Early Postoperative Pulmonary Edema Attributable to Reverse Stress-Induced Cardiomyopathy in a Recently Infected COVID-19 Patient: A Case Report

The coronavirus disease 2019 (COVID-19) pandemic has increased the incidence of stress-induced cardiomyopathy (SICMP). A 33-year-old woman without any notable medical history underwent an emergency operation to treat a ruptured ectopic pregnancy. She entered hemorrhagic shock attributable to massive bleeding of the ruptured ectopic sac, followed by rapid transfusion and hydration, and vasopressor therapy. Her COVID-19 rapid antigen test was negative before surgery. After surgery, her vital signs were stable and she was mentally alert. However, about 1 hour later, she developed pulmonary edema, was re-intubated, and was admitted to the intensive care unit. There, echocardiography revealed reverse SICMP, and a COVID-19 polymerase chain reaction test was positive. She recovered well on conservative treatment. After 9 days, her echocardiography profile was normal and she was discharged without any cardiac symptoms or complications. Anesthesiologists should be aware that COVID-19-infected patients may develop postoperative SICMP.

Cause of postoperative mortality in patients with end-stage renal disease

The number of patients with end-stage renal disease (ESRD) who are dependent on hemodialysis is increasing rapidly. As a result, more patients with ESRD need surgery. These patients have a significantly higher risk of postoperative death than those with normal kidney function. Therefore, this study analyzed the causes of postoperative mortality in ESRD patients undergoing surgery under general anesthesia and the risk factors for postoperative mortality. Methods: This retrospective analysis examined the mortality of ESRD patients, 20 to 80 years old, undergoing surgery under general anesthesia. We excluded patients who underwent cardiac, cancer, or emergency surgery or organ transplantation from the analysis. The primary outcome was the cause of postoperative 30-day mortality in ESRD patients. We also assessed the mortality rate and risk factors. Results: There were 2,459 eligible ESRD patients. When patients underwent multiple surgeries during the study period, only the last surgery was considered. In total, 167 patients died during the study period, including 65 within 30 days postoperatively. The cause of death was sepsis in 22 cases (33.8%) and a major cardiac event in 16 (24.6%). Atrial fibrillation, current angina, previous myocardial infarction, asthma, lower hemoglobin and albumin levels, and a larger intraoperative colloid volume were likely to increase mortality. Conclusions: Our study suggests that immunological issues have a significant role in the death of ESRD patients after general anesthesia.

Comparison of upper and lower body forced air blanket to prevent perioperative hypothermia in patients who underwent spinal surgery in prone position: a randomized controlled trial / 대한마취과학회지

Background@#We compared upper- and lower-body forced-air blankets in terms of their ability to prevent perioperative hypothermia, defined as a reduction in body temperature to < 36.0°C, during the perioperative period in patients undergoing spine surgery in the prone position. @*Methods@#In total, 120 patients scheduled for elective spine surgery under general anesthesia were divided into an upper-warming group (n = 60) and a lower-warming group (n = 60). After inducing anesthesia and preparing the patient for surgery, including prone positioning, the upper and lower bodies of the patients in the upper- and lower-warming groups, respectively, were warmed using a forced-air warmer with specified upper and lower blankets. Body temperature was measured using a tympanic membrane thermometer during the pre- and post-operative periods and using a nasopharyngeal temperature probe during the intraoperative period. Patients were evaluated in terms of shivering, thermal comfort, and satisfaction in the post-anesthesia care unit (PACU). @*Results@#The incidence of intraoperative and postoperative hypothermia was lower in the upper-warming group than in the lower-warming group ([55.2% vs. 75.9%, P = 0.019] and [21.4% vs. 49.1%, P = 0.002]). Perioperative body temperature was higher in the upper-warming group (P < 0.001). However, intraoperative blood loss, postoperative thermal comfort scale and shivering scores, patient satisfaction, and PACU duration were similar in the two groups. @*Conclusions@#The upper-body blanket was more effective than the lower-body blanket for preventing perioperative hypothermia in patients who underwent spine surgery in the prone position.

