Cutaneous leukocytoclastic vasculitis due to anti-tuberculosis medications, rifampin and pyrazinamide

Anti-tuberculosis drugs frequently result in cutaneous adverse reactions, including pruritus, maculopapular exanthems, and urticaria. However, anti-tuberculosis drug-associated cutaneous leukocytoclastic vasculitis (CLV) has been rarely reported. We describe a case of CLV induced by rifampin and pyrazinamide. A 38-year-old male had been diagnosed with pulmonary tuberculosis two months ago and then he started standard anti-tuberculosis therapy with isoniazid, rifampin, ethambutol, and pyrazinamide. Purpuric lesions developed in the extremities after 1.5 months of anti-tuberculosis medication; the lesions progressively spread over the entire body. Histopathology of the purpuric skin lesion was consistent with leukocytoclastic vasculitis. The skin lesion improved after cessation of anti-tuberculosis medications and treatment with oral corticosteroids and antihistamines. Anti-tuberculosis drugs were rechallenged one at a time over 3 days. Purpura recurred on the right forearm and forehead after taking 300 mg of rifampin. The skin lesion disappeared after taking oral prednisolone. Finally, 1,500 mg of pyrazinamide was readministrated, and then purpuric lesions recurred on both forearms. This report describes a case of leukocytoclastic vasculitis secondary to rifampin and pyrazinamide therapy.

Vasovagal Syncope during a Caudal Epidural Block in a Patient with Vertebral Fractures: A case report / 대한마취과학회지

Age-related vertebral fractures occur frequently in the elderly recently. An epidural block has been introduced as an effective management for the treatment of pain with vertebral compression fractures. While an epidural block is considered to be reasonably safe, serious complications may occur even when this invasive procedure is related to pain. Vasovagally mediated episodes of hypotension and bradycardia are thought to be a common cause of recurrent unexplained syncope. Precipitating factors include pain, trauma, fatigue, blood loss, or prolonged motionless standing. We report one case of vasovagal syncope associated with severe bradycardia and hypotension in a 78 year-old male patient with vertebral fractures. Syncopal attacks occurred during a caudal epidural block. The patient was resuscitated successfully and recovered without any adverse effects.

Status Epilepticus Following General Anesthesia in an Unrecognized Epilepsy Patient / 대한마취과학회지

Epileptic patients, who may be deprived of antiepileptic medication, are subject to stimuli that can result in seizures in the postoperative period. Status epilepticus is defined as a continuous seizure that lasts more than 30 minutes or serial seizures in which the patient does not regain a premorbid level of consciousness. Status epilepticus is considered a serious neurologic emergency that requires immediate recognition and prompt treatment to avoid life-threatening complications. We report a case in which status epilepticus developed unexpectedly after several recurrences of generalized convulsions on a 39 year old man who underwent the emergency repair of a bladder perforation. We should consider the influence of poor antiepileptic drug compliance on the precipitation of epileptic seizures when planning anesthesia for epileptic patients.

Anesthetic Management of Jehovah's Witness Parturient Undergoing Emergency Cesarean Section / 대한마취과학회지

Anesthesiologists are occasionally faced with a dilemma in managing Jehovah's witness patients who refuse transfusion of blood or blood products in life threatening situations. We report a case in which a 28-year old Jehovah's witness parturient underwent an emergency cesarean section due to complex problems of fetal distress, twin pregnancy and preeclampsia. Despite the severe anemia, she had a good postoperative recovery without any complications. We suggest that it is necessary to know the religious background, ethical issues and conflicts in caring for Jehovah's Witness patients, and be familliar with perioperative management without transfusion for these cases.

Anaphylactic Reaction after Aprotinin Reexposure: A case report / 대한마취과학회지

Aprotinin, a proteinase inhibitor, is known to significantly reduce blood loss during cardiac, thoracic and vascular surgery. Despite the wide use of this medication, there are only a few reports of anaphylactic reactions. We experienced a case of severe intraoperative anaphylactic reaction due to reexposure of aprotinin used to reduce intraoperative bleeding. During anesthesia for brain tumor removal, systemic hypotension and generalized rash were developed following the administration of aprotinin in a 34-year-old woman. We suggest that it is necessary, in patients known to have had previous aprotinin therapy, to perform skin test with diluted aprotinin before infusion.

