Negative pressure pulmonary edema after general anesthesia using the i-gel.

Negative pressure pulmonary edema (NPPE) is a rare complication that occurs mainly after tracheal extubation. We report a case of postoperative NPPE associated with the use of the i-gel. A 28-year-old woman was scheduled for an emergency right axillary sentinel lymph node excision. During emergence, the patient experienced a sudden onset of airway obstruction, and spontaneous ventilation through the i-gel was impossible. Pink and frothy secretions were noted in the i-gel and the patient's oral cavity. Positive airway pressure with 100% oxygen was applied using a facemask, and the patient was subsequently treated with high-flow oxygen therapy. In this case, laryngospasm or displacement of the i-gel was believed to be the cause of airway obstruction. We recognized that NPPE is likely to occur regardless of the airway device, and the use of the i-gel cannot completely eliminate the possibility of NPPE occurrence.

Effect on music therapy on quality of recovery and postoperative pain after gynecological laparoscopy.

BACKGROUND: Music therapy is safe, inexpensive, simple, and has relaxing properties for mental and physical capacities, as well as few side effects. Moreover, it improves patient satisfaction and reduces postoperative pain. Thus, we intended to evaluate the effect of music intervention on the quality of comprehensive recovery using quality of recovery 40 (QoR-40) survey in patients undergoing gynecological laparoscopic surgery. METHODS: Patients were randomly assigned to music intervention group or control group: 41 patients each. After anesthetic induction, headphones were placed on the patients, and then classical music selected by an investigator was started in the music group with individual comfortable volume during surgery, while the player was not started in the control group. On postoperatively 1 day, the QoR-40 (5 categories: emotions, pain, physical comfort, support, and independence) survey was evaluated, while postoperative pain, nausea, and vomiting were assessed at 30 minutes and 3, 24, and 36 hours postoperatively. RESULTS: Total QoR-40 score was statistically better in the music group, and among the 5 categories, the music group had a higher pain category score than the control group. The postoperative pain score was significantly lower in the music group at 36 hours postoperatively, although the requirement for rescue analgesics was similar in both groups. The incidence of postoperative nausea did not differ at any time point. CONCLUSION: Intraoperative music intervention enhanced postoperative functional recovery and reduced postoperative pain in patients who underwent laparoscopic gynecological surgery.

Laryngeal mass induced severe ventilatory impairment during induction of anesthesia.

A 77-year-old man with laryngeal cancer was scheduled for total laryngectomy and lymph node dissection surgery under general anesthesia. The patient did not present with airway obstruction signs, including dyspnea or wheezing sounds during spontaneous respiration, and the laryngeal opening could be easily identified on the fiberoptic bronchoscope examination preoperatively. Due to his poor cognition and cooperation, we decided not to try awake fiberoptic intubation. During the induction of general anesthesia, total airway obstruction occurred a few minutes after muscle relaxation. The patient could not be ventilated by mask ventilation; nevertheless, tracheal intubation using a conventional laryngoscope was performed without difficulty. It turned out that even a laryngeal mass that does not cause obstructive symptoms, not large in size or totally blocking the airway, can cause difficulty in mask ventilation.

Hypoxic hepatitis during the perioperative period in patients with severe pulmonary disease and cor pulmonale.

Hypoxic hepatitis (HH) is characterized by marked and transient elevations in liver enzyme levels in the absence of other potential causes of liver injury. Although rare, it can occur in the presence of hemodynamic instability and hypoxemia in patients with cor pulmonale. We report two cases of perioperative HH in patients with severe pulmonary disease and cor pulmonale. The first case is of a patient with cor pulmonale who underwent hemiarthroplasty for a femur fracture. Transient hypotension developed during spinal anesthesia and severe hypoxemia were observed in the postoperative period. After surgery, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels suddenly increased to 3740 and 817 U/L, respectively. The second case is of a patient with congestive heart failure and cor pulmonale whose blood pressure and oxygen saturation decreased during induction of general anesthesia and after surgery, and AST, ALT, and lactic dehydrogenase levels increased to 1291, 1292, and 2710 U/L, respectively. The liver enzyme levels normalized within 7-14 days in both cases. We speculate the diagnosis of these cases as HH.

Isolated MCA disease in patients without significant atherosclerotic risk factors: a high-resolution magnetic resonance imaging study.

