Duk-Hee Chun

Intrathecal meperidine reduces intraoperative shivering during transurethral prostatectomy in elderly patients

Background Shivering is a frequent event during the perioperative period. We performed a prospective, randomized, double-blind study to determine whether intrathecal meperidine (0.2 mg/kg) decreases the incidence and intensity of shivering after spinal anesthesia for transurethral operations. Methods Fifty patients scheduled for elective transurethral resection operations under spinal anesthesia were randomly allocated to two groups. Spinal anesthesia consisted of 0.5% hyperbaric bupivacaine 8 mg and, mperidine (0.2 mg/kg) (meperidine group) or, normal saline (saline group). Data collection, including sensory block level (by pinprick), blood pressure, heart rate, sublingual temperature, incidence and intensity of shivering, pruritus, nausea, and vomiting was performed at 10 minute intervals. Results The incidence and intensity of shivering was significantly less in the meperidine group than saline group (P = 0.012 and P = 0.008, for incidence and intensity, respectively). However, pruritus was more common in the meperidine group compared with the saline group (16% vs. 0%, P < 0.05). Conclusions The addition of meperidine 0.2 mg/kg to intrathecal bupivacaine lowers the incidence and severity of shivering during transurethral prostatectomy in elderly patients.

Effect of caudal block on sevoflurane requirement for lower limb surgery in children with cerebral palsy.

Background:  Caudal block is a widely used technique for providing perioperative pain management in children. In this randomized double‐blinded study, we evaluated the effects of preoperative caudal block on sevoflurane requirements in children with cerebral palsy (CP) undergoing lower limb surgery while bispectral index (BIS) values were maintained between 45 and 55.

The optimal effect-site concentration of remifentanil to attenuate the pain caused by propofol

Background The injection pain of propofol is a frequent and well-known adverse effect. This study was designed to determine the optimal effect-site concentration of remifentanil for minimizing injection pain during induction with propofol. Methods A total intravenous anesthetic technique was used for patients undergoing general anesthesia and remifentanil was pretreated to reach a certain target concentration before propofol injection. Using Dixons up-and-down method, the degree of pain described by the patient was used to adjust the target concentration of remifentanil for the next patient. Ten success-failure curves (crossovers) were sought to find the effect-site concentration (EC) of remifentanil for minimizing injection pain of propofol. Results The EC of remifentanil in 50% and 95% of adult female population (EC50 and EC95) for minimizing injection pain of propofol were 3.09 ng/ml (95% confidence limits [CI] 2.92-3.30 ng/ml) and 3.78 ng/ml (95% CI 3.45-3.95 ng/ml), respectively. Clinically significant hemodynamic compromise or respiratory complications were not found during remifentanil infusion. Conclusions Maintaining 3.78 ng/ml EC of remifentanil during induction with propofol attenuate propofol injection pain without serious adverse events in female patients undergoing general anesthesia and this method may provide the patients comfort without preparing other drugs for pain relief.

Pulmonary thromboembolism after tourniquet inflation under spinal anesthesia -A case report-

Pulmonary thromboembolism is one of the most important causes of morbidity and mortality in patients undergoing lower extremity orthopedic surgery. Early diagnosis and appropriate management are important clinical challenges. In this case, massive pulmonary embolism causing sudden cardiac arrest was attributed to use of tourniquet inflation during lower extremity orthopedic surgery. Resuscitation procedures were initiated and transesophageal echocardiography revealed pulmonary thromboembolism. Patients with high suspicion for the presence of deep vein thrombus must be monitored thoroughly during limb exsanguinations.

Inadequate spinal anesthesia in a parturient with Marfan's syndrome due to dural ectasia

