Jin-Tae Kim

Video-Assisted Thoracoscopic Lobectomy in Children: Safety, Efficacy, and Risk Factors for Conversion to Thoracotomy

BACKGROUNDnVideo-assisted thoracoscopic lobectomy in small children has not been widely performed because of difficulties in single-lung ventilation and surgical technique. This study assessed the feasibility, outcomes, and risk factors for conversion to thoracotomy of thoracoscopic lobectomy in children.nnnMETHODSnFrom 2005 to 2011, thoracoscopic lobectomy was tried in 50 consecutive pediatric patients. The median age was 3.2 years and the median body weight was 16 kg. Congenital cystic adenomatoid malformation (CCAM) (78%) and pulmonary sequestration (18%) were the most common diagnoses. Prenatal diagnosis by ultrasonography was made in 34% of patients (17 of 50), and a previous history of pneumonia was present in 46% (23 of 50). The most commonly used single-lung ventilation modality was endobronchial blocking by balloon catheter through a single-lumen endotracheal tube. The use of a stapler was minimized, with endoscopic clipping devices and energy-based cutting instruments used instead.nnnRESULTSnThoracoscopic lobectomy without conversion was accomplished in 82% of patients (41 of 50). There was no in-hospital mortality and 1 major morbidity (2%) with postoperative bleeding. Comparison with a group from an earlier period (∼2009) and a group from a later period (2010-2011) determined that thoracotomy conversion rates, mean operation times, and mean hospital days were 27% and 8%, 190±85 and 133±40 minutes, and 11.0±6.7 and 5.2±2.2 days, respectively. In univariate analysis, lower body weight (p=0.010), operations in the earlier period (p=0.040), single-lung ventilation failure (p=0.004), and a previous history of pneumonia (p<0.001) were related to conversion to thoracotomy. Multivariate analysis revealed a previous history of pneumonia to be the only independent risk factor for conversion to thoracotomy (p=0.0179).nnnCONCLUSIONSnThoracoscopic lobectomy in small children is a safe and effective treatment modality. Close cooperation with the anesthesiologist, use of adequate instruments, and selection of proper patients are important for the success of thoracoscopic lobectomy in small children. A previous history of pneumonia was an independent risk factor for conversion to thoracotomy.

Anesthetic management with scalp nerve block and propofol/remifentanil infusion during awake craniotomy in an adolescent patient -A case report-

Despite of various neurophysiologic monitoring methods under general anesthesia, functional mapping at awake state during brain surgery is helpful for conservation of speech and motor function. But, awake craniotomy in children or adolescents is worrisome considering their emotional friabilities. We present our experience on anesthetic management for awake craniotomy in an adolescent patient. The patient was 16 years old male who would undergo awake craniotomy for removal of brain tumor. Scalp nerve block was done with local anesthetics and we infused propofol and remifentanil with target controlled infusion. The patient endured well and was cooperative before scalp suture, but when surgeon sutured scalp, he complained of pain and was suddenly agitated. We decided change to general anesthesia. Neurosurgeon did full neurologic examinations and there was no neurologic deficit except facial palsy of right side. Facial palsy had improved with time.

Anesthetic management of video-assisted thoracoscopic surgery (VATS) in pediatric patients: the issue of safety in infant and younger children.

Background The purpose of this study was to assess the safety issues concerning anesthetic management of video-assisted thoracoscopic surgery (VATS) in pediatric patients. Methods The medical records of 52 pediatric patients undergoing VATS using general anesthesia and one-lung ventilation (OLV) were reviewed. OLV was achieved with a Fogarty catheter (n = 23) or endobronchial intubation (n = 7) in patients < 10 years of age (group Y, n = 30), and using a double-lumen tube (n = 19) or a univent (n = 3) in children aged between 10 and 16 years of age (group O, n = 22). Hypoxemia, hypercarbia, the difference between ETCO2 and PaCO2, and the effect of CO2 insufflation were assessed. Results A decrease in SpO2 less than 90% was observed in 40% of the group Y, compared to none of the group O (P < 0.05). A hypercarbia (ETCO2 > 50 mmHg) was observed more frequently in group Y (40%) than in group O (0%; P < 0.05). The difference between the ETCO2 and PaCO2 was 10.4 ± 8.9 mmHg in group Y and 4.6 ± 3.9 mmHg in group O (P < 0.05). Hypercarbia and acidosis occurred more frequently in patients with CO2 insufflation than those without insufflation in group Y. Conclusions Although the anesthesia for VATS in pediatric patients was successfully accomplished, the infants and younger children presented with more intra-operative problems when compared with older children. The anesthetic management for VATS in infants and younger children requires careful and vigilant monitoring.

