Airway dimensions and margin of safety with the left-sided double-lumen tube in patients of a short stature

BACKGROUND: The size and depth of the double-lumen tube (DLT) are important for one-lung ventilation (OLV). In patients of a short stature, it is difficult to perform OLV successfully. We designed this study to evaluate the dimensions and margin of safety of the left main bronchi in patients of a short stature for appropriate OLV. METHODS: Chest computed tomography (CT) scans of 241 patients (22 male, 219 female) of a short stature (height below 155 cm) were analyzed retrospectively. The diameters of the trachea (DT), the right and left main bronchi (DR and DL), and the lengths of the right and left main bronchi (LR and LL) were measured at the coronal section of the chest CT scans using a picture archiving communication system program. RESULTS: There were no significant correlations between the heights and lengths of the right and left main bronchi. In addition, the ages and weights of the patients showed no significant correlations with the airway dimensions. The lengths of the bronchial lumen of the left-sided Mallinckrodt DLT show variations of 3 to 5.5 mm with tubes of identical sizes. The margin of safety is 13.8 +/- 4.1 mm assuming that appropriately sized DLTs are inserted. CONCLUSIONS: For successful and safe OLV in patients of a short stature, anesthesiologists should consider the length of the main bronchus and the actual length of the bronchial lumen of the DLT.

Comparison of dexmedetomidine and remifentanil for attenuation of hemodynamic responses to laryngoscopy and tracheal intubation / 대한마취과학회지

BACKGROUND: This study was designed to compare the effect of dexmedetomidine and remifentanil used in anesthetic induction on hemodynamic change after direct laryngoscopy and tracheal intubation. METHODS: A total of 90 ASA class 1 or 2 patients were randomly assigned to one of 3 groups to receive one of the following treatments in a double-blind manner: normal saline (Group C, n = 30), dexmedetomidine 1 microg/kg (Group D, n = 30), remifentanil 1 microg/kg (Group R, n= 30). Anesthesia was induced with propofol 2 mg/kg and rocuronium 0.6 mg/kg and maintained with 2 vol% sevoflurane and 50% nitrous oxide in oxygen. In group D, dexmedetomidine 1 microg/kg was infused for 10 min before tracheal intubation. Patients in group R was received 1 microg/kg of remifentanil 1 minute before tracheal intubation. The systolic blood pressure, diastolic blood pressure and heart rate were recorded from entrance to operation room to 5 min after tracheal intubation. RESULTS: The percent increase in systolic and diastolic blood pressure due to tracheal intubation in group D and R were significantly lower than that of group C (P < 0.05). The heart rate 1 min after tracheal intubation was lower in groups R and D than in the group C (P < 0.05). CONCLUSIONS: In healthy normotensive patients, the use of dexmedetomidine during anesthetic induction suppressed a decrease in blood pressure due to anesthetic induction and blunted the hemodynamic responses to endotracheal intubation.

Epidural anesthetic management of achondroplastic parturient dwarf undergoing cesarean section: A case report

Achondroplasia is the most common non-lethal skeletal dysplasia. Underdevelopment and premature ossification of bones result in characteristic craniofacial and spinal abnormalities. Achondroplastic dwarfs have low fertility rates and require delivery by cesarean section due to their cephalo-pelvic disproportion. Controversy exists regarding the ideal anesthesia for an achondroplastic parturient dwarf for urgent cesarean section. Anesthesia, whether general or regional, presents many potential problems during cesarean section. We report the experience of the epidural anesthesia in an achondroplastic dwarf undergoing elective cesarean section.

Abrupt formation of a right atrium thrombus detected by transesophageal echocardiography during laparoscopic assisted vaginal hysterectomy and spontaneous resolution during thromboembolectomy: A case report / 대한마취과학회지

Intraoperative formation and management of a thrombus in right atrium has been reported occasionally. Nevertheless, it is rare that a right atrial thrombus with unstable hemodynamic changes detected by transesophageal echocardiography is resolved spontaneously. We report upon the 44-year-old woman, who had a right atrial thrombus detected by transesophageal echocardiography during laparoscopic assisted vaginal hysterectomy and resolved during thromboembolectomy.

