Search

Background Postoperative pain control after the minimally invasive repair of pectus excavatum (MIRPE) is essential, but there is a controversy about a better analgesic method between epidural and intravenous (IV) analgesia. This systematic review and meta-analysis aimed to compare the effect of epidural versus IV analgesia following MIRPE. Methods We searched PubMed, MEDLINE, EMBASE, Cochrane Central Register, and ClinicalTrials.gov for randomized control trials (RCTs) dated up to 31st May 2021. The primary outcome was the area under the curve (AUC) of the weighted mean visual analog scale (VAS) after MIRPE. The secondary outcomes were postoperative nausea, operation time, total operating room time, and postoperative length of hospital stay. Results Four RCTs involving 243 patients were finally included in this meta-analysis. The AUC of the weighted mean VAS was 343.62 in the epidural group and 375.24 in IV group. Epidural group showed lower VAS than IV group at 12 hours (mean difference -0.99 [95% CI: -1.52, -0.47], P = 0.001, I2 = 0%), at 24 hours (mean difference -0.65 [95% CI: -1.15, -0.16], P = 0.009, I2 = 0%), and 48 hours (mean difference -0.81 [95% CI: -1.61, -0.01], P = 0.046, I2 = 46%) after the surgery. Conclusion Epidural analgesia after the MIRPE had a better analgesic effect than IV analgesia from 12 hours to 48 hours after surgery, and AUC of VAS was lower in the epidural group. However, IV analgesia may also be a viable option, and physicians should wisely choose analgesic modalities after MIRPE.

Background: Giant lip hemangioma is a rare disease that may cause difficulty in preoxygenation and ventilation when using face masks and intubation during general anesthesia induction.Case: A laparoscopic cholecystectomy was planned for a 77-year-old woman. The patient had a giant lower lip hemangioma that was 12 x 5 x 5 cm, which made preoxygenation and ventilation through a face mask impossible and put her at risk of hemangioma rupture. We preoxygenated her through a high-flow nasal cannula (HFNC). Following propofol and succinylcholine administration, we intubated the patient with a video laryngoscope without desaturation, hemangioma rupture, or CO2 retention. Conclusions: HFNC is a useful tool when difficult intubation is expected in patients who have problems using conventional face masks.

Heat-moisture exchanger (HME) is an inexpensive and effective device used to prevent respiratory complications that can be caused by endotracheal tube insertion during general anesthesia. But, HME can increase airway resistance and be occluded by the patient’s secretions. Whether a HME could be occluded by clear fluids such as condensate in the airway circuit is not certain yet. In vitro, a case of HME occlusion by normal saline was reported. We report a case of HME obstruction by distilled water came from the heated wire circuit which was unintentionally connected to the HME.

We present successful epidural anesthesia and assisted mechanical ventilation in a parturient woman with respiratory failure. A 41-year-old woman at 35 weeks' of gestation was entering labor. She was pneumonectomized on the left, had bronchiectasis on the remnant lung, and was under assisted mechanical ventilation by continuous positive airway pressure (CPAP) because of severely restricted lung function and superimposed pneumonia. We administered continuous epidural analgesia for vaginal delivery, and extended it for cesarean section after failure of vaginal delivery. During the procedure, her ventilation was continuously assisted by CPAP. The maternal and fetal outcomes were successful.

We report a case of 29-year-old, morbidly obese, diabetic primigravida who had undergone previously primary percutaneous coronary intervention with stent placement for an inferior wall myocardial infarction at 10 weeks of gestation. She remained asymptomatic with medication during the remainder of her pregnancy, but preoperative echocardiography revealed left ventricular dilation and a restrictive diastolic dysfunction with a preserved ejection fraction (46%). She developed acute pulmonary edema associated with hypertension after an elective Cesarean delivery under continuous epidural anesthesia despite the meticulous restriction of fluid.

A 33-year-old male patient with multiple sclerosis (MS) received an emergency laparotomy because of perforated appendicitis. He had been suffering from MS for 2 years and the symptoms of MS were paraplegia and urinary incontinence. Anesthesia was induced with propofol and remifentanil and maintained with nitrous oxide, sevoflurane and remifentanil. Rocuronium was used for tracheal intubation. Train of four ratio and bispectral index scale were also monitored for adequate muscle relaxation and anesthetic depth. The patient emerged from general anesthesia smoothly and was extubated without any complication. Postoperative exacerbation of MS symptoms did not appear. However, he was rehospitalized because deep vein thrombosis (DVT) occurred after discharge and he received heparinization immediately. Eventually, he was discharged after a full recovery from DVT. We report a safe anesthetic management of the patient with MS, with the use of sevoflurane and with no the aggravation of MS during postoperative period.

