Ho Sik Moon

The effect of ulinastatin on hemostasis in major orthopedic surgery

Background Ulinastatin, a urinary trypsin inhibitor, is widely used to treat acute systemic inflammatory disorders. However, the effects of ulinastatin, especially on the potential for hemostasis, have not been fully elucidated. This study examined whether ulinastatin had any beneficial effects on blood loss and blood transfusion requirements in patients undergoing major orthopedic surgery. Methods Eighty patients, aged 18 to 75 years, scheduled for major orthopedic surgery were enrolled in this study and were divided into the ulinastatin (n = 40) and control (n = 40) groups. Following the induction of general anesthesia, and immediately before the surgical incision, the patients in the ulinastatin group were given 5,000 units/kg of ulinastatin, which were mixed in 100 ml normal saline intravenously over 30 min, while those in the control group received the same volume of normal saline. The amounts of blood loss, infused fluid, and transfused blood products were measured throughout the study period. Blood samples for coagulation parameters were obtained before inducing anesthesia (T1), at the end of surgery (T2), and 12 h after surgery (T3). Results The amounts of blood loss and infused fluid during surgery were not significantly different between the two groups. However, 12 h postoperative blood loss was significantly less in the ulinastatin group than in the control group (255.0 ± 133.2 ml VS. 395.4 ± 338.4 ml, P < 0.05). Conclusions Our data suggest that a single infusion of ulinastatin in major orthopedic surgery is associated with decreased blood loss in the early postoperative period.

Air-Q®sp-assisted awake fiberoptic bronchoscopic intubation in a patient with Ludwig's angina

A drastic, progressive gangrenous cellulitis of the soft tissues of the deep neck and mouth floor was described in 1836 by the German surgeon Karl Friedrich Wilhelm von Ludwig [1]. Current medical care practices have meant that Ludwig’s angina is rarely seen. However, once the disease process is underway, there is a serious risk of sudden death due to airway obstruction. We describe the successful management of a case of Ludwig’s angina and provide details of awake fiberoptic bronchoscope (FOB) intubation using the Air-Q Ⓡ sp as a conduit. A 57-year-old, 80 kg man presented complaining of a 3 day history of mouth and neck pain, dyspnea, and dysphagia. The patient had no recent history of dental treatment, but had a medical history of gout, hypertension for 10 years, and a mild cerebral stroke 8 years previously. Laboratory tests revealed acute kidney injury combined with severe dehydration. Despite the hospitalized treatment for 2 days, his symptoms worsened and he began to exhibit the features of Ludwig’s angina. Neck computed tomography (CT) showed severe swelling of the left peritonsilar region with parapharyngeal space-occupying lesions, the aryepiglottic folds with obstruction of the left pyriform sinus were suggestive of a deep neck infection. The patient was scheduled to undergo emergency intubation ahead of surgery. The patient underwent hemodialysis to correct his renal and hemodynamic conditions prior to the procedure. He was febrile (a tympanic temperature of 39 o C), a heart rate of 115 bpm, a respiratory rate of 25, and blood pressure of 150/90 mmHg. The extent of mouth opening was slightly restricted with an inter-incisor gap of 2.5 cm. Tracheostomy was considered, but it was rejected because of concerns over the reduction in the patient’s cricothyroid space caused by the swelling, the limited extension and shortness of the neck with vague landmarks. Awake FOB intubation was selected as the safest option. The necessity of the procedure was explained to the patient and written informed consent was obtained. Because of the patient’s status, no premedication was administered. It was difficult to effectively administer nebulized drugs, so topical 4% lidocaine drops and a 10% lignocaine spray puff was used. The FOB (outer diameter of 3.5 mm) was fitted with a size 7.0 endotracheal tube (ET). After preoxygenation (SpO2 was 98%) and meticulous suction of oral secretions, the FOB tip was gently introduced into the oral cavity with the full cooperation. The vocal cords were visible, but it was hard to move past them because of their swollen and distorted anatomy, and moving the tongue disturbed the progress, thereby stopping the FOB tip. For the second attempt, a lubricated Air-Q Ⓡ sp size 3.5 (Cookgas LLC, St. Louis, USA) was gently inserted without hindrance, and a bite block was inserted through the tube of the Air-Q Ⓡ sp after removing the red-color coded connector. The prepared FOB and ET were inserted using the Air-Q Ⓡ sp as a conduit; the FOB tip was able to easily pass over the vocal cords and into the trachea. There were no difficulties in removing the Air-Q Ⓡ sp after intubation. Successful tracheal intubation had been achieved while maintaining spontaneous ventilation. The patient was admitted to the ICU for intensive medical care. The following morning, the patient was stable but neck CT showed the deep neck regions were aggravated. Elective surgery to incise and drain the lesions was performed. Surgery and postextubation recovery was uneventful. Clinical recovery was slow, with a persistent fever that lasted until the fifth day of

