Awake craniotomy using a high-flow nasal cannula with oxygen reserve index monitoring - A report of two cases -

Background@#Awake craniotomy is a well-tolerated procedure for the resection of brain tumors residing within or close to the eloquent cortical areas. Monitored anesthesia care (MAC) is a dominant anesthetic approach for awake craniotomy; however, it is associated with inherent challenges such as desaturation and hypercapnia, which may lead to various complications. The prevention of respiratory insufficiency is important for successful awake craniotomy. As measures to avoid respiratory depression, the use of high-flow nasal cannula (HFNC) can improve patient oxygenation and monitor the oxygen reserve index (ORi) to detect hypoxia earlier. Case: We report two cases of awake craniotomy with MAC using HFNC and ORi. We adjusted the fraction of inspired oxygen of the HFNC according to the ORi level. The patient underwent successful awake craniotomy without a desaturation event or additional airway intervention. @*Conclusions@#Combined HFNC and ORi monitoring may provide adequate oxygen reserves in patients undergoing awake craniotomy.

Comparing the effects of vecuronium and cisatracurium on electrophysiologic monitoring during neurosurgery: a randomized controlled study

BACKGROUND: The differences between neuromuscular blocking (NMB) drugs on the efficacy of intraoperative motor-evoked potential (MEP) monitoring have not been established through clinical study. We compared the effects of vecuronium and cisatracurium on the efficacy of intraoperative MEP monitoring. METHODS: We enrolled 72 patients who had undergone neurosurgery with MEP monitoring. We randomly allocated the subjects into one of two groups, in whom we maintained continuous intravenous vecuronium (Group V) or cisatracurium (Group C) infusion during the surgeries; the target partial NMB for maintenance was T1/Tc 50% (T1, first twitch of TOF response; Tc, control response of T1 before NMB drug injection). We compared the means and coefficients of variation (CV, %) of all measured MEP amplitudes and the frequencies of NMB drug dose changes. RESULTS: The means and CVs of MEP amplitude and latency in all four limbs did not differ significantly between the groups, although we did change the continuous NMB drug doses in group V significantly less often than in group C. CONCLUSIONS: There were no significant differences between vecuronium and cisatracurium on the MEP variability and mean amplitudes. However, cisatracurium needed more frequent dose changes to maintain T1/Tc 50%.

Anesthetic management of awake craniotomy with laryngeal mask airway and dexmedetomidine in risky patients / 대한마취과학회지

No abstract available.

Postoperative obstructing laryngeal edema in patients with diffuse idiopathic skeletal hyperostosis of cervical spine: A report of two cases / 대한마취과학회지

Two cases were reported in which severe postoperative laryngeal edema were developed after the operation of diffuse idiopathic skeletal hyperostosis (DISH) of cervical spine. In the first case, sudden airway obstruction was developed in the general ward 6 hour after uneventful decompression surgery for osteophyte. In the second patient, an elective preoperative tracheostomy was performed before surgery but the tube could not be removed for 2 months because of laryngeal edema and decreased vocal cord mobility. It should be emphasized that this airway problem can develop during the postoperative as well as the preoperative period, especially in the case of anterior cervical spine surgery.

The comparison of complications on the endovascular and surgical treatment in elderly cerebral aneurysm patients / 대한마취과학회지

BACKGROUND: The aim of this study was to compare intraoperative and postoperative complications and clinical outcome of endovascular coiling (EVT) with neurosurgical clipping (NST) under general anesthesia in the cerebral aneurysm patients older than 60 years. METHODS: We retrospectively reviewed the charts, operative reports of patients who underwent EVT or NST at our hospital between January 2006 and August 2008. A total of 181 patients (EVT = 78, NST = 103) were included in this study. RESULTS: The rate of intraoperative event was higher in EVT than in NST but postoperative complication and Glasgow outcome scale (GOS) at 6 months did not show statically significance in both groups. Preoperative aneurysm rupture, age and the World Federation of Neurological Surgeons grade (WFNS) were the influencing factors for outcome in both groups. Anesthetic agents, body temperature and vasoactive drugs were significantly different between the two groups but the effects of these on the outcome of patients were insignificant. CONCLUSIONS: In EVT and NST, the variables related to the postoperative complications were preoperative aneurysm rupture, age and WFNS. When the elderly patients get these procedures, more close care should be considered postoperatively.