Recurrent Intracerebral Hemorrhage after Extubation in a Hypertensive Patient: A case report / 대한구급학회지

Postoperative hypertension occurs often in hypertensive patients due to pain, hypercapnia, hypoxemia, or excessive intravascular fluid volume. In addition, tracheal extubation exacerbates hypertension and tachycardia, which leads to left ventricular failure, myocardial infarction, or cerebral hemorrhage. We experienced a case of recurrent intracerebral hemorrhage after extubation in the postanesthetic care unit. The patient was 50-year old female who underwent total abdominal hysterectomy. Three months ago, she suffered a hypertensive cerebral hemorrhage with conservative treatment. Anesthesia induction and intraoperative course were relatively uneventful. In the postanesthetic care unit, she had voluntary movement of all limbs to command and fully awake consciousness. Immediately after tracheal extubation, the blood pressure was increased sharply to 200/110 mmHg. After then, the patient's mental status was deteriorated and the motor weakness of left extremities was developed. Brain CT showed a hypertensive hemorrhage at the right putamen and emergency stereotaxic aspiration was performed. After rehabilitative treatment, the patient was discharged with alert mental status and moderate improvement of motor weakness.

Superior Vena Caval and Airway Obstruction on Induction of Anesthesia in a Patient with Anterior Mediastinal Mass: A Case Report / 대한마취과학회지

Mediastinal masses may cause life-threatening complications such as major airways obstruction, superior vena caval obstruction, and cardiac compression during general anesthesia. We present a case in which superior vena caval and airway obstruction developed at induction of anesthesia in a patient with an anterior mediastinal mass. Shortly after induction of anesthesia in the supine position, the patient became difficult to ventilate and blood began to flow upward into the IV line. The patient was immediately turned to the right lateral position and allowed to breathe spontaneously. The ventilation of patient was improved significantly and cyanosis of the face and upper extremities disappeared. We think that general anesthesia should be avoided if at all possible in patients with mediastinal mass and alternative methods of diagnosis and management are discussed.

Severe Bradycardia and Hypotension during Spinal Anesthesia in a Patient with Agent Orange Sequela: A case report / 대한마취과학회지

Various defoliant herbicides were sprayed to kill vegetation and thereby denied cover to enemy forces in Vietnam war, and the defoliant was later alleged to have caused long-lasting health problems such as cancers, birth defects, skin disorders, hepatic dysfunction, porphyria, peripheral neuropathy, and impaired immune function. We experienced a case of severe bradycardia and hypotension during spinal anesthesia for diagnostic arthroscopy in a 53-year-old Vietnam veteran with peripheral neuropathy. We concluded that it should require constant monitoring and vigilance to prevent severe cardiovascular complications during spinal anesthesia in Agent Orange sequela patients with peripheral neuropathy.

Comparison of Isoflurane and Propofol Anesthesia on Postoperative Nausea, Vomiting and Recovery after Tonsillectomy in Children / 대한마취과학회지

BACKGROUND: The purpose of this study was to compare prospectively two different anesthetic techniques with isoflurane or propofol for postoperative nausea, vomiting and recovery after tonsillectomy in children. METHODS: Sixty children, ASA physical status I, were assigned randomly to one of two groups. In group I, anesthesia was induced with thiopental 5 mg/kg and maintained with isoflurane 1~1.5 vol%. In group P, anesthesia was induced with fentanyl 1 mcg/kg, propofol 2 mg/kg and maintained with propofol infusion 5~10 mg/kg/hr. Both group received vecuronium 0.1 mg/kg for tracheal intubation and were ventilated with 33% O2 in N2O. The time to extubation, time to eye opening, PACU time, incidence and numbers of postoperative nausea and vomiting, and degree of sedation were recorded as well as perioperative complications. RESULTS: There were no significant difference in the duration of anesthesia and PACU time between two groups. The time to extubation and eye opening of group P were significantly shorter than group I (p<0.05). The degree of sedation and incidence of postoperative nausea and vomiting of group P were significantly lower than group I (p<0.05). But the frequency of intraoperative bradycardia was significantly higher in group P than group I (p<0.05). CONCLUSIONS: Propofol-fentanyl anesthesia results in less nausea and vomiting during postoperative period and more rapid recovery compared to isoflurane anesthesia and may be recommended in children undergoing tonsillectomy and adenoidectomy.

Postoperative Severe Hemorrhage Due to Disseminated Intravascular Coagulation: A case report / 대한마취과학회지

Disseminated intravascular coagulation (DIC) is a pathological syndrome in which activation of coagulation cascade leads to fibrin clot formation, consumption of platelets and coagulation factors, and secondary fibrinolysis. We report a case of severe postoperative hemorrhagic diathesis due to DIC. A 59-year-old man was scheduled for reduction of tibia fracture and anatrophic nephrolithotomy of staghorn calculi. On the fifth postoperative day, second operation was performed for nephrectomy due to perirenal hematoma. Two days later, third operation was performed for hemostasis because of the continuous bleeding. Coagulation tests showed positive DIC profiles of thrombocytopenia, hypofibrinogenemia, increased fibrin degradation products, and prolonged prothrombin time and thrombin time. The patient recovered uneventfully and discharged on the 59th postoperative day.