Analgesic effect of preoperative versus intraoperative dexamethasone after laparoscopic cholecystectomy with multimodal analgesia / 대한마취과학회지

BACKGROUND: Pain after laparoscopy is multifactorial and different treatments have been proposed to provide pain relief. Multimodal analgesia is now recommended to prevent and treat post-laparoscopy pain. Dexamethasone is effective in reducing postoperative pain. The timing of steroid administration seems to be important. We evaluated the analgesic efficacy of preoperative intravenous dexamethasone 1 hour before versus during laparoscopic cholecystectomy with multimodal analgesia. METHODS: One hundred twenty patients aged 20 to 65 years old were allocated randomly into one of three groups (n = 40, in each). The patients in the group N received normal saline 1 hour before induction and after the resection of gall bladder. The patients in the group S1 received dexamethasone 8 mg 1 hour before induction and normal saline after the resection of gall bladder. The patients in the group S2 received normal saline 1 hour before induction and dexamethasone 8 mg after the resection of gall bladder. RESULTS: VAS scores of group S1 and S2 were lower than that of group N during 48 hours after laparoscopic cholecystectomy. There were no significant differences of VAS scores between the group S1 and the group S2. The analgesic consumption of group S1 and S2 were significantly lower than that of group N. CONCLUSIONS: A single dose of dexamethasone (8 mg) intravenously given 1 hour before induction or during operation was effective in reducing postoperative pain after laparoscopic cholecystectomy with multimodal analgesia. The analgesic efficacy of preoperative intravenous dexamethasone 1 hour before versus during surgery was not significantly different.

Lambert-Eaton myasthenic syndrome as a cause of persistent neuromuscular weakness after a mediastinoscopic biopsy: A case report / 대한마취과학회지

There are many causes of prolonged postoperative muscle weakness, including drugs, residual anesthetics, cerebrovascular events, electrolyte imbalance, hypothermia, and neuromuscular disease. Neuromuscular diseases are relatively rare, with the most common being myasthenia gravis and Lambert-Eaton myasthenic syndrome (LEMS). We report an unusual case in which a patient who was given a muscle relaxant during mediastinoscopy developed postoperative muscle weakness that was ultimately diagnosed as secondary to LEMS.

A patient with Churg-Strauss syndrome who underwent endoscopic sinus surgery under general anesthesia: A case report / 대한마취과학회지

There are many cause of cholinesterase deficiency, including drugs, liver disease, chronic anemia, malignant states, cardiac failure, severe acute infection, surgical shock, severe burn, collagen disease and vasculitis syndromes. Vasculitis syndromes are relatively rare, and among them, Churg-Strauss syndrome (CSS) is even rarer. We report here on a case of a patient with CSS who underwent endoscopic sinus surgery under general anesthesia.

Prevention of pain during injection of microemulsion propofol: application of lidocaine mixture and the optimal dose of lidocaine / 대한마취과학회지

BACKGROUND: Similar to lipid emulsion propofol, microemulsion propofol also causes a high incidence of pain during intravenous injection. Various methods have been used to minimize the incidence and severity of pain on injection of lipid emulsion propofol. In this study, we investigated the effect of a lidocaine mixture on pain induced by microemulsion propofol injection, and sought to determine the optimal dose of lidocaine that could reduce pain on injecting a propofol-lidocaine mixture. METHODS: One hundred sixty (n = 160) patients of American Society of Anesthesiologists physical status class I or II were randomly allocated to four groups: Group A, control; Group B, 20 mg lidocaine; Group C, 30 mg lidocaine; Group D, 40 mg lidocaine. In each patient, pain on microemulsion propofol solution injection was graded as none, mild, moderate, or severe. RESULTS: The incidence of pain in groups A, B, C, and D was 97.5%, 80%, 65%, and 50%, respectively. Increasing the lidocaine dose significantly reduced pain (P < 0.05). One patient in Group D (2.5%) had moderate to severe pain, which was significantly lower than groups B (42.5%) and C (32.5%) (P < 0.05). CONCLUSIONS: The lidocaine and propofol mixture is effective in alleviating pain associated with microemulsion propofol injection. Within this dose range and in this patients population, increasing lidocaine dosage significantly reduced pain during injection of microemulsion propofol.

Inter-arm arterial pressure difference caused by prone position in the thoracic outlet syndrome patient: A case report / 대한마취과학회지

Thoracic outlet syndrome has neurologic symptoms caused by compression of brachial plexus, blood vessel symptoms are caused by compression of the artery or vein. The authors report a case of sudden decrease in blood pressure of the left arm after turning the patient from supine position to prone position. They confirmed that the patient had thoracic outlet syndrome after performing computed tomography.

