Attenuation of pneumoperitoneum-induced hypertension by intra-peritoneal lidocaine before pneumoperitoneum in laparoscopic cholecystectomy / 영남의대학술지

BACKGROUND: We have previously found that intra-peritoneal lidocaine instillation before pneumoperitoneum attenuates pneumoperitoneum-induced hypertension. Whether this procedure alters patient's hemodynamic status during operation should be determined for clinical application. This study elucidated the possible mechanism of the attenuation of the pneumoperitoneum-induced hypertension by intra-peritoneal lidocaine before pneumoperitoneum. METHODS: Thirty-four patients underwent laparoscopic cholecystectomy (LC) were randomly allocated into two groups. After induction of general anesthesia, 200 mL of 0.2% lidocaine (lidocaine group, n=17), or normal saline (control group, n=17) were sub-diaphragmatically instilled 10 minutes before pneumoperitoneum. The changes in systolic blood pressure, heart rate, central venous pressure, stroke volume, cardiac output, and systemic vascular resistance were compared between the groups. The number of analgesics used during post-operative 24 h was compared. RESULTS: Systolic blood pressure was elevated during pneumoperitoneum in both groups (p<0.01), but the degree of elevation was significantly reduced in the lidocaine group than in the control (p<0.01). However, stroke volume and cardiac output were decreased and systemic vascular resistance was increased after induction of pneumoperitoneum (p<0.05) without statistical difference between two groups. The number of analgesics used was significantly reduced in the lidocaine group (p<0.01). CONCLUSION: These data suggest that intra-peritoneal lidocaine before pneumoperitoneum does not alter patient's hemodynamics, and attenuation of pneumoperitoneum-induced hypertension may be the consequence of reduced intra-abdominal pain rather than the decrease of cardiac output during pneumoperitoneum. Therefore, intra-peritoneal lidocaine instillation before pneumoperitoneum is a useful method to manage an intraoperative pneumoperitoneum-induced hypertension and to control postoperative pain without severe detrimental hemodynamic effects.

Clinical Significance of Fecal Lactoferrin and Multiplex Polymerase Chain Reaction in Patients with Acute Diarrhea

BACKGROUND/AIMS: The diagnostic yield of fecal leukocyte and stool cultures is unsatisfactory in patients with acute diarrhea. This study was performed to evaluate the clinical significance of the fecal lactoferrin test and fecal multiplex polymerase chain reaction (PCR) in patients with acute diarrhea. METHODS: Clinical parameters and laboratory findings, including fecal leukocytes, fecal lactoferrin, stool cultures and stool multiplex PCR for bacteria and viruses, were evaluated prospectively for patients who were hospitalized due to acute diarrhea. RESULTS: A total of 54 patients were included (male, 23; median age, 42.5 years). Fecal leukocytes and fecal lactoferrin were positive in 33 (61.1%) and 14 (25.4%) patients, respectively. Among the 31 patients who were available for fecal pathogen evaluation, fecal multiplex PCR detected bacterial pathogens in 21 patients, whereas conventional stool cultures were positive in only one patient (67.7% vs 3.2%, p=0.000). Positive fecal lactoferrin was associated with presence of moderate to severe dehydration and detection of bacterial pathogens by multiplex PCR (21.4% vs 2.5%, p=0.049; 100% vs 56.5%, p=0.032, respectively). CONCLUSIONS: Fecal lactoferrin is a useful marker for more severe dehydration and bacterial etiology in patients with acute diarrhea. Fecal multiplex PCR can detect more causative organisms than conventional stool cultures in patients with acute diarrhea.

Crohn's Disease Initially Accompanied by Deep Vein Thrombosis and Ulnar Neuropathy without Metronidazole Exposure

Extraintestinal manifestations are not uncommon in Crohn's disease, and a thromboembolic event is a disastrous potential complication. Deep vein thrombosis is the most common manifestation of a thromboembolic event and typically occurs in association with active inflammatory disease. Peripheral neuropathy in Crohn's disease has rarely been reported and is considered an adverse effect of metronidazole therapy. Here, we describe a patient who was initially diagnosed with Crohn's disease complicated with deep vein thrombosis and ulnar neuropathy without metronidazole exposure. The simultaneous occurrence of these complications in the early stage of Crohn's disease has never been reported in the English literature.

