Dilutional Hyponatremia during Hysteroscopic Myomectomy: A Case Report / 대한구급학회지

Hysteroscopy is utilized for making the diagnosis and treating a series of uterine disease. It's advantages are more accurate removal of lesion, a short operating time, low morbidity and rapid postoperative recovery. However, serious complications can happen following hysteroscopic surgery. The complications can be divided into the procedure-related, media-related and postoperative events. The procedure-related complications include cervical laceration, uterine perforation, bowel and bladder injury, and hemorrhage. The media-related complications include hyponatremia, gas embolism and excessive fluid absorption. The postoperative events include endometritis and postoperative synechiae. We experienced hyponatermia with pulmonary edema due to excessive fuid absorption in a 52-year-old woman who underwent elective hysteroscopic myomectomy under general anesthesia. She was treated with oxygen therapy, normal saline and furosemide and she recovered without sequelae.

Drip infusion method as a useful indicator for identification of the epidural space / 대한마취과학회지

BACKGROUND: Cervical epidural anesthesia (CEA) is used for pain control and surgical procedures of the head and neck or upper arm areas. However, the failure rate of CEA is reported to be high, is the failure rate being quite higher than other sites, because of the anatomical differences of the cervical spine. We hypothesized that the loss of resistance (LOR) method combined with the drip infusion method for confirmation of the cervical epidural space can reduce the failure rate. This study investigated the usefulness of the drip infusion method. METHODS: One hundred chronic renal failure patients undergoing arteriovenous bridge graft for hemodialysis at the upper arm under cervical epidural anesthesia were recruited for this study. In the cervical epidural puncture, we identified the cervical epidural space using a combination of the LOR method with the drip infusion method. After confirmation of the epidural space with LOR method, we decided it was the true epidural space when fluid dripping to the space was present. Otherwise, if fluid dripping was not present, we designated it was pseudo LOR, and we found the true epidural space using the drip infusion method only. RESULTS: In all cases, the combined LOR with drip infusion method, identify the epidural space. CONCLUSIONS: Combined LOR with drip infusion method is an efficacious method for the confirmation of the cervical epidural space.

Effect of normal saline dilution on prevention of rocuronium injection pain

BACKGROUND:Intravenous injection of rocuronium produces intense discomfort at the site of injection in 50?80% of conscious patients.Many trials have sought to lessen the injection pain.The present study evaluated the incidence and severity of pain associated with intravenous injection of rocuronium in conscious patients, and determined the efficacy of different doses of 50 mg rocuronium diluted in 0.9% NaCl at minimizing injection pain. METHODS:Sixty healthy patients scheduled for general anesthesia were randomly divided into three groups (n = 20 each) for injection of 10 ml (NS 10), 20 ml (NS 20), or 40 ml (NS 40) of the NaCl-diluted rocuronium. Before induction, the incidence of pain was ascertained and its severity during subsequent rocuronium injection was classified as none, mild, moderate, severe, very severe. RESULTS:The incidence and the severity of pain were significantly lower in the NS 40 group than in the NS 10 group (P< 0.05). Pain severity was mild or absent for all NS 20 and NS 40 patients. CONCLUSIONS:Rocuronium diluted with NaCl effectively reduces injection pain in a dose dependent manner. s

Effect of normal saline dilution on prevention of rocuronium injection pain

BACKGROUND:Intravenous injection of rocuronium produces intense discomfort at the site of injection in 50?80% of conscious patients.Many trials have sought to lessen the injection pain.The present study evaluated the incidence and severity of pain associated with intravenous injection of rocuronium in conscious patients, and determined the efficacy of different doses of 50 mg rocuronium diluted in 0.9% NaCl at minimizing injection pain. METHODS:Sixty healthy patients scheduled for general anesthesia were randomly divided into three groups (n = 20 each) for injection of 10 ml (NS 10), 20 ml (NS 20), or 40 ml (NS 40) of the NaCl-diluted rocuronium. Before induction, the incidence of pain was ascertained and its severity during subsequent rocuronium injection was classified as none, mild, moderate, severe, very severe. RESULTS:The incidence and the severity of pain were significantly lower in the NS 40 group than in the NS 10 group (P< 0.05). Pain severity was mild or absent for all NS 20 and NS 40 patients. CONCLUSIONS:Rocuronium diluted with NaCl effectively reduces injection pain in a dose dependent manner. s

