[Effectiveness of Sacral Intervertebral Epidural Block for Umbilical Hernia Repair in Children].

BACKGROUND: Effectiveness of sacral intervertebral epidural block (S 2-3 block) for umbilical hernia repair has not been clarified. METHOD: We investigate 24 children, undergoing umbilical hernia repair; mean age of 3 years (age range: 20-65 months). Under general anesthesia, epidural block was performed at S 2-3 interspace with 1 ml x kg(-1) ropivacaine (0.2%) at injecting rate of 1 ml x sec(-1) followed by 0.25 ml x kg(-1) normal saline. RESULTS: In all cases, neither systolic blood pressure nor heart rate increased > 15% from those just before the block. Postoperative analgesics were given in 6 patients (25%) rectally. Mean time between the block and the administration of analgesic was 10.5 hours. CONCLUSIONS: S 2-3 block can be effective for postoperative pain in umbilical hernia repair.

[The use of dexmedetomidine and Airwayscope in airway management of a child with Cornelia de Lange syndrome].

We report anesthetic management of a 22-month-old child with Cornelia de Lange syndrome scheduled for palatoplasty because of cleft palate. Micrognathia and short neck of the patient suggested difficult airway management. For anesthetic induction, 1 microg x kg(-1) dexmedetomidine was loaded intravenously, followed by infusion at a rate of 0.7 microg x kg(-1) x hr(-1) with incremental inhalation of sevoflurane. During the induction, spontaneous breathing was maintained. By laryngoscopy with Machintosh blade after intravenous propofol for the purpose of laryngeal reflex inhibition, only the tip of epiglottis was seen. Then, after another intravenous propofol, laryngoscopy was performed with Airwayscope, which enabled operators to see the glottis. Then, a RAE endotracheal tube (ID 4.5 mm) was inserted. During the Airwayscope operation, pharyngeal reflex, laryngeal reflex and saliva increase were inhibited resulting in good view of the larynx and the lowest Spo2 was 94% temporarily. After intubation, anesthesia was maintained with sevoflurane, remifentanil and fentanyl. Dexmedetomidine infusion was also useful to maintain adequate spontaneous breathing and to achieve awaking before extubation.

[Assessment of intraoperative hemodynamics, infusion volume, urinary output and dose of circulatory drugs in general anesthesia with transversus abdominis plane block for cholecystectomy].

We retrospectively reviewed intraoperative hemodynamics, infusion volume, urinary output and dose of circulatory drugs in patients undergoing cholecystectomy in 3 types of anesthesia group: General anesthesia (GA group), general anesthesia with epidural anesthesia (EPI group) and general anesthesia with transversus abdominis plane (TAP) block (TAPB group). TAP block was performed using ultrasound-guided subcostal method and 20-30 ml of ropivacaine (0.2-0.3%) was injected to TAP bilaterally. Though, the blood pressure in TAPB group was lower than that in GA group, the degree of low blood pressure was smaller than that in EPI group. Less changes in intraoperative blood pressure, infusion volume and dose of phenylephrine in TAPB group compared to those in EPI group can be the advantage of TAP block alternative to epidural anesthesia.

[Anesthetic management of an emergency open-heart surgery for entrapment of a circular mapping catheter by chordae tendineae with mitral valve damage undergoing atrial fibrillation ablation].

The entrapment of a circular mapping catheter by chordae tendineae during catheter ablation is a very rare but serious complication requiring, in some cases, surgical treatment. We report a case that required open heart surgery for catheter removal and mitral valve repair. A 79-year-old man underwent catheter ablation for paroxysmal atrial fibrillation in other hospital. During the operation, he moved accidentally, despite circular mapping catheter was in the left atrium. The circular mapping catheter was uncontrolable due to resistance interfering with catheter removal, and the patient was brought to our hospital for open heart surgery to remove catheter. General anesthesia was induced and maintained with midazolam, fentanyl. Transesophageal echocardiography was performed to monitor catheter position and mitral valve condition. Transesophageal echocardiography revealed that circular catheter tip was located adjacent to the posterior mitral leaflet and the presence of moderate mitral valve regurgitation. Circular catheter tip was entraped by chordae tendineae and caused posterior mitral leaflet damage. Intracardiac foreign body removal and posterior mitral leaflet repair were completed uneventfully under cardiopulmonary bypass. The postoperative course was uneventful. It is expected that catheter ablation for atrial fibrillation will increase in number. This rare complication of catheter ablation may become a threat to cardiologist, cardiac surgeon and anesthesiologist.

