Anesthetic Management and Bispectral Index in a Child with Miller-Dieker Syndrome: A Case Report.

Miller-Dieker syndrome (MDS) is a genetic disorder characterized by classic lissencephaly, distinctive facial features, intellectual disability, seizures, and early death. The anesthetic management of patients with MDS should focus on airway manipulation with the risk of potentially difficult intubation, seizure control due to lissencephaly, and any other clinical complications. Herein, we report a case of anesthetic management in a child with MDS and describe relevant clinical features in a perioperative anesthetic setting. This case highlights the importance of difficult airway manipulation using a videolaryngoscope, seizure management with regard to anesthetics use, and the low validity of BIS monitoring in patients with MDS.

Paradoxical vocal fold motion masquerading as post-anesthetic respiratory distress: A case report.

BACKGROUND: Functional vocal cord disorders can be a differential diagnosis for postoperative upper airway obstruction requiring urgent intervention. However, this may be unfamiliar to anesthesiologists who would favor inappropriate airway intervention and increased morbidity. CASE SUMMARY: A 61-year-old woman underwent cervical laminectomy, followed by laparoscopic cholecystectomy 10 mo later. Despite adequate reversal of neuromuscular blockade, the patient experienced repetitive respiratory difficulty with inspiratory stridor after extubation. After the second operation, the patient was diagnosed with paradoxical vocal fold motion (PVFM) by an otolaryngologist based on the clinical features and fiberoptic bronchoscopy results, and the patient was successfully treated. CONCLUSION: PVFM should be considered a differential diagnosis if a patient presents with stridor after general anesthesia.

Effects of Transfusion of Stored Red Blood Cells on Renal Ischemia-Reperfusion-Induced Hepatic Injury in Rats.

BACKGROUND: Renal ischemia-reperfusion (IR) injures the liver as well as the kidneys. Transfusion of stored red blood cells (RBCs) triggers inflammatory responses, oxidative stress, and activation of innate immunity. In the present study, we investigated the effect of transfusion of stored RBCs on renal IR-induced hepatic injury. METHODS: Sprague-Dawley rats were randomly divided into 3 groups based on the following treatments: rats subjected to sham operation (sham group), rats subjected to the induction of renal IR only (RIR group), and rats transfused with stored RBCs 1 hour after the start of reperfusion (RIR-TF group). Renal ischemia was induced for 1 hour, and reperfusion was allowed for 24 hours. After reperfusion, blood and liver tissue samples were obtained. RESULTS: Serum levels of aspartate and alanine aminotransferase were increased in the RIR-TF group compared with those in the RIR and sham groups. The hepatic mRNA expression levels of heme oxygenase-1 and neutrophil gelatinase-associated lipocalin were increased in the RIR-TF group compared with those in the RIR and sham groups. The mRNA expression level of high mobility group box-1 was also increased in the RIR-TF group compared with that in the RIR group. CONCLUSION: The transfusion of stored RBCs exacerbates renal IR-induced liver damage. Oxidative stress may be responsible for hepatic injury.

Effect of dexmedetomidine and remifentanil infusion on postoperative sore throat after lumbar spine surgery in the prone position.

BACKGROUND: A sore throat is an adverse postoperative consequence of tracheal intubation under general anesthesia. Recently, dexmedetomidine, an anesthetic adjuvant, has shown beneficial effects in postoperative sore throat (POST). Herein, we compared the effects of dexmedetomidine and remifentanil on POST after spinal surgery in the prone position, which is a risk factor for developing POST. METHODS: Ninety-eight patients were enrolled in the dexmedetomidine and remifentanil groups. Each drug was continuously infused using the following protocol: 1 µg/kg over 10 minutes followed by 0.2 to 0.8 µg/kg/h of dexmedetomidine, 3 to 4 ng/mL during induction followed by 1 to 3 ng/mL of remifentanil intraoperatively. The incidence and severity of POST were assessed serially at 24 hours postoperatively. Postoperative hoarseness, nausea, and pain scores were measured. RESULTS: The incidence and severity of POST were significantly lower in the dexmedetomidine group than that in the remifentanil group. However, the incidence of hoarseness was comparable between the 2 groups. Postoperative nausea was lower in the dexmedetomidine group at 1 hour postoperatively; however, the postoperative pain score and analgesic requirements did not differ significantly. CONCLUSIONS: Dexmedetomidine infusion as an adjuvant during sevoflurane anesthesia significantly reduced the incidence and severity of POST in patients who underwent lumbar surgery 24 hours postoperatively.