www.ekja.org Background: A prospective, double blind study was performed to compare the clinical effect of vertical infraclavicular and supraclavicular brachial plexus block using a nerve stimulator for upper limb surgery. Methods: One hundred patients receiving upper limb surgery under infraclavicular or supraclavicular brachial plexus block were enrolled in this study. The infraclavicular brachial plexus block was performed using the vertical technique with 30 ml of 0.5% ropivacaine. The supraclavicular brachial plexus block was performed using the plumb bob technique with 30 ml of 0.5% ropivacaine. The block performance-related pain was evaluated. This study observed which nerve type was stimulated, and scored the sensory and motor block. The quality of the block was assessed intra-operatively. The duration of the sensory and motor block as well as the complications were assessed. The patient’s satisfaction with the anesthetic technique was assessed after surgery. Results: There were no significant differences in the block performance-related pain, frequency of the stimulated nerve type, evolution of sensory and motor block quality, or the success of the block. There were no significant differences in the duration of the sensory and motor block. There was a significant difference in the incidence of Horner’s syndrome. Two patients had a pneumothorax in the supraclavicular approach. There were no significant differences in the patient’s satisfaction. Conclusions: Both infraclavicular and supraclavicular brachial plexus block had similar effects. The infraclavicular approach may be preferred to the supraclavicular approach when considering the complications. (Korean J Anesthesiol 2010; 58: 260-266)

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.

Pediatric intracranial aneurysms are uncommon. Moreover ruptured aneurysms are extremely rare in preterm neonate. In this article we report a case of a 1 month old infant with a ruptured middle cerebral artery (MCA) aneurysm. Aneurysm clipping surgery was scheduled for a 1 month 3 day old female neonate, weighing 2,450 g. She was born at a gestational age of 34 weeks and 2 days weighing 2,300 g. After birth, she was mechanically ventilated due to respiratory distress. On the 11th day after birth, she developed sepsis of unknown origin. She presented with abrupt anemia (hemoglobin dropped from 9.5 g/dl to 6.1 g/dl), and brain computerized tomogram (CT) with contrast enhancement was done identifying a intracranial hemorrhage. External ventricular drainage insertion was done. After the drainage, 3-dimensional CT angiography of the head and neck was done. About a 4.2 × 7.7 mm sized aneurysm, at the left MCA bifurcation site was found. She was transported to operating room for clipping. Before anesthesia, her heart rate was 131 beats/min and blood pressure 68/37 mmHg (arterial catheter at right radial artery) with an infusion of dopamine 10 µg/kg/min and dobutamine 20 µg/kg/min. We connected her endotracheal tube with a ventilator and volume control mechanical ventilation was applied with FIO2 0.5, tidal volume of 20 ml, respiratory rate of 40 breaths/min and positive end-expiratory pressure 4 cmH2O. Peak airway pressure was maintained at about 17-20 cmH2O and peripheral pulse oxygen saturation was maintained at 100% and the endtidal carbon dioxide was maintained at 28-32 mmHg during anesthesia. Anesthesia was maintained with sevoflurane (0.6 vol%) and remifentanil (0.5-1 µg/kg/min). During four hours after the induction, a mean blood pressure of 40-55 mmHg was maintained, but after that time, epinephrine infusion (0-0.6 µg/kg/min) was added because of a reduction in the blood pressure. Total anesthesia time was 7 hours 5 minutes. The patient recovered and was discharged 39 days after the surgery. Intracranial aneurysms occur rarely in preterm neonate so the cause