Ji Su Jang

Recurrent spinal myoclonus after two episodes of spinal anesthesia at a 1-year interval -A case report-.

Spinal myoclonus is an unusual, self-limiting, adverse event that may occur during spinal anesthesia. The exact cause and underlying biochemical mechanism of spinal myoclonus remain unclear. A few cases of spinal myoclonus have been reported after administration of intrathecal bupivacaine. We report a case in which spinal myoclonus recurred after two episodes of spinal anesthesia with bupivacaine at a 1-year interval in a 35-year-old woman. The myoclonus was acute and transient. The patient recovered completely, with no neurologic sequelae.

Effect of Pulsed Radiofrequency Neuromodulation on Clinical Improvements in the Patients of Chronic Intractable Shoulder Pain

Objective The aim of this study was to evaluate effect of pulsed radiofrequency (PRF) neuromodulation of suprascpaular nerve (SSN) in patients with chronic shoulder pain due to adhesive capsulitis and/or rotator cuff tear. Methods The study included 11 patients suffering from chronic shoulder pain for at least 6 months who were diagnosed with adhesive capsulitis (n=4), rotator cuff tear (n=5), or adhesive capsulitis+rotator cuff tear (n=2) using shoulder magnetic resonance imaging or extremity ultrasonography. After a favorable response to a diagnostic suprascapular nerve block twice a week (pain improvement >50%), PRF neuromodulation was performed. Shoulder pain and quality of life were assessed using a Visual Analogue Scale (VAS) and the Oxford Shoulder Score (OSS) before the diagnostic block and every month after PRF neuromodulation over a 9-month period. Results The mean VAS score of 11 patients before PRF was 6.4±1.49, and the scores at 6-month and 9 month follow-up were 1.0±0.73 and 1.5±1.23, respectively. A significant pain reduction (p<0.001) was observed. The mean OSS score of 11 patients before PRF was 22.7±8.1, and the scores at 6-month and 9 month follow-up were 41.5±6.65 and 41.0±6.67, respectively. A significant OSS improvement (p<0.001) was observed. Conclusion PRF neuromodulation of the suprascapular nerve is an effective treatment for chronic shoulder pain, and the effect was sustained over a relatively long period in patients with medically intractable shoulder pain.

Postoperative Nausea and Vomiting after Myringoplasty under Continuous Sedation Using Midazolam with or without Remifentanil

Purpose This prospective study evaluated the effects of continuous sedation using midazolam, with or without remifentanil, on postoperative nausea and vomiting (PONV) in patients undergoing myringoplasty. Materials and Methods Sixty patients undergoing myringoplasty were sedated with midazolam in the presence of remifentanil (group MR), or after saline injection instead of remifentanil (group M). Results Three patients (10%) in group M complained of nausea; two vomited. Four patients (13%) in group MR complained of nausea and vomited within 24 h after surgery. Rescue drugs were given to the six patients who vomited. No significant difference was detected between the two groups regarding the incidence or severity of nausea, incidence of vomiting, or need for rescue drugs. Conclusion Midazolam-based continuous sedation can reduce PONV after myringoplasty. Compared with midazolam alone, midazolam with remifentanil produced no difference in the incidence or severity of nausea, incidence of vomiting, or need for rescue drugs.

Two Complications of Tracheal Intubation in a Neonate Gastric Perforation and Lung Collapse

A N infant delivered in a private hospital after 33 weeks’ gestation weighed 2,050 g, had persistent tachypnea, and had associated hypoxia requiring intubation. After three esophageal intubations, the neonate’s trachea was successfully intubated. Despite mechanical ventilation, the infant had persistent tachycardia, hypoxemia (80–90% oxygen saturation) and a distended abdomen. A preoperative radiograph of this child shows the endotracheal tube tip in the right main bronchus (arrow A), atelectasis of the entire left lung (arrow B), pneumoperitoneum (white arrows), and increased abdominal gas. At surgery, a 1.5-cm perforation of the anterior wall of the lesser curvature of the stomach was identified and repaired. The radiograph emphasizes critical complications that can occur during airway management of a neonate. Inadvertent esophageal intubation is one of the most common causes of neonatal intubation failure, which can lead to catastrophic consequences. This condition can be rapidly detected by using end-tidal carbon dioxide monitoring, because it is the single most useful method in confirming endotracheal tube position. In this neonate, gastric perforation likely occurred as a result of distension associated with positive pressure ventilation after esophageal intubation. Endobronchial intubation is another common problem associated with airway management in a neonate. This child’s atelectasis likely developed after main stem intubation, when the endotracheal tube depth was noted to be 11 cm. As a guide to proper tracheal placement of an endotracheal tube, 1-, 2-, or 3-kg babies are intubated to a depth of 7, 8, or 9 cm, respectively. These two complications reinforce the need for specialized training and experience in neonatal airway management.

