Sedation with Dexmedetomidine during Tracheostomy in Severe Tracheal Stenotic Patients / 대한구급학회지

In patients with severely compromised airways, a tracheostomy is usually performed under local anesthesia. Dexmedetomidine can be a better choice of sedative for such patients because it causes minimal respiratory depression. We report two cases of patients with severe stenosis of the airways who underwent sedation with dexmedetomidine during tracheostomy under local anesthesia. In the first case, recurrent laryngeal cancer caused laryngeal stenosis, and the narrowest laryngeal width was less than 3 mm. In the second case, the tracheostomy opening site was narrowed to a diameter of 3.4 mm in a patient with a history of total laryngectomy. For both patients, sedation was induced by dexmedetomidine infusion and the tracheostomy was performed successfully under local anesthesia without any events. Dexmedetomidine seems to be an effective and safe sedative for tracheostomies in patients with critical airways. The management and implications of sedation with dexmedetomidine in the patients with severe stenotic airways are discussed.

The comparative study to evaluate the effect of palonosetron monotherapy versus palonosetron with dexamethasone combination therapy for prevention of postoperative nausea and vomiting / 대한마취과학회지

BACKGROUND: 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists are effective and safe on postoperative nausea and vomiting (PONV). Palonosetron, the newest 5-HT3 antagonist, has potent antiemetic property. We hypothesized that a combination of palonosetron and dexamethasone could more decrease PONV than palonosetron alone. METHODS: Among the patients scheduled to undergo laparoscopic gynecologic surgery, mastoidectomy with tympanoplasty or thyroidectomy under general anesthesia, eighty four female patients with at least two PONV risk factors were enrolled in this study. They were received randomly 0.075 mg palonosetron and 4 mg dexamethasone (group C) or 0.075 mg palonosetron alone (group P). The severity of PONV using Rhodes index and the percentage of complete response during postoperative 24 hours were compared between groups. RESULTS: The frequency of mild/moderate/great/severe PONV based on Rhodes index were 9.8%/0%/0%/0% and 9.3%/2.3%/2.3%/0% in group P and group C, respectively. Complete response for PONV was observed in 90.2% and 86% of patients in group P and group C, respectively. The overall incidence of PONV in group P and C was 9.8% and 14%, respectively. There was no significant difference between the two groups. CONCLUSIONS: There were no differences between palonosetron monotherapy and combination therapy of palonosetron and dexamethasone in patients with high emetogenic risk.

Analysis of prognostic factors and 5-year survival rate in patients with hepatocellular carcinoma: a single-center experience / 대한간학회지

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC), which is the third most common cancer in Korea, has a very poor prognosis. However, only a few studies have performed a comprehensive survival-related analysis in all patients who were consecutively diagnosed and treated over a given period of time. The aim of this study was to determine the 5-year survival rate and its prognostic factors among HCC patients. METHODS: In total, 257 patients who were consecutively diagnosed with HCC between January 2000 and December 2003 were followed until death or until December 2008. We analyzed their survival outcomes according to their clinical characteristics, tumor staging, and treatment modalities, and determined the independent prognostic factors affecting survival. RESULTS: The patients were aged 59+/-10 years (mean+/-SD). During the follow-up period, 223 patients (86.8%) died and the overall median survival was 10.8 months; the 1-, 3-, and 5-year survival rates were 44.4%, 21.0%, and 12.1%, respectively. The outcomes in patients with tumor node metastasis (TNM) stage I or II and Child-Pugh class A or B were significantly better with surgical resection than with other treatment modalities (P<0.01). Patients who underwent supplementary transcatheter arterial chemoembolization as a second-line treatment after surgical resection had better outcomes than those who underwent surgical resection alone (P=0.02). Initial symptoms, Child-Pugh class, serum alpha-fetoprotein, tumor size, portal vein thrombosis, and TNM stage were found to be independent prognostic factors for survival among HCC patients. CONCLUSIONS: This retrospective cohort study elucidated survival outcomes and prognostic factors affecting survival in HCC patients at a single center.

