Risk factors of emergency reoperations

Background@#Emergency reoperation is considered to be a quality indicator in surgery. We analyzed the risk factors for emergency reoperations. @*Methods@#Patients who underwent emergency operations from January 1, 2017, to December 31, 2017, at our hospital were reviewed in this retrospective study. Multivariate logistic regression was performed for the perioperative risk factors for emergency reoperation. @*Results@#A total of 1,481 patients underwent emergency operations during the study period. Among them, 79 patients received emergency reoperations. The variables related to emergency reoperation included surgeries involving intracranial and intraoral lesions, highest mean arterial pressure ≥ 110 mmHg, highest heart rate ≥ 100 /min, anemia, duration of operation ＞120 min, and arrival from the intensive care unit (ICU). @*Conclusions@#The type of surgery, hemodynamics, hemoglobin values, the duration of surgery, and arrival from ICU were associated with emergency reoperations.

Retrospective anesthetic evaluation of non-obstetric surgery during pregnancy: single center experience

BACKGROUND: Laparoscopic procedures and ultrasonography are now commonly used in the obstetric field, and more non-obstetric procedures are being performed. However, little domestic data has been published on the topic. This present retrospective study investigated the clinical information and the effect on perinatal outcomes of non-obstetric surgery during pregnancy. METHODS: This retrospective study was performed using data of all adult pregnant women that underwent non-obstetric surgery at our institute between from July 2009 to December 2016. Data was collected from the institutional computerized database. The causes, types, and the gestational ages at surgery were collected as our primary outcomes. Basic characteristics of patients, operation times, anesthesia times, anesthetic methods, anesthetic agents, and adverse perinatal outcomes such as abortion or preterm delivery were evaluated as secondary outcomes. RESULTS: During the study period, there were 2,421 deliveries and 60 cases of non-obstetric surgery, an operation rate of 2.48%. The most common cause of non-obstetric surgery was abdominal surgery, followed by orthopedic surgery and neurosurgery. Most of abdominal surgeries were performed laparoscopically during the first trimester. The incidence of adverse perinatal outcomes was increased in the first trimester, was not related with anesthesia. CONCLUSIONS: The rate of non-obstetric surgery was found to be 2.48%, which was higher than those reported in previous domestic studies. This increase seems to have resulted from early diagnosis by ultrasonography and non-invasive surgery using laparoscopy. Adverse perinatal outcomes are not related with age, surgery and anesthetic-related factors but seem to be associated with surgery exposure stage, especially the first trimester.

Anesthetic experience of patients with Fournier's syndrome / 대한마취과학회지

No abstract available.

Comparative Study of Brain Protection Effect between Thiopental and Etomidate Using Bispectral Index during Temporary Arterial Occlusion

OBJECTIVE: This study was conducted to compare the effect of etomidate with that of thiopental on brain protection during temporary vessel occlusion, which was measured by burst suppression rate (BSR) with the Bispectral Index (BIS) monitor. METHODS: Temporary parent artery occlusion was performed in forty one patients during cerebral aneurysm surgery. They were randomly assigned to one of two groups. General anesthesia was induced and maintained with 1.5-2.5 vol% sevoflurane and 50% N2O. The pharmacological burst suppression (BS) was induced by a bolus injection of thiopental (5 mg/kg, group T) or etomidate (0.3 mg/kg, group E) according to randomization prior to surgery. After administration of drugs, the hemodynamic variables, the onset time of BS, the numerical values of BIS and BSR were recorded at every minutes. RESULTS: There were no significant differences of the demographics, the BIS numbers and the hemodynamic variables prior to injection of drugs. The durations of burst suppression in group E (11.1+/-6.8 min) were not statistically different from that of group T (11.1+/-5.6 min) and nearly same pattern of burst suppression were shown in both groups. More phenylephrine was required to maintain normal blood pressure in the group T. CONCLUSION: Thiopental and etomidate have same duration and a similar magnitude of burst suppression with conventional doses during temporary arterial occlusion. These findings suggest that additional administration of either drug is needed to ensure the BS when the temporary occlusion time exceed more than 11 minutes. Etomidate can be a safer substitute for thiopental in aneurysm surgery.

