Ipsilateral Mydriasis after Open Reduction of a Left Blow Out Fracture: A case report / 대한마취과학회지

Perioperative unilateral mydriasis is a disturbing finding, which is suggestive of acute intracranial pathology during general anesthesia. In addition, the assessment of an abnormal neurological injury is limited during general anesthesia, with anisocoria requiring special consideration. The case of a 27 year old healthy male patient, with ipsilateral mydriasis found near the end of surgery of open reduction for left blow out fracture, was experienced. The patient's pupils were bilaterally equal four hours after uneventfully surgery. The possible causes of unilateral mydriasis include the effects of anesthetic agents, stellate ganglion block, impaired venous return from head and neck, an acute intracranial mass lesion or hemorrhagic event, direct eye trauma, pre-existing medical or surgical conditions (Adie's tonic pupil, artificial eye etc.) and inadvertent direct deposition of alpha-adrenergic or anticholinergic agents in the eye. The understanding and diagnosis of unusual mydriasis during general anesthesia requires knowledge of the autonomic nerve pathways and pharmacology of the eye. In this case, the myadriasis of the left eye was considered to have resulted from the absorption of 1:100.000 topical epinephrine infiltrated into the lower eyelid via episcleral vessels.

Developed Extrapotine Myelinolysis after Hysteroscopic Myomectomy: A case report / 대한마취과학회지

Transcervical resection of endometrium is under-utilized in the treatment of dysfunctional uterine bleeding, uterine myoma and menorrhagia. The procedure is similar to transurethral resection of prostate in men with a possibility of substantial absorption of irrigation fluid. Absorption of a large volume of fluid can cause excessive intravascular volume, hyponatremia, cerebral edema and death. Severe hyponatremia leading to extrapontine myelinolysis is an extremely rare complication of this procedure. So, We report a case of developed extrapontine myelinolysis after hysteroscopic myomectomy which, however, showed complete recovery.

Anesthetic Management of Emergent Cesarean Section in a Patient with Allergic Reaction to an Antibiotic: A case report / 대한마취과학회지

Allergic reactions developed in parturients can cause fetal asphyxia and some difficulties in anesthetic management. We performed general anesthesia for an emergent cesarean section on 30 yrs old woman who showed an allergic reaction to an antibiotic. Dyspnea, urticaria, sweating, generalized edema and fetal bradycardia suddenly occurred after an intravenous injection of the antibiotic. Dexamethasone 10 mg was administered intravenously. General anesthesia was induced with pentothal and succinylcholine. Despite of severe airway edema, endotracheal intubation was successful. During the operation, the allergic signs became decreased. After the operation, no additional problems were evident. Potential epitopes should be removed in susceptible parturients and medical staff should be familiar with anesthetic management in allergic patients during pregnancy.

Hydrohemothorax and Subclavian Artery Laceration during Internal Jugular Vein Cannulation: A case report / 대한마취과학회지

Central venous cannulation via an internal jugular vein has become a common procedure in the management and monitoring of severely ill patients. Although complications such as carotid artery puncture or pneumothorax have been reported, hemothorax is relatively uncommon. We describe a case of hydrohemothorax and subclavian artery laceration which occurred during right internal jugular vein cannulation. A 44-year-old female patient was admitted for laparoscopic adrenalectomy under general anesthesia. For central venous pressure monitoring, central venous cannulation performed. However, dilator overinsertion injured the right subclavian artery. This led to a massive ipsilateral hydrohemothorax requiring thoracotomy for subclavian artery repair. This case suggests that central venous cannulation should be done carefully and improves awareness of the potential for dilator induced injury.

Comparison of Postoperative Nausea and Vomiting between Gynecologic Surgery and Cesarean-Section during Intravenous Patient-Controlled Analgesia with Fentanyl / 대한마취과학회지

BACKGROUND: The purpose of this study was to compare the incidence of postoperative nausea and vomiting (PONV) in patients undergoing major gynecologic surgery with those undergoing Cesarean-section during intravenous patient-controlled analgesia (PCA). METHODS: Seventy two patients received general anesthesia with enflurane. Group 1 patients underwent major gynecologic surgery, and group 2 patients were parturients who underwent Cesarean-section. Postoperatively, fentanyl was continuously infused i.v. using Accufuser PLUS (basal, 2 ml/h; bolus, 0.5 ml; lockout interval, 15 min) containing fentanyl 25microgram/kg in saline. PONV was evaluated at 6, 12, 24 and 36 h after starting continuous infusion and compared in the two groups. RESULTS: The incidence of PONV was significantly lower in group 2 (14%) than in group 1 (67%) (P < 5). CONCLUSIONS: Our results show that the incidence of PONV was lower for Cesarean-section than for gynecologic surgery.