[Anesthetic management for laparoscopic adrenalectomy in a pregnant patient with Cushing's syndrome].

Cushing's syndrome is extremely rare during pregnancy, because it often causes amenorrhea and infertility. We experienced a case of Cushing's syndrome in the 23rd week of pregnancy receiving laparoscopic surgery. It was difficult to control the blood pressure and heart rate, but we succeeded in the safe management of both mother and fetus.

[Anesthetic hazards in an undiagnosed case of retroperitoneal paraganglioma].

We report a patient with undiagnosed retroperitoneal paraganglioma who developed an intraoperative hypertensive crisis. A 64-year-old female was scheduled for right partial mastectomy and removal of an abdominal mass, preoperatively diagnosed as a small intestine GIST. Surgery was performed under general anesthesia combined with epidural anesthesia with close monitoring. Immediately after the surgical manipulation of the abdominal mass, her systolic blood pressure rose to over 200 mmHg. This hypertensive crisis was managed with nicardipine and alprostadil combined with increased infusion rate of remifentanil and propofol. Thereafter, the patient was hemodynamically stable and the postoperative course was uneventful. Pathological examination identified the tumor as extraadrenal paraganglioma. The possibility of paraganglioma should be considered even in asymptomatic abdominal mass, and adequate precautions are required in such cases.

[Low doses of ketamine have no effect on bispectral index during stable propofol-remifentanil anesthesia].

BACKGROUND: Ketamine is associated with an increase in the bispectral index (BIS) values that can lead to an overdose of hypnotic agents. We investigated the effect of ketamine on BIS values during general anesthesia with a target-controlled infusion (TCI) of propofol and infusion of remifentanil. METHODS: Forty-five ASA I or II patients undergoing gynecological surgery were included in this study. After 5 min of steady-state anesthesia (BIS at 35-45) without surgical stimulation, patients received either a bolus administration of ketamine 0.2 mg x kg(-1) (LK group) or ketamine 0.5 mg x kg(-1) (HK group). Patients in the control group received no intervention. BIS values were recorded every minute until 15 min after ketamine administration. RESULTS: After ketamine administration, BIS value in HK group increased significantly compared with that at baseline. There were no significant changes for BIS values in LK group and control group over time. BIS values in HK group were significantly higher than those in the LK group and control group after ketamine injection. BIS values were not statistically different between LK group and control group. CONCLUSIONS: Under stable propofol and remifentanil anesthesia, a small dose of ketamine did not increase the BIS value over the next 15 min.

[Esophageal injury after insertion of a transesophageal echocardiography probe in a patient with an aberrant right subclavian artery].

We describe a case of an esophageal injury caused by insertion of a transesophageal cardiac echo probe in a 66-year-old man with an aberrant right subclavian artery, who was scheduled for Bentall surgery for aortic regurgitation and annuloaortic ectasia. Preoperative CT scan showed an aberrant right subclavian artery compressed from the back of the esophagus. General anesthesia was induced with midazolam and fentanyl, and maintained with midazolam, remifentanil and fentanyl. After induction of anesthesia, a transesophageal cardiac echo probe was inserted without abnormal resistance. The operation was performed uneventfully. On the second day after surgery, gastrointestinal bleeding was suspected and the upper gastrointestinal endoscopy (GIF) was performed. GIF revealed ulceration at the mid-esophagus and gastroesophageal junction, and a large amount of fresh blood in the stomach. The location of the ulcer at mid-esophagus was likely to be over the aberrant right subclavian artery. Ulcers were treated conservatively. GIF on the postoperative day 16 revealed that ulcers had healed. Transesophageal echo probe insertion is potentially hazardous in a patient with an aberrant right subclavian artery. Although aberrant right subclavian artery is rare, transesophageal echocardiography should be performed with extreme caution.