Anesthetic experience of a patient with hereditary factor XI deficiency (Hemophilia C) : A case report / 대한마취과학회지

Factor XI deficiency (also called Hemophilia C) rarely occurs among ethnicities other than Ashkenazi Jews. A boy was scheduled for frontoethmoidectomy due to bilateral chronic rhinosinusitis. He was incidentally found to have factor XI deficiency due to prolonged aPTT on preoperative laboratory finding. His medical history reveals frequent epistaxis 2 or 3 times per day and his factor XI and XII activity were 17% (normal; 60-140%) and 34% (normal; 60-140%), respectively on furthermore laboratory evaluation. He was diagnosed as hereditary factor XI deficiency. He underwent the operation with administration of the fresh frozen plasma without complication.

Clinical Experience of the Lower Extremity Nerve Block for a Neurocritically Ill Patient Who is Not Able to Communicate:A Case Report / 대한구급학회지

A 73-year-old man was scheduled for the surgical reduction of fractured femur which occurred ar 3 months ago by the accident. The mental status of the patient was stuporous (Glasgow coma scale: 5) due to the complication of the head trauma. We performed nerve blocks (femoral, sciatic, lateral femoral cutaneous, and illiohypogastric nerve blocks) for the surgical reduction of left femur with 55 ml of 0.25% ropivacaine. The electroencephalography was monitored continuously during the 4 hour operation as well as monitoring the hemodynamic and respiratory parameters. The operation was performed successfully and the patient recovered uneventfully.

Pulmonary Edema Caused by Massive Intraarterial Infusion and Flushing of Heparinized Saline during the Endovascular Embolization in a Patient with a Cerebral Aneurysm: A case report / 대한마취과학회지

Here we report, along with a review of the literature, our experience with a patient suffering from a cerebral aneurysm and developed volume overloading pulmonary edema during endovascular coiling. A 51-year-old female patient who had an aneurysm in the basilar artery tip and subarachnoid hemorrhage was scheduled for endovascular embolization under general anesthesia. She developed pulmonary edema during the procedure. Coiling failed so neurosurgeon performed aneurysmal clipping under general anesthesia. The massive intraarterial infusion and flushing with heparinized saline may have triggered the pulmonary edema. We monitored diuresis and hemodynamics following surgery, as a high degree of vigilance, including monitoring of arterial blood gas and electrolyte evaluation, of patients undergoing prolonged endovascular embolization and receiving many intra-arterial fluids may help recovery.

Acute Cerebral Infarction after General Anesthesia: A case report / 대한마취과학회지

Perioperative cerebrovascular accidents after general anesthesia are rare but devastating, and are often fatal. We experienced a case of acute cerebral infarction found at 2 days after general anesthesia. A 64 year old, ASA physical status II, hypertensive male patient underwent radical neck dissection due to right thyroid cancer. Anesthesia was induced with propofol and succinylcholine and maintained with vecuronium-enflurane-nitrous oxide-oxygen. No special event occurred during anesthesia, except for of three hypotensive events that required ephedrine. On the second day after the operation, he complained dysarthria and left facial weakness. Brain CT and MRI revealed an infarction of the right middle cerebral artery territory. He was transferred to the department of neurology and received conservative care. Fortunately, he was discharged at 20 days after surgery with much improved symptoms.

