The EZ-Blocker® for one-lung ventilation in a patient with Kartagener syndrome and tracheal bronchus -a case report- / 대한마취과학회지

Background@#The tracheal bronchus in Kartagener syndrome is a rare case that may cause difficulty in one-lung ventilation (OLV). Here we reported a case of successful OLV using bronchial blocker in a patient with tracheal bronchus and Kartagener syndrome (KS).Case: A 66-year-old female patient with Kartagener syndrome was admitted for left-side diaphragmatic plication. The patient’s preoperative computed tomography image showed a tracheal bronchus of the apical segment in the right upper lobe. The patient received epidural analgesia and general anesthesia through total intravenous anesthesia. An EZ-Blocker® (Teleflex Life Sciences Ltd., Ireland) was used to perform OLV. @*Conclusions@#OLV through an EZ-Blocker® can be successfully performed in tracheal bronchus patients with Kartagener syndrome without side effects.

General Anesthesia for a Patient with GNEMyopathy: a case report / 고신대학교의과대학학술지

GNE, or bifunctional UDP-N-acetylglucosamine 2-epimerase/N-acetylmannosamine kinase, myopathy presents with symptoms of foot drop, followed by lower and upper extremity muscle weaknesses and sparing of the quadriceps. Myopathies usually increase the risks of complications related to general anesthesia. The anesthetic management of patients with GNEmyopathy has not been previously reported. Herein, we report a case of GNEmyopathy in a 37-year-old woman and discuss anesthetic considerations for elective laparoscopic hysterectomy and bilateral salpingectomy, focusing on the postoperative airway management. We avoided administering neuromuscular-blocking agents and instead used a laryngeal mask airway. The anesthetic management combining the use of a laryngeal mask airway and desflurane without neuromuscular-blocking agents provided sufficient abdominal and diaphragmatic muscle relaxations for sustaining the pneumoperitoneum for laparoscopic surgery.

Change in fibrinogen levels and severe postoperative bleeding in cardiac surgery

Thromboelastography or rotational thromboelastometry, is being increasingly utilized in cardiac surgery of late. However, it is an indirect test and is not available in all centers. Low fibrinogen levels before and after cardiopulmonary bypass (CPB) have been described to be associated with postoperative bleeding in cardiac surgery. This study explored the usefulness of reduction ratio of the fibrinogen levels before CPB (preCPB) and after CPB (postCPB) in predicting postoperative hemorrhage. A retrospective, observational study of adult patients who underwent cardiac surgery with CPB between February 2014 and January 2016 was conducted, which included a total of 264 patients. The fibrinogen levels were measured twice, preCPB and postCPB, and the fibrinogen reduction ratio was acquired [(preCPB − postCPB)/preCPB]. Postoperative blood loss, which was defined as the blood collected from the chest drain for 12 hours following arrival at the intensive care unit, was considered severe if it was more than 1,000 mL. A multivariate analysis showed that fibrinogen reduction ratio, sex, and postCPB platelet count were significantly associated with severe postoperative bleeding. However, the pre- and postCPB fibrinogen levels were not significantly associated with severe bleeding. Furthermore, a fibrinogen reduction ratio of > 41.3% was independently associated with postoperative severe bleeding, with an odds ratio of 3.472 (1.483–8.162). These results suggest that the reduction ratio of pre- and postCPB fibrinogen levels may be utilized in predicting postoperative bleeding.

The analgesic efficacy of a single injection of ultrasound-guided retrolaminar paravertebral block for breast surgery: a prospective, randomized, double-blinded study

Background@#The thoracic paravertebral block is an effective analgesic technique for postoperative pain management after breast surgery. The ultrasound-guided retrolaminar block (RLB) is a safer alternative to conventional paravertebral block.Thus, we assessed the analgesic efficacy of ultrasound-guided RLB for postoperative pain management after breast surgery. @*Methods@#Patients requiring breast surgery were randomly allocated to group C (retrolaminar injection with saline) and group R (RLB with local anesthetic mixture).The RLB was performed at the level of T3 with local anesthetic mixture (0.75% ropivacaine 20 mL + 2% lidocaine 10 mL) under general anesthesia before the skin incision. The primary outcome was cumulative morphine consumption using intravenous patient-controlled analgesia (IV-PCA) at 24 hour postoperatively. The secondary outcomes were the visual analogue scale (VAS) scores at 1, 6, 24, and 48 hour postoperatively and the occurrence of adverse events and patient satisfaction after the surgery. @*Results@#Forty-six patients were included, 24 in group C and 22 in group R. The cumulative morphine consumption using IV-PCA did not differ between the two groups (P = 0.631). The intraoperative use of remifentanil was higher in group C than in group R (P = 0.025). The resting and coughing VAS scores at 1 hour postoperatively were higher in group R than in group C (P = 0.011, P= 0.004). The incidence of adverse events and patient satisfaction was not significantly different between the two groups. @*Conclusions@#A single injection of ultrasound-guided RLB did not reduce postoperative analgesic requirements following breast surgery.