Sudden Sensorineural Hearing Loss after General Anesthesia: A case report / 대한마취과학회지

Sudden hearing loss is a rare complication after general anesthesia.The variety of etiologies and the difficulty in treatment must be a challenge to anesthesiologists.In this patient who was otherwise normal in her right ear, sudden sensorineural hearing loss occurred immediately after general anesthesia.The possible causes of her sensorinerual hearing loss we supposed are the inner ear dysfunction by drilling noise or the pressure change of middle ear cavity or the microvascular circulatory deficiency related to head-rotated position.After steroid, prostaglandin injection and stellate ganglion block therapy, remarkable improvement of hearing was observed.

Effects of ascorbic acid on coagulation during living donor liver transplantation in adults / 대한마취과학회지

BACKGROUND: Prompt correction of hemostatic and thrombotic derangements during liver transplantation can play a key role in preventing excessive blood transfusion or thrombotic complications. It is well known that reactive oxygen species can affect coagulant and anticoagulant systems. Therefore, we investigated whether ascorbic acid (AA), one of potent antioxidant agents, can improve the coagulation during living donor liver transplantation (LDLT). METHODS: Thirty three adult patients undergoing LDLT were enrolled in this study. The blood samples of these patients were collected at 90 minutes after the beginning of operation and at 150 and 300 minutes after reperfusion. At each time period, blood samples were categorized into hypocoagulation, normal, and hypercoagulation. Within each category, the samples were further divided into three groups: whole blood (WB) (0.36 ml of native WB), AA (0.33 ml of native WB mixed with 0.03 ml of AA solution), and normal saline (NS) groups (0.33 ml of native WB mixed with 0.03 ml of NS), and these samples were analyzed using thromboelastogram (TEG). We compared the parameters of TEG (gamma time, K time, alpha angle, maximum amplitude (MA), and LY60) in each coagulation status. RESULTS: AA did not significantly affect TEG parameters in hypocoagulation or normal coagulation during LDLT. However, AA significantly decreased gamma time, alpha angle and MA at 150 minutes, and, K time and alpha angle at 300 minutes after reperfusion in the blood samples of hypercoagulation category. CONCLUSIONS: We may conclude that ascorbic acid inhibits hypercoagulation after reperfusion period during living donor liver transplantation.

The Effective Steroid Dose of Caudal Epidural Injection with Unilateral Epidural Catheter Position in Patients with Symptomatic Herniated Nucleus Purposus / 대한마취과학회지

BACKGROUND: The epidural steroid injection is commonly used in the management of chronic low back pain and radiating pain. We compared the efficacy of 40, 60, and 80 mg of methylprednisolone acetate in patients with lumbar herniated disc disease treated with caudal epidural block. METHODS: Seventy-two patients with lumbar herniated nucleus purposes on magnetic resonance imaging were included.All patients received fluoroscopically guided caudal epidural injections, with the guidewire-reinforced epidural catheter introduced through a Tuohy needle.After confirming the catheter tip position at the affected nerve root, contrasts were injected until patients felt discomfort in their site of pain.24 patients in each group received 40 mg, 60 mg, 80 mg of methylprednisolone acetate, respectively.We evaluated the improvements by pain relief scale (0-100%) after 2 weeks. RESULTS: There are no significant differences in the pain improvement between three groups (P = 0.537 ). CONCLUSIONS: Sixty and 80 mg methylprednisolone acetate injection during caudal epidural block showed no further benefit compared to 40 mg injection.