Shearing of an intrathecal catheter during insertion for cerebrospinal fluid drainage.

CC Intrathecal catheters has been placed for the management of a wide range of medical and surgical conditions [1]. As the use of intrathecal catheters increases, surgeons and anesthesiologists must be made aware of possible complications related to their placement, including infection, headache, pneumocephalus, cerebrospinal fluid (CSF) leakage, neuroaxial hematoma, intracra nial hemorrhage, and catheter fracture [2,3]. Breakage or shearing of a catheter is rare or under- reported, with an incidence rate of 0 to 3.3% [2,4]. We present a case of intrathecal catheter shearing and fragmentation during insertion, while turning the catheter clockwise through a Tuohy needle for lumbar CSF drainage, and the subsequent surgical removal of the fragment. A 74-year-old man, 160 cm tall and weighing 65 kg, un derwent a decompressive craniectomy due to malignant brain edema caused by left middle cerebral artery area infarction. He had right hemiplegia and atrial fibrillation. Two months later, cranioplasty was done for a skull defect, and the surgery was uneventful. Three days later, CSF leakage was observed on brain computed tomography. To promote dural healing, closed continuous lumbar drainage of the CSF was indicated. It was difficult to assume an optimal position for lumbar puncture because of the patient’s hemiplegia. The patient was placed in the left lateral decubitus position with flexion of the left hip and knee. A 14 G Tuohy needle was inserted into the L3-4 intervertebral space without difficulty, obtaining freeflowing CSF. As there was some resistance encountered during advancement of the catheter 8 cm beyond the tip of the needle

Esophageal misplacement of a single-lumen tube after its exchange for a double-lumen tube despite the use of an airway-exchange catheter

An airway-exchange catheter (AEC) can increase the safety of exchanges of endotracheal tubes (ETTs); however, the procedure is associated with potential risks. We describe a case of esophageal misplacement of a single-lumen ETT after switching from a double-lumen tube, despite the use of an AEC as a guidewire. To avoid this, physicians should consider the insertion depth and maintenance depth of the AEC and should verify its position before changing ETTs and should perform, if possible, with simultaneous visualization of the glottis with direct or video laryngoscopy during the exchange. Additionally, the new ETT position should be confirmed by auscultation, end-tidal carbon dioxide, and portable chest X-ray.

Anesthetic management of an adolescent with Dandy- Walker syndrome

Dandy-Walker syndrome is classically described as a neuropathological triad consisting of hypoplasia of the cerebellar vermis, cystic dilatation of the fourth ventricle, and hydrocephalus. Clinical manifestations of the syndrome usually appear in the first year of life, but can occur during the neonatal period. Asai et al. [1] reported that as many as 89% of patients are diagnosed before 1 year of age. However, in the absence of prenatal diagnosis, the symptoms usually become apparent in early infancy and include slow motor development, bulging anterior fontanel, and progressive enlargement of the skull. We report a rare case of anesthetic experience for an adolescent with Dandy-Walker syndrome. A 13-year-old, 140 cm, 29 kg, male adolescent who had been born prematurely at 28 weeks, weighing 850 g visited our urology for surgical treatment of scrotal hydrocele. The patient had mental retardation and general muscular dystrophy. Six months prior to admission, he had an episode of seizure with vomiting, and brain magnetic resonance imaging was performed. Magnetic resonance imaging showed a cyst in the posterior fossa, hypoplastic cerebellar hemispheres, and elevation of the hypoplastic cerebellar vermis due to the cyst (Fig. 1). He was diagnosed with Dandy-Walker syndrome. In the preoperative evaluation, he was found to have macrocephalus and micrognathia, which could render intubation difficult. He was also afflicted with general muscular dystrophy. During surgery, his vitals were monitored by electrocardiogram, pulse oximetry, noninvasive blood pressure (BP) monitoring, endtidal CO2, bispectral index (Aspect Medical Systems, Newton,

Difficult tracheostomy tube placement in an obese patient with a short neck -A case report-

We report a difficult case of tracheostomy in a 34-year-old obese woman with a short neck. The tracheostomy tube placement repeatedly failed because of anatomical changes due to obesity and a short neck, tracheal mucosal swelling due to prolonged intubation, and unexpected false passage; however, it was successfully performed using an endotracheal tube exchanger as a guidewire.

