A fiberoptic orotracheal intubation successfully performed using a modified Guedel airway in a sedated emergency patient - A case report -

Background@#An airway assessment is usually best performed before an elective operation. But in an emergency operation, proper airway assessment can often be difficult. Fiberoptic intubation is a powerful and safe technique to deal with airway difficulty, but it requires a lot of training to be able to perform correctly. There are various specialized oral airways for fiberoptic intubation, but none of them have perfect functionality.CaseA 75-year-old male (body weight 71.6 kg, height 159.3 cm, body mass index 28.22 kg/m2) was diagnosed with acute appendicitis, and it was decided to do a laparoscopic appendectomy. After the induction of general anesthesia, it was impossible to insert the direct laryngoscope deep enough for vocal cord visualization without damaging the teeth because of limited mouth opening. We successfully performed fiberoptic intubation with a newly modified Guedel airway via a longitudinal channel on the convex side and a distal opened lingual end. @*Conclusions@#Our modified Guedel airway can be useful in assisting fiberoptic intubation in unexpectedly difficult airway situations.

Adherence to Varenicline and Abstinence Rates for Quitting Smoking in a Private Health Promotion Center-Based Smoking Cessation Clinic / 결핵및호흡기질환

BACKGROUND: Varenicline is an effective smoking cessation aid. However, smokers prescribed with varenicline do not always receive varenicline for 12 weeks, as recommended. This study analyzed the subjects who received varenicline and investigated the effect of varenicline treatment duration on the success rate of 6-month smoking cessation. METHODS: This study retrospectively analyzed 78 subjects, who received varenicline, out of the 105 smokers that had visited the smoking cessation clinic after medical examination from September 2007 to December 2009. RESULTS: The subjects were all males. Twenty-two subjects (28.2%) had varenicline treatment for 12 weeks or longer; 18 subjects (23.1%) for 8~12 weeks; 22 subjects (28.2%) for 4~8 weeks; and 16 subjects (20.5%) for less than 4 weeks. The total success rate of the 6-month smoking cessation was 47.4%. The success rate of the 6-month smoking cessation was 63.6% in the group that received varenicline for 12 weeks or longer, which was higher than 41.1% of the group that early terminated the varenicline treatment (p=0.074). The period of varenicline treatment was extended for one more week, the odds ratio of the 6-month smoking cessation success increased to 1.172-folds (p=0.004; 95% confidence interval, 1.052~1.305). Adverse events occurred in 30.8% of the subjects who received varenicline, but no serious adverse events were found. CONCLUSION: If varenicline treatment period is extended, the odds ratio of the success rate for the 6-month smoking cessation increases. Therefore, an effort to improve drug compliance for varenicline in clinical practices could be helpful for the long-term success of smoking cessation.

Anesthetic experience of methemoglobinemia detected during general anesthesia for gastrectomy of advanced gastric cancer: A case report / 대한마취과학회지

Methemoglobinemia is an uncommon but potentially fatal disorder. Most cases have no adverse clinical consequence and require no treatment, but methemoglobinemia is often overlooked as a cause of low oxygen saturation, and often mistaken for the more common causes of hypoxia by anesthesiologists despite simple bedside tests that indicate the presence of this treatable abnormality. We present a 68-year-old female patient who underwent gastrectomy for advanced gastric cancer with bleeding. In the preoperative period, the patient showed cyanosis and oxygen saturation was 85% by pulse oximeter, but oxygen saturation by arterial blood gas analysis was 100%. After tracheal intubation, the methemoglobin level was 18.3%. Ascorbic acid and methylene blue were administered. During preanesthetic evaluation, the patient had not informed the anesthesiologist that she had been taking dapsone.

