Anesthetic management of a parturient with placenta previa totalis undergoing preventive uterine artery embolization before placental expulsion during cesarean delivery: a case report / 대한마취과학회지

Placenta previa totalis can cause life-threatening massive postpartum hemorrhage, and careful anesthetic management is essential. Preventive uterine artery embolization (UAE) before placental expulsion was introduced to reduce postpartum bleeding in cases of placenta previa totalis. We describe the case of a 40-year-old woman (gravida 0, para 0) with placenta previa totalis and uterine myomas who underwent intraoperative UAE, which was preoperatively planned at the strong recommendation of the anesthesiologist, immediately after delivery of a fetus and before removal of the placenta during cesarean delivery under spinal-epidural anesthesia. After confirming embolization of both uterine arteries, removal of the placenta resulted in moderate bleeding. The estimated blood loss was 2.5 L, and 5 units of red blood cells were transfused. The parturient was discharged uneventfully on postoperative day 4. This case shows that the bleeding risk is reduced by intraoperative UAE in a patient with placenta previa totalis, and anesthesiologists have an important role in a multidisciplinary team approach.

Anesthetic management of a parturient with placenta previa totalis undergoing preventive uterine artery embolization before placental expulsion during cesarean delivery: a case report / 대한마취과학회지

Placenta previa totalis can cause life-threatening massive postpartum hemorrhage, and careful anesthetic management is essential. Preventive uterine artery embolization (UAE) before placental expulsion was introduced to reduce postpartum bleeding in cases of placenta previa totalis. We describe the case of a 40-year-old woman (gravida 0, para 0) with placenta previa totalis and uterine myomas who underwent intraoperative UAE, which was preoperatively planned at the strong recommendation of the anesthesiologist, immediately after delivery of a fetus and before removal of the placenta during cesarean delivery under spinal-epidural anesthesia. After confirming embolization of both uterine arteries, removal of the placenta resulted in moderate bleeding. The estimated blood loss was 2.5 L, and 5 units of red blood cells were transfused. The parturient was discharged uneventfully on postoperative day 4. This case shows that the bleeding risk is reduced by intraoperative UAE in a patient with placenta previa totalis, and anesthesiologists have an important role in a multidisciplinary team approach.

Remifentanil dose for laryngeal mask airway insertion with a single standard dose of propofol during emergency airway management in elderly patients / 대한마취과학회지

BACKGROUND: This study determined the dose of remifentanil to use during insertion of a Classic(TM) laryngeal mask airway (LMA, The Laryngeal Mask Co., Nicosia, Cyprus) in elderly patients during emergency airway management when combined with a single dose of propofol. METHODS: Patients aged 65-80 years were enrolled. Anesthesia was induced with propofol 1 mg/kg, and then a blinded dose of remifentanil was infused over 30 s after confirming the patient's loss of consciousness. The dose of remifentanil was determined using Dixon's up-and-down method, starting at 0.5 microg/kg (a step size of 0.1 microg/kg). Insertion of the LMA was attempted 60 s after loss of consciousness. RESULTS: In total, 23 patients were recruited and the mean age +/- standard deviation was 72 +/- 3 years. The effective dose for successful LMA insertion in 50% of the patients (ED50) was 0.20 +/- 0.05 microg/kg. No patient needed more than 0.3 microg/kg. CONCLUSIONS: Remifentanil 0.20 +/- 0.05 microg/kg with propofol 1 mg/kg resulted in excellent LMA insertion in 50% of elderly patients without significant hemodynamic changes during emergency airway management.

Labor analgesia and anesthetic management during emergency cesarean section of parturient with spinal cord injury (SCI) / 대한마취과학회지

No abstract available.

Endotracheal cuff pressure change during gynecologic laparoscopic surgery: effect on the incidence of postoperative airway complications

BACKGROUND: Laparoscopic surgery with reverse Trendelenburg position and carbon dioxide pneumoperitoneum has been known to increase the endotracheal tube (ETT) cuff pressure and the incidence of postoperative sore throat. The purpose of this study was to evaluate the effect of the Trendelenburg position and pneumoperitoneum on the ETT cuff pressure and the effect of adjustment of ETT cuff pressure on the incidence of sore throat during laparoscopic gynecologic surgery. METHODS: One hundred fifty-four female patients undergoing laparoscopic gynecologic surgery were randomly assigned to either control group or adjusted group. In control group, initial cuff pressure was set at 30 cmH2O in the supine position without any adjustment during surgery. Cuff pressure of adjusted group was adjusted to maintain 30 cmH2O throughout the operation. Cuff pressures at intubation (P(imme)), at carbon dioxide insufflation and the Trendelenburg position (P0), and at 10 minute intervals throughout surgery (P10-P60 and P(end)) were checked. Postoperative airway complications including sore throat, hoarseness, dysphagia and cough were compared between the two groups at 2 hours and 24 hours after surgery. RESULTS: In control group, P0 and P10 were significantly higher than P(imme). The cuff pressure decreased with time, thereby; P50 (28.2 +/- 4.3), P60 (27.5 +/- 4.0) and P(end) (25.9 +/- 4.2) were significantly lower than P(imme) (P < 0.05). The incidences and severity of airway complications were not different between two groups. CONCLUSIONS: ETT cuff pressure decreased in laparoscopic gynecologic surgery. Therefore, controlled cuff pressure does not decrease the incidence of postoperative airway complications.

