Whole lung lavage using a rapid infusion system to treat a patient with pulmonary alveolar proteinosis / 영남의대학술지

Whole lung lavage (WLL) is a therapeutic procedure to remove accumulated material by infusing and draining the lungs with lavage fluid. This procedure has been regarded as the current standard of care to treat pulmonary alveolar proteinosis. However, the WLL protocol has not yet been standardized and the technique has been refined and modified a number of times. A rapid infusion system is a device used to infuse blood or other fluids at precise rates and normothermic conditions. This device is not typically used in WLL, which relies on the passive infusion of fluids using the gravitational force. However, in this study we performed WLL using a rapid infusion system, since we aimed to take advantage of its shorter operation time and greater degree of control over fluid volume and temperature. The patient’s symptoms improved without the occurrence of any complications.

Recurrent Occurrence of Idiopathic Ventricular Tachycardia after Extubation Undergoing Bile Duct Resection, Roux-en-Y Hepaticojejunostomy in Young Patient / 계명의대학술지

Arrhythmias occurring during surgery are mostly benign and improve without special treatment, but sometimes life threatening and poor vital signs may require immediate antiarrhythmic or electrotherapy. In some cases, permanent arrhythmias may require continued treatment after surgery. A cardiac event occurred to a 28-year-old man who underwent Bile duct resection/Roux-en-Y hepaticojejunostomy due to cholelithiasis with cholecystitis and choledocholithiasis. He diagnosed mental retardation level 2. Pre-operation laboratory test is normal except liver function test (AST 64, ALT 141). Electrocardiography shows 57 bpm heart rate, sinus rhythm, first degree AV block and long corrected QT interval that was checked 462ms and echocardiography shows LVEF 67%, normal echocardiogram. When we prepared extubation after finishing operation, Sugammadex 200mg was injected. Suddenly, patient’s oxygen saturation was low at 85%. We started manual ventilation for oxygenation and saturation was increased at 100%. When we extubated endotracheal tube, his ECG changed NSR to idiopathic VT. Firstly we considered that is PSVT and infused adenosine 6mg twice and 12mg once. But arrhythmia was continuous and vital sign changed unstable. We performed reintubation and defibrillated at 200J. After defibrillation, arrhythmia converted sinus rhythm. We transferred the patient to the ICU and evaluated further to see if the patient had heart problems. During admission in ICU, attending surgeon tried to extubate endotracheal tube 2 more times. But, Idiopathic VT occurred whenever try to extubate. Finally, in the fourth attempt, extubation without occurrence of VT succeeded with continuous IV esmolol and dexmedetomidine.

Recurrent Occurrence of Idiopathic Ventricular Tachycardia after Extubation Undergoing Bile Duct Resection, Roux-en-Y Hepaticojejunostomy in Young Patient / 계명의대학술지

Arrhythmias occurring during surgery are mostly benign and improve without special treatment, but sometimes life threatening and poor vital signs may require immediate antiarrhythmic or electrotherapy. In some cases, permanent arrhythmias may require continued treatment after surgery. A cardiac event occurred to a 28-year-old man who underwent Bile duct resection/Roux-en-Y hepaticojejunostomy due to cholelithiasis with cholecystitis and choledocholithiasis. He diagnosed mental retardation level 2. Pre-operation laboratory test is normal except liver function test (AST 64, ALT 141). Electrocardiography shows 57 bpm heart rate, sinus rhythm, first degree AV block and long corrected QT interval that was checked 462ms and echocardiography shows LVEF 67%, normal echocardiogram. When we prepared extubation after finishing operation, Sugammadex 200mg was injected. Suddenly, patient’s oxygen saturation was low at 85%. We started manual ventilation for oxygenation and saturation was increased at 100%. When we extubated endotracheal tube, his ECG changed NSR to idiopathic VT. Firstly we considered that is PSVT and infused adenosine 6mg twice and 12mg once. But arrhythmia was continuous and vital sign changed unstable. We performed reintubation and defibrillated at 200J. After defibrillation, arrhythmia converted sinus rhythm. We transferred the patient to the ICU and evaluated further to see if the patient had heart problems. During admission in ICU, attending surgeon tried to extubate endotracheal tube 2 more times. But, Idiopathic VT occurred whenever try to extubate. Finally, in the fourth attempt, extubation without occurrence of VT succeeded with continuous IV esmolol and dexmedetomidine.

