The authors describe a case of pneumocephalus following epidural anaesthesia for total knee arthroplasty. Multiple attempts in locating the epidural space for the anaesthesia and the use of loss of resistance to air (LORA) technique were identified as the source of air entry. Supportive management was given including high flow oxygenation therapy and spontaneous reabsorption of air was noted five days after surgery. The presence of pneumocephalus should be kept in mind if patient develops neurological complications postoperatively following epidural anaesthesia.
Pneumocephalus ; Anesthesia, Cardiac Procedures

Sudden cardiac arrest during epidural anesthesia is a rare but catastrophic complication. It was recently reported that occurs in one per 10,000 epidural anesthesia cases. We report one case of cardiac arrest in a healthy 45-year-old male patient undergoing relatively minor surgery. His preoperative blood pressure was 110-130/70-80 mmHg, heart rate 75-80 beats per minute, and oxygen saturation 98%. Immediately after tourniquet release, cardiac arrest was developed without warning signs. The patient was resuscitated by prompt precordial thump pacing, a fluid bolus, intravenous injection of atropine and ephedrine, and ventilated with oxygen. The procedure was completed and the patient recovered uneventfully.
Anesthesia, Epidural* ; Atropine ; Blood Pressure ; Death, Sudden, Cardiac* ; Ephedrine ; Heart Arrest ; Heart Rate ; Humans ; Injections, Intravenous ; Male ; Middle Aged ; Oxygen ; Surgical Procedures, Minor ; Tourniquets*

Removal of a left atrial myxoma using extracorporeal circulation was successfully performed first in 1954 by Craford. The problems of anesthesia for resection of atrial myxoma were the hemodynamic alterations, embolisation and valvular obstruction produced by tumor size and location, conduction defects due to myocardial invasion and anesthetic and operative procedures. Thus we have mad clinical analysis of 13 cases receiving anesthesia performend from 1976 to 1983 at Severance Hospital, Yonsei University College of Medicine. The results of clinical analysis are as follows: 1) Atrial myxomas were located(in the) in the lefte atrium except for 1 case. 2) Preoperatively most of these case showed congestive heart failure, cardiomegaly, arrhythmia and increased right atrial, pulmonary arterial and pulmonary capillary wedge pressures. 3) As premedicantes, one of the sedatives and a mild tranquilizer were given in all cases, atropine in about one third and triflupromaxine in about one half of the cases. 4) Anesthesia was induced with thiopental, morphine, midazolam, flunitrozepam and intubated after succinylchoilne or pancuronfum and maintained in the usual manner. 5) Myoxamas were resected during cardiopulmonary bypass and one case had to have a mitral value replacement. 6) The average duration of anesthesia and bypass was 372.14+/-42.0 and 104+/-12.9min. No mortality occurred. From the above results, it can be concluded that the understanding of the pathophysiology and the hemodynamic changes before anesthesia are important for safe anesthesia.
Anesthesia* ; Arrhythmias, Cardiac ; Atropine ; Capillaries ; Cardiomegaly ; Cardiopulmonary Bypass ; Extracorporeal Circulation ; Heart Failure ; Hemodynamics ; Hypnotics and Sedatives ; Midazolam ; Morphine ; Mortality ; Myxoma* ; Pulmonary Wedge Pressure ; Surgical Procedures, Operative ; Thiopental

Intraspinal narcotic anesthesia was performed in 180 open heart surgery patients. 0.1 mg/Kg of morphine or 1.5 mg/Kg of meperidine was administered as the primary anesthetic in the subarachnoid space using the barbotage technique. Of the 180 patients scheduled for open heart surgery, morphine was administered to 95 patients, meperidine to 55 and a mixture of morphine and meperidine to 30 patients. From a clinical point of view, there were no significant cardiovascular problems, however, respiratory depression seemed to be most serious after morphine administration. Mild complications such as pruritus (11.1%), voiding difficulty (10.6%), intraoperative awareness (4.4%) and spinal headache were observed, however these were mild, not major clinical problems and were acceptable. Postoperative analgesic effect and respiratory controllability were excellent.
Anesthesia, Spinal/adverse effects/*methods ; *Cardiac Surgical Procedures ; Humans ; Meperidine/*administration & dosage/adverse effects ; Morphine/*administration & dosage/adverse effects ; Respiratory Insufficiency/chemically induced

