An anesthetic experience of hereditary angioedema type I patient undertook total laparoscopic hysterectomy - A case report -

Background@#Hereditary angioedema (HAE) is an autosomal dominant disorder. The characteristic of HAE is recurrent angioedema episodes due to low C1 esterase inhibitor (C1-INH) level. HAE symptoms, especially those affecting oropharynx or larynx may develop respiratory distress syndrome due to impaired airway, which can be potentially fatal. Case: We report a clinical case of a 57 year-old woman, with type I HAE, scheduled for total laparoscopic hysterectomy under general endotracheal anesthesia, which was done successfully without inducing airway edema. Danazol, which increases liver synthesis of C1-INH, was administered and fresh frozen plasma (FFP), which contained C1-INH, was transfused after induction. @*Conclusions@#For HAE patients, the greatest concern is that general anesthesia can induces upper airway edema by direct mucosal irritation by the endotracheal tube. The perioperative management should include both prophylactic increase of C1-INH production and on-demand administration of C1-INH or FFP.

Hepatic failure caused by acute fatty liver of pregnancy treated by orthotopic liver transplantation: A case report

Acute fatty liver of pregnancy (AFLP) is unusual but can potentially progress to overwhelming liver failure, resulting in maternal and fetal death. AFLP is characterized by the accumulation of microvesicular fat within hepatocytes. We report the case of a 37-year-old woman at 36 weeks' gestation with a twin pregnancy who was admitted with the diagnosis of intrauterine fetal death of one baby. The patient showed profile of AFLP on her laboratory findings and underwent emergency cesarean section. Then she progressed to cryptogenic fulminant hepatic failure and underwent successful orthotopic liver transplantation on 9th day of admission. This case demonstrates that liver transplantation is a feasible therapeutic option for the treatment of patients with this condition.

Anesthetic Consideration for Peroral Endoscopic Myotomy

A recent achalasia guideline suggests that peroral endoscopic myotomy (POEM) is a safe option for achalasia that is as effective as Heller myotomy. It is recommended that POEM should be performed under general anesthesia. The incidence of adverse events such as bleeding, perforation, and carbon dioxide insufflation-related complications was lower in POEM under endotracheal general anesthesia than in POEM under sedation. Subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum, and accompanying hemodynamic instability can be caused by carbon dioxide insufflation. Treatment of possible physiological changes and adverse events during the POEM procedure from the point of view of anesthesiologists may give endoscopists a new perspective on improving patient safety. The territory of therapeutic endoscopy can be expanded through cooperation with other departments, including anesthesia services. Efforts to understand different perspectives will certainly help not only secure patient safety but also expand the area of treatment.

Brugada Syndrome Patient Undertaken Brachial Plexus Block / 이화의대지

Brugada syndrome is an arrhythmic syndrome characterized by right bundle branch block, ST segment elevation in the precordial lead (V1-V3), and sudden death caused by ventricular fibrillation, which is not effectively prevented by anti-arrhythmic drug therapy. We are reporting a 30-year-old male patient with Brugada syndrome who got an exploratory laparotomy and a tenorrhaphy due to stab wound which was managed with general anesthesia and brachial plexus block without any complications.

Concurrent meralgia paresthetica and radiculopathy of the left leg: A case report

Meralgia paresthetica (MP) is a painful mononeuropathy of the lateral femoral cutaneouse nerve (LFCN) characterized by localized symptoms of numbness, tingling, pain and paresthesia along the anterolateral thigh area. L4 and L5 radiculopathy is set of symptoms that include sharp, burning or shooting pain, which is usually localized to anterolateral leg area and along the dermatomal distribution. When symptoms of MP and lumbar disc disease occur together it is not easy to diagnose MP. We report a case of synchronous post-traumatic MP and radiculopathy due to intervertebral disc herniation at L3–4 and 4–5. A 59-year-old male patient was admitted to the emergency room with symptoms of low back pain with left severe L4, L5 radiculopathy. This patient also complained of numbness and paresthesia in the left anterolateral thigh. After detailed history taking and lateral femoral cutaneouse nerve block, he was diagnosed with MP.

