[Massive hemorrhage associated with undiagnosed placenta percreta in a second-trimester pregnancy receiving abortion procedure].

A 26-year-old woman presented with an incomplete miscarriage and was scheduled for curettage at 21 weeks of gestation. She received curettage under spinal anesthesia and vaginal hemorrhage could not be controlled due to placenta percreta and cesarean section was immediately performed. Profuse bleeding continued and the patient developed hemorrhagic shock. For the purpose of circulatory and respiratory management, general anesthesia was induced and a hysterectomy was performed. For treatment of hemorrhage-induced hypotension, dobutamine and norepinephrine were administrated, while fluid replacement was continued with packed blood cells. Hemorrhagic shock, however, was not responsive to catecholamines, and her arterial pressure decreased to 40/20 mmHg. She received a bolus injection of vasopressin, 1 U, by i.v. push. Her arterial pressure increased to 140/65 mmHg after vasopressin administration, and catecholamines were tapered off before operation was finished. The patient's total blood loss was estimated to be approximately 6,000 ml. She recovered without complications and was discharged on the 7th postoperative day. Vasopressin may be an option to stabilize cardiocirculatory function in patients with uncontrolled hemorrhagic shock.

In vitro study of patient's and physician's radiation exposure in the performance of epiduroscopy.

BACKGROUND AND OBJECTIVES: Epiduroscopy is a minimally invasive diagnostic and therapeutic technique, useful in the management of patients with back and leg pain. However, the dose of radiation exposure by fluoroscopy during epiduroscopy is not known. The endpoint of our study was to evaluate the amount of radiation exposure for patients and health care workers during epiduroscopy. METHODS: First, we measured the radiation dose during a 10-minute fluoroscopy exposure in humanoid models, which substituted for the patient and the physician. Second, we measured the duration of fluoroscopy during our clinical epiduroscopy in 14 patients and observed for radiation injury in these patients. RESULTS: In the humanoid models, the patient model skin exposure dose over a 10-minute period was measured as 238 mGy. The physician's exposure dose for 10 minutes was measured as 0.67 mGy outside the lead apron and 0.0084 mGy inside the lead apron. For the clinical epiduroscopic procedures, the average duration of fluoroscopy was 9 minutes and 26 seconds. No skin injuries in the patients were observed at a 1-month postprocedure assessment. CONCLUSIONS: The radiological dosages in the patient humanoid model were less than the threshold doses that could lead to organ injuries for 1 epiduroscopic procedure. However, care should be taken for cumulative exposures in repeated procedures.

[Granulomatous polyp in the bronchus caused by anticoagulant therapy].

A 73-year-old woman was scheduled for right lower lobectomy. Her trachea was intubated with a left double-lumen endobronchial tube (Sheribronch, 35 Fr). There was no bleeding at the trachea or the bronchus during the operation. She received intravenous heparin (4000 IU.day-1) for anticoagulant therapy one hour after operation. On the first post-operative day, the mucosal bleeding in the left main bronchus was confirmed, which developed a granulomatous polyp on the 17th post-operative day. The anticoagulant therapy may have worsened slight mucosal damage caused by double lumen tube. It is important to select suitable tube size especially in patients who will receive anticoagulant therapy.

[Postintubation granuloma of the larynx].

A 50-year-old woman underwent tonsillectomy under general anesthesia. She developed progressive hoarseness two month after the tonsillectomy, and a large granuloma of the larynx was found. Surgical removal of the granuloma was performed by laryngo-microsurgery. We should keep in mind that postintubation granuloma of the larynx might develop after tracheal intubation, and careful airway manipulation is needed to avoid this potential complication.