Fluid balance in late preterm infants with prenatal gastrointestinal pathology: a report of two cases / 대한마취과학회지

Intestinal obstruction was diagnosed in two fetuses at maternal antenatal care. Both received emergency surgery on the day of their birth, at about 35 weeks gestational age. The disease progressed for a long time in both cases because prompt diagnosis and surgery are difficult to perform in utero. As a result, severe adhesion and distorted anatomy were observed in both cases. Massive third space losses and bleeding were predicted during the surgery. However, the accurate ongoing losses were difficult to anticipate. The assessment of fluid deficits cannot be based on measured losses alone, but hemodynamic status including blood pressure, heart rate, urine output, capillary refill, and/or central venous pressure should be evaluated additionally.

The comparison of feasibility and safety on fiberoptic guided intubation under conscious sedation with remifentanil and propofol / 대한마취과학회지

BACKGROUND: Oropharyngeal manipulation is problematic when patients have a gag reflex. Sedation can suppress gag reflex, but can cause serious airway problems. We compared remifentanil (Group R) and propofol (Group P) in terms of cooperation and loss of gag reflex, while drugs were administered incrementally using target controlled infusion (TCI). METHODS: Fifty seven patients who required awake fiberoptic intubation were randomized to Group R or Group P. After measurement of baseline gag trigger point index (GTPI), TCI was set to effect-site concentration (Ce) of 1 ng/ml (Group R) or 1 microg/ml (Group P), then titrated by 0.5 increment until GTPI score reached 0. The incidence of drop-out and decreased cooperation, Ramsay sedation scale (RSS) and Ce at loss of GR, and complications were assessed. RESULTS: Seven patients were dropped out in Group P due to deep sedation and disobedient behavior, but none in Group R (P = 0.015). Gag reflex suppressed as RSS increased in both groups (P < 0.001), however, the incidence of elimination of gag reflex clustered at RSS 2 in Group R (P < 0.001), whereas it was evenly distributed in Group P (P = 0.20). The incidence of patients who were spontaneously roused (gag reflex elimination at RSS 1 and 2) were higher in Group R than in Group P (P = 0.002). CONCLUSIONS: Deep sedation and impaired cooperation were observed only in Group P and spontaneously roused patients were higher in Group R, suggesting that remifentanil is more suitable for cooperative elimination of GR.

An Acute Postoperative Intractable Hyperventilation after an Endoscopic Third Ventriculostomy

This report describes a rare case of postoperative hyperventilation attack after an endoscopic third ventriculostomy in a 46-year-old woman. About 60 min after the termination of the operation, an intractable hyperventilation started with respiratory rate of 65 breaths/min and EtCO2, 16.3 mm Hg. Sedation with benzodiazepine, thiopental sodium, fentanyl, and propofol/remifentanil infusion was tried under a rebreathing mask at a 4 L/min of oxygen. With aggressive sedative challenges, ventilation pattern was gradually returned to normal during the 22 hrs of time after the surgery. A central neurogenic hyperventilation was suspected due to the stimulating central respiratory center by cold acidic irrigation solution during the neuroendoscopic procedure.

An abrupt supraglottic obstruction during the induction of general anesthesia due to a rapid growing laryngeal tumor: A case report

A 68-year-old woman with laryngeal tumor was scheduled for a biopsy under the general anesthesia. As dyspnea or stridor was not present and half of the laryngeal opening could be easily seen by preoperative bronchoscopy which took one month prior to the surgery, anesthesia was induced with sedatives and muscle relaxant in stepwise patterns. However, an impending total airway obstruction developed after muscle relaxant administration and emergency tracheostomy became unwanted necessity. Since a laryngeal tumor could grow large enough to make trouble in general anesthesia in a short period of time from diagnosis to operation, preoperative anticipation of airway compromise, reevaluation just before the anesthesia, communication with all operating team workers, and prompt management were needed to avoid dread complications.

