Anesthetic management during surgery for left ventricular aneurysm and false aneurysm occurring in stage: a case report / 대한마취과학회지

Left ventricular aneurysm (LVA) and false aneurysm are complications of acute myocardial infarction, trauma, and cardiac surgery. Left ventricular false aneurysm (LVFA) is a particularly catastrophic complication owing to its high propensity for rupture. Surgical resection should be considered for LVFA occurring within three months after myocardial infarction or development of congestive heart failure. In this report, we describe a case of acute heart failure with LVA and LVFA occurring in stage as a complication of myocardial infarction in a 55-year-old man. The patient was also at risk of brain ischemia due to abnormal vessel status and a previous cerebrovascular accident with left-sided weakness. Successful perioperative anesthetic management was achieved by focusing on maintaining marginal upper normal blood pressure to ensure cerebral perfusion and to reduce the risk of false aneurysm rupture.

Comparison of emergence agitation between sevoflurane/nitrous oxide administration and sevoflurane administration alone in children undergoing adenotonsillectomy with preemptive ketorolac / 대한마취과학회지

BACKGROUND: Sevoflurane anesthesia commonly causes emergence agitation (EA) in children. One previous study has reported that the use of nitrous oxide (N2O) during the washout of sevoflurane may reduce EA by decreasing the residual sevoflurane concentration, while many animal studies suggest that N2O poses a potential risk to children. The present study was designed to compare EA in children assigned to receive sevoflurane with N2O (group N) or sevoflurane alone (group S). METHODS: We enrolled 80 children aged 3-10 years. Anesthesia was induced with 5 mg/kg thiopental sodium, 0.6 mg/kg rocuronium and 0.5 mg/kg ketorolac, and was maintained with 50% N2O and sevoflurane in group N or with sevoflurane alone in group S. The sevoflurane concentration was adjusted with a bispectral index (BIS) of 40-60. After completion of the surgery, N2O and sevoflurane were simultaneously discontinued and replaced with oxygen (O2) at 6 L/min. End-tidal sevoflurane concentration (Et Sevo) (%), BIS at the end of surgery, Et Sevo at recovery of self-respiration and emergence profiles were recorded. EA occurrence, pain score and rescue fentanyl consumption were assessed in the postanesthesia care unit. RESULTS: Et Sevo was significantly lower in group N (1.9%) than in group S (2.3%) at the end of surgery. However, there were no differences in Et Sevo at recovery of self-respiration, emergence times, the incidence of EA, pain score or dose of rescue fentanyl between the groups. CONCLUSIONS: In children undergoing adenotonsillectomy with preemptive ketorolac, anesthetic maintenance using sevoflurane alone does not affect the incidence of EA or emergence profiles compared to anesthetic maintenance using sevoflurane with N2O.

Insights into the Role of Follicular Helper T Cells in Autoimmunity

Follicular helper T (TFH) cells are recently highlighted as their crucial role for humoral immunity to infection as well as their abnormal control to induce autoimmune disease. During an infection, naive T cells are differentiating into TFH cells which mediate memory B cells and long-lived plasma cells in germinal center (GC). TFH cells are characterized by their expression of master regulator, Bcl-6, and chemokine receptor, CXCR5, which are essential for the migration of T cells into the B cell follicle. Within the follicle, crosstalk occurs between B cells and TFH cells, leading to class switch recombination and affinity maturation. Various signaling molecules, including cytokines, surface molecules, and transcription factors are involved in TFH cell differentiation. IL-6 and IL-21 cytokine-mediated STAT signaling pathways, including STAT1 and STAT3, are crucial for inducing Bcl-6 expression and TFH cell differentiation. TFH cells express important surface molecules such as ICOS, PD-1, IL-21, BTLA, SAP and CD40L for mediating the interaction between T and B cells. Recently, two types of microRNA (miRNA) were found to be involved in the regulation of TFH cells. The miR-17-92 cluster induces Bcl-6 and TFH cell differentiation, whereas miR-10a negatively regulates Bcl-6 expression in T cells. In addition, follicular regulatory T (TFR) cells are studied as thymus-derived CXCR5+PD-1+Foxp3+ Treg cells that play a significant role in limiting the GC response. Regulation of TFH cell differentiation and the GC reaction via miRNA and TFR cells could be important regulatory mechanisms for maintaining immune tolerance and preventing autoimmune diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Here, we review recent studies on the various factors that affect TFH cell differentiation, and the role of TFH cells in autoimmune diseases.