Successful Intraoperative Management to Minimize Blood Loss Using the Combination of Tranexamic Acid and Hemocoagulase for Jehovah’s Witnesses Patient with Liver Cirrhosis

A 78-year-old Jehovah’s Witnesses women with hepatitis B viral liver cirrhosis scored as Child-Pugh A was scheduled for debulking operation of peritoneal carcinomatosis due to right ovarian cancer. Despite the need for preoperative strategies for correction of anemia and coagulopathy due to the risk of significant intraoperative hemorrhage, preoperative management was missing. In addition, she exhibited preoperative hemoglobin, hematocrit levels, and platelet count of 10.5 g/dL, 33.6%, and 85,000/μL, respectively. To minimize intraoperative blood loss, we used the combination of tranexamic acid and hemocoagulase, intraoperative blood loss counted about 700 mL, and the immediate postoperative hemoglobin was 9.0 g/dL. She recovered well without any anemic complications or thromboembolic events.

Effects of 10-min of pre-warming on inadvertent perioperative hypothermia in intraoperative warming patients: a randomized controlled trial

Background@#This study aimed to evaluate the efficacy of 10-min pre-warming in preventing inadvertent perioperative hypothermia, which is defined as a reduction in body temperature to less than 36.0℃ during the perioperative period in intraoperative warming patients. @*Methods@#In this prospective randomized study, 60 patients scheduled for elective surgery under general anesthesia lasting less than 120 min were divided into two groups: the 10-min pre-warming group (n = 30) and the control group (n = 30). Patients in the 10-min pre-warming group were pre-warmed for 10 min in the pre-anesthetic area using a forced-air warmer set at 47ºC. Intraoperatively, we warmed all patients with a forced-air warmer. Body temperature was measured using a tympanic membrane thermometer pre- or postoperatively and a nasopharyngeal temperature probe intraoperatively. Patients were evaluated on the shivering and thermal comfort scale in the pre-anesthetic area and post-anesthesia care unit. @*Results@#The incidences of intraoperative hypothermia and postoperative hypothermia were similar in both groups (10.7% vs. 28.6%, P = 0.177; 10.7% vs. 10.7%, P = 1.000 respectively). Body temperature was higher in the 10-min pre-warming group (P = 0.003). Thermal comfort during the pre-warming period was higher in the 10-min pre-warming group (P < 0.001). However, postoperative thermal comfort and shivering grades of both groups were similar. @*Conclusions@#Ten minutes of pre-warming has no additional effect on the prevention of inadvertent perioperative hypothermia in intraoperative warming patients.

Comparison of palonosetron and ondansetron to prevent postoperative nausea and vomiting in women using intravenous patient-controlled analgesia

Background@#We compared the effects of palonosetron with ondansetron for preventing postoperative nausea and vomiting (PONV) during the first 24 h after surgery in women receiving intravenous patient-controlled analgesia (IV-PCA) with fentanyl for pain control. @*Methods@#In this prospective, randomized, double-blinded study, 204 healthy patients who were undergoing elective surgery with general anesthesia were enrolled. In the palonosetron group (n = 102), 0.075 mg bolus was given intravenously (i.v.) 30 min before the end of surgery and 8 ml saline was added to the IV-PCA. In the ondansetron group (n = 102), 8 mg bolus i.v. was given 30 min before the end of surgery and 16 mg of ondansetron was added to the IV-PCA. The incidence of PONV, severity of nausea, and use of rescue anti-emetics were evaluated 6 and 24 h after the operation. @*Results@#The incidences of nausea (55.6%) and vomiting (14.1%) in the palonosetron group did not differ from those (58.3 and 19.8%) in the ondansetron group during the first 24 h after surgery (P > 0.05). No significant differences were observed in the severity of nausea and use of rescue anti-emetics between the two groups (P > 0.05). @*Conclusions@#The effects of palonosetron in preventing PONV were not different from those of ondansetron during the first 24 h postoperatively in women receiving IV-PCA with fentanyl.

