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.

Intraarterial mechanical thrombectomy for the treatment of postoperative cerebral infarction: a case report / 대한마취과학회지

Perioperative ischemic stroke is an uncommon event associated with significant morbidity and mortality. The complexity of the surgical procedure and surgery induced hypercoagulable status also influence the incidence of stroke. The management of stroke involves a decision regarding the quickest suitable revascularization method. Endovascular mechanical thrombectomy, such as intra-arterial mechanical thrombectomy (IAMT), can restore vascular patency of the vessels, providing an alternative or synergistic method to restore blood flow. Although, there are no recommended treatment guidelines, IAMT is eligible to be a treatment of choice for perioperative ischemic stroke. We experienced a case of a patient who demonstrated hemiplegia and aphasia, the early symptom of acute ischemic stroke, in the post-anesthesia care unit and performed IAMT successfully. Thus we report the case with a review of the relevant literature.

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.

Remifentanil-induced pronociceptive effect and its prevention with pregabalin / 대한마취과학회지

BACKGROUND: Experimental and clinical studies have suggested that remifentanil probably causes acute tolerance or postinfusion hyperalgesia. This study was designed to confirm whether remifentanil given during propofol anesthesia induced postoperative pain sensitization, and we wanted to investigate whether pregabalin could prevent this pronociceptive effect. METHODS: Sixty patients who were scheduled for total abdominal hysterectomy were randomly allocated to receive (1) a placebo as premedication and an intraoperative saline infusion (control group), (2) a placebo as premedication and an intraoperative infusion of remifentanil at a rate of 3-4 ng/ml (remifentanil group), or (3) pregabalin 150 mg as premedication and an intraoperative infusion of remifentanil at a rate of 3-4 ng/ml (pregabalin-remifentanil group). Postoperative pain was controlled by titration of fentanyl in the postanesthetic care unit (PACU), followed by patient-controlled analgesia (PCA) with fentanyl. The patients were evaluated using the visual analogue scale (VAS) for pain scores at rest and after cough, consumption of fentanyl, sedation score and any side effects that were noted over the 48 h postoperative period. RESULTS: The fentanyl titration dose given in the PACU was significantly larger in the remifentanil group as compared with those of the other two groups. At rest, the VAS pain score in the remifentanil group at 2 h after arrival in the PACU was significantly higher than those in the other two groups. CONCLUSIONS: The results of this study show that remifentanil added to propofol anesthesia causes pain sensitization in the immediate postoperative period. Pretreatment with pregabalin prevents this pronociceptive effect and so this may be useful for the management of acute postoperative pain when remifentanil and propofol are used as anesthetics.

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.

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.

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 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.

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.

A Comparison of Remifentanil versus Fentanyl as an Adjuvant to Propofol Anesthesia for Ureteroscopic Lithotripsy / 대한마취과학회지

BACKGROUND: Remifentanil is a new member of fentanyl family and a short-acting, esterase-metabolized opioid.This study compared the perioperative characteristics of a remifentanil infusion with those of fentanyl bolus administration as an adjuvant to propofol infusion for the anesthetic management of patients undergoing ureteroscopic lithotripsy. METHODS: Eighty patients were randomly assigned to receive either remifentanil target controlled infusion (R group, effect-site concentration of 4.0 ng/ml for induction followed by 2.0 ng/ml) or fentanyl bolus (F group, 2.0microgram/kg before induction).All patients received propofol infusion as the part of the induction and maintenance.We investigated recovery profiles, adverse events and the ease of insertion of laryngeal mask airway (LMA) between the two groups.Heart rate (HR) and mean blood pressure (MBP) were also compared at baseline (T0), loss of consciousness (T1), insertion of LMA (T2), beginning and end of operation (T3, T4) and removal of LMA (T5). RESULTS: The time from the end of anesthesia to spontaneous respiration, eye opening and LMA removal were significantly shorter for patients receiving remifentanil than for those receiving fentanyl.HR at T3 and T4 were lower in the R group than in the F group.Aldrete recovery score, time to discharge from recovery ward, the ease of insertion of the LMA, MAP and adverse events did not differ significantly between the two groups. CONCLUSIONS: Target controlled infusion of remifentanil combined with propofol can significantly shorten the early recovery time than fentanyl bolus administration without increasing adverse events in patients undergoing ureteroscopic lithotripsy.

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.

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.

