Intractable postherpetic neuralgia after herpes zoster duplex bilateralis in an immunocompromised patient: A case report

Herpes zoster is caused by the reactivation of the varicella-zoster virus, and it typically presents as single dermatomal rash and vesicles. It can cause postherpetic neuralgia as a common complication. In immunocompromised patients, the lesions can be cutaneous, disseminated into two non-contiguous dermatomes, and this entity is referred to as herpes zoster duplex unilateralis or bilateralis. We present a case of postherpetic neuralgia after herpes zoster duplex bilateralis in a 60-year-old immunocompromised man. He had a past history of acute lymphocytic leukemia and was treated with allogeneic peripheral blood stem cell transplantation 1 year before herpes zoster reactivation. His postherpetic neuralgia pain was difficult to treat and it was refractory to conservative medication and neuraxial block.

Effects of topical dexamethasone in postoperative sore throat / 대한마취과학회지

BACKGROUND: Postoperative sore throat (POST) is a complication that undermines patient satisfaction and increases discomfort in the postoperative period. The present study examined the effects of dexamethasone gargle and endotracheal tube cuff soaking on the incidence and severity of POST. METHODS: Ninety patients undergoing laparoscopic cholecystectomy were randomly allocated into three groups: 0.9% normal saline gargling and tube soaking (group C), 0.05% dexamethasone solution gargling and 0.9% normal saline tube soaking (group G), 0.9% normal saline gargling and 0.05% dexamethasone tube soaking (group S). The incidence and severity of POST were then assessed and recorded at 24 hours after surgery. RESULTS: The total incidence of POST was significantly different among the groups (P < 0.05), and group S exhibited a significantly lower incidence of POST than group C (P < 0.0167). In addition, the POST intensity of group G and group S was less severe than those of group C (Both P < 0.0167). CONCLUSIONS: Among patients undergoing laparoscopic cholecystectomy, those who gargled with 0.05% dexamethasone solution exhibited lower severity of POST than the control group, and those whose endotracheal tube cuff was soaked in the dexamethasone solution before intubation exhibited significantly lower incidence and severity of POST than the control group.

Preoperative interscalene brachial plexus block aids in perioperative temperature management during arthroscopic shoulder surgery / 대한마취과학회지

BACKGROUND: Hypothermia is common during arthroscopic shoulder surgery under general anesthesia, and anesthetic-impaired thermoregulation is thought to be the major cause of hypothermia. This prospective, randomized, double-blind study was designed to compare perioperative temperature during arthroscopic shoulder surgery with interscalene brachial plexus block (IBPB) followed by general anesthesia vs. general anesthesia alone. METHODS: Patients scheduled for arthroscopic shoulder surgery were randomly allocated to receive IBPB followed by general anesthesia (group GB, n = 20) or general anesthesia alone (group GO, n = 20), and intraoperative and postoperative body temperatures were measured. RESULTS: The initial body temperatures were 36.5 ± 0.3℃ vs. 36.4 ± 0.4℃ in group GB vs. GO, respectively (P = 0.215). The body temperature at 120 minutes after induction of anesthesia was significantly higher in group GB than in group GO (35.8 ± 0.3℃ vs. 34.9 ± 0.3℃; P < 0.001). The body temperatures at 60 minutes after admission to the post-anesthesia care unit were 35.8 ± 0.3℃ vs. 35.2 ± 0.2℃ in group GB vs. GO, respectively (P < 0.001). The concentrations of desflurane at 0, 15, and 120 minutes after induction of anesthesia were 6.0 vs. 6.0% (P = 0.330), 5.0 ± 0.8% vs. 5.8 ± 0.4% (P = 0.001), and 3.4 ± 0.4% vs. 7.1 ± 0.9% (P < 0.001) in group GB vs. GO, respectively. CONCLUSIONS: The present study demonstrated that preoperative IBPB could reduce both the intraoperative concentration of desflurane and the reduction in body temperature during and after arthroscopic shoulder surgery.

The oropharyngeal bleeding after esophageal stethoscope insertion: A case report

The daily insertion of endotracheal tubes, laryngeal mask airways, oral/nasal airways, gastric tubes, transesophageal echocardiogram probes, esophageal dilators and emergency airways all involve the risk of airway structure damage. In the closed claims analysis of the American Society of Anesthesiologists, 6% of all claims concerned airway injury. Among the airway injury claims, the most common cause was difficult intubation. Among many other causes, esophageal stethoscope is a relatively noninvasive monitor that provides extremely useful information. Relatively not many side effects that hardly is ratable. Some of that was from tracheal insertion, bronchial insertion resulting in hypoxia, hoarseness due to post cricoids inflammation, misguided surgical dissection of esophagus. Also oropharyngeal bleeding and subsequent anemia probably are possible and rarely pharyngeal/esophageal perforations are also possible because of this device. Careful and gentle procedure is necessary when inserting esophageal stethoscope and observations for injury and bleeding are needed after insertion.

