Laryngeal granulomas in patients after two-jaw surgery: Four cases report

BACKGROUND: Endotracheal intubation can cause focal ischemia, damage or edema to the laryngeal mucosa, and may be followed by serious complications such as vocal cord paralysis, ulcers, and granulation tissue formation. Laryngeal granuloma is rare but also a significant late complication of endotracheal intubation, and anesthesiologists should be concerned about it.CASE: We experienced four cases of laryngeal granuloma that developed after two-jaw surgery January 2017–December 2018 in our hospital and would like to report these cases with brief review of literature.CONCLUSIONS: There are frequent movements on the head and neck in maxillofacial surgery and the nasotracheal intubation should be prolonged after bimaxillary osteotomy surgery because of post-operative airway problems. This may be why two-jaw surgery may have higher occurrence of laryngeal granuloma than others.

A comparison between the right side and the left side of head skin in a patient who received more than 450 sessions of left stellate ganglion block: A case report

Stellate ganglion block (SGB) is an effective method that is used by pain clinicians to treat patients who have pain in the head, neck and arm area. SGB acts mainly by increasing regional blood flow via peripheral vasodilation and decreasing pain sensation by reducing the afferent sensory signals of the sympathetic nervous system in the region. This patient had received more than 450 sessions of left SGB continually for the past 6 years to relieve her left-sided facial pain caused by facial trauma. Out of our curiosity, we tried to obtain some objective dermatological measurements like skin elasticity, water content, and hair follicle density on her scalp and we found that the values were different between the left side of her face and the right side of her face. Here, we report the results and we want pain clinicians to know that repeated SGBs may improve skin elasticity, water content in the skin, and increase the number of hair follicles on the scalp.

A comparison between the right side and the left side of head skin in a patient who received more than 450 sessions of left stellate ganglion block: A case report

Stellate ganglion block (SGB) is an effective method that is used by pain clinicians to treat patients who have pain in the head, neck and arm area. SGB acts mainly by increasing regional blood flow via peripheral vasodilation and decreasing pain sensation by reducing the afferent sensory signals of the sympathetic nervous system in the region. This patient had received more than 450 sessions of left SGB continually for the past 6 years to relieve her left-sided facial pain caused by facial trauma. Out of our curiosity, we tried to obtain some objective dermatological measurements like skin elasticity, water content, and hair follicle density on her scalp and we found that the values were different between the left side of her face and the right side of her face. Here, we report the results and we want pain clinicians to know that repeated SGBs may improve skin elasticity, water content in the skin, and increase the number of hair follicles on the scalp.

Posterior reversible encephalopathy syndrome after normal vaginal delivery: A case report

Benign primary headaches are common during the postpartum period. However, there are several other kinds of headaches caused by specific underlying pathologies like post-dural puncture headache (PDPH), pregnancy induced hypertension, cortical vein thrombosis, posterior reversible encephalopathy syndrome (PRES), subarachnoid hemorrhage, intracranial hemorrhage, brain tumor, and so on. These headaches are rare but each can be life threatening conditions when diagnosis is delayed. If a patient was treated for another type of headache, like a PDPH, the diagnosis would be even more difficult. We report on the case of a 24 year-old woman who suffered with PDPH followed by postpartum eclampsia with PRES.

Whole Spontaneous Spinal Epidural Hematoma

A 26-year-old male who had no underlying disease, including coagulopathy, underwent thoracotomy and bleeding control due to hemothorax. On the fifth postoperative day, paralysis of both lower limbs occurred. Urgent spine magnetic resonance imaging showed a massive anterior spinal epidural hematoma from C2 to L1 level with different signal intensities, which was suspected to be staged hemorrhage. Hematoma evacuation with decompressive laminectomy was performed. The patient's neurologic deterioration was recovered immediately, and he was discharged without neurological deficits. A drug history of naftazone, which could induce a drug-induced platelet dysfunction, was revealed retrospectively. To our knowledge, this is the first report of whole spontaneous spinal epidural hematoma in a young patient, with a history of hemorrhoid medication.

Epidural hematoma after thoracic epidural analgesia in a patient treated with ketorolac, mefenamic acid, and naftazone: a case report / 대한마취과학회지

A 26-year-old male undergoing thoracotomy and bleeding control received a preoperative thoracic epidural for postoperative analgesia. On the fifth postoperative day, paralysis of both lower limbs occurred and urgent magnetic resonance imaging showed massive anterior epidural hematoma. During laminectomy and decompression, platelet dysfunction was diagnosed and preoperative non-steroidal anti-inflammatory drugs medications were supposed to the cause of platelet dysfunction. After infusion of ten units of platelet concentrate, coagulopathy was improved. We should be more careful to drugs with antiplatelet effect when using regional analgesia.

