Non-intubated video-assisted thoracoscopic biopsy surgery of a large anterior mediastinal mass via epidural anesthesia: A case report

Anesthesia for a patient with a large mediastinal mass is a challenge for anesthesiologists, given the risk of airway collapse and hemodynamic compromise. Moreover, there are very few reports on the anesthetic management of non-intubated video-assisted thoracoscopic surgery (VATS). Thus, in the following case report, we provide an account of the successful anesthetic management and excisional biopsy of a large anterior mediastinal mass (measuring 13 × 10 cm) utilizing non-intubated VATS. The patient was kept awake, maintaining consciousness and spontaneous respiration throughout the procedure, in order to prevent devastating airway collapse and pain control and cough prevention were achieved by thoracic epidural analgesia and lidocaine nebulization.

Carbon dioxide pneumothorax occurring during laparoscopy-assisted gastrectomy due to a congenital diaphragmatic defect: a case report / 대한마취과학회지

During laparoscopic surgery, carbon dioxide (CO2) pneumothorax can develop due to a congenital defect in the diaphragm. We present a case of a spontaneous massive left-sided pneumothorax that occurred during laparoscopy-assisted gastrectomy, because of an escape of intraperitoneal CO2 gas, under pressure, into the pleural cavity through a congenital defect in the esophageal hiatus of the left diaphragm. This was confirmed on intraoperative chest radiography and laparoscopic inspection. This CO2 pneumothorax caused tolerable hemodynamic and respiratory consequences, and was rapidly reversible after release of the pneumoperitoneum. Thus, a conservative approach was adopted, and the remainder of the surgery was completed, laparoscopically. Due to the high solubility of CO2 gas and the extra-pulmonary mechanism, CO2 pneumothorax with otherwise hemodynamically stable conditions can be managed by conservative modalities, avoiding unnecessary chest tube insertion or conversion to an open procedure.

The effect of multimodal approach with combination of antiemetics and total intravenous anesthesia on postoperative nausea and vomiting in very high-risk patients

BACKGROUND: Postoperative nausea and vomiting (PONV) is a long standing problem in both surgical patients and anesthesiologists, and the treatment of this problem is very important.The purpose of this study was to evaluate the effect of multimodal approach with combination of antiemetics and total intravenous anesthesia (TIVA) on PONV in very high risk patients identified by the Korean predictive model. METHODS: Between March 2008 and February 2009, we evaluated 96 patients who were considered to be at very high risk of PONV according to the Korean predictive model.Among the patients, those who received antiemetic combination of dexamethasone and ondansetron were allocated to treatment group (T) and, those who underwent operation without antiemetics were placed in control group (C).All patients were anesthetized using propofol and remifentanil.We evaluated the incidences of PONV in two groups during the first 24 hours after surgery. RESULTS: The overall incidence of PONV was 14 (29.17%) in C group and 4 (8.33%) in T group, respectively (P = 0.027). CONCLUSIONS: The overall incidence of PONV in T group was significantly lower than that of C group.This study shows that multimodal approach with combination of antiemetics and TIVA was effective in preventing PONV in patients with very high risk.

Risk Factors for an Intraoperative Arrhythmia during Esophagectomy

PURPOSE: Arrhythmias after an esophagectomy (most commonly atrial fibrillation) are a significant contributing factor to patient morbidity. However, the significance of an intraoperative arrhythmia is not completely understood. The aim of this retrospective study was to determine the occurrence and risk factors for developing intraoperative arrhythmias in patients undergoing an esophagectomy. MATERIALS AND METHODS: We reviewed the records of 427 patients who underwent a transthoracic esophagectomy between 2001 and 2005. Variables such as age, sex, hypertension, diabetes, cardiac disease, preoperative pulmonary function test (PFT) results, cancer level, combined radiochemotherapy, intrathoracic cavity adhesions and anastomosis site, hemoglobin, central venous pressure (CVP), fluid balance, serum potassium level, dose of vasopressors, temperature, and combined general and epidural anesthesia were analyzed as risk factors for the occurrence of an arrhythmia. We defined this arrhythmia as one not originating from the sinus node. RESULTES: The incidence of intraoperative arrhythmia in this subset of patients was 17.1%, with a 37.2% reoccurrence rate during the first three postoperative days. Univariate and multivariate analysis revealed the presence of heart disease, poor PFTs, cervical anastomosis, elevated CVP, and higher ephedrine doses to be independent predictors of the development of an intraoperative arrhythmia. CONCLUSION: The incidence of intraoperative arrhythmia during esophagectomy was 17.1% with a 37.2% of reoccurrence rate.

