A fiberoptic orotracheal intubation successfully performed using a modified Guedel airway in a sedated emergency patient - A case report -

Background@#An airway assessment is usually best performed before an elective operation. But in an emergency operation, proper airway assessment can often be difficult. Fiberoptic intubation is a powerful and safe technique to deal with airway difficulty, but it requires a lot of training to be able to perform correctly. There are various specialized oral airways for fiberoptic intubation, but none of them have perfect functionality.CaseA 75-year-old male (body weight 71.6 kg, height 159.3 cm, body mass index 28.22 kg/m2) was diagnosed with acute appendicitis, and it was decided to do a laparoscopic appendectomy. After the induction of general anesthesia, it was impossible to insert the direct laryngoscope deep enough for vocal cord visualization without damaging the teeth because of limited mouth opening. We successfully performed fiberoptic intubation with a newly modified Guedel airway via a longitudinal channel on the convex side and a distal opened lingual end. @*Conclusions@#Our modified Guedel airway can be useful in assisting fiberoptic intubation in unexpectedly difficult airway situations.

Postoperative delirium in elderly patients with critical limb ischemia undergoing major leg amputation: a retrospective study / 대한마취과학회지

BACKGROUND: Critical limb ischemia has been identified as a risk factor for the incidence of postoperative delirium in elderly patients. Limb amputation is the last option in critical limb ischemia treatments. We investigated the incidence and predisposing factors of postoperative delirium in patients undergoing major leg amputation. METHODS: From January 2012 to December 2016, 121 patients aged over 60 years who had undergone major leg amputation were enrolled in this study. Various factors related to the patients’ outcomes were assessed, including demographic, preoperative laboratory, anesthetic, surgical, and postoperative indicators. RESULTS: Twenty two patients were excluded and 99 patients were assigned to either the delirium group or no delirium group. Forty of them (40%) developed a delirium during 30 days postoperatively. Univariate analysis implied that end-stage renal disease on hemodialysis, alcohol consumption, C-reactive protein, staying in an intensive care unit (ICU), duration of an ICU stay, occurrence of complications, and mortality during six months, were the factors that accounted for significant differences between the two groups. In multivariate analysis, three factors were significantly related to the development of delirium: mortality during six months (odds ratio [OR] = 13.86, 95% CI [2.10–31.90]), alcohol (OR = 8.18, 95% CI [1.13–16.60]), and hemodialysis (OR = 4.34, 95% CI [2.06–93.08]). CONCLUSIONS: Approximately 40% of the elderly patients suffered from postoperative delirium in major leg amputation. Identifying those with risk factors for postoperative delirium and intervening at the early stage will be of great benefit in major leg amputations for the elderly population.

Epidural anesthesia for permanent spinal cord stimulation with a cylindrical type lead: a case series / 대한마취과학회지

Spinal cord stimulation (SCS) in trials involving external stimulation are easily conducted under local anesthesia. However, implantation of a permanent SCS system is painful, and can be intolerable in some patients. Epidural anesthesia can be used to perform the SCS implantation without discomfort if the patient can localize the area of paresthesia. However, little is known about epidural anesthesia for SCS. This paper reports 23 cases of permanent SCS with a cylindrical type lead implanted under the epidural anesthesia. Epidural anesthesia was sufficient in 22 patients without discomfort and significant complications. The remaining patient experienced incomplete epidural anesthesia and required additional analgesics to blunt the pain. All the leads were placed consistent with the patient's report of paresthesia area under epidural anesthesia. Thus, epidural anesthesia is an effective and safe method for the optimal placement of SCS to minimize the discomfort for patients without impairing patients' response to the intraoperative stimulation test.