Comparison of ultrasound-guided supraclavicular block according to the various volumes of local anesthetic / 대한마취과학회지

BACKGROUND: The ultrasound guidance in regional nerve blocks has recently been introduced and gaining popularity. Ultrasound-guided supraclavicular block has many advantages including the higher success rate, faster onset time, and fewer complications. The aim of this study was to examine the clinical data according to the varied volume of local anesthetics in the ultrasound-guided supraclavicular block. METHODS: One hundred twenty patients were randomized into four groups, according to the local anesthetic volume used: Group 35 (n = 30), Group 30 (n = 30), Group 25 (n = 30), and Group 20 (n = 30). Supraclavicular blocks were performed with 1% mepivacaine 35 ml, 30 ml, 25 ml, and 20 ml, respectively. The success rate, onset time, and complications were checked and evaluated. RESULTS: The success rate (66.7%) was lower in Group 20 than that of Group 35 (96.7%) (P < 0.05). The average onset times of Group 35, Group 30, Group 25, and Group 20 were 14.3 +/- 6.9 min, 13.6 +/- 4.5 min, 16.7 +/- 4.6 min, and 16.5 +/- 3.7 min, respectively. There were no significant differences. Horner's syndrome was higher in Group 35 (P < 0.05). CONCLUSIONS: In conclusion, we achieved 90% success rate with 30 ml of 1% mepivacaine. Therefore, we suggest 30 ml of local anesthetic volume for ultrasound-guided supraclavicular block.

Minimum effective volume of mepivacaine for ultrasound-guided supraclavicular block / 대한마취과학회지

BACKGROUND: The aim of this study was to estimate the minimum effective volume (MEV) of 1.5% mepivacaine for ultrasound-guided supraclavicular block by placing the needle near the lower trunk of brachial plexus and multiple injections. METHODS: Thirty patients undergoing forearm and hand surgery received ultrasound-guided supraclavicular block with 1.5% mepivacaine. The initial volume of local anesthetic injected was 24 ml, and local anesthetic volume for the next patient was determined by the response of the previous patient. The next patient received a 3 ml higher volume in the case of the failure of the previous case. If the previous block was successful, the next volume was 3 ml lower. MEV was estimated by the Dixon and Massey up and down method. MEV in 95, 90, and 50% of patients (MEV95, MEV90, and MEV50) were calculated using probit transformation and logistic regression. RESULTS: MEV95 of 1.5% mepivacaine was 17 ml (95% confidence interval [CI], 13-42 ml), MEV90 was 15 ml (95% CI, 12-34 ml), and MEV50 was 9 ml (95% CI, 4-12 ml). Twelve patients had a failed block. Three patients received general anesthesia. Nine patients could undergo surgery with sedation only. Only one patient showed hemi-diaphragmatic paresis. CONCLUSIONS: MEV95 was 17 ml, MEV90 was 15 ml, and MEV50 was 9 ml. However, needle location near the lower trunk of brachial plexus and multiple injections should be performed.

Intracerebral hemorrhage in a patient with preeclampsia and HELLP syndrome which was diagnosed after caesarean section : A case report / 대한마취과학회지

Intracerebral hemorrhage (ICH) is one of very dangerous complications of preeclampsia/eclampsia. We experienced postoperative ICH in a 39-year-old woman with preeclampsia and HELLP syndrome. The paturient complained severe headache and upper abdominal pain with nausea and vomiting. Her initial blood pressure was 190/120 mmHg and her heart rate was 80 beat/min. The diagnosis of preeclampsia with HELLP syndrome was confirmed by the severe hypertension and the laboratory findings. She was drowsy at the emergency room but she lost consciousness when transferring to the operation room. Caesarean section was done under general anesthesia. After the operation she could not recover self-respiration and consciousness. Her brain CT showed ICH in the basal ganglia with intraventricular hemorrhage and severe brain edema. She expired one the 5 th post operative day due to brain death and multiple organ failure. Early diagnosis is the key to treating ICH.

The correlation between the effects of propofol on the auditory brainstem response and the postsynaptic currents of the auditory circuit in brainstem slices in the rat / 대한마취과학회지