The combination of sugammadex and neostigmine can reduce the dosage of sugammadex during recovery from the moderate neuromuscular blockade / 대한마취과학회지

BACKGROUND: Sugammadex is a novel neuromuscular reversal agent, but its associated hypersensitivity reaction and high cost have been obstacles to its widespread use. In the interest of reducing the necessary dosage of sugammadex, the reversal time of the combined use of sugammadex and neostigmine from moderate neuromuscular blockade were investigated. METHODS: The patients enrolled ranged in age from 18 to 65 years old with American Society of Anesthesiologists class 1 or 2. The subjects were randomly assigned into one of the four groups (Group S2, S1, SN, and N; n = 30 per group). The reversal agents of each groups were as follows: S2 - sugammadex 2 mg/kg, S1 - sugammadex 1 mg/kg, SN - sugammadex 1 mg/kg + neostigmine 50 microg/kg + glycopyrrolate 10 microg/kg, N - neostigmine 50 microg/kg + glycopyrrolate 10 microg/kg. The time to recovery of the train-of-four (TOF) ratio was checked in each group. RESULTS: The time to 90% recovery of TOF ratio was 182.6 +/- 88.9, 371.1 +/- 210.4, 204.3 +/- 103.2, 953.2 +/- 379.7 sec in group S2, S1, SN and N, respectively. Group SN showed a significantly shorter recovery time than did group S1 and N (P < 0.001). However, statistically significant differences between the S2 and SN groups were not be observed (P = 0.291). No hypersensitivity reactions occurred in all groups. CONCLUSIONS: For the reversal from rocuronium-induced moderate neuromuscular blockade, the combined use of sugammadex and neostigmine may be helpful to decrease the recovery time and can also reduce the required dosage of sugammadex. However, the increased incidence of systemic muscarinic side effects must be considered.

Airway dimensions and margin of safety with the left-sided double-lumen tube in patients of a short stature

BACKGROUND: The size and depth of the double-lumen tube (DLT) are important for one-lung ventilation (OLV). In patients of a short stature, it is difficult to perform OLV successfully. We designed this study to evaluate the dimensions and margin of safety of the left main bronchi in patients of a short stature for appropriate OLV. METHODS: Chest computed tomography (CT) scans of 241 patients (22 male, 219 female) of a short stature (height below 155 cm) were analyzed retrospectively. The diameters of the trachea (DT), the right and left main bronchi (DR and DL), and the lengths of the right and left main bronchi (LR and LL) were measured at the coronal section of the chest CT scans using a picture archiving communication system program. RESULTS: There were no significant correlations between the heights and lengths of the right and left main bronchi. In addition, the ages and weights of the patients showed no significant correlations with the airway dimensions. The lengths of the bronchial lumen of the left-sided Mallinckrodt DLT show variations of 3 to 5.5 mm with tubes of identical sizes. The margin of safety is 13.8 +/- 4.1 mm assuming that appropriately sized DLTs are inserted. CONCLUSIONS: For successful and safe OLV in patients of a short stature, anesthesiologists should consider the length of the main bronchus and the actual length of the bronchial lumen of the DLT.

Effect of perioperative infusion of lidocaine vs. dexmedetomidine on reduced consumption of postoperative analgesics after laparoscopic cholecystectomy

BACKGROUND: Postoperative pain is the most common complaint of patients following laparoscopic cholecystectomy (LC). Intravenous lidocaine has analgesic, anti-hyperalgesic, and anti-inflammatory effects, and dexmedetomidine has anti-nociceptive and analgesic sparing effects. We evaluated the effects of perioperative intravenous infusion of lidocaine and dexmedetomidine on postoperative pain control and analgesic consumption after LC. METHODS: Eighty-four patients, aged 20-60 years, who were undergoing elective LC were assigned randomly to three groups (n = 28 in each). The patients in group L received an intravenous lidocaine bolus of 1.5 mg/kg and then continuous infusion of 2 mg/kg/hr. The group D received an intravenous dexmedetomidine bolus of 1 microg/kg, followed by continuous infusion of 0.4 microg/kg/hr. The group N received saline as described for group L. Bolus doses were given during the 10 minutes before the induction of anesthesia, followed by continuous infusion until end of the surgery. Visual analogue scale (VAS) score and postoperative analgesics consumption were evaluated during 24 hours after the surgery. RESULTS: No significant difference was observed in VAS score among the groups during the first 24 hr after LC. The amount of fentanyl consumption in the post-anesthesia care unit was significantly less in groups L and D compared to group N. CONCLUSIONS: Both perioperative intravenous infusion of dexmedetomidine and lidocaine reduced postoperative requirements of fentanyl in the early post-operative period after LC. However, there was no significant difference between dexmedetomidine and lidocaine in the analgesic sparing effect.