is presumed to be various. In the case of this neonate, a definite causal bacterium was not identified in the culture, but because there was a precedent for sepsis, it is thought to be a septic aneurysm caused by infection. Neonates cannot localize pain due to a premature central nerve system, and it is known that they cannot interpret pain, because there is no memory of a pain experience. However Anand and Carr [1] stated that the pain sensation is conveyed to the brain region such as the sensory motor cortex and thalamus even in neonates. Appropriate anesthesia and analgesic are necessary even in neonates. For anesthesia methods, there is total intravenous anesthesia (TIVA) using propofol and anesthesia with inhalation agents. Propofol reduces the oxygen consumption in the brain, decreases the cerebral blood flow, and contracts the cerebral vessels. A target controlled infusion (TCI) model is required to perform TIVA using propofol, and TCI models applicable for infants is the 'Paedfusor' model which can be applied to patients 1 year or older with a weight of 5 kg or more. Our case was a 1 month 3 day old neonate weighing 2,450 g, so currently there are no applicable TCI models. There is controversy regarding the effect of volatile agents on the brain. Jevtoric-Todorovic confirmed that neuroapoptosis occurred in neonate rats when they were exposed to nitrous oxide, isoflurane, and midazolam for 6 hours [2]. Considering the above study, there was the possibility of potential neurotoxicity from the volatile agents; thus in this case, the authors used a minimum amount of 0.6 vol% sevoflurane and added a high dose of opioid. Using a high dose of opioid during anesthesia not only reduces the stress response but can also reduce the amount of anesthetic agent; therefore, it can reduce the neurotoxic effects [3]. Most complications anticipated when using opioids in infants or neonates are respiratory hold or apnea which appears during awakening or the recovery stage after surgery. In our case, the neonate was maintained in an intubation state and received ventilator care after surgery so it was not considered to be a problem. When anesthetizing brain nerves, mild hypothermia (32-34℃) may be maintained to reduce brain oxygen consumption, cerebral blood flow, and intracranial pressure, but the effect is not definite in young patients. Regarding indications for hypothermia, Abraham limited it to neonates with a gestational age of 36 weeks or more who developed hypoxic ischemic encephalopathy within 6 hours of birth, and also restricted it to those who satisfied two more separate criteria [4]. The temperature of the neonate measured in our case was 34.8-37.4℃, and although warm air was turned on intermittently to raise the temperature, there were limitations in stably maintaining body temperature due to loss and replenishment of fluid during surgery, and a relatively large body surface area compared to the weight. The total amount of infused fluid was 169 ml including leukocyte-depleted RBC 10 ml, and the predicted maintenance fluid requirement was calculated to be 100 ml and blood loss of 90 ml. The fluid administered was Lactated Ringer's solution 69 ml, 5% dextrose water 50 ml used to mix the inotropics, and normal saline 40 ml. Electrolyte imbalance was not observed in the blood test performed after surgery. Inotropics were used to maintain blood pressure during surgery, and 24.5 ml of urine was confirmed after surgery so the I/O balance is considered to be appropriate. A surgical case of intracranial aneurysm in a neonate is very rare, but it is believed to be on the rise as more low-birth weight neonates survive because of the development of medical technology. More cases and prospective studies are needed to search for an anesthesia method which is more ideal and has a better outcome for neonatal aneurysm patients.

