Won Joo Choe

Meta-Analysis of Sodium Bicarbonate Therapy for Prevention of Cardiac Surgery-Associated Acute Kidney Injury

OBJECTIVE The aim of this study was to determine whether or not perioperative administration of sodium bicarbonate had a preventive effect on cardiac surgery-associated acute kidney injury (CSA-AKI) as shown in randomized controlled trials. DESIGN The authors conducted a systematic review and meta-analysis using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and KoreaMed. SETTING The authors searched MEDLINE, EMBASE, CENTRAL, and KoreaMed without language and date restrictions. They used both MeSH and free-text terms to identify relevant studies. Electronic searches were undertaken on July 31, 2014. PARTICIPANTS Five randomized controlled studies included in this review. MEASUREMENTS AND MAIN RESULTS There were no differences in the development of CSA-AKI among patients in the sodium bicarbonate group compared with those in the control group (5 trials, 1,092 patients; n = 233 of 547 in sodium bicarbonate (SB) group versus 225 of 545 in control group (SC); risk ratio (RR), 0.95; 95% confidence interval (CI), 0.74-1.22. Also, there were no statistical differences in in-hospital mortality (3 trials, 573 patients; n = 21 of 288 in SB versus 14 of 285 in SC; RR, 1.44; 95% CI, 0.76-2.72), need for renal replacement therapy (4 trials, 1,000 patients; n = 21 of 503 in SB versus 23 of 497 in SC; RR, 0.90; 95% CI, 0.50-1.60), length of stay in the intensive care unit (ICU) (hours) (4 trials, n = 969 patients, weighted men difference (WMD), 2.17; 95% CI, -1.15-5.49), and length of ventilation (hours) (4 trials, 969 patients; WMD, 0.34; 95% CI,-0.80-1.48). CONCLUSIONS Perioperative administration of sodium bicarbonate did not reduce the rate of CSA-AKI in randomized controlled trials. Therefore, use of perioperative administration of sodium bicarbonate for the prevention of CSA-AKI is questionable.

Electromyographic response of facial nerve stimulation under different levels of neuromuscular blockade during middle-ear surgery

Objective To investigate facial nerve monitoring in patients receiving the partial nondepolarizing neuromuscular blocking agents (NMBAs), remifentanil and propofol. Methods Patients with normal facial function and advanced middle-ear disease were enrolled. For total intravenous anaesthesia (TIVA), propofol and remifentanil were infused as induction/maintenance anaesthesia. Stimulation thresholds and amplitudes were recorded at each train-of-four (TOF) nerve stimulation level. Time differences between start of TOF and electromyographic (EMG) amplitude decreases (Ti), and between complete recovery of TOF and EMG amplitudes (Tr), were calculated. Results Fifteen patients were enrolled. Mean ± SD Ti was 3.4 ± 1.28 min; Tr was 18.7 ± 4.41 min. Amplitude of stimulation was apparent mostly at TOF level 1. In most cases, no or a weak response (<100 µV) was observed at TOF 0. Mean ± SD threshold of electrical stimulation was 0.31 ± 0.10 mA at TOF 1. At TOF > 2, all cases showed EMG response on electrical stimulation. Conclusions Induction of TIVA using propofol and remifentanil provided reliable conditions for delicate microsurgery. Minimal NMBA use, considered as producing TOF levels >1, was sufficient for facial nerve monitoring in neuro-otological surgery.

Increasing the area and varying the dosage of Botulinum toxin a injections for effective treatment of hemifacial spasm

Abstract Conclusion: Wider-area botulinum toxin (BT) injection with the dosage depending on specific pathology is a promising approach for the treatment of hemifacial spasm (HFS), resulting in effective and long-lasting control of HFS with fewer side-effects. Objective: The aim of this study was to develop a BT injection strategy that minimizes complications by considering the causes, duration, and electrophysiologic features of the disease, as well as the patient’s age. Methods: From July 2011 to July 2015, 26 patients were included in the strategy. The mean age was 61.8 ± 14.6. In the case of essential HFS, 2 units/injection site was the standard dosage. If a patient was aged over 60 and had a reduced electromyogram (EMG) amplitude, the dosage was reduced by 0.5 units/site. In the case of post-paralytic and tumor-induced HFS, 1.5 units/site was the standard dosage. All cases were managed by alternating injections of Botox and Dysport with no physical therapy. Results: Most HFS patients treated with the injection strategy had complete remission of HFS within 1 week. The average number of BT injection sites was 22.6 ± 6.7. The mean total BT dosage on the affected side was 28.6 ± 4.9 units. The mean duration of BT efficacy was 28.6 ± 7.7 weeks.