Pretransplant diastolic wall strain assessed by transthoracic echocardiography and its implication on posttransplant survival rate in liver transplantation

BACKGROUND: In cirrhotic patients, left ventricular diastolic dysfunction is associated with poor outcomes. Diastolic wall strain (DWS) is a new index of left ventricular diastolic function that correlates with the myocardial stiffness. In this study, we aimed to determine whether DWS calculated from preoperative transthoracic echocardiography can predict the survival of liver transplantation recipients. METHODS: A total of 981 patients who underwent liver transplantation were enrolled. We collected the clinical, laboratory and echocardiographic data retrospectively. The left ventricular posterior wall thickness at end-systole (LVPWs) and end-diastole (LVPWd) were measured using M-mode imaging. DWS was calculated as follows: DWS = (LVPWs – LVPWd) / LVPWs. As previously reported, DWS ≤ 0.33 was defined as low DWS and DWS > 0.33 was defined as normal DWS. The primary outcome of this study was 2-years survival after liver transplantation. RESULTS: The 2-years mortality rate following liver transplantation was higher in low DWS group than normal DWS group (14.6% vs.10.0%, P = 0.038). In univariate Cox regression analysis, age, model for end-stage liver disease score, Child-Turcotte-Pugh score, creatinine, b-type natriuretic peptide, heart rate, left ventricular end-diastolic volume index, left ventricular stroke volume index, left ventricular ejection fraction, E/A ratio, e′, E/e′ ratio, and DWS were associated with 2-years survival after liver transplantation. In multivariate Cox regression analysis, DWS was an independent predictor of 2-years survival after adjusting significant univariate covariates. CONCLUSIONS: This study results indicated that the DWS is an independent prognostic predictor in liver transplantation recipients.

Thalamic Pain Misdiagnosed as Cervical Disc Herniation

Thalamic pain is a primary cause of central post-stroke pain (CPSP). Clinical symptoms vary depending on the location of the infarction and frequently accompany several pain symptoms. Therefore, correct diagnosis and proper examination are not easy. We report a case of CPSP due to a left acute thalamic infarction with central disc protrusion at C5-6. A 45-year-old-male patient experiencing a tingling sensation in his right arm was referred to our pain clinic under the diagnosis of cervical disc herniation. This patient also complained of right cramp-like abdominal pain. After further evaluations, he was diagnosed with an acute thalamic infarction. Therefore detailed history taking should be performed and examiners should always be aware of other symptoms that could suggest a more dangerous disease.

Comparison of 0.5% ropivacaine with fentanyl and 0.75% ropivacaine used in extension of a preexisting labor epidural for emergency cesarean section: retrospective study

BACKGROUND: Various regimens have been studied in extension of a preexisting labor epidural for emergency cesarean section. Lumbar epidural analgesia for delivery is safe and efficient. We compared retrospectively 0.5% ropivacaine with fentanyl and 0.75% ropivacaine in extension of a preexisting labor epidural for emergency cesarean section. METHODS: We investigated medical records of 61 parturients in extension of a preexisting labor epidural for emergency cesarean section. There were two regimens which was 0.5% ropivacaine with fentanyl (group 1) and 0.75% ropivacaine (group 2). We recorded demographic data, local anesthetic dose, surgical readiness time, maximum level of sensory block, surgery time, intravenous supplementation, number of hypotension and total dose of ephedrine between two groups. RESULTS: There were no differences between the study groups in demographic data, surgical readiness time, maximum sensory block level, intravenous supplementation, incidence of hypotension and total dose of ephedrine. Local anesthetic volume was larger in group 1 than group 2, but local anesthetic doses were lower in group 1 than group 2. CONCLUSIONS: 0.5% Ropivacaine with fentanyl regimen is as fast and efficacious as 0.75% ropivacaine in extension of a preexisting labor epidural for cesarean section and reduces the requiring total local anesthetic dose.

Cephalad malposition after central venous catheterization through right internal jugular vein / 대한마취과학회지

No abstract available.

A case of Brugada syndrome patient undertaken total intravenous anesthesia with remifentanil / 대한마취과학회지

No abstract available.