Therapy of Pulmonary Embolism under Cardiopulmonary Bypass during Bipolar Endoprosthesis of the Hip / 대한마취과학회지

Although the occurrence of fatal pulmonary embolism may be diminishing, it still accounts for a substantial proportion of postoperative deaths in the middle-aged and older persons, especially among those undergoing major orthopedic surgery, despite improvements in patient management. We experienced cardiac arrest during bipolar endoprosthesis. Cardiopulmonary resuscitation was started and the transesophageal echocardiogram showed right heart failure. We suspected acute pulmonary thromboembolism and decided to perform thromboembolectomy with cardiopulmonary bypass. A massive old blood clot and a 1.0 x 1.5 cm thrombus were removed from both pulmonary arteries. However, despite massive fluid therapy and the use of inotropic agent, the patient failed to recover successfully with postoperative management in the intensive care unit.

The Effect of Monitored Anesthesia Care using Alfentanil and Ketorolac in Patients Undergoing Endoscopic Sinus Surgery / 대한마취과학회지

BACKGROUND: Monitored anesthesia care (MAC) has become increasingly important as a means of ensuring patient comfort, safety and satisfaction during surgery under local anesthesia. The purpose of this study was to evaluate the effect of monitored anesthesia care using alfentanil and ketorolac in patients undergoing endoscopic sinus surgery (ESS). METHODS: We studied 47 adult patients premedicated with glycopyrrolate 0.2 mg and midazolam 0.02 mg/kg IV. Using a 5.0 endotracheal tube, 5 L/min of oxygen was delivered via mouth. A mixture of 30 mg of ketorolac and 2,500microgram of alfentanil in 25 ml of saline was infused to patients at a rate of 1microgram/kg/min alfentanil after a bolus injection of 5microgram/kg alfentanil before operation. During operations we monitered vital signs, SpO2, OAA/S (Observer's Assessment of Alertness/Sedation) scale and BIS scores. Six hours postoperatively we assessed patient degree of satisfaction via NRS (1-10) with the anesthetic technique and side effects. RESULTS: Mean duration of drug infusion was 35 +/- 10.1 min, and the mean infusion rate of alfentanil was 1.09 +/- 0.23microgram/kg/min. Significant differences were observed between OAA/S scale scores at 10 min and 30 min after drug infusion and those in the waiting room (4.63, 4.65 vs 5, P <0.05)(Fig. 4). The mean patient satisfaction score was 8.3 out of 10, and 93.6% (44/47) of patients said they would recommend this anesthetic technique to others for ESS. CONCLUSIONS: Our results suggest that MAC using a mixture of alfentanil and ketorolac during ESS is a good way of relieving patient anxiety and pain without respiratory depression or excessive sedation. This study also showed a high level of patient satisfaction for those undergoing ESS under local anesthesia.

Acute Dystonia by Droperidol during Intravenous Patient-Controlled Analgesia in Young Patients

Patient-controlled analgesia (PCA) is an important means for postoperative analgesia with parenteral opioid. However, postoperative nausea and vomiting (PONV) remains a major problem with a PCA system. Droperidol is used in PCA to prevent PONV. Extrapyramidal reactions by droperidol are, however, occasionally induced. We describe two cases of severe extrapyramidal hypertonic syndrome with an intravenous administration of droperidol in PCA in young patients, following orthopedic surgery.

Acute Dystonia by Droperidol during Intravenous Patient-Controlled Analgesia in Children / 대한마취과학회지

Patient-controlled analgesia (PCA) is an important means for postoperative analgesia with parenteral opioids. However, postoperative nausea and vomiting (PONV) remains a major complication with a PCA system. Droperidol is used in PCA to prevent PONV. Extrapyramidal reactions by droperidol are, however, occasionally induced. We describe two cases of severe extrapyramidal hypertonic syndrome with an IV administration of droperidol in PCA in two children, following orthopedic surgery. One patient showed a hypertonic syndrome 20 minutes after receiving droperidol 1.0 mg IV and the symptoms persisted for nearly 12 h without prescription. Another patient revealed an acute rigidity 19 h after the beginning of PCA and was treated with an IM administration of midazolam 2 mg successfully.