Lead fracture of peripheral nerve stimulator for brachial plexopathy -a case report-

Peripheral nerve stimulation (PNS) is a useful treatment for chronic pain, but it can cause damage depending on its application site. Here, we describe the case of a 54-year-old man who underwent PNS for brachial plexopathy in 2015. One lead was implanted on the left medial cord to stimulate the medial antebrachial cutaneous nerve, and the other was implanted on the radial nerve to stimulate the posterior antebrachial cutaneous nerve. Both leads were inserted near the shoulder joint but did not cross it. Before PNS, the patient did not move his shoulder and elbow because of severe pain, but the treatment greatly alleviated this pain. Twenty months after the operation, both leads were fractured, and the severe pain returned. Repetitive motion near the joint was closely related to the lead fractures. In conclusion, large joints as the insertion sites of PNS leads should be avoided to prevent lead fractures.

The effect of humidified heated breathing circuit on core body temperature in perioperative hypothermia during thyroid surgery

Purpose: During general anesthesia, human body easily reaches a hypothermic state, which is mainly caused by heat redistribution. Most studies suggested that humidified heated breathing circuits (HHBC) have little influence on maintenance of the core temperature during early phase of anesthesia. This study was aimed at examining heat preservation effect with HHBC in case of undergoing surgery with less exposure of surgical fields and short surgical duration. Methods: Patients aged 19 to 70 yr - old, ASA-PS I or II who were scheduled for elective thyroidectomy were assigned and divided to the group using HHBC (G1) and the group using conventional circuit (G2) by random allocation. During operation, core, skin, and room temperatures were measured every 5minutes by specific thermometer. Results: G1 was decreased by a lesser extent than G2 in core temperature, apparently higher at 30 and 60 minutes after induction. Skin and room temperatures showed no differences between the two groups (p>0.05). Consequently, we confirmed HHBC efficiently prevented a decrease in core temperature during early period in small operation which has difficulty in preparing warming devices or environments were not usually considered. Conclusions: This study showed that HHBC influences heat redistribution in early period of operation and can lessen the magnitude of the decrease in core body temperature. Therefore, it can be applied efficiently for other active warming devices in mild hypothermia.