Clinical benefits of preemptive thoracic epidural analgesia with hydromorphone and bupivacaine in open thoracotomy lung surgery

BACKGROUND: Preemptive analgesia is known to decrease the sensitization of the central nervous system and reduce subsequent amplification of nociceptive stimuli. We investigated whether preemptive thoracic epidural analgesia (TEA) demonstrated intraoperative and postoperative short and long term clinical advantages. METHODS: Thirty patients scheduled for open thoracotomy were randomly allocated to one of two groups to receive continuous TEA (0.15% bupivacaine and 8 microg/ml hydromorphone) either before surgical incision (preemptive group) or at the end of the operation (nonpreemptive group). Incidence of hypotension during surgery was recorded. Numerical rating scales (NRS) and the incidence of side effects such as nausea, pruritus, sedation, hypotension, and respiratory depression were recorded at 2, 6, 24, and 48 hours postoperatively. Pulmonary function test (PFT) was performed before, 24 and 48 hours after the operation. Persistence of pain control was investigated at 6 months postoperatively. RESULTS: The NRS score, side effects, and PFT changes were comparable between the two groups. TEA and intravenous rescue morphine consumed at 2, 6, 24, and 48 hours postoperatively were not different between the two groups. During surgery, the incidence of hypotension was significantly higher in the preemptive group (P = 0.027). At 6-month follow up, two patients in the nonpreemptive group complained of persistent pain at wound and none in the preemptive group. CONCLUSIONS: Preemptive TEA with hydromorphone and bupivacaine during surgery may cause unnecessary intraoperative hypotension without a prominent advantage in reducing acute or chronic pain or enhancing pulmonary function after thoracotomy. The advantageous concept of preemptive TEA may be dubious and may not provide perioperative clinical benefits.

Association between the use of gel pads under patients' knees and the incidence of peroneal neuropathy following liver transplantation

<p><b>INTRODUCTION</b>There have been intermittent reports of peroneal neuropathy (PN) occurring after liver transplantation. Although PN may not be viewed as a serious complication by liver transplant (LT) recipients who require the transplant for survival, PN can significantly reduce quality of life. The incidence of PN appears to have increased after the use of gel pads was introduced. These gel pads, which are placed under patients' knees during surgery, are used to reduce lower back strain and prevent contact between the peroneal nerve at the fibular head and the hard surface of the operating table. The aim of the present study was to investigate the association, if any, between the use of gel pads and the incidence of PN.</p><p><b>METHODS</b>The medical records of 261 adult LT recipients were retrospectively reviewed. The recipients were divided into gel pad (n = 167) and non-gel pad (n = 94) groups. The incidence and possible risk factors of PN were compared between the two groups.</p><p><b>RESULTS</b>The overall incidence of PN was 8.0% (21/261). The occurrence of PN was significantly higher in the gel pad group than in the non-gel pad group (10.8% vs. 3.2%; p < 0.05). Other possible risk factors were comparable between the two patient groups.</p><p><b>CONCLUSION</b>As the use of gel pads may increase the incidence of PN, we recommend against the use of gel pads under the knees of LT recipients.</p>

Treatment of digit ulcers in a patient with Buerger's disease by using cervical spinal cord stimulation: a case report / 대한마취과학회지

Buerger's disease (thromboangiitis obliterans) is known as a segmental inflammatory vasculitis that involves the small-sized and medium-sized arteries, veins, and nerves. Most effective treatment for Buerger's disease is smoking cessation. Except for the cessation of tobacco use, surgical revascularization is available in severe ischemia and a distal target vessel. Amputation has been used as the last treatment option of the disease up to the present. Increasing limb survival and decreasing amputation rate is important. This case describes the use of spinal cord stimulation (SCS) in patient with Buerger's disease and its effect is not only the complete healing of ulcers but also amputation is not performed.

Effect of pretreatment with gabapentin on withdrawal movement associated with intravenous rocuronium injection / 대한마취과학회지

BACKGROUND: The major disadvantage of rocuronium is the withdrawal movement associated with its injection. The analgesic effect of perioperative gabapentin has been evaluated. We investigated the effects of gabapentin on the withdrawal movement induced by rocuronium injection. METHODS: 86 ASA physical status I or II patients, aged 18-69 years who were scheduled to undergo elective surgery with general anesthesia were enrolled. Patients were randomly allocated into two groups to receive either gabapentin 600 mg or placebo 2 hours prior to surgery. The patient's response to rocuronium injection was graded using a 4-point scale. RESULTS: The incidence of withdrawal movement after rocuronium administration was significantly lower in the gabapentin group (55.0% in the control group vs 28.6% in the gabapentin group). The number of patients with generalized response indicating severe pain, was 9 (22.5%) in the control group and 3 (7.1%) in the gabapentin group. CONCLUSIONS: Pretreatment with a single oral dose of gabapentin 600 mg reduced the incidence and severity of withdrawal movement after rocuronium administration.