Management of traumatic pneumothorax with massive air leakage: role of a bronchial blocker: a case report / 대한마취과학회지

Massive air leakage through a lacerated lung produces inadequate ventilation and hypoxemia. Tube exchange from a single to double lumen endotracheal tube (DLT), and lung separation to maintain oxygenation, are challenging for seriously injured patients. In this case report, we aim to describe how a bronchial blocker (BB) makes it easier to perform a lung separation in this situation; it also increases the overall safety of the procedure. A 35-year-old female (163 cm, 47 kg) suffered from blunt chest trauma due to a traffic accident; the accident caused right-sided lung laceration with massive air leakage. Paradoxically, positive ventilation worsened SaO2 and leakage increased through a chest tube. We introduced BB while the patient was still awake: Left-side one-lung ventilation (OLV) was established and anesthesia was induced. After PaO2 was maximized with OLV, we changed the endotracheal tube to DLT without a hypoxic event. By BB placement, we maintained PaO2 at a secure level, conducted mechanical ventilation and exchanged the tube without deterioration.

Monitored anesthesia care using dexmedetomidine and remifentanil for the hip surgery in a high risk patient with brain metastasis of lung cancer, cerebral infarction, seizure and quadriplegia: A case report

To perform the major operation for high risk patients with both serious systemic diseases and major organ complications, the monitored anesthesia care could be available as a reasonable alternative for both general and regional anesthesia when it is impossible to administer; however, the choice of analgesics and sedatives is still an important and difficult task. We present a high risk patient who suffers from neurologic complications including decreased consciousness caused by brain metastasis of lung cancer, cerebral infarction, quadriplegia and seizure as well as decreased respiratory function and bleeding tendency. When performing the operation on hip joints, we administered both dexmedetomidine as a major sedative, and remifentanil as an adjunct analgesic; as a result, we could successfully perform the monitored anesthesia care without any complications including cardiovascular instability, respiratory depression, and seizure.

Right upper lobe tracheal bronchus: anesthetic challenge in one-lung ventilated patients: A report of three cases / 대한마취과학회지

Tracheal bronchus (TB) is an aberrant, accessary or ectopic bronchus arising almost exclusively from the right side of the tracheal wall above the carina. In our center, 673 bronchoscopic examinations were performed from 2009 to 2011 in patients undergoing one lung ventilation (OLV) and 3 TB were found. The incidence of a TB at bronchoscopy was 0.45% in our research, which is consistent with the reported incidence range from 0.1-5%. The clinician should consider the possibility of anomalous right upper lobe bronchus and perform bronchoscopy prior to the right bronchial blocker insertion, when left-sided OLV using bronchial blocker is planned. Also, for the patient with TB, a double lumen tube insertion is recommended than a blocker insertion to achieve OLV completely.

Unexpected tracheal narrowing during general anesthesia in the prone position of Duchenne muscular dystrophy patient: A report of two cases / 대한마취과학회지

Unexpected tracheal narrowing was observed in a patient with Duchenne muscular dystrophy during a corrective operation for thoracolumbar scoliosis. As the operating time progressed, peak airway pressure and end-tidal CO2 increased gradually in the prone position. We found a floppy portion of the trachea using fiberoptic bronchoscopy (FB) in the prone position. We advanced a wire-reinforced tube toward the carina beyond the lesion. This allowed correction of the ventilatory abnormalities. We encountered another patient scheduled for the same operation. We performed FB in advance before the position change and observed a narrowed portion of trachea. We advanced the tracheal tube under FB beyond the pathologic portion and then moved the patient into the prone position. The operation was done successfully without any problems.