BACKGROUND: We determined the protective effects of a high dose of ulinastatin on myocardial and renal function in patients undergoing aortic valve replacement with cardiopulmonary bypass (CPB). METHODS: Sixty patients were assigned randomly to either the ulinastatin group (n = 30) or the control group (n = 30). In the ulinastatin group, ulinastatin (300,000 U) was given after the induction of anesthesia, ulinastatin (400,000 U) was added to the CPB pump prime, and then ulinastatin (300,000 U) was administered after weaning from CPB. In the control group, the same volume of saline was administered at the same time points. Creatine kinase-MB levels were assessed 1 day before surgery, and on the first and second postoperative day (POD 1 and 2). Serum creatinine and cystatin C levels were assessed 1 day before surgery, upon intensive care unit arrival, and on POD 1 and 2. The level of plasma neutrophil gelatinase-associated lipocalin was assessed before induction of anesthesia, upon ICU arrival, and on POD 1. RESULTS: No significant differences were observed in serum levels of creatine kinase-MB and biomarkers of renal injury between the two groups at any point during the study period. CONCLUSIONS: Ulinastatin showed no cardiac or renal protective effects after CPB in patients undergoing aortic valve replacement.
Anesthesia ; Aortic Valve ; Biomarkers ; Cardiac Surgical Procedures ; Cardiopulmonary Bypass ; Creatine ; Creatinine ; Cystatin C ; Glycoproteins ; Humans ; Intensive Care Units ; Lipocalins ; Neutrophils ; Plasma ; Weaning

OBJECTIVETo summarize anesthetic management of low birth weight infants undergoing surgical intervention of congenital heart disease without cardiopulmonary bypass.

METHODSFifty-three low birth weight infants (including 49 premature infants) with congenital heart disease underwent surgical treatment without cardiopulmonary bypass during the period from June, 2003 to July, 2013. The mean gestational age of the infants was 30.96∓3.09 weeks (26-40 weeks) with a mean age on the operation day of 32.81∓20.76 days (4-87 days), birth weight of 1429.90∓455.08 g (640-2460 g), and weight on the operation day of 1750.20∓481.59 g (650-2460 g). All the infants underwent cardiac operations without cardiopulmonary bypass under general anesthesia. The respiratory parameters and acid-base and electrolyte balance were adjusted according to blood gas analysis. The inotropic drug was used to maintain the hemodynamic stability.

RESULTSForty-seven of the infants received patent ductus arteriosus (PDA) ligation. Of these infants, 1 had cardiac arrest before the operation with failed cardiopulmonary resuscitation, and in another case, PDA ligation was aborted due to severe hypoplasia of the aortic valve and ascending aorta found intraoperatively by transesophageal echocardiography. Two infants underwent coarctation of the aorta (CoA), and 1 of them died during the operation due to cardiac arrest. The total mortality of these infants was 3.77% and the early postoperative mortality (<72 h) was 5.66%.

CONCLUSIONSNon-cardiopulmonary bypass surgery can be performed in low birth weight infants in early stage, and effective anesthetic management can reduce the perioperative mortality and improve the postoperative survival rate.