Marfan syndrome (MFS) is a rare hereditary connective tissue disorder that affects the cardiovascular, musculoskeletal, and ocular systems. Pregnancy further increases the potential for cardiovascular risks due to increases in blood volume, heart rate and stroke volume. The choice of anesthetic technique is very important in patients with MFS. Dural ectasia (DE) in MFS patients may result in failure of spinal anesthesia. We reported a patient without typical symptoms related to DE who experienced spinal anesthesia failure. A-29-year-old female (weight, 58 kg; height, 161 cm) with known MFS was admitted for cesarean delivery at 37 + 6 weeks of gestational age. She had valve sparing aortic root replacement surgery due to aortic root aneurysm and was diagnosed with MFS 6 years ago. Preoperative echocardiography revealed a left ventricular ejection fraction of 68% with moderate aortic regurgitation (G2-3), trivial tricuspid regurgitation and intact aortic root graft. Aortic regurgitation had increased since the previous study conducted 6 months earlier. The patient was medicated with atenolol during pregnancy. Elective cesarean section was scheduled and routine monitoring devices were applied in the operating room. The left radial artery was cannulated for continuous monitoring of arterial pressure. The initial blood pressure was 140/73 mmHg, heart rate was 74 beats /min, and peripheral oxygen saturation was 100% at room air. Combined spinal-epidural (CSE) anesthesia was administered. The epidural space was found using a loss of resistance technique at the first attempt. Clear cerebrospinal fluid (CSF) was obtained on spinal needle insertion. There was no paresthesia. Eight mg of 0.5% hyperbaric bupivacaine and 10 ug of fentanyl was injected intrathecally. An epidural catheter was inserted without resistance and advanced 5 cm upward. The levels of sensory block were tested by alcohol swabs and pinprick tests. Ten minutes following the intrathecal injection, the patient had only limited lower limb analgesia. The epidural injection was titrated over the next 20 min, and 8 ml of 2% lidocaine and 8 ml of 0.75% ropivacaine were required to achieve T4 sensory block. The remainder of the procedure was uneventful. Ephedrine 4 mg IV was administered twice to maintain systolic blood pressure above 100 mm Hg and the patient was sedated with midazolam after delivery. The patients postoperative vital signs were stable with a blood pressure of 111/54 mmHg, a heart rate of 68 beats/min, and an oxygen saturation of 98%. The postoperative pain was managed with patient-controlled epidural analgesia. She had an uneventful postoperative course and was discharged 4 days later. DE is defined as 1) an enlarged neural canal along the spinal column, usually in the lower lumbar and sacral regions; 2) a thinning of the cortex of the pedicles and lamina of the vertebra; 3) a widening of the neural foramina; or 4) an anterior meningocele [1]. A more recent definition of DE is a widening of the dural sac or spinal nerve root sleeves. The most common clinical symptoms include low backpain, headache, weakness, and loss of sensation above and below the affected limb, bowel and bladder dysfunction, occasional rectal pain and pain in the genital area [2]. The incidence of DE in MFS patients reportedly ranges from 63% to 92% [3]. The associated increase in CSF volume due to DE, and the erratic spread of spinal anesthetic is thought to increase rate of spinal anesthesia failure in the MFS parturient [2]. A thorough reevaluation of patient DE symptoms was done before anesthesia. Our patient had no common clinical symptoms of DE, hence we expected success in spinal anesthesia. CSE anesthesia was performed in order to provide postoperative pain control, as well as epidural anesthesia in case of spinal anesthesia failure. Contrary to our expectations, spinal anesthesia failed to produce a block adequate for surgical procedure. Foran et al. [4] characterized DE in MFS patients and reported that such patients are usually asymptomatic. The severity of DE can only be radiologically evaluated by computed tomography or MRI, by assessing dural sac diameter, nerve root sleeve diameter, and lumbar pedicle width [3]. Despite lack of symptoms associated with DE the presence of DE could not be ruled out. The prevalence of DE is high among MFS patients, hence probable DE in the study patient resulted in failure of spinal anesthesia [3]. Baghirzada et al. [5] reported 2 cases of regional anesthesia in parturients with MFS with conflicting spinal anesthesia results. The success of spinal anesthesia differed based on the severity of the DE. Unless a patient undergoes radiologic examination for the presence and severity of DE before surgery, it is not possible to predict the success of spinal anesthesia in MFS patients. Epidural anesthesia provides a gradual titration of local anesthetics that ensures adequate post-operative pain control while minimizing potential hypotension caused by local anestheticinduced sympathectomy. Epidural anesthesia provides more stable hemodynamics in MFS patients with cardiovascular complications. We recommend the CSE technique or epidural anesthesia for MFS patients regardless of the presence of DE related symptoms, due to its high incidence among MFS patients and often asymptomatic occurrence.