Successful Treatment of Mycobacterium celatum Pulmonary Disease in an Immunocompetent Patient Using Antimicobacterial Chemotherapy and Combined Pulmonary Resection

Mycobacterium celatum is a nontuberculous mycobacterium that rarely causes pulmonary disease in immunocompetent subjects. We describe the successful treatment of M. celatum lung disease with antimicobacterial chemotherapy and combined pulmonary resection. A 33-year-old woman was referred to our hospital with a 3-month history of a productive cough. Her medical history included pulmonary tuberculosis 14 years earlier. Her chest X-ray revealed a large cavitary lesion in the left upper lobe. The sputum smear was positive for acid-fast bacilli, and M. celatum was subsequently identified in more than three sputum cultures, using molecular methods. After 1 year of therapy with clarithromycin, ethambutol, and ciprofloxacin, the patient underwent a pulmonary resection for a persistent cavitary lesion. The patient was considered cured after receiving 12 months of postoperative antimycobacterial chemotherapy. There has been no recurrence of disease for 18 months after treatment completion. In summary, M. celatum is an infrequent cause of potentially treatable pulmonary disease in immunocompetent subjects. Patients with M. celatum pulmonary disease who can tolerate resectional surgery might be considered for surgery, especially in cases of persistent cavitary lesions despite antimycobacterial chemotherapy.

Airway obstruction by extrinsic tracheal compression during spinal surgery under prone position: A case report / 대한마취과학회지

Tracheal compression by vascular anomalies in adults is uncommon and most related reports are of children. A 79-year-old woman without any respiratory history underwent a lumbar spine surgery under general anesthesia. She suddenly developed airway obstruction after a position change from supine to prone. A fiberoptic bronchoscopy showed the obstruction of endotracheal tube. The obstruction was relieved after we changed the depth of endotracheal tube and supported the patient's neck with a cotton roll. The surgery ended without any other event and the patient recovered safely. A computed tomography revealed the rightward tracheal deviation and tortuous innominate artery contact with trachea. The patient didn't manifest any respiratory related symptoms during postoperative period, and she was discharged without any treatment.

Suspicious stress induced cardiomyopathy following hemorrhoidectomy under spinal anesthesia: A case report / 대한마취과학회지

A 48-year-old healthy woman was admitted in our hospital for elective hemorrhoidectomy. She developed sudden headache and chest pain, and showed sinus bradycardia, arrhythmia and hypotension forty minutes after spinal anesthesia with 0.5% hyperbaric bupivacaine. An EKG showed ST depression and an transthoracic echocardiogram performed in PACU demonstrated mild LV dysfunction with hypokinesia of LV inferolateral wall. An coronary angiography on postoperative day 1 revealed normal coronary vessel and akinesia of LV inferior wall. Levels of CK-MB and Troponin I were mildly elevated. With medical therapy, the patient's symptoms improved and recovered without any complication.

Treatment Results and Prognostic Factors of Complicated Parapneumonic Effusion and Empyema / 결핵및호흡기질환

BACKGROUND: Pleural effusion develops in approximately 40% of pneumonia patients. In 5-10% of these cases, it progresses to complicated parapneumonic effusion (CPPE) or empyema that requires drainage. The prognostic factors of CPPE and empyema remain to be clarified. We examined the treatment outcomes of CPPE and empyema and elucidating their prognostic factors. METHODS: One hundred and fifteen patients with CPPE or empyema, who were diagnosed and treated in Kyungpook National University Hospital (Daegu, Korea) between September 2001 and December 2005, were retrospectively analyzed. All the data was acquired from their chart review, and regarding treatment results, the time to defervescence and the length of hospital stay were analyzed. RESULTS: The treatment was successful in 101 patients with a success rate of 87.8%. Multivariate analysis showed the level of pleural fluid lactate dehydrogenase (LDH) to be a significant prognostic factor (odds ratio [OR] 7.37; 95% confidence interval [CI], 1.63 to 33.37; p=0.009). Pussy pleural fluid (r=0.236; p=0.01) and the frequency of urokinase use (r=0.257; p=0.01) correlated with the time to defervescence. However, there was no clinical factor that correlated with the length of hospital stay. CONCLUSION: The pleural fluid LDH level is a useful prognostic factor for monitoring treatment results of CPPE and empyema.