Anesthetic management of a pediatric patient with Rett syndrome: A case report

Rett syndrome is a neurodevelopmental disease that almost always affects female patients. It is caused by mutations in MeCP2 in the majority of cases. Patients diagnosed with Rett syndrome may experience serious adverse events even with smaller amounts of medication for sedation and anesthesia. The major anesthetic concerns associated with Rett syndrome are lack of cooperation, abnormal continuous limb movements, abnormal respiratory control, difficult positioning secondary to scoliosis, and altered sensitivity to painful stimuli. Because of the risks caused by these problems, anesthesiologists should be aware of the specific anesthetic concerns of patients with Rett syndrome in order to safely administer anesthesia. Here, we describe the management of a pediatric patient diagnosed with Rett syndrome.

Epinephrine-induced lactic acidosis in orthognathic surgery: a report of two cases

Submucosal infiltration and the topical application of epinephrine as a vasoconstrictor produce excellent hemostasis during surgery. The hemodynamic effects of epinephrine have been documented in numerous studies. However, its metabolic effects (especially during surgery) have been seldom recognized clinically. We report two cases of significant metabolic effects (including lactic acidosis and hyperglycemia) as well as hemodynamic effects in healthy patients undergoing orthognathic surgery with general anesthesia. Epinephrine can induce glycolysis and pyruvate generation, which result in lactic acidosis, via β2-adrenergic receptors. Therefore, careful perioperative observation for changes in plasma lactate and glucose levels along with intensive monitoring of vital signs should be carried out when epinephrine is excessively used as a vasoconstrictor during surgery.

General anesthesia in a patient with multicentric Castleman's disease: a case report / 대한마취과학회지

Castleman's disease (CD) is a rare lymphoproliferative disorder of undetermined etiology. Unicentric Castleman's disease is confined to a single lymph node; it is usually asymptomatic though sometimes has local manifestations related to mass effects. In contrast, multicentric Castleman's disease (MCD) typically presents with lymphoid hyperplasia at multiple sites; it is associated with systemic symptoms and abnormal laboratory findings, with a less favorable prognosis. In case of anesthesia in CD, an exhaustive preanesthetic evaluation is essential to identify associated clinical manifestations which may influence the management of the anesthesia. Perioperative careful monitoring and proper anesthetic management are both important. We report a case of general anesthesia with anesthetic management in a patient with MCD that has not been documented in the literature.

Severe Hypernatremia with Craniopharyngioma - A Case Report - / 대한구급학회지

Hypernatremia, defined as a rise in the serum sodium concentration to a value exceeding 145 mM/L, is a common electrolyte disorder. Diabetes insipidus is a common cause of hypernatremia, caused by impaired production or reduced responses to vasopressin. The resultant morbidity may be inconsequential, serious, or even life-threatening. However, hypernatremia rarely occurs during anesthesia and surgery. A 45-year-old female patient with craniopharyngioma was scheduled for tumor resection. Hypernatremia (serum sodium, 170 mM/L) occurred suddenly at the end of the surgery. To treat hypernatremia, 0.45% normal saline was used. Although serum sodium concentration was reduced faster than expected, the patient did not have any complications.