Anesthetic experience of methemoglobinemia detected during general anesthesia for gastrectomy of advanced gastric cancer: A case report / 대한마취과학회지

Methemoglobinemia is an uncommon but potentially fatal disorder. Most cases have no adverse clinical consequence and require no treatment, but methemoglobinemia is often overlooked as a cause of low oxygen saturation, and often mistaken for the more common causes of hypoxia by anesthesiologists despite simple bedside tests that indicate the presence of this treatable abnormality. We present a 68-year-old female patient who underwent gastrectomy for advanced gastric cancer with bleeding. In the preoperative period, the patient showed cyanosis and oxygen saturation was 85% by pulse oximeter, but oxygen saturation by arterial blood gas analysis was 100%. After tracheal intubation, the methemoglobin level was 18.3%. Ascorbic acid and methylene blue were administered. During preanesthetic evaluation, the patient had not informed the anesthesiologist that she had been taking dapsone.

Airway obstruction by extrinsic tracheal compression during spinal surgery under prone position: A case report / 대한마취과학회지

Tracheal compression by vascular anomalies in adults is uncommon and most related reports are of children. A 79-year-old woman without any respiratory history underwent a lumbar spine surgery under general anesthesia. She suddenly developed airway obstruction after a position change from supine to prone. A fiberoptic bronchoscopy showed the obstruction of endotracheal tube. The obstruction was relieved after we changed the depth of endotracheal tube and supported the patient's neck with a cotton roll. The surgery ended without any other event and the patient recovered safely. A computed tomography revealed the rightward tracheal deviation and tortuous innominate artery contact with trachea. The patient didn't manifest any respiratory related symptoms during postoperative period, and she was discharged without any treatment.

Risk factors of postoperative delirium following liver transplantation / 대한마취과학회지

BACKGROUND: Postoperative delirium (POD) after liver transplantation is a serious complication. This study investigated the incidence and the risk factors of POD in liver transplantation recipients. METHODS: Three hundred and sixty eight adult recipients who had undergone liver transplantation were included. We reviewed medical records and the POD was determined by either psychiatric consultation or established diagnostic criteria. Recipients were divided into two groups according to the occurrence of POD: POD group (n = 150) and non-POD group (n = 218), and risk factors were assessed. RESULTS: One hundred fifty (40.8%) of the 368 recipients developed POD after liver transplantation. History of alcohol consumption and alcoholic liver disease, history of hepatic encephalopathy, preoperative mental status changes, ventilator care, dialysis, hypotension, and ICU care were significantly higher in the POD group. In the preoperative laboratory test, sodium was lower while bilirubin, PT (INR) and MELD score were higher in the POD group. Postoperative variables including dialysis, ventilator care duration, ICU stay, hospital stay, glucose and ammonia were significantly higher in the POD group. Three variables were identified as independent predictors of POD in a multiple regression analysis: history of alcohol consumption (odds ratio, 2.04; 95% confidence interval [CI], 1.12-3.72; P = 0.02), history of hepatic encephalopathy (odds ratio, 2.54; 95% CI, 1.46-4.41, P<0.01), and MELD score (odds ratio, 1.03; 95% CI, 1.00-1.06; P = 0.02). CONCLUSIONS: The development of POD and related morbidity and mortality would be reduced if we identified the recipients with risk factors preoperatively and applied early intervention.

Suspicious stress induced cardiomyopathy following hemorrhoidectomy under spinal anesthesia: A case report / 대한마취과학회지

A 48-year-old healthy woman was admitted in our hospital for elective hemorrhoidectomy. She developed sudden headache and chest pain, and showed sinus bradycardia, arrhythmia and hypotension forty minutes after spinal anesthesia with 0.5% hyperbaric bupivacaine. An EKG showed ST depression and an transthoracic echocardiogram performed in PACU demonstrated mild LV dysfunction with hypokinesia of LV inferolateral wall. An coronary angiography on postoperative day 1 revealed normal coronary vessel and akinesia of LV inferior wall. Levels of CK-MB and Troponin I were mildly elevated. With medical therapy, the patient's symptoms improved and recovered without any complication.