We report that intraoperative NIM-2 monitoring devices can interfere with bispectral index monitoring. A 45-year-old male with chronic otits media underwent tympanolasty under general anesthesia with NIM-2 monitoring and bispectral index monitoring at our institution. And then, bispectral index monitoring was severely interrupted by facial nerve monitoring.

Epiglottic cysts sometimes compromise a patient's airway, and may make airway management difficult. We report a novel method of intubating a patient with a large epiglottic cyst, using direct laryngoscopy and a light wand. A 53-year-old man with hoarseness was admitted to the hospital. He complained of a mild cough and sore throat for 2 days, without dyspnea. General anesthesia for microscopic laser surgery was planned. Neck computed tomography revealed a nearly non-enhancing cyst, 2.7 × 1.8 × 3.3 cm, located on the right prelingual surface of the epiglottis (Figs. 1A and 1B). Fig. 1 Neck computed tomography (CT) revealed a nearly non-enhancing cyst in the right pre-epiglottic space with concomitant mild airway obstruction ([A] Transverse and [B] Sagittal views). (C) This image shows direct laryngoscope, light wand and laser tube ... In addition to standard monitoring and preparations, we prepared laryngeal mask airways, adult and pediatric fiberoptic bronchoscopes, and an emergency cricothyrotomy kit at the bedside. Two attending anesthesiologists and one resident were present in the operating room. After preoxygenation, propofol 120 mg was given. The patient became unconscious, and we confirmed there was no difficulty with mask ventilation. We then administered rocuronium 25 mg intravenously. After 4 minutes, we attempted intubation with a Macintosh blade no. 3 and 5.0 laser tube (Laser-Flex® Tracheal Tube, Mallinckrodt, St. Louis, MO, USA) without stylet. We carefully placed the tip of the Macintosh blade at the vallecula, avoiding direct pressure on the cyst. After that, an assistant held the handle of the laryngoscope steady. The intubating anesthesiologist then held the hockey stick-shaped light wand in the left hand and used it both for leverage and as a light source. Gently elevating both the epiglottis and cyst with the light wand in the upper left direction revealed the lower third of the glottis with sufficient light. We then intubated the patient. After intubation, we began mechanical ventilation with air. Tidal volume was set to 500 ml, respiration rate was 12 per minute, and peak airway pressure was 26 cmH2O. Anesthesia was maintained with sevoflurane 1.5-2.0 vol% and remifentanil continuous infusion of 0.1-2.0 mcg/kg/min. Oxygen saturation was maintained at a minimum of 95% throughout the surgery and in the recovery room. The patient recovered and was discharged after 1 day without any adverse events. Most epiglottic cysts are located on the lingual surface or vallecula, which makes intubation difficult, when a cyst is large. For the treatment of epiglottic cysts, simple aspiration of the cyst results in frequent recurrence, so complete removal is recommended [1]. For this removal, laser surgery seems to be superior to cold instrument surgery, in many respects. During laser surgery, the use of laser resistant endotracheal tubes is recommended to avoid catastrophic airway fires. There are several choices for laser resistant endotracheal tubes, including wrapping metal foil around conventional tubes, Xomed Laser-Shield (Laser-Shield®II Endotracheal Tube, Medtronic Xomed, Jacksonville, FL, USA), and Mallinckrodt Laser-Flex. Inevitably, methods or tubes such as these are accompanied by an increase in the wall thickness of the tubes. With the Laser-Flex, for example, the outer diameter (OD) of the tubes is at least 2.5 mm greater than the internal diameter (ID). This number is considerable in comparison to the thickness of conventional tubes, which is 1.3 mm at minimum. In our case, when intubation was attempted, the epiglottic cyst blocked the light from the laryngoscope, so structures behind the cyst were not visible (Fig. 1C). To circumvent this problem, there are several possible options. First, we could use a Miller blade or a Magill blade. Holding the epiglottis from the lower surface, together with the cyst, may allow direct visualization of the vocal cords without blockage of the light. However, considering the size of the cyst, this maneuver might fail. In addition pressure of the blade may rupture the cyst and cause pulmonary aspiration of its contents. Second, we could aspirate the contents of the cyst and then try the conventional intubation method. If the mass was not entirely cystic, or lobulated, the chances of success would be slim. Furthermore, attempting aspiration without first securing the airway may significantly increase the risk of pulmonary aspiration of cyst contents. Lastly, we could choose larger diameter tubes to use a light wand, intubating stylet, or fiberoptic bronchoscope. For airway surgery, though, it is rational to choose the smallest tubes possible to facilitate the surgery. We chose an ID 5.0 Laser tube, the OD of which is equivalent to the OD of an ID 5.5 conventional tube. The OD of an adult fiberoptic bronchoscope used for awake intubation is 5.0 mm, the same as the ID of the Laser tube. The OD of a light wand is 5.55 mm, still larger than the ID of the tube. The OD of the intubating stylet was 4.65 mm, but due to small differences between the ID of the tube and the OD of the stylet, using it was impossible. In patients with more difficult airways, it may be rational to choose a Laser-Flex tube with a bigger ID and use a stylet in it, but this also may be difficult because of the dimmed light caused by the cyst. A light wand may still be difficult to use because of the large OD of a light wand for an ID 6.0 Laser tube. The difference in diameter between the two is only 0.45 mm. Laser tubes are rigid and difficult to use with a fiberoptic bronchoscope. In addition, to use an adult bronchoscope, one must use a tube with an ID larger than 6.0 mm. A McCoy blade can be helpful in some situations. In our case it might be effective, but considering the size and the location of the cyst, even elevating the epiglottis might not make it possible to move the cyst away from the light source. In actuality, levering of the epiglottis in the ventral and cranial direction would move the cyst closer to the light source and might make the view dimmer. Using a fiberoptic bronchoscope or light wand in the presence of a large epiglottic cyst is also a difficulty, because of the mass blocking the passage. Recently, Choi et al. [2] reported a case of intubation of a patient with a large glottic mass. In their report, introducing a flexible bronchoscope was difficult and ultimately not possible, in spite of attempts at guidance and visualization with the GlideScope® (Verathon Inc., Bothell, WA, USA) video laryngoscope. The authors did not report the size of the mass in their case, but the picture included in their report shows similarity to our case. Epiglottic cysts poses great challenges for anesthesiologists in some cases. Our method can be a relatively easy, less invasive, simple method dealing with some large epiglottic cysts.