The effect of propofol on emergence agitation in children receiving sevoflurane for adenotonsillectomy / 대한마취과학회지

BACKGROUND: The administration of a single dose of propofol is reported to be effective in decreasing the incidence and severity of emergence agitation (EA) in children following sevoflurane anesthesia. The aim of this study was to investigate the clinical usefulness of a single dose of propofol 1 mg/kg at the end of adenotonsillectomy for reducing the incidence of EA after sevoflurane anesthesia. METHODS: Ninety children, aged 3-8 years, undergoing adenotonsillectomy were randomized into two groups: the propofol group (n = 45) and the saline group (n = 45), of which 88 children completed the study. Anesthesia was maintained with sevoflurane 2-2.5 vol% and nitrous oxide/oxygen (50%/50%). At the completion of adenotonsillectomy, the propofol group patients were given 1 mg/kg of propofol and the saline group patients were given saline 0.1 ml/kg in the same volume. The incidence of EA was assessed with Aono's four point scale and the severity of EA was assessed with pediatric anesthesia emergence delirium (PAED) scale at 5 min (T5), 15 min (T15) and 30 min (T30) after emergence. RESULTS: Of the 88 patients, the incidence of EA at T5, T15 and T30 was 61.4%, 27.3%, and 4.5% in the propofol group while in the saline group was 68.2%, 29.5%, and 9.1%, respectively. The incidence and severity of EA were not found to be significantly different between the two groups, but the scales in each group decreased significantly over time. CONCLUSIONS: The administration of propofol 1 mg/kg at the end of surgery did not have any significant effect in reducing the incidence and severity of EA in children undergoing adenotonsillectomy under sevoflurane anesthesia.

Effect of bronchodilator on bronchial mucus transport velocity during inhalational anesthesia

BACKGROUND: Volatile-based anesthesia resulted in a significantly reduced cilia beat frequency. This study was to evaluate the effect of bronchodilator on bronchial mucus transport (BMT) distance measured with a bronchoscope during Inhalational anesthesia. METHODS: Twenty-four adult patients undergoing elective orthopedic surgery under inhalation anesthesia using sevoflurane and nitrous oxide were included. Twenty minutes after tracheal intubation, they were manually inspired without nebulization of salbutamol (control group: n = 12) or with nebulization of salbutamol(salbutamol group: n = 12). And then a single drop of 0.02 ml methylene blue was applied to the posterior mucosal surface of the right main bronchus 5 cm away from the carina under the bronchoscope. The distance of dye movement was measured 5 min after its application. RESULTS: BMT distance and velocity of methylene blue during 5min were 6.2 +/- 3.1 mm and 1.2 +/- 0.6 mm/min in control group, and 23.3 +/- 16.6 mm and 4.7 +/- 3.3 mm/min in salbutamol group, respectively. BMT distance and velocity of methylene blue in salbutamol group were longer and faster than those in control group(P < 0.05). CONCLUSIONS: Salbutamol facilitates the transport of bronchial secretion under sevoflurane-based inhalational anesthesia in term of BMT velocity.

General anesthesia for a spinal muscular atrophy type I patientundergoing feeding gastrostomy: A case report

Spinal muscular atrophy (SMA) in children leads to progressive muscle weakness, dysphagia, aspiration, and death. The most common and severe form of SMA is designated as type I, also known as Werdnig-Hoffman Disease or Floppy Baby syndrome. We anesthetized an 8 month-old female infant with SMA type I undergoing feeding gastrostomy. We planned to use inhalational anesthesia without muscle relaxants. Anesthesia and surgery were uneventful. We herein report a case of successful peri-operative anesthetic management for SMA type I infant with aspiration pneumonia.

Comparison of the effects of acetaminophen to ketorolac when added to lidocaine for intravenous regional anesthesia / 대한마취과학회지

BACKGROUND: This study was done to evaluate the effect on pain relief when acetaminophen was added to lidocaine for intravenous regional anesthesia (IVRA). METHODS: Sixty patients undergoing hand or forearm surgery received IVRA were assigned to three groups: Group C received 0.5% lidocaine diluted with 0.9% normal saline to a total volume of 40 ml (n = 20), Group P received 0.5% lidocaine diluted with intravenous acetaminophen 300 mg to a total volume of 40 ml (n = 20) and Group K received 0.5% lidocaine diluted with 0.9% normal saline plus ketorolac 10 mg made up to a total volume of 40 ml (n = 20). Sensory block onset time, tourniquet pain onset time, which was defined as the time from tourniquet application to fentanyl administration for relieving tourniquet pain and amount of analgesic consumption during surgery were recorded. Following deflation of tourniquet sensory recovery time, postoperative pain and quantity of analgesic uses in post-anesthesia care unit were assessed. RESULTS: Sensory block onset time was shorter in Group P compared to Group C (P < 0.05). Tourniquet pain onset time was delayed in Group P when compared with group C (P < 0.05). Postoperative pain and analgesic consumption were reduced in Group P and Group K compared to Group C (P < 0.001). CONCLUSIONS: The addition of acetaminophen to lidocaine for IVRA shortens the onset time of sensory block and delays tourniquet pain onset time, but not with ketorolac. Both acetaminophen and ketorolac reduce postoperative pain and analgesic consumption.

