Accidental left atrial appendage thrombus detected by intraoperative transesophageal echocardiography during coronary artery bypass graft: A case report

A 77-year-old woman was scheduled for a coronary artery bypass graft. Her preoperative transthoracic echocardiographic (TTE) examination revealed an enlarged left atrium with reduced systolic dysfunction (ejection fraction: 38%), moderate global hypokinesia of the left ventricle, and moderate mitral and tricuspid regurgitation. No thrombus was visualized on the preoperative TTE. However, the intraoperative transesophageal echocardiography performed before the cardiopulmonary bypass revealed a thrombus of approximately 1.3 × 1.8 cm in the left atrial appendage (LAA). The LAA thrombus was removed, an internal suture was placed on the LAA before the coronary artery bypass grafting, and the main operation was performed successfully. The patient was transferred to the intensive care unit to receive postoperative care. She was extubated 4 h after the surgery and was transferred to the general ward on postoperative day 3 without any neurological sequelae.

Head Elevation in Spinal-Epidural Anesthesia Provides Improved Hemodynamics and Appropriate Sensory Block Height at Caesarean Section

PURPOSE: We aimed to determine whether head elevation during combined spinal-epidural anesthesia (CSE) and Caesarean section provided improved hemodynamics and appropriate sensory block height. MATERIALS AND METHODS: Forty-four parous women undergoing CSE for elective Caesarean section were randomly assigned to one of two groups: right lateral (group L) or right lateral and head elevated (group HE) position, for insertion of the block. Patients were positioned in the supine wedged position (group L) or the left lateral and head elevated position (group HE) until a block height of T5 to light touch was reached. Group HE was then turned to the supine wedged position with maintenance of head elevation until the end of surgery. Hemodynamics, including the incidence of hypotension, ephedrine dose required, and characteristics of the sensory blocks were analyzed. RESULTS: The incidence of hypotension (16 versus 7, p=0.0035) and the required dose of ephedrine [24 (0-40) versus 0 (0-20), p<0.0001] were greater in group L compared to group HE. In group L, the time to achieve maximal sensory block level (MSBL) was shorter (11.8+/-5.4 min versus 20.1+/-6.3 min, p<0.0001) and MSBL was also higher than in group HE [14 (T2) versus 12 (T4), p=0.0015]. CONCLUSION: Head elevation during CSE and Caesarean section is superior to positioning without head elevation in the lateral to supine position, as it is associated with a more gradual onset, appropriate block height, and improved hemodynamics.

The effects of intravenous dexmedetomidine on spinal anesthesia: comparision of different dose of dexmedetomidine / 대한마취과학회지

BACKGROUND: In this prospective, randomized, double-blind, placebo-controlled trial, we tried to find out appropriate amounts of single-dose dexmedetomidine to prolong the duration of spinal anesthesia in a clinical setting. METHODS: Sixty patients who were scheduled for unilateral lower limb surgery under spinal anesthesia were randomized into three groups receiving normal saline (control group, n = 20) or 0.5 or 1.0 ug/kg dexmedetomidine (D-0.5 group, n = 20; D-1, n = 20) intravenously prior to spinal anesthesia with 12 mg of bupivacaine. The two-dermatome pinprick sensory regression time, duration of the motor block, Ramsay sedation score (RSS), and side effects of dexmedetomidine were assessed. RESULTS: The two-dermatome pinprick sensory regression time (57.6 +/- 23.2 vs 86.5 +/- 24.3 vs 92.5 +/- 30.7, P = 0.0002) and duration of the motor block (98.8 +/- 34.1 vs 132.9 +/- 43.4 vs 130.4 +/- 50.4, P = 0.0261) were significantly increased in the D-0.5 and D-1 groups than in the control group. The RSS were significantly higher in the D-0.5 and D-1 groups than in the control group. However, there were no patients with oxygen desaturation in dexmedetomidine groups. The incidences of hypotension and bradycardia showed no differences among the three groups. CONCLUSIONS: Both 0.5 and 1.0 ug/kg of dexmedetomidine administered as isolated boluses in the absence of maintenance infusions prolonged the duration of spinal anesthesia.