Effect on music therapy on quality of recovery and postoperative pain after gynecological laparoscopy.

BACKGROUND: Music therapy is safe, inexpensive, simple, and has relaxing properties for mental and physical capacities, as well as few side effects. Moreover, it improves patient satisfaction and reduces postoperative pain. Thus, we intended to evaluate the effect of music intervention on the quality of comprehensive recovery using quality of recovery 40 (QoR-40) survey in patients undergoing gynecological laparoscopic surgery. METHODS: Patients were randomly assigned to music intervention group or control group: 41 patients each. After anesthetic induction, headphones were placed on the patients, and then classical music selected by an investigator was started in the music group with individual comfortable volume during surgery, while the player was not started in the control group. On postoperatively 1 day, the QoR-40 (5 categories: emotions, pain, physical comfort, support, and independence) survey was evaluated, while postoperative pain, nausea, and vomiting were assessed at 30 minutes and 3, 24, and 36 hours postoperatively. RESULTS: Total QoR-40 score was statistically better in the music group, and among the 5 categories, the music group had a higher pain category score than the control group. The postoperative pain score was significantly lower in the music group at 36 hours postoperatively, although the requirement for rescue analgesics was similar in both groups. The incidence of postoperative nausea did not differ at any time point. CONCLUSION: Intraoperative music intervention enhanced postoperative functional recovery and reduced postoperative pain in patients who underwent laparoscopic gynecological surgery.

Unexpected Tension Pneumothorax after Double-Lumen Endotracheal Intubation in Patients with Pulmonary Edema: A Case Report.

Tension pneumothorax is a relatively rare complication after anesthetic induction that requires prompt diagnosis and treatment. Several handling errors related to intubation procedures or equipment and vigorous positive pressure ventilation are potentially important etiologies of tension pneumothorax in patients with underlying lung disease or in mechanically ventilated patients. We describe a case of tension pneumothorax observed after double-lumen tube (DLT) insertion followed by single-lumen tube replacement using an airway exchanger catheter in a mechanically ventilated patient. An 84-year-old female on mechanical ventilation underwent minimally invasive cardiac surgery under general anesthesia. Immediately after left-sided DLT insertion using an airway exchanger catheter, oxygen saturation decreased to 89%, peak airway pressure increased to 35 cm H2O with inadequate tidal volume, and blood pressure gradually dropped to 69/41 mmHg. Breath sounds from the right hemithorax were significantly reduced. Severe collapse of the right lung, a flattened diaphragm, and compressed abdominal organs were identified on chest radiography. Therefore, a tube thoracotomy was performed based on the findings of a tension pneumothorax. Then, oxygen saturation, peak airway pressure with adequate tidal volume, and blood pressure improved, and the distended abdomen normalized. After the pneumothorax resolved, a bronchoscopy was performed. Slight redness was noted in the right bronchus, indicating that the DLT was incorrectly inserted into the right side. In conclusion, the possibility of a tension pneumothorax should be considered during DLT intubation or endotracheal tube replacement with an airway exchange catheter.

50% effective concentration of sevoflurane for immobility in cerebral palsy children undergoing botulinum toxin injection.

BACKGROUND: This prospective study aimed to determine the optimum end-tidal sevoflurane concentration required for immobility during botulinum toxin injection in spontaneously breathing children with cerebral palsy (CP). METHODS: Twenty-three children with spastic CP, aged 3 to 12 years, with American Society of Anesthesiologists (ASA) physical status I and II, scheduled to receive botulinum toxin type A injection were enrolled in the study. After induction of deep sedation using pre-filled 8% sevoflurane in oxygen and maintenance of the predetermined end-tidal sevoflurane concentration, the botulinum toxin was injected in spontaneously breathing children. The response to the botulinum toxin injection was classified as "movement" or "no movement" by an independent investigator who was blinded to the predetermined end-tidal sevoflurane concentration and bispectral index (BIS) value. The end-tidal sevoflurane concentration was predetermined, initiating at 2.0% with 0.2% as a step size in the next patient depending on the previous patient's response using the modified Dixon's up-and-down method. RESULTS: Of 21 children, 12 (57.1%) showed "no movement" in response to the botulinum toxin injection. By Dixon's up-and-down method, the 50% effective end-tidal concentration (EC50) of sevoflurane for successful botulinum toxin injection was 1.76 ± 0.15% (95% CI 1.62-1.90). Based on the dose-response curve using probit analysis, the predicted EC50 and 95% effective end-tidal concentrations (EC95) of sevoflurane without movement were 1.77% (95% CI 1.59-2.35) and 2.09% (95% CI 1.89-5.80), respectively. CONCLUSION: Botulinum toxin injection can be successfully accomplished at an end-tidal sevoflurane concentration of 1.76 ± 0.15% in 50% of spontaneously breathing children with CP aged 3-12 years.