The effects of hydrogen sulfide under sevoflurane administration against ischemia and reperfusion injury in isolated rat heart / 대한마취과학회지

BACKGROUND: Hydrogen sulfide (H2S) produces a protective effect against myocardial ischemia and reperfusion injury. Sevoflurane, which is used for anesthesia in cardiac problem patients, also has a protective effect. This study is designed to reveal the effects of H2S under sevoflurane using rat hearts. METHODS: The hearts were Langendorff-perfused, subjected to 30 minutes ischemia and 60 minutes reperfusion. Group I was a control group. The other groups were pretreated for 15 minutes before ischemia as follows: 1.6% sevoflurane for group S; 18.5 microM H2S S for group H; and 1.6% sevoflurane and 18.5 microM H2S simultaneously for group HS. Hemodynamics and the infarct size were measured. RESULTS: Group HS presented depressed hemodynamics during pretreatment. LV function in group HS achieved better recovery than group I after reperfusion. The infarct size of groups S, H and HS was smaller than group I, while there were no differences between groups S, H and HS. CONCLUSIONS: Exogenous H2S did not enhance the preconditioning effects of sevoflurane. Rather, the results suggest that H2S under sevoflurane might depress hemodynamics.

Comparison of the clinical effectiveness between the streamlined liner of pharyngeal airway (SLIPA) and the laryngeal mask airway by novice personnel / 대한마취과학회지

BACKGROUND: The aim of this study was to compare the streamlined liner of the pharynx airway (SLIPA) with the classic laryngeal mask airway when used by novice personnel. METHODS: There were 114 patients enrolled into this study who underwent general anesthesia were randomly allocated into one of 2 groups; LMA group (n = 57) or SLIPA group (n = 57). After insertion, insertion success rate, insertion time, and hemodynamic responses to insertion were accessed. After surgery, postoperative airway morbidity (sore throat, dysphonia, dysphagia) were evaluated. RESULTS: The SLIPA was successfully inserted in 96% of patients (55/57) and the LMA in 93% (53/57) (P = 0.408). First attempt success rates were 88% (44/57) and 77% (50/57) in the SLIPA and the LMA (P = 0.142). The successful insertion time in SLIPA group (33.4 +/- 11.0 sec) was significantly shorter than that of LMA group (38.8 +/- 16.6 sec) (P = 0.048) and the insertion time at the first attempt was also shorter in SLIPA group (31.0 +/- 6.3 sec) than LMA group (34.7 +/- 8.6 sec) (P = 0.013). There was no statistically significant difference between the two groups in hemodynamic responses and postoperative airway morbidity. CONCLUSIONS: The SLIPA was similar to the LMA in insertion success rate, hemodynamic response, and postoperative airway morbidity by novice personnel. The insertion time at the first attempt and successful insertion time of the SLIPA were significantly shorter than those of the LMA. Therefore, the SLIPA could be a useful alternative to the LMA as primary SGA for novice personnel.

Tension pneumothorax after ultrasound guided internal jugular venous catheterization in an inadvertently endobronchially intubated patient with kyphosis / 대한마취과학회지

No abstract available.

The cardioprotective effect of microemulsion propofol against ischemia and reperfusion injury in isolated rat heart / 대한마취과학회지

BACKGROUND: Lipid-emulsion propofol (LP) has cardioprotective effects against ischemia-reperfusion injury, but it has lipid-related side effects. Microemulsion propofol (MP) is a lipid-free propofol emulsified with 10% purified poloxamer 188 (PP188). PP188 is a nonionic surfactant and has cardioprotective effects. However, some reports have suggested that reduced cardioprotective effects were observed when the cardioprotective agents were used in combination even though each cardioprotective agent has cardioprotective effects. The aims of this study were to examine and compare the cardioprotective effects of MP and LP. METHODS: 50 isolated rat hearts were perfused with modified Kreb's solution. They were divided into 4 groups and underwent 30 minutes of ischemia and 60 minutes of reperfusion. Control group: ischemia-reperfusion was performed without treatment. LP, MP and PP groups: LP, MP and PP188 were infused during the pre-ischemic and reperfusion period, respectively. Hemodynamic parameters and coronary effluent flow rate (CEFR) were measured. Infarct size was determined using triphenyl-tetrazolium staining. RESULTS: In the MP group, systolic pressure was maintained near baseline, the systolic pressure was higher than that in the other groups and HR was lower than that in the other groups during reperfusion. Diastolic pressure was transiently increased in the PP group after treatment and at 5 minutes after reperfusion compared with that in the control group and in the the LP group. There were no differences in dP/dtmax and CEFR between groups. Infarct size in the LP, MP and PP groups was smaller than that in the control group, but there were no significant differences between these three groups. CONCLUSIONS: MP has cardioprotective effects similar to those of LP. MP can be used for cardiac anesthesia in cases with ischemia-reperfusion injury to avoid the lipid-related side effects of LP.

