Won-Kyoung Kwon

Clinical effects of intrathecal fentanyl on shoulder tip pain in laparoscopic total extraperitoneal inguinal hernia repair under spinal anaesthesia: A double-blind, prospective, randomized controlled trial

Objective The study evaluated the clinical intraoperative effects of intrathecal administration of fentanyl on shoulder tip pain in patients undergoing laparoscopic total extraperitoneal inguinal hernia repair (TEP) under spinal anaesthesia. Methods Patients undergoing TEP were allocated in a double-blinded, prospective, randomized manner to two groups. Spinal anaesthesia was induced by intrathecal administration of 2.8 ml of 0.5% hyperbaric bupivacaine (14 mg) in the control group and with 2.6 ml of 0.5% hyperbaric bupivacaine (13 mg) and 10 µg fentanyl (0.2 ml) in the experimental group. Results The quality of muscle relaxation, adequacy of operative space and incidence of pneumoperitoneum were similar in the two groups (n = 36 per group). Compared with the control group, the experimental group had significantly fewer cases of hypotension (12 [33.3%]) versus 23 [63.9%]) and shoulder tip pain (nine [25%] versus 18 [50%]). Intraoperative shoulder tip pain was more severe in the control group than in the experimental group. Conclusions Addition of intrathecal fentanyl to local anaesthetic can relieve shoulder tip pain with no change in complications, especially hypotension, during TEP under spinal anaesthesia.

A heated humidifier does not reduce laryngo-pharyngeal complaints after brief laryngeal mask anesthesia

PURPOSE Warming and humidification of inspired gases is standard care for intubated patients whose lungs are ventilated mechanically for prolonged periods. We examined whether active humidification of inspired gases might reduce laryngo-pharyngeal discomfort in patients undergoing brief laryngeal mask airway (LMA) anesthesia. METHODS In a prospective trial, 200 adult patients undergoing elective surgery under general anesthesia were randomly assigned to receive ventilation without airway warming and exogenous humidification (Group C-control), or active warming and humidification of inspired gases (Group HUM-humidified), using a humidifier with a heated wire circuit. Inhalational anesthesia was maintained via a circle system. The temperatures and relative humidities of inspired gases were monitored continuously throughout surgery. Postoperative sore throat, dysphonia, and dysphagia were assessed one and 24 hr after anesthesia. Whenever symptoms were present, their severities were graded using a 101-point numerical rating scale. RESULTS The mean temperature and relative humidity of the inspired gases in Group HUM were greater compared to Group C (36.1+/-0.4 degrees C and 99.5+/-0.5% vs 26.9+/-0.8 degrees C and 76.4+/-10.9%, respectively). Postoperatively, the overall frequencies of laryngeal and pharyngeal discomfort were similar in the two groups (53.8% and 54.9% in Group C vs 51.6% and 41.9% in Group HUM at one and 24 hr respectively, P>0.05). The groups were also similar with respect to the severity scores of laryngo-pharyngeal discomfort. CONCLUSION Active warming and humidification of inspired gases has no clinically appreciable effect in reducing the incidence and severity of laryngo-pharyngeal complaints after brief (

Effect of Mechanical Ventilation Mode Type on Intra- and Postoperative Blood Loss in Patients Undergoing Posterior Lumbar Interbody Fusion Surgery: A Randomized Controlled Trial.

Background:The aim of study was to evaluate the effect of mechanical ventilation mode type, pressure-controlled ventilation (PCV), or volume-controlled ventilation (VCV) on intra- and postoperative surgical bleeding in patients undergoing posterior lumbar interbody fusion (PLIF) surgery. Methods:This was a prospective, randomized, single-blinded, and parallel study that included 56 patients undergoing PLIF and who were mechanically ventilated using PCV or VCV. A permuted block randomization was used with a computer-generated list. The hemodynamic and respiratory parameters were measured after anesthesia induction in supine position, 5 min after patients were changed from supine to prone position, at the time of skin closure, and 5 min after the patients were changed from prone to supine position. The amount of intraoperative surgical bleeding, fluid administration, urine output, and transfusion requirement were measured at the end of surgery. The amount of postoperative bleeding and transfusion requirement were recorded every 24 h for 72 h. Results:The primary outcome was the amount of intraoperative surgical bleeding, and 56 patients were analyzed. The amount of intraoperative surgical bleeding was significantly less in the PCV group than that in the VCV group (median, 253.0 [interquartile range, 179.0 to 316.5] ml in PCV group vs. 382.5 [328.0 to 489.5] ml in VCV group; P < 0.001). Comparing other parameters between groups, only peak inspiratory pressure at each measurement point in PCV group was significantly lower than that in VCV group. No harmful events were recorded. Conclusion:Intraoperative PCV decreased intraoperative surgical bleeding in patients undergoing PLIF, which may be related to lower intraoperative peak inspiratory pressure.

