and effective procedure commonly performed to remove renal stones. Although PNL is associated with low morbidity, unexpected complications may occur. We describe here a 44-year-old male patient with recurrent renal stones who experienced a renal rupture and massive bleeding following PNL. Left nephrectomy and intensive treatment did not improve the patient's condition, and he died 14 days later as a result of multi-organ failure.

Comparison of the Antiallodynic Effects of Intrathecal Lidocaine and MK-801 on Mechanical Allodynia in Two Neuropathic Pain Rat Models / 대한마취과학회지

BACKGROUND: Neuropathic pain can be induced by nerve injury or inflammation. An N-methyl-D-Aspartate (NMDA) antagonist (MK-801), and a sodium channel blocker (lidocaine) have been found to reduce mechanical allodynia. This study was conducted to determine whether intrathecal lidocaine or MK-801 had an antiallodynic effect on established mechanical allodynia in two well-characterized neuropathic pain rat models. METHODS: Male Sprague Dawley rats (n = 107) were anesthetized, and the left L5 and L6 spinal nerves were ligated (SNL group) or Freund complete adjuvant (FCA) was administrated to the same spinal nerves (FCA group) in order to cause neuropathic pain. A catheter was then implanted into the lumbar intrathecal space. After obtaining the baseline scores, time-effect curves of each drug were established for the antiallodynic effects of lidocaine (30g, 100g and 300g) and MK-801 (1g, 3g, 10g and 30g). The allodynic thresholds for the left hind paw withdrawal to von Frey hairs were assessed and converted to %MPE, and the ED50 value was then calculated using the %MPE. The antiallodynic effects of the two groups were then compared by analyzing the dose-response curves and the ED50 values. RESULTS: Both intrathecal lidocaine and MK-801 resulted in a dose dependent antiallodynic effect. ED50 values and the analysis of dose response curves showed that intrathecal lidocaine provided more effective antiallodynia in the SNL group, whereas intrathecal MK-801 resulted in a greater antiallodynic effect in the FCA group. CONCLUSIONS: In the SNL group, lidocaine had a better effect in reducing allodynic pain, whereas in the FCA group, MK-801 showed a greater antiallodynic effect.

Anesthetic Experience of Percutaneous Nephrolithotomy for Renal Calculi in a Patient with Lesch-Nyhan Syndrome: A case report / 대한마취과학회지

Lesch-Nyhan syndrome (LNS) is a rare, X-linked recessive inherited disorder caused by a deficiency of the enzyme hypoxanthine-guanine-phophoribosyltransferase, leading to excessive purine production and elevation of uric acid. Clinical manifestations include mental retardation, spasticity, choreathetosis, compulsive self-mutilation, renal calculi followed by obstructive nephropathy, and arthritis. Patient with LNS may have increased risk of aspiration pneumonia, acute renal failure and unexpected sudden death. We accomplished successful general anesthesia in a case of LNS requiring percutaneous nephrolithotomy due to renal calculi.

Effect of Administering Freund's Complete Adjuvant to Spinal Nerves on the Development of Allodynia in the Rat / 대한마취과학회지

BACKGROUND: Spinal nerve ligation injury causes a neuropathic pain syndrome that includes allodynia. Neuropathic pain is also induced by Freund's complete adjuvant (FCA)-induced inflammation. This study was designed to examine the development of mechanical and cold allodynia after FCA administration at the L4/L5 spinal nerves and to compare it with the effects of spinal nerve ligation at the same site. METHODS: Rats were randomly allocated into three groups: (i) treatment with tight ligation of the left L5/L6 spinal nerves, (ii) wrapping of the L5/L6 spinal nerves with Spongostan(R) soaked in FCA, or (iii) wrapping of the L5/L6 spinal nerves with Spongostan(R) soaked in saline. Mechanical and cold allodynia were measured by applying von Frey filaments or acetone in both hind paws. To examine the development of allodynia, the frequencies of hind paw withdrawal to each type of stimulus were measured. RESULTS: Both FCA administration and nerve ligation injury caused a marked mechanical and cold allodynia in the lesioned hind paw compared to saline treatment (P < 0.05). Furthermore, the frequencies of response of the lesioned hind paw to both types of stimulus were significantly greater than those on the contralateral side. CONCLUSIONS: These results suggest that administration of FCA to the spinal nerves can produce a mechanical and cold allodynia with a similar profile of pain facilitation as nerve ligation.

Fatal Cardiac and Pulmonary Embolisms during Radical Nephrectomy and Inferior Vena Cava Thrombectomy: A case report / 대한마취과학회지

Intraoperative pulmonary embolism can result in severe hemodynamic instability, including cardiac arrest. Therefore, immediate diagnosis and proper treatment are required. We report a case of the acute cardiac and pulmonary embolisms during radical nephrectomy and inferior vena cava (IVC) thrombectomy in a patient with renal cell carcinoma with thrombus in the IVC. We diagnosed the cardiac embolism intraoperatively using the transesophageal echocardiogram, and performed emergent cardiac and pulmonary embolectomies immediately. After the surgery, the patient was discharged without any complication.

Left Atrial Thrombus Diagnosed by Transesophageal Echocardiography Immediately after Induction in a Patient with Middle Cerebral Artery Infarction: A case report / 대한마취과학회지

Stroke is one of the most common causes of death; in particular, cardiac source of embolism may be responsible for 15-20% of ischemic strokes. Here we report a case of left atrial thrombus diagnosed by transesophageal echocardiography (TEE) immediately after induction of general anesthesia in a patient with infarction of the middle cerebral artery. In this case, an emergent craniectomy was cancelled and medical treatment was performed. This case report shows that TEE taken in the operating room may play an important role in the change of treatment plan in a patient displaying acute mental change.

Pulmonary Embolism in a Patient of Renal Cell Carcinoma with Inferior Vena Cava Thrombus : A case report

Renal cell carcinoma (RCC) involves frequently the inferior vena cava (IVC). As effective treatment of RCC with IVC thrombus is currently lacking, aggressive surgical treatment may be considered. However, this procedure can result in fatal complications such as pulmonary embolism. We experienced a case of pulmonary embolism diagnosed, not by intraoperative transesophageal echocardiography, but by a computed tomography scan taken just after radical nephrectomy with IVC thrombectomy in a 63-year-old patient with RCC extending to the IVC.