Comparison of Methods to Confirm the Cervical Epidural Space

BACKGROUND: The loss of resistance (LOR) method is most commonly used to identify the epidural space. This method is thought to rely on the penetration of the ligamentum flavum. Unfortunately the exact morphology of the ligamentum flavum is variable at different vertebral levels. Especially, it has been pointed out that the lower cervical ligamentum flavum may be discontinuous in the midline in up to 50% of patients. Thus, the LOR method may be inaccurate to confirm the cervical epidural space. The aim of this study is to determine which method is the safest and most exact for confirming the cervical epidural space. METHODS: 100 adult, chronic renal failure patients who were undergoing an arteriovenous bridge graft for hemodialysis at the upper arm under cervical epidural anesthesia were recruited for this study. During the cervical epidural puncture, we identified the cervical epidural space by subjectively feeling the resistance with using a finger just through the ligamentum flavum, and we also used the drip infusion method, the loss of resistance method using air, and the hanging drop method. By using 5 grades, we classified the extent of whether or not the techniques were effective. RESULTS: Using the drip infusion method, we identify the epidural space in all the patients as +/++ grade. The catheter insertion method was also successful in identifying those epidural spaces over a +/- grade. The pseudo LOR was over micro grade in 47 patients. CONCLUSIONS: The combined LOR/hanging drop with drip infusion method is useful for confirming the cervical epidural space.

The hemodynamic changes by different end-tidal CO2 under anesthesia using sevoflurane-N2O / 대한마취과학회지

BACKGROUND: Hypercapnia augments cardiac output and can initiate a sympathetically mediated release of catecholamines to increase cardiac output. Many studies of hemodynamic changes by hypercapnia under general anesthesia with inhalation anesthetics besides sevoflurane. This study examined the hemodynamic changes by increasing end-tidal carbon dioxide (EtCO2) under sevoflurane-N2O anesthesia. METHODS: Twenty patients were enrolled in the study. We studied stable, mechanically ventilated patients under general anesthesia maintained with O2 2 L/min - N2O 2 L/min - sevoflurane (1.5-2.5 vol%). Hypercapnia were obtained by reducing tidal volume and respiratory rate. EtCO2 was adjusted to 30, 40, 50 mmHg with each concentration maintained for 15 min. Global hemodynamic variables were monitored with a pulmonary artery catheter. RESULTS: There were no changes in mean arterial pressure or heart rate by hypercapnia. Acute moderate hypercapnia increased cardiac output (4.9 +/- 1.7, 5.5 +/- 1.7, 6.2 +/- 2.1 L/min; P 0.05). CONCLUSIONS: When we changed patient EtCO2 to 30, 40, and 50 mmHg, there were no changes in mean arterial blood pressure and heart rate, but systemic vascular resistance decreased, and cardiac output, cardiac index and mean pulmonary arterial pressure increased significantly.

The influence of head rotation on the anatomical relationship of the right internal jugular vein and the carotid artery / 대한마취과학회지