Comparision of Propofol and Thiopental for Electroconvulsive Therapy: Effects on Hemodynamic Changes and Intraocular Pressure / 대한마취과학회지

BACKGROUND: Electroconvulsive therapy (ECT) can produce dangerous complications, such as arrhythmias, transient hypertension, and increases in intraocular pressure. This study was designed to whether propofol, in comparision with thiopental, would attenuate these hypertensive responses and increases in intraocular pressure. METHODS: Twenty patients were studied during courses of ECT administrations, each patient receiving propofol or thiopental on different occasions. The induction dose was 1.6 mg/kg of propofol and 3 mg/kg of thiopental sodium. Mean arterial pressure, heart rate, cardiac rhythm and intraocular pressure were checked before induction (control), after administration of succinylcholine, immediately, 5 min, and 10 min after ECT administration. Recovery time was also compared between two groups. RESULTS: Mean arterial pressure was lower following propofol than thiopental (p<0.05) immediately after ECT. Heart rate was lower following propofol than thiopental (p<0.05) immediately, 5 min, and 10 min after ECT. Cardiac rhythm abnormalities were infrequent and not serious. Intraocular pressure was lower following propofol than thiopental (p<0.05) immediately, 5 min, and 10 min after ECT. Recovery time of propofol (6.5+/-0.8 min) was shorter than thiopental (7.5+/-0.9 min). CONCLUSIONS: Propofol for ECT induction would seem to be an ideal drug, as it attenuates hypertensive responses and increases in intraocular pressure.

Anaphylactoid Reactions after Thrombokinase Administration: Two cases / 대한마취과학회지

The incidence of life-threatening anaphylactoid reactions during anesthesia has been increasing. Specific allergic reactions during anesthesia are usually due to muscle relaxants, barbiturates, local anesthetics, narcotics, radiocontrast media, antibiotics, and colloids. Thrombokinase, a hemostatic agent, has been used widely in clinical practice and severe anaphylactoid reactions to thrombokinase can occur rarely. We experienced two cases of anaphylactoid reactions after thrombokinase administration.

Clinical Survey of Geriatric Anesthesia / 대한마취과학회지

Nowdays the number of geriatric patients has increased gradually and the risk for anesthesia and surgery is poor compared with younger patients because of chronic systemic diseases and aging of physiologic function. We analyzed 982 cases of geriatric anesthesia patients aged over 65 years performed at Presbyterian Medical Center from January 1992 to December 1993. The patients were evaluated according to age, sex, preoperative physical status, preoperative laborative findings, concurrent illness, anesthetic consult, department, operation site, anesthesia type, duration of anesthesia, intraoperative events, postoperative complications and mortality. The results were as follows; 1) The number of the cases older than 65 years was 982 cases(8.4%) out of total 11,629 cases. There were 548 cases(55.8%) of male and 434 cases(44.2%) of female. 2) By the classification of physical status of American Society of Anesthesiologist, the most common evidence was class 2 in 587 cases(59.8%) and emergency operation was performed in 237 cases(24.1%). 3) 520 cases(53.0%) had concurrent illness and hypertension was most common in 129 cases(24.8%). 4) Preoperative anesthetic consult was performed in 421 cases(42.9%) and the frequent consult problem was cardiovascular in 155 cases(36.8%). 5) The most common department and operation site was general surgery in 461 cases(47.0%), lower abdominal region in 265 cases(27.0%) respectively. 6) The anesthetic technique employed was usually general anesthesia; 710 cases(72.3%). 7) The intraoperative events and postoperative complications were revealed in 244 cases(24.8%), 225 cases (22.9%) respectively and hypertension was leading problem. 8) Overall mortality rate was 1.9%(19 cases). The mortality rate was 0.7% in elective cases and 5.9% in emergency cases. In conclusion, anesthesiologists should attention to perioperative management of geriatric patients to decrease the morbidity and mortality.