Incidental Removal of Pyogenic Granuloma of Vocal Cord during Blind Intubation with Lightwand : A case report

We experienced a case of incidental removal of granuloma of vocal cord after blind endotracheal intubation with lightwand. The patient was a 43-years-old female suffering from hoarseness for 2 months and diagnosed as vocal cord pyogenic granuloma developed after primary closure of thyroid cartilage laceration. She had a limited neck extension suggesting difficult intubation, so endotracheal intubation with lightwand was planned to secure airway. After endotracheal intubation using lightwand, the lesion of vocal cord could not be seen in the microscopic exam. We discovered and immediately removed the granuloma on the carina level using rigid bronchoscope.

Changes of Coagulation Status and Implication for the Use of Epidural Catheter after Donor Right Hepatectomy / 대한마취과학회지

BACKGROUND: Living donors for liver transplantations may have a low pain threshold and should be given effective postoperative pain control. However, epidural catheterization has been the subject of intense debate because of the possibility of severe coagulation derangement after a right hepatectomy. This study examined the changes in the coagulation status in right lobe donors. METHODS: The charts and computerized hospital data of 261 consecutive living donors who had undergone right hepatectomy were retrospectively reviewed. The coagulation profile including the platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) was analyzed at the preoperative period, immediately after surgery, and 5 days after surgery. RESULTS: The platelet count decreased significantly from immediately after surgery until postoperative day (POD) 5 (P 2.0 INR in only 4 donors (1.5%). The aPTT immediately after surgery showed severe prolongation (P < 0.001), but recovered rapidly on POD 1. CONCLUSIONS: Right lobe donors showed postoperative coagulation derangement but the changes appear to be acceptable for the maintenance and removal of the epidural catheters. These results suggest that careful epidural catheterizations are relatively safe in right lobe donors.

The Determination of Optimal Intramuscular Injection Time of Midazolam as a Premedication Agent for Minimizing Decrease of Serum Potassium / 대한마취과학회지

BACKGROUND: Pre-operative anxiety is known to cause an increase in plasma catecholamine levels, which, in turn, attributes to the decrease in serum K+ concentration. Midazolam is one of the most commonly used premedication agent for the purpose of anxiolysis in the pre-operative period. In this study, by measuring serum K+ concentration, we investigated the optimal intramuscular injection time for midazolam which maximally prevents the reduction of serum K+ concentration. METHODS: One hundred twenty three patients undergoing breast surgery were randomly assigned to one of 5 groups. Control group (n = 24) had no premedication. 30-minute group (n = 30), 60-minute group (n = 25), 90-minute group (n = 22) and 120-minute group (n = 22) received IM injection of midazolam (0.05 mg/kg) at 30, 60, 90, and 120 minutes before induction of anesthesia, respectively. Anxiety level, serum K+ concentrations, blood pressures and heart rates of all patients were measured at 7:00pm of the day before surgery and immediately before induction of anesthesia. RESULTS: Serum K+ concentrations of all groups showed significant decrease in the preinduction time compared with those values at 7:00 pm of the day before surgery. There were no significant changes of heart rates in all groups. Blood pressures immediately before induction of anesthesia elevated compared with those at 7"00 pm of the day before surgery in all groups. Immediately before induction of anesthesia, the K+ levels of 60-minute and 90-minute groups were higher than those of the control group. At this time, the rates of hypokalemia (K+ <3.5 mEq/L) of 60-minute and 90-minute groups were lower than those of the control group. 30-minute and 60-minute groups had significantly lower anxiety levels than the control group. CONCLUSIONS: When we consider anxiety and serum potassium levels, the optimal intramusculr injecting time of midazolam was 60 minutes before induction of anesthesia.