Estimation of the prevalence of Korean adults aged 50 years or more with knee osteoarthritis based on the data from fifth Korea National Health and Nutrition Examination Survey

This study estimated the number of Korean adults aged 50 years or more with osteoarthritis (OA) based on the data from fifth Korea National Health and Nutrition Examination Survey (K-NHANES). We analyzed the knee X-ray finding and symptom questionnaire data obtained from the fifth K-NHANES conducted in 2010. The number of Korean adults aged 50 years or more with radiographic OA (those who had grade II or higher Kellgren-Lawrence score for OA) and symptomatic OA (those who had grade II or higher Kellgren-Lawrence score for OA and knee pain) were estimated using surveyfreq procedure of the SAS statistical package. It was estimated that there were 5,294,073 (proportion, 37.8%; 95% confidence interval, 4,739,995 to 5,848,150) patients with radiographic OA and 2,003,471 (proportion, 14.3%; 95% confidence interval, 1,693,239 to 2,313,703) patients with symptomatic OA among 14,010,367 Korean adults aged 50 years or more in 2010. This study has a limitation that symptomatic OA based on only the self report of symptom questionnaire. So, it is important that the physician do a physical examination to diagnose OA. Also, further efforts to investigate large-scale prospective studies are needed.

Comparison between monitored anesthesia care with remifentanil under ilioinguinal hypogastric nerve block and spinal anesthesia for herniorrhaphy / 대한마취과학회지

BACKGROUND: The use of monitored anesthesia care (MAC) as the technique of choice for a variety of invasive or noninvasive procedures is increasing. The purpose of this study to compare the outcomes of two different methods, spinal anesthesia and ilioinguinal-hypogastric nerve block (IHNB) with target concentrated infusion of remifentanil for inguinal herniorrhaphy. METHODS: Fifty patients were assigned to spinal anesthesia (Group S) or IHNB with MAC group (Group M). In Group M, IHNB was performed and the effect site concentration of remifentanil, starting from 2 ng/ml, was titrated according to the respiratory rate or discomfort, either by increasing or decreasing the dose by 0.3 ng/ml. The groups were compared to assess hemodynamic values, oxygen saturation, bispectral index (BIS), observer assessment alertness/sedation scale (OAA/S), visual analogue scale (VAS) for pain score and patients' and surgeon's satisfaction. RESULTS: BIS and OAA/S were not significantly different between the two groups. Hemodynamic variables were stable in Group M. Thirteen patients in the same group showed decreased respiratory rate without desaturation, and recovered immediately by encouraging taking deep breaths without the use of assist ventilation. Although VAS in the ward was not significantly different between the two groups, interestingly, patients' and surgeon's satisfaction scores (P = 0.0004, P = 0.004) were higher in Group M. The number of the patients who suffered from urinary retention was higher in Group S (P = 0.0021). CONCLUSIONS: IHNB under MAC with remifentanil is a useful method for inguinal herniorrhaphy reflecting hemodynamic stability, fewer side effects and higher satisfaction. This approach can be applied for outpatient surgeries and patients who are unfit for spinal anesthesia or general anesthesia.

Intracerebral hemorrhage after inadvertent dural puncture and cesarean section under general anesthesia: A case report

Epidural analgesia is frequently used for control of labor pain. Seizure of parturient could be misdiagnosed as eclampsia. A parturient presented a generalized tonic clonic seizure during first stage of labor in two and a half hour after dural puncture and epidural blood patch. She had received an emergency cesarean section under general anesthesia and had another seizure during transfer to the intensive care unit. A brain computed tomography showed intracerebral hemorrhage and pneumocephalus. After conservative treatment, she could discharge without any sequelae in 13 days. The anesthesiologists should be aware of the possibility of intracerebral hemorrhage when they confront a seizure of parturient although there is no evidence of relation between dural puncture and intracerebral hemorrhage.