Successful Intraoperative Management to Minimize Blood Loss Using the Combination of Tranexamic Acid and Hemocoagulase for Jehovah’s Witnesses Patient with Liver Cirrhosis

A 78-year-old Jehovah’s Witnesses women with hepatitis B viral liver cirrhosis scored as Child-Pugh A was scheduled for debulking operation of peritoneal carcinomatosis due to right ovarian cancer. Despite the need for preoperative strategies for correction of anemia and coagulopathy due to the risk of significant intraoperative hemorrhage, preoperative management was missing. In addition, she exhibited preoperative hemoglobin, hematocrit levels, and platelet count of 10.5 g/dL, 33.6%, and 85,000/μL, respectively. To minimize intraoperative blood loss, we used the combination of tranexamic acid and hemocoagulase, intraoperative blood loss counted about 700 mL, and the immediate postoperative hemoglobin was 9.0 g/dL. She recovered well without any anemic complications or thromboembolic events.

A Comparison of Combined Superficial Cervical Plexus Block and Interscalene Brachial Plexus Block with General Anesthesia for Clavicle Surgery: Pilot Trial

OBJECTIVE: Recently, the cases about successful regional anesthesia using combined superficial cervical plexus block and interscalene brachial plexus block for clavicle surgery have been reported. The aim of this study was to compare regional anesthesia using combined superficial cervical plexus block and interscalene brachial plexus block with general anesthesia. METHODS: In this prospective randomized study, 26 patients scheduled for elective clavicle surgery were divided into two groups: the first group was general anesthesia group (GA group, n=13) and the second group for peripheral nerve block group (PNB group, n=13). Standardized general anesthesia was done to the patients assigned to the GA group and ultrasonography-guided combined superficial cervical plexus block and interscalene brachial plexus block was done to the patients assigned to the PNB group. Postoperative sedation scale was assessed at post-anesthesia care unit, and pain scale using 10-cm Visual Analog Scale (VAS) was assessed at immediate postoperative, 30 minutes, 1 hour, 6 hours, and 24 hours. Patients needed additional analgesics, and time for first analgesic demand and duration from surgery to discharge was recorded. RESULTS: The pain VAS scales were less in PNB group than GA group from immediate postoperative time to 6 hours. The patients' immediate postoperative sedation scale less than 4 were significantly less in PNS group than GA group. The duration from surgery to discharge was shorter in PNS group than GA group. CONCLUSION: Regional anesthesia using combined superficial cervical plexus block and interscalene brachial plexus block is a successful alternative to general anesthesia for clavicle surgery.

Assessment of phase-lag entropy, a new measure of electroencephalographic signals, for propofol-induced sedation / 대한마취과학회지

BACKGROUND: Phase-lag entropy (PLE) was recently described as a measurement of temporal pattern diversity in the phase relationship between two electroencephalographic signals from prefrontal and frontal montages. This study was performed to evaluate the performance of PLE for assessing the depth of sedation. METHODS: Thirty adult patients undergoing upper limb surgery with a brachial plexus block were administered propofol by target-controlled infusion. The depth of sedation was assessed using the Observer's Assessment of Alertness/Sedation (OAA/S) scale. The effect-site concentration (Ce) of propofol was initially started at 0.5 μg/ml and was increased in increments of 0.2 μg/ml until an OAA/S score of 1 was reached. Three minutes after the target Ce was reached, the PLE, bispectral index (BIS), and level of sedation were assessed. Correlations between the OAA/S score and PLE or BIS were determined. The prediction probabilities (P(k)) of PLE and BIS were also analyzed. RESULTS: The PLE values were closely correlated with the OAA/S scores (Spearman's Rho = 0.755; P < 0.001) to an extent comparable with the correlation between the BIS and OAA/S score (Spearman's Rho = 0.788; P < 0.001). The P(k) values of PLE and BIS were 0.731 and 0.718, respectively. CONCLUSIONS: PLE is a new and reliable consciousness monitoring system for assessing the depth of sedation induced by propofol, which is comparable with the BIS.