Effect of pretreatment with palonosetron on withdrawal movement associated with rocuronium injection / 대한마취과학회지

BACKGROUND: The main disadvantage of rocuronium is the pain associated with vascular injection. We evaluated the efficacy of palonosetron for reducing pain after rocuronium injection. METHODS: Eighty patients scheduled for elective surgery were randomly divided into two groups: Group C (normal saline 1.5 ml, n = 40) and Group P (palonosetron 0.075 mg, n = 40). Anesthesia was induced with thiopental 5 mg/kg and the test drug was injected over 10 seconds. Thirty seconds after the injection of the test drug, rocuronium 0.6 mg/kg was injected over 30 seconds and the response was recorded. Injection pain was graded using a 4-point scale. The grade was 0 points for no movement, 1 point for wrist movement, 2 points for elbow or shoulder movement, and 3 points for whole body movement. Mean arterial pressure and heart rate were recorded on arrival in the operating room and before and 30 seconds after rocuronim injection. RESULTS: There was no significant difference in the grade 1 response between the two groups; however, the grade 2 and 3 responses in Group P were 5 (12.5%) and 4 (10%), respectively, which were significantly lower than in Group C, with 13 (32.5%) responses for each grade. There were no significant differences in hemodynamic changes within each group. However, the difference in mean arterial pressure before and after the injection of rocuronium was significantly larger in Group C compared to Group P. CONCLUSIONS: Pretreatment with palonosetron 0.075 mg reduced the incidence and severity of withdrawal movement after rocuronium administration.

Anesthetic management of thyrotoxicosis patient using total intravenous anesthesia: A case report

It is uncommon that anesthesiologists experience patients with thyroid storms. In our case, the patient had been medicated for 5 years, however, she developed agranulocytosis. Anti-thyroid drugs were stopped and hyperthyroidism progressed. Her symptoms and laboratory results revealed manifestation of thyroid storm: TSH of 7.77 ng/dl, T3 of 403.1 ng/dl, and T4 of 22.15 microg/dl. The euthyroid state had not been achieved before the surgery. From the judgment of difficulty controls of hyperthyroidism, the surgeon requested for an emergency operation. We report a case of total intravenous anesthesia with propofol and remifentanil which achieved hemodynamic stability.

The comparison of the effects of intravenous ketamine or dexmedetomidine infusion on spinal block with bupivacaine / 대한마취과학회지

BACKGROUND: Ketamine and dexmedetomidine are commonly used for sedation and analgesia in patients. We tried to compare the effects of intravenous ketamine and dexmedetomidine infusion on spinal block with bupivacaine. METHODS: Ninety American Society of Anesthesiologists physical status class I or II patients, who were scheduled to spinal anesthesia were randomly assigned to one of three groups (n = 30). Normal saline 10 ml, 5 ml/hr (loading dose for 10 minutes, infusion) (Group NS), dexmedetomidine 1 microg/kg, 0.5 microg/kg/hr (Group DEX), or ketamine 0.2 mg/kg, 0.5 mg/kg/hr (Group KET) was infused intravenously before spinal anesthesia. We recorded the time to highest sensory block level, sensory and motor regression, and hemodynamic changes. RESULTS: Patients in Groups KET had a significantly faster onset time of sensory block than patients in Group NS. The highest sensory block levels were not significantly different between groups. Average time of sensory regression and knee flexion, was significantly longer in the Group KET and Group DEX than the Group NS. CONCLUSIONS: Intravenous dexmedetomidine and ketamine were found to have a similar synergistic effect with intrathecal bupivacaine. Hemodynamic stability showed better results in Group KET.