Delayed Emergence from General Anesthesia Caused by Acute Subdural Hematoma: A case report / 대한마취과학회지

Emergence from anesthesia may be neurologically unsatisfactory. Delayed awakening after general anesthesia is most commonly caused by the effects of anesthetic drugs, but primary central neurologic events (hemorrhage, ischemia, and embolus, etc) that occur during surgery can cause failure to awaken. We experienced a patient whose emergence was delayed from general anesthesia for zygomatic bone savage. The patient had such unexpected focal neurologic abnormalities as left ankle clonus and anisocoria (right dilation). Brain CT revealed acute subdural hematoma as a cause of delayed emergence in the postanesthetic care unit. An emergency craniectomy was performed to evacuate the hematoma, but the patient failed to regain consciousness following surgery. The patient regained consciousness on the 28th postoperative day, and had left hemiparesis and right blindness.

Anesthetic Management of Pediatric Pancreatic Insulinoma: A case report / 대한마취과학회지

Insulinomas are the most common type of islet cell tumor. Generally, these tumors are benign (90%), intrapancreatic, solitary, and small. Moreover, hyperinsulinemia in infants and children can result in permanent damage to the central nervous system. Thus, early diagnosis and treatment are important. The principal challenge during anesthesia is the avoidance of hypoglycemia, which may occur during tumor manipulation, though hyperglycemia may follow after successful surgical removal of the tumor. Because symptoms of hypoglycemia (systemic hypertension, tachycardia, diaphoresis) may be masked during anesthesia, it is important to monitor blood glucose levels frequently during the perioperative period. Here we report up on the case of a 3 year old female with insulinoma. We monitored blood glucose levels intermittently (about every 15 minutes) using a glucometer (Medisense Optium, Abbott, USA). No hypoglycemic episode occurred during anesthesia. We report this clinical experience and review anesthetic choices and the management of this patient.

The Effect of Isovolemic Hemodilution on the Autoregulation of Cerebral Blood Flow / 대한마취과학회지

BACKGROUND: Hemodilution may increase cerebral blood flow (CBF) but the mechanism(s) remain controversal. Autoregulation is easily modified or disturbed by several conditions. The aim of this study was to evaluate the effects of isovolemic hemodilution on the autoregulation of cerebral blood flow in a rabbit model. METHODS: Stepwise hemodilution was accomplished by incrementally removing whole blood from the animals in amounts of 8-12 ml and replacing this with an equal volume of 6% hetastarch in saline. This procedure was continued until the target content values of approximately Hct -18% were achieved. To evaluate the influence of pressure changes on CBF, mean arterial pressure (MAP) was increased from a baseline pressure (approximately 78 mmHg) to 145 mmHg by infusing methoxamine, and cerebral blood flow was measured at each MAP level using the hydrogen clearence method after MAP had been stabilized for 15 min. RESULTS: Stepwise hespen replacement caused a sudden drop of Hct from 37.4% to 18.5% and a simultaneously a significant increase in local CBF of 161% in the hemodilution group. Hemodilution significantly reduced CaO2 in the hemodilution group (9.45 +/- 1.7 ml O2/dl) versus the control group (18.34 +/- 1.3 ml O2/dl). However, despite these decrease in CaO2, calculated cerebral oxygen delivery (DO2) was as well maintained in the hemodilution group (22.47 +/- 7.28 ml O2/100 gm/min) as in the control group (24.14 +/- 8.67 ml O2/100 gm/min). MAP increases from 78 mmHg to 145 mmHg produced a significant increase in CBF from 122.4 +/- 32.8 ml/100 gm/min to 170.9 +/- 23.7 ml/100 gm/min in control group (39.6%) and from 218.4 +/- 75.6 ml/100 gm/min to 268.4 +/- 106.5 ml/100 gm/min in the hemodilution group (44.6%) (P<0.001). These CBF increases were not significantly different in the two groups. CONCLUSIONS: The present study demonstrates that in the normal brain the decrease in CaO2 caused by hemodilution is well compensated for by an increase CBF, and that oxygen transport to the brain is also well maintained during at a Hct value of 20%. Although the present study did not show the tight CBF control within the MAP range from 78 mmHg to 145 mmHg, hemodilution did not alter the response of the cerebral circulation to increased MAP.