Cerebral oxygenation monitoring of patients during arthroscopic shoulder surgery in the sitting position / 대한마취과학회지

BACKGROUND: Cerebral hypotension and desaturation can occur during shoulder surgery in the seated position. We evaluated the correlation of cerebral oxygen saturation (rSO2) using near infra-red spectroscopy (NIRS) and mean arterial pressures (MAP) (at the levels of the brain and heart). METHODS: Fifty patients, scheduled for the arthroscopic shoulder surgery in the seated position, were enrolled to monitor the rSO2, bispectral Index (BIS), and MAPs at the levels of the brain and heart. The values of each parameter were collected at 5 min after intubation, immediately after placing the patient in the sitting position, 5 min after the patient was seated, immediately after the surgical incision, and every 30 min after incision. RESULTS: A correlation between the cerebral rSO2 and the MAP at the level of brain were statistically significant. Cerebral rSO2 and MAP after a change of posture from supine to sitting position were significantly decreased, compared to the baseline value. CONCLUSIONS: Monitoring cerebral rSO2 and MAP at the level of brain can be helpful to detect the possibility of cerebral deoxygenation earlier.

Anaphylaxis induced by priming dose of rocuronium during induction of anesthesia: Report of two cases

We experienced 2 cases of anaphylaxis during induction of anesthesia. Anesthesia was induced with a priming dose of rocuronium and followed by thiopental sodium two minutes later. Immediately after injection of thiopental sodium, they showed a sudden active coughing, urticaria around neck, and difficult ventilation. The residual intubating dose of rocuronium was injected to do endotracheal intubation. Subsequently, patients showed severe hypotension, hypoxia, and erythema. Rapid treatment was applied and they were recovered without any complications. The first patient had rejected skin test for drugs, but the second patient had a positive skin test for rocuronium two weeks after event.

Hemodynamic Responses of Pretreatments Designed to Reduce Withdrawal Movements Following Rocuronium Injection: A Comparison of Alfentanil with Lidocaine / 대한마취과학회지

BACKGROUND: This study was conducted to compare the efficacy of intravenous alfentanil and lidocaine as a pretreatment for the prevention of withdrawal movements following a rocuronium injection and hemodynamic change following tracheal intubation. METHODS: This study evaluated 180 patients that were divided into the following 3 pretreatment groups: group C: normal saline, group L: lidocaine 1 mg/kg, group A: alfentanil 10microgram/kg. Anesthesia was induced using 5 mg/kg thiopental sodium, after which the test drug was injected. Rocuronium (1 mg/kg) was then administered 1 minute after the test drug was injected over 5 seconds and the response was characterized as one of the following: no movement, movement limited to the wrist, to the elbow or to the shoulder. Intubation was performed 1 minute later. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were then recorded at each of the following points: T1: preinduction, T2: immediately prior to rocuronium injection, T3: immediately after rocuronium injection, T4: immediately prior to intubation, T5: immediately after intubation, T6: 1 minute after intubation, T7: 5 minutes after intubation. RESULTS: The incidence of withdrawal movement was significantly lower in group A than groups C and L (P < 0.05). In addition, SBP, DBP and HR following intubation were significantly lower in group A than group C and group L (P < 0.05). CONCLUSIONS: Pretreatment with 10microgram/kg of alfentanil effectively reduced the incidence of withdrawal movement in response of rocuronium injection and caused minimal hemodynamic changes following intubation.

Clinical Usefulness of Computer Assisted Line Bisection Task for the Assessment of Sensory-Attenional Aspect of Visuospatial Neglect

OBJECTIVE: To assess the clinical usefulness of computer- assisted line bisection task for the patients with sensory- attentional visuospatial neglect. METHOD: Forty patients with unilateral hemispheric stroke (25 right, 15 left) and 15 normal age-matched subjects participated in this study. Computer-assisted line bisection task (CALBT) was designed using modified Milner landmark test to assess the sensory-attentional aspect of visuospatial neglect. Accuracy of response and reaction time for the transected lines, and response rate for the bisected lines were measured. Correlation between the results of CALBT and conventional line bisection test and Albert test was evaluated. RESULTS: In patients with right hemispheric lesion, results of CALBT demonstrated shifting of attention to the right hemifield and neglect of the stimulus in the left hemifield. In contrast, patients with left hemispheric lesion showed significantly decreased attention to the right hemifield and shifting of attention to the left hemifield. Performances of CALBT correlated with the line bisection test, but not with the Albert test. CONCLUSION: Computed assisted line bisection task can be used for the quantitative assessment of the sensory attentional aspect of visuospatial attention in patients with unilateral neglect.

