Complications of fluid overload during hysteroscopic surgery: cardiomyopathy and epistaxis - A case report -

Background@#Hysteroscopic surgery has been used in various gynecological fields. However, massive fluid overload can occur as a complication due to persistent infusion of media for uterine cavity distension. We present the case of a woman who developed cardiomyopathy with pulmonary edema and epistaxis during hysteroscopic surgery.Case: A 76-year-old female underwent hysteroscopic septectomy. She manifested abrupt, active nasal bleeding and regurgitation in the intravenous line. Heart rate, SpO2, and PETCO2 decreased from 55 beats/min to 29 beats/min, from 100% to 56%, and from 31 mmHg to 9 mmHg, respectively. After the operation, brain CT showed bilateral prominent superior ophthalmic vein dilation. Echocardiography showed left ventricle apical ballooning and global hypokinesia. The patient recovered after two days of conservative management, with no sequelae. @*Conclusions@#Although hysteroscopic surgery is a simple procedure, careful monitoring is necessary to prevent complications from absorption of fluid distending media during the procedure.

Suspected abdominal compartment syndrome during endoscopic diskectomy: A case report

Abdominal compartment syndrome can produce a critical situation if not diagnosed early and managed properly. We report a case of abdominal compartment syndrome that was caused by massive irrigation of surgical fluid during endoscopic lumbar diskectomy at the L4–L5 level. There was a sudden increase in peak inspiratory pressure during the operation, and the patient's tidal volume and blood pressure decreased. When the patient's position was changed from prone to supine, abdominal distension and cyanosis of both lower extremities were discovered. Ultrasonic findings showed fluid collection in both the chest and intra-abdominal cavity. Thoracentesis and abdominal decompression surgery were performed, and the patient's overall state improved. We concluded that irrigation fluid used during the endoscopic operation leaked into the retroperitoneal space and caused abdominal compartment syndrome.

Arginase Inhibition Suppresses Native Low-Density Lipoprotein-Stimulated Vascular Smooth Muscle Cell Proliferation by NADPH Oxidase Inactivation

PURPOSE: Vascular smooth muscle cell (VSMC) proliferation induced by native low-density lipoprotein (nLDL) stimulation is dependent on superoxide production from activated NADPH oxidase. The present study aimed to investigate whether the novel arginase inhibitor limonin could suppress nLDL-induced VSMC proliferation and to examine related mechanisms. MATERIALS AND METHODS: Isolated VSMCs from rat aortas were treated with nLDL, and cell proliferation was measured by WST-1 and BrdU assays. NADPH oxidase activation was evaluated by lucigenin-induced chemiluminescence, and phosphorylation of protein kinase C (PKC) βII and extracellular signal-regulated kinase (ERK) 1/2 was determined by western blot analysis. Mitochondrial reactive oxygen species (ROS) generation was assessed using MitoSOX-red, and intracellular L-arginine concentrations were determined by high-performance liquid chromatography (HPLC) in the presence or absence of limonin. RESULTS: Limonin inhibited arginase I and II activity in the uncompetitive mode, and prevented nLDL-induced VSMC proliferation in a p21Waf1/Cip1-dependent manner without affecting arginase protein levels. Limonin blocked PKCβII phosphorylation, but not ERK1/2 phosphorylation, and translocation of p47phox to the membrane was decreased, as was superoxide production in nLDL-stimulated VSMCs. Moreover, mitochondrial ROS generation was increased by nLDL stimulation and blocked by preincubation with limonin. Mitochondrial ROS production was responsible for the phosphorylation of PKCβII. HPLC analysis showed that arginase inhibition with limonin increases intracellular L-arginine concentrations, but decreases polyamine concentrations. L-Arginine treatment prevented PKCβII phosphorylation without affecting ERK1/2 phosphorylation. CONCLUSION: Increased L-arginine levels following limonin-dependent arginase inhibition prohibited NADPH oxidase activation in a PKCβII-dependent manner, and blocked nLDL-stimulated VSMC proliferation.

Hemisphere cerebral infarction after total laparoscopic hysterectomy in the Trendelenburg position: A case report

Perioperative stroke can lead to mortality or serious disability and usually occurs in patients undergoing cardiac, vascular, or neurologic surgery; it is rare in gynecological surgery. We report the case of a patient who suffered life-threatening cerebral infarction after elective laparoscopic hysterectomy. During the surgery, the patient was placed in the Trendelenburg position. On postoperative day one, the patient was diagnosed with right hemisphere cerebral infarction; brain computed tomographic angiography showed proximal right internal carotid artery occlusion. Decompressive craniectomy was performed to resolve brain swelling, but the patient died 10 days later.