The Examination of Internal Jugular Vein and Carotid Artery in Trendelenburg Position with Head Rotation; A Prospective, Randomized Study / 대한마취과학회지

BACKGROUND: This study evaluated the position and relationship between the right internal jugular vein (IJV) and the surrounding external landmarks using ultrasonography. METHODS: Fifty-four patients undergoing central vein access for cardiac surgery were enrolled in this study. The IJV, carotid artery (CA) and sternocleidomastoid muscle (SCM) at the cricoid cartilage level in 15o trendelenburg position with 30o head rotation were examined using a two dimensional ultrasound transducer of a TEE machine. Images of the vessels and the demographic data of the patients were recorded and analysed. RESULTS: At the level of the cricoid cartilage, the position of the right IJV was medial to middle of the clavicular head of the SCM muscle in 26 cases (48.2%), lateral in 11 cases (20.4%) and just above the middle of clavicular head of the SCM muscle in 17 cases (31.5%). In 43 patients (79.6%), the IJV overlapped the CA anterolaterlly < 5 mm, and these cases were regarded as normal. Ten patients (18.5%) had a medially positioned IJV overlapping the CA more than 5 mm and the IJV was positioned lateral to CA in 1 (2%) patient. The mean ratio of the overlapped diameter and the diameter of the CA was 33.6% and the overlapping ratios were greater than 50% in 10 patients (31.4%). The mean skin-to-vein distance at the angle of 30degrees was 1.82 cm. CONCLUSIONS: In 18.5% of patients positioned in the 15o Trendelenburg position, with their head turned to the left 30degrees, the IJV overlapped the CA medially more than 5 mm, which increased the risk of a carotid puncture using the blind technique.

Anesthetic Care of a Patient with Williams Syndrome-Underwent Preauricular Fistulectomy and Medial Rectus Resection: A case report / 대한마취과학회지

Williams syndrome, initially described by Williams et al. in 1961 is associated with characteristic dysmorphic features, congenital heart disease, distinctive behavior, and emotional traits. Sudden death has been reported perioperatively due to congenital heart disease in patients suffering from Williams syndrome. We present a case of a patient with Williams syndrome underwent preauricular fistulectomy and medial rectus recession. Airway management and tracheal intubation were successfully performed on the patient. For anesthetic management, sevoflurane and vecuronium, as well as sevoflurane and rocuronium were employed during the first and second operation, respectively. Anesthetic managements were performed uneventfully in this patient.

The Effects of Perioperative Ketorolac Infusion on Platelet Function and Blood Loss: Comparison of Anesthesia Methods / 대한마취과학회지

BACKGROUND: The purposes of this study were to investigate the effects of perioperative continuous infusion of ketorolac on platelet function and blood loss under either general or spinal anesthesia. METHODS: The patients under general anesthesia received saline 1 ml (C group) or ketorolac 30 mg (GK group) intravenously 10 min before skin incision, followed, respectively, by a continuous infusion of saline (4 ml/h) or ketorolac (2.5 mg/h) for 24 h. The patients under spinal anesthesia (SK group) received the same amount of ketorolac as that of the GK group. Blood loss was collected and measured at 3 h, 6 h, 12 h and 24 h postincision. Platelet count, hemoglobin, platelet aggregometry (PA) with adenosine diphosphate (ADP) and collagen, and bleeding time (BT) were measured at 30 min before skin incision and at 3 h and 24 h postincision. Blood coagulation status was analysed using thromboelastography (TEG) at 30 min before skin incision and at 3 h postincision. RESULTS: BT in the SK group at postincision increased significantly compared to preoperative value and were significantly higher than those of the GK and C group. PA with collagen at 3 h after skin incision was lower in the SK group than in the C group. There were no significant differences in any of the TEG variables among the three groups. No significant differences were observed in blood loss among the three groups. CONCLUSIONS: Blood loss was not increased by ketorolac under either general or spinal anesthesia, although platelet function was impaired under spinal anesthesia.

