Vaginal Delivery under Epidural Analgesia in a Patient with Takayasu Arteritis : A case report

Takayasu arteritis is a nonspecific chronic inflammatory disease of the aorta and its major branches, which has a higher incidence during the child-bearing years. There have been several reports of Takayasu arteritis during pregnancy with Cesarean delivery under general or epidural anesthesia. However, there have been few reports of successful vaginal delivery under epidural analgesia. We report a case of successful vaginal delivery under epidural analgesia in a 31-year-old primigravida with a history of Takayasu arteritis.

Retropharyngeal Abscess after an Unexpected Difficult Tracheal Intubation: A case report / 대한마취과학회지

A retropharyngeal abscess is a rare complication of tracheal intubation.A case of retropharyngeal abscess after unexpected difficult tracheal intubation is presented with a review of the medical literature.A 45-year-old female patient underwent excision and biopsy of the left false vocal cord mass under general anesthesia with tracheal intubation.There was unexpected difficulty of the tracheal intubation and several trials of intubations were performed.The patient complained of pain on the left side of the neck, a sore throat, dysphagia, and chest discomfort one day postoperatively.The patient had fever of 38.7degrees C.Flexible laryngoscopy, neck X-ray, neck computed tomography, and pharyngoesophagographic studies were performed, which revealed a retropharyngeal abscess.The patient was treated with antibiotics, nil per os, nasogastric tube feeding and underwent surgery for incision and drainage of the retropharyngeal abscess under local anesthesia.The patient recovered without complications, and the patient was discharged 12 days postoperatively.

Obstruction of Airway Filter/Heat and Moisture Exchanger during Cardiac Surgery: A case report / 대한마취과학회지

An acute obstruction of the breathing circuit during surgery can be a devastating situation. A 45-year old man who diagnosed with infective endocarditis and aortic valve regurgitation underwent emergency cardiac surgery. However, an obstruction of the breathing circuit occurred when the cardiopulmonary bypass was weaned. Fortunately, the ventilation normalized after removing the airway filter/heat and moisture exchanger (HME). We report this case of a HME obstruction of the breathing circuit with a review of the relevant literature.

Comparison of Intra-articular versus Intra-venous Patient Controlled Analgesia (PCA) following Arthroscopic Shoulder Surgery / 대한마취과학회지

BACKGROUND: The purpose of this study was to compare the postoperative analgesic effects and side effects of an intra-articular PCA infusion of bupivacaine and morphine using an intravenous PCA infusion of morphine following arthroscopic shoulder surgery. METHODS: Seventy-one patients, undergoing arthroscopic shoulder surgery under general anesthesia, were randomly assigned to one of two groups. In group 1 (n = 32), morphine and ondansetron, 8 and 4 mg, respectively, were intravenously injected following surgery, with the subsequent infusion of normal saline 100 ml, including morphine and ondansetron, 32 and 12 mg, respectively, through an intra-venous PCA catheter. In group 2 (n = 39), 0.25% bupivacaine, 40 ml, including an intra-articular injection of morphine, 3 mg, followed by an infusion of 0.25% bupivacaine, 100 ml, including morphine, 5 mg, were administered through an intra-articular PCA catheter. In groups 1 and 2, the PCA infusion rate was 2 ml/h, with a bolus dose of 0.5 ml, with a lock out time of 8 min. The VAS for pain at rest, and the range of motion (ROM) exercise and side effects were assessed 0.5, 1, 2, 4, 12, 18 and 24 h postoperatively. RESULTS: The patients in group 2 had significantly lower VAS for pain for the ROM than those in group 1 30 min postoperatively. However, the VAS for pain at rest was significantly lower in group 1 than 2 after 18 and 24 h, but the VAS for pain for the ROM was significantly lower in group 1 than 2 24 h postoperatively. There was no significant difference in the side effects between the two groups, with the exception of dizziness, which was more severe in group 2 at 1, 2 and 4 h postoperatively. CONCLUSIONS: An intra-articular PCA infusion of bupivacaine and morphine is no more effective than an intra-venous PCA infusion of morphine and ondansetron with respect to postoperative analgesia and side effects.

Anesthetic Management of Tracheal Stenosis Assisted with the Extracorporeal Life Support: A case report / 대한마취과학회지

In tracheal stenosis, airway management is most challenging for anesthesiologists. A small sized endotracheal tube, laryngeal mask airway, with high frequency jet ventilation can be used, but may result in ineffective oxygenation and ventilation. In such cases, extracorporeal life support, ECLS, can be helpful. Herein, a case of tracheal stenosis in an adult assisted with the ECLS is reported.

