Anesthetic management of the first forearm transplantation in Korea / 대한마취과학회지

Vascularized composite allotransplantation for the forearm is a complex surgical procedure, requiring multidisciplinary collaboration. It is important to provide optimal blood flow to the grafts, effective immunosuppression, and early rehabilitation for graft survival and good functional outcomes. As ischemia-reperfusion injury and substantial but unquantifiable blood loss are inevitable in this type of surgery, anesthetic management should focus on providing adequate hemodynamic management with proper monitoring, and anesthetic and analgesic strategies to prevent vasoconstriction in the graft. In this paper, we describe the anesthetic management of the first forearm transplantation performed in Korea.

Response to neuromuscular blockade with rocuronium during general anesthesia in a patient with dermatomyositis: A case report

Dermatomyositis is an idiopathic inflammatory myopathy characterized by skin changes and muscle weakness. Depending on the involvement of various muscles, dermatomyositis can cause aspiration pneumonia, ventilatory impairment, and heart failure. Several reports have documented normal or prolonged neuromuscular blockade following administration of different non-depolarizing neuromuscular blockers in patients with dermatomyositis. We observed delayed onset of blockade and prolonged recovery following administration of 0.6 mg/kg rocuronium in a patient with dermatomyositis. However, when the train-of-four ratio reached 0.3, the patient was administered pyridostigmine and glycopyrrolate, which led to normal response to reversal of rocuronium. The patient was extubated without respiratory complications. The outcomes of this case indicate that response to the usual dosage of muscle relaxants in patients with dermatomyositis might be different from that in patients without this condition. Anesthesiologists should pay attention to preoperative cardiorespiratory evaluation and intraoperative neuromuscular monitoring.

Anesthetic management of the first forearm transplantation in Korea / 대한마취과학회지

Vascularized composite allotransplantation for the forearm is a complex surgical procedure, requiring multidisciplinary collaboration. It is important to provide optimal blood flow to the grafts, effective immunosuppression, and early rehabilitation for graft survival and good functional outcomes. As ischemia-reperfusion injury and substantial but unquantifiable blood loss are inevitable in this type of surgery, anesthetic management should focus on providing adequate hemodynamic management with proper monitoring, and anesthetic and analgesic strategies to prevent vasoconstriction in the graft. In this paper, we describe the anesthetic management of the first forearm transplantation performed in Korea.

The effect of intravenous labetalol administration on hemodynamic responses during desflurane inhalation / 대한마취과학회지

BACKGROUND: Inspired concentrations of desflurane > or = 1 minimum alveolar anesthetic concentration (MAC) have been related to sympathetic stimulation such as hypertension and tachycardia. The current study examined whether labetalol, an alpha1 and beta-adrenergic antagonist would blunt these hemodynamic responses. METHODS: Fifty-four ASA physical status I patients, aged 20-60 years, were enrolled in this study. The patients were randomly divided into 2 groups. The breathing circuit was primed with an end-tidal desflurane concentration of 1.2 MAC in 6 L/min O2. Normal saline 5 ml or labetalol 0.3 mg/kg was injected into groups S and L respectively. After 5 minutes, anesthesia was induced with intravenous etomidate 0.2 mg/kg and vecuronium 0.1 mg/kg. Each patient inhaled desflurane through a tight fitting facemask. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and end-tidal concentration of desflurane (et-des) were measured at 5 minutes after saline or labetalol injection (baseline) and every 1 minute for 5 minutes after desflurane inhalation and for 2 minutes after intubation. RESULTS: In the saline injection group (group S), desflurane inhalation increased heart rate and blood pressure, while labetalol 0.3 mg/kg attenuated the heart rate and blood pressure increase in group L. After tracheal intubation, heart rate and blood pressure were significantly lower in group L than in group S. CONCLUSIONS: These results demonstrate that administration of intravenous labetalol is effective in attenuating tracheal intubation and desflurane-induced hemodynamic responses.