Incidental Intraspinal Tumor Detection during Treatment of Myofascial Pain Syndrome : A case report

Differential diagnosis of posterior neck and occipital pain is difficult based on symptoms and physical examination only. We report a case of patient who complained of pain in the posterior neck and occiput, with the initial diagnosis of myofascial pain syndrome, but who did not improve with conventional treatments. Magnetic resonance imaging revealed a cervical intraspinal tumor, and the patient developed subsequent motor weakness and sensory changes. Comprehensive diagnostic approaches are strongly recommended when the patient manifests symptoms unresponsive to treatment.

Spinal myoclonus on upper extremities following spinal anesthesia: A case report / 대한마취과학회지

Clonic movement is a rare complication that occurs after neuraxial blockade. We report our experience with an 18-year-old man developing myoclonic movement on his both upper extremities following intrathecal injection of 0.5% hyperbaric bupivacaine for varicocelectomy. One and half hour after spinal anesthesia, he developed bilateral, rhythmic myoclonic movements on upper extremities. Two days after surgery, neck flexion was observed. Symptoms sustained for about one month but frequency and severity of clonic movement had been reduced by anticonvulsants and muscle relaxant therapy. Four weeks later, he recovered without any complication.

The effects of amounts of intraoperative intravenous fluid administration on postoperative nausea and vomiting during gynecological surgery / 대한마취과학회지

BACKGROUND: Perioperative fluid deficits is known to induce the intestinal ischemia and release the emetogenic factors like serotonin. Many studies have reported that there is a close association between the amount of perioperative fluid administration and the incidence of postoperative nausea and vomiting (PONV). In this study, we examined whether amounts of intraoperative intravenous fluid administration would be related with the incidence of PONV in patients scheduled for gynecological surgery. METHODS: One hundred twenty gynecological patients with ASA I-II were randomized to receive either large (18 ml/kg/hr) or small (6 ml/kg/hr) volume infusion of lactated Ringer's solution intraoperatively. The incidence of PONV, severity of pain, and need for supplemental antiemetic and analgesic therapy were assessed by a blinded investigator at 0-2, 2-6, and 6-24 h postoperatively. RESULTS: There were no significant differences between the two groups in the severity of pain and amounts of rescue antiemetics and rescue analgesics administration at any given time. There were no differences between the two groups regarding the incidence of PONV at 0-2, 2-6, and 6-24 h, postoperatively. CONCLUSIONS: Intraoperative large volume infusion of lactated Ringer's solution was ineffective in reducing the incidence of PONV in patients scheduled for gynecological surgery during the postoperative period.

Atrial Fibrillation during Ethanol Sclerotherapy in a Patient with Lower Limb Arteriovenous Malformation: A case report / 대한마취과학회지

Alcohol embolization or sclerotherapy has been commonly used for a treatment of arteriovenous malformation (AVM). Alcohol sclerotherapy frequently produces minor local complications but may rarely produce catastrophic cardiopulmonary complications. In this case, general anesthesia was induced and the pulmonary artery pressure was monitored. After absolute alcohol (99.6% ethanol) injection, the systolic pulmonary artery pressure was increased, the systemic blood pressure was decreased and the EKG rhythm revealed supraventricular tachycardia and atrial fibrillation. Nitroglycerine, dobutamine, and milrinone infusions were started for the treatment of pulmonary hypertension. The EKG was restored to normal sinus rhythm two hours after judicious fluid administration and other vital signs were also recovered. The anesthesiologists must be aware of potentially serious cardiopulmonary complications possible with alcohol sclerotherapy and be prepared to manage severe cardiovascular compromise.