BACKGROUND AND PURPOSE: Diagnosis of intracranial artery atherosclerosis remains often uncertain. The high-resolution magnetic resonance imaging (HR-MRI) enables vessel wall assessment for more precise diagnoses. The aim of the present study was to investigate the etiologies of middle cerebral artery steno-occlusive disease in young adult patients with few atherosclerotic risk factors using HR-MRI. METHODS: We prospectively studied patients who visited a tertiary hospital in Seoul, Korea, and had (1) unilateral middle cerebral artery disease (≥50% stenosis or occlusion), (2) were ≤55 years old and had no or minimal (≤1) atherosclerotic risk factors. We excluded patients with a confirmed diagnosis of Moyamoya disease, vasculitis, or dissection and those having emboligenic sources. A presumptive diagnosis was made based on HR-MRI findings, and patients were categorized as HR-athero (atherosclerotic disease), HR-MMD (Moyamoya disease), HR-dissection, or HR-vasculitis. RESULTS: Among 95 patients analyzed, 26 (27.4%) had HR-athero who were more often male (P=0.004), smokers (P=0.018), and had focal stenosis (P=0.003) than others.As compared with the HR-athero patients, 29 HR-MMD patients were more often female (P<0.001) and more often had occlusive lesions (P=0.001) and nonfocal stenosis (P<0.001). The 22 HR-dissection patients tended to have hypertension less often, and the 13 HR-vasculitis patients were younger (P=0.004) and tended to have nonfocal stenosis. [corrected]. CONCLUSIONS: In our cohort of young patients with minimal risk factors, atherosclerosis seems to be an uncommon pathology of middle cerebral artery stenosis. HR-MRI aids us to make a more reliable diagnosis.

Endovascular therapy of bronchial artery aneurysm: five cases with six aneurysms.

The objective of this study was to investigate the effect of transcatheter arterial embolization (TAE) with N-butyl-2-cyanoacrylate (NBCA)-Lipiodol mixture in patients with bronchial artery aneurysm (BAA). From January 2005 to January 2010, five patients presenting hemoptysis with six BAAs were treated with NBCA-Lipiodol mixture, including intra-aneurysm embolization (IAE) in one patient. Adjuvant embolization with spherical polyvinyl alcohol (PVA) embolic microparticles or NBCA was first performed to embolize the distal engorged bronchiectatic arteries. Bronchial arterial angiography showed six BAAs (four in the right lobe and two in the left lobe) and some engorged, tortuous bronchial arteries. TAE through microcatheter was successful in all cases. Postembolization angiogram demonstrated the NBCA cast and total occlusion of BAAs and bronchiectatic engorged vessels. After these procedures, hemoptysis completely disappeared in all patients. Follow-up computed tomography (CT) scan was performed at an average of 3 months (range 2 to 6), which showed no enhancement of BAAs and accumulation of NBCA. TAE is a minimally invasive, effective, and reliable approach for treatment for patients with BAA. NBCA-Lipiodol mixture provides a good choice for treatment of BAA, especially when catheterization of the efferent branches is impossible.

Polyphenol (-)-epigallocatechin gallate during ischemia limits infarct size via mitochondrial K(ATP) channel activation in isolated rat hearts.

Polyphenol (-)-epigallocatechin gallate (EGCG), the most abundant catechin of green tea, appears to attenuate myocardial ischemia/reperfusion injury. We investigated the involvement of ATP-sensitive potassium (K(ATP)) channels in EGCG-induced cardioprotection. Isolated rat hearts were subjected to 30 min of regional ischemia and 2 hr of reperfusion. EGCG was perfused for 40 min, from 10 min before to the end of index ischemia. A nonselective K(ATP) channel blocker glibenclamide (GLI) and a selective mitochondrial K(ATP) (mK(ATP)) channel blocker 5-hydroxydecanoate (HD) were perfused in EGCG-treated hearts. There were no differences in coronary flow and cardiodynamics including heart rate, left ventricular developed pressure, rate-pressure product, +dP/dt(max), and -dP/dt(min) throughout the experiments among groups. EGCG-treatment significantly reduced myocardial infarction (14.5+/-2.5% in EGCG 1 microM and 4.0+/-1.7% in EGCG 10 microM, P<0.001 vs. control 27.2+/-1.4%). This anti-infarct effect was totally abrogated by 10 microM GLI (24.6+/-1.5%, P<0.001 vs. EGCG). Similarly, 100 microM HD also aborted the anti-infarct effect of EGCG (24.1+/-1.2%, P<0.001 vs. EGCG ). These data support a role for the K(ATP) channels in EGCG-induced cardioprotection. The mK(ATP) channels play a crucial role in the cardioprotection by EGCG.

Primary malignant melanoma of the cervical spinal nerve root.

The authors report on a case of primary malignant melanoma of the 7th cervical spinal nerve root in a 45-year-old woman. Neuro-radiological features of this extra-dural mass were suggestive of a nerve sheath tumor. The lesion underwent total gross resection through the anterolateral approach. The patient's postoperative course was uneventful. Histopathological investigation confirmed malignant melanoma. There was no evidence of tumor recurrence or other melanotic lesions on regular follow-up examinations until the postoperative eighth month. When treating a common, benign-looking lesion of the cervical spinal nerve root, surgeons should be aware of the potential to encounter such a malignant tumor.