Tearing of the lingual frenulum caused by insertion of the proSeal LMA in a child - A case report -

The laryngeal mask airway (LMA) is widely used as an adjunctive airway device composed of a tube with a cuffed mask-like projection on the distal end. The LMA is simple to use and less invasive to pharynx and larynx than endotracheal tube. The LMA is inserted blindly into the hypopharynx, forms a low pressure seal around the laryngeal inlet. It is minimally stimulating the airway. Microscopic mucosal injuries are common during laryngeal mask airway (LMA) insertion but macroscopic injuries are rare and few have been reported with the ProSeal LMA. This report describes a case of the tearing of the lingual frenulum incidentally caused by insertion of the ProSeal LMA in a child.

Hemothorax due to injuries of subclavian artery and first intercostal artery after subclavian venous catheterization in a pediatric patient - A case report -

Central venous catheterization is useful to evaluate intravascular volume status, while it has a chance of severe complications such as tension pneumothorax, cardiac tamponade, and so on. Now, we report a case of hemothorax after trying subclavian venous catheterization over again in a 2-year-old patient undergoing encephalo-duro-arterio-synangiosis, that required surgical intervention at the end. Though arterial puncture and massive hemothorax is a possible complication of subclavian venous catheterization, the injury of first intercostal artery might be due to inappropriate introducer needle accidentally. In conclusion, both routine chest image confirmation and close observation of expert might be important to prevent iatrogenic complication by anesthetic maneuvers.

Effect of triamcinolone added to scalp nerve block for postoperative pain management of Moyamoya disease

nerve block failed, we gave routine medication for pain. The time when the patient first complained of pain was recorded. The anesthesiologist visited the children and parents at 8 and 16 hours after the operation to evaluate visual analogue scale (VAS 0-10, > 8 years) or faces pain scale (FPS, < 8 years). We also reviewed medical records for routine analgesics used during the hospital stay, and incidence of nausea or vomiting. Brain MRI was performed if any signs or symptoms of brain infarction were observed. Patients who recovered from the operation without complications made follow-up visits after 6 months, at which brain MRI scans were performed. Sample size was determined according to a pilot study of 13 patients performed in 2006. The time at which patients first complained of pain was 12.9 ± 5.3 hours in group T and 6.3 ± 5.2 hours in group R. If we hypothesize that a difference in block times between groups exists, we would need at least 9 subjects in each group at a significance level of 5% and power of 80%. We used SPSS 12.0 for statistics analysis; the unpaired T-test was used to compare continuous variables between two groups. Pearson’s Chi square was used to determine difference of frequency of nausea, vomiting or brain infarction after the operation. P < 0.05 was considered statistically significant. There was no difference in demographic characteristics, preoperative infarction history, operation time, anesthesia time, PACU stay time, or medication during the postoperative period. Group R patients first complained of pain at 9.2 ± 9.4 hours and Group T patients at 14.2 ± 10.0 hours (P = 0.11). VAS at 8 hours after surgery was 1.2 ± 1.5 in group R and 1.5 ± 2.4 in group T (P = 0.56); at 16 hours it was 1.2 ± 1.7 in group R and 2.3 ± 2.8 in

Mechanical Valvular Dysfunction Detected by Intraoperative Transesophageal Echocardiography After Valvular Replacement in Patients With Congenital Heart Disease