The Effect of High FiO2 Plus Liberal Intraoperative Fluid on the Early PONV and Pain in Patients undergoing Intra-abdominal Surgery / 대한마취과학회지

BACKGROUND: The previous studies on the influence of perioperative supplemental oxygen or generous fluid on postoperative nausea and vomiting (PONV) were inconsistent. We hypothesized in this trial that together with supplemental intraoperative oxygen and liberal fluid therapy would decrease PONV and pain. METHODS: Two hundred ASA 1 or 2 patients undergoing laparotomy and laparoscopic abdominal or gynecological surgery were randomly assigned to one of 4 groups: intraoperative FiO2 0.3 and crystalloid 6 ml/kg/h; FiO2 0.3 and 18 ml/kg/h; FiO2 0.8 and 6 ml/kg/h; FiO2 0.8 and 18 ml/kg/h. The incidence of PONV, nausea and pain scores, and amount of rescue antiemetic and analgesic drugs were studied. RESULTS: Overall incidence of PONV was 38%, 50%, 48%, 44% for group 1, 2, 3, and 4, respectively. There were no statistically significant differences among the 4 groups in the incidence of PONV, degree of nausea and pain, and the amount of antiemetics and analgesics in 2, 6, and 24 h postoperatively. The number of laparotomy and laparoscopy, and gender ratio were similar among the groups. CONCLUSIONS: We could not demonstrate an advantage of combination of intraoperative supplementary oxygen and liberal fluid in reducing PONV, pain, and amount of antiemetics and analgesics after intra-abdominal surgery.

The Effects of Supplemental Oxygen on Postoperative Nausea and Vomiting, Pain, and Stress Hormones / 대한마취과학회지

BACKGROUND: Supplemental oxygen has been reported to diminish postoperative nausea and vomiting (PONV). Surgical trauma causes increased response of stress hormones. Therefore, we aimed to investigate whether supplemental oxygen attenuates release of adrenocorticotrophic hormone (ACTH) and cortisol as well as PONV in patients undergoing thyroidectomy. METHODS: One hundred female patients were randomly assigned to two groups: 30% oxygen (Group 30) and 80% oxygen (Group 80). The incidence and the severity of PONV and pain score were evaluated 2, 6, 24 h postoperatively. PaO2, ACTH and cortisol were measured in 40 patients before tracheal intubation under 100% oxygen and at the end of surgery under designated oxygen concentration. RESULTS: The PaO2 at induction was similar between the groups, but significantly higher in the group 80 than group 30 at the end of surgery. There were no differences in the incidence and the severity of PONV and pain score postoperatively between the groups. ACTH increased significantly at the end of surgery in both groups, but cortisol did not. There were no differences in ACTH and cortisol between the groups. CONCLUSIONS: Supplemental oxygen during thyroidectomy did not reduce the incidence and severity of PONV, postoperative pain, and stress hormone responses.

Hemodynamic Responses to Rapid Sequence Endotracheal Intubation Using Propofol and Rocuronium at Three Different Doses of Remifentanil Infusion / 대한마취과학회지

BACKGROUND: This study compared the effect of the three different infusion doses of remifentanil on the hemodynamic response to rapid sequence anesthesia induction and tracheal intubation. METHODS: In this prospective, randomized double-blind study, 60 ASA I or II patients without any airway abnormalities, who were scheduled to undergo elective surgery requiring endotracheal intubation, were allocated to receive remifentanil 0.25, 0.5, or 1.0 microgram/kg/min. Anesthesia was induced with a remifentanil infusion and propofol 2.0 mg/kg. Rocuronium 1.0 mg/kg was given after a loss of consciousness and endotracheal intubation was performed 1 min after the rocuronium injection. The remifentanil infusion was stopped immediately before intubation. The noninvasive blood pressure (BP) and heart rate (HR) were recorded before induction (baseline), immediately before intubation, and at 1 min intervals until 5 min after intubation. RESULTS: The HR and BP measured immediately before intubation decreased significantly in the three doses. The HR was similar in the three doses, and the BP was significantly different only between the 0.25 and 1.0 microgram/kg/min doses (P < 0.05). The hemodynamic response to endotracheal intubation was very well blunted in 0.5 and 1.0 microgram/kg/min, but not in 0.25 microgram/kg/min. The HR and BP increased significantly 1 min after intubation in the 0.25 microgram/kg/min (P < 0.05). There were no significant differences between the 0.5 and 1.0 microgram/kg/min doses until 5 min after intubation. CONCLUSIONS: Remifentanil 0.5 microgram/kg/min infusion without a bolus provides excellent hemodynamic stability for a rapid sequence endotracheal intubation using propofol and rocuronium. There are no advantages in using remifentanil doses higher than 0.5 microgram/kg/min.