The Effects of Remifentanil and Fentanyl on Emergence Agitation in Pediatric Strabismus Surgery.

Emergence agitation (EA) is one of the main concerns in the field of pediatric anesthesia using sevoflurane. We investigated the effects of remifentanil and fentanyl on the incidence of EA in pediatric patients undergoing strabismus surgery. Ninety children were randomly allocated into two groups and received either remifentanil (group R: intraoperatively remifentanil 0.2 µg/kg/min) or fentanyl (group F: fentanyl 2 µg/kg at anesthetic induction) intraoperatively. After surgery, EA incidence was assessed using a four-point agitation scale and Pediatric Anesthesia Emergence Delirium (PAED) scale in the post-anesthesia care unit. Face, leg, activity, cry, and consolability (FLACC) scores for postoperative pain were also assessed. The incidence of EA using the four-point agitation scale (scores ≥ 3) was similar in both groups (remifentanil group, 28.89% vs. fentanyl group, 24.44%). Similar results were obtained using the PAED scale (scores > 12), with an incidence of 33.33% in the remifentanil group and 26.67% in the fentanyl group. Differences in FLACC scores were not found to be statistically significant. A single bolus administration of fentanyl during anesthetic induction and continuous infusion of remifentanil during surgery had similar effects on the EA incidence in these pediatric patients.

Effects of Blood Transfusion on Hepatic Ischemia-Reperfusion Injury-Induced Renal Tubular Injury.

OBJECTIVES: Hepatic ischemia-reperfusion injury and transfusion of red blood cells in liver surgery are wellknown risk factors to induce acute tubular injury. Transfusion of stored red blood cells may affect hepatic ischemia-reperfusion injury-induced acute tubular injury. Here, we hypothesized whether preischemic (due to increased severity of hepatic injury) and postischemic (due to renal uptake of free heme and iron) transfusion of stored red blood cells may potentiate acute tubular injury in rats subjected to hepatic ischemia-reperfusion injury. MATERIALS AND METHODS: Sprague Dawley rats (n = 24) were divided into 4 groups: sham operation (sham group), hepatic ischemia-reperfusion injury only (injury-only group), red blood cell transfusion before hepatic ischemia-reperfusion injury (preinjury transfusion group), and red blood celltransfusion after hepatic ischemia-reperfusion injury (postinjury transfusion group). Partial hepatic ischemia was induced for 90 minutes, with reperfusion allowed for 12 hours. Hepatic and renal tubular injury markers, renal mRNA levels of oxidant stress markers, and inflammatory markers were assessed. Renal cortex samples were examined under hematoxylin and eosin staining for tubular histopathologic score and immunohistochemical staining forinflammatory cells. RESULTS: With regard to hepatic and renal tubular injury markers, serum alanine aminotransferase, serum urea nitrogen, and histopathologic scores were increased in the preinjury and postinjury transfusion groups versus injury-only group, with moderate to strong correlation between alanine aminotransferase and tubular injury markers. Renal oxidative stress markers (heme oxygenase-1 and neutrophil gelatinaseassociated lipocalin) were correlated with increased alanine aminotransferase, with upregulation of oxidant stress markers in the preinjury transfusion group versus sham group (all markers), as well as in the injury-only and postinjury transfusion groups (heme oxygenase-1 only). We observed no changes in renal inflammatory responses among the groups. CONCLUSIONS: Preischemic transfusion potentiated acute tubular injury without triggering renal inflammatory responses. Exacerbation of hepatic injury may induce acute tubular injury via renal oxidant stress.

Comparison of ultrasound-guided stellate ganglion block at 6th and 7th cervical vertebrae using the lateral paracarotid out-of-plane approach for sympathetic blockade in the upper extremity.