BACKGROUND: The purpose of this study was to evaluate the effect of head rotation on the anatomical relationship of the right internal jugular vein (RIJV) and the carotid artery (CA) with using ultrasound images in Korean patients. METHODS: We investigated 117 patients (age range: 16-87 years old) who were placed in the supine position, but not in the Trendelenburg position. An ultrasound probe was placed on the right neck at the apex of the triangle formed by the head of the sternocleidomastoid muscle and the clavicle, and it was directed toward the ipsilateral nipple at a 30 degree angle to the coronal plane. For each head rotation (0, 30, 60 degrees), we measured the horizontal diameter of the RIJV and CA, and the percentage of overlap of the CA and the RIJV with using an ultrasound system. RESULTS: The mean RIJV diameter was 18.4 +/- 4.3 mm and the mean CA diameter was 7.5 +/- 1.2 mm at the neutral head position. Following head rotation, the percentage overlap of the CA and RIJV increased significantly (0degrees: 32.7%, 30degrees: 45.4%, 60degrees: 57.0%) (P < 0.05). The percentage overlap of the CA and RIJV in the neutral head position increased more in the patients with a BMI over 25. However, age did not have any effect on the percentage of overlap. CONCLUSIONS: Head rotation toward the contralateral side increases the percentage of overlap of the CA and RIJV. To decrease the risk of CA puncture, rotate the head from the neutral position as little as possible when performing RIJV catheterization.

The influence of head rotation on the anatomical relationship of the right internal jugular vein and the carotid artery / 대한마취과학회지

BACKGROUND: The purpose of this study was to evaluate the effect of head rotation on the anatomical relationship of the right internal jugular vein (RIJV) and the carotid artery (CA) with using ultrasound images in Korean patients. METHODS: We investigated 117 patients (age range: 16-87 years old) who were placed in the supine position, but not in the Trendelenburg position. An ultrasound probe was placed on the right neck at the apex of the triangle formed by the head of the sternocleidomastoid muscle and the clavicle, and it was directed toward the ipsilateral nipple at a 30 degree angle to the coronal plane. For each head rotation (0, 30, 60 degrees), we measured the horizontal diameter of the RIJV and CA, and the percentage of overlap of the CA and the RIJV with using an ultrasound system. RESULTS: The mean RIJV diameter was 18.4 +/- 4.3 mm and the mean CA diameter was 7.5 +/- 1.2 mm at the neutral head position. Following head rotation, the percentage overlap of the CA and RIJV increased significantly (0degrees: 32.7%, 30degrees: 45.4%, 60degrees: 57.0%) (P < 0.05). The percentage overlap of the CA and RIJV in the neutral head position increased more in the patients with a BMI over 25. However, age did not have any effect on the percentage of overlap. CONCLUSIONS: Head rotation toward the contralateral side increases the percentage of overlap of the CA and RIJV. To decrease the risk of CA puncture, rotate the head from the neutral position as little as possible when performing RIJV catheterization.

Effects of Continuous Epidural Infusion after Thoracic Epidural Anesthesia for Mastectomy on Postoperative Pain, Nausea and Vomiting / 대한마취과학회지

BACKGROUND: Breast cancer is the most common cause of tumors in Korean women. Until recently, oncologic breast surgery was performed by using general inhalation anesthesia. However, this anesthetic method is associated with incomplete postoperative pain control and significantly more postoperative nausea and vomiting (PONV). Therefore, this study examinated the value of thoracic epidural anesthesia (TEA) for a mastectomy, and evaluated the effects of a continuous epidural infusion on postoperative pain control and the PONV, which is known to be a better method than general anesthesia with intravenous patient controlled analgesia (IV PCA). METHODS: Sixty five patients scheduled for a mastectomy were randomly assigned and divided into two groups. The GA group underwent general anesthesia using O2-N2O-sevoflurane with IV PCA. The TEA group was injected with 20 ml of 0.375% ropivacaine with fentanyl 50microgram at T4-5. After surgery the visual analogue scale (VAS) score of postoperative pain and nausea was checked. RESULTS: The postoperative pain intensity was significantly (P < 0.05) lower in the TEA group at the postoperative period and during 6 hours compared with the GA group. Postoperative nausea intensity was significantly (P < 0.05) lower in the TEA group during 6 hours. CONCLUSIONS: These results suggest that TEA is a method suitable of regional anesthesia for a mastectomy and a continuous epidural catheter infusion is more effective on postoperative pain control than general anesthesia with IV PCA. In addition, it is a good method for decreasing the PONV to a similar level as IV PCA with antiemetics.