Brachial Plexus Injury after Thoracoscopic Sympathectomy: A case report / 대한마취과학회지

Unilateral brachial plexus injury is a rare complication of thoracoscopic sympathectomy, which is generally considered to be a simple and safe procedure. We report on a 20-year-old female patient who developed persistent pain and weakness of the left arm after thoracoscopic sympathectomy for hyperhidrosis. An electromyographic study revealed evidence of denervation at the C5-C7 level, and a nerve conduction study on the left brachial plexus showed decreased amplitude of the compound muscle action potential of the left musculocutaneous and axillary nerves. The above findings are compatible with left brachial plexopathy, with predominant involvement of the lateral and posterior cord. We suggest that this complication was caused by stretch and/or compression of the left brachial plexus when the arm was hyperabuducted upwards during the operation. Careful attention to positioning by the surgeon and anesthesiologist is needed to prevent this debilitating injury.

Severe Postoperative Delirium Lasting for Three Weeks: A Case Report / 대한구급학회지

Postoperative delirium in the intensive care unit is a serious problem that has recently attracted much attention. We present a 73-year-old female patient who was admitted by multiple fractures induced by an accident. We started general anesthesia for the operation of open reduction and internal fixation. After the discontinuation of general anesthesia, the patient was transported to the intensive care unit. The symptoms of delirium were developed and controlled with medications including haloperidols, benzodiazepines, and vitamins. The patient was recovered three weeks after the management and received two other operations, but delirium did not be developed again. She was discharged from the hospital without complications.

Steroid on Hyperalgesia in Nerve Ligation Induced Neuropathic Pain Rat Model / 대한마취과학회지

BACKGROUND: Neuropathic pain is resistant to conventional treatments, and may seriously affect the quality of life. Insufficient has been done on drug combination for the treatment of neuropathic pain. So we undertook to determine the effect of ketamine and steroid on mechanical hyperalgesia in rats with spinal nerve ligation. METHODS: Rats were administerend L5 and L6 spinal nerve ligation to cause mechanical hyperalgesia. Control group (n = 6) were administered normal saline 5 ml intraperitoneally, the ketamine group (n = 6) ketamine 1mg/kg, and the steroid group (n = 6) ketamine 1 mg/kg and methylprednisolone 10 mg/kg. Mechanical hyperalgesia was assessed using a von Frey filament before injection, and then 15, 30, 60, 120, and 180 min after injection. RESULTS: Ketamine 1 mg/kg significantly attenuated mechanical hyperalgesia for 60 min. The combination of ketamine 1 mg/kg and methylprednisolone 10 mg/kg also significantly attenuated mechanical hyperalgesia. But the combination group did not exert a superior attenuating effect than ketamine alone. CONCLUSIONS: The combination of ketamine and metylprednisolone did not exert a superior antinociceptive effect than ketamine alone in rats with spinal nerve ligation.

The Effect of an Intraperitoneal Injection of Ketamine and Ketorolac on Mechanical Allodynia in Rats with Spinal Nerve Ligation / 대한마취과학회지