N CERTAIN congenital heart diseases, such as corrected transposition of the great arteries or the double-outlet right ventricle (RV) with a hypoplastic left ventricle (LV), the RV assumes the role of a systemic ventricle after cardiac surgery. As the patient grows older, progressive valvular dysfunction can develop, and the valve of the RV needs to be replaced. It is recommended to preserve the subvalvular apparatus to conserve ventricular function during mitral valve replacement in adults. 1-3 However, the remnant subvalvular structures can hinder the motion of the leaflet of the prosthesis, resulting in significant regurgitation. This complication can occur after tricuspid valve replacement in a morphologic RV or after atrioventricular valve replacement in a single ventricle when the subvalvular apparatus is preserved. Two cases of artificial valvular dysfunction detected by intraoperative transesophageal echocardiography (TEE) secondary to native subvalvular apparatus entrapment in patients whose RV functioned as a systemic ventricle are reported. CASE 1 A 19-year-old male patient with corrected transposition of the great arteries, situs inversus, and dextrocardia was admitted for tricuspid valve replacement caused by severe tricuspid regurgitation. After correction of an atrial septal defect, his RV assumed the role of a systemic ventricle for 18 years. Preoperative transthoracic echocardiography revealed decreased RV function, with an RV Tei index of 0.52 (normal value of systemic LV, 0.39 0.05), tricuspid regurgitation (TR) dP/dt of 1114 mmHg/s (normal value of systemic LV 1,200 mmHg/s), and tricuspid valve annulus of 31.5 mm in addition to severe TR caused by anterior tricuspid valvular prolapse and annular dilatation.4,5 He underwent implantation of a 29-mm St Jude bileaflet mechanical prosthesis (St Jude Medical, St Paul, MN) with preservation of the native subvalvular apparatus. TEE (Vivid 7 Pro; GE, Horten, Norway) was performed after weaning from cardiopulmonary bypass (CPB). One leaflet closed incompletely because of entrapment of the subvalvular tissue, and severe valvular regurgitation was observed (Fig 1 and Videos 1 and 2). CPB was reinitiated, and remnants of the subvalvular apparatus were shown to interfere with prosthetic leaflet motion and were excised. TEE showed physiologic intraprosthetic regurgitation without an abnormal jet, and the postoperative course was uneventful.

Cardiac arrest induced by tension pneumothorax during ventilating bronchoscopy -A case report-

Tension pneumothorax during ventilating bronchoscopy for foreign body removal is a rare but life-threatening complication. The authors present a case of cardiac arrest caused by tension pneumothorax in a 9-month-old girl who underwent ventilating bronchoscopy for foreign body (peanut) removal. Tension pneumothorax was due to tracheobronchial lacerations caused by a bronchoscope. The patient was successfully resuscitated by cardiopulmonary resuscitation and chest tube insertion. The airway injury was effectively repaired by thoracotomy under extracorporeal membrane oxygenation.

Anesthetic management of children with Beckwith-Wiedemann syndrome - Two cases report -

Beckwith-Wiedemann syndrome consists of various abnormalities, including macroglossia, visceromegaly, omphalocele, and neonatal hypoglycemia. These abnormalities frequently require operative correction and careful anesthetic management. Principal problems associated with anesthetic management in this syndrome are congenital heart disease, hypoglycemia, and difficult airway combined with macroglossia. We report two cases of general anesthetic management in children with Beckwith-Wiedemann syndrome.

Measuring depth of anesthesia with EEG and ECG in children

BACKGROUNDnHeart rate is tightly controlled by brain. If activity of brain and electroencephalograph (EEG) are changed by anesthetics, electrocardiograph (ECG) might be changed. We investigated whether there is a correlation between EEG and ECG, ECG could replace EEG as a monitor for depth of anesthesia.nnnMETHODSnWe recruited 50 patients, aged 2-8 years. Inspired and expired end-tidal sevoflurane concentrations were held constant at 1.0 or 2.5 vol%, after which ECG and EEG were obtained for 15 minutes. Total power (TP), low-frequency power (LFP), high-frequency power (HFP), approximate entropy (ApEn), and Hurst exponent (H) were calculated from the ECG. The relationship between EEG and ECG indices at the two sevoflurane concentrations was measured by Pearsons correlation coefficient.nnnRESULTSnAs anesthesia deepened, ApEn, H of ECG and beta wave decreased and those of delta and theta increased in 4 channels. In FP2, changes of beta and theta wave were negatively correlated with ApEn and H of ECG (P < 0.05), and changes of delta wave was positively correlated with ApEn (P < 0.05) and H (P < 0.01). In F8, changes of beta and theta wave were negatively correlated with ApEn (P < 0.05) and only theta wave was negatively correlated with H (P < 0.05). In C4, change of delta wave was positively correlated with ApEn (P < 0.001) and H (P < 0.05).nnnCONCLUSIONSnEEG and ECG indices are correlated during sevoflurane anesthesia in children, and ECG-derived indices could possibly be used to monitor depth of anesthesia.