The effects of intravenous dexmedetomidine on spinal anesthesia: comparision of different dose of dexmedetomidine / 대한마취과학회지

BACKGROUND: In this prospective, randomized, double-blind, placebo-controlled trial, we tried to find out appropriate amounts of single-dose dexmedetomidine to prolong the duration of spinal anesthesia in a clinical setting. METHODS: Sixty patients who were scheduled for unilateral lower limb surgery under spinal anesthesia were randomized into three groups receiving normal saline (control group, n = 20) or 0.5 or 1.0 ug/kg dexmedetomidine (D-0.5 group, n = 20; D-1, n = 20) intravenously prior to spinal anesthesia with 12 mg of bupivacaine. The two-dermatome pinprick sensory regression time, duration of the motor block, Ramsay sedation score (RSS), and side effects of dexmedetomidine were assessed. RESULTS: The two-dermatome pinprick sensory regression time (57.6 +/- 23.2 vs 86.5 +/- 24.3 vs 92.5 +/- 30.7, P = 0.0002) and duration of the motor block (98.8 +/- 34.1 vs 132.9 +/- 43.4 vs 130.4 +/- 50.4, P = 0.0261) were significantly increased in the D-0.5 and D-1 groups than in the control group. The RSS were significantly higher in the D-0.5 and D-1 groups than in the control group. However, there were no patients with oxygen desaturation in dexmedetomidine groups. The incidences of hypotension and bradycardia showed no differences among the three groups. CONCLUSIONS: Both 0.5 and 1.0 ug/kg of dexmedetomidine administered as isolated boluses in the absence of maintenance infusions prolonged the duration of spinal anesthesia.

Comparison of effects of intraoperative esmolol and ketamine infusion on acute postoperative pain after remifentanil-based anesthesia in patients undergoing laparoscopic cholecystectomy / 대한마취과학회지

BACKGROUND: Remifentanil is a short-acting drug with a rapid onset that is useful in general anesthesia. Recently, however, it has been suggested that the use of opioids during surgery may cause opioid-induced hyperalgesia (OIH). Researchers have recently reported that esmolol, an ultra-short-acing beta1 receptor antagonist, reduces the postoperative requirement for morphine and provides more effective analgesia than the administration of remifentanil and ketamine. Hence, this study was conducted to determine whether esmolol reduces early postoperative pain in patients who are continuously infused with remifentanil for anesthesia during laparoscopic cholecystectomy. METHODS: Sixty patients scheduled to undergo laparoscopic cholecystectomy were randomly divided into three groups. Anesthesia was maintained with sevoflurane and 4 ng/ml (target-controlled infusion) of remifentanil in all patients. Esmolol (0.5 mg/kg) was injected and followed with a continuous dosage of 10 microg/kg/min in the esmolol group (n = 20). Ketamine (0.3 mg/kg) was injected and followed with a continuous dosage of 3 microg/kg/min in the ketamine group (n = 20), while the control group was injected and infused with an equal amount of normal saline. Postoperative pain score (visual analog scale [VAS]) and analgesic requirements were compared for the first 6 hours of the postoperative period. RESULTS: The pain score (VAS) and fentanyl requirement for 15 minutes after surgery were lower in the esmolol and ketamine groups compared with the control group (P < 0.05). There were no differences between the esmolol and ketamine groups. CONCLUSIONS: Intraoperative esmolol infusion during laparoscopic cholecystectomy reduced opioid requirement and pain score (VAS) during the early postoperative period after remifentanil-based anesthesia.

Anesthetic experience of Cesarean section in a patient with coexistence of Addison's disease with autoimmune thyroiditis: A case report

Addison's disease is a rare chronic endocrine disorder which results from progressive destruction of the adrenal glands. It is kind of autoimmune polyendocrine syndrome type 2 with autoimmune thyroiditis, and can lead to fatal outcomes when complicated in pregnancy. We report on an anesthetic experience with 38-year-old primigravida with Addison's disease and hypothyroidism who was followed up from the early stage of pregnancy to delivery by a multidisciplinary medical board. Great attention was given to steroid replacement therapy as well as fetal surveillance in order to lower the risk of maternal and fetal mortality. This report describes our experience of the spinal anesthetic management for Cesarean section of a patient with Addison's disease and hypothyroidism.

Anesthetic experience of Cesarean section in a patient with coexistence of Addison's disease with autoimmune thyroiditis: A case report

Addison's disease is a rare chronic endocrine disorder which results from progressive destruction of the adrenal glands. It is kind of autoimmune polyendocrine syndrome type 2 with autoimmune thyroiditis, and can lead to fatal outcomes when complicated in pregnancy. We report on an anesthetic experience with 38-year-old primigravida with Addison's disease and hypothyroidism who was followed up from the early stage of pregnancy to delivery by a multidisciplinary medical board. Great attention was given to steroid replacement therapy as well as fetal surveillance in order to lower the risk of maternal and fetal mortality. This report describes our experience of the spinal anesthetic management for Cesarean section of a patient with Addison's disease and hypothyroidism.

