Severe pancytopenia and coagulopathy discovered during anesthesia after pre-anesthetic evaluation – A report of two cases –

Pre-anesthetic evaluation is an important aspect of perioperative patient management. However, anesthesiologists often encounter challenges during anesthesia due toconditions that are not detected during pre-anesthetic evaluations.Case: Case 1 involved a 74-year-old female patient scheduled for cranioplasty and meningioma excision. Severe pancytopenia was detected during anesthesia. Cranioplasty was onlyperformed, the surgery was terminated, and drug-induced pancytopenia was diagnosed andtreated. The pre-anesthetic test results were normal, except for anemia. Case 2 involved a71-year-old male patient who discovered large ecchymosis during general anesthesia preparation in the operating room for choledochal cyst surgery. Surgery was canceled to evaluatethe bleeding tendency, and acquired coagulation factor VIII deficiency was diagnosed andtreated. The pre-anesthetic tests were normal, except for prolongation of the activated partial thromboplastin time.Conclusions: Abrupt hematologic and hemostatic changes may occur during anesthesiaeven though pre-anesthetic evaluation findings are normal.

Herpes zoster after COVID-19 vaccination, aspect of pain medicine: a retrospective, single-center study

Herpes zoster (HZ) is one of the most common cutaneous adverse reactionsassociated with the coronavirus disease 2019 (COVID-19) vaccine and has been widely reported. This study aimed to evaluate HZ following COVID-19 vaccination from the viewpointof pain management.Methods: A retrospective study was conducted on 42 patients with HZ who visited the painclinic between August 2021 and October 2021. Medical records were reviewed to comparepain severity, treatment methods, treatment duration, and incidence rate of postherpeticneuralgia (PHN) in patients who received COVID-19 vaccination within 6 weeks prior to developing symptoms compared with other patients with HZ.Results: Fourteen patients developed HZ within 6 weeks after vaccination and were significantly younger than the other HZ groups. There were no significant differences in the frequency of prodromal pain, location of pain, pain severity, treatment methods, treatmentduration, or incidence of PHN compared with the other HZ groups.Conclusions: COVID-19 vaccination-related HZ showed clinical features similar to those ofthe other HZ.

The effect of interscalene brachial plexus block with propofol sedation on preventing perioperative hypothermia during arthroscopic shoulder surgery / 대한마취과학회지

Background@#Interscalene brachial plexus block (ISBPB) is commonly used with general anesthesia for postoperative pain management in shoulder surgery. This study investigated the incidence of hypothermia and changes in the body temperature in patients undergoing arthroscopic shoulder surgery under ISBPB with propofol sedation. @*Methods@#This retrospective study enrolled 220 patients who underwent arthroscopic shoulder surgery. Patients were divided into general anesthesia (n = 34) and ISBPB with propofol sedation (n = 186) groups, and medical records were retrospectively compared. In addition, patients from the ISBPB group were further divided according to age (elderly, [≥ 65 years]; n = 98 vs. young, [< 65 years]; n = 88), and the incidence of hypothermia and changes in the body temperature were compared. @*Results@#Twenty-seven patients (12.3%) experienced perioperative hypothermia (range; 35.3–35.9℃). The incidence of perioperative hypothermia was 29.4% and 9.1% in the general anesthesia and ISBPB groups, respectively, and there was a significant difference between the two groups (P = 0.002). The incidence of perioperative hypothermia according to age in the ISBPB group was 9.2% and 9.1% in the elderly and young groups, respectively, and there was no significant difference between the two groups (P = 0.983). @*Conclusions@#The incidence of perioperative hypothermia during arthroscopic shoulder surgery under ISBPB with propofol sedation is lower than that under general anesthesia. Furthermore, when using ISBPB with propofol sedation, the incidence of perioperative hypothermia in elderly patients is similar to that in younger patients.