Assessment of phase-lag entropy, a new measure of electroencephalographic signals, for propofol-induced sedation / 대한마취과학회지

BACKGROUND@#Phase-lag entropy (PLE) was recently described as a measurement of temporal pattern diversity in the phase relationship between two electroencephalographic signals from prefrontal and frontal montages. This study was performed to evaluate the performance of PLE for assessing the depth of sedation.@*METHODS@#Thirty adult patients undergoing upper limb surgery with a brachial plexus block were administered propofol by target-controlled infusion. The depth of sedation was assessed using the Observer's Assessment of Alertness/Sedation (OAA/S) scale. The effect-site concentration (Ce) of propofol was initially started at 0.5 μg/ml and was increased in increments of 0.2 μg/ml until an OAA/S score of 1 was reached. Three minutes after the target Ce was reached, the PLE, bispectral index (BIS), and level of sedation were assessed. Correlations between the OAA/S score and PLE or BIS were determined. The prediction probabilities (P(k)) of PLE and BIS were also analyzed.@*RESULTS@#The PLE values were closely correlated with the OAA/S scores (Spearman's Rho = 0.755; P < 0.001) to an extent comparable with the correlation between the BIS and OAA/S score (Spearman's Rho = 0.788; P < 0.001). The P(k) values of PLE and BIS were 0.731 and 0.718, respectively.@*CONCLUSIONS@#PLE is a new and reliable consciousness monitoring system for assessing the depth of sedation induced by propofol, which is comparable with the BIS.

Estimation of Cardiac Index: Validation of the Mobil-O-Graph NG in Comparison with the FloTrac/Vigileo

OBJECTIVE: Although the reference value of cardiac index (CI) is derived by pulmonary arterial pressure, the use of pulmonary arterial catheterization is limited by low cost effectiveness and many concerns regarding complications. Therefore, relatively noninvasive indirect measurement is used widely perioperatively. The goal of this study was to determine the accuracy of the CI derived by Mobil-O-Graph NG (cCI) noninvasively in patients undergoing general anesthesia by comparing that measured by FloTrac/Vigileo (fCI), the minimal invasive method. METHODS: The Bland-Altman method was used to quantify agreement. Bias (mean difference between fCI-cCI) represents the systematic error between methods and precision (standard deviation of the bias) represents the random error or variability between techniques. The percentage error was considered clinically acceptable, and the tested method (Mobil-O-Graph NG) was regarded as interchangeable with the reference method (FloTrac/Vigileo), if it was below 30%. RESULTS: One hundred and ninety-five patients were included in this study, and CI, measured in the 121 patients. The Bland-Altman analysis revealed a bias −0.01 and the percentage error of 32.4%. And the difference is inversely increased according the mean CI. CONCLUSION: Results showed that CI measured by Mobil-O-Graph NG had a wide limit of agreement with that measured by FloTrac/Vigileo, therefore regarded as not interchangeable.

Aprepitant in combination with palonosetron for the prevention of postoperative nausea and vomiting in female patients using intravenous patient-controlled analgesia / 대한마취과학회지

BACKGROUND: The aim of this study was to evaluate aprepitant in combination with palonosetron as compared to palonosetron alone for the prevention of postoperative nausea and vomiting (PONV) in female patients receiving fentanyl- based intravenous patient-controlled analgesia (IV-PCA). METHODS: In this randomized single-blinded study, 100 female patients scheduled for elective surgery under general anesthesia were randomized to two groups: Group AP (80 mg aprepitant plus 0.075 mg palonosetron, n = 50) and Group P (0.075 mg palonosetron, n = 50). The patients in group AP received 80 mg aprepitant per oral 1–3 h before surgery, while all patients received 0.075 mg palonosetron after induction of standardized anesthesia. All patients had postoperative access to fentanyl-based IV-PCA. The incidence of nausea and vomiting, use of rescue medication, and severity of nausea were evaluated at 6 and 24 h after surgery. RESULTS: The incidence of nausea (54%) and vomiting (2%) in group AP did not differ significantly from that in group P (48% and 14%, respectively) during the first 24 h after surgery (P > 0.05). Patient requirements for rescue medication in group AP (29%) were similar to those in group P (32%) at 24 h after surgery (P > 0.05). There was no difference between the groups in severity of nausea during the first 24 h after surgery (P > 0.05). CONCLUSIONS: Aprepitant combined with palonosetron did not reduce the incidence of PONV as compared to palonosetron alone within 24 h of surgery in women receiving fentanyl-based IV-PCA.