Arginase Inhibition Restores Peroxynitrite-Induced Endothelial Dysfunction via L-Arginine-Dependent Endothelial Nitric Oxide Synthase Phosphorylation

PURPOSE: Peroxynitrite plays a critical role in vascular pathophysiology by increasing arginase activity and decreasing endothelial nitric oxide synthase (eNOS) activity. Therefore, the aims of this study were to investigate whether arginase inhibition and L-arginine supplement could restore peroxynitrite-induced endothelial dysfunction and determine the involved mechanism. MATERIALS AND METHODS: Human umbilical vein endothelial cells (HUVECs) were treated with SIN-1, a peroxynitrite generator, and arginase activity, nitrite/nitrate production, and expression levels of proteins were measured. eNOS activation was evaluated via Western blot and dimer blot analysis. We also tested nitric oxide (NO) and reactive oxygen species (ROS) production and performed a vascular tension assay. RESULTS: SIN-1 treatment increased arginase activity in a time- and dose-dependent manner and reciprocally decreased nitrite/nitrate production that was prevented by peroxynitrite scavenger in HUVECs. Furthermore, SIN-1 induced an increase in the expression level of arginase I and II, though not in eNOS protein. The decreased eNOS phosphorylation at Ser1177 and the increased at Thr495 by SIN-1 were restored with arginase inhibitor and L-arginine. The changed eNOS phosphorylation was consistent in the stability of eNOS dimers. SIN-1 decreased NO production and increased ROS generation in the aortic endothelium, all of which was reversed by arginase inhibitor or L-arginine. N(G)-Nitro-L-arginine methyl ester (L-NAME) prevented SIN-1-induced ROS generation. In the vascular tension assay, SIN-1 enhanced vasoconstrictor responses to U46619 and attenuated vasorelaxant responses to acetylcholine that were reversed by arginase inhibition. CONCLUSION: These findings may explain the beneficial effect of arginase inhibition and L-arginine supplement on endothelial dysfunction under redox imbalance-dependent pathophysiological conditions.

Clinical performance comparison of I-gel insertion by anesthesiology residents versus novice clinicians

BACKGROUND: I-gel is a recently developed supraglottic airway device with many advantages. Like laryngeal mask airway (LMA), I-gel is an easier and quicker intubation alternative to endotracheal intubation in certain situations. In this study, we assessed the ease of I-gel insertion and compared the clinical performance of anesthetsiology residents (group R) experienced in endotracheal intubation versus that of interns (group I) with little intubation experience. METHODS: This prospective and randomized study included 60 patients. The ease of insertion, number of I-gel insertion attempts, presence of air leakage, and postoperative complications such as bleeding, dental trauma, hoarseness, and sore throat were evaluated in each group. RESULTS: Insertion was successful on the initial attempt in 29 of 30 cases in group R. In group I, 24 initial insertions were successful. The mean insertion times were 12.5 +/- 4.8 and 27.9 +/- 12.5 seconds for group R and group I, respectively (P < 0.001). No significant differences were observed between the two groups regarding postintubational air leakage. Regarding complications, two cases of bleeding, one case of dental trauma, and two cases of sore throat were recorded. No significant differences were observed between the two groups for any of the complications examined. CONCLUSIONS: I-gel is a suitable alternative insertion device that enables rapid and easy intubation by physicians who are experienced with endotracheal intubation. Moreover, this device also enables efficient and safe insertion during emergent situations for novice clinicians, even those who have little experience in intubation.

Korean Red Ginseng Water Extract Restores Impaired Endothelial Function by Inhibiting Arginase Activity in Aged Mice