Effectiveness of Initial Extracorporeal Shock Wave Therapy on the Newly Diagnosed Lateral or Medial Epicondylitis

OBJECTIVE: To evaluate the effectiveness of initial extracorporeal shock wave therapy (ESWT) for patients newly diagnosed with lateral or medial epicondylitis, compared to local steroid injection. METHOD: An analysis was conducted of twenty-two patients who were newly confirmed as lateral or medial epicondylitis through medical history and physical examination. The ESWT group (n=12) was treated once a week for 3 weeks using low energy (0.06-0.12 mJ/mm2, 2,000 shocks), while the local steroid injection group (n=10) was treated once with triamcinolone 10 mg mixed with 1% lidocaine solution. Nirschl score and 100 point score were assessed before and after the treatments of 1st, 2nd, 4th and 8th week. And Roles and Maudsley score was assessed one and eight weeks after the treatments. RESULTS: Both groups showed significant improvement in Nirschl score and 100 point score during the entire period. The local steroid injection group improved more in Nirschl score at the first week and in 100 point score at the first 2 weeks, compared to those of the ESWT group. But the proportion of excellent and good grades of Roles and Maudsley score in the ESWT group increased more than that of local steroid injection group by the final 8th week. CONCLUSION: The ESWT group improved as much as the local steroid injection group as treatment for medial and lateral epicondylitis. Therefore, ESWT can be a useful treatment option in patients for whom local steroid injection is difficult.

Rupture of abdominal aortic aneurysm after spine surgery in the patient with Ehlers-Danlos syndrome: A case report / 대한마취과학회지

Ehlers-Danlos syndrome (EDS) is a rare inherited disorder of the connective tissue that is characterized by hyperextensible skin, hypermobile joints and abnormalities of the cardiovascular system. A 15-year-old girl with Ehlers-Danlos syndrome underwent thoracolumbar surgery for deformity correction. After surgery, an abdominal aortic rupture occurred, and she complained of abdominal distension had an abdominal circumference of 80 cm. Abdominal computed tomography revealed a pseudoaneurysm and a large hematoma at the retroperitoneum. She died of a massive hemorrhage during subsequent abdominal aortic surgery.

A survey of postoperative residual neuromuscular block and neuromuscular monitoring

BACKGROUND: To aware of postoperative residual neuromuscular block (PRNB) is important in that it can cause apnea, delay of awakening and recovery and dissatisfaction of patient.This study aimed to evaluate the PRNB at recovery room and it's course during postoperative periods. METHODS: A questionnaire designed to provide information concerning PRNB, monitoring and reversal on neuromuscular block was sent to all members of the Korean Society of Anesthesiologists by e-mail.The contents of survey were about the incidence of PRNB, the monitoring methods of the muscle relaxation.We also investigated the usual type of neuromuscular blocker and reversal agents. RESULTS: Most responders (85.9%) concerned about the PRNB of which causing a serious problem.More people answered that clinical evaluation was more reliable (83.3%) than tetanic stimulation (46.2%) and neuromuscular monitoring might reduce PRNB. Some responders (11.5%) sometimes omitted the reversal of neuromuscular block.Quantitative neuromuscular monitoring devices were not enough to use in all patients at all hospitals. CONCLUSIONS: The responders had great interest to PRNB but neuromuscular monitoring and reversal of neuromuscular blockade were underused.

Factors that influence awakening in coronary artery bypass graft using propofol and remifentanil / 대한마취과학회지

BACKGROUND: The development of total intravenous anesthesia in coronary artery bypass graft (CABG) surgery has led to increased interest in the use of combination of propofol and remifentanil. Early extubation in post-cardiac surgery reduces the length of stay in intensive care unit and hospital and costs. The purpose of this study is to evaluate which anesthetic factors affect awakening time after anesthesia. METHODS: We enrolled twenty patients of ASA physical status II or III, scheduled for CABG in this study. All patients received a standardized propofol/remifentanil anesthesia as an effect site target controlled infusion. We recorded times to awakening and tracheal extubation, duration of cardiopulmonary bypass (CPB) period, total time of anesthesia and operation. Also, we recorded dose of propofol, remifentanil, fentanyl and minimum body temperature during CPB. To predict the factors that affect awakening time as a dependent variable, we considered all measured parameters as independent variables, and analyzed multiple linear regressions. RESULTS: The mean time responded to verbal command was 216.5 +/- 124.8 minutes after end of surgery. Among several parameters, minimum body temperature during CPB (P = 0.001) and total time of anesthesia (P = 0.003) were considered as significant factors that influence awakening time after CABG. CONCLUSIONS: Minimum body temperature during CPB and the duration of anesthesia influence awakening time after CABG, significantly.