Long-term Prognosis and Physiologic Status of Patients Requiring Ventilatory Support Secondary to Chest wall Disorders / 결핵및호흡기질환

BACKGROUND: Chest wall deformities such as kyphoscoliosis, thoracoplasty, and fibrothorax cause ventilatory insufficiency that can lead to chronic respiratory failure, with recurrent fatal acute respiratory failure(ARF). This study evaluated the frequency and outcome of ARF, the physiologic status, and the long-term prognosis of these patients. METHODS: Twenty-nine patients with chest wall disorders, who experienced the first requirement of ventilatory support from ARF were examined. The mortality and recurrence rate of ARF, the pulmonary functions with arterial blood gas analysis, the efficacy of home oxygen therapy, and the long-term survival rate were investigated. RESULTS: 1) The mortality of the first ARF was 24.1%. ARF recurred more than once in 72.7% of the remaining 22 patients, and overall rate of successful weaning was 73.2%. 2) Twenty-two patients who recovered from the first ARF showed a restrictive ventilatory impairment with a mean FVC and TLC of 37.2% and 62.4 % of predicted value, respectively, and a mean PaCO2 of 57mmHg. Among the parameters of pulmonaty functions. the FVC(p=0.01) and VC(p=0.02) showed a significant correlation with the PaCO2 level. 3) There were no significant differences between the patients treated with conservative medical treatment only and those with additional home oxygen therapy due to significant hypoxemia in the patients with recurrent ARF and the mortality. 4) The 1, 3, 5-year survival rates were 75%, 66%, and 57%, respectively, in the 20 patients who had recovered from the first ARF, excluding the two patients managed by non-invasive nocturnal ventilatory support. CONCLUSION: These results suggest that active ventilatory support should be provided to patients with ARF and chest wall disorders. However, considering recurrent ARF and weak effect of home oxygen therapy, non-invasive domiciliary ventilation is recommended in those patients with these conditions to achieve a better long-term prognosis.

The Effect of alpha2 Adrenoceptors and Imidazoline Receptors on the Mechanical Allodynia in Rats with Nerve Ligation Injury / 대한마취과학회지

BACKGROUND: Clonidine, an alpha2 adrenoceptor agonist, has been known to have an antiallodynic effect in many animal and human studies. Clonidine, however, acts on imidazoline receptors as well as alpha2 adrenoceptors. Recently, the effect of clonidine on the symapthetic nervous system was reported to be mediated via the activation of the imidazoline receptor system but not the alpha2 adrenergic receptor system. Therefore, we conducted a behavioral test to investigate the effects of alpha2 adrenoceptors and imidazoline receptors on mechanical allodynia in rats with spinal nerve ligation (SNL) injury. METHODS: Male Sprague Dawley rats were prepared with tight ligation of the left lumbar 5th and 6th spinal nerves and chronic lumbar intrathecal catheter implantation for drug administration. Using a von Frey hair (VFH) test, we examined the effects of intrathecal (IT) brimonidine (0.03 - 3 microgram), clonidine (3 - 10 microgram), and rilmenidine (1 - 30 microgram) in SNL rats. Measurements of the baseline value VFH test was conducted at each dose to compare with the preoperative state. In addition, an antagonistic study with rauwolscine or yohimbine was performed to investigate the reversal of antiallodynic effects of each agonist. Allodynic thresholds for the withdrawal response of the left lesioned hindpaw to VFH stimuli were assessed and converted to %MPE. RESULTS: The antiallodynic effects of brimonidine, clonidine, and rilmenidine were produced in a dose dependent manner. The antiallodynic effects of IT brimonidine but not rilmenidine were significantly antagonized by alpha2 antgonists rauwolscine and yohimbine (P < 0.05). CONCLUSIONS: The results suggest that mechanical allodynia produced by a SNL injury is reduced by an imidazoline receptor agonist as well as alpha2 adrenergic receptor agonists and sympathetic activation is more likely mediated by spinal imidazoline receptors.