A comparative study of glottis visualization according to the method of lifting the epiglottis in video laryngoscopy: indirect and direct lifting methods

Background@#The direct entry of the camera under the epiglottis may provide a better view of the glottis than the indirect lifting of the epiglottis by placing the Macintosh blade tip on the vallecula when using the video laryngoscope. This study aimed to compare the efficiency of two different methods of lifting the epiglottis during the visualization of glottis using video laryngoscopy in the same patient. @*Methods@#This prospective study enrolled 60 patients who underwent general anesthesia with tracheal intubation. In each patient, glottic views were obtained by directly (group DE) and indirectly lifting the epiglottis (group IE). These two methods were compared using the modified Cormack and Lehane grade and the percentage of glottis opening (POGO) score as assessment parameters. @*Results@#Modified Cormack and Lehane grade showed a significant difference between the groups DE and IE (P = 0.004). The difference in the POGO score between the groups DE and IE was also statistically significant (87.5% and 64.4%, respectively; P < 0.001). @*Conclusions@#Our results, therefore, revealed that the method of directly lifting epiglottis was better at exposing glottis than the method of indirectly lifting epiglottis using a video laryngoscope.

A comparative study of glottis visualization according to the method of lifting the epiglottis in video laryngoscopy: indirect and direct lifting methods

Background@#The direct entry of the camera under the epiglottis may provide a better view of the glottis than the indirect lifting of the epiglottis by placing the Macintosh blade tip on the vallecula when using the video laryngoscope. This study aimed to compare the efficiency of two different methods of lifting the epiglottis during the visualization of glottis using video laryngoscopy in the same patient. @*Methods@#This prospective study enrolled 60 patients who underwent general anesthesia with tracheal intubation. In each patient, glottic views were obtained by directly (group DE) and indirectly lifting the epiglottis (group IE). These two methods were compared using the modified Cormack and Lehane grade and the percentage of glottis opening (POGO) score as assessment parameters. @*Results@#Modified Cormack and Lehane grade showed a significant difference between the groups DE and IE (P = 0.004). The difference in the POGO score between the groups DE and IE was also statistically significant (87.5% and 64.4%, respectively; P < 0.001). @*Conclusions@#Our results, therefore, revealed that the method of directly lifting epiglottis was better at exposing glottis than the method of indirectly lifting epiglottis using a video laryngoscope.

Invisible perforation during an endoscopic procedure of the esophagus under general anesthesia - A case report -

Background@#Endoscopic procedures of the esophagus are more complicated than those of other regions of the gastrointestinal tract. They have a relatively long procedure time and high risk of complications, such as perforation and bleeding. Perforations that occur during the procedure can accompany pneumoperitoneum and pneumomediastinum through leakage of insufflation air and cause severe ventilatory impairment.Case: A 58-year-old male patient underwent enucleation of leiomyoma in the esophagus using endoscopy under general anesthesia. Ventilatory impairment occurred 15 min after commencement of the procedure. Subsequently, subcutaneous emphysema and severe abdominal distension were observed. We suggested the possibility of microperforation during the procedure to the endoscopist, and he performed endoscopic clipping around the excision site of leiomyoma. @*Conclusions@#Providing anesthetic care by anesthesiologists during endoscopic procedures is considered necessary for patient safety. Complications of endoscopic procedures can be detected and managed early without sequelae during anesthetic care.

Comparison of chemical pregnancy rates according to the anesthetic method during ultrasound-guided transvaginal oocyte retrieval for in vitro fertilization: a retrospective study

Background@#Oocyte retrieval is the most important procedure in in vitro fertilization (IVF). Various anesthetic methods are used to control a patient’s anxiety and pain during IVF; however, there are no recommended anesthetic methods at present. In this study, we retrospectively investigated chemical pregnancy rates according to the anesthetic method used for oocyte retrieval. @*Methods@#We reviewed records of patients who underwent oocyte retrieval between January 1, 2012 and December 31, 2017. Patients were divided into the spinal anesthesia (SA) and monitored anesthesia care (MAC) groups. The primary outcome was chemical pregnancy rate after IVF. @*Results@#The study included 95 patients. SA was administered in 77 (81%) and MAC in 18 (19%). The overall chemical pregnancy rate was 32.6% (31/95). According to the anesthetic method, the pregnancy rate was 32.5% (25/77) in the SA group and 33.3% (6/18) in the MAC group. There was no statistical difference in the pregnancy rate between the groups (P = 0.575). The procedural time was significantly shorter in the SA group than in the MAC group (P < 0.001). @*Conclusions@#Chemical pregnancy rates were not significantly different between the SA and MAC groups. However, the procedure duration was shorter in the SA group than in the MAC group.

