Hyun Kyoung Lim

Minimal Volume of Local Anesthetic Required for an Ultrasound‐Guided SGB

BACKGROUND  Compared with the blind technique, ultrasound-guided stellate ganglion block (SGB) reduces the amount of local anesthetic needed for a successful block. The purpose of this study is to determine the minimal, optimal volume of local anesthetic required for successful ultrasound-guided SGB and to reduce its adverse effects. METHODS  Thirty-five patients with postherpetic neuralgia and complex regional pain syndrome of the upper extremity and the facial area were selected. For ultrasound-guided SGB by subfacial method, each patient was injected with 0.5% mepivacaine mixed with contrast media in 2 mL, 3 mL, and 4 mL doses at 2-week intervals. After the procedure, the spread of contrast media in the spine was checked by fluoroscopy. Ptosis and conjunctival flushing were rated and recorded. Adverse effects, such as hoarseness, foreign body sensation, swallowing difficulty, and upper arm weakness, were also recorded. RESULTS  Out of the 35 initial patients, the results for 33 patients who received all three SGBs were included in this study. The contrast media spread to 4.80 ± 0.82, 4.94 ± 0.86, and 5.09 ± 0.97 total spinal segments in the 2 mL, 3 mL, and 4 mL groups, respectively. The cephalad spread of contrast media was 2.16 ± 0.74, 2.23 ± 0.85, and 2.30 ± 0.78 spinal segments for the 2 mL, 3 mL, and 4 mL groups, respectively, and the caudad spread of contrast media was 2.64 ± 0.51, 2.70 ± 0.61, and 2.89 ± 0.64 segments in the 2 mL, 3 mL, and 4 mL groups, respectively. There were no significant statistical differences in any segments for the three groups (P > 0.05). Review of the fluoroscopic images showed spread of the contrast media below the C7-T1 junction in all three groups. Ptosis developed in all three groups after the procedure. CONCLUSION  In conclusion, when performing an ultrasound-guided SGB, 2 mL dosage was sufficient for a successful block as the previous, conventional volume. Therefore, when performing an ultrasound-guided SGB, we recommend the 2 mL dosage of local anesthetics for a successful block.

Post-operative nausea and vomiting after gynecologic laparoscopic surgery: comparison between propofol and sevoflurane

Background We compared the incidence and degree of post-operative nausea and vomiting (PONV) in patients who received general anesthesia with propofol or sevoflurane using the Rhodes index of nausea, vomiting, and retching (RINVR) to assess the degree of PONV quantitatively and objectively during the post-anesthetic period. Methods We performed a prospective study involving 38 patients who underwent gynecologic laparoscopic surgery in our hospital between September 2008 and August 2009. Nineteen patients were anesthetized with propofol during the entire anesthetic period and the other 19 patients received 2.0 mg/kg of propofol intravenously, followed by sevoflurane inhalation. Three patients who were anesthetized with sevoflurane were excluded from the analysis because they were omitted during the survey. We studied the patients who had PONV and RINVR scores 1, 6, and 24 hours post-operatively. Results The propofol group had a statistically lower incidence of PONV and lower RINVR scores in the following subclasses within 1 hour of surgery: symptom occurrence; symptom distress; and symptom experience. Conclusions Propofol at induction and during maintenance of anesthesia can be used to prevent PONV within 1 hour post-operatively in patients undergoing gynecologic laparoscopic surgery.

Surface Landmarks do not Correspond to Exact Levels of the Cervical Spine: References According to the Sex, Age and Height.