Aorta-right atrial tunnel

Aorta-right atrial tunnel (ARAT), first reported in 1980 by Coto, is a rare congenital vascular anomaly. A 36-year-old female was admitted with chest discomfort, dyspnoea, palpitations, and general weakness. She had been treated for rheumatic fever at the age of 10, with no sequelae. Physical exam was normal except a grade 3/6 continuous murmur at the right sternal border. Transthoracic echocardiography (TTE) showed a tunnel-like shape …

Left atrial wall dissection after mitral valve replacement.

Left atrial dissection does occur, though rarely, after mitral valve surgery. A 68-year-old Korean female presented with moderate mitral stenosis, mild mitral regurgitation, moderate tricuspid regurgitation and mild aortic regurgitation. She was scheduled for mitral valve replacement and tricuspid annuloplasty. We experienced a left atrial dissection after weaning from cardiopulmonary bypass and decided not to repair it. The patient recovered uneventfully. We suggest that a specific type of left atrial dissection can be treated conservatively.

The use of laryngeal mask airway in pediatric patient with massive post-tonsillectomy hemorrhage

The Laryngeal Mask Airway (LMA) is not only used in patients who have a difficult airway with a conventional laryngoscope, but it is also used in children who have a tonsillectomy to manage the airway [1]. However, cases related to the airway management of young children with massive post-tonsillectomy hemorrhage (PTH) have not been reported yet. Here, we report a case in which we have successfully performed airway management using LMA during severe ventilatory difficulty, which had occurred in a young child patient with massive PTH, in which we failed to perform an endotracheal intubation under general anesthesia. A 6-year old female patient visited the hospital complaining of massive hematemesis. A physical examination confirmed acute oozing bleeding in the left tonsillar fossa. We decided to perform an emergent operation under general anesthesia for surgical ligature. After arrival to the operating room, we continuously carried out oral suction in the patient, who was in the trendelenburg position, in order to prevent aspiration caused by the hematemesis, while also providing her with 100% oxygen via a mask. A rapid sequence intubation (RIS) could be performed. We performed an endotracheal intubation immediately under the Sellicks maneuver, but constant intraoral bleeding inhibited us from securing a clear view, so we failed to intubate. After which, we performed a blind intubation by inserting a stylet, but we failed to do this as well. Meanwhile, the patients oxygen saturation plunged to 79%, so another doctor performed the intubation procedure, but was also unsuccessful. After which, the oxygen saturation decreased to 52%, so a cricothyrotomy and tracheostomy were planned for an instant surgical airway. Because of intraoral bleeding that occurred in the tonsil and that the surgical airway was difficult due to differences in anatomical structures compared to adults, in addition, our hospital routinely prepares a LMA to general anesthesia;thus, we attempted to insert the LMA before the surgical airway. Number two of the LMA (LMA Supreme™, LMA Company Ltd, UK) was inserted immediately under the Sellicks maneuver. After the successful insertion of the LMA, ventilation was performed well without any air leakage, and the auscultation sound was normal. Oxygen saturation normalized, increasing from 48% to 100%. With a Yankauer suction catheter, we suctioned by inducing pressure with a gauze on the site of bleeding, and thus, we were able to secure our view. And then, we removed the LMA, and successfully performed a RIS. A blood clot was found behind the cuff of the removed LMA (Fig. 1). After the operation, we confirmed that the patient recovered from her unconsciousness with oxygen saturation maintained at 99-100%. Afterwards, since the lung sounds was normal, the patient was extubated, and was transferred to the recovery room. One hour later, the patient was then transferred to the ward since oxygen saturation was maintained at 100% without oxygenation. The results of the chest radiograph performed after the operation was normal, and the patient was discharged without any particular problems ten days later. Fig. 1 Image shows that a blood clot was found behind the cuff of the removed LMA. In general, a surgical airway is not widely used in children aged 8 years or younger in contrast to adults [2]. The reasons for this is that the cricothyroid membrane of adults is 13.7 mm in length and 12.4 mm in width on average [3], whereas the membrane of children is merely 2.6 mm in length and 3 mm in width [4], so unlike adults, it is a much more delicate process when performing a cricothyrotomy on children. Moreover, even if the excision succeeds, damage to the larynx can be a possibility and should not be ruled out due to their small anatomical structures [3]. In addition, the hyoid and the cricoid cartilage commonly protrude more than the thyroid cartilage in children, so a cricothyrotomy could possibly be mistakenly performed on the other site [2,4]. Besides, children have a lower capacity for residual pulmonary function and consume more oxygen per hour, so even a short time of apnea could result in hypoxia. In cases of an absence of spontaneous respiration, the risk of aspiration to the lungs, caused by acute intraoral bleeding, cannot be underestimated. For these specific cases, we prepared an apparatus for children in order to immediately perform cricothyrotomy in cases of endotracheal intubation failure;however, we attempted to insert a LMA due to the risks mentioned above and due to time constraints. The LMA is widely used since the LMA is a ventilation method that anesthesiologists can do well during emergent situations.Moreover, since the cuff of the LMA adheres to the entry of the trachea and larynx, we thought we could prevent the bleeding that was occurring in the tonsil, outside of the cuff, from being aspirated. As a result, we successfully performed the LMA at a trial before carrying out the surgical airway, and removed the blood clot behind the cuff when we removed the LMA after securing our view with a Yankauer suction catheter (Fig. 1). Like in this case, a LMA can be considered in which a child with massive PTH experiences an emergent situation, such as ventilatory failure or hypoxemia, that was caused due to failure of endotracheal intubation. Furthermore, the LMA should always be prepared in order to successfully manage anesthesia for patients who are not susceptible to endotracheal intubation, and for patients in which endotracheal intubation failed for the induction of general anesthesia.