Background: The authors have performed ultrasound-guided stellate ganglion block (SGB) in our clinic using a lateral paracarotid approach at the level of the 6th cervical vertebra (C6). Although SGB at C6 is a convenient and safe method, there are ongoing concerns about the weak effect of sympathetic blockade in the ipsilateral upper extremity. Therefore, ultrasound-guided SGB was attempted using a lateral paracarotid approach at the level of the 7th cervical vertebra (C7). This prospective study aimed to compare changes in skin temperature after SGB was performed at C6 and C7, and to introduce a lateral paracarotid approach for SGB. Methods: Thirty patients underwent SGB twice: once at C6 and once at C7. For every SGB, the skin temperature of the patient's hypothenar area was measured for 15 min at 1-min intervals. Skin temperatures before and after SGB and side effects were compared between C6 and C7 groups. Results: The temperature of the upper extremity increased after SGB was performed at C6 and C7. There were significant differences between mean pre-SGB and the largest increases in post-SGB temperatures (0.50±0.38℃ and 1.41±0.68℃ at C6 and C7, respectively; p<0.05). Significantly increased post-SGB temperatures (difference >1℃) were found in 5/30 (16.7%) and 24/30 (80%) cases for C6 and C7, respectively (p<0.05). There were no significant differences in side effects between SGB performed at C6 or C7 (p>0.05). Conclusion: The lateral paracarotid approach using out-of-plane needle insertion for ultrasound-guided SGB performed at C7 was feasible and more effective at elevating skin temperature in the upper extremity than SGB at C6.

Preischemic transfusion of old packed RBCs exacerbates early-phase warm hepatic ischemia reperfusion injury in rats.

BACKGROUND: Hepatic innate immune cells are considered to play a central role in the early phase of hepatic ischemia reperfusion (IR) injury. Transfusion of old red blood cells (RBCs) is known to prime immune cells, and transfusion before IR may exacerbate liver injury because of the expected hyperresponsiveness of immune cells. MATERIALS AND METHODS: Twenty-four Sprague-Dawley rats were divided into four groups: sham operation (Sham); hepatic IR only (IR Control); and two transfusion groups, preischemic (Pre-T) and postischemic (Post-T), in which allogeneic RBCs stored for 2 weeks were transfused before hepatic IR or after reperfusion, respectively. Partial hepatic ischemia was induced for 90 min, and reperfusion was allowed for 120 min. Serum alanine transaminase levels, area of necrosis, and apoptotic cells were then assessed. Inflammatory (tumor necrosis factor alpha, interleukin 1 beta [IL-1ß], IL-6, IL-10, and cyclooxygenase 2) and oxidative mediators (heme oxygenase 1, superoxide dismutase, and glutathione peroxidase 1) were assessed for elucidating the relevant mechanisms underlying the hepatic injury. RESULTS: Pre-T, but not Post-T, showed increased serum alanine transaminase levels than IR Control (P < 0.05). Area of necrosis was more severe in Pre-T than in IR Control or Post-T (P < 0.01), and apoptotic cells were also more abundant in Pre-T than in IR Control (P < 0.01). tumor necrosis factor alpha and IL-6 levels were higher in Pre-T than in IR Control or Post-T (P < 0.05), with no significant difference in cytoprotective protein levels. CONCLUSIONS: Preischemic transfusion of old RBCs aggravated hepatic injury. Inflammatory cytokines seemed to play a crucial role in liver injury exacerbation. Our results indicate that transfusion before hepatic ischemia may be detrimental.

Optimal effect-site concentration of remifentanil for inhibiting response to laryngeal mask airway removal during emergence.

PURPOSE: This randomized, controlled, double-blind study was designed to determine the optimal dose of remifentanil for preventing complications associated with the removal of a laryngeal mask airway (LMA) without delaying emergence. MATERIALS AND METHODS: This study randomly assigned 128 patients to remifentanil effect-site concentrations (Ce) of 0 ng/mL (group R0), 0.5 ng/mL (group R0.5), 1.0 ng/mL (group R1.0), and 1.5 ng/mL (group R1.5) during emergence. The emergence and recovery profiles were recorded. Adverse events such as coughing, airway obstruction, breath-holding, agitation, desaturation, nausea, and vomiting were also evaluated. RESULTS: The number of patients with respiratory complications such as coughing and breath-holding was significantly lower in the R1.0 and R1.5 groups than in the R0 group (p<0.05). Emergence agitation also decreased in the R1.0 and R1.5 groups (p<0.0083). The time to LMA removal was significantly longer in the R1.5 group than in the other groups (p<0.05). CONCLUSION: Maintaining a remifentanil Ce of 1.0 ng/mL during emergence may suppress adverse events such as coughing, breath-holding, and agitation following the removal of LMA without delayed awakening.