A Case of Lesch-Nyhan Disease Manifesting Gouty Arthritis without Self-mutilation / 대한신장학회지

Lesch-Nyhan disease is a very rare X-linked recessive disorder characterized by mental retardation, spasticity resembling cerebral palsy, choreoathetosis, self-mutilation and hyperuricemia. Self-mutilative behavior is a hallmark of the disease. The underlying defect is a deficiency of hypoxanthine-guanine phosphoribosyltransferase (HPRT). We report on a fourteen-year-old boy, who manifested gouty arthritis and mild renal insufficiency with Lesch-Nyhan disease, lacking self-mutilative behavior in spite of undetectable HPRT activity. Though there were several reports about some cases of Lesch-Nyhan disease in the past Korean literature, the cases were classic forms with definite neurological manifestation. As far as we know, this is the first case of Lesch-Nyhan disease without self-mutilation in Korea.

A Case of Hypersensitivity Pneumonitis Following Placenta Extract Injection / 결핵및호흡기질환

Human placenta contains various kinds of nutritional elements essential for embryonic development. Currently, human placenta extracts are widely overused in Korea to improve certain health conditions (postmenopausal syndrome, liver function, and cosmetic purposes) without scientific evidence that they actually work. The use of placenta extracts should be restricted, due to a lack of systematic research on the therapeutic effectiveness and adverse results from these treatments. While the common adverse effects that have been reported are fever, rash, itching, nausea, vomiting, breast pain, and rare cases of anaphylactic shock, there have been no reports of pulmonary complications such as hypersensitivity pneumonitis. Recently, we experienced a patient with hypersensitivity pneumonitis following a placenta extract injection. To our knowledge, this is the first case of hypersensitivity pneumonitis associated with placenta extract use.

An analysis of correlation between remifentanil effect site concentration and age blunting hemodynamic response to endotracheal intubation

BACKGROUND: There are many studies using propofol-remifentanil target controlled infusion (TCI) for the prevention of adverse hemodynamic changes during tracheal intubation. Most of these studies suggested optimal remifentanil target concentration without considering age. The purpose of this study is to analyze the correlation between concentration of remifentanil and age to blunting adverse hemodynamic responses during tracheal intubation. METHODS: We enrolled ASA physical state I or II 55 patients, aged 12-75 years undergoing elective surgery. Anesthesia was induced using a propofol TCI (Marsh model). A 4micro/ml effect-site concentration of propofol was chosen. Rocuronium 0.6 mg/kg was administered after the patients lost consciousness. Remifentanil TCI (Minto model) was started 1 minute after the propofol injection. Initially, a 3 ng/ml effect-site concentration was chosen. The next concentration was chosen using Dixon's up-and-down method. The non-invasive blood pressure and heart rate were recorded before induction (baseline), after the remifentanil infusion, immediately after intubation as well as 1 and 3 minutes after intubation. RESULTS: Probit analysis revealed a remifentanil effect site EC50 and EC95 in all patients to be 1.768 ng/ml (S.E. +/-0.136) and 2.912 ng/ml (S.E. +/-0.307). Final probit equation was as following consisted with age and remifentanil effect site concentration. Probit = -2.588 + 1.886 remifentanil effect site concentration -0.022 x Age. CONCLUSIONS: The probability of success rate of blunting adverse hemodynamic response is related to the concentration of remifentanil directly and age inversely.