[Use of temporary aortic balloon occlusion of the abdominal aorta was useful during cesarean hysterectomy for placenta accreta].

We describe the use of an abdominal aortic occlusion balloon catheter to control excessive blood loss at cesarean hysterectomy for placenta accreta. Prophylactic abdominal aortic occlusion balloon catheter was placed in the angiography suite under local anesthesia before surgery. The 38-year-old parturient was anesthetized with propofol, sevoflurane, ketamine, remifentanil and fentanyl under close monitoring and appropriate respiratory management. The occlusion balloon was inflated after the infant had been delivered, and bleeding at the placenta required cesarean hysterectomy. There was a sudden and dramatic reduction in blood loss, and hysterectomy was performed uneventfully. An aortic occlusion was sustained for 25 min. Intraoperative blood loss was 1,800 g, and 300 g of autologous blood and 4 units of red cell concentrates were transfused. The postoperative course was uneventful. The present case suggests that prophylactic insertion of an aortic occlusion balloon catheter seems to be a safe and an effective method in controlling anticipated bleeding for caesarean hysterectomy in a parturient with placenta accreta.

[Endotracheal tube selection in children: which is the better predictor for the selection, tracheal internal diameter in X-ray photograph or age-based formula?].

BACKGROUND: Age-based formula has been widely used to predict the appropriate size of the endotracheal tube in children. Tracheal internal diameter in X-ray photograph is reported to show higher correlation with a correct tube than age. In our institution, X-ray photographs were stored as digital images, enabling us to measure tracheal internal diameters more accurately than conventional X-ray films. Therefore, we investigated whether tracheal size in digital X-ray photograph is a better predictor for the tube selection than age. METHODS: We reviewed data from children aged 1 to 8 years for the past 5 years. The data included age, tracheal internal diameter at 6th cervical (C6), 2nd thoracic vertebrae (T2) in X-ray photograph and selected tube size. The tube size was estimated by the age-based formula or on the basis of tracheal size. RESULTS: The endotracheal tube size correlated significantly with the age, and tracheal internal diameter at C6 or T2 in X-ray photograph (correlation coefficients P=0.898, 0.653, and 0.771 respectively; P<0.0001). The tube size predicted by the age allowed appropriate intubation in 62.2%, but that by the tracheal size at C6 and T2 in 42.8% and 43.7% respectively. CONCLUSIONS: The age-based formula is more reliable and appropriate to decide the size of endotracheal tube for children than the tracheal size.

[Prevention of postoperative nausea and vomiting by metoclopramide combined with dexamethasone in gynecological surgery].

BACKGROUND: The authors evaluated the efficacy of a combination of dexamethasone and metoclopramide for the prophylaxis of postoperative nausea and vomiting (PONV) after gynecological abdominal surgery. METHODS: One-hundred and seventeen patients scheduled for gynecological abdominal surgery were analyzed retrospectively. Patients were classified into three groups by anti-emetics administered; none (Group C, n = 38); metoclopramide 10 mg (Group M, n = 39); or a combination of metoclopramide 10 mg with dexamethasone 8 mg (Group MD, n = 40) at 30 to 60 minutes prior to the end of surgery. Anesthesia was induced by propofol and maintained with isoflurane-nitrous oxide inhalation and intermittent administration of fentanyl. Postoperative pain was treated with continuous subcutaneous infusion of pentazocine via a patient controlled analgesia device. PONV was assessed using a 5 rating verbal score in early (0-6 hr) and in late (6-24 hr) period. RESULTS: The 3 groups were similar in demographic characteristics. The incidence of nausea and vomiting in early period was significantly lower in Group MD compared with Group C and Group M. Rescue anti-emetic requirements were fewer in Group MD compared with Group C. There are no severe complications. CONCLUSIONS: A combination of metoclopramide and dexamethasone was more effective in preventing PONV compared with metoclopramide alone.