An abrupt supraglottic obstruction during the induction of general anesthesia due to a rapid growing laryngeal tumor: A case report

A 68-year-old woman with laryngeal tumor was scheduled for a biopsy under the general anesthesia. As dyspnea or stridor was not present and half of the laryngeal opening could be easily seen by preoperative bronchoscopy which took one month prior to the surgery, anesthesia was induced with sedatives and muscle relaxant in stepwise patterns. However, an impending total airway obstruction developed after muscle relaxant administration and emergency tracheostomy became unwanted necessity. Since a laryngeal tumor could grow large enough to make trouble in general anesthesia in a short period of time from diagnosis to operation, preoperative anticipation of airway compromise, reevaluation just before the anesthesia, communication with all operating team workers, and prompt management were needed to avoid dread complications.

The optimal volume of 0.2% ropivacaine required for an ultrasound-guided stellate ganglion block / 대한마취과학회지

BACKGROUND: This study was performed to find the optimal volume of local anesthetics needed for a successful ultrasound-guided stellate ganglion block (SGB) to treat head and neck pathology. METHODS: Fifteen female and fourteen male sensory-neural hearing loss patients received 4 times SGBs with 0.2% ropivacaine in volumes of 6, 4, 3 and 2 ml at 1 to 3 day intervals. Using the transverse short-axis view of the neck that showed Chassaignac's tubercle at the C6 level, a 25-gauge, and 4 cm needle was inserted via the lateral paracarotid approach with out-of-plane targeting between the prevertebral fascia and the ventral surface of longus colli muscle (subfascial injection). A successful block was confirmed with the onset of ptosis (Horner's syndrome). RESULTS: There were no significant statistical differences between the presence of Horner's syndrome and the volume of local anesthetics given. However, Horner's syndrome was present in all trials for the 4 ml and 6 ml groups. Six (20.7%) and three out (10.4%) of twenty-nine trials in the 2 ml and 3 ml groups, respectively, failed to elicit Horner's syndrome. The duration of action was significantly different in the 2 ml group compared to that of the 6 ml group, but there was no significant difference between the other groups, including the 4 ml vs. 6 ml groups. The side effects were not different between the groups. CONCLUSIONS: This data suggests that the optimal volume of 0.2% ropivacaine for ultrasound-guided SGB to treat the head and neck pathology in daily practice is 4 ml.

Anesthetic management of non-cardiac surgery with adult onset type of cor triatriatum sinister: A case report / 대한마취과학회지

A 45-year-old woman with cor triatriatum sinister was admitted for laparoscopic resection of an ovarian tumor. Her medical history was benign with the exception of a single episode of syncope one year ago. A 1.5-cm membrane fenestration was found on echocardiography, but there were no other cardiac structural anomalies. General anesthesia was established with etomidate, sevoflurane, and remifentanil; no notable events occurred during the anesthesia. As cor triatriatum shows a clinical picture of mitral stenosis (MS), careful anesthetic management is required.

Anesthesia for Cesarean Section in a Parturient with Dilated Cardiomyopathy: A Case Report / 영남의대학술지

Idiopathic peripartum cardiomyopathy is an uncommon malady disease. Making the diagnosis is often difficult and it is always necessary to exclude other prior heart disease and other causes of left ventricular dysfunction in pregnant women. Heart failure in these women ensues when the cardiovascular demands of normal pregnancy are further amplified when the common complications of pregnancy complications superimposed upon these underlying conditions that cause compensated ventricular hypertrophy. This may be aggravated by making a late diagnosis and providing inappropriate treatment. We experienced a 38-year-primigravida who has diagnosed with idiopathic peripartum cardiomyopathy and underwent elective cesarean section with general anesthesia.