Breakage of thoracic epidural catheter: How can we deal with it?: A report of 2 cases

Breakage of epidural catheter during insertion and removal is a rare but dilemmatic complication. Although it is favorable to remove a broken catheter entrapped in tissue, there is a controversy about whether retained fragments should be managed even in asymptomatic patients. We experienced two cases of breakage of epidural catheter in patients with thoracic epidural analgesia. One case happened during removing of the entire catheter and needle together and the other, during the removal of the catheter alone. Because neurologic or infective complications were not detected until 14 days after the events, surgical interventions were withheld. In both cases, there were no sequelae on long-term follow up.

Effect of remifentanil on QT dispersion / 대한마취과학회지

BACKGROUND: QT dispersion (QT(d)) is an indirect measure of the heterogeneity of ventricular repolarization and can be used as a risk factor for complex ventricular arrhythmias. We measured the effect of remifentanil on QT(d) and heart-rate corrected QT dispersion (QT(cd)). METHODS: Sixty ASA class I and II patients, who were between 20 and 60 years old, and who were scheduled for general anesthesia, were studied. After the patient entered the operating room, a 12 lead EKG recording was taken and intravenous infusion of remifentanil was started. The infusion rate was 0.1 microg/kg/min in group 1 and 0.2 microgram/kg/min in group 2. Another EKG recording was taken 10 minutes after infusion had started. RESULTS: In both groups, QT(d) following remifentanil infusion was not significantly different than control values (76.6 +/- 23.3 ms vs 81.8 +/- 34.9 ms, P = 0.459 in group 1; 70.7 ms +/- 29.7 ms vs 73.7 ms +/- 37.1 ms, P = 0.734 in group 2). Neither was QT(cd): (83.2 ms +/- 25.2 ms vs 89.6 ms +/- 36.2 ms, P = 0.371 in group 1; 81.0 ms +/- 35.2 ms vs 83.4 ms +/- 40.9 ms, P = 0.829 in group 2). CONCLUSIONS: Remifentanil infusion at a rate less than 0.2 microg/kg/min does not change QT(d) or QT(cd).

Uncontrollable hyperthermia in acute cerebral injury: A case report / 대한마취과학회지

A 39 year old man arrived at the hospital with semi-comatose state as a result of spontaneous intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). For emergency craniectomy and hematoma removal, general anesthesia with desflurane and vecuronium was planned. Before the induction of anesthesia, the body temperature and end-tidal carbon dioxide (ETCO2) levels were 38.3degrees C and 38 mmHg, respectively. The body temperature and ETCO2 increased during surgery. After 2 hours of anesthesia, the temperature had increased to 41degrees C, despite bladder irrigation and body cooling. After 3 hours of anesthesia, the temperature reached 43.5degrees C and cardiac arrest developed. Cardiopulmonary resuscitation was attempted, but the patient expired.

The Aspiration of Injected Air via an Epidural Catheter as an Indicator for Appropriate Placement of the Catheter in the Epidural Space

BACKGROUND: The "gold standard" for proper epidural catheter positioning is a clinical response, as assessed by a pinprick test. Yet it may take time or it may be difficult to perform this test after epidural catheter placement in sedated or uncooperative patients or during general anesthesia. We assessed the usefulness of aspirating injected air via an epidural catheter as an indicator of correct epidural catheter placement. METHODS: We surveyed 200 patients who underwent surgery under general or epidural anesthesia. A Tuohy needle was inserted into the epidural space with using the hanging drop technique. After placement of the epidural catheter, 3 ml of air was injected via the catheter, and then the volume of aspirated air was measured. RESULTS: The mean volume of aspirated air was 2.3 +/- 0.7 ml (75% of the injected air volume) and this ranged from 0 to 3 ml. CONCLUSIONS: Aspiration of injected air is a simple alternative method for identifying the appropriate placement of epidural catheters in the epidural space.