[Postoperative nausea and vomiting after laparoscopic cholecystectomy under total intravenous anesthesia using propofol combined with fentanyl or pentazocine].

BACKGROUND: The aim of this study was to compare the incidence of postoperative nausea and vomiting (PONV) in propofol-anesthetized patients receiving either fentanyl or pentazocine as opioid supplement. METHODS: Sixty-seven patients scheduled for laparoscopic cholecystectomy were analyzed retrospectively. Patients were classified into two groups according to opioid supplement under propofol-anesthesia; pentazocine group (n = 26) and fentanyl group (n = 41). Anesthesia was induced with propofol using target controlled infusion method, and was maintained with propofol infusion with pentazocine or fentanyl and intermittent administration of vecuronium with 40% oxygen in air. RESULTS: The incidence of PONV was 23.1% in fentanyl group and 22.0% in pentazocine group, respectively. The incidence of PONV was not different between the groups. There were no severe complications. CONCLUSIONS: The incidence of PONV in propofol-anesthetized patients receiving pentazocine as opioid supplement is not different from that in patients receiving fentanyl.

[Anesthetic managements for emergency cesarean section and craniotomy in patients with intracranial hemorrhage due to ruptured cerebral aneurysm and arteriovenous malformation].

We report two cases of anesthetic management for emergency cesarean sections and craniotomies in patients with intracranial hemorrhage. Case 1: A 32-year-old woman at 33 weeks gestation suffered from subarchnoid hemorrhage due to the rupture of cerebral aneurysm. Case 2: A 38-week-pregnant woman aged 32 developed intracerebral hematoma resulting from ruptured arteriovenous malformation. The weights of the fetuses were estimated to be 1756 g and 1996 g respectively, and they were expected premature. Discussions with obstetricians, neurosurgeons and neonatologists encouraged us to schedule cesarean section followed by craniotomy under general anesthesia. Before deliveries we selected isoflurane and avoided excessive hyperventilation to maintain uteroplacental circulation. After deliveries, isoflurane was changed to propofol and prostaglandin E1 was infused to control blood pressure and to avoid uterine atonic bleeding. Uneventful anesthetic course resulted in both the mothers and the fetuses surviving. It is important to develop good relationships among the specialists for the management of pregnant woman with intracranial hemorrhage.

[Dose requirements of pentazocine during abdominal surgery in total intravenous anesthesia using propofol].

BACKGROUND: To determine the dose requirements of pentazocine when administered as a single bolus dose in total intravenous anesthesia with propofol for abdominal surgery. METHODS: One hundred and fifty-six patients scheduled for abdominal surgery were analyzed retrospectively. Patients were classified into three groups according to duration of the operation ; under 120 min (Group 1, n=87) ; 120-240 min (Group 2, n=56) ; over 240 min (Group 3, n=13). Anesthesia was induced with propofol using target controlled infusion method, and was maintained with propofol infusion, pentazocine as a single dose before incision, and intermittent administration of vecuronium with 40% oxygen in air. RESULTS: Dosage of pentazocine was significantly increased according to length of the operation. The maintenance doses of propofol were not different among the three groups. Awakening time in about 80% of patients in each group was within 15 minutes. There are no severe complications. CONCLUSIONS: Total intravenous anesthesia with propofol and pentazocine is useful to stabilize hemodynamics and to achieve rapid recovery. For the operation within 120 min, 0.7 mg x kg(-1) of pentazocine is necessary whereas 0.8 mg x kg(-1) of pentazocine is needed in the operation of 120-240 min.

[The effects of continuous infusion of landiolol on heart rate changes after neostigmine-atropine administration during recovery from general anesthesia].