Anesthetic Experience for Trans-Sphenoidal Surgery of Pituitary Adenoma on a Patient with Brugada Syndrome: A Case Report / 영남의대학술지

Brugada syndrome is characterized by an ECG pattern of right bundle branch block and ST segment elevation in the right precordial leads (V(1)-V(3)) without structural heart disease. It is also characterized by sudden cardiac death that's caused by ventricular fibrillation. This is a familial syndrome with an autosomal dominant inheritance pattern and it may be considerably more common in Southeast Asia. Many factors during anesthesia can precipitate malignant dysrrhythmia in these patients, so careful choice of anesthetics is required. We experienced a case of Brugada syndrome in a 59-year-old male patient who was under general anesthesia for trans-sphenoidal surgery to treat a pituitary adenoma, and the patient was diagnosed as having Brugada syndrome without any untoward cardiovascular events.

Effects of Remifentanil on Hemodynamic Responses of Exogeneous Epinephrine during Endoscopic Sinus Surgery / 대한마취과학회지

BACKGROUND: Epinephrine is commonly used to reduce bleeding by constriction of nasal vessels in endoscopic sinus surgery. However, when it absorbs to other organs systemically, tachycardia and hypertension may occur and result in more bleeding. This study is performed to evaluate the dose response effects of remifentanil infusion to suppress these adverse responses without delaying emergence. METHODS: Sixty healthy patients who scheduled for endoscopic sinus surgery were randomly allocated into three groups by the dose of remifentanil infusion. For induction and maintenance of anesthesia, 0.05, 0.15, 0.25microgram/kg/min of remifentanil and 3.5microgram/ml of intravenous propofol by TCI were infused to each group. Systolic and diastolic blood pressure, heart rate and bispectral index were measured for 15 minutes at the 1 minute intervals after nasal packing of epinephrine. RESULTS: Systolic and diastolic blood pressure in R0.15 and R0.25 group were significantly lower compared to R0.05 group during 9 to 12 minutes after epinephrine packing, but heart rate and bispectral index were not significantly different among the groups. The frequency of hypotension and bradycardia were significantly higher in R0.25 than R0.05 and R0.15. CONCLUSIONS: Continuous infusion of 3.5microgram/ml of propofol with 0.15microgram/kg/min of remifentanil attenuate hypertension and tachycardia induced by epinephrine with little side effects.

Risk Factors of Acute Renal Failure after Colorectal Surgery / 영남의대학술지

BACKGROUND: Acute renal failure is one of the leading causes of postoperative morbidity and mortality. The purpose of this study was to determine the risk factors that are associated with acute renal failure after colorectal surgery. MATERIALS AND METHODS: Five hundred seventy patients who operated colorectal surgery at the Yeungnam University Medical Center over three years from 2004 to 2006 were enrolled in this study. The effects of gender, age, ASA classification, concomitant disease, surgery type and duration, reoperation, urogenital manipulation, medication, hypotension, hypovolemia, transfusion, and postoperative ventilatory care on the occurrence of acute renal failure after colorectal surgery were studied. RESULTS: The major risk factors of acute renal failure after colorectal surgery were age of patients (P=0.003), ASA classification (P<0.001), concomitant disease (P<0.001), duration of the time surgery (P=0.034), reoperation (P=0.001), use of intraoperative diuretics (P=0.005), use of postoperative diuretics (P<0.001), intraoperative hypotension (P=0.018), intraoperative transfusion (P<0.001), postoperative transfusion (P<0.001), and postoperative ventilatory care (P=0.001). CONCLUSION: Multiple factors cause synergistic effects on the development of acute renal failure after colorectal surgery. Therefore, efforts to reduce the risk factors associated with acute renal failure are needed. In addition, intensive postoperative care should be provided to all patients.

