Meralgia paresthetica following hemorrhoidectomy in the jack-knife position: A case report

Meralgia paresthetica (MP) is a neuropathic pain caused by the entrapment of the lateral femoral cutaneous nerve (LFCN). There have been reports of MP following various surgeries; however, it has not yet been reported after hemorrhoid surgery. We report a case of bilateral MP after hemorrhoid surgery in a jack-knife position. The patient presented with pain, tightness, and a tingling sensation in the anterolateral aspect of both thighs. Ultrasonography-guided LFCN block was used for diagnosis and treatment, along with conservative management for 20 days with oral medication. One month later, the patient's symptoms had resolved completely. MP due to the jack-knife position may occur postoperatively in patients with predisposing risk factors such as obesity and diabetes mellitus, despite adequate padding and a shorter operating time.

Effects of warmed carrier fluid on nefopam injection-induced pain

BACKGROUND: Nefopam is a non-opioid, non-steroidal analgesic drug with fewer adverse effects than narcotic analgesics and nonsteroidal anti-inflammatory drugs, and is widely used for postoperative pain control. Because nefopam sometimes causes side effects such as nausea, vomiting, somnolence, hyperhidrosis and injection-related pain, manufacturers are advised to infuse it slowly, over a duration of 15 minutes. Nevertheless, pain at the injection site is very common. Therefore, we investigated the effect of warmed carrier fluid on nefopam injection-induced pain. METHODS: A total of 48 patients were randomly selected and allocated to either a control or a warming group. Warming was performed by diluting 40 mg of nefopam in 100 ml of normal saline heated to 31–32℃ using two fluid warmers. The control group was administered 40 mg of nefopam dissolved in 100 ml of normal saline stored at room temperature (21–22℃) through the fluid warmers, but the fluid warmers were not activated. RESULTS: The pain intensity was lower in the warming group than in the control group (P < 0.001). The pain severity and tolerance measurements also showed statistically significant differences between groups (P < 0.001). In the analysis of vital signs before and after the injection, the mean blood pressure after the injection differed significantly between the groups (P = 0.005), but the heart rate did not. The incidence of hypertension also showed a significant difference between groups (P = 0.017). CONCLUSIONS: Use of warmed carrier fluid for nefopam injection decreased injection-induced pain compared to mildly cool carrier fluid.

Effects of nefopam on catheter-related bladder discomfort in patients undergoing ureteroscopic litholapaxy / 대한마취과학회지

BACKGROUND: Patients who undergo urinary catheterization may experience postoperative catheter-related bladder discomfort (CRBD). Previous studies have indicated that drugs with antimuscarinic effects could reduce the incidence and severity of CRBD. Accordingly, this study was carried out to investigate whether nefopam, a centrally acting analgesic with concomitant antimuscarinic effect, reduces the incidence and severity of CRBD. METHODS: Sixty patients with American Society of Anesthesiologists physical status I and II and aged 18–70 years who were scheduled to undergo elective ureteroscopic litholapaxy participated in this double-blinded study. Patients were divided into control and nefopam groups, comprising 30 patients each. In the nefopam group, 40 mg nefopam in 100 ml of 0.9% saline was administered intravenously. In the control group, only 100 ml of 0.9% saline was administered. All patients had a urethral catheter and ureter stent inserted during surgery. The incidence and severity of CRBD, numerical rating scale (NRS) score of postoperative pain, rescue pethidine dose, and side effects were recorded in the post-anesthesia care unit after surgery. RESULTS: The incidence (P = 0.020) and severity (P < 0.001) of CRBD were significantly different between the control group and the nefopam group. The NRS score of postoperative pain (P = 0.006) and rescue dose of pethidine (P < 0.001) were significantly higher in the control group than in the nefopam group. CONCLUSIONS: Intravenous administration of nefopam in patients scheduled to undergo ureteroscopic litholapaxy reduced the incidence and severity of CRBD, NRS score of postoperative pain and analgesic requirements.

