Keon Sik Kim

Comparison of surgical condition in endoscopic sinus surgery using remifentanil combined with propofol, sevoflurane, or desflurane

Background Various maneuvers are commonly used to achieve the ideal operative field necessary for successful endoscopic sinus surgery (ESS). There are a few contradictory reports on this subject and the consensus is that propofol anesthesia results in a better or similar surgical field and less or similar amount of bleeding than volatile anesthesia. The aim of this study was to compare the surgical field in patients in whom intravenous anesthesia is used as opposed to balanced general anesthesia. Methods Sixty patients undergoing ESS were randomly assigned into three groups, each of which used a different type of anesthesia: propofol/remifentanil (PRO/REM) group, sevoflurane/remifentanil (SEV/REM) group, and desflurane/remifentanil (DES/REM) group. We aimed to maintain the intraoperative mean blood pressure (MBP) at 65 mmHg and the heartrate (HR) at about 75 beats per minute. The quality of visibility of the surgical field was graded, using a validated scoring system, 60 minutes after the start of the operation. Results All groups had a similar MBP and mean HR at 60 minutes after the operation started. There was no significant differences among the three groups for surgical grade score (P = 0.83). Conclusions In this comparative study of three anesthetic combinations (PRO/REM, SEV/REM, and DES/REM) in patients undergoing ESS with controlled BP and HR, we did not observe any significant differences in the surgical grade scores.

Matrix Metallopeptidase 2 Gene Polymorphism is Associated with Obesity in Korean Population

The aim of this study was to determine whether single nucleotide polymorphisms (SNPs) of matrix metallopeptidase 2 (MMP2) are associated with obesity. MMP2 is an enzyme with proteolytic activity against matrix and nonmatrix proteins, particularly basement membrane constituents. To identify the relationship between polymorphisms of MMP2 and overweight/obese, we genotyped 5 SNPs (rs17242319, rs1053605, rs243849, rs2287074, and rs10775332) of the coding region of MMP2 using the Golden Gate assay on an Illumina BeadStation 500 GX. One hundred and forty two overweight/obese (BMI >/=23) and 145 normal (BMI 18 to <23) subjects were analyzed. SNPStats, Haploview, HapAnalyzer, SNPAnalyzer, and Helixtree programs were used for the analysis of genetic data. A linkage disequilibrium (LD) block was discovered among the 5 SNPs selected, including rs17242319, rs1053605, rs243849, and rs2287074. Of the 5 polymorphisms, 2 synonymous SNPs [rs17242319 (Gly226Gly) and rs10775332 (Phe602Phe)] were found significant associations with overweight/obese. Recently, rs1132896 replaced rs17242319 as a new number (SNP database, BUILD 129). In haplotype analysis using Haploview, a haplotype (haplotype: CCCA) containing a meaningful polymorphism (rs17242319) was found to be significantly different. The results suggest that MMP2 may be associated with overweight/obese in Korean population.

Pentax-AWS videolaryngoscope for nasotracheal intubation in patients with difficult airways