Rotational Thromboelastometry as a Routine Point-of-Care Test Immediately after Cardiopulmonary Bypass Facilitated Earlier Diagnosis of Unexpected Hyperfibrinolysis and Hypofibrinogenemia During Cardiac Surgery

The present case was to show the efficacy of implementing routine intra operative parallel rotational thromboelastometry (ROTEM) assays immediately after cardiopulmonary bypass (CPB) in diagnosis and management of unexpected post-CPB bleeding diathesis in cardiac and major vascular surgery. A 54-year-old male gone under an elective aortic valve repair and graft interposition procedure. The routine INTEM, EXTEM, FIBTEM, and APTEM assays started immediately after CPB and protamine administration showed tracings indicating hyperfibrinolysis and hypofibrinogenemia. Tranexamic acid was administered intravenously within 30 minutes the start of the ROTEM assay and transfusion of cryoprecipitate was decided. The implementation of routine intra operative parallel ROTEM assays immediately after CPB enabled earlier determination of unexpected post-CPB bleeding diathesis due to hyperfibrinolysis and hypofibrinogenemia and facilitated timely and appropriate coagulation management in cardiac and major vascular surgery.

Intraoperative Three-Dimensional Transesophageal Echocardiography Facilitates Aortic Plaque Evaluation.

354 www.anesthesia-analgesia.org February 2016 • Volume 122 • Number 2 A 54-year-old male patient underwent off-pump coronary artery bypass surgery. Given severely compromised left ventricular (LV) performance with LV distension and chordal tethering of the mitral leaflet, high-dose inotropic therapy and intraaortic balloon pump (IABP) counterpulsation were initiated before his arrival in the operating room. Through anesthetic induction, mean arterial blood pressure 70 to 75 mm Hg and heart rate 90 to 100 beats/min were maintained. Intraoperative 2-dimensional (2D) transesophageal echocardiography (TEE; iE33TM, Philips Healthcare, Bothell, WA) revealed hypokinesia in the basal and apical inferolateral LV segments with an LV ejection fraction of 40% to 50%. The IABP tip was located approximately 10 to 12 cm distal to the opening of the left subclavian artery in the descending aorta. Orthogonal (short and long axis) 2D images were obtained to delineate the descending aorta around the IABP by advancing/ withdrawing the 3-dimensional (3D) matrix array TEE probe (X7-2tTM, Philips Healthcare). “X-plane” 2D images revealed diffuse thickening of the intimal layer with 2 small (<3 mm) protruding atheromatous plaques on the posterolateral walls of the descending aorta (Fig. 1A; Supplemental Digital Content 1, Supplemental Video 1, http://links.lww.com/AA/B319), corresponding to a “mild-grade” atheroma (Table 1).1 Real-time 3D, zoomed imaging of the same region of interest (ROI) revealed larger (>5 mm) atheromatous plaques with irregular surfaces (Fig. 1, B and C; Supplemental Digital Content 2, Supplemental Video 2, http://links.lww.com/ AA/B320). Additional 3D “en face” (3D zoom) imaging, in which the ROI was rotated and adjusted to focus on the posterolateral aortic wall, revealed additional larger (>5 mm) plaques that were mobile and had irregular surfaces (Fig. 2, A and B; Supplemental Digital Content 3, Supplemental Video 3, http://links.lww.com/AA/B321). Additional multiplanar images with 3 different axes, which were rendered by the use of installed software (3DQ in QLabTM, Philips, Baltimore, MD), confirmed the size of the larger plaques (Fig. 2, C and D), corresponding to “severe and complex grade” on the atheroma grading system (Table 1). These plaques were felt to have potential to liberate emboli by the repetitive IABP inflation/deflation with possible mobilization into the cerebral circulation. An epiaortic 2D scan of the ascending aorta was performed and revealed small intimal thickenings in the anterior aspect of the sinotubular junction. Considering the relative thromboembolic risks of the descending aortic plaques, on-pump beating coronary artery bypass graft surgery with partial cardiopulmonary bypass (CPB) support through an ascending aortic cannula was performed, instead of the planned off-pump coronary artery bypass procedure with IABP support. During cardiac displacement for anastomosis of the distal bypass grafts to the left anterior descending, the obtuse marginal, and the posterior descending arteries, CPB flow ranging from 1.5 to 2.0 L/min was applied with intermittent cardiac pacing. The IABP was then removed without further use during weaning from CPB, and, instead, high-dose inotropic support with milrinone, dobutamine, and phenylephrine was used until the immediate postoperative period. The patient was discharged 6 days after surgery without any thromboembolic complications. An atherosclerotic plaque (atheroma) is a vascular deposit of calcium and fatty materials.2 Atheromas in the ascending or arch segment of the aorta are associated with a greater prevalence of stroke and embolic complications than in the descending aorta, because direct aortic cannulation, crossclamping for CPB, and turbulent flow from the cannula can mobilize embolic debris out of atheromas located in these segments and into the cerebral circulation during cardiac surgery.3 Therefore, echocardiographic grading scales have been developed to evaluate atheromas in the ascending and arch segments of the aorta and to identify their risks to the patient. Atheromas that are large (>5 mm), mobile, or ulcerated, which are located in the ascending aorta, carry the greatest risk of stroke and embolic complications.1 In contrast, atheromas in the descending aorta have been regarded as having a lower risk of stroke. However, the repetitive inflation/deflation of an IABP and counterpulsation in the descending aorta may increase the risk of stroke attributable to atheromas in this area.3 Therefore, echocardiographic evaluation for atheromas in the descending aorta may be necessary when weighing the risk-benefit ratio of the use of an IABP in coronary artery bypass graft surgery patients. Early imaging data for the surgeon can be helpful to facilitate treatment strategies, based on the local surgical preferences, as in this case. Intraoperative 2D TEE imaging is useful for detecting aortic atheromas and to making detailed evaluations during cardiac surgery,4,5 despite its inability to delineate the distal portion of the ascending aorta. However, 2D TEE requires frequent modification of the probe position and use of multiplane angles to detect and evaluate atheromas located at different levels of the aorta. X-plane imaging with the use Copyright

