Correction of malposition of central venous catheter with 9-Fr introducer sheath assisted by mobile type diagnostic X-ray apparatus: a case report / 대한마취과학회지

Central venous catheters provide long-term available vascular access. They are useful for central venous pressure monitoring, rapid fluid management, massive transfusion and direct cardiovascular medication, especially in operation. Central venous catheterization is usually performed by the landmark bedside technique without imaging guidance. The complications of central venous catheterization are frequent, which include malposition, pneumothorax, hemothorax, chylothorax, arterial puncture, hematoma, air embolism and infection. Malposition of a central venous catheter is not rare and may cause several complications such as malfunction of the catheter, default measurement of central venous pressure, catheter erosion, thrombophlebitis and cardiac tamponade. In this case, we report a malposition of central venous catheter with 9-Fr introducer sheath which is located in the right subclavian vein via ipsilateral internal jugular vein and the correction of this misplacement assisted by mobile type diagnostic X-ray apparatus (C-arm fluoroscope).

Anesthetic experience using extracorporeal membrane oxygenation for cesarean section in the patient with peripartum cardiomyopathy: a case report / 대한마취과학회지

Peripartum cardiomyopathy is a rare form of cardiomyopathy that is associated with significant mortality. It can cause a cardiac arrest during cesarean section even though the patient does not have any previous symptom and sign. The most important thing of anesthesia in this patient is an optimization of hemodynamic and respiratory status. We report the successful general anesthesia using of extracorporeal membrane oxygenation for cesarean section in a 34-year-old woman with fulminant peripartum cardiomyopathy.

Effect of behavioral intervention using smartphone application for preoperative anxiety in pediatric patients / 대한마취과학회지

BACKGROUND: Children and parents experience significant anxiety and distress during the preoperative period. This is important because preoperative anxiety in children is associated with adverse postoperative outcome. So we suggest behaviorally oriented preoperative anxiety intervention program based on the anesthesia and psychology with smartphone application, world-widely used. METHODS: A total 120 patients (aged 1-10 years old) who were scheduled for elective surgery under general anesthesia was included in this randomized controlled trial. We randomized the patients into three groups, with using intravenous (IV) midazolam sedation (M group), with using smartphone application program (S group), and with using low dose IV midazolam plus smartphone application program (SM group). And the child anxiety was assessed using the modified Yale Preoperative Anxiety Scale (mYPAS) at holding area, 5 min after intervention, entrance to operating room. RESULTS: In all three groups, mYPAS after intervention were lower than the preoperative holding area (M group 52.8 +/- 11.8 vs 41.0 +/- 7.0, S group 59.2 +/- 17.6 vs 36.4 +/- 7.3, SM group 58.3 +/- 17.5 vs 26.0 +/- 3.4). A comparison of mYPAS scores between each group showed that the S group reduced anxiety lower than M group (P < 0.01), and the SM group exhibited significantly lower anxiety than the two other groups (P < 0.01). CONCLUSIONS: The preoperative preparation program using smartphone application is simple and customized by individual development that effective in the reduction of preoperative anxiety.

Anesthetic management of a parturient for combined cesarean section and surgical removal of pituitary tumor: A case report / 대한마취과학회지

A 40-year-old woman was referred to our hospital because of bitemporal hemianopsia at 23 weeks of gestation. A brain magnetic resonance imaging showed a pituitary tumor having suprasellar extension. At 30 weeks of gestation, she complained of rapidly deteriorating vision and bitemporal hemianopsia in both eyes and the ensuing radiological examination revealed increased tumor size, displaced tumor location and compressed optic chiasm. The cesarean section was performed at 31 weeks and 3 days of gestation and simultaneous surgical removal of pituitary tumor was carried out due to the risk of irreversible blindness. Anesthetic management for combined cesarean section and brain surgery can be more complex and challenging for anesthesiologists, and the aim was to achieve both the control of intracranial pressure and fetal well being at the same time. In this case, maternal outcome was somewhat improved after the procedure, and neonatal complications were not detected.

Anesthetic experience in patient for single lung transplantation with previous contralateral pneumonectomy: A case report / 대한마취과학회지

A 48-year-old woman with cystic fibrosis and a previous left pneumonectomy had surgery planned for single lung transplantation under general anesthesia. Due to progressive dyspnea and recurrent respiratory infection, she could not maintain her normal daily life without lung transplantation. The anesthetic management and surgical procedure was expected to be difficult because of the left mediastinal shift and an asymmetric thorax after the left pneumonectomy, but the single lung transplantation was successfully done under cardiopulmonary bypass.