Bronchial foreign body removal under general anesthesia with a modified port, a fogarty balloon catheter and a grasping forceps / 대한마취과학회지

No abstract available.

A Clinical Analysis on Schwannoma in Head and Neck / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Neurogenic tumors in the head and neck are relatively rare and constitute around 0.5% of all head and neck tumors. Schwannoma, among neurogenic tumors, is a benign tumor originating from the spinal nerve root, peripheral nerve and all kinds of cranial nerves except the optic nerve and olfactory nerve. By presenting a series of head and neck schwannomas treated during a fifteen-year period, we aimed to analyze the clinical features, diagnosis, treatment and prognosis of schwannomas retrospectively. SUBJECTS AND METHOD: We retrospectively reviewed and analyzed clinical records of 34 patients with head and neck schwannomas who were treated surgically at the University Hospital from January, 1995 to January, 2010. RESULTS: We found 34 cases of schwannoma in the head and neck. Among the patients, 14 were males and 20 were females. The most common age group was the 60's while the most common site was the parapharyngeal space. The most common presenting symptom was palpable neck mass and the mean duration of symptoms was 41.6 months. The most common nerve of origin was the cervical plexus (29.4%). Preoperative diagnostic tools were FNA, CT and MRI. All cases were treated surgically and the most common postoperative complication was both transient and permanent voice changes. The mean follow-up period was 18.3 months and recurrence was not found during this period. CONCLUSION: Thirty-four cases of schwannoma in the head and neck were presented with respect to their clinical features.

Elbow pain proven to be tuberculous arthritis: A case report / 대한마취과학회지

Elbow tuberculosis is a rare disease which accounts for 1-3% of all cases of osteoarticular tuberculosis. The diagnosis of tuberculous arthritis is very difficult in most clinical situations because of the insidious onset, indolent process, and mild and non-specific local or systemic symptoms. Thus, the confirmatory diagnosis and effective treatment for tuberculous arthritis are delayed until the disease progresses to an advanced stage in many clinical settings. Herein we report a case of septic arthritis of the elbow due to Mycobacterium tuberculosis as a result of misdiagnosis and delayed treatments.

Elbow pain proven to be tuberculous arthritis: A case report / 대한마취과학회지

Elbow tuberculosis is a rare disease which accounts for 1-3% of all cases of osteoarticular tuberculosis. The diagnosis of tuberculous arthritis is very difficult in most clinical situations because of the insidious onset, indolent process, and mild and non-specific local or systemic symptoms. Thus, the confirmatory diagnosis and effective treatment for tuberculous arthritis are delayed until the disease progresses to an advanced stage in many clinical settings. Herein we report a case of septic arthritis of the elbow due to Mycobacterium tuberculosis as a result of misdiagnosis and delayed treatments.

Multiple Psoas Abscess Formation after Pharmacopuncture: A Case Report

Acupuncture has been widely used in alternative medicine for pain relief but may have many complications due to lack of appropriate cares. Pharmacopuncture is a sort of acupuncture that injects a herbal ingredient through a thin tube for the purpose of combining the effects of the herb and acupuncture and it has many pitfalls. The agents used in pharmacopuncture are not refined for a desired effect and not produced by sterile standard processes under strict medical surveillance. We report a case of a 44-yr-old male patient who had multiple abscesses in the psoas region with fever, right low back and hip pain that began after the pharmacopuncture treatment. This case shows that although pharmacopuncture has been practiced widely, it is important that the appropriate aseptic technique should be used to prevent severe infections and other complications.

Surgical Results of the Intraoral Removal for Plunging Ranula / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Although sclerotherapy has been recently applied for plunging ranula, surgical approaches such as marsupialization have been the primary mode of treatment. Marsupialization may be done through simple excision via transcervical approach or via combined approach, intraorally and trabscervically. This study examined the effectiveness of intraoral excision for the treatment of plunging ranula. SUBJECTS AND METHOD: This prospective clinical study was comprised of 15 patients who were treated for plunging ranula through intraoral excision of the raluna and sublingual gland. RESULTS: All of the 15 patients showed a complete removal of sublingual gland. The cystic wall of ranula could be dissected for only three patients (20%) and for twelve patients (80%), it could not be dissected intraorally. Rupture of ranula developed in all patients (100%) during intraoral dissection. Recurrence did not occurr at all during a median follow-up period of 14 months (range, 7-35 month) after the intraoral excision. There were no side effects and external scarring. CONCLUSION: The intraoral approach for removal of the plunging ranula is highly effective as a primary treatment modality of plunging ranula.