BACKGROUND: Although there have been reports showing the changes of the auditory brainstem response (ABR) waves by propofol, no detailed studies have been done at the level of brainstem auditory circuit. So, we studied the effects of propofol on the postsynaptic currents of the medial nucleus of the trapezoid body (MNTB)-lateral superior olive (LSO) synapses by using the whole cell voltage clamp technique and we compared this data with that obtained by the ABR. METHODS: 5 rats at postnatal (P) 15 days were used for the study of the ABR. After inducing deep anesthesia using xylazine 6 mg/kg and ketamine 25 mg/kg, the ABRs were recorded before and after intraperitoneal propofol injection (10 mg/kg) and the effects of propofol on the latencies of the I, III, and V waves and the I-III and III-V interwave intervals were evaluated. Rats that were aged under P11 were used in the voltage clamp experiments. After making brainstem slices, the postsynaptic currents (PSCs) elicited by MNTB stimulation were recorded at the LSO, and the changes of the PSCs by the bath application of propofol (100 microM) were monitored. RESULTS: We found small, but statistically significant increases in the latencies of ABR waves III and V and the interwave intervals of I-III and III-V by propofol. However, no significant changes were observed in the glycinergic or glutamatergic PSCs of the MNTB-LSO synpases by the application of propofol (100 microM). CONCLUSIONS: Glycinergic or glutamatergic transmission of the MNTB-LSO synapses might not contribute to the propofol-induced changes of the ABR.

Tuberculosis like lesion on the epiglottis of a patient with an extrapulmonary tuberculosis abscess: A case report / 대한마취과학회지

Epiglottic tuberculosis without pulmonary involvement is an uncommon disease that has rarely been described in Korea. We report here a case of a 36 year-old man with a recurrent tuberculosis abscess in his thigh. He had been treated with steroids for systemic lupus erythematosus, and he suffered from recurrent tuberculosis abscess in the thigh where he had received total hip replacement arthroplasty. When inducing general anesthesia for incision and drainage, we noticed a destroyed epiglottis. After consultation with an otolaryngologist, we concluded that the patient has had epiglottic tuberculosis and precautions against tuberculosis infection were taken. The surgery ended without event. The patient recovered safely and was transferred from the operating room directly to the general ward. In this paper, we also discussed the epiglottic tuberculosis and precautions that were taken to prevent tuberculosis infection of the healthcare workers in the operating theater.

Dyspnea after supraclavicular brachial plexus block in a morbidly obese patient due to phrenic nerve block: A case report / 대한마취과학회지

A 57-year-old woman with morbid obesity (BMI: 37.39) was scheduled for ligament reconstruction with tendon interposition of the carpometacarpal joint. A difficult supraclavicular brachial plexus block was performed using a 22-gauge regional block needle with a nerve stimulator and 40 ml of 1% mepivacaine. Approximately 10 minutes after the injection, she complained dyspnea, shortness of breath and right mid-thoracic pain. Her oxygen saturation decreased from 100% to 95%. Diagnostic workup revealed right diaphragmatic elevation caused by phrenic nerve block. General anesthesia was induced because of the unsuccessful brachial plexus block and dyspnea with chest pain. She recovered without any residual complications and was discharged on the third postoperative day. Phrenic nerve block is a common complication in supraclavicular brachial plexus block but it is usually not severe and reassurance is enough to control it. However, pre-operative physical conditions that may lead to decreased respiratory reserves, such as morbid obesity should be considered as a risk factors when conducting supraclavicular brachial plexus block.

Sinus arrest during valsalva maneuver after pneumonectomy: A case report / 대한마취과학회지

We report a case of cardiac arrest in a 71 year old male during the Valsalva maneuver that had been performed immediately after completing a pneumonectomy. The patient had a subclinical atrial septal defect (1.08 cm sized) and he previously undergone a left upper lobectomy of the lung without complications 11 months earlier. He underwent a left completion pneumonectomy due to recurrent lung cancer. After surgery a Valsalva maneuver was performed with 35 cmH2O to relocate the mediastinum. During this procedure, the patient experienced a cardiac arrest and was resuscitated with difficulty. It is believed that the cardiac arrest was due to pulmonary hypertension, right ventricular failure and right to left shunt caused by several factors, such as the pneumonectomy, subclinical atrial septal defect (1.08 cm sized), and Valsalva maneuver. In addition, the hypovolemia caused by fluid restriction and the epidural injection of local anesthetics might have contributed to this incident. Although it is a rare complication, it is suggested that subclinical ASD can cause severe hypoxemia, dyspnea even cardiac arrest after pneumonectomy. In order to avoid these complications, ASD should be treated with percutaneous closure or surgical intervention. If these are not possible, care must be taken when anesthetizing the patient, and anything that can increase the pulmonary vascular resistance and right to left shunt should be avoided.

Use of the Airtraq(R) optical laryngoscope as a rescue airway device following failed awake flexible fiberoptic nasotracheal intubation of a patient with severe microsomia: A case report / 대한마취과학회지

We report here the successful use of the Airtraq(R) optical laryngoscope (AOL) as a rescue device following failed awake flexible fiberoptic nasotracheal intubation of a patient with severe mandibular microsomia. We attempted awake fiberoptic nasotracheal intubation following topical anesthesia with 4% lidocaine spray three times to induce general anesthesia for distraction osteogenesis of mandibular bone. However, due to a shallow pharyngeal cavity and cranially displaced larynx, we failed to locate the larynx each time and were therefore not able to intubate the patient. Awake orotracheal intubation using the AOL allowed us to easily intubate the patient. Therefore, we recommend that the AOL be used as a rescue airway device for intubation of difficult airways.