Anesthetic management for cesarean delivery in a Guillain-Barre syndrome patient: A case report / 대한마취과학회지

Guillain-Barre syndrome is an acute inflammatory demyelinating polyradiculopathy characterized by progressive motor weakness, areflexia, and ascending paralysis. Guillain-Barre syndrome is extremely rare in pregnant patients, and there are no established guidelines for delivery or safest anesthetic methods. We report a Cesarean delivery in the case of a 32-year old woman who was diagnosed with Guillain-Barre syndrome 18 weeks into gestation. Tracheostomy was performed due to progressive respiratory muscle weakness and respiratory failure, and ventilator support was required in the intensive care unit. The respiratory difficulty was exacerbated by the growth of the fetus, necessitating emergency Cesarean delivery. The delivery was successfully performed under general anesthesia, and the patient recovered without neurological sequelae.

The impact of anthrometric measurements on hypotension during spinal anesthesia for cesarean delivery: comparison of body weight, body height, body mass index, and abdominal circumference

BACKGROUND: Hypotension is a common complication of spinal anesthesia for cesarean delivery. The incidence and severity of hypotension is reported higher compared with other surgeries due to aortocaval compression. We evaluated whether body weight, body height, body mass index (BMI) and abdominal circumference effected on the incidence of hypotension and ephedrine requirement. METHODS: A total of 55 parturients undergoing elective cesarean delivery were enrolled in this prospective observational study. Preeclampsia or eclampsia was excluded. Abdominal circumference, body weight, body height were assessed before anesthesia. Spinal anesthesia was conducted in the right lateral position using 8 mg of 0.5% hyperbaric bupivacaine and 15 microg of fentanyl. Blood pressure was measured before anesthesia and at 1 min interval after intrathecal injection. Nausea was assessed during spinal anesthesia. Hypotension was defined that blood pressure decreased below 80% of baseline value and ephedrine was given if blood pressure dropped below 70% (severe hypotension). RESULTS: The total incidence of hypotension was 65% (36/55) and ephedrine was administered in 38% (21/55) of parturients. Except height, abdominal circumference, body weight and body mass index were associated with the incidence of hypotension (P < 0.05). However, severe hypotension requiring ephedrine (P = 0.001, OR = 1.16, [95% CI 1.04-1.30]), ephedrine requirement (P = 0.001, R = 0.43) and nausea (P = 0.026, R = 0.31) were significantly related only with abdominal circumference. CONCLUSIONS: Abdominal circumference of parturients may be a good parameter to predict both of the incidence and the severity of hypotension during spinal anesthesia for cesarean delivery.

Clinical applications of alpha2 adrenoceptor agonist

alpha2 adrenoceptor agonists have been used successfully to treat patients with hypertension and patients withdrawing from long-term abuse of drugs or alcohol. alpha2 adrenoceptor agonists have also proved to be a clinically useful adjunct in clinical anesthetic practice as well as in chronic pain therapy because they have both anesthetic and analgesic-sparing activity. In addition, they have a role in providing hemodynamic stability in patients who are at risk of perioperative ischemia. Dexmedetomidine, a novel selective alpha2 adrenoceptor agonist, has been registered for use as a sedative-analgeic in a variety of clinical setting including monitored anesthesia care and intensive care unit. However, the side-effects of hypotension and bradycardia have limited the routine use of alpha2 adrenoceptor agonists perioporeatively. In this review, we discuss the pharmacology of alpha2 adrenoceptor agonists and their useful applications in anesthesia and intensive care unit.

Retroperitoneal hematoma after coil embolization of cerebral aneurysm: A case report / 대한마취과학회지

We present the case of a 57-year-old man who developed retroperitoneal hemorrhage due to unintentional arterial puncture during femoral artery cannulation for Guglielmi detachable coil embolization. On emergence from anesthesia, he developed severe hypotension. Computed tomographic angiogram of the abdomen showed retroperitoneal hematomas around the urinary bladder, liver, and spleen. Because femoral artery cannulation is a common procedure for intravascular embolization in neuroradiologic procedures, Clinicians should be aware of the development of severe hematomas as a consequence of femoral artery puncture.

The effects of epidural labor analgesia on the progress of labor: a retrospective study

BACKGROUND: Epidural analgesia provides effective pain control during labor. However, its influence on the course of delivery is controversial. The aim of this study was to assess the effect of epidural analgesia on the course of delivery and the perinatal outcome and to examine the changes of the cesarean delivery rates that are associated with epidural analgesia. METHODS: Among 1,200 parturients who delivered in our hospital from 2003 to 2005, we obtained the demographic and obstetric data for 240 primiparous deliveries (120 women in the epidural group [group E] and 120 women in the nonepidural group [group N]). The duration of the active phase and the second and third stages of labor, the perinatal outcome and the incidence of emergency cesarean delivery were analyzed. RESULTS: The duration of the second stage of labor was longer in group E (41 +/-23 min in group N vs. 49 +/-28 min in group E, P = 0.02). The incidences of cesarean delivery were similar between the two groups [15 (12.5%) in group N vs. 18 (15%) in group E, P = 0.6]. The incidences of fetal distress during the active phase of labor did not differ in both groups (48% vs. 41%, respectively, P = 0.4). The neonatal outcomes, including the birth weight, fetal heart rate deceleration or bradycardia during labor and the Apgar score, were similar between the two groups. CONCLUSIONS: We conclude that epidural labor analgesia does not seem to be associated with an increased incidence of cesarean delivery. In addition, epidural labor analgesia seems to have no adverse effect on the perinatal outcomes of primiparous women.

