Smooth Emergence from General Anesthesia after Deep Extubation in a Pediatric Patient Diagnosed with Catecholaminergic Polymorphic Ventricular Tachycardia: A Case Report.

Background: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare genetic disorder where catecholamine causes bidirectional ventricular tachycardia, potentially leading to cardiac arrest. In patients undergoing surgery, sympathetic responses can be triggered in situations associated with surgical stimulations as well as high anxiety before the surgery, anesthetic maneuvers such as endotracheal intubation and extubation, and postoperative pain. Therefore, planning for surgery demands meticulous attention to anesthesia during the perioperative period in order to prevent potentially life-threatening arrhythmias. Case: We discuss a case of an 11-year-old male pediatric patient with known CPVT who required elective strabismus surgery for exotropia involving both eyes. After thorough planning of general anesthesia to minimize catecholamine response, sufficient anesthesia and analgesia were achieved to blunt the stressful response during intubation and maintained throughout the surgical procedure. Complete emergence was achieved after deep extubation, and the patient did not complain of pain or postoperative nausea and vomiting. Conclusions: Anesthesiologists should not only be able to plan and manage the catecholamine response during surgery but also anticipate and be prepared for situations that may lead to arrhythmias before and after the procedure. In certain cases, deep extubation can be beneficial as it reduces hemodynamic changes during the extubation process.

Unexpected Tension Pneumothorax Developed during Anesthetic Induction Aggravated by Positive Pressure Ventilation: A Case Report.

Background and Objectives: Tension pneumothorax is a life-threatening emergency condition that requires immediate diagnosis and intervention. However, due to the non-specific symptoms and the rarity of its occurrence during surgery, anesthesiologists encounter difficulties in promptly diagnosing tension pneumothorax when it arises intraoperatively. Diagnosing tension pneumothorax can become even more challenging in unexpected situations in patients with normal preoperative evaluation for general anesthesia. Materials and Methods, Results: We report the case of a 66-year-old woman who underwent general anesthesia for oblique lateral interbody fusion surgery of her lumbar spine. Though she did not have any respiratory symptoms prior to the induction of anesthesia, auscultation following endotracheal intubation indicated decreased breathing sound in the left hemithorax of the chest. Subsequently, her vital signs showed tachycardia, hypotension, and hypoxemia, and the ventilator indicated a gradual increase in the airway pressure. We verified the proper depth of the endotracheal tube to exclude one-lung ventilation, and, in the meantime, learned that there had been unsuccessful attempts at left subclavian venous catheterization by the surgical department on the previous day. Tension pneumothorax was diagnosed through portable chest radiography in the operating room, and needle thoracostomy and chest tube insertion were performed immediately, which in turn stabilized her vital signs and airway pressure. The surgery was uneventful, and the chest tube was removed one week later after evaluation by the cardiothoracic department. The patient was discharged from hospital on postoperative day 14 without known complications. Conclusions: Anesthesiologists should be aware of the conditions and risk factors that may cause tension pneumothorax and remain vigilant for signs of its development throughout surgery, even for patients who show normal preoperative assessments. An undetected small pneumothorax without any symptoms can progress to tension pneumothorax through positive pressure ventilation during general anesthesia, posing a life-threatening situation. If a tension pneumothorax is highly suspected through clinical assessments, its prompt differentiation and timely diagnosis are crucial, allowing for rapid intervention to stabilize vital signs.

Asymptomatic Type 2 Perioperative Myocardial Infarction Detected before Anesthetic Induction in a Patient Undergoing Non-Cardiac Surgery-A Case Report.

Background: Perioperative myocardial infarction (PMI) is a life-threatening complication in major non-cardiac surgeries (NCS) and constitutes the most common cause of postoperative morbidity and mortality. A PMI that is associated with prolonged oxygen supply-demand imbalance and its etiology is defined as a type 2 MI. Asymptomatic myocardial ischemia can occur in patients with stable coronary artery disease (CAD), especially those with comorbidities such as diabetes mellitus (DM), hypertension, or, in some cases, without any risk factors. Case: We report a case of asymptomatic PMI in a 76-year-old patient with underlying hypertension and DM without a previous history of CAD. During the induction of anesthesia, abnormal electrocardiography was discovered, and the surgery was postponed after further studies revealed almost completely occluded three-vessel CAD and type 2 PMI. Conclusions: Anesthesiologists should closely monitor and evaluate the associated cardiovascular risk, including cardiac biomarkers of each patient before surgery, to minimize the possibility of PMI.

Management of unanticipated difficult airway in a patient with well-visualized vocal cords using video laryngoscopy - A case report.

BACKGROUND: Difficult airway occurs due to anatomical abnormalities of the airway that can be predicted through airway assessments; however, abnormalities beyond the vocal cord can be clinically asymptomatic and undetected until intubation failure to advance the endotracheal tube. CASE: We present a case of an unanticipated difficult airway in a stuporous 80-year-old female with a recent history of intracerebral hemorrhage and prolonged intubation. She required emergency ventriculo-peritoneal shunt surgery due to the progression of her hydrocephalus. Under anesthesia, facemask ventilation was easy and video laryngoscopy provided a full view of the glottis; however, endotracheal tube (ETT) entry failed. We suspected stenosis beyond the vocal cord, and a smaller diameter ETT was inserted and maintained for airway management during emergency surgery. Postoperative neck computed tomography findings revealed laryngotracheal stenosis (LTS). CONCLUSIONS: Anesthesiologists should be aware that LTS may be asymptomatic and consider difficult airway guidelines in patients with history of prolonged endotracheal intubation.

Educational value of spinal injection therapy videos in Korean YouTube for back pain patients.

BACKGROUND: YouTube, the largest online video platform, has become increasingly popular as a source of health information to patients. The aim of the study was to assess whether Korean patients were well informed about spinal injection from YouTube. METHODS: Search for the keyword "cheog-chu ju-sa" in Korean language was done, and the quality of the 51 videos with the highest number of views was evaluated independently by two pain management doctors. RESULTS: The averages of global quality scores evaluated by the two doctors were 3.0 and 3.5 and modified DISCERN (mDISCERN) scores were 2.8 and 3.0, respectively. The Kappa statistic between the two doctors' scores was 0.285 and 0.417. CONCLUSIONS: The percentage of low-quality videos with a global quality score of 2 or less is 18-36%, which indicated that these videos might provide inaccurate or misleading medical information to the patient. Pain clinic doctors should be wary of medically misleading information available on online platforms, such as YouTube, and strive to create and distribute professional quality educational materials.

Spinal intramedullary cavernous angioma patient in a pain clinic - A case report.

BACKGROUND: Spinal intramedullary cavernous angioma is a rare form of spinal cord tumor that is associated with myelopathy and significant morbidity and surgical treatment is almost always required. CASE: We report a case of spinal intramedullary cavernous angioma in a pain clinic with initial symptoms of unilateral interdigital space sensory change. Morton's neuroma and piriformis syndrome were clinically suspected, however, symptoms acutely aggravated, and paraplegia developed following the patient's COVID-19 vaccination. Vaccine-associated side effects were ruled out and spinal intramedullary cavernous angioma was confirmed through magnetic resonance image. The patient underwent surgery for complete mass excision. CONCLUSIONS: Recent reports of COVID-19 vaccine-associated side effects have raised sensitive concerns to both health care providers and the public, that in some cases when the symptoms coincide with vaccination history, it may delay time-sensitive diagnosis and treatment and spend unnecessary costs.