Subcutaneous Emphysema and Inflammation of the Neck after Tracheal Puncture by an Intubating Stylet / 영남의대학술지

Laryngo-tracheal perforation caused by the use of a stylet during tracheal intubation is a rare complication. We present a case of subcutaneous emphysema and connective tissue inflammation after tracheal intubation. The patient was a 41-year-old male undergoing general anesthesia for an appendectomy. The intubation was difficult during laryngoscopy (Cormack-Lehane Grade III). An assistant provided an endotracheal tube with a stylet inside while the laryngoscope was in place. During intubation, a short, dull sound was heard with a sudden loss of resistance after the distal tip of the endotracheal tube passed the rima glottis. A sonogram and computerized tomography revealed subcutaneous emphysema from the neck to the upper mediastinum and fluid collection between the trachea and the thyroid. This lesion appeared to have been caused by the protruded, loose stylet. Anesthesiologists should be aware of the damage a loose stylet protruding beyond the tip of the endotracheal tube can cause.

Cardiovascular Effects of Free Movement of Abdominal Muscle in Prone Positioning during General Anesthesia / 영남의대학술지

BACKGROUND: The prone position is often used for operations involving the spine and provides excellent surgical access. The complications associated with the prone position include ocular and auricular injuries, and musculoskeletal injuries. In particular, the prone position during general anesthesia causes hemodynamic changes. To evaluate the cardiovascular effects of the prone position in surgical patients during general anesthesia, we investigated the effects on hemodynamic change of the prone position with the Jackson spinal surgery table. MATERIALS AND METHODS:Thirty patients undergoing spine surgery in the prone position were randomly selected. After induction of general anesthesia, intra-arterial and central venous pressures (CVP) were monitored and cardiac output was measured by NICO(R). We measured stroke volume, cardiac index, cardiac output, mean arterial pressure, heart rate, CVP and systemic vascular resistance (SVR) before changing the position. The same measurements were performed after changing to the prone position with the patient on the Jackson spinal surgery table. RESULTS: In the prone position, there was a significant reduction in stroke volume, cardiac index and cardiac output. The heart rate, mean arterial pressure and CVP were also decreased in the prone position but not significantly. However, the SVR was increased significantly. CONCLUSION: The degree of a reduced cardiac index was less on the Jackson spinal surgery table than other conditions of the prone position. The reduced epidural pressure caused by free abdominal movement may decrease intraoperative blood loss. Therefore, the Jackson spinal surgery table provides a convenient and stable method for maintaining patients in the prone position during spinal surgery.

Upper Airway Obstruction in a Child with Unrecognized Obstructive Sleep Apnea during Anesthetic Induction - A case report- / 대한마취과학회지

The definition of obstructive sleep apnea (OSA) is an absence of air flow at the mouth and nose despite respiratory movement. In these patients, OSA does not occur during the awake state due to pharyngeal dilator muscles, but occurs due to loss of muscle tone during sleep. Moreover, sleep and anesthesia are related. Anesthesia and sedatives aggravate or precipitate OSA by the inhibiting neural and muscle activity and suppressing protective arousal responses. Therefore, the identification of OSA patients at greatest risk during the perioperative period is a major concern of anesthesiologists during preoperative visits. We experienced a case of acute upper airway obstruction in a child with unrecognized obstructive sleep apnea that occurred during anesthetic induction for adenotonsillectomy.

The Effect of Lesser Palatine Nerve Block on Pain after Elective Pediatric Tonsillectomy / 대한마취과학회지

BACKGROUND: This prospective, double-blind randomized study was performed to evaluate the analgesic effect of lesser palatine nerve block for postoperative pain control after a pediatric tonsillectomy, and to compare the analgesic effects of pre-emptive versus postoperative blocks. METHODS: Forty-eight ASA class 1 children, scheduled for an elective tonsillectomy were randomized into three groups. Patients received lesser palatine nerve blocks, using divided doses of 0.05 ml/kg of 0.2% ropivacaine, 5 min prior to the beginning of tonsillectomy (Pre-block group) or immediately after surgery (Post-block group). Patients allocated into the Control group did not receive any nerve block. Postoperative pain was measured immediately after surgery, 3, 6, 12 and 24 hours following operation using a 0 to 4 points pain scale, based on a facial expression of pain scale ruler. Side effects and the number of analgesic injections were observed for 24 hours postoperatively. RESULTS: No significant differences in the pain scores were observed immediately after surgery and at 3, 6, 12 and 24 hours after operation in the three groups (P > 0.05). The number of analgesic injections was similar in the groups. CONCLUSIONS: The results of this study reveal that the lesser palatine nerve block was not effective for postoperative pain control following pediatric tonsillectomy, and that the pre-emptive block offered no pain control benefit over the postoperative block. Therefore, we do not recommend lesser palatine nerve blocks for the management of postoperative pain after pediatric tonsillectomy.

