Epidural anesthesia for permanent spinal cord stimulation with a cylindrical type lead: a case series / 대한마취과학회지

Spinal cord stimulation (SCS) in trials involving external stimulation are easily conducted under local anesthesia. However, implantation of a permanent SCS system is painful, and can be intolerable in some patients. Epidural anesthesia can be used to perform the SCS implantation without discomfort if the patient can localize the area of paresthesia. However, little is known about epidural anesthesia for SCS. This paper reports 23 cases of permanent SCS with a cylindrical type lead implanted under the epidural anesthesia. Epidural anesthesia was sufficient in 22 patients without discomfort and significant complications. The remaining patient experienced incomplete epidural anesthesia and required additional analgesics to blunt the pain. All the leads were placed consistent with the patient's report of paresthesia area under epidural anesthesia. Thus, epidural anesthesia is an effective and safe method for the optimal placement of SCS to minimize the discomfort for patients without impairing patients' response to the intraoperative stimulation test.

Spinal Cord Stimulation for Intractable Visceral Pain Due to Sphincter of Oddi Dysfunction

Sphincter of Oddi dysfunction (SOD) is a syndrome of chronic biliary pain or recurrent pancreatitis due to the functional obstruction of the pancreaticobiliary flow. We report a case of spinal cord stimulation (SCS) for chronic abdominal pain due to SOD. The patient had a history of cholecystectomy and had suffered from chronic right upper quadrant abdominal pain. The patient had been diagnosed as having SOD. The patient was treated with opioid analgesics and nerve blocks, including a splanchnic nerve block. However, two years later, the pain became intractable. We implanted percutaneous SCS at the T5-7 level for this patient. Visual analog scale (VAS) scores for pain and the amount of opioid intake decreased. The patient was tracked for more than six months without significant complications. From our clinical case, SCS is an effective and alternative treatment option for SOD. Further studies and long-term follow-up are necessary to understand the effectiveness and the limitations of SCS on SOD.

A Case of Squamous Cell Carcinoma in Nasal Cavity Treated with Conversion to Sirolimus in a Patient with Kidney Transplantation / 대한이식학회지

Conversion of immunosuppressants to sirolimus, an inhibitor of mammalian target of rapamycin, is a useful treatment option for prevention of the adverse events of immunosuppressants such as calcineurin inhibitor in renal transplantation recipients. In addition, sirolimus has been improving the quality of life and increasing the survival of patients with renal transplantation by decreasing immunosuppression-related malignancies, particularly skin cancer. However, complete remission of skin squamous cell carcinoma after renal transplantation only by conversion to sirolimus has not been well reported, although its preventive effect on skin cancer is well known. We report on a 72-year-old male with squamous cell carcinoma in his nasal cavity consequent to renal transplantation, which was treated completely with the conversion of cyclosporine to sirolimus without surgical removal or chemotherapy.

Using Sirolimus for Posttransplant Management and Reduction of Tuberous Sclerosis Complex Progression in a Patient with End Stage Renal Disease Caused by Tuberous Sclerosis Complex / 대한이식학회지

Tuberous sclerosis complex (TSC) is a neurocutaneous disease characterized by the formation of hamartomas in multiple organs. TSC can show lesions including facial angiofibroma, shagreen patch on the skin, cortical tuber, subependymal nodule, astrocytoma in the brain, cardiac rhabdomyoma, and renal angiomyolipoma. In particular, renal angiomyolipoma may be a cause of end-stage renal disease (ESRD). On the other hand, sirolimus has regulatory effects on cellular growth and proliferation via its inhibitory effect on a protein, mammalian target of rapamycin. We report on a case of an 18-year-old male who underwent renal transplantation due to ESRD induced by TSC. Sirolimus played a role in successful treatment of TSC and effective immunosuppression for transplantation.

A Case of Intrathoracic Omental Herniation through the Esophageal Hiatus in a Patient with Continuous Ambulatory Peritoneal Dialysis / 대한내과학회지

Intrathoracic omental herniation through the esophageal hiatus is extremely rare. Here, we report a case of a 57-year-old male with continuous ambulatory peritoneal dialysis (CAPD) who was admitted to our hospital after experiencing nausea and abdominal discomfort for 3 days. Computed tomography (CT) revealed a fatty mass, extended continuously through the esophageal hiatus into the thoracic cavity. Laparoscopic surgery revealed an omental herniation through the esophageal hiatus. There was no herniation of the stomach or intestines. Peritoneal dialysis was resumed six weeks later. This is a report of omental herniation through the esophageal hiatus in a patient with CAPD.

Uncommon Ocular Manifestations of Neurofibromatosis: Case Report and Review

PURPOSE: To report and review several cases of uncommon ocular manifestations in neurofibromatosis patients. CASE SUMMARY: A 19-year-old woman diagnosed with type 2 neurofibromatosis visited our hospital with amblyopia of the right eye and mild visual disturbance of the left eye. Best corrected visual acuity was 20/250 in the right eye, 20/25 in the left eye and relative afferent pupillary defect in the right eye was observed. Fundus examination of both eyes showed papilledema. Magnetic resonance imaging showed schwannoma from the optic nerve to the optic chiasm. A 28-year-old woman diagnosed with type 2 neurofibromatosis visited our hospital with amblyopia of the right eye. Best corrected visual acuity was finger count in the right eye, 20/20 in the left eye and relative afferent pupillary defect in the right eye was observed. Fundus examination of the right eye showed a slightly elevated lesion at the macula, as well as dragged optic disc and retinal vessels to the macula. An 8-year-old girl diagnosed with type 1 neurofibromatosis visited our hospital with enophthalmos and strabismus of the left eye. On exophthalmometry, enophthalmos in the left eye was found; measurements were 15.0 mm in the right eye and 13.0 mm in the left eye. Three-dimensional computed tomography revealed sphenoidal hypoplasia and a left lateral orbital wall defect. CONCLUSIONS: The authors of the present study report on neurofibromatosis patients who had an uncommon ocular manifestation. Neurofibromatosis can represent various ocular manifestations but reports of compressive optic neuropathy, dragged disc syndrome and sphenoidal hypoplasia are rare.