A Comparison of Transcutaneous and End-tidal Measurements of CO2 in One Lung Ventilation / 대한마취과학회지

BACKGROUND: In thoracic anesthesia with one lung ventilation (OLV), end-tidal CO2 (PeTCO2) monitoring may not be accurate to estimate PaCO2 mainly due to ventilation/perfusion mismatching.This study aimed to asses the clinical usefulness and accuracy of a transcutaneous CO2 (PtCCO2) monitoring in thoracic anesthesia, compared with PeTCO2. METHODS: 18 patients of ASA physical status 1 or 2, required a long period of OLV were researched.The lungs were mechanically ventilated in the lateral decubitus position.We measured PaCO2, PeTCO2, PtCCO2 during two lung ventilation (TLV) and 15 min, 30 min, 60 min after OLV.For comparing the differences of PtCCO2/PaCO2 and PtCCO2/PaCO2, we figured out bias (mean difference between values) and precision (standard deviation of bias) by using Bland-Altman plot.We compared the differences of each value, PeTCO2/PaCO2, PtCCO2/PaCO2, using the student's t-test. RESULTS: The bias +/- precision of PeTCO2/PaCO2 and PtCCO2/PaCO2 was each 7.82 mmHg +/- 3.98 mmHg, 1.95 mmHg +/- 2.66 mmHg during TLV and that of mean value of PeTCO2/PaCO2 and PtCCO2/PaCO2 was each 6.93 mmHg +/- 2.6 mmHg, 2.35 mmHg +/- 1.66 mmHg during OLV.PtCCO2/PaCO2 differences were significantly less than PeTCO2/PaCO2 differences (P < 0.05). CONCLUSIONS: During one lung ventilation, PtCCO2 monitoring is more useful and accurate than PeTCO2 monitoring for assessing PaCO2 levels.

The Prevalence of Initial Drug Resistance among Pulmonary Tuberculosis Patients / 결핵및호흡기질환

BACKGROUND: Drug resistant tuberculosis (TB) in patients who have not received previous TB treatment (initial drug resistance) is a serious problem for the control of TB. However, prevalence of initial drug resistance among pulmonary TB patients has not been well characterized in Korea, especially in the private sector. We assessed the prevalence of initial drug resistance and evaluated the risk factors for drug resistance in pulmonary TB patients, at a regional tertiary hospital in Cheonan. METHODS: We performed a drug susceptibility test for both first and second line anti-TB drugs in all culture-confirmed pulmonary TB patients who had not received a previous TB treatment at Dankook University Hospital from September 2005 to September 2007. In addition, we evaluated the initial drug resistance pattern and clinical characteristics of patients to evaluate the risk factors for initial drug resistance. We also assessed the influence of the drug susceptibility test results on the treatment regimen. RESULTS: Of the total 156 cases where the drug susceptibility test was performed, resistance to at least one anti-TB drug was found in 21 cases (15.6%) and multidrug resistance, where TB was resistant to at least isoniazid and rifampin, was found in one case (0.6%). Multivariate logistic regression showed no clinical characteristics were independently associated with initial drug resistance. Of the total 156 patients who underwent the drug susceptibility test, the treatment regimen was changed for 15 patients (9.6%) according to the results of the drug susceptibility test. CONCLUSION: Initial drug resistance is common and the drug susceptibility test is informative for pulmonary TB patients who have not received previous TB treatment.

Clinical, Radiological and Pathological Exploration of Focal Nodular Hyperplasia of Liver Reported in Korea / 대한소화기학회지

BACKGROUND/AIMS: Focal nodular hyperplasia (FNH) is mandatory to be differentiated from other hepatic tumorous conditions such as hepatocellular carcinoma and adenoma. The purpose of this study was to explore the clinical, radiological and pathological features of FNH cases reported in Korea. METHODS: We have searched the journals from the web site "http://koreamed.org" using keywords "focal nodular hyperplasia" and "liver" - total of 38 cases of FNH, 37 cases from 17 published articles and one case from our experience confirmed histologically, were reviewed and analyzed. RESULTS: Thirty eight cases were diagnosed between gestational age of 36 weeks and 67 years. Seventeen female patients (45%) had no history of taking oral contraceptives. Twenty cases (52.6%) experienced clinical symptoms such as abdominal pain and palpable mass. Computed tomography revealed contrast-enhancement in 34 nodules (85%) and typical central stellate scar in 9 (22.5%) of 40 nodules. Magnetic resonance imaging showed T1 weighted low signal in 18 (60%) and T2 weighted high signal in 22 (73.3%) of 30 nodules. Six (60%) of 10 cases showed hypervascular staining on hepatic angiography. Among 38 cases, 32 (84.2%) cases had single nodule and their mean size was 3.9 cm (0.5-16 cm). Pathologically, fibrous septa, proliferation of bile ductules and arterial wall thickening were seen in most cases. CONCLUSIONS: Of all the FNH cases reported in Korea, there were some differences in clinical aspects of sex ratio, accompanying clinical symptoms, and relationship with oral contraceptives, compared with previous reports. Further prospective studies are needed by means of nation-wide clinical survey and analysis.