Asymptomatic pneumomediastinum resulting from air in the epidural space: a case report / 대한마취과학회지

There are no reports regarding pneumomediastinum caused by thoracic epidural block complications. We believe that it is possible to experience an occurrence of pneumomediastinum caused by air in the epidural space after performing a thoracic epidural block using the loss of resistance (LOR) technique with air. We report a witnessed case where pneumomediastinum appeared after a thoracic epidural block. Pneumorrrhachis, paravertebral muscle emphysema, and pneumomediastinum were diagnosed by Positron Emission Tomography-Computed Tomography. Although extremely rare, pneumomediastinum can be caused by an epidural block using LOR technique with air. In order to avoid the above danger, the use of saline or very minimal amount of air is required during a careful LOR technique.

Comparison of spread of subarachnoid sensory block and incidence of hypotension in early and late second trimester of pregnancy / 대한마취과학회지

BACKGROUND: Obstetric or non-obstetric surgery can be performed in pregnant women during the second trimester. We evaluated maximal sensory block level (MSBL), and other sensory block characteristics after spinal anesthesia in early and late second trimester pregnant women. METHODS: Forty-four pregnant women scheduled for cervical cerclage under spinal anesthesia in the early second trimester (Group E) or in the late second trimester (Group L) were enrolled in this study. Spinal anesthesia was performed at the L3/4 and 7 mg of 0.5% hyperbaric bupivacaine was injected into the subarachnoid space. Hemodynamic variables, incidence of nausea/vomiting, ephedrine dose, and sensory block were recorded every 2.5 min during the first 15 min and 20 min after the injection. The MSBL, the time at which MSBL was achieved, and the time to the two-segment regression of the sensory level were also recorded. RESULTS: The maximum number of segments blocked was significantly greater in the Group L than in the Group E. The incidence of nausea/vomiting and hypotension, and dose of administrated ephedrine were significantly higher in the Group L than in the Group E. The mean arterial pressure during the 15 min after subarachnoid injection was significantly lower compared to the baseline value in the Group L. CONCLUSIONS: The MSBL of spinal anesthesia with hyperbaric bupivacaine 7 mg were T9 in the early and T5 in the late second trimester groups. Pregnant women in the late second trimester exhibited increased incidence of hypotension and need for ephedrine than women in the early second trimester.

Pyomyositis of the iliacus muscle and pyogenic sacroiliitis after sacroiliac joint block: A case report / 대한마취과학회지

Sacroiliac joint block can be performed for the diagnosis and treatment of sacroiliac joint dysfunction. Although sacroiliac joint block is a common procedure, complications have not been reported in detail. We report a case of iliacus pyomyositis and sacroiliac joint infection following a sacroiliac joint block. A 70-year-old female patient received sacroiliac joint blocks to relieve pelvic pain. The patient was admitted to the emergency room two days after the final sacroiliac joint block (SIJB) with the chief complaints of left pelvic pain corresponding to a visual analogue scale (VAS) score of 9 and fever. A pelvic MRI indicated a diagnosis of myositis. After 1 month of continuous antibiotic therapy, the patient's erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level remained elevated. A 67Ga SPECT/CT was done. Abnormal uptake was seen at the left sacroiliac joint (SIJ), and septic sacroiliitis was suspected. The CRP normalized to 0.29 mg/dl and the ESR decreased to 60 mm/hr, and the patient had no fever after 57 days of antibiotic therapy. She was directed for follow up at an outpatient clinic.

Motor Weakness after Caudal Epidural Injection Using the Air-acceptance Test

Air injected into the epidural space may spread along the nerves of the paravertebral space. Depending on the location of the air, neurologic complications such as multiradicular syndrome, lumbar root compression, and even paraplegia may occur. However, cases of motor weakness caused by air bubbles after caudal epidural injection are rare. A 44-year-old female patient received a caudal epidural injection after an air-acceptance test. Four hours later, she complained of motor weakness in the right lower extremity and numbness of the S1 dermatome. Magnetic resonance imaging showed no anomalies other than an air bubble measuring 13 mm in length and 0.337 ml in volume positioned near the right S1 root. Her symptoms completely regressed within 48 hours.

Complete obstruction of an endotracheal tube due to an unexpected blood clot in a patient with a hemo-pneumothorax after repositioning of the patient for lumbar spine surgery / 대한마취과학회지

No abstract available.