Experience of significant hemodynamic instability that occurred during excisional biopsy in a patient with unrecognized bronchial carcinoid tumor / 대한마취과학회지

No abstract available.

A Severe Retropharyngeal Hematoma after Stellate Ganglion Block: A case report / 대한통증학회지

A 73-year-old man with sudden sensory neural hearing loss received a stellate ganglion block. Two hours after the block, the patient complained of newly developed neck discomfort. After an additional two hours, the neck swelled up gradually and neck pain and dyspnea developed. A plain radiograph of neck revealed narrowing of the upper airway; a tracheostomy was performed and the dyspnea was improved. On the next day, the pain site extended to the right scapula and a CT image revealed a huge retropharyngeal hematoma. Hematoma evacuation and bleeder ligation were then performed and the patient was discharged on the fourth day after admission without any complications. A practitioner should always remember to educate the patients about possible complications and undertake intensive observation when performing procedures, even in patients who do not initially present with a compromised airway.

Anesthetic Management of Two Patients with Williams Syndrome: Two cases reports / 대한마취과학회지

Williams syndrome is a rare genetic disorder with a frequency of one per 20,000-50,000 live births. It is caused by a deletion of one elastin allele located within chromosome subunit 7q11.23 (long arm). This syndrome is frequently accompanied by congenital heart disease, facial anomalies, and mental retardation and as a result, anesthetic management may be complicated by hemodynamic instability and difficult intubation. Also, as it was reported that this disease is associated with malignant hyperthermia, careful anesthetic selection is required. We experienced the anesthetic management of a 3-year-old girl with Williams syndrome who received dental treatment for severe dental caries under general anesthesia, and of a 4-year-old girl underwent aortoplasty for supravalvular aortic stenosis. Airway management and tracheal intubation was accomplished successfully in both patients. For anesthetic management, propofol, fentanyl and rocuronium, and fentanyl, isoflurane and vecuronium were used in the first and second patients, respectively. Surgeries were performed uneventfully in both cases, and the patients were discharged without complication.

Effect of Pulmonary Artery Pressure on Changes in Right Ventricular Function according to Norepinephrine Infusion in Patients with Valvular Heart Disease / 대한마취과학회지

BACKGROUND: Increasing coronary perfusion pressure by using a vasopressor is one of the important treatment strategies in pulmonary hypertension. In present study, we evaluated whether chronic pulmonary hypertension influences the effect of norepinephrine (NE) on right ventricular function and hemodynamic variables in patients with valvular heart disease. METHODS: Forty eight patients undergoing valve replacement surgery were divided into two groups according to pulmonary artery pressure, i.e., a control (n = 28) and a pulmonary hypertension group (n = 20). A thermodilution pulmonary artery catheter for continuous monitoring of cardiac output, right ventricular (RV) ejection fraction and RV volume was inserted before the induction of anesthesia. When systemic hypotension occurred following induction of anesthesia, norepinephrine was infused at rates of 0.03 and then 0.06microgram/kg/min for 10 minutes, respectively and hemodynamic variables were measured after anesthesia induction, and at the end point of each infusion rate. RESULTS: No significant differences occurred in systemic or pulmonary hemodynamic variables according to the infusion of norepinephrine between the two groups. And, no significant changes were observed in right ventricular performance according to the infusion of norepinephrine in two groups. CONCLUSIONS: Norepinephrine did not show different systemic or pulmonary hemodynamic effects in patients with or without chronic pulmonary hypertension. Norepinephrine did not increase the right ventricular ejection fractions or cardiac outputs of patients with chronic pulmonary hypertension.

The Potential of Peripheral Venous Pressure as a Substitutional Hemodynamic Parameter of Central Venous Pressure in Hypovolemic Patients with Coronary Artery Disease / 대한마취과학회지

BACKGROUND: Peripheral venous pressure (PVP) was known to have significant correlation with central venous pressure (CVP) in patients with normal and abnormal cardiac function. The purpose of this study is to evaluate the possibility of PVP as a substitute of CVP for volume status monitoring. METHODS: 41 hypovolemic patients with pulmonary capillary wedge pressure (PCWP) below 10 mmHg, scheduled for elective coronary artery bypass graft were included. CVP and PVP were measured from proximal port of pulmonary artery (PA) catheter and antecubital vein, respectively. Each was connected to the same monitoring system by rigid tubes of same length. Measurements were performed as follows: after PA catheter insertion; after increasing PCWP above 10 mmHg by I.V. fluid infusion; and after anesthesia induction. Hemodynamic variables were recorded at end-expiration after stabilizing for 5 10 minutes. For statistical analysis, Bland and Altman plot was created. RESULTS: The overall mean bias between CVP and PVP was 0.7 mmHg (95% confidence interval, 1 0.5). Limits of agreement of mean bias was 2.1 3.6 mmHg. 118 out of 121 PVP measurements were within the ranges of CVP +/- 3 mmHg (98%). The direction of CVP change was predicted by PVP in 68%. However, larger changes of PVP (> or = 2 mmHg) predicted the changes of CVP with increased accuracy (90%). There were only 5 cases that CVP and PVP had changed in opposite direction. CONCLUSIONS: In conclusion, PVP has a potential to be a substitutional hemodynamic parameter of CVP.