Opposite Sciatic Nerve Injury after Fixation of Femur Shaft Fracture: Two case reports / 대한마취과학회지

A sciatic nerve injury as a complication of the position appears to be rare. There are several reports on sciatic nerve injuries that occurred as complications of the lithotomy position. We present two cases of an opposite sciatic nerve injury after the fixation of a femur shaft fracture. Two patients complained of hyperesthesia of the right foot and a foot drop after surgery. Nerve conduction and electromyographic studies were performed, which revealed a sciatic nerve injury. The patients were treated with physiotherapy and an ankle-foot orthotic. In the case 1, patient had completely recovered ten months after surgery. However, in case 2, the patient still had residual hyperesthesia and weakness two months after surgery when he was lost to follow-up. The mechanism of nerve injury in these patients was a stretching of the nerve. Tension was placed on the nerve as a result of the external rotation of the thigh with the hip and knee joints flexed.

Rate-dependent Left Bundle Branch Block during General Anesthesia : A case report / 대한마취과학회지

Rate-dependent left bundle branch block during general anesthesia is rare, but its occurrence makes the electrocardiographic diagnosis of acute myocardial ischemia or infarction difficult. It can also be confused with slow rate ventricular tachycardia. Herein, a case of rate-dependent left bundle branch block, in a patient with no previous history of ischemic heart disease, is reported. The administration of esmolol resulted in a decrease in the heart rate, with reversion to normal sinus rhythm.

Nonlinear Analysis of Heart Rate Variability: Possible Predictor for Atrial Fibrillation after Coronary Artery Bypass Graft (CABG) Surgery / 대한구급학회지

BACKGROUND: Heart Rate Variability (HRV) is a valuable marker of autonomic tone and may assist evaluating the prognosis in patients with heart disease. The purpose of this study was to assess whether preoperative heart rate variability analysis predicts atrial fibrillation in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: This study was designed as a prospective observational study. After IRB approval was obtained by our institution, 76 patients scheduled for elective CABG surgery underwent a 10-min electrocardiogram recordings 1~2 hours prior to surgery. Heart rate variability analysis was performed with spectral analysis and point correlation dimension. RESULTS: There was no significant difference in the low and high frequency component (LF/HF) ratio preoperatively between patients with atrial fibrillation and patients with normal sinus rhythm postoperatively (3.0+/-2.45, 4.25+/-3.70, p=0.085). Baseline peak point correlation dimension (pPD2) was significantly higher in patients with atrial fibrillation than in patients with normal sinus rhythm postoperatively (4.2+/-0.8, 3.8+/-0.7, p=0.042). CONCLUSIONS: Patients who developed atrial fibrillation postoperatively had a higher baseline pPD2 value preoperatively. Point correlation dimensions may predict the occurrence of postoperative atrial fibrillation after CABG surgery. However, further studies are needed to confirm whether point correlation dimensions are an effective predictor for postoperative atrial fibrillation.

Spontaneous Subcutaneous Emphysema and Pneumomediastinum after Vesico-urethral Reimplantation under General Anesthesia / 대한마취과학회지

Mediastinal emphysema (pneumomediastinum) may result from lung disease, trauma, surgery, diagnostic or therapeutic procedure, but spontaneous occurrence is rare. Patients presenting with chest pain, radiating pain to neck and back, cough, dyspnea, dysphagia and demonstrate air-shadow line on left cardiac border by chest radiography. The authors' case is presented of pneumomediastinum, with subcutaneous emphysema occurring three days postoperatively, in a 12-year-old male patient who underwent bilateral vesico-urethral reimplantation under general anesthesia. The patient was treated conservatively with oxygen and had an uneventful recovery. The authors discuss the possible causes and its management with a review of the relevant literature.

Shock after Ureteroscopic Lithotripsy: A case report / 대한마취과학회지

One of the most fearful rare complication of ureteroscopic lithotripsy is sepsis. Since sepsis after endourological maneuvers usually occur immediately after procedure, it is important to pay attention to symptoms representing sepsis such as pyrexia, tachycardia, tachypnea, and oliguria. In addition to clinical symptoms, laboratory tests including white blood cell (WBC) count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and urine and blood cultivating can help to diagnosis of sepsis. We present a case of shock after ureteroscopic lithotripsy, which was suspected with septic shock strongly.

Neuroleptic Malignant Syndrome Caused by Risperidone Overdose: A case report / 대한마취과학회지

Neuroleptic malignant syndrome (NMS) is a rare, but potentially fatal idiosyncratic reaction to neuroleptics characterized by muscle rigidity, fever, altered consciousness, autonomic instability, leukocytosis and elevated creatinine phosphokinase level suggesting muscle injury. The incidence of NMS is estimated to be between 0.07 and 2.2% among patients receiving neuroleptics, with a motality of 11%. Although the pathophysiology of NMS is not completely understood, reduced dopaminergic activity secondary to antipsychotic induced dopamine receptor blockage is considered to be the best explanation to date. We experienced NMS in a 22-year-old male with antipsychotic drug intoxication who underwent primary closure of dual, self-inflicted wrist laceration. We recognized as NMS about 30 minutes after induction of general anesthesia. All anesthetics were stopped, and supportive care was performed with management of hyperthermia and fluid. Also, Dantrolene sodium and bromocriptine were administered. The patient recovered without any complication.