The effect of 10 minutes of prewarming for prevention of inadvertent perioperative hypothermia: comparison with 30 minutes of prewarming

BACKGROUND: At least 30 minutes of pre-warming has been recommended for the prevention of redistribution hypothermia. However, it has been reported that less than 30 minutes of pre-warming is also effective. The aim of this study was to evaluate the ability of 10 minutes of pre-warming to prevent inadvertent perioperative hypothermia. Results were compared with 30 minutes of pre-warming. METHODS: In this prospective randomized study, 59 patients scheduled for elective surgery less than 120 minutes under general anesthesia were divided into 2 groups: the first group was pre-warmed for 10 minutes (n = 30), the second group for 30 minutes (n = 29). The patients were pre-warmed for 10 or 30 minutes in the pre-anesthetic area using a forced-air warmer. When the patients' body temperatures decreased below 36℃, we warmed them with a forced-air warmer intraoperatively and postoperatively. Body temperatures were recorded during perioperative periods. Shivering and thermal comfort were evaluated in the pre-anesthetic area and post-anesthesia care unit. RESULTS: The incidence of intraoperative and postoperative hypothermia were not significantly different (P > 0.05). However, the temperatures were higher in the 30 minute group from the post-warming time to 90 minutes after anesthetic induction (P < 0.05). CONCLUSIONS: Ten minutes of pre-warming has the same effectiveness as 30 minutes of pre-warming for preventing inadvertent perioperative hypothermia. It is a preferable choice for the patients scheduled for surgery less than 120 minutes under general anesthesia.

Desaturaton due to Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the Patient Who Underwent the Cephalic Vein Bypass Surgery under Epidural Anesthesia

A 72-year-old man with chronic renal failure underwent cephalic vein bypass surgery. He also had diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. To avoid the exacerbation of chronic obstructive pulmonary disease, the surgery began under epidural anesthesia with no sedation and oxygen supply via simple mask. During the surgery, desaturation occurred abruptly to 83%. Desaturation continued after intubation for a while and slowly disappeared as time went by. After the surgery, in the intensive care unit we performed a bronchoscopic examination and found large amount of sputum in both bronchioles. After bronchial suction and toileting, extubation was performed. In the patient with chronic obstructive pulmonary disease, it is possible that desaturation occurs abruptly due to acute exacerbation, although the surgery is conducted under epidural anesthesia with no sedation.

Prediction of midline depth from skin to cervical epidural space by lateral cervical spine X-ray

BACKGROUND: Previous studies have shown that measuring the distance from the skin to the ligamentum flavum by ultrasound preceding cervical epidural block can be beneficial in excluding false loss of resistance. However, the measurement value using ultrasound may vary depending on the degree of operator experience. Therefore, we aimed to determine the depth from skin to cervical epidural space by using lateral cervical spine X-ray, which is a more intuitive method. METHODS: We enrolled 102 adult patients who were scheduled to undergo cervical epidural anesthesia for vascular bypass surgery of upper arm. After attaching a steel rod on the needle insertion site, lateral cervical spine X-ray was taken before the epidural procedure. We measured the distance from the steel rod to the midpoint of interlaminar space on the spinolaminar line. The X-ray depth was compared with needle depth. RESULTS: Of the 102 enrolled patients, 18 patients including 13 in whom we were unable to measure X-ray depth were excluded from the analysis. In total, 84 patients were included in the analysis. Concordance correlation coefficient between the X-ray-measured depth and needle depth was 0.925. Bland-Altman analysis indicated a mean difference of ± 1.96 SD with 0.06 ± 0.56 cm. CONCLUSIONS: Lateral cervical spine X-ray can be useful for prediction of the midline depth from skin to epidural space, particularly for operators who are not skilled at spine ultrasound or the use the C-arm fluoroscopy.