Epidural hematoma occurred by massive bleeding intraoperatively in cesarean section after combined spinal epidural anesthesia: A case report / 대한마취과학회지

We describe a case of acute lumbar epidural hematoma at the L2-3 level complicated by paraplegia, which occurred after coagulation disorder because of massive bleeding intraoperatively in cesarean section. The preoperative coagulation laboratory finding was in normal range and so we tried combined spinal epidural anesthesia. Uterine atony occurred in the operation, and there was persistant bleeding during and after the operation. After the operation, she complained of paresthesia on her both legs and was diagnosed with epidural hematoma (EDH) by radiologic examination. Emergency laminectomy on lumbar spine was carried out for hematoma evacuation and decompression of the epidural space at once. In our experience, massive bleeding during surgery may potentially increase the risk of EDH postoperatively.

The effect of the humidifier on sore throat and cough after thyroidectomy / 대한마취과학회지

BACKGROUND: This study was performed to determine the effects of a humidifier with heated wire circuits on the incidence and severity of postoperative sore throat (POST) and cough after thyroidectomy. METHODS: A total of 61 patients scheduled for elective thyroid surgery under general anesthesia were included in this prospective study. We randomized the patients in to two groups, "without active warming and humidification" (Group C) and "using a heated humidifier" (Group H). The patients were interviewed to obtain the POST and cough scores at 1, 6, 24 and 48 hours after thyroidectomy. RESULTS: The incidence of POST was significantly lower in Group H compared to Group C at 6 hours (57% vs 84%, P = 0.041), 24 hours (37% vs 65%, P = 0.045), and 48 hours (10% vs 52%, P = 0.001). Also the incidence of cough was significantly lower in Group H at 6 hours (27% vs 71%, P = 0.001), 24 hours (13% vs 45%, P = 0.015), and 48 hours (7% vs 32%, P = 0.028). The severity of POST was significantly lower in Group H at all times. In addition, the severity of cough was lower in Group H at other times except at 1 hour. CONCLUSIONS: This result suggests that an active humidification of inspired gases may have the appreciable effect on reducing the incidence and severity of sore throat and cough after thyroid surgery using the endotracheal tube.

Maintenance of nitric oxide inhalation to a patient with hemoperitonium and acute respiratory distress syndrome during anesthesia: A case report / 대한마취과학회지

Inhaled nitric oxide (NO) is occasionally used to treat hypoxemia for patients with acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU). However, it is controversial whether or not to maintain inhalation of NO during general anesthesia because of complications, such as nitrogen dioxide (NO2) production, methemoglobinemia, and inhibition of platelet aggregation. In this case, a 67-year-old male fell from a roof and was brought to an emergency care center. During management, he vomited gastric contents and aspirated. In spite of tracheal intubation and mechanical ventilation with high oxygen therapy, the hypoxia did not improve. NO inhalation with mechanical ventilation was performed to treat hypoxemia due to ARDS in the ICU. We maintained the NO inhalation during the surgery for a hemoperitonium. The surgery was completed without intra-operative hemodynamic instability or any complications.

Resveratrol Inhibits Nicotinic Stimulation-Evoked Catecholamine Release from the Adrenal Medulla

Resveratrol has been known to possess various potent cardiovascular effects in animal, but there is little information on its functional effect on the secretion of catecholamines (CA) from the perfused model of the adrenal medulla. Therefore, the aim of the present study was to determine the effect of resveratrol on the CA secretion from the isolated perfused model of the normotensive rat adrenal gland, and to elucidate its mechanism of action. Resveratrol (10~100micrometer) during perfusion into an adrenal vein for 90 min inhibited the CA secretory responses evoked by ACh (5.32 mM), high K+ (a direct membrane-depolarizer, 56 mM), DMPP (a selective neuronal nicotinic Nn receptor agonist, 100micrometer) and McN-A-343 (a selective muscarinic M1 receptor agonist, 100micrometer) in both a time- and dose- dependent fashion. Also, in the presence of resveratrol (30micrometer), the secretory responses of CA evoked by veratridine 8644 (an activator of voltage-dependent Na+ channels, 100micrometer), Bay-K-8644 (a L-type dihydropyridine Ca2+ channel activator, 10micrometer), and cyclopiazonic acid (a cytoplasmic Ca2+ -ATPase inhibitor, 10micrometer) were significantly reduced. In the simultaneous presence of resveratrol (30micrometer) and L-NAME (an inhibitor of NO synthase, 30micrometer), the CA secretory evoked by ACh, high K+, DMPP, McN-A-343, Bay-K-8644 and cyclopiazonic acid were recovered to a considerable extent of the corresponding control secretion compared with the inhibitory effect of resveratrol alone. Interestingly, the amount of nitric oxide (NO) released from the adrenal medulla was greatly increased in comparison to its basal release. Taken together, these experimental results demonstrate that resveratrol can inhibit the CA secretory responses evoked by stimulation of cholinergic nicotinic receptors, as well as by direct membrane-depolarization in the isolated perfused model of the rat adrenal gland. It seems that this inhibitory effect of resveratrol is exerted by inhibiting an influx of both ions through Na+ and Ca2+ channels into the adrenomedullary cells as well as by blocking the release of Ca2+ from the cytoplasmic calcium store, which are mediated at least partly by the increased NO production due to the activation of NO synthase.