Refractory intercostal neuralgia due to intercostal schwannoma: A case report

Intercostal neuralgia is neuropathic pain that develops in the thorax and abdomen. It usually occurs as a result of injury or inflammation associated with the intercostal nerve triggered by trauma, surgery, or herpes zoster. Primary intercostal neuroma is a rare cause of intercostal neuralgia. A 69-year-old male patient without a history of thoracic trauma or surgery underwent repeated testing and intermittent treatment for refractory pain in the right chest and abdomen for several years. However, the treatment had limited effect. Abdominal computed tomography performed to diagnose recent pain aggravation revealed schwannoma of the 11th intercostal nerve. The patient's pain was relieved following surgical excision of the tumor.

Postherpetic Neuralgia Aggravated by Upper Complete Denture / 이화의대지

Postherpetic neuralgia (PHN) is a chronic and refractory pain disease. It requires longterm treatment and follow-up. Comorbid diseases can change or aggravate the pain condition and responsiveness of patients to PHN treatment. In such cases, the cause of pain should be identified through proper testing, and appropriate treatment should be administered. Herein, we report the case of a 67-year-old man with PHN in the maxillary nerve. As the pain was being controlled with medication and infraorbital nerve block, the patient experienced deterioration of pain caused by a newly worn upper complete denture. The patient's pain was relieved following correction of the upper complete denture.

Intradermal skin tests for rocuronium and cisatracurium in patients with a history of allergy: a retrospective study / 대한마취과학회지

BACKGROUND: Neuromuscular blocking agents (NMBAs) are a leading cause of perioperative anaphylaxis. However, the performance of systematic screening skin tests to detect reactions for NMBAs prior to general anesthesia is not recommended. We retrospectively examined intradermal tests (IDTs) for rocuronium and cisatracurium in patients with a history of allergy. METHODS: We reviewed the records of patients who underwent IDTs for NMBAs between January 1 and December 31, 2016. We analyzed the patients’ allergy histories and skin test results for NMBAs. RESULTS: The overall prevalence of positive IDTs was 5.8% (26/451), and there was no significant difference in prevalence among allergy types (P = 0.655). In logistic regression analysis, there was no allergy history that had a significant effect on positive IDT for NMBAs. CONCLUSIONS: We found no association between allergy history and positive skin test for NMBAs. Therefore, a systematic screening test for NMBAs or other anesthetic agents before anesthesia is not considered necessary even in patients with an allergy history.

Diagnosis of diaphragmatic paralysis using ultrasound in a cervical herpes zoster patient: A case report

Herpes zoster is a varicella-zoster virus reactivation that is characterized by pain and rash. It can cause motor paresis on affecting muscles, but diaphragmatic paralysis is a rare complication. Methods of evaluation of diaphragmatic paralysis include plain radiography, fluoroscopy and electroneurography. The direct movement of diaphragmatic muscles on ultrasound can also be used to diagnose diaphragmatic paralysis. We reported a case of a 72-year-old woman who developed left hemidiaphragmatic paralysis after herpes zoster. The diaphragmatic paralysis occurred 3 weeks after appearance of a typical skin rash on the left C4-5 dermatomes. We diagnosed diaphragmatic paralysis using ultrasound.

Nerve injury in an undiagnosed adult tethered cord syndrome patients following spinal anesthesia: A case report

Spinal anesthesia is a safe and widely used procedure. Spinal cord injury is a rare but serious complication from spinal anesthesia occurs, unexpectedly. Risks of direct neural injury from spinal anesthesia increase in tethered cord syndrome that the spinal cord is tethered by the inelastic structure and is, also, extended to the lower lumbar vertebra. A 52-years-old female patient undergoing anti-incontinence surgery developed neurologic symptoms following spinal anesthesia. The low-lying conus (L5 body level) and tethered cord were found during the assessment of neurological symptoms.