Intraoperative three-dimensional transesophageal echocardiography for evaluating an unusual structure in the left ventricular outflow tract: a case report

Intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) facilitates an understanding of the complex cardiac pathology that is not fully delineated in a two-dimensional (2D) echocardiographic evaluation, and it suggests earlier and more precise surgical planning and intraoperative decision making. In the present case, the intraoperative 2D-TEE midesophageal long-axis view indicated a significant narrowing of the left ventricular outflow tract (LVOT) area by a band-like structure that vertically traversed the middle of the LVOT and connected to the anterior mitral leaflet base and the interventricular septum. However, additional 3D-TEE images of the LVOT and their cropped and rendered 2D images showed that web-like tissue, which presumably had grown around the patch closure from a previous atrioventricular septal defect, was obstructing the LVOT partially.

Intraoperative echocardiographic delineation of the high take-off coronary ostia during an extensive surgical repair of the bicuspid aortic valve and dilated sinotubular junction: a case report.

BackgroundThis study reports the efficacy of intraoperative transesophageal echocardiography (TEE) for evaluation of high take-off coronary ostia and proximal coronary arterial flows as an alternative to preoperative coronary angiography.Case presentationIn a 65-year old male undergoing the bicuspid aortic valve (BAV) repair and the extensive remodeling of dilated sinus and tubular junction, and preoperative coronary angiography were unsuccessfully completed due to an allergic reaction to the contrast medium. Intraoperative TEE by employing various 3-dimensional volume images of coronary ostia and Doppler tracings of the coronary arterial flows enabled a thorough pre-procedural evaluation of the high take-off coronary arteries and post-procedural evaluation by confirming the absence of any compromise in coronary arterial flow.ConclusionIn the present case, intraoperative application of various TEE imaging modalities enabled comprehensive evaluation of high-taking off coronary artery, as an alternative to preoperative coronary angiography, in a patient undergoing an extensive aortic valve and aortic root repair procedure.

Anesthetic managements for correction of aortic valve regurgitation in a patient with Loeys-Dietz Syndrome - A case report -

Loeys-Dietz Syndrome (LDS) is a recently described autosomal dominant aortic aneurysm syndrome with widespread systemic involvement. It is characterized by the triad of 1) arterial tortuosity and aneurysms, 2) hypertelorism, and 3) bifid uvula or cleft palate. A 12-year-old boy with LDS was scheduled to undergo correction of aortic valve regurgitation due to aortic annuloectasia. We report our clinical experiences of a case of LDS patient with brief review of related literatures and relevant anesthetic problems.