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.

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.

Synergism between rocuronium and cisatracurium: comparison of the Minto and Greco interaction models / 대한마취과학회지

BACKGROUND: This study was conducted to investigate the pharmacodynamic interaction between rocuronium and cisatracurium using the response surface model, which is not subject to the limitations of traditional isobolographic analysis. METHODS: One hundred and twenty patients were randomly allocated to receive one of the fifteen predefined combinations of rocuronium and cisatracurium. To study single drugs, cisatracurium 0.2, 0.15, or 0.1 mg/kg or rocuronium 0.8, 0.6 or 0.4 mg/kg doses were administered alone. To study the pharmacodynamic interaction, drugs were applied in three types of combination ratio, i.e., half dose of each drug alone, 75% of each single dose of rocuronium and 25% of each single dose of cisatracurium, and vice versa. Train-of-four (TOF) ratio and T1% (first twitch of the TOF presented as percentage compared to the initial T1) were used as pharmacodynamic endpoints, and the Greco and Minto models were used as surface interaction models. RESULTS: The interaction term α of the Greco model for TOF ratio and T1% measurements showed synergism with values of 0.977 and 1.12, respectively. Application of the Minto model resulted in U₅₀ (θ) values (normalized unit of concentration that produces 50% of the maximal effect in the 0 <θ< 1 region) less than 1 for both TOF ratio and T1% measurements, indicating that rocuronium and cisatracurium exhibit synergism. CONCLUSIONS: Response surface modeling of the interaction between rocuronium and cisatracurium, based on considerations of their effects on muscle relaxation as measured by TOF ratio and T1%, indicated that the two drugs show considerable synergism.

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.

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

No abstract available.

A Case of Hemoperitoneum due to Spontaneous Rupture of Visceral Artery Aneurysm after Ingestion of Puffer Fish / 대한구급학회지

Ingestion of puffer fish can cause intoxication, which produces a wide range of symptoms due to the presence of neurotoxins, such as tetrodotoxin, in puffer fish. Abdominal pain is just one of the symptoms that should be treated with symptomatic and supportive therapy. This study reports a case of a 56-year-old male patient with abdominal pain, who was admitted to the emergency room with a diagnosis of puffer fish poisoning. In this case, the abdominal pain did not improve, but rather, the symptoms worsened. Finally, the cause of the abdominal pain was found to be hemoperitoneum due to active bleeding at the greater omentum, as observed on abdominal computed tomography; the source of bleeding was the right colic artery branch. Embolization was performed successfully, and the post-intervention course was uneventful. The patient was discharged without any complications within 13 days after admission.

Acute onset Lance-Adams syndrome following brief exposure to severe hypoxia without cardiac arrest: a case report / 대한마취과학회지

Myoclonic status epilepticus (MSE) within the first 24 hours after cardiopulmonary resuscitation (CPR) predicts poor prognosis, enough to discontinue the treatment. In contrast, chronic MSE appearing a few days after CPR is called Lance-Adams syndrome (LAS), which is characterized by preserved intellect and a favorable prognosis. We herein report a case of LAS, which developed after a transient hypoxic event without an overt cardiac arrest due to hematoma formation in the neck after partial glossectomy. Differential diagnosis was also challenging as LAS was developed 8 hours after the hypoxic event.

External Validation of the Acute Physiology and Chronic Health Evaluation II in Korean Intensive Care Units

PURPOSE: This study was designed to validate the usefulness of the Acute Physiology and Chronic Health Evaluation (APACHE) II for predicting hospital mortality of critically ill Korean patients. MATERIALS AND METHODS: We analyzed data on 826 patients who had been admitted to nine intensive care units and were included in the Fever and Antipyretics in Critical Illness Evaluation study cohort. RESULTS: Among the patients enrolled, 62% (512/826) were medical and 38% (314/826) were surgical patients. The median APACHE II score was 17 (11 to 23 interquartile range), and the hospital mortality rate was 19.5%. Age, underlying diseases, medical patients, mechanical ventilation, and renal replacement therapy were independently associated with hospital mortality. The calibration of APACHE II was poor (H=57.54, p<0.0001; C=55.99, p<0.0001), and the discrimination was modest [area under the receiver operating characteristic (aROC)=0.729]. Calibration was poor for both medical and surgical patients (H=63.56, p<0.0001; C=73.83, p<0.0001, and H=33.92, p<0.0001; C=33.34, p=0.0001, respectively), while discrimination was poor for medical patients (aROC=0.651) and modest for surgical patients (aROC=0.704). At the predicted risk of 50%, APACHE II had a sensitivity of 36.6% and a specificity of 87.4% for hospital mortality. CONCLUSION: For Koreans, the APACHE II exhibits poor calibration and modest discrimination for hospital mortality. Therefore, a new model is needed to accurately predict mortality in critically ill Korean patients.