Comparison of patient-controlled epidural analgesia with patient-controlled intravenous analgesia for laparoscopic radical prostatectomy

BACKGROUND: Patient-controlled epidural analgesia (PCEA) is known to provide good postoperative analgesia in many types of surgery including laparoscopic surgery. However, no study has compared PCEA with patient-controlled intravascular analgesia (PCIA) in laparoscopic radical prostatectomy (LARP). In this study, the efficacy and side effects of PCEA and PCIA after LARP were compared. METHODS: Forty patients undergoing LARP were randomly divided into two groups: 1) a PCEA group, treated with 0.2% ropivacaine 3 ml and 0.1 mg morphine in the bolus; and 2) a PCIA group, treated with oxycodone 1 mg and nefopam 1 mg in the bolus. After the operation, a blinded observer assessed estimated blood loss (EBL), added a dose of rocuronium, performed transfusion, and added analgesics. The numeric rating scale (NRS), infused PCA dose, and side effects were assessed at 1, 6, 24, and 48 h. RESULTS: EBL, added rocuronium, and added analgesics in the PCEA group were less than those in the PCIA group. There were no significant differences in side-effects after the operation between the two groups. Patients were more satisfied with PCEA than with PCIA. The NRS and accumulated PCA count were lower in PCEA group. CONCLUSIONS: Combined thoracic epidural anesthesia could induce less blood loss during operations. PCEA showed better postoperative analgesia and greater patient satisfaction than PCIA. Thus, PCEA may be a more useful analgesic method than PICA after LARP.

Pharyngeal reperforation following incentive spirometry: A case report

Despite its widespread use, complication of incentive spirometry has been rarely reported. We report a case of pharyngeal reperforation following incentive spirometry. A 75-year-old female, had a history of long-term steroid use, entered the intensive care unit for maintenance of mechanical ventilation following surgical repair of a pharyngeal perforation. After ventilator weaning, incentive spirometry was implemented on postoperative day 4. Immediately after incentive spirometry use, patient's neck began to swell, and subcutaneous emphysema was palpated. Pharyngeal reperforation was suspected on neck computed tomography, and emergency surgery was performed. Surgery revealed a 3-cm long rupture from the hypopharynx to the esophagus. The causes were thought to be delayed wound healing due to long-term steroid use and a sudden increase in pharyngeal pressure due to incentive spirometry. In conclusion, particular attention should be paid when using incentive spirometry after head and neck surgery in patients with a history of long-term steroid use.

Cloudy urine developed during total intravenous anesthesia with 2% propofol in the patient taking hydroxyurea: A case report

We report a case that a 68-year-old man taking hydroxyurea for essential thrombocythemia produced milky urine during propofol infusion. Under microscopic analysis, the cloudy urine sample was revealed to comprise uric acid crystals. Postoperatively, kidney function such as urine output and blood urea nitrogen to creatinine ratio showed no abnormality. We suggest that the cloudy urine may be due to the increased excretion of uric acid after administration of propofol. Although this rare case of cloudy milky urine is resolved on its own, we need to consider the possibility of such urine color changes. It is particularly important to understand that medication, preoperative serum uric acid level, urine pH, and the hypothermal operating room can change the color of urine through the presence of uric acid crystals.

Anesthetic experience of frontotemporal dementia patient with severe autonomic dysfunction: a case report / 대한마취과학회지

Anesthetic experience in frontotemporal dementia (FTD) with severe hypotension associated autonomic dysfunction has not yet been reported. Here in case, we report on the case of treatment with vasopressin to refractory hypotension in FTD patient. A 54-year-old male presented with a ten-year history of FTD with frequent syncope. The patient was scheduled to undergo subtotal gastrectomy for resection of stomach cancer. During the operation, sudden hypotension occurred and it was refractory to fluid and 1 unit of blood resuscitation and did not respond to catecholamine. Transesophageal echocardiography showed normal heart with adequate volume state. After intravenous administration of arginine vasopressin, the patient's vital signs returned to baseline values. Arginine vasopressin might be considered as a valuable alternative for treatment of severe refractory hypotension in autonomic dysfunction patients with FTD.

The change of sevoflurane to desflurane after anesthesia induction induces rapid emergence without increased cardiovascular responses and emergence delirium in pediatric strabismus surgery patients