Anesthesia ; methods ; Anesthetics ; Birth Weight ; Cardiac Surgical Procedures ; Cardiopulmonary Bypass ; Gestational Age ; Heart Defects, Congenital ; surgery ; Humans ; Infant ; Infant, Low Birth Weight ; Infant, Newborn ; Infant, Premature ; Ligation

BACKGROUND: Remifentanil-propofol combination is used to minimize the cardiovascular responses during anesthetic induction; however, it may generate side effects such as hypotension or bradycardia. The authors investigated the changes of stroke volume and cardiac output using impedance cardiography (ICG) when hypotension or bradycardia is generated during propofol-remifentanil anesthetic induction. METHODS: Ninety ASA physical status class I patients who were scheduled to undergo elective ambulatory surgery were randomly assigned to one of three groups (n = 30 each). Normal saline (Group S), remifentanil 0.25microgram/kg/min (Group R0.25), or remifentanil 0.5microgram/kg/min (Group R0.5) was infused intravenously. Propofol was slowly administered two minutes after the administration of remifentanil or normal saline. Heart rate, mean arterial pressure, cardiac output and stroke volume were measured at preinduction (baseline), preintubation and postintubation. RESULTS: Mean arterial pressure in Group R0.5 at preintubation decreased compared to that of the baseline, however, the stroke volume index was sustained. The stroke volume index at postintubation decreased proportionally as heart rate increased in heart rate in all groups, and then cardiac index was preserved. CONCLUSIONS: Hypotension was generated during induction of anesthesia when remifentanil 0.5microgram/kg/min and propofol 1.0 mg/kg were used, however, the stroke volume index was sustained.
Ambulatory Surgical Procedures ; Anesthesia ; Arterial Pressure ; Bradycardia ; Cardiac Output ; Cardiography, Impedance* ; Electric Impedance* ; Heart Rate ; Hemodynamics* ; Humans ; Hypotension ; Propofol ; Stroke Volume

We retrospectively report the first use of intrathecal morphine prior to incision in two male patients undergoing a complex aortic reconstruction, who required complete circulatory arrest under deep hypothermia for intraoperative and postoperative pain control. We administered intrathecal morphine to two male patients undergoing circulatory arrest and deep hypothermia. Patients were fully heparinized prior to cardiopulmonary bypass. Deep hypothermic circulatory arrest was performed by cooling the patients to 18degrees C. Following the surgery, the neurologic status was monitored. The management of postoperative pain is a quality standard in health care. During the first 24 hours after surgery, we observed excellent analgesia without the associated side effects, thus, reducing the time required for pain control by the nursing staff. A successful analgetic strategy not only enhances the patient satisfaction, but may improve the postoperative outcome. However, complications, such as increased risk of epidural hematoma formation, are of special concern in cardiac surgery.
Analgesia ; Anesthesia, Spinal ; Cardiac Surgical Procedures ; Cardiopulmonary Bypass ; Circulatory Arrest, Deep Hypothermia Induced ; Delivery of Health Care ; Hematoma ; Heparin ; Humans ; Hypothermia ; Male ; Morphine ; Nursing Staff ; Pain, Postoperative ; Patient Satisfaction ; Retrospective Studies ; Thoracic Surgery

OBJECTIVETo explore the effect of acupuncture-drug compound anesthesia on immune function in patients with extracorporeal circulation undergoing cardiac surgery.

METHODSThirty cases undergoing cardiac surgery which included atrial septal defect neoplasty, ventricular septal defect neoplasty, mitral valve replacement and pulmonary valve coarctotomy were randomly divided into group A and group B, 15 cases in each group. Group A was given general anesthesia plus acupuncture at Neiguan (PC 6), Lieque (LU 7) and Yunmen (LU 2), and group B was given simple general anesthesia. Tumor necrosis factor-alpha (TNF-alpha), interleukin-2 (IL-2) and interleukin-10 (IL-10) levels before and after surgery were compared.

RESULTSThe level of TNF-alpha was increased and the levels of IL-2 and IL-10 in the serum were decreased in both groups after extracorporeal circulation for 2 h and 24 h, and the ranges of all changes were more less in group A (all P < 0.05).

CONCLUSIONCompared with simple general anesthesia, acupuncture-drug compound anesthesia can improve immune suppression partially in the perioperative periods under the same conditions of controlling anesthesia degree.