A Clinical Anlaysis of Anesthesia for Emergency Operation / 대한마취과학회지

The proportion of emergency operation is increasing gradually and the state of emergency patients is more critical than elective patients because of poor physical and laboratory examinations. The evaluation of perioperative data will improve the outcome of emergency operation. We analyzed l654 cases of emergency anesthesia performed at Presbyterian Medical Center from January to December 1994. The patients were evaluated clinically and/or statistically according to age and sex, ASA clssification of physical status, preoperative NPO time, day and month of operation, premedicants, department and diseases, concurrent diseases, place of preoperative patient care, time from administration of emergency room to operation room, trauma, anesthesia duration and methods, beginning time of operation, frequency of transfusion, and postoperative mortality rate. The results were as follows; 1) The percent of emergency surgery was 29.2% of total surgical patients. 2) There were 22.5% of cases whose NPO time was less than 8 hours. 3) The most common premedicant was glycopyrrolate only(32.4%). 4) 50.5% of emergency operation was performed by obstetrics and gynecology department and most common operation was Cesarean section(43.6%). 5) The most common concurrent disease was viral B hepatitis(23.3%). 6) The percent of injury was 13.5% of total emergency operation. Blunt trauma was 71.0% and penetrating trauma was 29.0%. 7) The most common anesthesia method was inhalation anesthesia with enflurane(55.4%) and followed by intravenous anesthesia with propofol(31.8%). In conclusion, anesthesiologists should attention to perioperative management to decrease the incidence of morbidity and mortality of emergency operation.

Intracranial Hemorrhage in Eclamptic Patient undergoing Cesarean Section / 대한마취과학회지

Preeclampsia is defined as the development of hypertension with proteinuria, edema induced by pregnancy after 20th week of gestation. Eclampsia implies the occurrence of convulsions unrelated to any coexisting neurologic disease in a preeclamptic. The leading cause of maternal death in preeclampsia-eclampsia is intracranial hemorrhage. Other causes of morbidity include congestive heart failure with pulmonary edema, pulmonary aspiration of gastric contents, disseminated intravascular coagulation, acute renal failure, and septic shock. We experienced a case of death from intracranial hemorrhage in eclamptic patient undergoing cesarean section.

Comparative Study of Ondansetron versus Droperidol versus Placebo to Prevent Postoperative Nausea and Vomiting after Strabismus in Children / 대한마취과학회지

Postoperative nausea and vomiting is a troublesome problem in pediatric patients undergo- ing strabismus surgery. We compared the effects of ondansetron with those of droperidol and placebo within the 24hrs postoperative period. 54 children, who admitted to Presbyteri- an Medical Center to receive strabismus operations, with ASA physical status 1, were as- signed to one of three groups according to uncontrolled parallel comparative study design. A standard anesthetic technique consisting of thiopental-vecuronium for induction and N2O-O2-enflurane for maintenance of anesthesia was used. The data showed that ondansetron 0. 067mg/kg i.v. before induction was significantly more effective in preventing emesis (n=19, 100%) than placebo(n=17, 58.8%). But, there was no significant difference between droperidol group and placebo group. In conclusion, ondansetron(0.067mg/kg) given intravenously before induction to prevent postoperative nausea and vomiting in patients undergoing elective strabismus surgery in children was effective.

Effects of Laparoscopic Cholecystectomy on the Cardiopulmanary and Neuroendocrine System / 대한마취과학회지

Laparoscopy is a useful procedure for the diagnostic and therapeutic purpose, but it may be associated with many complieations related to large amounts of CO2 insufflation into the peritoneal cavity. To investigste the influence of laparoscopy 15 ASA classification I, II sur- gical patients were selected. We measured the changes in mean arterial pressure(MAP), heart rate(HR), PaO2, PaCO2, end tidal CO2 tension(PETCO2) and stress hormones such as plsma epinephrine, norepinephrine and cortisol. Above parameters were messured 10 minutes after intubation(control value), immediately after CO2 insufflation, 30 minutes after CO2 insufflation and 20 minutes after CO deflation. The results were ss follows 1) Mean arterial pressure was increased at immediately after CO2 insufflation, 30 minutes after CO2 insufflation(p<0.01) and 20 minutes after CO2 deflation(p<0.05). Heart rate was not changed significsntly. 2) PaCO2 was decreased at 30 minutes after CO2 insufflation(p<0.05), but PaCO2 snd PaCO2 were increased at 30 minutes after CO2 insufflation and 20 minutes efter CO2 deflation (p <0.01). 3) The increase of plasma epinephrine at immediately after CO2 insufflation end 30 minutes after CO2 insufflation was not significant, but plasma norepinephrine was increased at immediately after CO2 insufflstion and 30 minutes after CO2 insufflation(p<0.01). Plasme cortisol was increased at immediately after CO2 insufflstion, 30 minutes after CO2 insufflation and 20 minutes after CO2 deflation(p<0.01). We concluded that laparoscopy with CO2 insufflation has some effects on cardiopulmonary and neuroendocrine system and it is recommended to monitor carefully blood pressure, heart rate and PETCO2 for preventing hypercarbia related complications.