Clinical experience of one lung ventilation using an endobronchial blocker in a patient with permanent tracheostomy after total laryngectomy / 대한마취과학회지

No abstract available.

The effect-site concentration of propofol producing respiratory depression during spinal anesthesia / 대한마취과학회지

BACKGROUND: Propofol is used worldwide for its sedative effective; nonetheless, has the serious side effect of respiratory depression. An increased blood concentration of propofol is well known to be associated with increased respiratory depression. However, there are no studies of the effect site concentration inducing respiratory depression. The purpose of this study was to determine the effect site concentration inducing respiratory depression of propofol when sedating a patient after spinal anesthesia. METHODS: This study included thirty seven males who received operations with spinal anesthesia, which was performed on L3-4 and L4-5. All patients were monitored with the bispectral index and were continuously infused with propofol using target controlled infusion. Respiratory depression was diagnosed when one of the following was evident without upper respiratory obstructive signs: a greater than 20% increase of end tidal carbon dioxide from baseline pressure or pulse oximetry oxygen saturation lower than 95%. We obtained the EC5, EC10, and EC50 of the effect site propofol for respiratory depression. RESULTS: The EC5 of propofol for respiratory depression was 3.09 mcg/ml (95% CI, 2.60-3.58). The EC10 of propofol for respiratory depression was 3.18 mcg/ml (95% CI, 2.57-3.80). The EC50 of propofol for respiratory depression was 3.99 mcg/ml (95% CI, 2.36-5.61). CONCLUSIONS: The EC5, EC10, and EC50 of effect site propofol for respiratory depression during spinal anesthesia were 3.09 mcg/ml ,3.18 mcg/ml, and 3.99 mcg/ml, respectively.

Clinical experience in the treatment of piriformis syndrome using pulsed radiofrequency: A case report

Piriformis syndrome consists of pain, tingling sensation, and paresthesia in areas innervated by sciatic nerve and is one of the main causes of low back pain. A 43-year-old male made a visit for continuous left buttock pain and tingling sensation in lower limbs for three years. Medication, epidural block and sacroiliac joint block were performed, but without effect. Sciatic nerve block with local anesthetics and steroid, however, showed some improvement for a short period of time. The patient's symptoms, physical examination, and the fact that sciatic nerve block showed improvement for a while led to the suspicion of piriformis syndrome. Thus, pulsed radiofrequency was performed on sciatic nerve twice. Visual analog scale (VAS) was 8-9 on first visit, which decreased to 1 after treatment and lasted for more than 18 months.

Post-operative nausea and vomiting after gynecologic laparoscopic surgery: comparison between propofol and sevoflurane / 대한마취과학회지

BACKGROUND: We compared the incidence and degree of post-operative nausea and vomiting (PONV) in patients who received general anesthesia with propofol or sevoflurane using the Rhodes index of nausea, vomiting, and retching (RINVR) to assess the degree of PONV quantitatively and objectively during the post-anesthetic period. METHODS: We performed a prospective study involving 38 patients who underwent gynecologic laparoscopic surgery in our hospital between September 2008 and August 2009. Nineteen patients were anesthetized with propofol during the entire anesthetic period and the other 19 patients received 2.0 mg/kg of propofol intravenously, followed by sevoflurane inhalation. Three patients who were anesthetized with sevoflurane were excluded from the analysis because they were omitted during the survey. We studied the patients who had PONV and RINVR scores 1, 6, and 24 hours post-operatively. RESULTS: The propofol group had a statistically lower incidence of PONV and lower RINVR scores in the following subclasses within 1 hour of surgery: symptom occurrence; symptom distress; and symptom experience. CONCLUSIONS: Propofol at induction and during maintenance of anesthesia can be used to prevent PONV within 1 hour post-operatively in patients undergoing gynecologic laparoscopic surgery.