Cardiovascular disease is the prime cause of morbidity and mortality and the population ages that may contribute to increase in the occurrence of cardiovascular disease. Arginase upregulation is associated with impaired endothelial function in aged vascular system and thus may contribute to cardiovascular disease. According to recent research, Korean Red Ginseng water extract (KRGE) may reduce cardiovascular disease risk by improving vascular system health. The purpose of this study was to examine mechanisms contributing to age-related vascular endothelial dysfunction and to determine whether KRGE improves these functions in aged mice. Young (10+/-3 weeks) and aged (55+/-5 weeks) male mice (C57BL/6J) were orally administered 0, 10, or 20 mg/mouse/day of KRGE for 4 weeks. Animals were sacrificed and the aortas were removed. Endothelial arginase activity, nitric oxide (NO) generation and reactive oxygen species (ROS) production, endothelial nitric oxide synthase (eNOS) coupling, vascular tension, and plasma peroxynitrite production were measured. KRGE attenuated arginase activity, restored nitric oxide (NO) generation, reduced ROS production, and enhanced eNOS coupling in aged mice. KRGE also improved vascular tension in aged vessels, as indicated by increased acetylcholine-induced vasorelaxation and improved phenylephrine-stimulated vasoconstriction. Furthermore, KRGE prevented plasma peroxynitrite formation in aged mice, indicating reduced lipid peroxidation. These results suggest KRGE exerts vasoprotective effects by inhibiting arginase activity and augmenting NO signaling and may be a useful treatment for age-dependent vascular diseases.

Effects of Seasonal Differences in Testosterone and Cortisol Levels on Pain Responses Under Resting and Anxiety Conditions

PURPOSE: This study investigated whether hormones and pain perception are associated with exam anxiety, and also whether exam anxiety is affected by seasonal differences in testosterone and cortisol levels. MATERIALS AND METHODS: Forty-six healthy males were recruited from a medical college. Anxiety was induced by having participants perform the Objective Structured Clinical Examination. Pressure was applied to the participants to induce pain. Pain thresholds, pain ratings, anxiety ratings, blood pressure, heart rate, salivary testosterone and cortisol levels were measured under resting and anxiety conditions in the spring and summer. Data were collected from 46 participants during the spring (n=25) and summer (n=21). RESULTS: Pain thresholds and testosterone levels were significantly lower under anxiety than at rest for all participants (n=46), while cortisol levels, pain ratings, and anxiety ratings were significantly higher under anxiety than at rest. In the spring (n=25), testosterone levels were significantly higher at rest than under anxiety, while there was no difference in cortisol levels between resting and anxiety conditions. In the summer (n=21), cortisol levels were significantly higher under anxiety than at rest, while there was no difference in testosterone levels between resting and anxiety conditions. There were no significant seasonal differences in pain and anxiety ratings and pain threshold. CONCLUSION: These results indicate that seasonal differences in testosterone and cortisol levels under anxiety and at rest may affect pain responses. These results also suggest that acute clinical pain may be relieved by managing anxiety that is related to a decrease of testosterone in spring and a large increase of cortisol in summer.

A failure of internal jugular vein catheterization caused by the internal jugular vein occlusion / 대한마취과학회지

No abstract available.

Ankle-brachial blood pressure differences before and during anesthesia

BACKGROUND: In surgeries involving the upper extremities and breast, the blood pressure is frequently measured at the ankles. As the blood pressure is used as a pain indicator in the full surgical anesthesia, the ankle blood pressure higher than the brachial blood pressure may be misinterpreted by the anesthesiologist, in determining the depth of the anesthesia. This paper investigated whether the ankle blood pressure is significantly higher than the brachial blood pressure before the anesthesia induction, during induction, and after tracheal intubation. METHODS: Two hundred seventeen patients requiring general anesthesia for elective surgery were included in this study. Ankle and brachial blood pressure were simultaneously measured before the anesthesia induction, during induction, and after tracheal intubation. RESULTS: The ankle blood pressure was higher than the brachial blood pressure before induction, during induction, and after tracheal intubation. Ankle-brachial blood pressure differences were significantly higher before induction and after intubation as compared to that during induction. The correlation coefficient between the systolic ankle-brachial blood pressure difference before induction and that after tracheal intubation was 0.623. In 33 child patients with an ankle-brachial blood pressure index > or =1 before induction, there were no significant differences in the ankle-brachial blood pressure during induction. The brachial systolic blood pressure could be predicted by simple and multiple regression equations (R2 = 0.349-0.828). CONCLUSIONS: The results of the study suggest that the anesthesiologists need to consider the ankle-brachial blood pressure differences in monitoring the anesthesia, in cases where the brachial blood pressure cannot be measured during surgery.

Change of respiratory mechanics at different intra-abdominal pressures and position change during laparoscopic surgery / 대한마취과학회지

No abstract available.