It is difficult to intubate with Macintosh laryngoscope or fiberoptic bronchoscope in patients with narrow oropharyngeal space, deformed oro-pharyngeal-larynx structures, or restricted neck movement. The Pentax-AWS (AWS®, Pentax, Tokyo, Japan) (Fig. 1) is a rigid video laryngoscope for intubation, which consists of a disposable transparent blade (Pblade), a camera, and a monitor. A target mark on the monitor suggests the tracheal tube direction of advance, facilitating easy and accurate intubation. Fig. 1 Photograph of the Pentax-Airway scope with Pblade separated. We report on the use of the AWS® for nasotracheal intubation in two patients with oropharyngeal lesions, in whom Macintosh laryngoscopic and fiberoptic bronchoscopic intubation had failed. The first patient was a 56-yr-old man (163 cm, 64 kg), who was presented with right facial palsy after a right radical parotidectomy about 8 months ago due to an adenocystic parotid cancer. He had limited neck motion, which was expected due to the radiation therapy and prior neck dissection. For tensor fascia lata sling operation, anesthesia was induced with a bolus of propofol (2 mg/kg) and rocuronium (0.8 mg/kg) intravenously. We tried to insert a 7.0 mm ID nasal RAE™ tracheal tube through the nose, because the nasotracheal intubation offers more convenience for surgical maneuvering. Nasotracheal intubation with Macintosh laryngoscope was attempted, but visualization of the glottis was impossible (Cormak and Lehane [C/L] grade 3). Secondly, with passing the fiberoptic bronchoscope (LFTP, Olympus, Fukushima, Japan) (diameter; 5.0 mm) through the nasal RAE™ tube, we tried to locate the tip of the fiberoptic bronchoscope to the glottis. But it was impossible to see the glottis mainly due to swelling in the pharynx. Next, nasal intubation, with the AWS®, was attempted. With the nasal tube in place, the AWS® was easily inserted orally with its tip toward the glottic side of the epiglottis, and a full view of the glottis was displayed on the videoscreen. The Magill forceps could not be used because when the AWS® was in the mouth, there was not enough space to manipulate a Magill forceps. Also, without any introducer, the tube was smoothly advanced into the trachea without any difficulty by external pressure to the neck for targeting symbol mark. Nasotracheal intubation using the AWS® was achieved within 20 seconds. The second patient was a 71-yr-old woman (153 cm, 48 kg), who was scheduled with an operation for a wide excision of the recurred right tonsillar cancer. We induced anesthesia with propofol (2 mg/kg) and rocuronium (0.8 mg/kg), intravenously. Then, a 6.0 mm ID reinforced endotracheal tube was passed through the nose, securing the space for the operation. Nasotracheal intubation with Macintosh laryngoscope was attempted, but it failed due to a large cancer hindering a visualization of the glottis (C/L grade 3). Secondly, fiberoptic bronchoscope was passed through the tube, but it was not available to advance the fiberoptic bronchoscope to the glottis, due to interfered passage by the large tonsillar mass. We made several attempts, but that failed. So we decided to stop using the fiberoptic bronchoscope as a fear of pharyngeal edema. A final attempt was made to intubate with the AWS®. With a nasal tube in place, instead of holding on the tube groove on the Pblade, oral insertion of the AWS® was easily done, and a full view of the glottis was obtained with reserving space pushing the tonsil lesion by the Pblade. With external pressure to the neck, the tube was gently advanced into the trachea, without using any introducer and the Magill forceps. Total time taken for a successful tracheal intubation with the AWS® was within 15 seconds. The AWS® has the Pblade that fits the oropharyngeal anatomic configuration and is wide and rigid enough to push away the structures around the larynx, facilitating a visualization of the glottis and tracheal intubation by making sufficient room in the pharyngeal space. Also, the image of the glottis, captured near the tip of the laryngoscope before the device insertion, makes it possible to easily locate the tip of an endotracheal tube. Enomoto et al. [1] reported that, in patients with restricted neck movements, the AWS® provided a better view of the glottis and a higher success rate of the oro-tracheal intubation, compared with the Macintosh laryngoscope. Asai et al. [2] studied concerning the effectiveness of the AWS® in patients with difficult airways because of several different anatomical or pathological changes, such as restricted neck movement, deformity of the airway, and tumors in the airways. The authors demonstrated that intubation with the AWS® was successful in 268 of the total 270 patients with difficult Macintosh laryngoscope. Fiberoptic intubation has to accompany with assistance, skills and experience, especially under the condition of a narrowing oropharyngeal space and an unpredictable anatomical structure. It is reported that owing to several specialties of the AWS® and no particular special skills required to use the AWS®, even a naive operator can quickly and easily perform successful tracheal intubation [3]. In this letter, we intend to demonstrate that with the use of the AWS®, successful nasotracheal intubation can also be done, instead of orotracheal intubation, in difficult airways. In one case report, the AWS® was used for an awake nasal intubation in patients with unstable necks [4]. The AWS® was initially designed for orotracheal intubation. However, that report suggests that the AWS® may be a useful for nasotracheal intubation in cervical immobilization. Besides, Hirabayashi [5] reported the safety and availability of the AWS® in nasotracheal intubation. In this study, the nasotracheal intubating time, performed by non-anesthesia residents, using the AWS® is within 56 ± 11 seconds, compared to that by Macintosh laryngoscope and Magill forceps, which was within 114 ± 37 seconds. In summary, our cases show that the AWS® may be useful for a safe nasotracheal intubation and has potential advantages over the Macintosh laryngoscope and the fiberoptic bronchoscope in patients with narrowing pharyngeal space, due to pharyngeal edema or mass and restricted neck movement. We should consider that nasotracheal intubation with the AWS® may be useful in patients who have predicted difficult airways to undergo a head and neck surgery.

Deep vein thrombosis after spine operation in prone position with subclavian venous catheterization: a case report.