Effect of Repetitive Transcranial Magnetic Stimulation in Patients with Intractable Neuropathic Pain: Cases report

Drug resistant neuropathic pain can be relieved by non-invasive new therapy of repetitive transcranial magnetic stimulation (rTMS). Three patients who have been suffered from intractable neuropathic pain with diverse underlying causes were enrolled. The causes of their pain were the thalamic hemorrhage, the complex regional pain syndrome (CRPS) after resection of neurilemmoma, and the trigeminal schwanoma respectively. A thousand pulses of 10 Hz rTMS were delivered over the contralateral primary motor cortex at 80% of resting motor threshold for a period of 20 minutes per each treatment session. The intensity of pain was assessed using a visual analogue scale before and after rTMS session for 5 consecutive days. Immediate and dramatic analgesic effects were noticed as a result of rTMS in patients with thalamic hemorrhage and trigerminal schwanoma. Moderate analgesic effect was noticed in patient with CRPS. The duration of analgesic effect was variable.

A Baker's Cyst Causing Common Peroneal Nerve and Tibial Nerve Entrapment Neuropathy : A Case Report / 대한정형외과학회잡지

Degenerative disc disease of the lumbar spine caused leg pain with associated calf weakness and atrophy. However, an unusual case of leg pain and calf atrophy due to neural compression is reported. We reported a rare case of a Baker's cyst causing common peroneal nerve and tibial nerve entrapment neuropathy. Initially, after arthroscopic menisectomy and cyst decompression, Baker's cyst was recurred and then open excision was done. Until 1 year after surgery, the cyst was not recurred, increased muscle bulk was noted and EMG showed improved findings. But she continued to complain of lower leg weakness and sole paresthesia owing to delayed diagnosis and cyst decompression.

Factors Predicting Prolongation of the Prothrombin Time after Liver Donor Hepatectomy / 대한마취과학회지

BACKGROUND: The increasing shortage of liver donors has resulted in exponential growth of living donor liver transplantation (LDLT). There are obvious concerns about the increased risk to the donors. There has been study on the impact of donation as a function of the degree of resection. However, the effect of inhaled anesthetics combined with the degree of parenchymal loss on the liver function has not been quantified. We analyzed the prothrombin time (PT), as hepatic synthetic function, after donor hepatectomy (DH) with the recipient undergoing general anesthesia with different types of inhaled anesthetics. METHODS: One-hundred thirty-four patients who underwent DH were enrolled. The patients were randomly divided into four groups: enflurane (group E), isoflurane (group I), sevoflurane (group S), and desflurane (group D). Anesthesia was performed according to institutional standards. The PT was measured for 7 days before and daily after DH (POD). Total liver volume and resected liver volume were measured and fraction of the graft volume was calculated. RESULTS: The PT peaked on POD 1 in all groups. A significantly lower PT was observed in group D compared to the other groups until POD 3. The fraction of the graft volume showed significant correlation with the PT change. PT abnormalities were affected by the preoperative PT, the graft fraction and inhaled anesthetics. CONCLUSIONS: Desflurane induced lesser elevation of the PT than did the other inhaled anesthetics until POD 3. The preoperative PT, the graft fraction and the inhaled anesthetics may be key factors for inducing postoperative PT abnormalities.

Severe Oropharyngeal Angioedema Caused by Propofol: A case report / 대한마취과학회지

Although propofol is thought to be a relatively safe intravenous anesthetic with regard to histamine release reactions, anaphylactoid reactions to propofol may sometimes occur, especially in patients with a history of allergy, atopy, or asthma. Here we report a patient with allergies to sesame leaves and cold medications who experienced an anaphylactic reaction with severe oropharyngeal edema a few minutes after receiving propofol (Anepol(R)). This finding suggests that propofol should be used with caution in patients with a history of allergy. Because profound airway edema can occur, the airway should be evaluated before extubation of the trachea.