Effect of Intraoperative 80% Inspired Oxygen on Postoperative Nausea and Vomiting in Patients undergoing Vitreoretinal Surgery / 대한마취과학회지

BACKGROUND: Most recently, the antiemetic effects of high inspired oxygen have been discussed and various results have been reported according to the types of surgeries and the groups of patients. In ophthalmic surgical patients, surgical procedures involving intraoperative manipulation of the eye and giving rise to residual eye discomfort were associated with the increased incidences of postoperative nausea and vomiting (PONV). The antiemetic effect of 80% inspired oxygen for the patients undergoing vitreoretinal surgery is unknown. Therefore, we examined the efficacy of 80% inspired oxygen in the decrease of the PONV incidences after vitreoretinal surgery under general anesthesia. METHODS: 170 adults under 70 years of age have received standardized sevoflurane anesthesia. After tracheal intubation, they were randomly assigned to two groups: 30% inspired oxygen in air (Group 30), and 80% inspired oxygen in air (Group 80). Postoperative nausea and vomiting were evaluated at the 2, 6, and 24 h postoperatively by an investigator unaware of patients' allocation. RESULTS: There was a significantly lower incidence of PONV during the first 2 h postoperatively in the Group 80 (22%) compared with the Group 30 (40%) (P = 0.024). The Group 80 (33.8%) showed the decreased incidence of PONV during the first 24 h postoperatively compared with the Group 30 (48.8%), but these differences were not statistically significant (P = 0.081). CONCLUSIONS: The use of 80% inspired oxygen during vitreoretinal surgery reduced the incidence of PONV during the first 2 h postoperatively.

Effects of Epidural Naloxone on Pruritus Induced by Hydromorphone Epidural Patient-Controlled Analgesia / 대한통증학회지

BACKGROUND: Opioid delivered by epidural patient-controlled analgesia (PCA) is effective in relieving pain after surgery, but it is associated with side effects, such as nausea, vomiting, pruritus, respiratory depression, and urinary retention. The purpose of this study was to compare hydromorphone related side effects and the quality of analgesia when naloxone was added to epidural PCA regimen. METHODS: Fifty-two thoracotomy patients with PCA were allocated blindly into two groups. Patients in group H (n = 26) received continuous epidural hydromorphone (16microgram/ml) in 0.1% bupivacaine; patients in group N (n = 26) received an epidural infusion containing naloxone (2 microgram/ml) and hydromorphone (16microgram/ml) in 0.1% bupivacaine. The basal rate of PCA was 4 ml/hr and the demand dose was 1.5 ml with a lockout time of 15 min. Pain intensity, sedation, pruritus, nausea and vomiting, respiratory depression were checked at 6, 12, 24 hours postoperatively. RESULTS: The Visual Analog Scale (VAS) scores were significantly lower in group H than in group N. There were no significant differences in the overall incidence of pruritus, nausea and sedation between the two groups. CONCLUSIONS: Continuous epidural infusion of naloxone combined with hydromorpho-ne is not effective in reducing the incidence and severity of pruritus induced by epidural hydromorphone.

The Comparison of Transfusion Practice and Prognosis according to Transfusion Guidelines of Packed Red Blood Cells in Off-Pump Coronary Artery Bypass Graft Surgery / 대한마취과학회지

10.0 g/dl in group B (minimum Hb 10.4 g/dl). The rate of bloodless OPCAB increased from 2% to 57%. There was a similar number of blood restorations and wastage, incidence of wound infections, bleeding, arrhythmias, myocardial infarctions, sudden death, length of the ICU stay and postoperative admissions in the two groups. CONCLUSIONS: With the new transfusion guideline, number of P-RBC preparations and transfusions was decreased significantly without an increase in the incidence of complications.