Compromised ventilation caused by tracheoesophageal fistula and gastrointestinal endoscope undergoing removal of disk battery on esophagus in pediatric patient -A case report-

Ingestion of disk batteries may have serious complications such as esophageal burn, perforation, and tracheoesophageal fistula, particularly when the battery is caught in the esophagus. Proper placement of the tracheal tube is critical when tracheoesophageal fistula was occurred from esophageal impaction the battery. Endoscopy of upper gastrointestinal tract in infants and children is an important and effective tool for the diagnosis and treatment of foreign body ingestion. But upper gastrointestinal endoscopy in infant and children has very high risk of tracheal compression and airway compromise. We present a case of ventilatory compromise during insertion of the upper gastrointestinal endoscopy in 16-month-old child with tracheoesophageal fistula secondary to disk battery ingestion.

Peroneal nerve palsy after compression stockings application

Peroneal nerve palsy can be caused by various etiology. We report unilateral peroneal nerve palsy after compression stockings application. A 64-year-old man underwent off-pump coronary bypass graft. Surgeon did not use saphenous vein for the bypass graft. Sedation was stopped after 3 h postoperative. After 16 h, for prophylaxis of deep vein thrombosis, knee-high elastic stocking was applied. After 1 h, he took off right stocking because of numbness but left stocking was kept. After 24 h postoperative, (8 h after stocking application) patient complained suddenly left foot drop. Manual muscle test revealed 0/5 of ankle dorsiflexion, ankle eversion, and toe extension. Sensory was decreased to 70% in lower half of anterolateral aspect of tibia, foot dorsum, and toes. Foot drop and sensory abnormality decreased in 3 weeks. Cardiac surgery patients already have many risk factors for peripheral neuropathy. Clinicians should be careful when applying stockings on those patients.

Postpartum spinal subdural hematoma: irrelevant epidural blood patch: a case report

We report a healthy patient with postpartum headache and neck stiffness which were diagnosed as symptoms of pseudoaneurysm of vertebral artery. She had received a Cesarean section under the spinal anesthesia, and complaint of headache and neck stiffness. Epidural blood patches were done twice, but symptoms persisted. Eight days later, she experienced sensory disturbance and emergent laminectomy was done. When persistent postpartum headache occurs after epidural blood patch, more precise differential diagnosis should be made and considering other possible pathologies.

Anticholinergic premedication-induced fever in paediatric ambulatory ketamine anaesthesia.

Objective A randomized, double-blind, prospective study to evaluate the effect of anticholinergic drugs on thermoregulation in paediatric patients undergoing ambulatory anaesthesia with ketamine. Methods Patients were randomized to receive either 0.005 mg/kg glycopyrrolate or the equivalent volume of normal saline (placebo) at 30 min before ketamine anaesthesia. Body temperature was measured tympanically at baseline and at 0, 30, 60 and 90 min postoperatively. The quantity of saliva prodiced during surgery and incidence of fever were recorded. Results Body temperature was significantly higher in the glycopyrrolate group (n = 42) than the placebo group (n = 42) at 30, 60 and 90 min after surgery, and higher than baseline at 0, 30, 60 and 90 min after surgery. In the placebo group, body temperature was significantly higher than baseline at 0 and 30 min after surgery. Saliva secretion was significantly lower in the glycopyrrolate group than the placebo group. Conclusion Routine premedication with adjunctive anticholinergics should not be considered in paediatric patients receiving ketamine sedation due to the increased risk of fever. Trial registration number, Clinicaltrials.gov: NCT02430272