Splenic Abscess Arising from a Dental Abscess in Healthy Man

Isolated splenic abscess of spleen is very rare, which is increasingly recognized with immunosuppressed states due to the use of chemotherapy to malignancy, immunosuppression for transplantation and AIDS recently. The most fre-quent cause of splenic abscess is septic embolism arising from bacterial endocarditis. While splenic abscess can be seen rarely in healthy men, it has a high rate of mortality when it is diagnosed lately. A healthy 66-year-old male patient who presented with a 7 month history of intermittent spiking fever, toothache was admitted to the emergency room with clinical and biochemical signs of sepsis. Vital sign were 90/60-112-20-38.9 degrees C. He had left subcostal tenderness, a 15 cm palpable spleen and no medical history except toothache. The laboratory values were as follows: leukocyte 289,200/mm(3)(segmented neutrophil 94.3 %), hemoglobin 10.5 g/dl, platelet 119,000/mm(3), AST/ALT 85/84 U/L, total bil-irubin 10.8 mg/dl, BUN/Creatinine 25/1.3 mg/dl. Streptococcus viridians grew in blood culture. Computerized tomography showed a splenomegaly with multifocal round or tubular shaped cystic lesions in spleen as well as infiltrative low density lesions in pancreatitic taie like intrasplenic pseudocysts, which was failed by ultrasound-guided aspiration due to multiple, small and scattered location. Echocardiography showed no evidence of intracardiac source of infective thromboembolism. Endoscopic retrograde cholangiography shows mild intrahepatic duct and common bile duct dilataton with no evidence of stone. Exploratory laparotomy was performed. The spleen being found enlarged and distal pan creas with probably pseudocystic involvement were removed. It was also noticed that there were cystic-like structure filled with pus on crosssectional surface. The result of pus cultures was no organism.

Laparoscopic Removal of an Ingested Needle, which was Penerated to the Lesser Omentum of the Stomach

The perforation and migration of ingested sharp metallic bodies is a rare event. A perforation of the gastrointestinal tract is difficult to accurately and quickly diagnose when there is no peritonitis or abscess formation. Patients often present with no symptoms. The discovery of a foreign body on a radiological examination of the abdomen may be made incidentally. Moreover, a history of ingestion is usually difficult to obtain. Foreign bodies after perforation have been reported to migrate to any intra-abdominal site and to extra-abdominal sites in rare cases. We report one case of young man with ingested needle in which perforated silently and migrated to the lesser omentum. A 23-year-old man presented with an incidental foreign body. He has no definite ingestion history or psychiatric disorder, but was a heavily drinker. An abdominal plain X-ray showed a needle in the upper abdominal area. Computed tomography revealed the foreign body to be located beneath the liver and in the lesser omentum. The patient underwent a laparoscopic examination performed in the supine position. After creating a pneumoperitoneum by CO2 gas insufflation at 12 mmHg, 3 trochars (two 5-mm and 12-mm) were introduced at each subcostal and supraumbilical area. Surgical management using laparoscopic extraction was successful. The patient was discharged in good health on the 3rd day after the procedure. Laparoscopy can be used to remove ingested foreign bodies when surgery is indicated.