We experienced a case of deep vein thrombosis after spine surgery in the prone position with a central venous catheter (CVC). Posterior lumbar interbody fusion was performed on a 73-year-old female patient who was diagnosed with spinal stenosis. Accordingly, in the operation room under general anesthesia, two-lumen CVC were inserted into the left subclavian vein. The surgery was performed in the prone position with a Wilson frame. On the next day, there was a sudden occurrence of severe edema in the patients left arm. By ultrasonography and computed tomography scanning, extensive deep vein thrombosis was observed in the left subclavian vein. The existence of a factor affecting blood flow such as the prone position may increase the risk of thrombus formation. Therefore, careful perioperative evaluation should be implemented.

Paradoxical air embolism due to electrosurgical vaporization during hysteroscopic myomectomy

Air emboli can arterialize and result in paradoxical air embolism (PAE). In most cases there is a right to left shunt, and for this to occur during a hysteroscopic surgery is extremely rare. This case report describes a PAE found in the left heart during hysteroscopic myomectomy without an anatomical right to left shunt. A 29-yr-old woman (height 170 cm, weight 62 kg, American Society of Anesthesiologists I) was seen at our gynecologic clinic due to a known uterine myoma. She had no specific medical history, and had given birth to a preterm baby of 24 weeks by cesarean section under general anesthesia 6 months earlier. There were no abnormal findings in the preoperative examination and she had no risk factors for cardiac or pulmonary disease. For maintenance during the operation, O2 2.0 L/min, N2O 2.0 L/min, and desflurane 4.0-6.0 vol% was used. Though at the beginning of the surgery vital signs were stable, after 15 min systolic and diastolic blood pressure decreased to 80-100 mmHg, and 40-60 mmHg respectively. Arterial blood gas analysis (ABGA) revealed that the pH was 7.384, PaO2 271.9 mmHg, PaCO2 29.8 mmHg, hemoglobin 6.9 g/dl, Hct 20%. As systolic blood pressure continued to drop to 80-90 mmHg, diastolic blood pressure to 40-50 mmHg, and mean arterial pressure (MAP) to 60-65 mmHg, 10 mg of ephedrine was administered, while 2 units of packed RBC transfusion was initiated. In order to continue measuring blood pressure and arterial blood gas, a 20 gauge catheter was inserted in the left radial artery. The results of the ABGA after the radial artery cannulation were pH 7.336, PaO2 291.1 mmHg, PaCO2 35.9 mmHg, and PETCO2 25 mmHg. Though PETCO2 decreased only slightly, the decreasing blood pressure and signs of increase in PaCO2 gave rise to suspicions of pulmonary embolism, so N2O was discontinued and oxygen and medical air were both maintained at 2.0 L/min. Ninety minutes after the beginning of the surgery, the MAP suddenly dropped to 60 mmHg and the PETCO2 could not be detected (having decreased to 0 mmHg). The ABGA initiated at this point and showed pH 7.149, PaO2 65.4 mmHg, and PaCO2 35.9 mmHg. Because the changes in hemodynamics coupled with the results of the ABGA lead to suspicions of pulmonary embolism, O2 supply was kept at 100% and positive pressure ventilation was initiated. Transthoracic echocardiography (TTE) was used to confirm an air embolism in the left heart (Fig. 1). The lung perfusion scan performed after the surgery revealed multiple non-matched small non-segmental perfusion defects in both lungs indicating pulmonary embolism. Two days after the surgery, the patient returned from the ICU to the general ward, and a TTE investigation with an agitate saline test was performed to exclude any possible intracardiac shunt. The chest computed tomography (CT) revealed no evidence of thromboembolism. Fig. 1 Transthoracic echocardiogram in the parasternal long axis view at the operation room shows air bubbles in the left heart. Gas embolism occurs when large quantities of gas from an open noncollapsible vein or artery enter systemic circulation. This gas embolism rarely arterializes and becomes a PAE to be confirmed by TTE. In this case we used normal saline as a uterine distension medium to remove air in all intravenous lines and hysteroscopic instruments. A tenaculum was used to minimize cervical exposure after cervical dilation and a continuous outflow system was used to refresh the bubbles and debris in the uterus. Thus, we were able to eliminate the possibility of gas entering from an outside source, and suspect that the highly soluble gases, such as hydrogen, carbon monoxide, and carbon dioxide produced during electrosurgical vaporization of the myoma created an unlikely air entrainment and entered the circulation [1]. There are known possible mechanisms that venous air embolism (VAE) from the right heart can cross over to the left heart to become a PAE. The most common mechanism of PAE is caused by abnormal intracardiac communication, such as ASD, VSD, or patent foramen ovale (PFO). When we had done the TTE test 2 days after the event, we were able to exclude PFO or other intracardiac shunts as causes of the embolism. Other possible mechanisms of arterialized air embolism include pathological dilatation in intrapulmonary vessels or pulmonary AV malformation in patients suffering from hereditary hemorrhagic telangiectasia or chronic liver disease [2]. These patients have a pulmonary right to left shunt or high sensitivity to contrast in enhanced TTE diagnosis. However, in our patient we discovered no atypical hereditary or genetic disorders and no particular reason to suspect intrapulmonary shunt. Upon TTE, none were found. In patients without anatomical shunt, transpulmonary passage of venous air emboli could be a cause for the PAE. Typically, pulmonary circulation has filtering capabilities with respect to air emboli. However, paradoxical air emboli may occur, for e.g. emboli are too small to properly filter the lung capillaries [3] or the embolis total volume is above fixed levels and exceeds the lungs filtration capacity [4]. Lung capillaries have a diameter of approximately 3-15 µm and they can filter any dysmorphic emboli with a diameter greater than 14-22 µm. Although the precise amount of suspected high soluble gases produced by electrosurgical vaporization is unknown, it is very possible that a considerable number of microbubbles smaller than 14-22 µm in diameter can form. Data from an animal study suggests that the lung acts as a physiologic filter, which becomes overwhelmed above 0.3 ml/kg/min [3], but the exact maximum volume of air filtering capacity in the human lung is not known. In vitro studies have proven that electrosurgical vaporization can produce gas at up to 60 ml/min [5]. Therefore, the total volume of gas in the patient could have exceeded the lungs filtering capacity and caused the PAE. The transpulmonary passage of venous air emboli can be a pertinent cause for our case. In conclusion, this case demonstrates that paradoxical emboli may develop during hysteroscopic surgery in patients without an anatomical right to left shunt. Although hysteroscopic surgery is not typically thought to be a high risk procedure for air embolism, this case demonstrates the possibility of air embolism by electrosurgical vaporization.