Influence of Nicorandil on Catecholamine Release in the Perfused Rat Adrenal Medulla

The present study was attempted to investigate the effect of nicorandil, which is an ATP-sensitive potassium (KATP) channel opener, on secretion of catecholamines (CA) evoked by cholinergic stimulation and membrane depolarization from the isolated perfused rat adrenal glands. The perfusion of nicorandil (0.3~3.0 mM) into an adrenal vein for 90 min produced relatively dose-and time-dependent inhibition in CA secretion evoked by ACh (5.32 mM), high K+ (a direct membrane depolarizer, 56 mM), DMPP (a selective neuronal nicotinic receptor agonist, 100micrometer for 2 min), McN-A-343 (a selective muscarinic M1 receptor agonist, 100micrometer for 4 min), Bay-K-8644 (an activator of L-type dihydropyridine Ca2+ channels, 10micrometer for 4 min) and cyclopiazonic acid (an activator of cytoplasmic Ca2+-ATPase, 10micrometer for 4 min). In adrenal glands simultaneously preloaded with nicorandil (1.0 mM) and glibenclamide (a nonspecific KATP-channel blocker, 1.0 mM), the CA secretory responses evoked by ACh, high potassium, DMPP, McN-A-343, Bay-K-8644 and cyclopiazonic acid were recovered to the considerable extent of the control release in comparison with that of nicorandil-treatment only. Taken together, the present study demonstrates that nicorandil inhibits the adrenal CA secretion in response to stimulation of cholinergic (both nicotinic and muscarinic) receptors as well as by membrane depolarization from the isolated perfused rat adrenal glands. It seems that this inhibitory effect of nicorandil may be mediated by inhibiting both Ca2+ influx and the Ca2+ release from intracellular store through activation of KATP channels in the rat adrenomedullary chromaffin cells. These results suggest that nicorandil-sensitive KATP channels may play an inhibitory role in the regulation of the rat adrenomedullary CA secretion.

Influence of Cilnidipine on Catecholamine Release in the Perfused Rat Adrenal Medulla

The present study was attempted to investigate the effect of cilnidipine (FRC-8635), which is a newly synthesized novel dihydropyridine (DHP) type of organic Ca2 channel blockers, on secretion of catecholamines (CA) evoked by acetylcholine (ACh), high K, DMPP and McN-A-343 from the isolated perfused rat adrenal gland. Cilnidipine (1~10microM) perfused into an adrenal vein for 60 min produced relatively dose- and time-dependent inhibition in CA secretory responses evoked by ACh (5.32 10 3 M), DMPP (10 4 M for 2 min) and McN-A-343 (10 4 M for 2 min). However, lower dose of cilnidipine did not affect CA secretion by high K (5.6 10 2 M), higher dose of it reduced greatly CA secretion of high K. Cilnidipine itself did fail to affect basal catecholamine output. In the presence of cilnidipine (10microM), the CA secretory responses evoked by Bay-K-8644 (10microM), an activator of L-type Ca2 channels and cyclopiazonic acid (10microM), an inhibitor of cytoplasmic Ca2 -ATPase were also inhibited. Moreover, omega-conotoxin GVIA (1microM), a selective blocker of the N-type Ca2 channels, given into the adrenal gland for 60 min, also inhibited time-dependently CA secretory responses evoked by Ach, high K, DMPP, McN-A-343, Bay-K-8644 and cyclopiazonic acid. Taken together, these results demostrate that cilnidipine inhibits CA secretion evoked by stimulation of cholinergic (both nicotinic and muscarinic) receptors from the isolated perfused rat adrenal gland without affecting the basal release. However, at lower dose, cilnidipine did not affect CA release by membrane depolarization while at larger dose inhibited that. It seems likely that this inhibitory effect of cilnidipine is exerted by blocking both L- and N-type voltage-dependent Ca2 channels (VDCCs) on the rat adrenomedullary chromaffin cells, which is relevant to inhibition of both the Ca2 influx into the adrenal chromaffin cells and intracellular Ca2 release from the cytoplasmic store. It is thought that N-type VDCCs may play an important role in regulation of CA release from the rat adrenal medulla.