Displacement of a Double - Lumen Endobronchial Tube from Left to Right Bronchus during Surgical Dissection: A case report / 대한마취과학회지

Correct positioning of a double-lumen endobronchial tube (DLT) is essential for adequate ventilation, oxygenation, and lung separation during one-lung anesthesia. The displacement of a DLT by surgical manipulation, coughing, movements, or patient position changes have been reported. We experienced displacement of a left-sided DLT into the right bronchus during hilar dissection for carina sleeve right upper lobectomy in a 60-yr-old male patient. We emphasize the possibility of DLT dislocation during hilar dissection, so careful attention must be carried.

Correlation of AEP, BIS and OAA/S Scores Under Stepwise Sedation Using Propofol TCI in Orthopedic Patients Undergoing Total Knee Replacement Arthroplasty Under Spinal Anesthesia / 대한마취과학회지

BACKGROUND: We performed a prospective, randomized study to investigate the relations between BIS (bispectral index, BISTM monitor), AAI (mid-latency AEP, A-line ARX index) and depth of sedation, and assessed two different memory functions at OAA/S score 2 under spinal anesthesia. METHODS: 44 ASA physical status 1-2 patients, scheduled for elective total knee replacement arthroplasty were randomly allocated to either the BIS group (22) or the AEP group (22). Under spinal anesthesia, patients were sedated with propofol TCI to OAA/S score 2. BIS and AAI at each OAA/S score were measured and patients were maintained at an OAA/S score 2. A specific picture was shown during the operation. At PACU, an interview was done to determine whether patients recalled specific picture (picture recall) or any intra-operative noises or scenes (op recall). RESULTS: BIS decreased as OAA/S score reduced from 5 to 2 (P < 0.05), but AAI could not differentiate between an OAA/S score 3 and 2 (P = 0.0690). There were correlations of 0.827 and 0.610, respectively, (Spearman's rho) between BIS and OAA/S scores and between AAI and OAA/S scores. BIS was higher at all OAA/S scores (P < 0.05), and the standard deviations of BIS were smaller. There was a statistically significant difference between the recalls (P = 0.0253). CONCLUSIONS: Both BIS and AAI provided information about the depth of sedation, but BIS was more accurate. The difference between 'op recall' and 'picture recall' requires further investigation.

Does the Venovenous Bypass influence Coagulation Status in Living-Related Liver Transplantation? / 대한마취과학회지

BACKGORUND: Venovenous bypass (VVB) in liver transplantation has been used to decrease the acute hemodynamic and metabolic changes during anhepatic periods. But, the use of VVB in patients undergoing liver transplantation is still under debate concerning its relative risks and benefits. Therefore, the aim of this study was to examine the influences of VVB on the coagulation status and the amount of transfusion in living-related liver transplantation. METHODS: We conducted this retrospective study on 39 patients who underwent orthotopic living-related liver transplantation using the piggyback technique from March 2001 to April 2002. While 19 patients did not receive venovenous bypass, 20 patients received. We compared the two groups in terms of coagulation-related parameters (prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen and thromboelastograph), the amount of transfusion during intraoperative and post-operative 1day. We also compared the incidences of post-reperfusion syndrome in the two groups. RESULTS: The group that underwent living-related liver transplantation with VVB required more packed red blood cell (p-RBC) transfusion than the other group without VVB from post-reperfusion untill the end of operation (P<0.05). This difference in the amount of p-RBC transfusion may be due to the blood remained in the VVB circuit at the termination of VVB. However, the two groups were similar in terms of coagulation-related parameters, the amount of other blood components, such as fresh frozen plasma, platelet concentrates, cryoprecipitate, total amount of transfusion during the 24 hours post- operatively, and the incidence of post-reperfusion syndrome. CONCLUSiONS: We conclude that the using of venovenous bypass in living-related liver transplantation did not influence coagulation status and the amount of transfusion perioperatively.