Hemodynamic and Metabolic Changes Induced by Tourniquet Release during Both Total Knee Replacement Arthroplasty / 대한마취과학회지

BACKGROUND: A tourniquet is usually used for total knee replacement arthroplasty (TKR) to provide a bloodless surgical field. However, hemodynamic and metabolic changes result from the ischemia after application of a tourniquet. Moreover, the hemodynamic and metabolic effects of tourniquet application during both TKR under general anesthesia have been rarely reported. METHODS: Fifteen patients undergoing both TKR were studied during general anesthesia. Hemodynamic and metabolic parameters were measured before inflating the tourniquet, just before release of the tourniquet and 3, 6, 15 min after tourniquet release. Stroke volume (SV), cardiac index (CI), systemic vascular resistance (SVR) and end-tidal CO2 (ETCO2) were measured using a non-invasive cardiac output monitor. RESULTS: Mean arterial pressure (MAP) decreased after tourniquet release, but was not different from MAP before tourniquet inflation. After tourniquet release, central venous pressure, SVR, arterial pH, bicarbonate and calcium decreased significantly (P <0.05), and heart rate, CI, ETCO2, PaCO2 and potassium increased significantly (P <0.05). But, the hemodynamic and metabolic changes after tourniquet release in the subsequent TKR were not affected by those after tourniquet release in the antecedent TKR. CONCLUSIONS: During both TKR, although there was no difference in the hemodynamic and metabolic changes after tourniquet release between the antecedent and the subsequent TKR, there were significant hemodynamic and metabolic changes after tourniquet release. These findings indicate the need for more active hemodynamic and metabolic monitoring in patients with a compromised cardiopulmonary function.

Correlations between Numerical Rating Scale and Visual Analog Scale Pain Scores in the Assessment of Postoperative Pain / 대한마취과학회지

BACKGROUND: We wondered what type of pain scores is more available and reliable during the immediate postoperative period. In this study, we compared a numerical rating scale (NRS) with a visual analog scale (VAS) pain scores to assess postoperative pain. METHODS: Fifty patients were educated as to how to describe pain intensity using the NRS (11-point) and VAS (10 cm) scores during the evening before elective laparoscopic cholecystectomy. Following their operation, patients checked their pain intensity using NRS and VAS at postoperative 1 hour in the recovery room with the assistance of an anesthesiologist, and 3, 6, 12, 18 and 24 h by themselves. The absolute values of the NRS and VAS scores were analyzed for inter-individual variability and for correlations between the two. RESULTS: Forty-eight patients finished this study. The absolute value of the mean NRS score was slightly higher than that of the mean VAS score at each time point. However, the mean difference was only 0.4. Overall, the two parameters correlated well at each of the six measurement times. The correlation coefficients between the absolute values of the NRS and VAS pain scores for all measurement times were over 0.95. CONCLUSIONS: This data suggests that NRS and VAS pain scores are well correlated, and that they are equally useful at assessing immediate postoperative pain.