Mechanism of epibatidine-induced catecholamine secretion in the rat adrenal gland

The present study was attempted to investigate the characteristics of epibatidine on secretion of catecholamines (CA) from the isolated perfused model of the rat adrenal gland, and to establish the mechanism of action. Epibatidine (3X10(-8) M) injected into an adrenal vein produced a great inhibition in secretory response of CA from the perfused rat adrenal gland. However, upon the repeated injection of epibatidine (3X10(-8) M) at 15 min-intervals, CA secretion was rapidly decreased after second injection of epibatidine. However, there was no statistical difference between CA secretory responses of both 1st and 2nd periods by the successive administration of epibatidine at 120 min-intervals. Tachyphylaxis to releasing effects of CA evoked by epibatidine was observed by the repeated administration. Therefore, in all subsequent experiments, epibatidine was not administered successively more than twice only 120 min-intervals. The epibatidine-induced CA secretion was markedly inhibited by the pretreatment with atropine, chlorisondamine, pirenzepine, nicardipine, TMB-8, and perfusion of Ca2+/-free Krebs solution containing EGTA, while was not affected by diphenhydramine. Moreover, the CA secretion evoked by ACh for 1st period (0apprx4 min) was greatly potentiated by the simultaneous perfusion of epibatidine (1.5X10(-8) M), but followed by time-dependently gradual reduction after 2nd period. The CA release evoked by high potassium (5.6+/-10(-8) M) for 1st period (0apprx4 min) was also enhanced by the simultaneous perfusion of epibatidine, but those after 2nd period were not affected. Taken together, these experimental data suggest that epibatidine causes catecholamine secretion in a calcium dependent fashion from the perfused rat adrenal gland through activation of neuronal cholinergic (nicotinic and muscarinic) receptors located in adrenomedullary chromaffin cells. It also seems that epibatidine-evoked catecholamine release is not relevant to stimulation of histaminergic receptors.

Influence of Total Ginseng Saponin on Contractile Responses of Vasoconstrictors in the Isolated Rat Aorta

BACKGROUND: It has been known that Ginseng extract causes the hypotensive action while it rather produces the hypertensive action. Some studies have suggested that Ginseng extract causes a biphasic response on blood pressure, namely, transient fall followed by prolonged elevation. It has been also shown that administration of Korean Red Ginseng powder has no effect on blood pressure in normotensive and hypertensive rats. The present study was designed to examine the effect of total Ginseng saponin on contractile responses of vasoconstrictors in the rat aorta and to establish the mechanism of its action. METHODS: The ring segment of aorta was mounted in a muscle bath filled with oxygenated Krebs solution for the measurement of isometric tension. After the equilibration period, under the presence of total Ginseng saponin, isometric tension induced by some vasoconstrictors were observed and compared to the control responses. The data were expressed as % of the control tension. RESULTS: Phenylephrine (an adrenergic alpha1-receptor agonist) and high potassium (a membrane depolarizing agent) caused greatly contractile responses in the rat aorta, respectively. However, in the presence of total ginseng saponin (600 g/ml), the contractile responses of phenylephrine (10(-6) and 10(-5) M) and high potassium (3.5 x 10(-2) and 5.6 x 10(-2) M) were markedly potentiated whereas prostglandin F2alpha(5 x 10(-6) M)-induced contractile responses was not affected. The contractile responses induced by phenylephrine (10(-5) M) and high potassium (3.5 x 10(-2) M) even under the presence of total ginseng saponin (600 g/ml) were greatly inhibited by the pretreatment of nicardipine (10(-6) M), a calcium channel blocker. CONCLUSION: Taken together, these experimental results suggest that total ginseng saponin can enhance the contractile responses evoked by stimulation of adrenergic alpha1-receptor and the membrane depolarization in the isolated rat aortic strips, which seems to be associated to calcium influx.

Anesthetic management for Liver transplantatin : 4 cases / 대한마취과학회지

We managed four cases of anesthesia for liver transplantation from August, 1992 to January, 1993. Four recipients, all male patients and ages of 40th, were suffered from liver cirrhosis related to Chronic hepatitis B and one recipient (case 1) was diagnosed as combined hepatocellular carcinoma. Operation risks by Pugh's classification were 10 (case 1), 8 (case 2), 7 (case 3) and 12 (case 4). Duaration of anesthesia was in the range of 13 to 22.5 hours. Various hemodynamic monitorings were observed and anesthetic managements were uneveritful. C.O., SVR, temperature and coagulation factors were analyzed. 2 patients (case 1 & 4) were expired due to acute rejection (case 1) and primary non-function of the grafted liver (case 4) postoperatively.