Does dexmedetomidine reduce postoperative pain after laparoscopic cholecystectomy with multimodal analgesia? / 대한마취과학회지

BACKGROUND: Pain after laparoscopy is multifactorial and different treatments have been proposed to provide pain relief. Multimodal analgesia is now recommended to prevent and treat post-laparoscopy pain. Dexmedetomidine, an alpha2 agonist, has well-known anesthetic and analgesic-sparing effects. We evaluated the analgesic effect of perioperative dexmedetomidine infusion during laparoscopic cholecystectomy with multimodal analgesia. METHODS: Forty-two patients aged 20 to 60 years old were allocated randomly into one of 2 groups (n = 21, in each). All patients underwent laparoscopic cholecystectomy under multimodal analgesia. The patients in group P received dexmedetomidine 1 microg/kg during 10 min before induction and then 0.5 microg/kg/h continuously until the removal of the gall bladder while the patients in the group C received saline by the same methods as group P. Total analgesic consumption and VAS score were recorded for the first 24 hr. RESULTS: There were no significant differences in VAS scores between group P and group C during 24 hr after laparoscopic cholecystectomy. VAS scores of group P were lower than that of group C during the 1st hr after operation. The amount of ketorolac required during the 24 hr after the operation was significantly less in group P compared to group C. CONCLUSIONS: The administration of dexmedetomidine during laparoscopic cholecystectomy with multimodal analgesia has minimal benefits on the reduction of the postoperative pain score. The amount of ketorolac requirements during 24 hr after the operation showed significant difference. Dexmedetomidine might be helpful for the postoperative pain after laparoscopic cholecystectomy with multimodal analgesia.

Abrupt formation of a right atrium thrombus detected by transesophageal echocardiography during laparoscopic assisted vaginal hysterectomy and spontaneous resolution during thromboembolectomy: A case report / 대한마취과학회지

Intraoperative formation and management of a thrombus in right atrium has been reported occasionally. Nevertheless, it is rare that a right atrial thrombus with unstable hemodynamic changes detected by transesophageal echocardiography is resolved spontaneously. We report upon the 44-year-old woman, who had a right atrial thrombus detected by transesophageal echocardiography during laparoscopic assisted vaginal hysterectomy and resolved during thromboembolectomy.

Comparison of dexmedetomidine and remifentanil for attenuation of hemodynamic responses to laryngoscopy and tracheal intubation / 대한마취과학회지

BACKGROUND: This study was designed to compare the effect of dexmedetomidine and remifentanil used in anesthetic induction on hemodynamic change after direct laryngoscopy and tracheal intubation. METHODS: A total of 90 ASA class 1 or 2 patients were randomly assigned to one of 3 groups to receive one of the following treatments in a double-blind manner: normal saline (Group C, n = 30), dexmedetomidine 1 microg/kg (Group D, n = 30), remifentanil 1 microg/kg (Group R, n= 30). Anesthesia was induced with propofol 2 mg/kg and rocuronium 0.6 mg/kg and maintained with 2 vol% sevoflurane and 50% nitrous oxide in oxygen. In group D, dexmedetomidine 1 microg/kg was infused for 10 min before tracheal intubation. Patients in group R was received 1 microg/kg of remifentanil 1 minute before tracheal intubation. The systolic blood pressure, diastolic blood pressure and heart rate were recorded from entrance to operation room to 5 min after tracheal intubation. RESULTS: The percent increase in systolic and diastolic blood pressure due to tracheal intubation in group D and R were significantly lower than that of group C (P < 0.05). The heart rate 1 min after tracheal intubation was lower in groups R and D than in the group C (P < 0.05). CONCLUSIONS: In healthy normotensive patients, the use of dexmedetomidine during anesthetic induction suppressed a decrease in blood pressure due to anesthetic induction and blunted the hemodynamic responses to endotracheal intubation.

Comparison of surgical conditions during propofol or desflurane anesthesia for endoscopic sinus surgery / 대한마취과학회지

BACKGROUND: Reduction of intraoperative bleeding is necessary to achieve the ideal surgical field for the endoscopic sinus surgery (ESS). Intraoperative intra nasal bleeding is influenced by various anesthetics. This study compared surgical field condition between propofol/remifentanil (PR) based anesthesia and desflurane/remifentanil (DR) based anesthesia. METHODS: American Society of Anesthesiologists physical status class I or II patients undergoing ESS were randomly assigned to group PR (n = 36) or group DR (n = 32). The extent of the preoperative surgical lesion was classified as high (> 12) and low (< or = 12) Lund-Mackay (LM) scores according to the computed tomography findings. The target mean blood pressure was maintained at 70-80 mmHg. Only one surgeon was involved in rating the visibility of the surgical field on a numeric rating scale (NRS) every 10 minutes. RESULTS: There was a different surgical field grade from PR to DR. The mean (SD) surgical field score of NRS for the PR and DR was 2.3 (0.57) and 2.7 (0.67), respectively (P = 0.006). Especially in the high-LM score patients, the mean (SD) of surgical field score for the PR and DR was 2.4 (0.67) and 3.0 (0.63), respectively (P = 0.012). CONCLUSIONS: In the high-LM score patients, PR based anesthesia resulted in better surgical field condition for ESS than DR based anesthesia. In ESS, PR based anesthesia is considered to be helpful.