The Effect of the Lithotomy-Trendelenburg Position on Respiratory and Hemodynamic Changes during General Anesthesia / 대한마취과학회지

BACKGROUND: The effects of Trendelenburg positions used to expose the surgical field may induce intraoperative hemodynamic and respiratory changes that complicate anesthetic management. This study was performed to evaluate the effects of the lithotomy-Trendelenburg position on respiratory and hemodynamic changes with time passage during general anesthesia. METHODS: Twenty patients undergoing anorectal surgery with general anesthesia were studied. Hemodynamic and respiratory parameters were measured before the lithotomy-Trendelenburg position (L) and 3 min (LT3), 6 min (LT6), 12 min (LT12), 30 min (LT30) and 60 min (LT60) after the 30 degree Trendelenburg position. The cardiac index (CI), stroke volume (SV), systemic vascular resistance (SVR), airway resistance (Raw) and dynamic compliance (Cdyn) were measured by a non-invasive cardiac output monitor. RESULTS: Central venous pressure and peak inspiratory pressure were markedly increased from the lithotomy to the lithotomy-Trendelenburg position. Heart rate was slightly increased while SV, CI, SVR and MAP were decreased. No significant changes of the SV or CI were observed during surgery. The Cdyn was significantly decreased. CONCLUSIONS: The steep lithotomy-Trendelenburg position induces moderate adverse hemodynamic and respiratory effects in healthy patients. These findings indicate the need for more active hemodynamic and respiratory monitoring in patients with a compromised cardiopulmonary function.

Anesthetic Consideration Concerning a Congenital Diaphragmatic Hernia in a Patient with a Single Ventricle: A case report / 대한마취과학회지

A congenital diaphragmatic hernia is a life threatening condition. It causes pulmonary hypertension with right to left shunting that contributes to severe hypoxemia in neonates. A particulary poor prognosis is predicted if a congenital diaphragmatic hernia is associated with cardiac deformities and pulmonary hypoplasia. We experienced a case of a 3,500 gm female infant with a congenital diaphragmatic hernia and a single ventricle with left pulmonary atresia. Of prime concern was the maintenance of pulmonary vascular resistance, and this was achieved by altering ventilation, inspired oxygen concentration and blood pH. Also postoperative management of pulmonary hypertension is as important as surgical correction of the congenital diaphragmatic hernia. We performed general anesthesia with O2-fentanyl-isoflurane for correction of diaphragmatic hernia. The fentanyl infusion continued after the operation for blunting of stress responses in the pulmonary circulation. The patient was given a Blalock-Taussig shunt at postoperative day 12.

The Effects of Intraperitoneal Instillation of Lidocaine before Pneumoperitoneum on Postoperative Pain Score and Intraoperative Changes of Blood Pressure in Patients with a Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: This study was performed to evaluate the effects of pre-emptive subdiaphragmatic instillation of lidocaine before pneumoperitoneum on postoperative pain following a laparoscopic cholecystectomy (LC) and also to evaluate it's effect on the changes of blood pressure during an operation. METHODS: Thirty-three relatively healthy patients for an LC were allocated into the two groups. after the induction of general anesthesia with sodium thiopental, vecuronium, nitrous oxide and enflurane (1-2 vol%), 0.2% lidocaine 200 ml was subdiaphragmatically instilled 10 min before pneumoperitoneum in the lidocaine group (n = 15), and normal saline in the control group (n = 18). The changes of the systolic and mean arterial pressure (SAP and MAP), postoperative pain score, and the number of analgesics used during the postoperative 24 h were compared between two groups. RESULTS: The pain scores at postoperative 1, 3, 6, 12, 18 and 24 h and the number of analgesics used were significantly low in the lidocaine group compared to the control group (P<0.01). The elevations of SAP and MAP during pneumoperitoneum were significantly attenuated in the lidocaine group (P<0.01). CONCLUSIONS: This data suggests that subdiaphragmatic instillation of lidocaine before pneumoperitoneum is effective in the control of postoperative pain following an LC and also effective to attenuate the elevation of blood pressure during pneumoperitoneum. However, further study is needed to evaluate the safety of these methods before recommendation of routine use.