BACKGROUND: It is difficult to manage the symptoms of neuropathic pain, especially alloynia. The mechanism of the induction and maintenance of mechanical allodynia has been extensively researched for several decades. N-methyl-D-aspartate (NMDA) receptor antagonists are known to reduce mechanical allodynia. Recently, the role of prostaglandins in spinal nociceptive processing has been the focus of attention. Therefore, the present study was designed to investigate the effect of a combination of ketamine, a non-competitive NMDA antagonist, and of ketorolac, non-selective cyclooxygenase (COX) inhibitor on mechanical allodynia. METHODS: Male SD rats were prepared by tightly ligating the left L5 and L6 spinal nerves. All rats developed mechanical allodynia 7 days after surgery. N group (control, n = 6) received 5 ml of 0.9% normal saline intraperitoneally. K group (n = 6) received ketamine 1 mg/kg. T group received ketorolac 30 mg/kg, and KT group received ketamine 1 mg/kg and ketorolac 30 mg/kg simultaneously. Paw withdrawal thresholds to von Frey hairs were measured before and at 15 min, 30 min, 60 min and 120 min after drug administration. RESULTS: Normal saline and ketamine 1 mg/kg did not increase the paw withdrawal threshold from baseline. Ketorolac 30 mg/kg increased the paw withdrawal threshold only at 120 min after intraperitoneal injection. However, the co-administration of ketamine 1 mg/kg and ketorolac 30 mg/kg increased the paw withdrawal threshold significantly from baseline for 120 min. CONCLUSIONS: Intraperitoneal injection of ketamine and ketorolac attenuated the mechanical allodynia developed by spinal nerve ligation. Therefore, we suggest that combination of ketamine and ketorolac might be useful for the management of neuropathic pain.

Clinical Experience of General Anesthesia in a Child with Status Epilepticus Induced by Febrile Convulsion: A case report / 대한마취과학회지

When continuous seizures are refractory to conventional intravenous anticonvulsant drugs, general anesthesia has been recommended to control status epilepticus. We present the case of a 6-year-old male patient who was admitted for generalized tonic-clonic status epilepticus secondary to febrile convulsion due to an upper respiratory infection. The tonic-clonic status epilepticus was refractory to all anticonvulsant measures and drugs including, phenytoin, phenobarbital, diazepam and lorazepam. After about 32 hours of unsatisfactory seizure activity control, we started general anesthesia for the management of his status epilepticus. After discontinuing general anesthesia, the patient developed a small number of episodes of epilepsia partialis, but seizure activity was well controlled by conventional anticonvulsants. The patient was extubated after three days and was discharged from hospital as cured 12 days after general anesthesia management.

Clinical Experience of General Anesthesia in a Child with Status Epilepticus Induced by Febrile Convulsion: A case report / 대한마취과학회지

When continuous seizures are refractory to conventional intravenous anticonvulsant drugs, general anesthesia has been recommended to control status epilepticus. We present the case of a 6-year-old male patient who was admitted for generalized tonic-clonic status epilepticus secondary to febrile convulsion due to an upper respiratory infection. The tonic-clonic status epilepticus was refractory to all anticonvulsant measures and drugs including, phenytoin, phenobarbital, diazepam and lorazepam. After about 32 hours of unsatisfactory seizure activity control, we started general anesthesia for the management of his status epilepticus. After discontinuing general anesthesia, the patient developed a small number of episodes of epilepsia partialis, but seizure activity was well controlled by conventional anticonvulsants. The patient was extubated after three days and was discharged from hospital as cured 12 days after general anesthesia management.

Early Effect of Endotoxin on Cerebral Autoregulation / 대한마취과학회지

BACKGROUND: Under normal conditions, cerebral blood flow is regulated as cerebral perfusion pressure changes (autoregulation). Inflammatory conditions like bacterial meiningitis result in a loss of cerebral autoregulation several hours after exposure to bacterial endotoxin. Endotoxin appears to produce effects via the production of reactive oxygen species, such as the superoxide anion. METHODS: Cerebral blood flow (CBF) was measured by hydrogen clearance in anesthetized rats 30 minutes after intravenous endotoxin 5 mg/kg or normal saline (control). Mean arterial pressure was reduced from 100 mmHg to 80 mmHg and 60 mmHg by hemorragic hypotension, and cerebral blood flow was measured at each pressure. RESULTS: In the control group, CBF did not change when arterial pressure was reduced to 80 mmHg (113.9 ml vs 111.9 ml), but declined significantly at 60 mmHg (113.9 ml vs 88.4 ml). In the group treated with endotoxin, both a reduction of mean arterial pressure to 80 mmHg (129.8 ml vs 101.8 ml) and 60 mmHg (129.8 ml vs 78.4 ml) caused a significant reduction in CBF, indicating that autoregualtion had been abolished. CONCLUSIONS: The results of this study indicate that within minutes of endotoxin exposure, CBF markedly increased, and that the autoregualtion of CBF was inhibited.