Postoperative Psychogenic Non-epileptic Seizure in the Post-Anesthesia Recovery Unit

A 43-year-old woman with left facial pain caused by occipital neuralgia was scheduled for C2 ganglionotomy and adhesiolysis of left C2 root. General anesthesia, surgical procedure, and emergence have done uneventfully. However, she developed seizure after 5 minutes postoperatively in post-anesthesia recovery unit. She showed loss of consciousness and generalized muscular rigidity after shouting “I want to die”. Neurologic examination and neuroimaging revealed no neuronal damage. Her generalized muscular rigidity improved by her daughter's visit and worsened by mention about her husband, and disappeared after 40 minutes spontaneously.

Loop Formation and Malposition of Subclavian Vein Catheter

Central venous catheterization is a useful procedure for administrating fluids and drugs as well as monitoring central venous pressure in the operating room. The internal jugular vein and the subclavian vein are preferred as catheter insertion sites because of the low risk of infection and mechanical complications. However, the risk of venous malposition is higher in subclavian vein. The loop formation of the central venous catheter accompanied by its malposition increases the risk of thrombosis. If the procedure is to be performed with any difficulty, early radiologic examination should be required to detect and avoid complications. We report a case of malposition and loop formation of central venous catheter located in subclavian vein confirmed by chest X-ray after transferred to the intensive care unit.

The Use of Total Intravenous Anesthesia Without Muscle Relaxation in Amyotrophic Lateral Sclerosis Patient

66-year-old woman with amyotrophic lateral sclerosis was scheduled for closed reduction and external fixation of left tibio-fibula. Total intravenous anesthesia using 2% propofol and remifentanil was done without muscle relaxant to avoid possible postoperative respiratory complication and pulmonary aspiration. The surgery had done without difficulty and she recovered from anesthesia promptly without respiratory complication and pulmonary aspitation. She discharged satisfactorily 15 days after surgery.

Effects of Thoracic Epidural Anesthesia on Hemodynamic Changes Induced by Hypercapnia during Sevoflurane Anesthesia

OBJECTIVE: Many studies have demonstrated that carbon dioxide has direct depressive effects on the myocardium and dilates the vascular bed. However, it leads to an increase in arterial blood pressure and cardiac output because of sympathetic stimulating effect. Extensive epidural block may impair the sympathetic innervation to the heart as well as to the adrenal gland. The present study was set up in order to investigate how an extensive epidural block would affect the hemodynamic response to sympathetic stimulation induced by hypercapnia. METHODS: Twenty patients were mechanically ventilated under general anesthesia after epidural catheter insertion on T6–T7 intervertebral space. Hypercapnia was obtained by CO2 breathing. PaCO2 (partial pressure of CO2, arterial) was adjusted to 30, 45, and 60 mm Hg with each concentration being maintained for 10 minutes. In each period, hemodynamic variables were monitored by pulmonary artery catheter. After returning to normocarbia for 15 minutes, 20 mL of 0.375% ropivacaine was injected epidurally and PaCO2 was adjusted in the same manner, and then, the hemodynamic variables of each period were checked. RESULTS: There were no changes in mean arterial pressure and heart rate by hypercapnia after combined epidural anesthesia compared with general anesthesia only. Hypercapnia increased cardiac output and cardiac index. Systemic vascular resistance was decreased significantly. Pulmonary artery pressure was increased but not significantly. The degrees of hemodynamic changes were similar between in general anesthesia alone and in combined epidural anesthesia. CONCLUSION: In spite of an extensive epidural block, hemodynamic changes induced by hypercarbnia were not changed. There are some ‘escaped’ sympathetic nerve fibers.

Suspected anaphylactic reaction associated with sugammadex: a case report / 대한마취과학회지

We describe a case of a 35-year-old male patient who was scheduled for laparoscopic cholecystectomy and developed a life-threatening anaphylactic reaction 2 min after the administration of sugammadex. He manifested erythematous wheals on the entire body, dyspnea, hypotension, and tachycardia. These symptoms disappeared after the administration of epinephrine. The patient recovered and was discharged at postoperative day 5 without any complications. After 7 weeks, we performed a skin prick test, and there was a weakly positive reaction for sugammadex. This case is suspected anaphylaxis associated with sugammadex, and we need to be aware that the use of sugammadex is associated with a serious risk of anaphylaxis.