Anesthetic management of a neonate with congenital laryngeal cyst

Congenital laryngeal cysts are rare, with an incidence of 1.82 per 100,000 live births [1]. They arise from the glottic area (58.2%), ventricular fold (18.3%), vallecula (10.5%), epiglottis (10.1%), and the aryepiglottic fold, as an order of frequency [2]. A congenital laryngeal cyst may easily obstruct the smaller airway of a neonate [3]. During anesthesia for patients with laryngeal cysts, anesthesiolosists can face the risk of obscured views of the larynx, loss of the airway, risk of rupturing the cyst, and potential aspiration of cyst contents. A 3.83 kg-weighed, 21-day-old female neonate was scheduled for an elective operation on a laryngeal cyst. She was born at 39 weeks and two days of gestation by cesarean section at 3.7 kg body weight. She started to cough at 7 days after birth, exacerbated by feeding. Her chest x-ray was normal. The otolaryngologist heard stridor, and confirmed a laryngeal cyst by flexible fiberoptic laryngoscopy. They confirmed a 1.2 × 0.9 cm - sized large fluid attenuation mass at the right oropharyngeal region immediately below the vallecula by CT (Fig. 1). Her weight gain was only 130 gm during the 3 weeks after birth. She was inactive and cried very weakly. Fig. 1 Neck CT sagittal view shows a 1.2 × 0.9 cm - sized cyst (arrow) just below the vallecula, protruding into the airway. The major concern in anesthesia was how to intubate the trachea of the neonate. Our flexible endoscope has an outer diameter of 3.1 mm, unusable through 3.0 mm and 3.5 mm inner diameter endotracheal tubes. We decided to attempt an awake intubation. When the neonate arrived at the operating suite, her blood pressure was 75/40 mmHg, heart rate was 135 beats/min, and SpO2 was 97%. We injected glycopyrrolate 0.04 mg intravenously. After sufficient preoxygenation at right-side down decubitus position, we attempted a direct laryngoscopy with a Macintosh #1 blade. However, while the attempted intubation failed, her SpO2 did not decrease. From a brief observation during the first attempt, the laryngeal cyst completely blocked our view of the larynx. It appeared that she did not need sedative or anesthetics for further intubation procedure because she was inactive and her struggling was very weak during laryngoscopy. After the second trial of laryngoscopy that brought the same result, we decided to aspirate the cystic contents. We punctured the cyst with a 22 gauge needle and aspirated about 1 ml of the viscous fluid under the laryngoscopy at decubitus position, while an assistant suctioned the leaking fluid simultaneously. The cyst was decompressed and we intubated the trachea with a 3.0 mm inner diameter uncuffed endotracheal tube under the view of the entire glottis while the patient breathed spontaneously. We used 2% sevoflurane-O2 1 L/min-N2O 1 L/min through a semiclosed circuit and injected 0.5 mg of vecuronium bromide. Excision of the cyst under a microscope by the otolaryngologist took 40 minutes. The neonate recovered spontaneous ventilation and her trachea was extubated after an injection of glycopyrrolate 0.04 mg and pyridostigmine 1 mg. Her recovery process was unremarkable. At the follow-up to 4 months after surgery, her body weight had increased to 7.7 kg, and stridor no longer occurred during feeding. The presenting symptoms of laryngeal cysts can vary with age of the patient, and the size and location of the cyst. Laryngeal cysts in adults can either be asymptomatic until it is detected incidentally such as during intubation, or symptoms are similar to other space occupying lesions of the airway. In neonates and infants, they produce clinical presentations of upper airway obstruction, such as dyspnea, inspiratory stridor, and feeding difficulty soon after birth or during the first weeks of life [1-3]. In the series of pediatric vallecular cysts, the most common symptoms were stridor and feeding problems [3], causing our patient to fail to thrive. These conditions of the patient and the degree of airway obstruction influenced our plan to give her only minimal drugs during anesthesia. In diagnosis of a laryngeal cyst, flexible fiberoptic laryngoscopy is essential, as well as CT, MRI, or ultrasonography [4]. When we planned anesthesia, airway management was the most problematic aspect. There was the possibility of airway loss by sedation and paralysis. Through the first trial of direct laryngoscopy at awaken state, we judged that the neonate was tolerable for laryngoscopy and the airway was very difficult to intubate. Several reports have described the method of intubation in pediatric patients with laryngeal cysts. Ahrens et al. [4] intubated bronchoscopically through the laryngeal mask airway (LMA) in a 3-month-old infant with a vallecular cyst, using a 2.2 mm diameter very thin bronchoscope. In pediatric airway emergencies on children with vallecular cysts, emergency cyst puncture or tracheotomy have been performed [3]. The surgeons should be asked to be on standby for emergency tracheotomy. We considered which laryngoscopy blade would be useful. Any blade could compress the cyst, increasing the risk of rupture and aspiration. However, Kalra et al. [5] reported successful intubation in a neonate using a right paraglossal straight blade laryngoscopy (Miller size 0 blade) with the aid of an intubating stylet. It was considered appropriate to try the paraglossal approach in our case. The success of puncture and aspiration depends on the characteristics of the cystic contents. Very thick cystic content cannot be aspirated. For this reason, the authors recommended the use of a wide-bore needle to aspirate [1]. Fortunately in our case, the cystic contents were slightly turbid but aspirated well through a 22G needle. We kept in mind the possibility of pulmonary aspiration and suctioned the leaking contents at immediately below the decubitus position under laryngoscopic view. Congenital laryngeal cysts in pediatric patients are challenging cases for anesthesiologists. When we planned anesthesia, we thoroughly evaluated the general condition of the patient and the endoscopic and radiologic results of the epiglottic cyst. We could intubate successfully after aspiration of the cyst contents while the neonate breathed spontaneously. Also, alternative methods could be to use fiberoptic intubation with an ultrathin bronchoscope, intubating LMA, or paraglossal straight blade laryngoscopic technique. Whatever intubation methods are chosen, anesthesiologists should always be reminded of the potentially life-threatening nature of congenital laryngeal cysts.