Heparin responsiveness during off-pump coronary artery bypass graft surgery: predictors and clinical implications

Aim:To evaluate the clinical impact of reduced heparin responsiveness (HRreduced) on the incidence of myocardial infarction (MI) following off-pump coronary artery bypass graft surgery (OPCAB), and to identify the predictors of HRreduced.Methods:A total of 199 patients scheduled for elective OPCAB were prospectively enrolled. During anastomosis, 150 U/kg of heparin was injected to achieve an activated clotting time (ACT) of ≥300 s, and the heparin sensitivity index (HSI) was calculated. HSIs below 1.0 were considered reduced (HRreduced). The relationships between the HSI and postoperative MI, cardiac enzyme levels and preoperative risk factors of HRreduced were investigated.Results:There was no significant relationship between the HSI and cardiac enzyme levels after OPCAB. The incidence of MI after OPCAB was not higher in HRreduced patients. HRreduced occurred more frequently in patients with low plasma albumin concentrations and high platelet counts.Conclusion:HRreduced was not associated with adverse ischemic outcomes during the perioperative period in OPCAB patients, which seemed to be attributable to a tight prospective protocol for obtaining a target ACT regardless of the presence of HRreduced.

The relationship between symphysis-fundal height and intravenous ephedrine dose in spinal anesthesia for elective cesarean section.

Background A decreased lumbosacral subarachnoidal space volume is a major factor in the cephalad intrathecal spread of local anesthetics in term parturients and their subarachnoidal space is decreased due to the compressive effect of huge uteri. Therefore, they show a higher level of sensory block and hypotensive episodes. The purpose of this study is to investigate whether the symphysis-fundal height (SFH) correlates with the highest sensory level and the amount of ephedrine administered under spinal anesthesia. Methods Fifty-two uncomplicated parturients who consented to spinal anesthesia for elective cesarean section were studied. The SFH of all parturients had been measured just before the spinal anesthesia administered by one person. Hyperbaric bupivacaine with fentanyl 20 µg, was administered for spinal anesthesia. The amount of 0.5% bupivacaine was adjusted according to the patients height and weight. The level of sensory block and the amounts of ephedrine to treat hypotension, nausea and vomiting were assessed. Linear regression and correlation analysis were applied to analyze the data. Results According to the results of correlation analysis, there was no significant correlation between the level of sensory block and SFH. There were statistically significant positive correlations between the amount of ephedrine administered due to hypotension and SFH. Conclusions In term parturients choosing elective cesarean section, the SFH is not correlated with the sensory level of spinal anesthesia, but is correlated with the amount of ephedrine administered during spinal anesthesia.

Malposition of central venous catheter in the jugular venous arch via external jugular vein -a case report-

The central venous cannulation is commonly performed in the operating rooms and intensive care units for various purposes. Although the central venous catheter (CVC) is used in many ways, the malpositioning of the CVC is often associated with serious complications. We report a case of an unexpected malposition of a CVC in the jugular venous arch via external jugular vein.

Unexpected difficulty in ventilating the lungs after tracheal intubation -A case report-

We experienced difficulty in ventilating the lungs of a patient after tracheal intubation. After intubation, an insufficient amount of tidal volume (VT) was delivered to the patient and the fiberoptic bronchoscopic examination identified partial abutment of the endotracheal tube (ETT) orifice against the tracheal wall. After various attempts to correctly place the ETT, a double-lumen endotracheal tube was placed to achieve a sufficient VT. It is important to notice that even an appropriately placed ETT may get obstructed due to the left sided bevel at its tip.

Anesthetic management for cesarean section in a patient with Budd-Chiari syndrome - A case report -

Budd-Chiari syndrome (BCS) represents a spectrum of disease states resulting in hepatic venous outflow occlusion. Prothrombotic disorders, such as protein S deficiency may cause thrombosis of the portal and hepatic veins. We report the management of a 30-year-old BCS primigravida with protein S deficiency and destroyed lung by the pulmonary tuberculosis scheduled for Cesarean section. Moreover, patients lungs were destroyed by the pulmonary tuberculosis. Spinal anesthesia was selected for the anesthetic management. The patient recovered without any complication and discharged from hospital on the fifth postoperative day.