Shivering after retrobulbar block during cataract surgery: A case report / 대한마취과학회지

Retrobulbar block is commonly performed under monitored anesthesia prior to cataract surgery. Known complications associated with retrobulbar block include cranial nerve palsies, seizures, and cardiorespiratory arrest. We report a case of severe shivering following a retrobulbar block. Two minutes after the block was administered, the patient experienced severe shivering, which subsided after injection of pethidine 25 mg. The likely etiology of the shivering was inadvertent dural puncture of the optic nerve sheath and local anesthetic spread into the cerebrospinal fluid space. Shivering may be a warning sign of brain stem anesthesia, and in such a scenario the clinician should direct special attention to possible life-threatening complications.

Association of 5-HT3A receptor Pro16Ser polymorphism with the incidence of PONV and the response to ondansetron in Korean patients

BACKGROUND: Postopertative nausea and vomiting (PONV) are frequent and distressing side effects of surgery. Even though many drugs has been developed, PONV still remains unsolved problem. Ondansetron is a commonly used 5-HT3 receptor antagonist. It acts through specific binding to the 5-HT3A, 5-HT3B receptor complex. We hypothesized that patients with genetic variation in 5-HT3A receptor might have variable incidence of PONV and respond differently to ondansetron. METHODS: We included 204 patients undergoing gynecologic laparoscopic surgery. PONV were documented during 24 hours after operation. Ondansetron was injected to every patient who had PONV at PACU and PONV reassessed after 15 minutes. DNA was extracted from blood and 5-HT3A Pro16Ser missense mutation was analyzed by using real-time PCR. RESULTS: The incidence of PONV were 50% for wild type, 53% for heterozygote and 0% for homozygote. There were no significant differences between wild type and heterozygote in VAS of nausea and VAS change after ondansetron. CONCLUSIONS: 5-HT3A receptor Pro16Ser polymorphism is not associated with the incidence of PONV and the response to ondansetron in Korean patients.

Remifentanil increases the activity of the glutamate transporter, EAAC1, expressed in Xenopus oocytes

BACKGROUND: Remifentanil has gained wide clinical acceptance during anesthesia due to its short context-sensitive half time and organ-independent metabolism. However, its mechanism as an anesthetic remains unclear. Glutamate transporters may be important targets for anesthetic action in the central nervous system, and we tested whether remifentanil affected the activity of the primary neuronal glutamate transporter, EAAC1 (excitatory amino acid carrier 1). METHODS: EAAC1 was expressed in Xenopus oocytes by mRNA injection. By using two-electrode voltage clamping, membrane currents were recorded before, during, and after application of L-glutamate (30microM) in the presence or absence of remifentanil. Oocytes were exposed to a protein kinase C (PKC) activator and inhibitor to study the role of PKC on EAAC1 activity. RESULTS: L-Glutamate induced an inward current in EAAC1-expressing oocytes. This response increased in a bell-shaped manner in the presence of 0.1microM to 1 mM remifentanil. Remifentanil significantly increased Vmax (3.1 +/- 0.2microC for controls vs. 4.9 +/- 0.3 microC for remifentanil treatment; n = 12-15; P < 0.05). However, remifentanil did not significantly change Km. Treatment of the oocytes with phorbol-12-myristate-13-acetate (PMA), a PKC activator, caused a significant increase in transporter current (1.00 +/- 0.03 to 1.35 +/- 0.03microC; P < 0.05). Oocytes pretreated with the PKC inhibitor alone (staurosporine) abolished remifentanilenhanced EAAC1 activity. CONCLUSIONS: Our data suggests that remifentanil enhances EAAC1 activity and that PKC is involved in mediating this effect.

Rupture of hepatic hemangioma during pregnancy : A case report

We report a case of hepatic hemangioma rupture in a 36-year-old woman with a 34-week twin pregnancy. Hemangiomas are the most common benign tumors of the liver and most of them are small and asymptomatic. However, they can induce severe abdominal pain or fatal hemorrhage when ruptured spontaneously during pregnancy. Because of non-specific symptoms and the presence of the large gravid uterus during pregnancy, it is difficult to reach this diagnosis. Under spinal anesthesia, a cesarean section for twin delivery and removal of the hematoma in the abdominal cavity were performed. However, the source of active bleeding was not found during the operation. The spontaneous rupture of hepatic hemangioma was diagnosed after postoperative hepatic angiography and treated successfully by embolization of the left hepatic artery.