Persistent Brachial Plexus Injury Associated with Axillary Brachial Plexus Block: A case report / 대한마취과학회지

A 26-year-old male patient presented for stump revision of an amputated right 3rd finger and neurorrhaphy for a lacerated right 2nd finger. An axillary brachial plexus block was performed using the transarterial technique. Postoperatively, the patient demonstrated signs and symptoms of brachial plexus injury. He exhibited paresthesia in the distribution of the ulnar nerve and motor weaknesses the wrist, elbow, and shoulder. On the 18th postoperative day, nerve conduction and electromyographic studies were performed, which revealed possible right radial neuropathy and axillary neuropathy, or right brachial plexopathy with posterior cord involvement. After seven months of medical and physical treatment, the pain subsided but slight paresthesia and muscle weaknesses still remained. We describe a case of postoperative neuropathy, which is believed to be caused by a direct nerve injury after an axillary brachial plexus block with persistent signs and symptoms over a considerable period.

Hyperamylasemia Due to Ruptured Cerebral Aneurysm: A case report / 대한마취과학회지

Unexpected findings of hyperamylasemia have been observed in patients with primary neurosurgical abnormalities without abdominal trauma or evidence of pancreatitis. However, the causes of hyperamylasemia in abovementioned cases have not been clearly elucidated. We have experienced hyperamylasemia in a 66 year-old female patient with subarachnoid hemorrhage caused by ruptured cerebral aneurysms who had had 2 aneurysms in right pericallosal and left middle cerebral trifurcational artery. Among the 2 aneurysms, the one in right pericallosal artery was ruptured and subarachnoid, intraventricular and intracranial hemorrhage was observed on the initial brain CT scan. There was no specific problem during operation and patient's staying in recovery room. Seven hours after the operation finished, severe hypotension and metabolic acidosis were occurred. Vital signs and acidosis were corrected with fluid and bicarbonate therapy. We incidentally found marked hyperamylasemia in the first postoperative day and serum amylase level was decreased and thereafter normalized through the seventh postoperative day. There was no evidence of acute pancreatitis on either clinical examination or radiologic study of abdominal sonography and CT scan. On the brain CT scan which was taken on the third postoperative day, the increase in the amount of hemorrhage in bilateral frontal area was found and cerebral ischemia was observed in the territory of bilateral anterior cerebral artery.

Rebounded Response in Propofol Coma Therapy / 대한마취과학회지

Barbiturate has been used for the therapy of increased intracranial pressure (ICP) patients. However, it has some serious side effects such as rebound response or convulsion. According to recent reports, propofol can be used for coma therapy and the therapeutic result has been satisfactory. We used propofol instead of barbiturate in coma therapy and experienced a case of rebound response. On admission day, a 20-year-old female patient received an endovascular embolization for an arteriovenous malformation (AVM) in the left occipital lobe. The next day, she went into a coma and the brain CT showed a massive intracerebral hematoma at the AVM site. The patient was transferred to the operating room for decompressive surgery. At the end of the surgery, the brain edema did not subside. The patient was infused with propofol (4 mg/kg/h) after the surgery for propofol coma therapy. During the 6 day propofol therapy, ICP was effectively controlled under 20 mmHg. After completion of the propofol coma therapy, the patient was revived enough to verbally obey. 16 hours later, ICP increased to more than 30 mmHg and the patient was reinfused with propofol. We experienced a rebound response in propofol coma therapy similar to that in barbiturate coma therapy.

Temperature Difference between the Brain and the Axilla according to the Patients Body Temperature / 대한마취과학회지

BACKGROUND: It is believed that the brain temperature is about 1oC higher than the peripheral temperature. However the result has been mostly obtained in normothermia patients. The objective of this study was to evaluate whether the brain and axillary temperature difference would be increased or decreased in hypothermic patients. METHODS: Sixty-six patients who underwent a craniotomy with implantation of the thermal diffusion flowmetry sensor (SABER 2000; Flowtornics, Phonics, USA) were included in this study. The temperature of the cerebral cortex and axilla were measured simultaneously every 2 hours. The patient groups were divided according to their axillary temperature, hyperthermia (over 38oC: 127 paired data), normothermia (36 38oC: 1626 paired data) and hypothermia (under 36oC: 285 paired data). A total 2048 paired sample data were collected and analyzed. RESULTS: The temperature difference between the cerebral cortex and the axilla was 0.46 +/- 1.04 oC in hyperthermic patients, 0.89 +/- 1.65 C in normothermia patients and 1.04 +/- 0.82 C in hypothermic patients. The temperature difference has statistical significance in each group (unpaired t-test, P > 0.05). CONCLSIONS: Our results demonstrate that the temperature difference in the brain shows a difference according to the patients, body temperature. In normothermia the temperature difference between the brain and the axilla was about 1oC. However in a hyperthermic state, the temperature difference decreased and in a hypothermic state, the temperature difference increased.