Sung Mi Hwang

Extracorporeal Membrane Oxygenation for Acute Life-Threatening Neurogenic Pulmonary Edema following Rupture of an Intracranial Aneurysm

Neurogenic pulmonary edema (NPE) leading to cardiopulmonary dysfunction is a potentially life-threatening complication in patients with central nervous system lesions. This case report describes a 28-yr woman with life-threatening fulminant NPE, which was refractory to conventional respiratory treatment, following the rupture of an aneurysm. She was treated successfully with extracorporeal membrane oxygenation (ECMO), although ECMO therapy is generally contraindicated in neurological injuries such as brain trauma and diseases that are likely to require surgical intervention. The success of this treatment suggests that ECMO therapy should not be withheld from patients with life-threatening fulminant NPE after subarachnoid hemorrhage.

Efficacy of Veno-Venous Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Failure

Purpose The objective of this study was to evaluate our institutional experience with veno-venous (VV) extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory failure (ARF). Materials and Methods From January 2007 to August 2013, 31 patients with severe ARF that was due to various causes and refractory to mechanical ventilation with conventional therapy were supported with VV ECMO. A partial pressure of arterial oxygen (PaO2)/inspired fraction of oxygen (FiO2) <100 mm Hg at an FiO2 of 1.0 or a pH <7.25 due to CO2 retention were set as criteria for VV ECMO. Results Overall, 68% of patients survived among those who had received VV ECMO with a mean PaO2/FiO2 of 56.8 mm Hg. Furthermore, in trauma patients, early use of ECMO had the best outcome with a 94% survival rate. Conclusion VV ECMO is an excellent, life-saving treatment option in patients suffering from acute and life-threatening respiratory failure due to various causes, especially trauma, and early use of VV ECMO therapy improved outcomes in these patients.

A complication of subclavian venous catheterization: extravascular kinking, knotting, and entrapment of the guidewire -A case report-

Various complications of central venous catheterization have been reported, some of which are well-known, while others are described as a sporadic events. We experienced a case of left subclavian venous catheterization complicated by extravascular knotting, kinking, and entrapment of the guidewire and the guidewire was removed surgically. Although minimal resistance was encountered during guidewire insertion, the guidewire was advanced approximately 30 cm. Physicians should be aware of these rare potential complications when a guidewire is advanced if any resistance is encountered.

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.

The effect of dexmedetomidine as an adjuvant to ropivacaine on the bispectral index for supraclavicular brachial plexus block

Background The aim of this study was to evaluate the sedative effect of dexmedetomidine (DEX) added to ropivacaine for supraclavicular brachial plexus block (BPB) using the bispectral index (BIS). Methods Sixty patients (American Society of Anesthesiologists physical status 1 or 2, aged 20-65 years) undergoing wrist and hand surgery under supraclavicular BPB were randomly allocated to two groups. Ultrasound-guided supraclavicular BPB was performed with 40 ml of ropivacaine 0.5% and 1 µg/kg of DEX (Group RD) or 0.01 ml/kg of normal saline (Group R). The primary endpoint was the BIS change during 60 min after block. The secondary endpoint was the change in the mean arterial blood pressure (MAP), heart rate (HR), and SpO2 and the onset time and duration of the sensory and motor block. Results In Group RD, the BIS decreased significantly until 30 min after the block (69.2 ± 13.7), but remained relatively constant to 60 min (63.8 ± 15.3). The MAP, HR and BIS were significantly decreased compared with Group R. The onset time of the sensory and motor block were significantly faster in Group RD than in Group R. The duration of the sensory and motor block were significantly increased in Group RD. Conclusions DEX added to ropivacaine for brachial plexus block induced sedation that corresponds to a BIS value of 60 from which patients are easily awakened in a lucid state. In addition, perineural DEX shortened the onset time and prolonged the duration of the sensory and motor blocks.

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

Midgut volvulus as a complication of intestinal malrotation in a term pregnancy

Intestinal malrotation is an uncommon cause of abdominal pain and normally presents during infancy. Approximately 90% of patients with malrotation are diagnosed within the first year of life, 80% of whom are diagnosed within the first month of life [1]. Intestinal malrotation complicated by midgut volvulus, a well recognized disease entity in infants and children, is rare in adults [2]. We report a pregnant woman with rare small and large bowel infarctions due to intestinal malrotation complicated by midgut volvulus whose signs and symptoms were misunderstood as labor. A 22-year-old primigravida at 38 weeks and 2 days gestation who had been followed during pregnancy at a private obstetric clinic visited our emergency room with the chief complaint of labor pain that had developed 1 h and 30 min previously. On admission, her vital signs were blood pressure 130/90 mmHg and heart rate 83 beats/min, however, the patient suddenly developed hypotension (80/50 mmHg) and tachycardia (134 beats/min) 7 h later, and the fetal heart rate trace decreased from 120-130 to 90-100 beats/min. An emergency Cesarean section was performed and a male newborn (2,870 g) was delivered with an Apgar score of 1 at 1 min. Emergency resuscitation was initiated, at the same time, a 3.0 mm uncuffed endotracheal tube was intubated by the anesthesiologist. The 5 min Apgar score was 4, and he was transferred to the neonatal intensive care unit by a pediatric physician. The obstetric physician found an ischemic change in the small intestine above the uterus of the mother (Fig. 1A). A general surgeon was called, and upon entering the abdominal cavity, the areas of ischemic change were observed from Treitzs ligament of the small intestine to the proximal transverse colon, but no perforation was detected. A congenital intestinal malrotation and mobile colon were observed, and the ischemic ascending colon was located in the middle of the peritoneal cavity (Fig. 1B). The ischemic portion of the ascending colon was completely gangrenous; thus, a right hemicolectomy was performed. Unfortunately, the mother died 2 days after surgery. However, the baby had no major medical problems and was discharged 2 weeks after birth. Fig. 1 (A) Small intestine with ischemic change above the uterus. (B) The ischemic intestine due to volvulus from the proximal transverse colon, with the ischemic portion extending toward to Treitzs ligament of the small intestine. The ischemic ascending colon ... In the present case, the mother had a congenital intestinal malrotation of which she was unaware, and the malrotation was complicated by midgut volvulus at full-term pregnancy; thus, the abdominal pain was misunderstood as labor pain. Furthermore, the physical findings associated with a midgut volvulus during pregnancy can be confusing and are not always those of a classic bowel obstruction [3]. Bowel sounds may be normal, and distention may be absent. Furthermore, she unfortunately had no nausea, vomiting, or constipation. The only abnormal finding was an elevated WBC count before she showed unstable vital signs. The duodenum and cecum incompletely rotate and become close in proximity in cases of intestinal malrotation. This malpositioning results in a short stalk of mesentery that easily twists upon itself, resulting in compression of the superior mesenteric artery. This vascular compression results in ischemia of the intestine and necrosis of the intestinal wall in 1-2 h if left untreated [4], and the necrosis can compromise fetal health. Thus, a high level of diagnostic suspicion is needed for an early diagnosis in such a case. Anesthesiologists should be aware of these conditions and similar cases to rapidly and definitively control vital signs, replace volume, and correct an electrolyte imbalance during anesthesia and to prepare for resuscitation of the neonate if needed. Knowledge of the management of this condition by anesthesiologists may decrease morbidity and mortality of the mother and neonate.