Atrial Fibrillation during General Anesthesia Induction and Paroxysmal Supraventricular Tachycardia on Emergence / 이화의대지

A healthy 35-year-old man who was scheduled for closed reduction of nasal bone fracture developed atrial fibrillation during induction of general anesthesia after intravenous glycopyrrolate injection. During emergence of general anesthesia, atrial fibrillation was suddenly changed to paroxysmal supraventricular tachycardia with 200 beat per minute and lasted for about 10 seconds. Because blood pressure was stable, esmolol was used to reduce ventricular response. At recovery room, ventricular response reduction about 55 beat per minute was observed after intravenous injection of verapamil 5 mg. Thereafter, the rhythm was returned to normal sinus rhythm with bradycardia.

Comparison of clinical effects according to the dosage of sufentanil added to 0.5% hyperbaric bupivacaine for spinal anesthesia in patients undergoing cesarean section / 대한마취과학회지

BACKGROUND: Subarachnoid block is a widely used technique for cesarean section. To improve the quality of analgesia and prolong the duration of analgesia, addition of intrathecal opioids to local anesthetics has been encouraged. We compared the effects of sufentanil 2.5 microg and 5 microg, which were added to intrathecal hyperbaric bupivacaine. METHODS: We enrolled 105 full term parturients were randomly divided into 3 groups: Group 1 (control), Group 2 (sufentanil 2.5 microg), and Group 3 (sufentanil 5 microg). In every group, 0.5% heavy bupivacaine was added according to the adjusted dose regimen. We determined the maximum level of sensory block and motor block, the quality of intraoperative analgesia, the duration of effective analgesia and side effects. RESULTS: There were no significant differences among the 3 groups in the maximum level of the sensory block and motor block. Recovery rate of the sensory block, however, was significantly slower in Group 3 than Group 1. Quality of intraopertive analgesia, muscle relaxation, and duration of effective analgesia were enhanced by increasing the dosage of intrathecal sufentanil. Frequencies of hypotension, maximum sedation level, and pruritus were directly related to the dosage of intrathecal sufentanil, whereas nausea and vomiting occurred only in the groups using sufentanil. CONCLUSIONS: The addition of sufentanil 2.5 microg for spinal anesthesia provides adequate intraoperative analgesia and good postoperative analgesia with minimal adverse effects on the mother.

General anesthesia for cesarean section in a patient with multiple sclerosis: A case report

A 34-year-old female with multiple sclerosis (MS) was scheduled Cesarean section. She had been suffering from MS for 10 years and the symptoms of MS were paraplegia and urinary incontinence. After informed consent, anesthesia was induced with propofol and maintained with nitrous oxide, sevoflurane and fentanyl. Rocuronium was used for muscle relaxation and tracheal intubation. Train of four (TOF) ratio and bispectral index scale were monitored for adequate muscle relaxation and depth of anesthesia. She gave birth to a baby within 7 minutes after skin incision. When operation was over, TOF ratio was 0.8. She emerged from general anesthesia smoothly and was extubated. There was no febrile event or exacerbation of MS after Cesarean section under general anesthesia. We report a safe anesthetic management of the parturient with MS, using sevoflurane.

Monitored anesthesia care with remifentanil for femoro-femoral bypass graft patients / 대한마취과학회지

No abstract available.

Monitored anesthesia care for unilateral inguinal herniorrhaphy in high risk patients: Two cases report

Remifentanil, an ultra-short acting opioid, exhibits at low doses distinct sedative properties that may be useful for supplementation of regional or local anesthesia. We described two patients suffered from serious underlying medical problems who underwent unilateral inguinal herniorrhaphy. One of them was 61 year-old male patient who had type B viral hepatitis, Child class B liver cirrhosis and rheumatoid arthritis with severe joint deformity including instability of cervical vertebrae. The other patient was 73 year-old man who had severe coronary artery occlusive disease which was recently managed with coronary stent and was underwent hemodialysis three times a week due to chronic renal failure. Monitored anesthesia care (MAC) with remifentanil through target controlled infusion (TCI) and local infiltration and ilioinguinal-hypogastric nerve block (IHNB) were done for herniorrhaphy. The operations were performed successfully without any complications such as respiratory depression or hypoxia and all patients and surgeon were very satisfied with MAC.