Acupuncture Analgesia ; Adult ; Anesthesia, General ; Cardiac Surgical Procedures ; Female ; Heart Diseases ; blood ; immunology ; surgery ; Humans ; Inflammation Mediators ; blood ; Interleukin-10 ; blood ; Interleukin-2 ; blood ; Male ; Middle Aged ; Perioperative Care ; Tumor Necrosis Factor-alpha ; blood ; Young Adult

Fentanyl-O2 anesthesia has gained wide popularity as an anesthetic technique for patients undergoing cardiac surgery because of its minimal cardiovascular effects and total amnesia for intraoperative events. But, some authors recently reported intraoperative awareness and the excessive cardiovascular response to surgical stimulation during high dose fentanyl-oxygen anesthesia far cardiac operation and suggested the necessity of supplementary anesthetic agent in addition to fentanyl to prevent the intraoperative awareness and maintain hemodynamic stability during the surgical procedure. A variety of supplementary drugs have been used in combination with the opioids in an effort to reduce the incidence of awareness, to control hypertension, and to attenuate the extent of postoperative respiratory depression. One of supplementary drugs, diazepam has little cardiovascular effects by itself, but causes significant depression of arterial blood pressure and cardiac output when given to patients who have received fentanyl or morphine. We measured the heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and rate pressure product (RPP) at induction, tracheal intubation, skin incision, and sternotomy time to evaluate the effects of the diazepam on reduction of the excessive cardiovascular response to anesthetic and surgical stimulation and observed the presence of the intraoperative awareness, under fentantyl-diazepam-O2 anesthesia for open heart surgery on 12 patients with cardiac disease. Anesthesia was induced with fentanyl 20 ug/kg + diazepam 0.1 mg/kg and maintained with continuous infusion of fentanyl (1.5 ug/kg/min. prior to sternotomy and 0.3 ug/kg/min. until the end of cardiopulmonary bypass) and diazepam 0.1 mg/kg was injected just before sternotomy and at the end of cardiopulmonary bypass. The patients required the total dose of fentanyl 76+13.1 ug/kg and diazepam 0.3 mg/kg for the entire operation. These measurements were compared with control data (before induction). The results were as followings: 1)During induction period (infusion of fentanyl 20 ug/kg with diazepam 0.1 mg/kg); HR, SBP, DBP, and MAP slightly decreased compared with control data, but there were not statistically significant. RPP decreased significantly from 15898+/-5099 torr. beatsmin. to 12371+/-2407 torr. beatsmin. and there was statistical significance (p<0.05). 2) During intubation and skin incision; HR, SBP, DBP, MAP and RPP revealed no significant change compared with control data. 3) During sternotomy; HR, SBP, DBP, MAP, and RPP slightly increased, but there were not statistically significant. 4) There was no patient who had the recall or awareness for intraoperative events. 5) Duration of controlled or assisted ventilatory support. postoperatively, was 216+/-36 min. These results suggest that fentanyl-diazepam-O2 anesthesia might be more useful than fentanyl-O2 anesthesia for prevention of intraoperative awareness and attenuation of excessive cardiovascular response during open heart surgery. But, continuous and careful monitoring for hemodynamic changes of patients will be needed necessarily to prevent the significant depression of arterial blood pressure and cardiac output throughout the entire operative procedures.
Amnesia ; Analgesics, Opioid ; Anesthesia* ; Anesthetics ; Arterial Pressure ; Benzodiazepines ; Blood Pressure ; Cardiac Output ; Cardiopulmonary Bypass ; Depression ; Diazepam* ; Fentanyl* ; Heart Diseases ; Heart Rate ; Heart* ; Hemodynamics ; Humans ; Hypertension ; Hypnotics and Sedatives ; Incidence ; Intraoperative Awareness ; Intubation ; Morphine ; Respiratory Insufficiency ; Skin ; Sternotomy ; Surgical Procedures, Operative ; Thoracic Surgery*