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. (Korean J Anesthesiol 2011; 61: 257-261)

Open heart surgery under cardiopulmonary bypass (CPB) in patients with liver cirrhosis is prone to the development of various complications associated with high mortality rates. According to recent studies, patients with advanced cirrhosis (Child-Pugh class B or C cirrhosis) have a significantly higher mortality rate (50−100%) after open heart surgery under CPB. We report the anesthetic management of cardiac surgery using CPB of 61-year-old man with aortic valve regurgitation, tricuspid regurgitation and ventricular septal defect (VSD) who had complicated by liver cirrhosis of Child-Pugh class B. The patient underwent successfully aortic valve replacement, tricuspid valvuloplasty and VSD closu re. The use of tranexamic acid and transfusion of fresh whole blood appears to produce beneficial effects for outcome. (Korean J Anesthesiol 2009; 56: 578～82)

The trigeminocardiac reflex (TCR) consists of the sudden development of severe bradycardia or even asystole with arterial hypotension during manipulation of branches of the trigeminal nerve.TCR can occur during craniofacial surgery, rhizolysis of the trigeminal ganglion, and tumour resection in the cerebellopontine angle.We report a case of TCR-induced asystole during skin flap elevation in a patient undergoing craniotomy for cerebral aneurysm clipping.

Thoracic epidural analgesia is a common method of pain relief for thoracic and upper abdominal surgery. Misplacement of the epidural catheter is one of the complications associated with epidural analgesia. A 60-year-old man was scheduled for a right pneumonectomy under general anesthesia. Before inducing general anesthesia, the patient was placed in the left lateral decubitus position. A 18-gauge Tuohy needle was inserted into the T6-T7 level using the left paramedian approach 1.5 cm lateral to the midline with a loss of resistance at 7 cm, and uneventful catheter advancement was performed. Approximately 30 minutes after commencing surgery, the surgeon found the epidural catheter in the right pleural cavity. We report a case of the accidental intrapleural positioning of a thoracic epidural catheter.

Although there are no verified relationship between ICH and spinal anesthesia, there has been a few articles that report ICH after spinal anesthesia. We report a parturient with postpartum headache, nausea and vomiting which were diagnosed as symptoms of intracerebral hemorrhage, later. She had received a cesarean section under the spinal anesthesia, and developed a light headache, nausea, and vomiting at the ninth hour after the operation. She presented a generalized tonic seizure two hours later, and had other seizure on the day after operation. A brain computed tomography was performed and it revealed an intracerebral hemorrhage. She discharged 16 days after the surgery, without any sequelae. Parturients are prone to develop PDPH after spinal anesthesia, and other diseases with symptoms of headache, nausea, and vomiting may be misdiagnosed as PDPH. A cautious diagnosis should be made when one confronts a headache after spinal anesthesia, especially with a parturient. (Korean J Anesthesiol 2008; 54: 217∼9)

HELLP syndrome (Hemolysis, Elevated Liver enzymes, and a Low Platelet count) is a severe complication of preeclampsia or eclampsia, and is associated with a high risk of maternal and neonatal morbidity and mortality. In cases of delivery management in patients with HELLP syndrome, general anesthesia is required for cesarean sections in the presence of severe thrombocytopenia. These patients have a high risk of uncontrollable hypertension under stressful conditions, such as laryngoscopic intubation, surgical incision, and delivery. Remifentanil is an ultra-short-acting opioid with rapid onset and offset of action. In addition, remifentanil has a potent analgesic effect and provides cardiovascular stability during surgery. This paper reports a 33-year-old patient with HELLP syndrome, who was referred to our hospital for a cesarean section. The procedure was performed under general anesthesia with remifentanil being used as an adjunct for cardiovascular stability.

Background : Most of nonrebreathing circuits were used for pediatrics, not for adults and the high flow of fresh gas and specially designed valve or lever should be needed. The current study was designed to compare between one corrugated tube(universal FTMcircuit) and two corrugated tube in patients with oral and maxillofacial surgery under general anesthesia. Methods : Twenty adults undergoing oral and maxillofacial surgery were anesthetized with enflurane- N2O-fentanyl after radial arterial cannulation. Under the condition with stable vital signs, ventilator was setted with tidal volume 10ml/kg, respiratory rate 11 breaths/min using two separate limbs(expiratory and inspiratory limbs) and one corrugated tube of anesthesia machine. Mean arterial pressure, heart rate, saturated pulse oxygen, end tidal carbon dioxide, peak inspiratory oxygen, arterial blood gas analysis were measured at 15, 30min during the use of each circuit. Results; There were no differences of mean arterial pressure, heart rate, end tidal carbon dioxide, saturated pulse oxygen. peak inspiratory presssure and arterial blood gas analysis between 2 circuits during mechanical ventilation. Conclusions: Universal FTMcircuit of single limb could substituted for the two corrugated tube, especially in patients with oral and maxiolofacial surgery. (Korean J Anesthesiol 1997; 32: 366∼369)