BACKGROUND: On reversal of muscle relaxants when neostigmine-atropine mixture is used, heart rate changes occurr. We examined whether landiolol attenuate the initial increases in heart rate after intravenous injections of a neostigmine-atropine mixture. METHODS: Twenty-four patients were assigned to one of two groups (n=12 each): control group and landiolol group. Anesthesia was induced with propofol and was maintained with isoflurane-nitrous oxide-pentazocine. A mixture of neostigmine 2 mg and atropine 1 mg was injected intravenously over 30s in the control group. In the landiolol group, 0.125 mg x kg)-1) x min(-1) of landiolol for 1 minute was administered immediately after neostigmine-atropine injection. Blood pressure and heart rate were measured noninvasively. RESULTS: Heart rate was significantly increased after neostigmine-atropine administration compared with that at pre-administration in both groups. At 2 and 3 minutes after neostigmine-atropine administration, heart rate in the landiolol group was significantly lower than that in the control group. The maximum increase in heart rate after the neostigmine-atropine injections was significantly less in the landiolol group than that in the control group. Blood pressure showed no significant changes in both groups during the observation period. CONCLUSIONS: Landiolol was useful for heart rate control after neostigmine-atropine administration during recovery from general anesthesia.

[Comparison of pentazocine and fentanyl in total intravenous anesthesia using propofol].

BACKGROUND: Pentazocine may be an alternative for fentanyl during total intravenous anesthesia (TIVA) using propofol. The authors compared the efficacy and safety of pentazocine for analgesics in TIVA using propofol. METHODS: Eighty-nine patients scheduled for mastectomy were analyzed retrospectively. Patients were classified into two groups by used analgesics; pentazocine (Group P, n = 34) and fentanyl (Group F, n = 55). Anesthesia was induced with propofol, using target controlled infusion method, and ketamine 20-50 mg, and was maintained with propofol infusion and increments of fentanyl or single dose of pentazocine with 40% oxygen in air. Postoperative pain was assessed using a visual analogue pain scale (VAS). RESULTS: There were no differences in the patient background between both groups. Systolic as well as diastolic blood pressure and heart rate were not different between both groups during surgery. The maintenance dose of propofol was not different between the two groups. Awakening time in about 80% of patients was within 15 minutes and is not different between the two groups. There were no differences between the two groups regarding VAS. There are no severe complications. Incidence of nausea and vomiting was not different between the two groups. CONCLUSIONS: The results suggest that pentazocine would provide a stable hemodynamic state, rapid recovery and an effective postoperative pain relief to the same degree as with fentanyl in TIVA with propofol.

[Efficacy of subcutaneous patient-controlled analgesia using pentazocine for major abdominal surgery in elderly patients].

BACKGROUND: Subcutaneous patient-controlled analgesia (PCA) may be an alternative method for pain control in patients without an epidural catheter. The authors evaluated the efficacy and safety of subcutaneous PCA using pentazocine for postoperative analgesia after major abdominal surgery. METHODS: Sixty-three patients scheduled for major abdominal surgery were analyzed retrospectively. Patients were classified into three groups by age; under 65 years of age (Group 1, n = 23) ; 65-75 years (Group 2, n = 30); over 75 years (Group 3, n = 10). Anesthesia was induced with propofol and was maintained with isoflurane-nitrous oxide inhalation. All patients received 30-45 mg of pentazocine before incision. At the end of surgery, subcutaneous pentazocine PCA was begun at a rate of 0.5 ml x hr(-1). Given regimen was pentazocine 240-390 mg and droperidol 5 mg with 1% lidocaine, and the total amount of dose was 40 ml. Postoperative pain control was assessed using a 5 rating verbal pain score (VPS) and a visual analog pain scale (VAS). RESULTS: Subcutaneous PCA of pentazocine provided adequate analgesia over 70% of the patients studied. There were no differences between the three groups regarding VPS and VAS. There are no severe complications. CONCLUSIONS: Subcutaneous PCA of pentazocine is a simple, safe, and effective method to control postoperative pain after major abdominal surgery. Effectiveness of subcutaneous PCA of pentazocine did not depend on age of patients.

[Effect of esmolol on cardiovascular responses induced by scopolamine butylbromide].