Effect of Glucose on Isolated Rat Sciatic Nerve Compound Action Potentials / 대한마취과학회지

BACKGROUND: When performing spinal anesthesia, glucose is frequently added to control the extent of the anesthesia by increasing the specific gravity of the local anesthetic solution. It is not clearly known whether the added glucose directly affects the nerve blockade or not. The purpose of this study is to examine the effect of glucose solution on isolated nerve fibers in vitro. METHODS: Compound action potentials (CAPs) of A-fiber range were recorded from isolated nerves of adult Sprague-Dawley rats (300 400 gm). Tonic (0.5 Hz) and phasic (30 Hz) supramaximal stimuli were repeatedly applied to one end of the nerves and the recordings were made on the other end. Nerves were perfused with modified Krebs solution for 45 minutes initially to get baseline data and then perfused with test solutions containing different concentrations of glucose (2.5%, 5%, 7.5%) for 30 minutes. The same experiments were repeated with mannitol at the same osmolality as the glucose. RESULTS: Glucose produced a decrease in the amplitude of CAPs in a dose-dependent manner (79.2 +/- 3.4, 50.3 +/- 3.7, 34.6 +/- 4.0 for 2.5%, 5%, 7.5% glucose solutions, respectively). At each of the same concentration levels, the degree of nerve conduction blockade did not have any significant difference within the glucose groups and mannitol groups. CONCLUSIONS: Glucose, in clinically employed concentration range, directly depressed peripheral nerve conduction in vitro, probably via osmotic effect.

Does Autonomic Dysfunction in Diabetic Patients Affect Intraoperative Hemodynamic Instability during Coronary Artery Bypass Surgery? / 대한마취과학회지

BACKGROUND: In this study, we examined diabetic patients scheduled for elective coronary artery bypass surgery to determine whether there is an association between autonomic dysfunction and intraoperative hemodynamic instability, and if perioperative autonomic function tests are effective predictors for diabetic patients at greatest risk for hemodynamic events during the intraoperative period. METHODS: We examined 52 patients, 25 without diabetes (nonDM group) and 27 with diabetes (DM group). Preoperative autonomic function tests included are the valslava maneuver (valsalva ratio, valsalva index, strain response), change in heart rate with deep breathing (I/E ratio), change in heart rate (30:15 ratio, stress response) and diastolic blood pressure (L-S(d)) while standing. Anesthesia was established with midazolam, fentanyl, isoflurane and vecuronium. Several hemodynamic variables such as heart rate (HR), mean arerial pressure (MAP), central venous pressure (CVP), mean pulmonary artery pressure (MPAP), pulmonary capillary wedge pressure (PCWP), systemic vascular resistance index (SVRI), pulmonary vascular resistance index (PVRI), cardiac output (CO), and cardiac index (CI) were obtained at the following times: before induction; after induction; after intubation; after skin incision and after sternotomy. RESULTS: The DM group had a significantly diminished response compared with the nonDM group in the valsalva ratio, valsalva index, 30:15 ratio, and L-S(d). The remaining tests (I/E ratio, strain response, stress response) showed similar but nonsignificant diminished trend response in the DM group. Most patients had one or more abnormal test results in this group (76%), whereas in the control group most patients did not show any abnormal test results (74.1%). The comparison of hemodynamic response between the DM group and non-DM group reveal a significant difference between times within each group but not between groups. CONCLUSIONS: This study indicates that increased hemodynamic instability during the intraoperative period is not an obligatory association with diabetes and autonomic dysfunction and is not detected bypreoperative autonomic function tests in patients with coronary artery disease and diabetes mellitus when anesthesia is induced and maintained with a large dose of opioid and anesthetic agent which has minimal hemodynamic effects.

Dextromethorphan Pretreatment Does not Reduce the Tourniquet Pain in Normal Volunteers / 대한마취과학회지

BACKGROUND: Dextromethorphan (DEX) is an NMDA receptor antagonist which has recently been introduced for the treatment of chronic pain mainly to reduce the central sensitization component of pain. It is also reported to reduce the pain from acute ischemia of an extremity in a rat model which has a similar mechanism as tourniquet pain. The purpose of this experiment was to see if dextromethorphan could reduce tourniquet pain in normal volunteers. METHODS: A double blind randomized cross-over test was done on ten healthy male volunteers. Each subject was orally administered with three different doses of DEX (placebo, 30, 60 mg) 1 h before the study according to a preallocated randomized table. The subject was not reallocated for the test within two weeks of the previous test. After a 10 minute acclimation period before each test, the degree of tourniquet pain measured by VAS, arterial blood pressure, heart rate, respiration rate, and pressure-evoked pain were measured before and every 5 minutes after inflation of the tourniquet until the subject felt unbearable pain. A mixed model for repeated measurement of data was used for statistical analysis (P 0.05). CONCLUSIONS: DEX is not effective in controlling tourniquet pain in normal awake subjects.