Anaphylaxis during patient transfer to the operating room following ranitidine administration -A case report -

A 43-year-old male was admitted for reconstruction surgery to repair posterolateral rotatory instability of the knee. At the request of the surgeon, ranitidine was slowly administered intravenously immediately before the patient was transferred to the operating room to reduce the incidence of acid reflux. A few minutes later, during the transfer of the patient, anaphylaxis developed with hypotension, nausea, dyspnea, change in consciousness and urticaria. The patient had no previous history of any allergic tendency. After appropriate management, he recovered without complication. Following surgery, an allergic skin prick test was performed to determine if the patient was allergic to any of the drugs used during the surgery. According to the results, only ranitidine showed a positive reaction.

Lumbosacral plexus injury following vaginal delivery with epidural analgesia -A case report-

A 26 year old, healthy, 41 week primiparous woman received a patient-controlled epidural analgesia (PCEA) and experienced paraplegia 11 hours later after a vaginal delivery. This was thought to be the result of complications from PCEA but there was no specific abnormality on magnetic resonance imaging (MRI) of the lumbosacral spine. On an electromyography (EMG) study performed 15 days following delivery, signs of tibial neuropathy were present and peripheral nerve injury during vaginal delivery was suspected. Motor weakness and hypoesthesia of both lower extremities improved rapidly, but a decrease in the desire to urinate or defecate, followed by urinary incontinence and constipation persisted, We suspected the sacral plexus had been severely damaged during vaginal delivery. Seven months later, the patients conditions improved but had not fully recovered.

Correlations between the Changes of Pain and Temperature by Infrared Thermography in Central Poststroke Pain

Central poststroke pain can occur as a result of lesion or dysfunction of the brain from stroke, and may influence the autonomic nervous system to regulate the vasomotor activity which could result in the lowered skin temperature. In order to assess CPSP objectively, seventy patients with CPSP were evaluated as their pain with VAS pain score and the skin temperature of pain site by infrared thermography before and after pain treatment. And evaluated correlation between changes of temperature and VAS. The skin temperature of pain site was significantly lower than non-pain before treatment and improved after treatment(p<0.05), in accordance with significant improvement of VAS pain scores after treatment(p<0.05). And there was highly correlation between the changes of temperature and VAS(p<0.05). Therefore, it is suggested that the infrared thermography is very useful device for the evaluation of CPSP and its treatment.