Comparison of bispectral index (BIS) and entropy in patients with cerebral palsy during sevoflurane induction / 대한마취과학회지

BACKGROUND: Demand of anesthesia for patients with cerebral palsy is more increasing. But there is still lacking in clinical research regarding how BIS and entropy reflect well on sedative and hypnotic state in patients with cerebral palsy. METHODS: Fifteen patients with cerebral palsy (Group CP) and fifteen patients without cerebral palsy (Group NL) scheduled for elective orthopedic surgery were included in the study. Induction of anesthesia was done by having the patient inhale 1 vol% sevoflurane and 100% oxygen using a total fresh gas flow of 8 L/min. Simultaneously BIS, state entropy (SE), response entropy (RE), end-tidal sevoflurane concentration were recorded every 15 seconds till there was no self respiration. When end-tidal sevoflurane concentration had not risen any more for 30 seconds, we increased inhaled sevoflurane concentration in 1 vol% increments. End point of recording was when self respiration was lost or the time sevoflurane concentration reached 8 vol%. RESULTS: No significant differences in RE, SE, BIS at baseline and end point were found between the two groups. No significant difference in the time reach end point was found between the two groups. BIS, SE and RE correlated with end-tidal sevoflurane concentration in the two groups. CONCLUSIONS: The authors found no significant difference in the entropy values between patients with CP and normal patients. Also, the entropy values could be interpreted like BIS in patients with CP. And BIS showed a stronger correlation with end tidal sevoflurane concentrations than entropy.

Antihistamine Pretreatment to Reduce Incidence of Withdrawal Movement After Rocuronium Injection

The purpose of this study was to determine the effectiveness of antihistamine therapy for withdrawal movements caused by rocuronium injection. One hundred seventy one ASA I-II adults undergoing elective surgery were randomly assigned to one of two groups. Patients in the control group (Group C) were premedicated with 2 mL normal saline, and those in the antihistamine group (Group A) were pre-medicated with 2 mL (45.5 mg) pheniramine maleate. After the administration of thiopental sodium 5 mg/kg, rocuronium 0.6 mg/kg was injected. Withdrawal movements were assessed using a four-grade scale. The administration of antihistamine reveals lower grade of withdrawal movement after rocuronium injection.

Comparison of Isoflurane-nitrous Oxide Anesthesia and Isoflurane-remifentanil Anesthesia during Tympanoplasty / 대한마취과학회지

BACKGROUND: Nitrous oxide (N2O) may increase middle ear pressure during anesthesia, resulting in the displacement of tympanic membrane graft for tympanoplasty.This study was performed to assess the feasibility of remifentanil instead of N2O by comparing hemodynamics, recovery profiles, postoperative analgesia and complications during isoflurane-based anesthesia for tympanoplasty. METHODS: Forty patientsundergoing tympanoplasty were randomly allocated to N2O-isoflurane anesthesia (group N) and remifentanil-isoflurane anesthesia (group R).In group N, N2O was used from induction to 15-30 minutes prior to grafting tympanic membrane and then N2O was changed to air.In group R, remifentanil was infused to the end of surgery.Isoflurane was used in both groups.We compared mean arterial pressure (MAP), heart rate (HR) and recovery times between groups during perioperative period.Postoperative pain, analgesic demand and nausea/vomiting during postoperative period were also compared. RESULTS: MAP and HR were significantly higher in group N than group R at 1 minute, 5 minutes after intubation, skin incision and closure.Hypertensive and tachycardiac events were also more frequent in group N during operation.Time to spontaneous respiration was significantly shorter in group N, but times to eye opening, extubation and recovery of orientation were significantly shorter in group R.There were no significant differences in pain scores, analgesic demand and nausea/vomiting during postoperative period. CONCLUSIONS: Remifentanil can provide more stable hemodynamic status and faster emergence than N2O without significant increase of pain level, analgesic demand and adverse effects in isoflurane-based anesthesia for tympanoplasty.