Electrolyte and Gas Analysis from Dorsal Vein of Hand during General Inhalational Anesthesia / 대한구급학회지

BACKGROUND: To assess the acid-base status and to measure PO2 and PCO2, arterial blood gases (ABG) has been checked usually. We compared the venous blood gases (VBG) from dorsal vein of hand to ABG from radial artery, and tried to determine whether venous blood gas analysis (VBGA) could be the alternative of ABGA. METHODS: Thirty patients who needed continuous arterial pressure monitoring were chosen. At the completion of stability of HR and BP after induction of general inhalational anesthesia, the ABG from radial artery and VBG from dorsal vein of hand were compared. RESULTS: Laboratory findings were as follows (mean+/-SD): arterial pH, 7.44+/-0.04; venous pH, 7.43+/-0.04; arterial HCO3-, 25.56+/-2.39 mmol/L; venous HCO3-, 25.51+/-2.09 mmol/L. The mean values of arterial and venous PO2 were significantly different (247.8+/-48.9 mmHg versus 187.8+/-41.6 mmHg), but the arterial and venous PO2 values were significantly correlated (r=0.706). The PCO2 (r= 0.883), pH (r=0.912), and HCO3- (r=0.901) values, and base excesses of arterial and venous blood (r=0.926) were highly correlated. Also, arterial and venous serum electrolyte (sodium, potassium, and calcium) were highly correlated. CONCLUSIONS: Venous blood gas analysis from dorsal vein of hand can be effectively used as the alternative method to evaluate the acid-base status, PO2, and PCO2, instead of ABGA during general inhalational anesthesia.

Effect of Intraarticular Ketamine after Knee Arthroscopy / 대한통증학회지

BACKGROUND: This study was designed to demonstrate the peripheral effect of ketamine on the synovia of the knee joint and evaluate the analgesic effect of an intraarticular ketamine injection following knee arthroscopy. METHODS: In a double blind randomized study, 80 ASA class 1 or 2 patients were selected for elective arthroscopic knee surgery. The patients received either 20 ml of normal saline (Group C, n = 19), 20 ml of 0.5% ropivacaine (Group R, n = 21), 1 mg/kg of ketamine mixed with 20 ml of normal saline (Group K, n = 20) or 1 mg/kg of ketamine mixed with 20 ml of 0.5% ropivacaine (Group RK, n = 20), intraarticularly, just prior to wound closure. Postoperative pain was evaluated using a visual analogue scale (VAS 0 to 100) score at 1, 2, 6, 12, 24 and 48 hours after the intraarticular injection, with the side effects found in the four groups also evaluated. The patients' requests for rescue analgesic were recorded, total doses of tarasyn calculated and the overall patient satisfaction also evaluated. RESULTS: The difference in the VAS scores for all time periods was not significant. The number of patients receiving rescue analgesics and the total doses received in Group C were greater than those for the other groups, but this was not significant. No side effects were observed in any of the patients. CONCLUSIONS: Ketamine and local anesthetics have been reported to have peripheral analgesic effects, with variable duration in the measurements of pain and hyperalgesia. However, we failed to demonstrate a peripheral analgesic effect on postoperative arthroscopic pain.

The Effect of Lithotomy-Trendelenburg Position and Carbon Dioxide Insufflation on the Distance from the Upper Incisor to the Carina / 대한마취과학회지

BACKGROUND: The carbon dioxide (CO2) insufflation and lithotomy-Trendelenburg position are required in the laparoscopic gynecologic surgery. However, they can change the distance from the upper incisor to the carina. This may increase the risk of endobronchial intubation. METHODS: Nineteen patients, aged 29-50 yr, who were undergoing laparoscopic surgery were enrolled. We measured the distance from the upper incisor to the carina of them with fiberoptic bronchoscope. Measurements were taken in the each point of lithotomy position, lithotomy-Trendelenburg position, and lithotomy-Trendelenburg position after CO2 insufflation. RESULTS: The average distance from the upper incisor to the carina was 23.1 +/- 1.4 cm in the lithotomy position (0 degree) and was significantly decreased to 22.6 +/- 1.4 cm in the lithotomy-Trendelenburg position (15 degrees) (P<0.05). After CO2 insufflation into the abdominal cavity, the mean distance in the lithotomy-Trendelenburg position (15 degrees) was significantly decreased to 22.1 +/- 1.4 cm (P<0.05). CONCLUSIONS: The lithotomy-Trendelenburg position and CO2 insufflation decrease the distance from the upper incisor to the carina.