The Efficacy of Short-term Administration of Revaprazan on Gastroesophageal Reflux Symptoms: Comparison with Half Dose Esomeprazole, a Pilot Study

BACKGROUND/AIMS: Revaprazan, an acid pump antagonist, is a kind of gastric acid suppressant and is prescribed for the treatment of peptic ulcers and gastritis. However, the efficacy of revaprazan on gastroesophageal reflux symptoms has not been established. The aim of this study was to evaluate the short-term efficacy of revaprazan on gastroesophageal reflux symptoms. MATERIALS AND METHODS: Patients who complained of gastroesophageal reflux symptoms without any specific diseases except gastritis on esophagogastroduodenoscopy were included in this study. Patients were randomized to receive revaprazan 200 mg or esomeprazole 20 mg for 2 weeks. Symptoms were assessed by using the frequency score questionnaire before and after treatment. RESULTS: Fifteen patients received revaprazan and 19 patients received esomeprazole. The changes of the symptom frequency score before and after treatment were 7.0 in revaprazan group and 8.6 in esomeprazole group (P=0.778). CONCLUSIONS: Revaprazan is not inferior to esomeprazole in therapeutic efficacy for gastroesophageal reflux symptoms and is a safe and useful therapeutic agent to reduce the frequency of gastroesophageal reflux symptoms.

The Effect of Co-Administration of Rebamipide on the Expression of Serum Gastrin in Long-term Proton Pump Inhibitor Users: A Prospective Pilot Study

BACKGROUND/AIMS: In one animal study, co-administration of rebamipide with proton pump inhibitors (PPIs) could suppress hypergastrinemia but there have been no such reports on humans. The aim of this study was to evaluate whether rebamipide could prevent hypergastrinemia in long-term PPI users. MATERIALS AND METHODS: Patients who were diagnosed with reflux esophagitis endoscopically were enrolled in this study. In the control group, lansoprazole 30 mg was administered for 8 weeks and in the rebamipide group, lansoprazole 30 mg with rebamipide 300 mg was administered for 8 weeks. Serum gastrin level was checked before and after administration of the drugs. RESULTS: Thirty patients were enrolled in this study. The control group included 17 patients and the rebamipide group included 13 patients. The gastrin level was elevated in the control group (28.4 pg/mL) compared to the rebamipide group (38.5 pg/mL). However, the gastrin level was decreased in 3 patients in the rebamipide group (23.1%) compared to 2 patients in the control group (11.8%). CONCLUSIONS: Not all patients who are taking PPIs develop hypergastrinemia. Co-administration of rebamipide with PPI does not affect the serum gastrin level.

Anesthetic management of non-cardiac surgery with adult onset type of cor triatriatum sinister: A case report / 대한마취과학회지

A 45-year-old woman with cor triatriatum sinister was admitted for laparoscopic resection of an ovarian tumor. Her medical history was benign with the exception of a single episode of syncope one year ago. A 1.5-cm membrane fenestration was found on echocardiography, but there were no other cardiac structural anomalies. General anesthesia was established with etomidate, sevoflurane, and remifentanil; no notable events occurred during the anesthesia. As cor triatriatum shows a clinical picture of mitral stenosis (MS), careful anesthetic management is required.

A Case of Renal Angiomyolipoma with Lymph Node-Associated Elevation of Tumor Markers / 대한내과학회지

Angiomyolipoma is a rare, benign, mesenchymal hamartomatous neoplasm consisting of a mixture of adipose tissue, smooth muscle cells, and anomalous blood vessels. The kidney is a common origin site, but extrarenal angiomyolipoma has been reported. Simultaneous involvement of the kidney and regional lymph nodes is uncommon, and may be confused with a metastatic malignant lymph node. Lymph node involvement in angiomyolipoma represents a multifocal invasion of the tumor, rather than metastatic disease. Tumor markers usually associate with malignancy but they have sometimes been detected in benign conditions. We report a case of bilateral renal angiomyolipoma with tuberous sclerosis simultaneously involving regional lymph nodes confused with metastatic malignant lymph node enlargement due to associated elevation of serum tumor markers.

An Anomalous Right Coronary Artery Originating From the Distal Left Circumflex Artery: A Case Report / 대한내과학회지

Single coronary artery (SCA) is a rare congenital anomaly and commonly associated with other congenital cardiac malformations. Some subgroups of SCA can lead to angina pectoris, acute myocardial infarction, or even sudden cardiac death in the absence of atherosclerosis. An anomalous origin of the right coronary artery, arising from the distal portion of the left circumflex artery, has previously been reported in a few cases. In this article, we report a case of a right coronary artery arising from the distal portion of the left circumflex artery with no other cardiac congenital anomaly.