Comparison of palonosetron with ondansetron in prevention of postoperative nausea and vomiting in patients receiving intravenous patient-controlled analgesia after gynecological laparoscopic surgery / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) are common complications after anesthesia and surgery. This study was designed to compare the effects of palonosetron and ondansetron in preventing PONV in high-risk patients receiving intravenous opioid-based patient-controlled analgesia (IV-PCA) after gynecological laparoscopic surgery. METHODS: One hundred non-smoking female patients scheduled for gynecological laparoscopic surgery were randomly assigned into the palonosetron group (n = 50) or the ondansetron group (n = 50). Palonosetron 0.075 mg was injected as a bolus in the palonosetron group. Ondansetron 8 mg was injected as a bolus and 16 mg was added to the IV-PCA in the ondansetron group. The incidences of nausea, vomiting and side effects was recorded at 2 h, 24 h, 48 h and 72 h, postoperatively. RESULTS: There were no significant differences between the groups in the incidence of PONV during 72 h after operation. However, the incidence of vomiting was lower in the palonosetron group than in the ondansetron group (18% vs. 4%, P = 0.025). No differences were observed in use of antiemetics and the side effects between the groups. CONCLUSIONS: The effects of palonosetron and ondansetron in preventing PONV were similar in high-risk patients undergoing gynecological laparoscopic surgery and receiving opioid-based IV-PCA.

Pulsed radiofrequency lesioning of the median nerve in a patient with bilateral carpal tunnel syndrome: A case report

Carpal tunnel syndrome, compression of the median nerve in the carpal tunnel at the wrist, is the most common entrapment syndrome of peripheral nerve. It is characterized by sensory and motor symptoms and signs in the distribution of the median nerve. Radiofrequency thermocoagulation is a neuroablative treatment for various chronic pain disorders, but is associated with neural injury, neuritis, and occasional neuroma. Unlike RF, pulsed radiofrequency, the use of the high current intensity and electrical fields, has been proposed for the modulation of the excited nervous system pathway of pain without neuro-destruction and other potential complications. We report a case of bilateral carpal tunnel syndrome that was relieved after PRF lesioning of both median nerves.

Comparison of palonosetron with ondansetron in preventing postoperative nausea and vomiting after thyroidectomy during a 48-hour period

BACKGROUND: Postoperative nausea and vomiting (PONV) are common complications after general anesthesia. This study compared the effects of palonosetron and ondansetron in preventing PONV in patients undergoing thyroidectomy. METHODS: 100 non-smoking female subjects were randomly assigned to a palonosetron group (n = 50) or an ondansetron group (n = 50). The patients of each group received 0.075 mg of palonosetron or 8 mg of ondansetron through intravenous bolus injection before induction of general anesthesia. The incidence of nausea and vomiting were monitored at 2 h, 24 h and 48 h after operation. RESULTS: The incidence of PONV during 48 h after operation had no significant differences between the groups. However, the incidence of nausea was lower in the palonosetron group than in the ondansetron group (34% vs. 56%, P = 0.027). No differences were observed in incidences of vomiting, use of antiemetics and adverse events between the groups. CONCLUSIONS: Palonosetron was more effective than ondansetron in preventing nausea for patients undergoing thyroidectomy. However, the effect of palonosetron or ondansetron in preventing PONV was similar.

Acute-on-chronic subdural hematoma by spinal anesthesia in a patient with undiagnosed chronic subdural hematoma: A case report / 대한마취과학회지

Subdural hematoma is a serious but rare complication of spinal anesthesia. A 70-year-old woman patient underwent elective total knee replacement under spinal anesthesia. At 4 days postoperatively, the patient complained of headache and vomiting. Brain computed tomography revealed an acute-on-chronic subdural hematoma with midline shift. The patient recovered completely after surgical decompression. We report a patient with an undiagnosed chronic subdural hematoma, who developed acute-on-chronic subdural hematoma after spinal anesthesia.

Spinal Nerve Root Swelling Mimicking Intervertebral Disc Herniation in Magnetic Resonance Imaging: A Case Report

A herniated intervertebral disc is the most common type of soft tissue mass lesion within the lumbar spinal canal. Magnetic resonance imaging (MRI) is a useful tool for the assessment of patients with lower back pain and radiating pain, especially intervertebral disc herniation. MRI findings of intervertebral disc herniation are typical. However, from time to time, despite an apparently classic history and typical MRI findings suggestive of disc herniation, surgical exploration fails to reveal any lesion of an intervertebral disc. Our patient underwent lumbar disc surgery with the preoperative diagnosis of lumbar disc herniation; however, nothing could be found during the surgical procedure, except a swollen nerve root.