Suspicious psychogenic hiccup after interventional pain procedures: A case report

Several cases of the hiccups that occurred after interventional pain procedures have been previously reported. A 34-year-old man had suffered from persistent hiccups that started after epidural and trigger point injection of steroid. His hiccups were stopped during meals and sleep. Furthermore, hiccups did not occur after intravenous or intramuscular steroid injection due to eczema and bronchitis, and after interventional pain procedure that was performed under sedation with midazolam. Hence, we suspected that his hiccups had resulted from a psychogenic cause.

Tracheal injury as a perforation of a newly formed tracheal diverticulum after tracheal intubation: A case report

Although tracheal injury after tracheal intubation has been reported often, the formation of acquired tracheal diverticulum as the complications of intubation has not been reported before. In a 57-year-old woman, emergency coil embolization was performed for the treatment of a ruptured cerebral aneurysm. Then, the over-ballooning of an endotracheal tube cuff and deep intubation were observed on a chest X-ray. So, the tube was re-ballooned and re-positioned before surgery. Five hours after extubation in the intensive care unit at postoperative 5 days, a perforation of the tracheal diverticulum wall, leading to subcutaneous emphysema around her neck and pneumomediastinum, was diagnosed using CT and bronchoscopy. The cause of the tracheal diverticulum was suspected over-ballooning of the endotracheal tube cuff because the diverticulum site and size were the same as those of the over-ballooning cuff.

Probable tramadol-induced atypical serotonin syndrome in a patient receiving selective serotonin reuptake inhibitor and stopped at 10 days before surgery: A case report

Tramadol can increase the serum level of serotonin, causing serotonin syndrome, which is a potentially life-threatening condition. Serotonin syndrome occurs when tramadol is used in combination with other drugs that affect serotonin. A patient who had been taking selective serotonin reuptake inhibitor and stopped at 10 days before surgery experienced intermittent heart rate elevation, tremor of the upper extremities and mental change after receiving an infusion of tramadol for postoperative pain control. Although he did not show the typical triad of serotonin syndrome (systemic autonomic dysfunction, neuromuscular impairment and mental status change), the patient was suspected to have serotonin syndrome caused by tramadol.

The correlation between the Trendelenburg position and the stroke volume variation / 대한마취과학회지

BACKGROUND: The stroke volume variation (SVV), based on lung-heart interaction during mechanical ventilation, is a useful dynamic parameter for fluid responsiveness. However, it is affected by many factors. The aim of this study was to evaluate the effects of SVV on Trendelenburg (T) and reverse Trendelenburg (RT) position and to further elaborate on the patterns of the SVV with position. METHODS: Forty-two patients undergoing elective surgery were enrolled in this study. Fifteen minutes after standardized induction of anesthesia with propofol, fentanyl, and rocuronium with volume controlled ventilation (tidal volume of 8 ml/kg of ideal body weight, inspiration : expiration ratio of 1 : 2, and respiratory rate of 10-13 breaths/min), the patients underwent posture changes as follows: supine, T position at slopes of operating table of -5degrees, -10degrees, and -15degrees, and RT position at slopes of operating table of 5degrees, 10degrees, and 15degrees. At each point, SVV, cardiac output (CO), peak airway pressure (PAP), mean blood pressure, and heart rate (HR) were recorded. RESULTS: The SVV was significant decreased with decreased slopes of operating table in T position, and increased with increased slopes of operating table in RT position (P = 0.000). Schematically, it was increased by 1% when the slope of operating table was increased by 5degrees. But, the CO and PAP were significant increased with decreased slopes of operating table in T position, and decreased with increased slopes of operating table in RT position (P = 0.045, 0.027). CONCLUSIONS: SVV is subjected to the posture, and we should take these findings into account on reading SVV for fluid therapy.