Objective A general orientation along the cervical spine could be estimated by external landmarks, and it was useful, quick and less exposable to radiation, but, sometimes it gave reference confusion of target cervical level. The authors reviewed the corresponding between the neck external landmarks and cervical levels. Methods Totally 1,031 cervical lateral radiographs of different patients were reviewed in single university hospital. Its compositions were 534 of males and 497 females; 86 of second decades (10-19 years-old), 169 of third decades, 159 of fourth decades, 209 of fifth decades, 275 of sixth decades, and 133 of more than seventh decades (>60 years-old). Reference external landmarks (mandible, hyoid bone, thyroid cartilage, and cricothyroid membrane) with compounding factors were reviewed. Results The reference levels of cervical landmarks were C2.13 with mandible angle, C3.54 with hyoid bone, C5.12 with thyroid cartilage, and C6.01 with cricothyroid membrane. The reference levels of cervical landmarks were differently observed by sex, age, and somatometric measurement (height) accordingly mandible angle from C1 to C3, hyoid bone from disc level of C2 and C3 to C5, thyroid cartilage from disc level of C3 and C4 to C7, and cricothyroid membrane from C4 to disc level of C7 and T1. Conclusion Surface landmarks only provide general reference points, but not correspond to exact levels of the cervical spine. Intraoperative fluoroscopy ensures a more precise placement to the targeted cervical level.

Complete obstruction of an endotracheal tube due to an unexpected blood clot in a patient with a hemo-pneumothorax after repositioning of the patient for lumbar spine surgery

Endotracheal intubation is widely used to maintain the airway during general anesthesia. Intraoperative endotracheal tube obstruction can be caused by biting, kinking, external compression, and secretions or other intraluminal material [1]. We experienced a case of complete obstruction of the endotracheal tube due to a blood clot during surgery with a patient in the prone position who had a hemo-pneumothorax. A 40-year-old male with bilateral multiple rib fracture associated with a hemo-pneumothorax without hemoptysis, L2 spine fracture and left distal tibia medial malleolar fracture were the result of an accident in which the patient fell down 3 meters. On the seventh day of hospitalization, posterior lumbar interbody fusion was scheduled to correct the L2 spine fracture. Intubation was performed with an 8.0 mm armored tube, and vital signs were stable: blood pressure, 100-120 systolic and 60-70 diastolic; heart rate, 75-90 beats/min; the electrocardiogram showed a normal sinus rhythm with 99-100% oxygen saturation: ETCO2, 34-36 mmHg; peak inspiratory pressure, 18-22 cmH2O. After repositioning the patient for spinal surgery from the supine to the prone position, there was a slight increase in the peak inspiratory pressure to 23-25 cmH2O, but there was no change in both lungs sound and in rib cage movement during mechanical ventilation. Thirty minutes after maintaining the patient in the prone position, a sudden rise in the peak inspiratory pressure and ETCO2 were detected at 32-35 cmH2O and 43-45 mmHg, respectively, with a change in the capnograph indicating an obstructive pattern. Endotracheal suction was done immediately, but was unsuccessful in relieving the pressure. Mechanical ventilation was turned off and manual ventilation was performed, during which progressive increases in resistance were sensed. Eventually, the capnograph was flattened with a gradual decline in oxygen saturation to 75%. Based on suspicion of endotracheal tube obstruction, a bronchoscopy was done using a flexible bronchoscope while intermittent manual ventilation with 100% O2 was carried out. In addition, we confirmed the presence of total occlusion of the endotracheal tube at the distal end by a blood clot. Without delay, the patient was turned back to the supine position and the endotracheal tube was extubated, at which point, the blood pressure was between 160-170 systolic and 95-110 diastolic; the heart rate was 120-130 beats/min and the oxygen saturation was at 45%. Immediate mask ventilation was performed until pulse oximetry Oxygen saturation rose up to 95% and the patient was re-intubated with a 7.5 mm armored tube. The formally extubated tube was fully obstructed with a huge blood clot at the distal end to the cuff site (Fig. 1). The vital signs became stable after re-intubation, and the ETCO2 and peak inspiratory pressure were maintained between 34-36 mmHg and 18-22 cmH2O, respectively. The surgery was completed without further incidence, and the patient was transferred to the general ward without any sequelae, and eventually discharged at POD 21. Fig. 1 (A) Anterior view of removed armored endotracheal tube showing complete obstruction of distal lumen due to impaction of blood clot. (B) Side view of removed armored endotracheal tube showing complete obstruction of distal lumen due to impaction of blood ... There are several reported cases on airway obstruction due to blood clots. Arney et al. [2] reported on the cleansing, aspiration, removal, and careful use of thrombolytic agents after identifying a blood clot through direct bronchoscopy, when there was a partial airway obstruction due to endobronchial blood clot. Veronese et al. [3] reported a case, in which, a large blood clot in the endotracheal tube was removed by extubation without using invasive measures. Lin et al. [4] reported a case of acute endotracheal tube obstruction caused by unexpected hemoptysis in a patient with inactive tuberculosis undergoing spinal surgery in the prone position, which was relieved by just placing the patient back into the supine position allowing for direct visualization of the bleeding site with a flexible bronchoscopy. What we experienced was a case of endotracheal tube obstruction due to a blood clot in a patient with a traumatic hemo-pneumothorax without preoperative hemoptysis who underwent spinal surgery in the prone position. In conclusion, when general anesthesia is performed in patients with a hemo-pneumothorax who need to be positioned in the prone position for the surgery, it is essential to consider the possibility of an endotracheal tube obstruction, and a tracheobronchial tree evaluation should be performed with a flexible bronchoscope for direct detection of bleeding sites and for the removal of any visible blood clots even in cases where there is no evidence of preoperative hemoptysis. Additionally, it should be kept in mind that a blood clot could migrate into the endotracheal tube due to gravitational force when the patient is moved into the prone position even though endotracheal suction was applied to eliminate secretions in the supine position.