Comparison between the index finger insertion and catheter-guided insertion techniques for airway placement of a ProSeal(TM) laryngeal mask by inexperienced personnel / 대한마취과학회지

BACKGROUND: Insertion of a ProSeal(TM) laryngeal mask airway (PLMA(TM)) by experienced users was more successful with using a catheter-guided (CG) technique than a digital technique. The purpose of this study is to assess the efficacy of the CG insertion technique for a PLMA(TM) by inexperienced personnel. METHODS: Forty patients aged 18-65 yr and who were undergoing general anesthesia were randomly allocated to the index finger (IF) or CG insertion techniques for PLMA(TM) insertion. The IF technique was performed with the routine insertion technique. The CG technique was performed using a catheter inserted PLMA(TM), which was primed into the drain tube of the PLMA(TM) with using a soft flexible catheter. Successful insertion was primarily judged by the clinical function of the airway. The number of insertion attempts and the insertion time were recorded. Postoperative airway morbidity (sore throat, dysphonia, dysphagia) was assessed at 24 hr postoperatively. RESULTS: The success rate was similar between the groups (IF, 18/20; CG, 15/20). The successful insertion time (the time to provide an effective airway) was similar between the groups but the insertion time at the first attempt was shorter for the IF technique (IF, 21.6 +/- 5.3 s; CG, 27.4 +/- 10.3 s). There were no differences between the groups for the postoperative airway morbidity. CONCLUSIONS: This study suggests that the CG insertion technique is not a useful alternative technique for inexperienced personnel.

Evaluation of the Spreading Effect of Injection Volume due to Use of the Modified Injection Technique in Stellate Ganglion Block / 대한마취과학회지

BACKGROUND: Stellate ganglion block (SGB) results in a sympathetic block of the head, neck, and upper extremities. In a previous study, the modified injection technique (MIT) was found to exert a better sympathetic block effect on the upper extremities than the classic injection technique (CIT). Therefore, this study was conducted to evaluate the spreading effect of injection volume when the MIT was used in the paratracheal SGB at the 6th cervical level. METHODS: One hundred patients were equally divided into 4 groups. Patients in Groups I, II, and III were subjected to paratracheal SGB at the 6th cervical level with 6 ml, 8 ml, 10 ml of 0.5% mepivacaine administered using the CIT, respectively, whereas patients in Group IV were subjected to block with 6 ml of 0.5% mepivacaine by the MIT using a method such as strong pressure at the cephalad portion of the needle entry point. The skin temperature of the second finger was measured before and after SGB, and the occurrence of warm sensation on the face and upper extremities, and the occurrence of hoarseness were evaluated. RESULTS: The increase in the skin temperature of patients in Groups I, II, III, and IV were 0.28 +/- 0.29, 0.52 +/- 0.58, 0.82 +/- 0.77, and 0.80 +/- 0.72, respectively, with the increases in skin temperature observed in the Groups III and IV being statistically significant when compared to Group I (P < 0.05). There were no significant differences observed in the occurrence of warm sensations on the face and upper extremities, or in the occurrence of hoarseness among the groups. CONCLUSIONS: The results of this study could not differentiate the spreading effect of injection volume that occurred when the MIT was used from the effect that occurred as a result of injection of 8 or 10 ml using the CIT. However, the MIT showed better sympathetic block on the upper extremities than the CIT when the same volume was used. Taken together, these results suggest that the spread effect of 6 ml administered by MIT is similar to that of 10 ml administered by CIT.

The malfunction of self-inflating bag resuscitator due to mis-assembly: A case report / 대한마취과학회지

A self-inflating bag resuscitator is universally used to ventilate patients during cardiopulmonary resuscitation and transfer. This device can be reused after sterilization and reassembly, and the mis-assembly of a resuscitator can possibly happen. We report here on a case of mis-assembly of a resuscitator valve that resulted to barotrauma and instability of a patient.