The Effects of Enflurane, Isoflurane and Regional Anesthesia on the Liver Function in HBsAg Positive Patients / 대한마취과학회지

It is already well known that there are relatively many patients in Korea who have hepatitis B surface antigen. Anesthesiologists are often put into such a dilemma that they can't decide definitely whether going on procedures or not for HBsAg positive patients with or without mildly impaired liver function. The effects of enflurane, isoflurane and regional anesthesia on the liver function were compared in 85 patients with hepatitis B surface antigen. All the patients were randomly divided into 3 groups of enflurane(n=8), isoflurane(n=60) and regional anesthesia(n=17), and subdivided into 4 groups according to the preoperative value of liver functuion test and the presence of hepatitis B e antigen. Liver function tests were performed preoperatively, and on the 1st, 3rd and 7th, days postoperatively. Postoperative values of liver function tests were compared to preoperative ones within each group, and were also compared between groups. The results showed no significant differences between groups of hepatitis B eantigen positive and hepatitis B e antigen negative, but showed slight differences between anesthetics or anesthetic methads. In conclusion, anesthetic management of hepatitis B surface antigen positive patients could be performed without regard to the presence of hepatitis B e antigen. However, regional anesthesia seemed to be better than inhalation anesthesia in patients with hepatitis B surface antigen.

Effects of Midazolam and Propofol as Sedative Agents on Cardiopulmonary Function under Spinal Anesthesia / 대한마취과학회지

Many agents such as analgesics and sedatives have been used to decrease pain, anxiety and awareness during anesthesia. The effects of midazolam and propofol on cardiopulmonary functions and sedation were evaluated in a clinical study during spinal anesthesia. Thirty adult patients were received either midazolam 0.05mg/kg IV or propofol 1.25mg/kg IV after spinal anesthesia. Minute volume, arterial oxygen saturation, blood pressure, and heart rate were checked before and 20min after spinal anesthesia, as well as 2 min, 5 min, 10 min, 30 min, 60 min after each drug administration. The results were as follows ; 1) Minute volume and SaO2 were decreased from 2 min to 10 min in each group. 2) Mean arterial pressure was decreased from 2 min to 60 min in each group, but there was no significant difference between the two groups. Heart rate was increased at 2 min in propofol group 3) Recovery time from sedation was faster in the propofol group than the midazolam group. From the above results, we have concluded that midazolam and propofol have some effects on cardiopulmonary function and many advantages if used carefully during spinal anesthesia.

Clinical Survey of Patients in the General Intensive Care Unit / 대한마취과학회지

The general intensive care unit of Presbyterian Medical Centar was opened in 1965 with 3 beds and expanded to 17 heds in 1981. Generally, the type of I.C.U. is multidisciplinary and intensive care often means a combination of recovery room service and intensive therapy. Here, we have analyzed clinically 4, 986 LC.U. patients admitted between Jan. 1986 and Dec. 1990. to obtain a better guide and management in the I.C.U.. The results were as follows I) Total number of patients for 5 years was 4,986; 1,071 patients in 1986, 1,102 patients in 1987, 1,012 patients in 1988, 952 patients in 1989, 849 patients in 1990. The ratio of male to female patients was almost 2: 1. 2) Total admission days in the I.C.U. was 26,892 days and average patient stay being 5.5 days. The average age for 5 years was 50.9 year-old-age. 3) The majority of the patients(3,526 cases, 70%) stayed in the I.C.U. less than 5 days The number of patients staying more than 9 days increased from 127 cases(12%) in 1986 to 155 cases (18%) in 1990 4) The group representing the highest number of patients admitted was in the 50 to 59 year-old-age group. About 60% of the patients admitted were in the 40 to 69 year-old-age groups and the highest mortality rate occurred in the 70 to 79 year-old-age group(24.4%). 5) The number of the patients admitted to the department of internal medicine, which was the highest among all departments, was 3,564 caaes. Mortality rate was highest in the department of pediatric. 6) During 5 years, overall mortality rate was 21.9%(1,091 cases) inclusive of the hopeless-dis-charged patients. 7) Liver cirrhosis & variceal rupture of esophagus was the commonest disease. Mortality rate WS8 highest in leukemia(50%) & lymyhoma(50%) and lowest in acute renal failure(0%). 8) After putting into operation of nation-wide medical. insurance scheme, average patient stay and average age were increased. From the above results, it can be concluded that average admission days, average age and patients staying more than 9 days in the I.C.U. increased annually.