The Impact of Primary Spontaneous Pneumothorax on Multiphasic Personal Inventory Test Results in Young South Korean Males

Purpose Few reports have documented psychopathological abnormalities in patients with primary spontaneous pneumothorax (PSP). We analyzed the results of a multiphasic personal inventory test to investigate the psychopathologic impact of PSP in young Korean males. Materials and Methods The authors reviewed the results of a Korean military multiphasic personal inventory (KMPI) administered to military conscripts in South Korea. A total of 234 young males participated in this study. The normal volunteer group (n=175) comprised individuals who did not have any lung disease. The PSP group (n=59) included individuals with PSP. None of the examinees had any psychological problems. The KMPI results of both groups were compared. Results There were more abnormal responses in the PSP group (17.0%) than the normal volunteer group (9.1%, p=0.002). The anxiety scale and depression scale scores of the neurosis category were greater for the PSP group than the normal group (p=0.039 and 0.014, respectively). The personality disorder and paranoia scale scores of the psychopathy category were greater for the PSP group than the normal group (p=0.007 and 0.018, respectively). Conclusion Young males with PSP may have greater tendencies to suffer from anxiety, depression, personality disorders, and paranoia compared to normal individuals. Clinicians should be advised to evaluate the psychopathological aspects of patients with PSP.

Cerebellar hemorrhage after spine fixation misdiagnosed as a complication of narcotics use -A case report-

Cerebellar hemorrhage occurs mainly due to hypertension. Postoperative cerebellar hemorrhage is known to be associated frequently with frontotemporal craniotomy, but quite rare with spine operation. A 56-year-old female received spinal fixation due to continuous leg tingling sensation for since two years ago. Twenty-one hours after operation, she was disoriented and unresponsive to voice. Performed computed tomography showed both cerebellar hemorrhage. An emergency decompressive craniotomy was carried out to remove the hematoma. On the basis of this case, we reported this complications and reviewed related literature.