The Efficacy of DuaLight(TM) Treatment for Localized Vitiligo / 대한피부과학회지

BACKGROUND: DuaLight(TM) is a recently developed phototherapeutic device that is used for targeted phototherapy. However, the efficacy of DuaLight(TM) therapy for vitiligo has not been evaluated nor has it been reported on in the Korean medical literature. OBJECTIVE: This study was conducted to evaluate the efficacy of DuaLight(TM) therapy for treating localized vitiligo and we wanted to determine the clinical parameters that could affect the therapeutic outcome. METHODS: Eighty-three lesions from thirty-eight patients were treated by using DuaLight(TM) once or twice a week. The repigmentation grade of each treated lesion was evaluated on a 5-point scale from 0 (no repigmentation), 1 (1~24%), 2 (25~49%), 3 (50~74%), to 4 (75~100%). Results: Thirty-four lesions of the 83 lesions (40.9%) improved to 50% repigmentation after DuaLight(TM) therapy. The clinical parameters that affected the therapeutic outcome were the lesions' anatomical location and the clinical subtype of vitiligo. Yet a history of previous treatment and the skin type did not affect the therapeutic result. Perilesional hyperpigmentation (47.4%) was the most common side effect, but the other adverse effects were limited and transient. CONCLUSION: DuaLight(TM) therapy is an effective, safe therapeutic modality for localized vitiligo. However, similar to other non-surgical therapeutic modalities, the therapeutic outcome is mainly dependent on the anatomical location.

The Efficacy of DuaLight(TM) Treatment for Localized Vitiligo / 대한피부과학회지

BACKGROUND: DuaLight(TM) is a recently developed phototherapeutic device that is used for targeted phototherapy. However, the efficacy of DuaLight(TM) therapy for vitiligo has not been evaluated nor has it been reported on in the Korean medical literature. OBJECTIVE: This study was conducted to evaluate the efficacy of DuaLight(TM) therapy for treating localized vitiligo and we wanted to determine the clinical parameters that could affect the therapeutic outcome. METHODS: Eighty-three lesions from thirty-eight patients were treated by using DuaLight(TM) once or twice a week. The repigmentation grade of each treated lesion was evaluated on a 5-point scale from 0 (no repigmentation), 1 (1~24%), 2 (25~49%), 3 (50~74%), to 4 (75~100%). Results: Thirty-four lesions of the 83 lesions (40.9%) improved to 50% repigmentation after DuaLight(TM) therapy. The clinical parameters that affected the therapeutic outcome were the lesions' anatomical location and the clinical subtype of vitiligo. Yet a history of previous treatment and the skin type did not affect the therapeutic result. Perilesional hyperpigmentation (47.4%) was the most common side effect, but the other adverse effects were limited and transient. CONCLUSION: DuaLight(TM) therapy is an effective, safe therapeutic modality for localized vitiligo. However, similar to other non-surgical therapeutic modalities, the therapeutic outcome is mainly dependent on the anatomical location.

An Experience of Anesthesia of Congenital Anomaly with Airway Involvement : 46 case report

As the improved medical techniques and environmental changes have increased the frequency of general anesthesia for uncommon congenital anomalies. The airway management for a patient with congenital anomaly gives significant challenges to the anesthesiologist. The purpose of this report is to review the authors' experience with airway management and ventilatory support during the perioperative period in children with congenital anomalies with airway involvement, and to summarize anesthetic implications associated with particular congenital anomalies by literature review. Total 46 cases of general anesthesia for operation of congenital anomalies were performed from January 2000 to August 2005 in our hospital. Most common congenital anomaly is a Down syndrome (17 cases, 37%), and most common cause of surgery is the orthopedic surgery for correction of deformed spine (18 cases, 41%). Direct laryngoscopy was successfully used to establish an airway in 35 (76.1%) cases, whereas 5 (11%) cases required the use of fiberoptic bronchoscopy to establish an airway before surgery.