A comparative study of emergence agitation between sevoflurane and propofol anesthesia in adults after closed reduction of nasal bone fracture / 대한마취과학회지

BACKGROUND: Emergence agitation is associated with increased morbidity and hospital costs. However, there have been few reports in the medical literature on the occurrence of emergence agitation in adults. The aim of this study was to compare emergence agitation between sevoflurane and propofol anesthesia in adults after closed reduction of nasal bone fracture. METHODS: Forty adults (ASA I-II, 20-60 yr) undergoing closed reduction of nasal bone fracture were randomly assigned to either sevoflurane or propofol group and anesthesia was maintained with sevoflurane or propofol. The bispectral index (BIS) was monitored and maintained within 40-60. At the end of surgery, patients were transported to the post anesthetic care unit (PACU) and agitation state scale was checked by Aono's four-point scale (AFPS). Emergence agitation was defined as and AFPS score of 3 or 4. Pain score were measured by numeric rating scale (NRS) on arrival and peak value at PACU. RESULTS: Nine (45.0%) patients in the sevoflurane group and 2 (10.0%) patients in the propofol group developed emergence agitation in the PACU (P = 0.031). There was no correlation between peak NRS and Aono's four-point scale. CONCLUSIONS: Propofol may decrease incidence of emergence agitation compared to sevoflurane in adults undergoing closed reduction of nasal bone fracture.

A comparison of the recovery characteristics of propofol-remifentanil and desflurane-remifentanil anesthesia under bispectral index (BIS) monitoring following laparoscopic cholecystectomy

BACKGROUND: The aim of this prospective, double-blind randomized study was to compare the recovery characteristics of desflurane-remifentanil and propofol-remifentanil anesthesia in patients undergoing a laparoscopic cholecystectomy under BIS monitoring. METHODS: Eight patients (ASA I-II, 20-65 yr) undergoing laparoscopic cholecystectomy were randomly assigned to receive propofol-remifentanil anaesthesia or desflurane-remifentanil. The BIS was monitored and maintained between 45-55. At the end of surgery all anesthetics were discontinued. Time to eye opening and time to extubation was recorded. Subsequently, the patients were transported to the post-anesthetic care unit (PACU) and the modified aldrete score, visual analogue scale (VAS), blood pressure, heart rate, and postoperative nausea and vomiting (PONV) were recorded upon arrival at the PACU, as well as at 15 min, 30 min, 1 hr, 2 hr, and 24 hr. RESULTS: There were no significant differences in the incidence of PONV between the two groups. Modified aldrete scores were significantly higher in the propofol group at 15 min postoperative period (P = 0.013, Propofol = 9.87, Desflurane = 9.62). Further, VAS scores were significantly higher in the desflurane group at 30 min (P = 0.037, Propofol = 4.26, Desflurane = 5.0), and the number of antiemetic injections were significantly higher in the desflurane group at arrival to the PACU (P = 0.035, Propofol = 0, Desflurane = 0.11 +/- 0.052) and at 24 hr (P = 0.03, Propofol = 0.41 +/- 0.562, Desfluarane = 0.62 +/- 0.157). CONCLUSIONS: In patients undergoing laparoscopic cholecystectomy with BIS monitoring, there is no significant differences in the incidence of PONV. The use of propofol is associated with less postoperative pain.

The Effects of Postoperative Brachial Plexus Block Using MgSO4 on the Postoperative Pain after Upper Extremity Surgery

BACKGROUND: Although a brachial plexus block can be used to provide anesthesia and analgesia for upper extremity surgery, its effects using MgSO4 on postoperative pain management have not been reported. The aim of this study was to evaluate brachial plexus block using MgSO4 on postoperative analgesia. METHODS: Thirty-eight patients who were scheduled to undergo upper extremity surgery were randomly allocated into two groups: patients receiving axillary brachial plexus block with 0.2% ropivacaine 20 ml and normal saline 2 ml (group S) or 0.2% ropivacaine 20 ml and MgSO4 200 mg (group M). Before extubation, the blocks were done and patient controlled analgesia was started, and then, the patients were transported to a postanesthetic care unit. The postoperative visual analogue scale (VAS), opioid consumption, and side effects were recorded. RESULTS: The two groups were similar regarding the demographic variables and the duration of the surgery. No differences in VAS scores were observed between the two groups. There was no statistically significant difference in opioid consumption between the two groups. Nausea was observed in three patients for each group. CONCLUSIONS: Axillary brachial plexus block using MgSO4 did not reduce the level of postoperative pain and opioid consumption.