Noninvasive Regional Cerebral Oxygenation Monitoring in Patients with Moyamoya Disease / 대한마취과학회지

Moyamoya disease is a rare progressive occlusive disease in the internal carotid arteries, along with the presence of an abnormal capillary network of vessels at the base of the brain. In moyamoya disease, the manitaining of cerebral perfusion and cerebral oxygen saturation are required to reduce complications of this disease including cerebral ischemia and cerebral hemorrhage. The authors measured regional oxygen saturation (rSO2) nonivasively by INVOS 5100 (Somanetics, USA) in patients with moyamoya disease who were scheduled for an encephalo-duro-arterio-myo synangiosis (EDAMS) operation. We therefore report our findings that deep breathing decreased rSO2 and oxygen, elevated blood pressure, and that the cerebral vasodilating drug increased rSO2.

The Effects of Pressor Response upon Intravenous Ephedrine Following Oral Clonidine Premedication in Anesthetized Patients / 대한마취과학회지

BACKGROUND: In some studies, 5 microgram/kg clonidine premedication was claimed to enhance the pressor effects of ephedrine in anesthetized patients. We studied hemodynamic responses to intravenous responses, themselves responses to intravenous ephedrine in patients who received clonidine 3 microgram/kg. METHODS: 40 ASA pysical status I or II patients were randomly assigned to either the clonidine group (n = 20), receiving oral clonidine 3 microgram/kg 90 min before general anesthesia, or the control group (n = 20), receiving no clonidine. Hemodynamic measurements were made at one-minute intervals for ten minutes after ephedrine 0.1 mg/kg was injected as a bolus. RESULTS: The magnitude of maximal systolic blood pressure increases in the clonidine group (13.2+/-9.3%) was no different in the control group (12.4+/-12.3%). There were no difference in the pressor effect and duration of response of ephedrine in both groups. CONCLUSIONS: The pressor effect of ephedrine is not enhanced in patients given 3 microgram/kg clonidine premedication during general anesthesia.

The Effect of Oral Clonidine Premedication on Changes in Respiratory System Mechanics by Tracheal Intubation / 대한마취과학회지

BACKGROUND: The aim of this study was to evaluate the influence of oral clonidine premedication on respiratory mechanics by tracheal intubation in smokers. METHODS: Thirty male smoker patients were randomly divided into 3 groups. For group 1 (n = 10), l microgram/kg of clonidine was premedicated. For group 2 (n = 10), 2 microgram/kg of clonidine was premedicated. Group 3 (n = 10, control group) was the no premedication group. After anesthetic induction, CMV was applied with a Siemens Servo 900C ventilator, and anesthetic gases were supplied via the low pressure inlet of the ventilator. Tidal volume (10 ml/kg) was fixed during measurements for each patient. End-inspiratory occlusion was applied for at least 3 seconds and tracheal pressure was measured at the distal end of the endotracheal tube. Pressure, flow and volume were monitored and recorded with a Bicore CP-100 pulmonary monitor. Data were measured after 2 (100% O2) and 5 (1.5 vol% enflurane with 50% N2O) minutes of tracheal intubation. Data were transferred to PC and analyzed by processing software (ANADAT). Total respiratory (Rrs), airway (Raw) and tissue (Rve) resistances, along with static (Cstat), dynamic (Cdyn) compliances were calculated. RESULTS: There were no significant differences for Rrs, Raw, Rve, Cstat and Cdyn in the three groups. CONCLUSIONS: Oral clonidine premedication in dosages up to 2 microgram/kg do not affect the changes of respiratory mechanics caused by tracheal intubation in smokers.