The Effect of Fentanyl and Remifentanil on Postoperative Nausea and Vomiting, and Pain after Gynecologic Laparoscopic Ovarian Cyst Enucleation by Balanced Anesthesia with Sevoflurane / 대한마취과학회지

BACKGROUND: Opioids are known to increase the incidence of postoperative nausea and vomiting (PONV). Remifentanil is an ultrashort-acting opioid with a potent analgesic effect and is useful for rapid emergence. This study compared the effect of remifentanil on the incidence and severity of PONV and postoperative pain with that of fentanyl in patients undergoing laparoscopic surgery, which is normally associated with a high incidence of PONV. METHODS: Forty-four adult female patients, who were scheduled for laparoscopic ovarian cyst enucleation, were randomly assigned to either the remifentanil or fentanyl group. Anesthesia was induced with propofol after injecting fentanyl 2 microgram/kg or remifentnail 1 microgram/kg and was maintained with sevoflurane. Remifentanil and fentanyl was infused continuously in the range of 0.2-0.5 microgram/kg/min and 0.03-0.05 microgram/kg/min, respectively. Ketorolac 0.5 mg/kg was injected 30 min before the end of surgery. The incidence and severity of PONV and pain were recorded upon arrival at the recovery room and 2, 6, 12 and 24 hours thereafter. RESULTS: The incidence and severity of PONV and pain were significantly higher in the remifentanil group upon arrival at the recovery room than in the fentanyl group. The incidence and severity of PONV and pain at the other measurement times were similar. CONCLUSIONS: Despite the ultrashort action duration of the remifentanil, the incidence and severity of PONV and postoperative pain immediately after awakening was higher in the remifentanil group undergoing laparoscopic ovarian cyst enucleation than in the fentanyl group. However, there were no significant differences after two hours in the recovery phase.

Spinal Anesthesia of a Patient with Brugada Syndrome: A case report / 대한마취과학회지

Brugada syndrome is an arrhythmic syndrome characterized by right bundle branch block, ST segment elevation in the precordial lead (V1-3), and sudden death caused by ventricular fibrillation, but with no evidence of an underlying structural heart disease. We report one case of spinal anesthesia for an appendectomy in a 44-year-old male patient diagnosed as having Brugada syndrome by characteristic ECG findings without untoward cardiovascular events.

Transilluminated Powered Phlebectomy under Local Anesthesia

PURPOSE: Transilluminated powered phlebectomy (TIPP) has emerged as a very attractive surgical procedure for varicose vein because of it's many advantages. However, it also has some problems such as hematoma, and skin perforation, and needs general or spinal anesthesia and hospitalization. To overcome these shortcomings, we performed TIPP under only local anesthesia using the tumescent method. METHOD: Eleven (12 limbs) patients were operated and we prospectively estimated the operative complication, pain, duration of hospital stay, side effects and amounts of lidocaine. Lidocaine was infiltrated for groin dissection, and tumescent anesthesia was used on the calf area for TIPP. Great saphenous veins were stripped in 9 limbs, and closed suction drains were inserted in the calf area in 11 limbs. We calculated the amounts of lidocaine, according to the unit area of TIPP, body weight, and body surface area. RESULT: The mean age of the 11 patients was 55.4+/-10.7 years, and 3 patients (27.3%) had risk factors for general anesthesia. Mean operation time was 54.9+/-9.2 minutes, the number of incisions including groin was 4.7+/-0.6, and the area of TIPP was 272.6+/-85.3 cm2. The total lidocaine used was 495.4+/-167.5 mg (1.45 mg/cm2, 8.3 mg/kg, 302.1 mg/BSA m2). Except 2 patients (16.6%) who complained of mild pain and 2 of hematoma (16.6%), there were no side effects of lidocaine or operative complication. Mean hospital stay was 5.8+/-1.4 hours. CONCLUSION: TIPP under local anesthesia might be a relative safe method, and it could reduce the risks and complications of general or spinal anesthesia, hospital stay, and hesitancy to operation.

Massive Subcutaneous Emphysema and Hypercarbia during Endoscopic Thyroidectomy: A case report / 대한마취과학회지

Endoscopic thyroidectomy is being performed increasingly, because it is less invasive and more cosmetically advantageous, and thus improves the postoperative quality of life. However, the technical aspects of this procedure can increase the risk of certain complications, which include subcutaneous emphysema, hypercarbia, pneumothorax, and pneumomediastinum. This report describes the case of a 37-year-old female patient who had subcutaneous emphysema and hypercarbia due to increased carbon dioxide absorption during endoscopic thyroidectomy. After increasing minute ventilation, paying cautious attention to signs of other complications, the operation proceeded and blood gas findings improved. The operation ended successfully and she showed no further problems.