Propofol-N2O versus Seveflurane-N2O during Outpatient Knee Arthroscopic Surgery Using the Laryngeal Mask Airway: Hemodynamic Responses and Recovery Profiles / 대한마취과학회지

BACKGROUND: The increasing number of outpatient surgery which requiring the rapid, smooth induction of anesthesia with rapid recovery may lead to the use propofol or sevoflurane. Our objective was to compare the hemodynamic responses and recovery profiles obtained by sevoflurane inhalation with propofol infusion using a laryngeal mask airway (LMA) in an ambulatory setting. METHODS: Forty patients undergoing knee arthroscopic surgery were randomized into two groups. The laryngeal mask airway insertion was accomplished by using the voluntary maximal vital capacity breathing method (VCB) with sevoflurane 7% in nitrous oxide 50% (sevoflurane group) or by the infusion of propofol (target: 7microgram/ml) (propofol group). Under BIS monitoring (40-60), anesthesia was maintained by sevoflurane (2-3%) or propofol (range of 3.7-4.2microgram/ml) with spontaneous respiration. Time to loss of consciousness (LOC) and LMA insertion from induction of anesthesia, hemodynamic responses, end tidal CO2, and recovery profiles were evaluated. RESULTS: The mean time to LOC and to successful LMA insertion were similar in the groups. Hemodynamic responses in the sevoflurane group were not significantly different from those of the propofol group. However, in both groups, systolic and diastolic blood pressure were lower at the time of loss of consciousness and 5 min of after LMA insertion versus preinduction and LMA insertion values (P<0.05). Heart rate was significantly lower in the propofol group (P<0.05). After cessation of anesthesia, hemodynamic responses and to the time for LMA removal or to the time for responding to a verbal command were similar in both groups. CONCLUSIONS: Sevoflurane inhalation and propofol infusion anesthesia with spontaneous respiration provided comparable conditions for outpatient surgery.

Accidental Intravenous Administration of Magnesium Sulfate during Cesarean Section: A case report / 대한마취과학회지

We report a case of the accidental intravenous administration of a large dose of magnesium sulfate during cesarean section. A 41-year-old woman, at 33 weeks gestation, with pregnancy-aggravated hypertension, headache and generalized edema presented in acute labor and showed fetal bradycardia on a nonstress test. Laboratory tests demonstrated an increased level of magnesium (5.4 mg/dl). A cesarean section was performed under general anesthesia with O2-N2O-enflurane and vecuronium. After delivery 2,000 mg of magnesium sulfate was mixed with the lactated Ringer's solution 1,000 ml and 550 ml administered to the patient. After noticing the accidental infusion of the magnesium sulfate, we replaced the lactated Ringer's solution with normal saline 1,000 ml and performed arterial blood gas analysis, checked serum electrolyte, including Mg2+ and Ca2+, and had monitored depth of muscle relaxation and vital signs. The level of magnesium had increased to 8.9 mg/dl after the accidental magnesium infusion. For about one and half hours after emergence from general anesthesia, she complained of dyspnea and paraparesis of extremities. To treat the hypermagnesemia, 3% calcium gluconate 1,000 mg and furocemide were given intravenously to antagonize magnesium and to increase the urine output. The depth of neuromuscular block was frequently monitored using a nerve stimulator. After conservative treatment, she recovered from the effect of the hypermagnesemia and was discharged on the fifth postoperative day. Anesthesiologists must to keep in mind the preoperative patients' pathophysiologic conditions, check co-administered drugs and the contents of intravenously connected solutions.