The Pain Alterations in Terminal Cancer Patients Who Received Pain Control / 대한마취과학회지

BACKGROUND: The prevalence of cancer pain was 64% in advanced or terminal cancer patients. In the world, about 25% of all cancer patients had been died without pain control despite of severe pain. We relieved cancer pain with the three methods of treatment such as continuous epidural morphine infusion, alcohol sympathetic block and continuous epidural morphine infusion with alcohol block in the patients requested from other departments. The change of pain was investigated retrospectively. METHODS: The alteration of cancer pain in 26 terminal cancer patients were recorded in visual analogue scale from June 1996 to May 1998 retrospectively. RESULTS: Patients lived average 38.5 days from beginning of pain control. All patients complained severe pain at the point of time requested to pain clinic. But 2 days after pain control, most patients were comfortable or tolerable to pain. At 1 week before death, pain were aggravated and sometimes uncontrolled. CONCLUSIONS: At first time, cancer pain was controlled but it becomes uncontrollable and aggravated in the patients time was drawing near.

Comparison of the Effects of Morphine Versus Morphine Plus Butorphanol in Epidural Anesthesia for Postoperative Analgesia / 대한마취과학회지

BACKGROUND: Epidural morphine has been commonly used to provide postoperative pain relief, but it has many side effects such as nausea, vomiting, respiratory depression, and pruritus. The purpose of this study was to evaluate the analgesic efficacy and side effects by combination use of epidural morphine and butorphanol. METHODS: Forty five patients were randomly divided into 3 groups. For group I, a bolus of 4.7 ml of saline and 3 mg of morphine were administered. For group II, a bolus of 4.2 ml of saline and 3 mg of morphine and 1 mg of butorphanol were administered. For group III, a bolus of 3.2 ml of saline and 3 mg of morphine and 3 mg of butorphanol were administered. Continuous epidural analgesia were administered for all groups; group I (saline 99.4 ml and morphine 6 mg), group II (saline 98.4 ml, morphine 6 mg, and butorphanol 2 mg), group III (saline 96.4 ml, morphine 6 mg, and butorphanol 6 mg) by two day infuser, 2 ml/hr. We compared the side effects and analgesic effect of the three groups for 2 days. RESULTS: The incidence of pruritus, nausea and vomiting was reduced significantly in the group II and III, but the incidence of somnolence increased in the group III. There were no significant differences in analgesic effect and the other side effects among the three groups. CONCLUSION: Above results suggest that the addition of butorphanol to morphine in epidural infusion reduce the incidence of pruritus, nausea and vomiting, but increase the incidence of somnolence.

Comparison of the Effects of Morphine Versus Morphine Plus Butorphanol in Epidural Anesthesia for Postoperative Analgesia / 대한마취과학회지

BACKGROUND: Epidural morphine has been commonly used to provide postoperative pain relief, but it has many side effects such as nausea, vomiting, respiratory depression, and pruritus. The purpose of this study was to evaluate the analgesic efficacy and side effects by combination use of epidural morphine and butorphanol. METHODS: Forty five patients were randomly divided into 3 groups. For group I, a bolus of 4.7 ml of saline and 3 mg of morphine were administered. For group II, a bolus of 4.2 ml of saline and 3 mg of morphine and 1 mg of butorphanol were administered. For group III, a bolus of 3.2 ml of saline and 3 mg of morphine and 3 mg of butorphanol were administered. Continuous epidural analgesia were administered for all groups; group I (saline 99.4 ml and morphine 6 mg), group II (saline 98.4 ml, morphine 6 mg, and butorphanol 2 mg), group III (saline 96.4 ml, morphine 6 mg, and butorphanol 6 mg) by two day infuser, 2 ml/hr. We compared the side effects and analgesic effect of the three groups for 2 days. RESULTS: The incidence of pruritus, nausea and vomiting was reduced significantly in the group II and III, but the incidence of somnolence increased in the group III. There were no significant differences in analgesic effect and the other side effects among the three groups. CONCLUSION: Above results suggest that the addition of butorphanol to morphine in epidural infusion reduce the incidence of pruritus, nausea and vomiting, but increase the incidence of somnolence.

Pulmonary Aspiration and Local Anesthetic Systemic Toxicity following Epidural Anesthesia / 대한마취과학회지

Aspiration can generate postoperative pulmonary morbidity of varing severity, depending on the type and volume of the aspirate. Epidural anesthesia can lead to local anesthetic systemic toxicity with mental change, followed by respiratory depression and abdominal and intercostal muscle weakness depressing the ability of the patient to cough and clear the airway. The authors experienced a case of pulmonary aspiration with systemic toxicity after epidural anesthesia for cesarean section. The chest X-ray showed alveolar consolidation at left lower lung field and arterial blood gases showed that PaO2 decreased. The exact causes of mental change and respiratory depression were unknown, but we suspected it lidocaine induced systemic toxicity due to vascular absorption, When airway reflexes are ineffective during face mask ventilation of the lungs, aspiration of clear oral secretions can generate small airway obstruction.