The effect of milrinone infusion on right ventricular function during coronary anastomosis and early outcomes in patients undergoing off-pump coronary artery bypass surgery / 대한마취과학회지

BACKGROUND: During coronary anastomosis in off-pump coronary artery bypass surgery (OPCAB), hemodynamic alternations can be induced by impaired diastolic function of the right ventricle. This study was designed to examine the effect of milrinone on right ventricular function and early outcomes in patients undergoing OPCAB. METHODS: Forty patients undergoing OPCAB were randomly assigned in a double-blind manner to receive either milrinone (milrinone group, n = 20) or normal saline (control group, n = 20). Hemodynamic variables were measured after pericardiotomy (T1), 5 min after stabilizer application for anastomosis of the left anterior descending coronary artery (LAD, T2), the obtuse marginalis branch (OM, T3), the right coronary artery (RCA, T4), 5 min after sternal closure (T5), and after ICU arrival. The right ventricular ejection fraction (RVEF) and right ventricular volumetric parameters were also measured using the thermodilution technique. For evaluation of early outcomes, the 30-day operative mortality and morbidity risk models were used. RESULTS: There was no significant difference in hemodynamic variables, including mean arterial pressure, between the 2 groups, except for the cardiac index and RVEF. The cardiac index and RVEF were significantly greater at T3 in the milrinone group than in the control group. CONCLUSIONS: Continuous infusion of milrinone demonstrated a beneficial effect on cardiac output and right ventricular function in patients undergoing OPCAB, especially during anastomosis of the graft to the OM artery, and it had no adverse effect on early outcomes.

Pneumothorax occurring during laparoscopic anterior resection of sigmoid colon cancer: A case report

Pneumothorax during laparoscopic surgery is a potentially fatal complication.We present a case of left-sided pneumothorax complicating laparoscopic anterior resection of the sigmoid colon cancer.After signs suggestive of pneumothorax were recognized during carbon dioxide pneumoperitoneum, chest X-ray confirmed the diagnosis.Oxygen saturation and vital signs were maintained by increasing the inspired oxygen fraction and deflating the pneumoperitoneum.The pneumothorax resolved spontaneously after surgery and there were no complications.This case shows the importance of vigilance on the part of the anesthesiologist during laparoscopic surgery.

The effects of lidocaine and fentanyl on airway irritability during inhalation induction with desflurane / 대한마취과학회지

BACKGROUND: Inhalation induction with desflurane can cause airway irritability and sympathetic stimulation. The aim of this study was to investigate whether lidocaine and fentanyl could reduce these unwanted reactions. METHODS: Seventy-five patients who had premedication with midazolam were randomly allocated to one of three groups to receive intravenous saline (S group), lidocaine 1.5 mg/kg (L group), fentanyl 1 microgram/kg (F group), respectively, before tidal volume induction with desflurane in oxygen and nitrous oxide. We recorded airway irritability such as cough, apnea, laryngospasm and excitatory movement and hemodynamic changes. RESULTS: Airway irritability was not significantly different between the groups. In F group, mean blood pressure at LOC ver and LOC BIS and heart rate at LOC ver, LOC BIS and just before intubation were lower than those of S group (P < 0.05). Other results were not significantly different. CONCLUSIONS: The results of the study showed that intravenous fentanyl and lidocaine had no beneficial effects to reduce airway irritability, but intravenous fentanyl could significantly reduce hemodynamic stimulation during inhalation induction with desflurane in the patients who were premedicated with midazolam.

Traumatic Tricuspid Regurgitation Following Cardiac Massage

We report a 66-yr-old male patient who developed tricuspid regurgitation secondary to internal cardiac massage. After uneventful off-pump coronary artery bypass surgery, the subject experienced cardiac arrest in the intensive care unit. External cardiac massage was initiated and internal cardiac massage was performed eventually. A transesophageal echocardiography revealed avulsion of the anterior papillary muscle and chordae to the anterior leaflet after successful cardiopulmonary resuscitation. Emergency repair of the papillary muscle was performed under cardiopulmonary bypass.