The Analgesic Effect of Different Dosing Methods When Using Transdermal Fentanyl Patches after Laparoscopic Cholecystectomy

BACKGROUND: The advances in surgical technology, anesthesia and perioperative care have made it possible to perform laparoscopic cholecystectomy on an outpatient basis. This study was conducted to assess the analgesic effect and the adverse events of different dosing methods when using transdermal fentanyl patches (TDFPs) after laparoscopic cholecystectomy. METHODS: Sixty patients who were to undergo laparoscopic cholecystectomy under general anesthesia were divided into two groups. Group 1: 2 TDFPs that released 12microgram/h were applied after the induction of anesthesia and these 2 patches were removed after 24 hours. Group 2: 2 TDFPs that released 12microgram/h were applied after the induction of anesthesia and one patch was removed after 7 hours and the other patch was removed after 24 hours. The intensity of the postoperative pain was assessed by using a visual analogue scale (VAS) and assessing the adverse events, including dizziness, pruritus and nausea/vomiting, were recorded for 48 hours postoperatively. RESULTS: The VAS score of postoperative pain was not significantly different between the two groups at all times. The incidence of dizziness in groups I and II was 10 and 3, respectively, and the incidence of nausea/vomiting in group I and II was 4 and 0, respectively. The incidences of dizziness and nausea/vomiting in group II were significantly lower than those of group I (P < 0.05). CONCLUSIONS: A dosing method that removes half of the TDFPs (24microgram/h) after 7 hours of application caused a lower incidence of dizziness and nausea/vomiting without any significant difference of postoperative analgesic efficacy, as compared to leaving on both the TDFPs (24microgram/h) for 24 hours after laparoscopic cholecystectomy.

Comparison of ramosetron plus dexamethasone with ramosetron alone in the prevention of nausea and vomiting after gynecologic laparoscopic surgery / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) is extremely distressing and uncomfortable, and is noted frequently in patients who have undergone gynecologic laparoscopic surgery. In this study, we compared the efficacy of a combination of ramosetron plus dexamethasone and ramosetron alone in reducing of PONV after gynecologic laparoscopic surgery. METHODS: Sixty patients who received gynecologic laparoscopic surgery were randomly divided into two groups: the R group (ramosetron 0.3 mg) and RD group (ramosetron 0.3 mg plus dexamethasone 5 mg). Dexamethasone, 5 mg, or saline, 1 ml, was administered randomly before the induction of anesthesia in each group. The two groups received intravenous ramosetron, 0.3 mg, at the end of surgery. General anesthesia was induced using thiopental and rocuronium, and maintained with sevoflurane in nitrous oxide. The incidence and severity of nausea, frequency of vomiting and rescue medication, VAS score, and adverse events were evaluated for 48 hours after the operation. RESULTS: In the first 12 hours after operation, the incidence of PONV in the RD group (33%) was significantly lower than the R group (67%; P < 0.05). However, there were no significant differences between two groups in PONV incidence 12-48 h postoperatively. Adverse events and VAS scores were similar in the two groups. CONCLUSIONS: The combination of ramosetron plus dexamethasone is superior to ramosetron alone for prevention of PONV during the first 12 hours after gynecologic laparoscopic surgery.

Priming technique can alleviate the withdrawal responses associated with intravenous administration of rocuronium / 대한마취과학회지

BACKGROUND: Intravenous injection of rocuronium is associated with withdrawal responses which are attributable to the pain from the injection of rocuronium. Several methods have been proposed to abolish and attenuate rocuronium-induced pain. We hypothesized priming dose of rocuronium could reduce withdrawal responses associated with administering a second large dose of rocuronium for tracheal intubation. We compared the efficacy of the priming dose technique of rocuronium with intravenous lidocaine as a pre-treatment for the prevention of withdrawal responses associated with rocuronium injection. METHODS: We recruited 150 patients aged between 18 and 60 years, ASA physical status 1 or 2, who were going to undergo elective surgery requiring general anesthesia. Patients were allocated into three groups. Group C received normal saline, Group L received lidocaine 1 mg/kg, and Group P received rocuronium 0.06 mg/kg 2 minutes before administering a second large dose of rocuronium for tracheal intubation. After the loss of consciousness, rocuronium 0.6 mg/kg was administered intravenously over 10 seconds for tracheal intubation. The withdrawal responses to the injection of rocuronium were evaluated. RESULTS: The incidence of withdrawal responses associated with rocuronium injection for tracheal intubation was 56, 50, 24% in group C, group L, and group P, respectively. The incidence of withdrawal responses was lower in group P than group C and group L, but there was no difference between group L and group C. CONCLUSIONS: Priming dose technique is a useful clinical method to alleviate withdrawal responses associated with rocuronium injection.