Effects of Isosulfan Blue and Methylene Blue on Oxygen Saturation by Pulse Oximetry in Sentinel Lymph Node Biopsy / 대한마취과학회지

BACKGROUND: In breast cancer, lymphatic mapping with blue dye has been used intraoperatively to identify the sentinel lymph nodes. Several blue dyes are known to cause spurious desaturation when measured by a pulse oximeter. This study examined the differential effects of isosulfan blue (IB) and methylene blue (MB) on the level of oxygen saturation by pulse oximetry according to the sites measured. METHODS: Forty women with breast cancer were divided into two groups according to the dyes used. The level of oxygen saturation by pulse oximetry was measured on the index finger of the unoperated arm and on the 2nd toe, respectively, before injecting the dye and, 5, 10, 15, 20, 25, 30, 60, 90, 120, and 150 minutes after. The color of the skin was evaluated on a 4 point scale. RESULTS: In the IB group, the level of oxygen saturation on the finger was significantly lower immediately after injection than the level of oxygen saturation on the toe, and remained at a significantly lower level for up to 150 minutes. In the MB group, there was no significant reduction in the level of oxygen saturation at both sites after injecting the dye. The lowest oxygen saturation in each group was 95.8 +/- 1.9%, 97.5 +/- 1.2%, 99.0 +/- 1.0%, and 99.4 +/- 1.0% in the IB-finger, IB-toe, MB-finger, and MB-toe, respectively. The color change in the skin according to the dye injection was significant in the IB group but, not in MB group. CONCLUSIONS: IB decreased the level of oxygen saturation as measured by pulse oximetry, and its effects were more pronounced on the finger than toe. MB did not decrease the level of oxygen saturation as measured by pulse oximetry at both sites. Oxygen saturation monitoring on the toe is more desirable in a sentinel lymph node biopsy using IB than the finger.

Analysis of Postoperative Liver Function and Complications versus Donor Hepatectomy Type for Living-Related Liver Transplantation / 대한마취과학회지

BACKGROUND: Although living related liver transplantation (LRLT) has several advantages over cadaveric liver transplantation, there still is considerable debate concerning donor safety. We analyzed postoperative liver function and complications versus type of donor hepatectomy for LRLT. METHODS: The charts, anesthetic records and computerized hospital data of 135 consecutive donors registered for LRLT from June 1996 to February 2003 were retrospectively reviewed. Donors were divided into three groups: a left lateral segmentectomy (group LLS; n = 37), a left lobectomy (group LL; n = 8), and a right lobectomy (group RL; n = 90). Volume and weight of the resected liver, volume of blood loss, fluids and blood administered, surgical time and anesthetic time, duration of hospital stay, complications, and perioperative changes in hemoglobin (Hb), aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and prothrombin time (PT) were investigated. RESULTS: No significant differences in donor characteristics, blood loss, and duration of hospital stay were observed. But surgical and anesthetic times in the group RL were longest. The postoperative peak level of AST and ALT in the group LLS were significantly higher than those of the other groups. Postoperative PT and total bilirubin in the group RL were highest. AST, ALT, and PT peaked on the first postoperative day and decreased gradually thereafter. None of the donors experienced a critical complication, including liver failure. CONCLUSIONS: Significant differences in surgical time, postoperative liver function and incidence of hyperbilirubinemia were observed according to the type of hepatectomy. But, serious complication occurred in any donor.

Prolonged Respiratory Failure after General Anesthesia for Cesarean Section in a Presumed Myotonic Dystrophy Patient: A case report / 대한마취과학회지

Myotonic dystrophy is the most common manifestation of mytonic disease. It is a systemic disease and its most serious complications after general anesthesia result from respiratory failure. We report a case of prolonged respiratory failure after general anesthesia for cesarean section in a presumed myotonic dystrophy patient. A 36-year-old parturient underwent emergency cesarean section under general anesthesia for premature rupture of the amniotic membrane with fetal distress. At the end of the operation, the recovery of respiratory muscle from paralysis was insufficient to maintain spontaneous ventilation despite the administration of reversel agents. Her TOF count was 3/4 and she was reintubated in the PACU. The patient was transferred to the ICU for proper respiratory care and her respiration fully recovered after 21 hours of conservative supportive care.