BACKGROUND: Scopolamine butylbromide (hyoscine-N-butylbromide, HB) is an anticholinergic drug used as a smooth muscle relaxant, and is used even in some surgical procedures during general anesthesia. HB also causes an increase in heart rate as a side effect. The authors evaluated the efficacy of esmolol on hemodynamic changes induced by HB in major abdominal surgery under inhalation anesthesia. METHODS: Seventeen patients for major abdominal surgery were randomly assigned to control group (C group, n = 9) or to esmolol group (E group, n = 8). Anesthesia was induced with propofol and was maintained with isoflurane-nitrous oxide inhalation and intermittent administration of fentanyl and vecuronium. At the time of bowel anastomosis, 20 mg of HB was administrated as an antispasmodic. In E group, esmolol 0.6 mg x kg(-1) was administered immediately after HB administration. RESULTS: There were no differences in the patient background between the two groups. At 1 to 10 minutes after HB administration, heart rate increased significantly compared with that at pre-administration in C group, while there was no significant change in heart rate in E group. Heart rate in E group was significantly lower than that in C group at 2 and 3 minutes after HB administration. Blood pressure was not significantly changed in both groups during the observation period. CONCLUSIONS: The simultaneous administration of HB and esmolol was useful for heart rate control after HB administration.

[Efficacy of continuous subcutaneous pentazocine infusion for the postoperative analgesia in lower abdominal surgery].

BACKGROUND: Continuous subcutaneous infusion (CSI) of analgesics may be an alternative for pain control in patients without an epidural catheter. The aim of this study was to investigate the efficacy of CSI using pentazocine in lower abdominal surgery with inhalation anesthesia or with total intravenous anesthesia. METHODS: One hundred forty-seven patients scheduled for gynecological abdominal surgery were analyzed retrospectively. Anesthesia was induced with propofol and was maintained with propofol infusion or isoflurane-nitrous oxide inhalation. All patients received 30-75 mg of pentazocine before incision. At the end of surgery, CSI of pentazocine was begun at a rate of 0.5 ml x hr(-1) x Given regimen was pentazocine 240-390 mg and droperidol 5 mg with 1% lidocaine, and the total amount of dose was 40 ml. RESULTS: Over 80% of patients were assessed to have effective pain relief and minimum side effects. Patients were classified into two groups by anesthetics during anesthesia; propofol, pentazocine, ketamine group (PPK group, n = 61); nitrous oxide, isoflurane, pentazocine group (GOI group, n=88). There were no differences between the two groups regarding postoperative pain relief, while total dose of pentazocine used during anesthesia were lower in GOI group than PPK group. CONCLUSIONS: In patients undergoing lower abdominal surgery, CSI of pentazocine provided effective postoperative pain relief and effectiveness did not depend on anesthetics during anesthesia.

[Anesthetic management by total intravenous anesthesia with propofol, pentazocine and ketamine].

BACKGROUND: The authors evaluated the efficacy of anesthetic management by total intravenous anesthesia with propofol, pentazocine and ketamine. METHODS: Thirty-five patients for mastectomy were anesthetized by propofol, pentazocine and ketamine. Patients were divided into two groups by age; one is patients under 61 years of age and the others are patients above 61 years. Analysis was made retrospectively. Anesthesia was induced with propofol and ketamine and was maintained with propofol infusion and intermittent administration of vecuronium with 40% oxygen in air. Pentazocine was administrated as a bolus dose before incision. RESULTS: There were no differences in the patient background except age and height between the two groups. After induction of anesthesia, systolic and diastolic blood pressures decreased compared with those before induction in both groups. Systolic and diastolic blood pressures and heart rate increased after tracheal intubation, but the hemodynamics remained stable after the start of surgery. The induction and maintenance doses of propofol were not different between the two groups. Patients above 61 years had smaller dosage of pentazocine compared with those in patients under 61 years. The dosage of ketamine was not different between two groups. Awakening time in about 80% of patients was within 15 minutes and is not different between the two groups. Postoperative pain relief was good in both groups. Incidence of nausea and vomiting was 25% and was not the different between the two groups. CONCLUSIONS: Total intravenous anesthesia with propofol, pentazocine and ketamine would be useful to stabilize hemodynamic state, to obtain rapid recovery and to provide effective postoperative pain relief.