Tracheal Intubation using Remifentanil and No Muscle Relaxants: the Effect of Thiopental, Propofol, or Etomidate on Tracheal Intubating Conditions and Hemodynamic Changes / 대한마취과학회지

BACKGROUND: Many studies have suggested that propofol in combination with remifentanil may provide adequate conditions for tracheal intubation without the use of muscle relaxants. Other hypnotic drugs have not been thoroughly investigated in this regard. The goal of our study was to evaluate the effect of thiopental, propofol or etomidate on tracheal intubating conditions and hemodynamic changes using remifentanil in the absence of muscle relaxants. METHODS: A total of 45 healthy adults were divided randomly into three groups. After iv lidocaine 1.5 mg/kg, thiopental 5 mg/kg (thiopental group) or propofol 2.5 mg/kg (propofol group), or etomidate 0.4 mg/kg (etomidate group) were injected. After the injection of study drugs, remifentanil 2 mcg/kg was administered. Ninety seconds after the administration of remifentanil, laryngoscopy and intubation were attempted. Intubating conditions were assessed and the mean arterial pressure and the heart rate was measured. RESULTS: There were no significant differences in intubating conditions between patients in the three groups. The heart rate was significantly lower in the propofol and etomidate group patients when compared to the thiopental group patients after anesthetic induction. The mean arterial pressure was significantly lower in the propofol group patients when compared to the thiopental and etomidate group patients. Both heart rate and mean arterial pressure after tracheal intubation were significantly elevated in etomidate group patinets when compared to their preintubation value. CONCLUSIONS: The use of thiopental 5 mg/kg, propofol 2.5 mg/kg, and etomidate 0.4 mg/kg did not differ in effect under intubating conditions for tracheal intubation using remifentanil in the absence of muscle relaxants. Thiopental provided the best hemodynamic conditions.

Effect of Preoperative Omitting Angiotensin-converting Enzyme Inhibitor on Hemodynamics in Patients Undergoing Off Pump Coronary Artery Bypass Surgery / 대한마취과학회지

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACE-I) have been widely used for cardiac patients. This study investigated the effect of omitting ACE-I medication on hemodynamics during induction of anaesthesia and operation in patients chronically treated with ACE-I undergoing off pump coronary artery bypass graft surgery (OPCAB). METHODS: Sixty patients scheduled for OPCAB were included in this study. Patients not treated with ACE-I were included in control group (Group 1, n = 20). And then, patients treated with ACE-I more than 4 weeks were randomly divided into two groups: continuing group including patients who continued ACE-I medication until the morning of surgery (Group 2, n = 20) and discontinuing group including patients who discontinued ACE-I one day before the surgery (Group 3, n = 20). Norepinephrine (8microgram/ml) was infused when systolic blood pressure decreased below 90 mmHg during induction and operation. Amount of norepinephrine infused and hemodynamic data were recorded. RESULTS: Significantly larger amount of norepinephrine was infused in Group 2 than in other two groups during obtuse marginal artery anastomosis. Total amount of norepinephrine infused during the all coronary anatsomosis was significantly larger in Group 2 than those values in other two groups. CONCLUSIONS: Continuing ACE-I treatment until the morning of surgery significantly increased the use of norepinephrine during the anastomosis. In contrast, there was no significant difference in the use of norepinephrine between Group 1 and Group 3. Discontinuing ACE-I before the surgery may helpful to maintain hemodynamics stable during coronary anastomosis in OPCAB.

Estrogen receptor independent neurotoxic mechanism of bisphenol A, an environmental estrogen