The effects of desflurane and sevoflurane on the intraocular pressure associated with endotracheal intubation in pediatric ophthalmic surgery / 대한마취과학회지

BACKGROUND: For ophthalmic surgery anesthesia, it is vital that intraocular pressure (IOP) is controlled. Most anesthetic drugs affect IOP dose-dependently, and inhalational anesthetics dose-dependently decrease IOP. In this study, we compared the effects of desflurane and sevoflurane on IOP and hemodynamics in pediatric ophthalmic surgery. METHODS: Thirty eight pediatric patients from the age of 6 to 15 years, who were scheduled for strabismus surgery and entropion surgery, were randomized to be administered desflurane (group D, n = 19) or sevoflurane (group S, n = 19). IOPs and hemodynamic parameters were measured before induction of anesthesia (B), after induction but immediately before intubation (AI), 1 min after intubation (T1), 3 min after intubation (T3), and 5 min after intubation (T5). RESULTS: The mean arterial pressure (MAP) at T1 and heart rates (HRs) at T1 and T3 were significantly higher in group D than those in group S. There was no significant difference between the groups in IOP, cardiac index (CI) and stroke index (SI). There was a significant difference within the group in IOP, SI, MAP and HR. There was no significant difference within the group in CI. CONCLUSIONS: There was no significant difference between the groups in IOP and hemodynamic parameters. The two anesthetic agents maintained IOP and hemodynamic parameters in the normal range during anesthetic induction.

Thyroid storm during induction of anesthesia / 대한마취과학회지

No abstract available.

Herpes zoster induced pure motor segmental paresis: A case report

Segmental zoster paresis is characterized by skin rash, sensory change and motor weakness in the myotome that corresponds to the dermatome of the rash. Herpes zoster induced pure motor paresis is a rare complication of herpes zoster without sensory involvement in brachial plexopathy. We present a case of segmental paresis, which involved motor nerve without sensory nerve involvement electrophysiologically.

Acute liver injury after desflurane anesthesia: A case report

Most general anesthesia procedures are performed without any complications, but volatile agents may have adverse effects on various organ systems. Volatile anesthetic agents can cause mild to fulminant liver failure. However, while desflurane is a theoretical cause of hepatotoxicity, such cases have rarely been reported. We present here a 49-year-old man who developed hepatic dysfunction after laparoscopic cholecystectomy and this procedure was done under desflurane anesthesia.

A comparison of the influence of 2.7% sorbitol-0.54% mannitol and 5% glucose irrigating fluids on plasma serum physiology during hysteroscopic procedures / 대한마취과학회지

BACKGROUND: 2.7% sorbitol-0.54% mannitol has been selected as an alternative irrigating fluid during endoscopic surgery for its theoretical advantages. We compared the influence of 2.7% sorbitol-0.54% mannitol (Urosol(TM), CJ Pharma, Seoul, Korea) and 5% glucose as an irrigating solution for hysteroscopic myomectomy & polypectomy in the occurrence of associated complications. METHODS: Thirty patients scheduled for a hysteroscopic operation were included in a prospective randomized trial comparing 2.7% sorbitol-0.54% mannitol solution (Group S, n = 15) and 5% glucose (Group G, n = 15) as an irrigating fluid. We recorded the amount of the irrigating fluids, the amount of fluid intake, and the duration of the procedure. Serum sodium, chloride, potassium, glucose values, and serum osmolality were measured before (just after the induction, T1), during (when 2 L of irrigation fluid was infused, T2), and after (1 h after the end of the operation, T3) the hysteroscopic procedure. RESULTS: The mean volume of absorbed irrigating fluid was 185.0 +/- 73.5 ml in Group G and 175.4 +/- 50.5 ml in Group S. Transient hyperglycemia occurred in one patient of Group G. No differences were found in the intraoperative and postoperative levels of serum sodium, potassium, chloride, glucose and osmolality in both groups. CONCLUSIONS: There was no clinical evidence of hyponatremic hypoosmolality in any of the patients. We found no difference between 2.7% sorbitol-0.54% mannitol and 5% glucose as an irrigating fluid for hysteroscopic procedures with mild to moderate irrigant absorption.

Endothelial arginase II and atherosclerosis / 대한마취과학회지

Atherosclerotic vascular disease is the leading cause of morbidity and mortality in developed countries. While it is a complex condition resulting from numerous genetic and environmental factors, it is well recognized that oxidized low-density lipoprotein produces pro-atherogenic effects in endothelial cells (ECs) by inducing the expression of adhesion molecules, stimulating EC apoptosis, inducing superoxide anion formation and impairing protective endothelial nitric oxide (NO) formation. Emerging evidence suggests that the enzyme arginase reciprocally regulates NO synthase and NO production by competing for the common substrate L-arginine. As oxidized LDL (OxLDL) results in arginase activation/upregulation, it appears to be an important contributor to endothelial dysfunction by a mechanism that involves substrate limitation for endothelial NO synthase (eNOS) and NO synthesis. Additionally, arginase enhances production of reactive oxygen species by eNOS. Arginase inhibition in hypercholesterolemic (ApoE-/-) mice or arginase II deletion (ArgII-/-) mice restores endothelial vasorelaxant function, reduces vascular stiffness and markedly reduces atherosclerotic plaque burden. Furthermore, arginase activation contributes to vascular changes including polyamine-dependent vascular smooth muscle cell proliferation and collagen synthesis. Collectively, arginase may play a key role in the prevention and treatment of atherosclerotic vascular disease.