Experience of Suspected Propofol Infusion Syndrome in a Status Epilepticus Patient: A case report / 대한마취과학회지

Propofol is used for the treatment of refractory status epilepticus. When given as a long-term infusion, in combination with catecholamines and/or steroids, propofol rarely causes the fatal complication, known a propofol infusion syndrome. Herein, the case of a previously healthy 8-years-old boy with status epilepticus is reported. He was treated with propofol, in doses ranging from 8.6 to 10.9 mg/kg/h, for 43 hours. The propofol resulted in multiple organ failure, with rhabdomyolysis, which caused the death of the patient. This case fulfills all the criteria of propofol infusion syndrome.

The Change of Arterial Blood Gas during Endoscopic Saphenous Vein Harvesting for Coronary Artery Bypass Grafting / 대한마취과학회지

BACKGROUND: Endoscopic surgical procedure has recently been applied to not only intraabdominal or intrathoracic surgery but also saphenous vein harvesting, because it is less invasive and more cosmetically advantageous. Carbon dioxide insufflation during an endoscopic saphenous vein harvesting may cause an adverse effects on arterial blood gas and hemodynamic variables. This study was conducted to evaluate the safety of carbon dioxide insufflation during endoscopic saphenous vein harvesting. METHODS: Patients in ASA physical status III or IV, scheduled for an endoscopic saphenous vein harvesting (n=30) were gathered for the evaluation. Until the end of the procedure, controlled mechanical ventilation (tidal volume: 10 ml/kg, respiratory rate: 10 rates/min) and ventilator mode was fixed in this tidal volume and respiratory rate. Arterial blood gas analysis, end-tidal carbon dioxide, blood pressure and heart rate were measured before and at 10, 20, 30, 40 minutes after carbon dioxide insufflation. RESULTS: Preinsufflation values of PaCO2 (partial pressure of arterial carbon dioxide) and PETCO2 (partial pressure of end-tidal carbon dioxide) were 33.4 +/- 3.6 mmHg and 24.1 +/- 4.1 mmHg, respectively. PaCO2 was significantly increased at 30 and 40 minutes after carbon dioxide insufflation (40.1 +/- 7.4 mmHg and 41.4 +/- 8.6 mmHg). PETCO2 was significantly increased at 20, 30 and 40 minutes after carbon dioxide insufflation(27.6 +/- 5.5 mmHg, 28.9 +/- 7.0 mmHg and 29.6 +/- 7.8 mmHg). But, the magnitude of difference between PaCO2 and PETCO2 was not significantly different. CONCLUSIONS: During endoscopic saphenous vein harvesting, PaCO2 was significantly increased compared with preinsufflation values. Careful monitoring of PaCO2 is mandatory during the procedure.

A Study of Frequency and Factors of Voiding Dysfunction Occurred after Epidural Anesthesia Using Bupivacaine / 대한비뇨기과학회지

PURPOSE: Epidural anesthesia(EPA) has been performed in various operations; however, it frequently induces postoperative voiding dysfunction. The frequency, duration and risk factors of voiding dysfunction occurring after EPA using long-acting anesthetics bupivacaine were evaluated. MATERIALS AND METHODS: 100 patients, who underwent orthopedic surgery (under knee, operation time

A Case of Proliferative Fasciitis in the Finger

Proliferative fasciitis is a rare reactive condition that presents with pseudosarcomatous lesions in subcutaneous tissues. Clinically, most patients present with firm, rapidly growing subcutaneous nodule and two thirds of patients complained of pain and tenderness. Most of lesions occur in the extremities, with the upper extremity (especially the forearm) affected more commonly than the lower extremity. Microscopically, proliferative fasciitis is composed of spindle cells that are deposited in a variably myxoid and collagenous stroma. It is characterized by the presence of large basophilic cells with one or two vesicular nuclei. Proliferative fasciitis could be confused with sarcomas because of intense cellularity, high mitotic index, and rapid growth. A 26-year-old woman complained of a painful nodule on her right second finger. Its size was gradually increased and pain was worsened. Histopathological examination revealed that the lesion consisted predominantly of spindle-shaped cells intermingled with a few gangliocyte-like giant cells. We herein report a rare case of proliferative fasciitis in the finger in a 26-year-old woman.