The Psychopathological Influence of Congenital Heart Disease in Korean Male Adolescents: An Analysis of Multiphasic Personal Inventory Test Results

Purpose The aim of this study was to evaluate the psychopathological influence of congenital heart disease (CHD) in Korean 19-year-old males. Materials and Methods The authors compared the Korean military multiphasic personal inventory (KMPI) military profiles of 211 CHD cases (atrial septal defect, ventricular septal defect, patent ductus arteriosus, or combined CHD) with the KMPI profiles of 300 normal controls. The CHD group was also divided according to whether or not the subjects had undergone open cardiac surgery in order to evaluate the psychopathological effects of an operation among the subjects. Results A decreased result on the faking-good response scale and an increased result on the faking-bad response were observed in the CHD group compared to the control (p<0.01). The neurosis scale results, including anxiety, depression and somatization symptoms, were markedly increased in the CHD group compared to the control (p<0.01). The severity level of personality disorder was also increased in the CHD group (p<0.001). Differences in KMPI scale scores were not related to open cardiac surgery history. Conclusion In this study, young males with CHD tended to report more abnormal results on the multiphasic personal inventory test in comparison to normal subjects, suggesting that CHD may be related to psychopathology in young males in Korea. Therefore, clinicians are recommended to evaluate the psychopathological traits of patients with CHD.

Effects of increasing the dose of ropivacaine on vertical infraclavicular block using neurostimulation.

Background Use of an infraclavicular block is appropriate for surgery of the upper limb. However, it does not consistently block the entire brachial plexus. The aim of this study was to investigate whether increasing the dose of ropivacaine could enhance the success rate, onset time, and efficacy of the sensory and motor block during the use of a vertical infraclavicular block using neurostimulation in upper limb surgery. Methods Two hundreds and ten patients were prospectively randomized into three groups: Group 1 (30 ml of 0.5% ropivacaine; n = 70), Group 2 (40 ml of 0.5% ropivacaine; n = 70), and Group 3 (40 ml of 0.75% ropivacaine; n = 70). Patients in each group received a vertical infraclavicular block using neurostimulation and obtained a distal motor response of the ulnar or median nerve. Recorded outcome measures included block success rate, onset time, sensory and motor blocks, and adverse events. Results No differences were found in the block success rate among the three groups (92.8%, 97.1%, and 94.2% for Groups 1, 2, and, 3, respectively; P = 0.346). There were no significant differences in onset time (P = 0.225) among groups, nor was there enhancement in the sensory block, but the motor block was enhanced. Local anesthetic toxicity was observed in five female patients from group 3 (P = 0.006). Conclusions Although the efficacy of the motor block was significantly improved, success rate, onset time, and efficacy of sensory block were not enhanced significantly among groups despite differences in volume and volume/concentration of the local anesthetic.

Segregation for reduction of regulated medical waste in the operating room: a case report

One-third of all hospital-regulated medical waste (RMW) comes from the operating room (OR), and it considerably consists of disposable packaging and wrapping materials for the sterilization of surgical instruments. This study sought to identify the amount and type of waste produced by ORs in order to reduce the RMW so as to achieve environmentally-friendly waste management in the OR. We performed an initial waste segregation of 4 total knee replacement arthroplasties (TKRAs) and 1 total hip replacement arthroplasty, and later of 1 extra TKRA, 1 laparoscopic anterior resection of the colon, and 1 pelviscopy (with radical vaginal hysterectomy), performed at our OR. The total mass of non-regulated medical waste (non-RMW) and blue wrap amounted to 30.5 kg (24.9%), and that of RMW to 92.1 kg (75.1%). In the course of the study, we noted that the non-RMW included recyclables, such as papers, plastics, cardboards, and various wrapping materials. The study showed that a reduction in RMW generation can be achieved through the systematic segregation of OR waste.

Asymptomatic pneumomediastinum resulting from air in the epidural space -a case report-.

There are no reports regarding pneumomediastinum caused by thoracic epidural block complications. We believe that it is possible to experience an occurrence of pneumomediastinum caused by air in the epidural space after performing a thoracic epidural block using the loss of resistance (LOR) technique with air. We report a witnessed case where pneumomediastinum appeared after a thoracic epidural block. Pneumorrrhachis, paravertebral muscle emphysema, and pneumomediastinum were diagnosed by Positron Emission Tomography-Computed Tomography. Although extremely rare, pneumomediastinum can be caused by an epidural block using LOR technique with air. In order to avoid the above danger, the use of saline or very minimal amount of air is required during a careful LOR technique.