Airway Sealing Effect and Gastroesophageal Regurgitation of Laryngeal Mask Airway-Proseal in Laparoscopy / 대한마취과학회지

BACKGROUND: The laryngeal mask airway Proseal (LMA-Proseal) is a renewed airway device with a modified cuff to improve the mask seal around the larynx. The classic LMA is known to have an incomplete mask seal during high positive pressure ventilation. Therefore, we examined whether the ventilation via a LMA-Proseal during laparoscopic surgery may be adequate and also observed the complications associated with a LMA-Proseal. METHODS: Thirty four patients undergoing elective gynecological laparoscopies were studied. After the insertion of a LMA-Proseal, we measured the peak airway pressure, plateau airway pressure, oropharyngeal leakage pressure, and the leakage around the neck before and after intra-abdominal CO2 insufflation. After extubation, we observed the complications, including the gastroesophageal regurgitation using a methylene blue staining method. RESULTS: The peak and plateau airway pressures after pneumoperitoneum increased significantly (P<0.05), compared with those before insufflation. However, the oropharyngeal leakage pressure was not changed and leakages around the neck were not observed. After extubation, a cuff stained with methylene blue occurred in 10 of 34 patients. Sore throat and dysphagia occurred in 8 and 4 of 34 patients, respectively. CONCLUSIONS: A LMA-Proseal during laparoscopic surgery permits adequate airway pressure, but does not protect the gastroesophageal regurgitation.

Alterations of the Ventilation-Perfusion Ratio Measured by Using a Multiple Inert Gas Elimination Technique (MIGET) in One Lung Ventilated Rabbit / 대한마취과학회지

BACKGROUND: In this study, we performed one-lung ventilation (OLV) in rabbits to assess the effects of OLV on the VA/Q ratio and the respiratory physiological changes using MIGET. METHODS: Ten male New Zealand white rabbits, weighing 3-4 kg were selected. To perform MIGET, six inactive gases (SF6, krypton, desflurane, enflurane, diethyl ether, acetone) in 500 ml normal saline were injected intravenously. During two-lung ventilation (TLV), and after OLV for 30 minutes, blood was sampled for blood gas analysis and MIGET, hemodynamic variables were measured. For MIGET, the concentrations of the injected inert gases were measured and converted to retention/excretion data; the VA/Q distribution curve was obtained using a computer. RESULTS: Systolic, mean, and diastolic pulmonary pressures were elevated significantly and pulmonary resistance was doubled (P<0.05) in OLV compared to TLV. Blood pH decreased in OLV. The calculated intrapulmonary shunt was 19% and 52%, TLV and OLV, respectively. The analysis of VA/Q using MIGET showed that the VA/Q distribution curve was wider and that the VA/Q area was larger in normal rabbits. And, that intrapulmonary shunt approximated to 11%. In the case of OLV, a significant increase in shunt was observed but no change in the amount of dead space at distribution area, (log SDQ, log SDV) remained the same, whereas the VA/Q distribution curve shifted toward the right. CONCLUSIONS: OLV in rabbits showed severe hypercapnia and hypoxemia leading to a considerable increase in shunt. Because of the wide range of VA/Q distribution in TLV, no significant changes in respiratory variables were observed during OLV.

A New External-landmark Technique of Right Internal Jugular Vein Cannulation / 대한마취과학회지

BACKGROUND: Central venous cannulation is one of the important parts of anesthetic management. Because general anesthesia causes external-landmarks (e.g. sternocleidomastoid muscle, carotid artery pulse) indistinct, we developed a new external landmark for internal jugular vein cannulation that can be easily detected under general anesthesia. METHODS: We cannulated the right internal jugular vein of 110 patients under general anesthesia. We used the external jugular vein and cricoid cartilage as a landmark. RESULTS: Cannulation of the right internal jugular vein was successful in 108 out of 110 patients (98.2%). Patients required an average 1.48+/-0.63 attempts. There were 2 carotid punctures (1.8%), 3 discomforts (2.7%) and no brachial plexus irritation. CONCLUSIONS: This new landmark technique has a high success rate and few complications.