The effects of adjuvant intrathecal fentanyl on postoperative pain and rebound pain for anorectal surgery under saddle anesthesia / 대한마취과학회지

BACKGROUND: Intrathecal opioid has been known to enhance the quality and prolong the duration of spinal anesthesia, as well as to reduce postoperative pain. The purpose of this study was to evaluate postoperative analgesic characteristics of intrathecal fentanyl for the first 48 hours after anorectal surgery under saddle anesthesia. METHODS: Eighty patients were recruited in our study. Forty patients were randomly allocated to group B that received 0.5% bupivacaine 5 mg with 0.3 ml normal saline. The other 40 patients were assigned to group BF which was given 0.5% bupivacaine 5 mg with fentanyl 15 μg. The primary outcome variable was a numeric rating scale (NRS) at six hours postoperatively. Secondary outcomes included changes in the NRS score between one and 48 hours postoperatively, consumption of rescue analgesics, and the frequency of rebound pain. RESULTS: Group BF exhibited a lower mean NRS score at postoperative six hours compared to group B (P < 0.001). However, the mean NRS score was not different after postoperative six hours between the two groups. The median consumption of rescue analgesics in group BF was less than that of group B (P = 0.028) and the frequency of rebound pain decreased in group BF when compared to group B (P = 0.021). The levels of sensory block were S1 dermatome and motor block scores were 0 for both groups. There was no significant difference in adverse effects between the groups. CONCLUSIONS: Intrathecal fentanyl 15 μg for anorectal surgery under saddle anesthesia led to an improved pain score for the first six hours after surgery and decreased postoperative analgesic use. Rebound pain diminished with intrathecal fentanyl and adverse effects did not increase.

Airway obstruction by dissection of the inner layer of a reinforced endotracheal tube in a patient with Ludwig's angina: A case report

Intraoperative airway obstruction is perplexing to anesthesiologists because the patient may fall into danger rapidly. A 74-year-old woman underwent an emergency incision and drainage for a deep neck infection of dental origin. She was orally intubated with a 6. 0 mm internal diameter reinforced endotracheal tube by video laryngoscope using volatile induction and maintenance anesthesia (VIMA) with sevoflurane, fentanyl (100 µg), and succinylcholine (75 mg). During surgery, peak inspiratory pressure increased from 22 to 38 cmH₂O and plateau pressure increased from 20 to 28 cmH₂O. We maintained anesthesia because we were unable to access the airway, which was covered with surgical drapes, and tidal volume was delivered. At the end of surgery, we found a longitudinal fold inside the tube with a fiberoptic bronchoscope. The patient was reintubated with another tube and ventilation immediately improved. We recognized that the tube was obstructed due to dissection of the inner layer.

Quadriplegia as a position-related complication after parotidectomy: the need for cooperation between anesthesiologists and surgeons when positioning patients: A case report

During surgery, the patient is positioned optimally according to the type of operation. Careful attention is required because damage associated with patient positioning may occur during the course of the surgery. Here, we present a case of hyperextension neck injury observed following parotidectomy. A 68-year-old man who was diagnosed with a parotid tumor underwent an elective right partial superficial parotidectomy. After surgery, the patient was not able to move his upper and lower extremities and experienced voiding difficulty. Cervical magnetic resonance imaging showed spinal cord injury at the C3-4 and C5-6 levels. High-dose steroid treatment was started, and emergency laminoplasty C4-5 to C5-6 was performed. Following laminoplasty, motor function was almost fully recovered, but proprioception was weak, and voiding difficulty remained a problem. The patient received rehabilitation treatment in the hospital for about 3 months, demonstrating improvement. He was discharged and continued treatment in the outpatient department.

Quadriplegia as a position-related complication after parotidectomy: the need for cooperation between anesthesiologists and surgeons when positioning patients: A case report

During surgery, the patient is positioned optimally according to the type of operation. Careful attention is required because damage associated with patient positioning may occur during the course of the surgery. Here, we present a case of hyperextension neck injury observed following parotidectomy. A 68-year-old man who was diagnosed with a parotid tumor underwent an elective right partial superficial parotidectomy. After surgery, the patient was not able to move his upper and lower extremities and experienced voiding difficulty. Cervical magnetic resonance imaging showed spinal cord injury at the C3-4 and C5-6 levels. High-dose steroid treatment was started, and emergency laminoplasty C4-5 to C5-6 was performed. Following laminoplasty, motor function was almost fully recovered, but proprioception was weak, and voiding difficulty remained a problem. The patient received rehabilitation treatment in the hospital for about 3 months, demonstrating improvement. He was discharged and continued treatment in the outpatient department.