Pulseless Electrical Activity of Unknown Origin during Total Gastrectomy: A case report / 대한마취과학회지

Pulseless electrical activity refers to a heterogeneous group of cardiac rhythm disorders, all characterized by pulselessness in the presence of some type of electrical activity other than ventricular tachycardia or ventricular fibrillation. We experienced a case of sudden pulseless electrical activity and cardiac arrest during hetastarch infusion in general anesthesia in an adult who had total gastrectomy. We report this experience with a brief review of literature.

Assessment of Progressive Changes in the Amount of Blood Transfusion of Adult Liver Transplantation / 대한마취과학회지

BACKGROUND: Liver transplantation often requires a large amount of blood products. To reduce blood bank workload and excessive blood products preparation, we evaluated the blood components use in liver transplantation. METHODS: We enrolled 300 patients who underwent liver transplantation between May 1996 to December 2003 (235 adults, 58 children, 7 retransplantations) at Samsung Medical Center, Seoul, Korea. The patients were divided into 6 groups of 50 cases per group by their operation date. We excluded children and adult patients who received retransplantation. All patient groups were retrospectively evaluated using hospital charts and computerized data. We investigated the amounts of blood components transfused during the intraoperative period. RESULTS: The amount of leukocyte-depleted red blood cells transfused showed a significant decrease when the first group (32.1+/-17.8 units) was compared to the last (5.9+/-3.2 units). Also the amount of fresh frozen plasma and leukocyte-depleted platelet concentrate transfusion showed a significant decrease but cryoprecipitate did not. When the groups were re-divided into 3 groups (liver cirrhosis, hepatocellular carcinoma, fulminant hepatitis) according to disease type, the decrease in the transfusion amounts of each disease groups were similar to the overall group. CONCLUSIONS: An improved surgical technique was verified as the most important factor with respect to decreasing the blood transfusion amount. The results of this study offfer a guideline for estimating blood product preparation requirement for liver transplantation.

Effect of Cryoanalgesia Combined with Intravenous Continuous Analgesia in Thoracotomy Patients

Fifty patients undergoing thoracotomy was studied to compare the effects of cryoanalgesia combined with intravenous continuous analgesia (IVCA). Patients were randomized into two groups: IVCA group and IVCA-cryo group. Subjective pain intensity was assessed on a visual analogue scale at rest (VAS-R) and during movement (VAS-M). Analgesic requirements were evaluated over the 7 days following surgery. Forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV1) were measured before operation, on the 2nd and 7th postoperative days (POD). We interviewed patients by telephone to evaluate the prevalence of post-thoracotomy pain at the 1st, 3rd, and 6th months postoperatively. No significant differences were observed between the two groups with respect to postoperative pain, analgesic requirements, side effects, respiratory complications, or prevalence of post-thoracotomy pain. However, a significant increase in FVC and FEV1 was observed on the 7th POD in IVCAcryo group. The incidence of the post-thoracotomy pain at the 1st, 3rd, and 6th months postoperatively was 68, 60, and 44% in IVCA group, and 88, 68, and 28% in IVCAcryo group, respectively. Our study showed that cryoanalgesia combined with IVCA effectively restore respiratory function on 7th POD, but that it was not effective at reducing the incidence of post-thoracotomy pain.

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.

Postoperative Outcome in Formerly Premature Infants undergoing Herniorrhaphy: Comparison of Spinal and General Anesthesia

To compare the postoperative outcome according to the type of anesthesia, formerly prematured and high-risk infants who had received and weaned ventilator care preoperatively and had undergone inguinal herniorrhaphy were enrolled in this study. Immediate pre- and post-operative respiratory data which contained the lowest respiratory rates, SpO2, heart rates and the incidence of hypoxemia and bradycardia were collected with the incidence of ventilator care, application of continuous positive airway pressure (CPAP), application of oxygen, hospital stay, and respiratory mortality by chart review, retrospectively. Among the twenty-nine infants, fourteen received the general anesthesia (GA group), and fifteen received the spinal anesthesia (SA group). Postoperatively, the infants in the GA group had lower SpO2 (77.1 +/- 20.9% vs. 93.0 +/- 5.5%), higher incidence of hypoxemia (6 vs. 0), ventilator care (5 vs. 0) and application of CPAP (4 vs. 0) than the infants in the SA group. One infant in the GA group died because of acute respiratory failure caused by respiratory syncythial virus pneumonia. We concluded that spinal anesthesia reduces postoperative oxygen desaturation and respiratory morbidity in formerly prematured and high-risk infants who underwent inguinal herniorrhaphy.