Position of dorsal root ganglia in the lumbosacral region in patients with radiculopathy / 대한마취과학회지

BACKGROUND: When applying pulsed radiofrequency on dorsal root ganglia for treating chronic lower back pain, maximum efficiency can be expected when a needle is placed 1-2 cm peripheral to the dorsal root ganglion. The object of this study is to analyze images taken after adding contrast to transforaminal epidural injection, categorize root ganglia according to anatomical position, and provide a reference for efficient needle positioning in applying pulsed radiofrequency on dorsal root ganglia. METHODS: From January 2008 to January 2009, 457 patients who visited our hospital for root pain or radiculopathy were treated with transforaminal epidural injection on the nerve roots based on the dermatome of the painful area. Anteroposterior views were taken after injection of contrast. A virtual line was made by connecting the internal and external parts of the spinal pedicle from the contrast images. Then the dorsal root ganglia were categorized as intraspinal (IS), intraforaminal (IF), or extraforaminal (EF). RESULTS: In the fourth lumbar spine, dorsal root ganglia positions were 48% IF, 41% IS, and 6% EF. In the fifth lumbar spine, dorsal root ganglia positions were 75% IF, 10% IS, and 6% EF. In the first sacral spine, dorsal root ganglia locations were 8% IF and 83% IS. CONCLUSIONS: Positional categorization of dorsal root ganglia according to contrast images was proven to be good anatomical references for effective radiofrequency or blocking of dorsal root ganglia.

Transient quadriplegia after fluoroscopic-guided selective cervical nerve root block in a patient who received cervical interbody fusion: A case report / 대한마취과학회지

Selective cervical nerve root block is executed for patients who have symptoms of cervical radiculopathy for diagnostic and therapeutic purposes. However several catastrophic complications caused by this procedure have been reported including neurological complications. A 43-year-old male received a C5 selective cervical nerve root block procedure due to continuous radiating pain even after cervical discectomy and interbody fusion was performed. At the time of the procedure, the contrast outline revealed reflux of the nerve root and epidural space. But after the procedure was performed, the patient experienced decreased sensation in the upper and low extremities as well as motor paralysis of both extremities. Our sspecting diagnosis was anterior spinal artery syndrome but both sensory and motor functions were subsequently recovered within a few hours after the procedure was completed. Due to the difficult nature of this case, we reported these complications and reviewed current literature related to this study.

The Comparison of Laryngeal Mask Airway and Laryngeal Tube in Spontaneous Breathing Anesthetized Pediatric Patients / 대한마취과학회지

BACKGROUND: During general anesthesia, the most commonly used way of keeping airway patency is endotracheal intubation. However, for relatively short and simple surgery, less invasive method using laryngeal tube (LT) or laryngeal mask airway (LMA) is generally accepted and the comparative study between the two apparatus is now being actively done. In this study, we evaluated the usefulness of two apparatus from pediatric patients. METHODS: We select 58 children from one to ten years old who are to be given short operation and then anesthetize 30 children by using LT and 28 children by LMA. The size of LT and LMA is chosen by body weight according to the manufacturer's recommendation. We evaluated the seal pressure of LT and LMA, ventilatory efficiency, attempt number, facility of insertion, proper positioning confirmed by fiberoptic bronchoscopy, and complications. RESULTS: There was no statistically significant difference in the attempt number and facility of insertion between the two groups. LT and LMA were both properly positioned and the ventilation efficiency was not different from the two groups. The LT group shows higher seal pressure than the LMA group and there is no correlation between sealing pressure and ventilation efficiency. There is close correlation between bronchoscopic grade and ventilatory efficiency. complications are not different between two groups. CONCLUSIONS: Both LT and LMA are useful for simple surgery of children and LT has higher sealing pressure.

Active Warming during Preanesthetic Period Reduces Hypothermia without Delay of Anesthesia in Cardiac Surgery / 대한마취과학회지

BACKGROUND: Intra-operative hypothermia adversely affects hemodynamics and post-operative recovery in cardiac surgery patients. This study evaluated the efficacy of active warming during the preanesthetic period on the prevention of intraoperative hypothermia in cardiac surgery patients. METHODS: After gaining the approval of Institutional Review Board and informed consent from the patients, sixty patients undergoing cardiac surgery were divided into control and prewarming group. The control group (n = 30) were managed with warm mattresses and cotton blankets, whereas the prewarming group (n = 30) were actively warmed with a forced-air warming device before anesthesia. Hemodynamic variables and temperature were recorded before anesthesia (Tpre) and at 30 min intervals after anesthesia (T30, T60, and T90). RESULTS: Before anesthesia, skin temperature was significantly higher in the prewarming group than in the control group. At T90, core temperature was significantly higher in the prewarming group than in the control group. Intraoperative hypothermia (core temperature < 35.5oC) developed by T90 in 78% of patients in the control group and 44% of patients in the prewarming group. Moreover, temperatures below 35oC developed in 58% of the conrol group and 17% of the prearming group. CONCLUSIONS: Active warming just before anesthesia reduced the incidence and degree of hypothermia in patients undergoing cardiac surgery, with no delay of anesthesia.