Arrhythmogenic potential develops rapidly at graft reperfusion before the start of hypotension during living-donor liver transplantation / 대한마취과학회지

BACKGROUND: Detailed profiles of acute hypothermia and electrocardiographic (ECG) manifestations of arrhythmogenicity were examined to analyze acute hypothermia and ventricular arrhythmogenic potential immediately after portal vein unclamping (PVU) in living-donor liver transplantation (LT). METHODS: We retrospectively analyzed electronically archived medical records (n = 148) of beat-to-beat ECG, arterial pressure waveforms, and blood temperature (BT) from Swan-Ganz catheters in patients undergoing living-donor LT. The ECG data analyzed were selected from the start of BT drop to the initiation of systolic hypotension after PVU. RESULTS: On reperfusion, acute hypothermia of < 34degrees C, < 33degrees C and < 32degrees C developed in 75.0%, 37.2% and 11.5% of patients, respectively. BT decreased from 35.0degrees C +/- 0.8degrees C to 33.3degrees C +/- 1.0degrees C (range 35.8degrees C-30.5degrees C). The median time to nadir of BT was 10 s after PVU. Difference in BT (DeltaBT) was weakly correlated with graft-recipient weight ratio (GRWR; r = 0.22, P = 0.008). Compared to baseline, arrhythmogenicity indices such as corrected QT (QTc), Tp-e (T wave peak to end) interval, and Tp-e/QTc ratio were prolonged (P < 0.001 each). ST height decreased and T amplitude increased (P < 0.001 each). However, no correlation was found between DeltaBT and arrhythmogenic indices. CONCLUSIONS: In living-donor LT, regardless of extent of BT drop, ventricular arrhythmogenic potential developed immediately after PVU prior to occurrence of systolic hypotension.

A comparison of systolic and diastolic time variation with pulse pressure variation as a predictor of fluid responsiveness during pediatric liver transplantation

BACKGROUND: In pediatric patients, dynamic preload indices to predict fluid responsiveness remain controversial. Because each beat of blood pressure (BP) - waveform - contains evidence of a systolic and diastolic time interval (STI, DTI), we compared pulse pressure variation (PPV) with respiratory STI and DTI variation (STV, DTV) as predictors of fluid responsiveness during pediatric liver transplantation. METHODS: A total of 61 datasets from 16 pediatric liver transplant patients (age range one month to seven years), before and after an inferior vena cava clamp was applied, were retrospectively evaluated from electronically archived BP and central venous pressure (CVP) waveforms. STI and DTI were separated by a beat-to-beat blood pressure waveform. STV, DTV and PPV were calculated by averaging three consecutive respiratory cycles. Averaged CVP was used as a static preload index. A PPV threshold of > or =16%, a known cutoff value in pediatric surgery, was used to discriminate fluid responsiveness in the receiver operating characteristic (ROC) curve analysis. RESULTS: PPV showed correlations with STV and DTV (r = 0.65 and 0.57, P < 0.001, respectively), but not with CVP (r = -0.30, P = 0.079). The area under the ROC curves (AUC) of STV, DTV and CVP were 0.834, 0.872, and 0.613, respectively. Cut-off values of STV and DTV were 7.7% (sensitivity/specificity, 0.80/0.83) and 7.7% (sensitivity/specificity, 0.70/0.88), respectively. CONCLUSIONS: This study demonstrates that STV and DTV from a BP waveform showed the potential to predict fluid responsiveness as a surrogate of PPV during pediatric surgery.

Prolonged post-reperfusion syndrome during multivisceral organ transplantation in a pediatric patient: a case report / 대한마취과학회지

Multivisceral organ transplantation involves the transplantation of three or more abdominal organs, including small bowel, duodenum, stomach, liver, pancreas, colon, and so on. The large amounts of cold and acidic loading into systemic circulation from the graft during multivisceral organ transplantation may result in severe post-reperfusion syndrome (PRS). We describe here a 6-year-old pediatric patient with chronic intestinal pseudo-obstruction who experienced prolonged PRS and severe metabolic acidosis during seven abdominal organ transplantation including the liver, spleen, stomach, duodenum, small bowel, colon and pancreas. The hypotensive period lasted approximately 10 minutes after graft reperfusion and was accompanied by severe metabolic acidosis and hypothermia. Since PRS can be easily associated with adverse outcomes, such as poor early graft function and primary non-function, not only meticulous surveillance for aggravating factors for PRS but also their immediate correction were necessary in managing a pediatric patient undergoing multivisceral organ transplantation.