Epidural anesthetic management of achondroplastic parturient dwarf undergoing cesarean section: A case report

Achondroplasia is the most common non-lethal skeletal dysplasia. Underdevelopment and premature ossification of bones result in characteristic craniofacial and spinal abnormalities. Achondroplastic dwarfs have low fertility rates and require delivery by cesarean section due to their cephalo-pelvic disproportion. Controversy exists regarding the ideal anesthesia for an achondroplastic parturient dwarf for urgent cesarean section. Anesthesia, whether general or regional, presents many potential problems during cesarean section. We report the experience of the epidural anesthesia in an achondroplastic dwarf undergoing elective cesarean section.

General anesthetic management of Prader-Willi syndrome patient undergoing middle cerebral artery-superficial temporal artery anastomosis / 대한마취과학회지

No abstract available.

Analgesic effect of preoperative versus intraoperative dexamethasone after laparoscopic cholecystectomy with multimodal analgesia / 대한마취과학회지

BACKGROUND: Pain after laparoscopy is multifactorial and different treatments have been proposed to provide pain relief. Multimodal analgesia is now recommended to prevent and treat post-laparoscopy pain. Dexamethasone is effective in reducing postoperative pain. The timing of steroid administration seems to be important. We evaluated the analgesic efficacy of preoperative intravenous dexamethasone 1 hour before versus during laparoscopic cholecystectomy with multimodal analgesia. METHODS: One hundred twenty patients aged 20 to 65 years old were allocated randomly into one of three groups (n = 40, in each). The patients in the group N received normal saline 1 hour before induction and after the resection of gall bladder. The patients in the group S1 received dexamethasone 8 mg 1 hour before induction and normal saline after the resection of gall bladder. The patients in the group S2 received normal saline 1 hour before induction and dexamethasone 8 mg after the resection of gall bladder. RESULTS: VAS scores of group S1 and S2 were lower than that of group N during 48 hours after laparoscopic cholecystectomy. There were no significant differences of VAS scores between the group S1 and the group S2. The analgesic consumption of group S1 and S2 were significantly lower than that of group N. CONCLUSIONS: A single dose of dexamethasone (8 mg) intravenously given 1 hour before induction or during operation was effective in reducing postoperative pain after laparoscopic cholecystectomy with multimodal analgesia. The analgesic efficacy of preoperative intravenous dexamethasone 1 hour before versus during surgery was not significantly different.

Lambert-Eaton myasthenic syndrome as a cause of persistent neuromuscular weakness after a mediastinoscopic biopsy: A case report / 대한마취과학회지

There are many causes of prolonged postoperative muscle weakness, including drugs, residual anesthetics, cerebrovascular events, electrolyte imbalance, hypothermia, and neuromuscular disease. Neuromuscular diseases are relatively rare, with the most common being myasthenia gravis and Lambert-Eaton myasthenic syndrome (LEMS). We report an unusual case in which a patient who was given a muscle relaxant during mediastinoscopy developed postoperative muscle weakness that was ultimately diagnosed as secondary to LEMS.

A patient with Churg-Strauss syndrome who underwent endoscopic sinus surgery under general anesthesia: A case report / 대한마취과학회지

There are many cause of cholinesterase deficiency, including drugs, liver disease, chronic anemia, malignant states, cardiac failure, severe acute infection, surgical shock, severe burn, collagen disease and vasculitis syndromes. Vasculitis syndromes are relatively rare, and among them, Churg-Strauss syndrome (CSS) is even rarer. We report here on a case of a patient with CSS who underwent endoscopic sinus surgery under general anesthesia.

Breakage of thoracic epidural catheter: How can we deal with it?: A report of 2 cases

Breakage of epidural catheter during insertion and removal is a rare but dilemmatic complication. Although it is favorable to remove a broken catheter entrapped in tissue, there is a controversy about whether retained fragments should be managed even in asymptomatic patients. We experienced two cases of breakage of epidural catheter in patients with thoracic epidural analgesia. One case happened during removing of the entire catheter and needle together and the other, during the removal of the catheter alone. Because neurologic or infective complications were not detected until 14 days after the events, surgical interventions were withheld. In both cases, there were no sequelae on long-term follow up.