The Effect of Oral Clonidine Premedication on Changes in Respiratory System Mechanics by Tracheal Intubation / 대한마취과학회지

BACKGROUND: The aim of this study was to evaluate the influence of oral clonidine premedication on respiratory mechanics by tracheal intubation in smokers. METHODS: Thirty male smoker patients were randomly divided into 3 groups. For group 1 (n = 10), l microgram/kg of clonidine was premedicated. For group 2 (n = 10), 2 microgram/kg of clonidine was premedicated. Group 3 (n = 10, control group) was the no premedication group. After anesthetic induction, CMV was applied with a Siemens Servo 900C ventilator, and anesthetic gases were supplied via the low pressure inlet of the ventilator. Tidal volume (10 ml/kg) was fixed during measurements for each patient. End-inspiratory occlusion was applied for at least 3 seconds and tracheal pressure was measured at the distal end of the endotracheal tube. Pressure, flow and volume were monitored and recorded with a Bicore CP-100 pulmonary monitor. Data were measured after 2 (100% O2) and 5 (1.5 vol% enflurane with 50% N2O) minutes of tracheal intubation. Data were transferred to PC and analyzed by processing software (ANADAT). Total respiratory (Rrs), airway (Raw) and tissue (Rve) resistances, along with static (Cstat), dynamic (Cdyn) compliances were calculated. RESULTS: There were no significant differences for Rrs, Raw, Rve, Cstat and Cdyn in the three groups. CONCLUSIONS: Oral clonidine premedication in dosages up to 2 microgram/kg do not affect the changes of respiratory mechanics caused by tracheal intubation in smokers.

The Effect of Brimonidine Premedication on the Sympathetic Nervous System during Ketamine Anesthesia in the Ratv / 대한마취과학회지

BACKGROUND: The use of ketamine as the sole anesthetic induces marked central sympathetic stimulation, causing an increase of heart rate and blood pressure. alpha2-receptor agonist has been demonstrated to attenuate many of these undesirable effects when used as a premedicant. Brimonidine is a new and highly selective alpha2-receptor agonist, and rauwolscine is a selective alpha2-receptor antagonist with little affinity for imidazoline receptors. Using power spectral analysis of heart rate variability, this study examines the effect of brimonidine premedication during ketamine anesthesia on the changes in the autonomic nervous system. METHODS: From 57 Sprague-Dawley rats, 12 rats were anesthetized by urethane (U Group, 1.5 g/kg), 18 rats by ketamine (K Group, 100 mg/kg, 2 mg/kg/min continuous infusion) intraperitoneal injection after saline premedication. Brimonidine (BK Group, 30 microgram/kg, n=15), brimonidine with rauwolscine (BRK Group, 30 microgram/kg, 20 mg/kg, n=12) were adminstered as a premedicant before induction of ketamine anesthesia. ECG signals were recorded for 5 min after a period of 10 min of anesthetic stabilization. Power spectal analysis of the data was computed, using short-time Fourier transform. The spectral peaks within each measurement were calculated; a low frequency area (0.04~1.0 Hz), a high frequency area (1.0~5.0 Hz), and a total frequency area (0.04~5.0 Hz) were measured. RESULTS: The results documented that the K Group showed sympathetic activation as compared with the U Group (p<0.001). The BK Group showed sympathetic depression compared with the K and BRK Groups (p<0.001). There were no significant differences in sympatho-vagal balance between the K and BRK Groups. CONCLUSIONS: These results suggest that premedication with brimonidine is effective in attenuating the sympathetic stimulatory effect of ketamine.

An Anesthetic Experience for Automatic Implantable Cardioverter Defibrillator Implantation: A case report / 대한마취과학회지

Automatic implantable cardioverter defibrillator(AICD) is a device that senses ventricular tarchycardia and ventricular fibrillation and responses with counter-shocks to the heart. We experienced a case of AICD implantation to prevent sudden cardiac death. A-22-year-old male was operated under O2, N2o, fentanyl, low dose enflurane anesthesia. The diagnosis was familial long QT syndrome. Lead was introduced to the right ventricular apex through left subclavian vein and generator was placed between pectoralis muscles. Then defibrillation threshold testing was performed. Ventricular fibrillation was induced with Twave shock of 3 joule and defibrillation with 5 joule terminated ventricular fibrillation successfully. After ventricular fibrillation, his blood pressure decreased to 30mmHg. When ventricular fibrillation was converted to normal rhythm, it retured to normal range. After operation, patient was transferred to the ICU and stayed there for 3 days.