Anesthetic considerations of percutaneous transcatheter aortic valve implantation: first attempt in Korea: A report of 2 cases / 대한마취과학회지

Conventional aortic valve replacement for severe aortic stenosis is associated with a high operative mortality in the elderly patients with significant comorbidities, including severe respiratory dysfunction, renal insufficiency, and compromised cardiac function. Human transcatheter aortic valve implantation was first reported in 2002 and has become a valid alternative in selected high-risk patients in Europe and North America. This article describes the first attempt of transfemoral transcatheter aortic valve implantation in Korea. The procedure was applied in two consecutive patients with severe aortic stenosis. Despite several intra-operative complications during procedure, the post-operative outcomes were good for both patients. At post-operative 30 days there was satisfactory prosthetic valve function and hemodynamic stability.

Comparison of intermittent versus continuous interscalene brachial plexus block for postoperative analgesia

BACKGROUND: Interscalene brachial plexus block (IBPB) is an effective method of postoperative analgesia after shoulder surgery. This study evaluates the effects and complications of IBPB with two different infusion methods (using intermittent bolus infusion versus automated continuous infusion). METHODS: Thirty six patients who were scheduled for shoulder surgery were randomly assigned into two groups (the continuous vs. intermittent groups). All the patients received preoperative IBPB using 15 ml of 0.25% ropivacaine followed by insertion of a 20 gauge catheter. This catheter was connected to a patient controlled analgesia (PCA) pump after the operation. The intermittent group (n = 18) received IBPB with 0.2% ropivacaine 100 ml (bolus 15 ml, lock time 4 h) without basal infusion. The continuous group (n = 18) received IBPB with 0.2% ropivacaine 100 ml (basal rate 4 ml/h) without bolus injection. All the patients were given meperidine 25 mg when the postoperative visual analogue score (VAS) >40 mm. The VAS, heart rate, noninvasive blood pressure, respiratory rate, consumption of meperidine and complications were measured during the 64 h following surgery at intervals of 8 h. RESULTS: The VAS was higher in the intermittent group than that in the continuous group at 24 h after surgery (P < 0.01).However, there was no significant difference for the VAS between the groups for the other assessment periods.There was no significant difference for the amount of meperidine consumed and the incidence of complications between the groups. CONCLUSIONS: Intermittent IBPB's analgesic effects and complications for treating pain after shoulder surgery are similar to those of continuous IBPB. Therefore, intermittent IBPB could be used for the management of pain after shoulder surgery.

A survey on informed consent process for epidural analgesia in labor pain in Korea / 대한마취과학회지

BACKGROUND: There is a legal obligation to explain the procedure and use of epidural analgesia in labor primarily due to the possibility of potential risks and associated complications. The present study details on the survey carried out to ascertain the current status of obtaining informed consent (IC) for explaining the epidural analgesia in labor. METHODS: The present study is based on a survey through a telephone questionnaire that covered all the hospitals in Korea where the anesthesiologists' belonged to and are registered with Korean Society of Anesthesiologists. The questionnaire included questions pertaining to administration of epidural analgesia to a parturient, information on different steps of obtaining an IC, whether patient status was evaluated, when the consent was obtained, and the reasons behind, if the consent had not being given. RESULTS: A total of 1,434 respondents took part in the survey, with a response rate of 97% (1,434/1,467). One hundred seventy-four hospitals had conducted epidural analgesia on the parturient. The overall rate of obtaining IC for epidural analgesia during labor was 85%, of which only 13% was conducted by anesthesiologists. The rate of evaluating preoperative patient status was 74%, of which 45% was conducted by anesthesiologists. Almost all of the consent was obtained prior to the procedure. CONCLUSIONS: The rate of obtaining IC for epidural analgesia in labor is relatively high (85%) in Korea. However, it is necessary to discuss the content of the consent and the procedure followed for obtaining IC during the rapid progress of labor.