Current Status of Anesthesia for Emergency Surgical Patients / 대한마취과학회지

Emergency surgical patients are more frequently critical to anesthesia and surgery more than elective cases. They are not ready to anesthesia and surgery, because they have not enough time for physical and laboratory examinations. In addition, they are usually exposed to operative situations to anesthetists and/or surgeons who made little assessments of patient's pathological and physical conditions. The goal of preoperative preparation is to assess the degree and process of disease with physiological changes and to improve them before surgery as possible and to get the better outcome of anesthesia and surgery. The outcome of emergency operation influenced by good or poor physiological states and many factors, that is , preanesthetic assessment, laboratory examination, operation time(day time or night), operative personnel(professor or trainee)and coorperating system in operating theater. We analized 1406(male 704, female 702) emergency surgical patients from March 1990 to February 1991 in order to find out andy problems in procedures of emergency anesthesia and/or surgical patients. The results were as follows. 1) The rate of emergency operation was over-all 19.1 percent. The was no sexual difference in number of patients and third and fourth decade of age group were highest candidates for emergency operation(52.9%). 2)Emergency patients were prevalent in obstetic(28.6%) and general surgery department(25.2%) and acute appendicitis was most common emergency disease in both sex, if excluding Cesarean section. 3)Over-all rate of cesarean section was 33.9%, of which 54.4% were managed in emergency situation. 4)Physical status by ASA classification was mainly in 1E and 2E status(72.7%). 5)Almost of cases(87.7%) were operated under endotracheal inhalational anesthesia and enflurane was mainly administered for them as inhalation anesthetics(84.4%). 6)Anesthesis was started in day-time(47.2%) and in extr-day time(52.8%). With above results, we recognized that these emergency cases resulted in good outcomes because they were in mostly good physical status(1E and 2E), relatively healthy adults, and noncomplicated disease process. However we hope that anestheslologists as well surgeons should always be careful to check and manage emergency operating patients in the perioperative period.

Comparison of the Recovery from Pancuronium-induced Neuromuscular Blockade in Rabbit by Different Method of Nerve Stimulations / 대한마취과학회지

The methods commonly used for monitoring neuromuscular transmission do not allow evaluating of an intense neuromuscular blockade. A sufficient dose of non-depolarizing relaxant used for endotracheal intubation causes disappearance of the response to single, tetanic and train of four (TOF)nerve stimulation for a variable period of time during which the magnitude of neuro-muscular blockade can not be evaluated by the traditional stimulation forms. Enhancement of posttetanic twitch tension in partially curarized patients remains constant regardless of the dose of non-depolarizing muscle relaxant or magnitude of neuromuscular blockade. If this also holds true for an intense neuromuscular blockade, the response to posttetanic twitch stimulation after the injection of a non-depolarizing muscle relaxant must appear earlier than the response to pretetanic twitch or TOF neve stimulation. The present study was designed to evaluate neuromuscular blockade during the period of no response to single or TOF stimulation by quantifying the degree of posttetanic potentiation. The possibility existed that the relatively frequent use of a tetanic stimulation (every 6 minutes) might have influenced the recovery of neuromuscular blockade. Therefore, we have studied the conventional TOF stimulation comparing with posttetanic count stimulation which may affect the recovery of intravenous pancuronium(0.08 mg/kg) induced neuromuscular block. The results were as follows; 1) The time of the T1 appearance was 815 seconds and 50% T4 ratio was 1,214.3 seconds in TOF group. 2) The time of the T1 appearance was 790 seconds and 50% T4 ratio was l,l35.5 seconds in PTC group, The recovery time appeared to be shorter in this group but statistically not signifi cant. 3) ln PTC group, TOF recovery was observed after average 2.3 times of tetanic stimulation. Above findings may suggest that intense pancuronium block in rabbit is not affeced by the TOF or PTC stimulation.

Comparative Study of Vecurnium and Domestic Product of Vecaron in Human / 대한마취과학회지

The introduction of musele relaxants was an epoch-making event in the development of clinical anesthesia and their use has hecome essential to anesthesia practice. Vecuronium, one of the newest muscle relaxant, has many advantages; it is rapid and short-acting, noncumulative, has minimal side reactions and is promptly antagonized by anticholinesterases was introduced recently our clinical anesthesia practice. Fortunately, domestic product of vecuronium as vecaron was introduced lately. Therefore, this study was performed to evaluate the effects of vecaron and as compare with vecuronium. The results were as follows: 1) Similar effects of muscle relaxation was observed in both group except the onset time of twitch depression was shorter in vecuronium group than vecaron group. 2) Blood pressure and heart rate was increased during intubation in groups. 3) Recovery index was slightly prolonged in vecuronium group than vecaron group but no significance was observed. However, this recovery index of vecuronium was slightly shorter than previous observations.