BACKGROUND: Desflurane has lower solubility and shows a more rapid induction and recovery than sevoflurane, although it often induces increased cardiovascular response, emergence delirium, and respiratory complications. The change of anesthetic agent from sevoflurane to desflurane after induction may provide a smooth induction and rapid emergence. The aim of this study was to evaluate the effect of changing sevoflurane to desflurane after induction on the cardiovascular response, emergence delirium, and recovery characteristics during pediatric strabismus surgery. METHODS: For the study, 135 children scheduled for strabismus surgery were randomly divided into three groups: the S group (n = 45) and D group (n = 45) received sevoflurane or desflurane, respectively, for induction and maintenance, while the C group (n = 45) received sevoflurane for induction and desflurane for maintenance. Cardiovascular responses, pediatric anesthesia emergence delirium (PAED) scale scores, post-anesthesia care unit (PACU) length of stay, and the incidence of postoperative complications were compared between groups. RESULTS: The blood pressure of the D group was significantly different from that of the S and C groups (P < 0.05). The time to extubation and first crying were significantly longer in the S group (P < 0.001). There were no significant differences in PAED score, PACU length of stay, and the incidence of postoperative complications, except for cough, among the three groups. CONCLUSIONS: The change of desflurane after sevoflurane induction in pediatric strabismus surgery provided rapid emergence compared with sevoflurane, and attenuated cardiovascular responses and lesser respiratory complications as compared to desflurane. The emergence delirium was not influenced by either inhalational anesthetic.

Postoperative pain and side effects after thyroidectomy: randomized double blind study comparing nefopam and ketorolac

BACKGROUND: Nefopam is a centrally acting, non-opioid analgesic drug used to reduce opioid consumption and so reduce the prevalence of postoperative nausea and vomiting (PONV). This study compared and assessed the effects of nefopam and ketorolac on postoperative pain and PONV after thyroid surgery. METHODS: Two hundred patients underwent total thyroidectomy with central compartment neck dissection in our hospital during a 5 month enrollment period. Group N and Group T was administered nefopam 20 mg and ketorolac 30 mg, respectively, during the last 30 minutes of surgery. Pain was measured using a 10-point numerical rating scale. Pain scores and PONV were assessed 30 min, 1, 6, and 24 h postoperatively. RESULTS: Pain scores and episodes of vomiting and shivering did not differ significantly between the two groups. Group N patients experienced fewer episodes of nausea at 30 min, 1 h and 6 h after the operation. CONCLUSIONS: Nefopam and ketorolac are similarly effective in reducing postoperative pain after thyroid surgery. Postoperative nausea was less in Group N patients within 6 h postoperatively, especially 1 h. Nefopam is favored for pain management after thyroidectomy.

Hemorrhagic shock occurring due to a concealed hematoma after insertion of a subclavian venous catheter in a patient undergoing anticoagulation therapy: a case report / 대한마취과학회지

A 74-year-old man who had been receiving warfarin for atrial fibrillation, underwent emergency thrombectomy. A central venous catheter (CVC) was inserted via the left subclavian vein, and heparin was administered to prevent preoperative and postoperative thrombotic events. After an uneventful thrombectomy, the patient was transferred to the intensive care unit (ICU). On the second postoperative day, the patient developed syncope and his blood pressure and oxygen saturation decreased. A computed tomography (CT) revealed a huge hematoma under the pectoralis major muscle. The patient was then treated with continuous renal replacement therapy and mechanical ventilation for multiorgan dysfunction syndrome, which developed due to hemorrhagic shock in the ICU. These findings suggest that when a CVC is inserted in patients requiring anticoagulant therapy, the possible risk of excessive bleeding must be carefully considered. Further, choosing a proper insertion site and performing an ultrasound-guided aspiration may be helpful in preventing these complications.

Trajectory avoiding kidney and ureter injury for percutaneous lumbar sympathetic block / 대한마취과학회지

No abstract available.

Gender differences in paclitaxel-induced neuropathic pain behavior and analgesic response in rats / 대한마취과학회지

BACKGROUND: Females show greater sensitivity than males to several modalities of experimental pain. However, the gender differences in paclitaxel-induced neuropathic pain have not been studied. The current study examined the gender differences in neuropathic pain behavior and the effect of analgesics in a paclitaxel-induced neuropathic pain model in rats. METHODS: Neuropathic pain was induced by intraperitoneal injection of paclitaxel (2 mg/kg) on 4 alternate days in Sprague-Dawley rats of both genders. Mechanical allodynia was measured using a von Frey filament. The gender differences in analgesic responses were determined after administration of morphine (2 or 5 mg/kg), ketamine (2 or 5 mg/kg), or combined morphine (2 mg/kg) and ketamine (2 mg/kg). RESULTS: Paclitaxel induced mechanical allodynia, which began to manifest on day 4, peaked within 10 days, and plateaued for at least 2 months after the first paclitaxel injection. No gender difference in the manifestation of mechanical allodynia was observed. A 2 mg/kg dose of ketamine increased the mechanical threshold only in males. The 5 mg/kg dose of ketamine significantly increased the mechanical threshold in both genders. Morphine (2 and 5 mg/kg) dose-dependently increased the mechanical thresholds in both genders. The 2 mg/kg dose of ketamine enhanced the antinociceptive effect of 2 mg/kg morphine only in females. CONCLUSIONS: No gender difference in paclitaxel-induced neuropathic pain or analgesic response to ketamine or morphine was observed in Sprague-Dawley rats. Low dose ketamine enhanced the analgesic effect of morphine on paclitaxel-induced mechanical allodynia but only in female rats.