Clinical manifestations and anesthetic management of Kearns-Sayre syndrome: A case report

Kearns-Sayre syndrome (KSS) is a mitochondrial disorder resulting in multi-system dysfunction. A 14-year-old boy with KSS underwent external levator muscle resection for correction of ptosis. There were no abnormalities on the pre-operative evaluation, except for low-grade heart block and ocular problems. General anesthesia was conducted with a minimum dose of thiopental sodium and sevoflurane under close monitoring, and a laryngeal mask was inserted without muscle relaxation. The surgery was uneventful; however, a careful approach was required during anesthesia because life-threatening complications may occur in patients with KSS.

Hyperamylasemia following the trans-sphenoidal resection of pituitary tumor: can propofol-remifentanil TIVA cause postoperative hyperamylasemia?: A case report

The trans-sphenoidal resection of a recurred pituitary tumor was performed in a 42 years old man under general anesthesia with propofol and remifentanil. Neither massive bleeding nor hypotension was observed intraoperatively, but bradycardia was sustained over five hours. The patient did not suffer from hypertriglyceridemia and there was no evidence of drug toxicity or vigorous intervention during the surgery, however hyperamylasemia was observed one day after the surgery. It is presumed that vagal stimulation by propofol and remifentanil infusion might induce bradycardia and abnormal pancreatic enzyme secretion consequently.

A Case of Citrobacter braakii Sepsis Complicated with Hepatocellular Carcinoma / 감염과화학요법

Citrobacter species is a gram-negative bacilli that can cause opportunistic infections in immunocompromised hosts. Citrobacter braakii refers to the genomospecies 6 of the Citrobacter freundii complex. There are no detailed studies on infections caused by this newly identified specific genetic species in Korea. We herein report a case of a patient with hepatocellular carcinoma who, after undergoing transcatheter arterial chemoembolization, developed biloma which later progressed to C.braakii sepsis and did not respond to treatment. To our knowledge, this is the first reported case in Korea on C. braakii infection resulting in septic shock in a patient with malignancy in Korea.

Functional MRI findings showing cortical reorganization in a patient with type 2 complex regional pain syndrome: A case report / 대한마취과학회지

The patients suffering with complex regional pain syndrome (CRPS) reveal sensory, motor and autonomic abnormalities. The pathogenesis of CRPS is poorly understood. Some recent studies have reported that the functional magnetic resonance image (fMRI) findings support that cortical reorganization occurred in the patients with CRPS. We compared the cortical responses on fMRI in a 54-year-old right-handed male patient who suffered with type 2 CRPS on his left hand following an injury 4 years ago. He complained of severe pain and allodynia on the left hand that spread up to the left chest, and he showed abnormal involuntary movement and significant hypothermia on the left hand. The fMRI findings, when a mechanical stimulus was applied on both hands with a brush, showed significantly increased abnormal cortical responses on the primary and secondary somatosensory areas and the distinct parietal association area on the contra-lateral side of the brain to the stimuli on the affected painful hand relative to the stimuli on the unaffected hand. We report on the fMRI findings showing the cortical reorganization in a patient with type 2 CRPS.

Effects of Remifentanil on Hemodynamic Responses of Exogeneous Epinephrine during Endoscopic Sinus Surgery / 대한마취과학회지

BACKGROUND: Epinephrine is commonly used to reduce bleeding by constriction of nasal vessels in endoscopic sinus surgery. However, when it absorbs to other organs systemically, tachycardia and hypertension may occur and result in more bleeding. This study is performed to evaluate the dose response effects of remifentanil infusion to suppress these adverse responses without delaying emergence. METHODS: Sixty healthy patients who scheduled for endoscopic sinus surgery were randomly allocated into three groups by the dose of remifentanil infusion. For induction and maintenance of anesthesia, 0.05, 0.15, 0.25microgram/kg/min of remifentanil and 3.5microgram/ml of intravenous propofol by TCI were infused to each group. Systolic and diastolic blood pressure, heart rate and bispectral index were measured for 15 minutes at the 1 minute intervals after nasal packing of epinephrine. RESULTS: Systolic and diastolic blood pressure in R0.15 and R0.25 group were significantly lower compared to R0.05 group during 9 to 12 minutes after epinephrine packing, but heart rate and bispectral index were not significantly different among the groups. The frequency of hypotension and bradycardia were significantly higher in R0.25 than R0.05 and R0.15. CONCLUSIONS: Continuous infusion of 3.5microgram/ml of propofol with 0.15microgram/kg/min of remifentanil attenuate hypertension and tachycardia induced by epinephrine with little side effects.