Ultrasound Guided Bronchoscopic Balloon Dilatation in the Management of Tracheal Stenosis: A Case Report / 대한구급학회지

We performed a balloon dilatation without a fluoroscopy monitoring by ultrasound. A 44 year old female patient was presented with subglottic stenosis, due to prolonged intubation. Although she had undergone tracheal resection and end-to-end anastomosis, the tracheal stenosis had recurred. She was scheduled for balloon dilatation. However, fluoroscopic guidance was not available, and thus, we used ultrasonographic monitoring as an alternative method. We performed a transverse scan, just cranial to the suprasternal notch, and we obtained a real time image of the trachea dilated by the balloon. We suggest that ultrasonographic monitoring is a useful adjunct to balloon dilatation in patients with tracheal stenosis.

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.

Identification of novel peptides that stimulate human neutrophils

Neutrophils play a key role in innate immunity, and the identification of new stimuli that stimulate neutrophil activity is a very important issue. In this study, we identified three novel peptides by screening a synthetic hexapeptide combinatorial library. The identified peptides GMMWAI, MMHWAM, and MMHWFM caused an increase in intracellular Ca2+ in a concentration-dependent manner via phospholipase C activity in human neutrophils. The three peptides acted specifically on neutrophils and monocytes and not on other non-leukocytic cells. As a physiological characteristic of the peptides, we observed that the three peptides induced chemotactic migration of neutrophils as well as stimulated superoxide anion production. Studying receptor specificity, we observed that two of the peptides (GMMWAI and MMHWFM) acted on formyl peptide receptor (FPR)1 while the other peptide (MMHWAM) acted on FPR2. Since the three novel peptides were specific agonists for FPR1 or FPR2, they might be useful tools to study FPR1- or FPR2-mediated immune response and signaling.

Remifentanil or dexmedetomidine for monitored anesthesia care during cataract surgery under topical anesthesia / 대한마취과학회지

No abstract available.

The effects of sevoflurane and propofol anesthesia on cerebral oxygenation in gynecological laparoscopic surgery / 대한마취과학회지

BACKGROUND: Both the Trendelenburg position and pneumoperitoneum with carbon dioxide have been reported to increase intracranial pressure (ICP) and to alter cerebral blood flow or cerebral blood volume. Also anesthetic agents have variable effects on cerebral hemodynamics and ICP. The present study was conducted to determine whether regional cerebral oxygen saturation (rSO2) values differ between propofol and sevoflurane anesthesia during laparoscopic surgery in the Trendelenburg position. METHODS: Thirty-two adult women undergoing gynecological laparoscopic surgery were divided into sevoflurane and propofol groups. rSO2 values were recorded at 10 min after induction in the neutral position (Tpre), 10 min after the pneumoperitoneum in the Trendelenburg position (Tpt) and 10 min after desufflation in the neutral position (Tpost). For analysis of rSO2, we did ANOVA and univariate two-way ANCOVA with covariates being mean arterial pressure and end tidal carbon dioxide tension. RESULTS: Between sevoflurane and propofol groups, the change in rSO2 was significantly different even after ANCOVA. rSO2 at Tpt (76.3 +/- 5.9% in sevoflurane vs 69.4 +/- 5.8% in propofol) and Tpost (69.5 +/- 7.1% in sevoflurane vs 63.8 +/- 6.6% in propofol) were significantly higher in the sevoflurane group compared with the propofol group. In the propofol group, rSO2 at Tpost was significantly lower than at Tpre (71.1 +/- 4.8%) and cerebral oxygen desaturation occurred in two patients (14.3%). CONCLUSIONS: Significantly lower rSO2 values were observed in the propofol group during gynecological laparoscopic surgery. The possibility of cerebral oxygen desaturation should not be overlooked during propofol anesthesia even after desufflation of the abdomen in the neutral position.

Inflammation and Sepsis / 대한구급학회지

Despite the development of modern intensive care and new antimicrobial agents, the mortality of the patients with severe sepsis and septic shock remains high. The poor outcome is considered to be a consequence of an overactive systemic inflammatory response. Sepsis is now defined as systemic inflammatory response syndrome (SIRS) in which there is an identifiable focus of infection. As a consequence of the overactive SIRS response, the function of various organ systems may be compromised, resulting in multiple organ dysfunction syndrome (MODS) and death. Systemic inflammation is a consequence of activation of the innate immune system. It is characterized by intravascular release of pro-inflammatory cytokines and other vasoactive mediators, and the concurrent activation of the innate immune cells. In addition to the pro-inflammatory reactions, the host's anti-inflammatory mechanisms are also activated and aimed at counteracting the inflammatory response. The balance between pro- and anti-inflammatory reactions is critical for the outcome of the patient. Understanding the mechanisms of acute inflammatory responses in critical ill patients is necessary for the development of urgently needed therapeutics. The aim of this review is to provide a description of the key components and mechanisms involved in the inflammatory response in patients with SIRS and sepsis.