Native Low-Density Lipoprotein-Dependent Interleukin-8 Production Through Pertussis Toxin-Sensitive G-Protein Coupled Receptors and Hydrogen Peroxide Generation Contributes to Migration of Human Aortic Smooth Muscle Cells

PURPOSE: Stimulation of human aortic smooth muscle cells (hAoSMCs) with native low-density lipoprotein (nLDL) induced the production of interleukin-8 (IL-8) that is involved in the pathogenesis of cardiovascular diseases. However, the process of signal transduction of nLDL was currently uncharacterized. Therefore, the aim of this study was to investigate the signal transduction pathway of nLDL-dependent IL-8 production and the effect of IL-8 on hAoSMCs migration. MATERIALS AND METHODS: nLDL was prepared by ultracentrifugation with density-adjusted human serum of normocholesterolemia. In hAoSMCs, IL-8 secreted to medium was measured using ELISA assay, and Western blot analysis was performed to detect p38 MAPK activation as a key regulator of IL-8 production. nLDL-dependent H2O2 generation was determined by microscopic analysis using 2',7'-dichlorofluoroscein diacetate (DCF-DA). IL-8-induced migration of hAoSMCs was evaluated by counting the cell numbers moved to lower chamber using Transwell plates. RESULTS: nLDL-induced IL-8 production was completely blocked by preincubation of hAoSMCs with pertussis toxin (PTX), which inhibited nLDL-dependent p38 MAPK phosphorylation. PTX-sensitive G-protein coupled receptor was responsible for nLDL-dependent H2O2 generation that was abrogated with preincubation of the cells with of polyethylene glycol-conjugated catalase (PEG-Cat). Pretreatment of PEG-Cat prevented nLDL-induced p38 MAPK phosphorylation and IL-8 production, which was partly mimicked by treatment with exogenous H2O2. Finally, IL-8 increased hAoSMCs migration that was completely blocked by incubation with IL-8 neutralizing antibody. CONCLUSION: PTX-sensitive G-protein coupled receptor-dependent H2O2 generation by nLDL plays a critical role in IL-8 production in hAoSMC, and IL-8 may contribute to atherogenesis through increased migration of hAoSMCs.

Arginase Inhibition by Ethylacetate Extract of Caesalpinia sappan Lignum Contributes to Activation of Endothelial Nitric Oxide Synthase

Caesalpinia sappan (C. sappan) is a medicinal plant used for promoting blood circulation and removing stasis. During a screening procedure on medicinal plants, the ethylacetate extract of the lignum of C. sappan (CLE) showed inhibitory activity on arginase which has recently been reported as a novel therapeutic target for the treatment of cardiovascular diseases such as atherosclerosis. CLE inhibited arginase II activity prepared from kidney lysate in a dose-dependent manner. In HUVECs, inhibition of arginase activity by CLE reciprocally increased NOx production through enhancement of eNOS dimer stability without any significant changes in the protein levels of eNOS and arginase II expression. Furthermore, CLE-dependent arginase inhibition resulted in increase of NO generation and decrease of superoxide production on endothelium of isolated mice aorta. These results indicate that CLE augments NO production on endothelium through inhibition of arginase activity, and may imply their usefulness for the treatment of cardiovascular diseases associated with endothelial dysfunction.

Stress-induced cardiomyopathy after general anesthesia for total gastrectomy: A case report / 대한마취과학회지

Stress-induced cardiomyopathy, which is also known as takotsubo cardiomyopathy, is a cardiac syndrome of a transient, reversible left ventricular dysfunction that is caused by emotional and/or physical stress and surgery. Its clinical manifestations are similar to those of myocardial ischemia without a coronary artery lesion. Stress-induced cardiomyopathy is more common in middle-aged women, and the prognosis is favorable. We report the case of a 50-year-old female patient who underwent a total gastrectomy and developed stress-induced cardiomyopathy after surgery.