Risk Factors of Acute Renal Failure after Colorectal Surgery / 영남의대학술지

BACKGROUND: Acute renal failure is one of the leading causes of postoperative morbidity and mortality. The purpose of this study was to determine the risk factors that are associated with acute renal failure after colorectal surgery. MATERIALS AND METHODS: Five hundred seventy patients who operated colorectal surgery at the Yeungnam University Medical Center over three years from 2004 to 2006 were enrolled in this study. The effects of gender, age, ASA classification, concomitant disease, surgery type and duration, reoperation, urogenital manipulation, medication, hypotension, hypovolemia, transfusion, and postoperative ventilatory care on the occurrence of acute renal failure after colorectal surgery were studied. RESULTS: The major risk factors of acute renal failure after colorectal surgery were age of patients (P=0.003), ASA classification (P<0.001), concomitant disease (P<0.001), duration of the time surgery (P=0.034), reoperation (P=0.001), use of intraoperative diuretics (P=0.005), use of postoperative diuretics (P<0.001), intraoperative hypotension (P=0.018), intraoperative transfusion (P<0.001), postoperative transfusion (P<0.001), and postoperative ventilatory care (P=0.001). CONCLUSION: Multiple factors cause synergistic effects on the development of acute renal failure after colorectal surgery. Therefore, efforts to reduce the risk factors associated with acute renal failure are needed. In addition, intensive postoperative care should be provided to all patients.

Anaphylaxis after Injection of Rocuronium: A case report / 대한마취과학회지

Anaphylaxis is one of major causes of morbidity and mortality during anesthesia. Even when treated appropriately, these reactions are usually unpredictable and potentially life-threatening. A 26-year-old male patient, who had previously undergone surgery under general and spinal anesthesia twice without any problems, was scheduled for a reconstruction of the anterior cruciate ligament. Lidocaine, thiopental sodium and rocuronium were injected sequentially to induce general anesthesia. Two minutes after the rocuronium injection, severe hypotension, tachycardia and bronchospasm developed, and delayed skin rashes appeared. These unexpected events resulted in the operation being aborted. The patient recovered without any significant complications under immediate proper intensive care.

Effects of Uncooked Powdered Food on Antioxidative System and Serum Mineral Concentrations in Rats Fed Unbalanced Diet

Antioxidative function of uncooked powdered food (Sangsik) was evaluated in rats consuming nutritionally unbalanced diet including 1% cholesterol, high proportion of animal lipids (lard : soybean oil : 8 . 2) , sub-optimal levels of vitamin and mineral mixture along with 0.5% ethanol in drinking water. The uncooked powdered food tested in the present study was a mixture composed of 42 kinds of plant foods (cereals, legumes, seaweeds, vegetables, and fruits) supplemented with vitamins and minerals, and dietary fiber. Control rats were fed the semi-purified diet based on the AIN-93G composition, and nutritionally unbalanced rats were divided into 3 groups, and fed one of the following diets with 0.5% ethanol in drinking water for 5 weeks : unbalanced control diet (UC) ,20% Sangsik powder supplemented diet (S20), and 40% Sangsik powder supplemented diet (S40) . Food efficiency ratio was significantly higher in rats fed S40 compared to the value for rats fed UC (p<0.05). Hepatic level of thiobarbituric acid reactive substances (TBARS) was significantly lower in rats fed UC compared to that for control rats (p<0.05), and was not influenced by dietary supplementation of the Sangsik powder. Hepatic superoxide dismutase (SOD) activity was significantly higher in rats fed UC compared to that for control rats (p<0.05), and significantly reduced in rats fed S20 or S40 compared to the value for unbalanced control rats. Feeding unbalanced control diet significantly reduced the ratio of hepatic GSH-Px + catalase/SOD activities compared to the value for control rats, and this decrease in the ratio of antioxidant enzyme activities was reversed by adding the Sangsik powder to the diet at 20% (p<0.05) . Based on the results of antioxidant enzyme activities, feeding uncooked powdered diet appears to provide a favorable environment for body's antioxidative defense mechanism. Serum levels of Fe and Cu were significantly lower in rats fed the Sangsik powder supplemented diets compared to the value for unbalanced control rats (p<0.05), and levels of Se, Mn, and Zn were also tended to be decreased by dietary supplementation of the Sangsik powder. These results postulate the possibility that ingredients used in the uncooked powdered food may decrease the bioavailability of trace elements in rats.