Right axillary vein thrombosis due to malpositioning of a central venous catheter via the internal jugular vein

Central venous catheterization (CVC) is commonly used in the operative setting for central venous pressure monitoring, drug administration, and the rapid introduction of fluids. However, CVC can have many severe complications, even for experienced physicians. Furthermore, complications of CVC are increasingly being recognized as a major source of morbidity. We report a rare, but serious, case of right axillary vein thrombosis due to malpositioning of a central venous catheter tip following right internal jugular venous (IJV) catheterization. A 67-year-old, 40-kg, 158-cm-tall female with cholangiocellular carcinoma of the liver required CVC. With the patient supine, the neck was prepped and draped sterilely. The position of the IJV was determined using a 7.5-MHz linear ultrasound probe (M-Turbo; SonoSite, Bothell, WA, USA) and ultrasound (MicroMaxx; SonoSite). A central venous catheter (Two-Lumen Central Venous Catheterization Set with Blue FlexTip; Arrow, Reading, PA, USA) was advanced into the IJV. Subsequently, the aspiration of blood via the two lumens of the catheter was observed, and the catheter was secured at a depth of 15 cm below the skin. On connecting the transducer to the monitor, the opening central venous pressure (CVP) was noted as 7 mmHg, and a waveform was observed. However, we did not carefully check whether the wave had an ideal CVP waveform. Six days after CVC, the patient complained of pain in the right upper arm, with swelling. On the chest radiograph, the terminus of the central venous catheter was located in the right axillary vein (Fig. 1A). An ultrasonographic examination showed vein thrombosis of the right axillary vein (Fig. 1B). Fig. 1 (A) Plain chest radiograph showing the catheter tip location in the right axillary vein (white arrows). (B) Ultrasonography showing a thrombus in the right axillary vein. The traditionally preferred position of the central venous catheter tip is within the caudal third of the superior vena cava. However, central venous catheters placed without imaging guidance have a 10-30% incidence of malpositioning of the catheter tip in the right atrium [1]. When the central venous catheter is abnormally located in the right atrium, the risk for thrombosis increases [2]. Interestingly, the present rare case showed that the catheter tip could be abnormally located in the right axillary vein, and that this malpositioning could lead to thrombus formation. This complication should not be underestimated because it may be a source of pulmonary embolism. Malpositioning of a guidewire placed in the vein during CVC can be detected with a real-time ultrasonic examination. After the procedure, chest radiography should be performed to assess the location of the central venous catheter tip. These examinations can reduce the risk for thrombosis due to malpositioning. In addition, correct placement of the catheter tip is important for obtaining accurate CVP measurements. Inaccurate CVP measurements or the inability to obtain an ideal waveform is suggestive of an undesirable location of the catheter tip [3]. Therefore, as we did not carefully check the waveform to confirm the location of the tip, the CVP measurements of 7 to 9 mmHg in this case might not have been correct. A thrombus in the subclavian, axillar, or brachial vein is defined as an upper-extremity deep-vein thrombosis (UEDVT). Gbaguidi et al. [4] reported that the most common cause of UEDVT was central venous catheters (62.2%), with malignancy being second (27.2%). Thus, physicians should carefully consider these complications of CVC, especially in patients with malignancies and a high risk for thrombosis. In conclusion, malpositioning of a central venous catheter can increase the risk for thrombosis, which may lead to pulmonary embolism. To detect the malpositioning of a central venous catheter tip, the location of the guidewire should be checked using ultrasonography during the procedure and chest radiography after the procedure, and the CVP waveform should be closely examined.

Acute, fatal postoperative myocardial infarction after laparoscopic cholecystectomy in a cardiac patient -A case report-

This report presents the case of a 63-year-old man who had a myocardial infarction leading to coronary artery bypass graft 2 years earlier who subsequently underwent elective laparoscopic cholecystectomy. After an uneventful operation, the patient developed an acute postoperative myocardial infarction in the recovery room and died 19 days postoperatively. Anesthesiologists should be aware of the rare possibility of acute, fatal postoperative myocardial infarction and consider this complication when they perform the preoperative risk evaluation, anesthesia, and postoperative care for cardiac patients undergoing noncardiac surgery.