Bisphenol A (BPA), a ubiquitous environmental contaminant, has been shown to cause developmental toxicity and carcinogenic effects. BPA may have physiological activity through estrogen receptor (ER) -alpha and -beta, which are expressed in the central nervous system. We previously found that exposure of BPA to immature mice resulted in behavioral alternation, suggesting that overexposure of BPA could be neurotoxic. In this study, we further investigated the molecular neurotoxic mechanisms of BPA. BPA increased vulnerability (decrease of cell viability and differentiation, and increase of apoptotic cell death) of undifferentiated PC12 cells and cortical neuronal cells isolated from gestation 18 day rat embryos in a concentration-dependent manner (more than 50 micrometer). The ER antagonists, ICI 182,780, and tamoxifen, did not block these effects. The cell vulnerability against BPA was not significantly different in the PC12 cells overexpressing ER-alpha and ER-beta compared with PC12 cells expressing vector alone. In addition, there was no difference observed between BPA and 17-beta estradiol, a well-known agonist of ER receptor in the induction of neurotoxic responses. Further study of the mechanism showed that BPA significantly activated extracellular signal-regulated kinase (ERK) but inhibited anti-apoptotic nuclear factor kappa B (NF-kappaB) activation. In addition, ERK-specific inhibitor, PD 98,059, reversed BPA-induced cell death and restored NF-kappaB activity. This study demonstrated that exposure to BPA can cause neuronal cell death which may eventually be related with behavioral alternation in vivo. However, this neurotoxic effect may not be directly mediated through an ER receptor, as an ERK/NF-kappaB pathway may be more closely involved in BPA-induced neuronal toxicity.

Spontaneous Intracranial Hypotension Treated with CT-guided Cervical Epidural Blood Patch : A case report / 대한마취과학회지

Spontaneous intracranial hypotension due to spinal cerebrospinal fluid leakage is uncommon, relatively benign and usually self-limiting. However it is being increasingly recognized as a cause of postural headaches. The treatment options range from conservative supportive measures to an pidural blood patch. We report a 40-year-old woman who developed intracranial hypotention without any preceding events such as lumbar puncture, back trauma, surgical procedures or medical illnesses. The site of the cerebrospinal fluid leakage was identified at between the C1 to C2 level using computerized tomographic myelography. Consequently, the patient underwent a CT-guided autologous epidural blood patch at the C3-C4 level. Her symptoms were relieved immediately without recurrence.

Tearing of the Mitral Valve during Vent Removal after a Successful Mitral Valve Repair: a Beneficial Role of Transesophageal Echocardiography

In this case, a successful mitral valve repair was confirmed by transesophageal echocardiography (TEE) at the end of a cardiopulmonary bypass. The left ventricular vent was placed through the mitral valve to remove the air after the TEE examination, and on its way out, the left ventricular vent damaged the anterior mitral leaflet (AML). Re-examination of the valve with TEE detected the new mitral valve insufficiency. The CPB was reinstituted, and tearing of the lateral third part of the anterior mitral leaflet was found. This case emphasizes the importance of TEE in the operating room as a continuous monitor, not only to evaluate the result of the cardiac surgery, but also to detect any unpredictable events during the surgery.

Comparison of Clinical Characteristics in Controlled Ventilation and Spontaneous Breathing during Vital Capacity Inhalation Induction with Sevoflurane / 대한마취과학회지

BACKGROUND: Although controlled ventilation can shorten the induction time during vital capacity inhalation induction (VCII) with sevoflurane, it may associated with decrease in blood pressure and hyperventilation-related hyperdynamic responses such as hypertension and tachycardia. This study was designed to compare the clinical effects between controlled ventilation (CV) within acceptable ranges of PETCO2 and spontaneous breathing (SB) during VCII. METHODS: 100 patients were randomly allocated to the one of two groups. After the loss of consciousness during VCII with sevoflurane, controlled ventilation was applied in CV group within acceptable ranges of PETCO2 and spontaneous breathing was maintained in SB group. Alfentanil 4 mcg/kg was given i.v. 2 minutes prior to intubation. PETCO2, mean arterial pressure (MAP), heart rate (HR), SPO2, and BIS were measured at 1, 2 and 3 minute after the loss of consciousness (LOC). Clinical side effects were evaluated. RESULTS: MAP and HR were significantly decreased and increased in CV group compare to the baseline values at 1 minute after LOC. There were statistical differences of MAP and HR between two groups at 1 and 2 minutes after LOC. 46 of 50 (92%) showed delayed expiration with holding their breath > 20 s in SB group. No differences of other clinical side effects except hypotension between two groups. CONCLUSIONS: We conclude that spontaneous breathing provides a stable hemodynamic status and relatively acceptable ventilation profile compare to controlled ventilation during VCII.