Frequent anomalies causing a left-sided appendix are situs inversus and malrotation. The ectopic position of the appendix frequently causes a delay or error in diagnosis because of atypical symptoms. A physical examination is of limited value unless dextrocardia is present. A left-sided appendix is a rare anomaly, but when other diseases are ruled out, it must be considered especially at the emergency department.
Appendicitis* ; Appendix ; Dextrocardia ; Diagnosis ; Emergency Service, Hospital ; Physical Examination ; Situs Inversus

Background: Spontaneous pneumopericardium is a very rare condition. Spontaneous pneumothorax and pneumomediastinum have been reported to be associated with an idiopathic pulmonary fibrosis (IPF). However, spontaneous pneumopericardium has not yet been reported in association with IPF. Here we report a case of spontaneous pneumomediastinum and pneumopericardium in a patient with acute exacerbation of IPF with a review of the relevant literature.
Humans ; Idiopathic Pulmonary Fibrosis* ; Mediastinal Emphysema* ; Pneumopericardium* ; Pneumothorax

BACKGROUND: Laryngeal mask airway (LMA) is a useful instrument for routine anesthesia. It permits spontaneous or positive pressure ventilation but its use in obstetric anesthesia has not been described. In this study, we evaluated the effectiveness and the side effects of the LMA during elective cesarean sections. METHODS: Institutional approval and patients' permission were obtained. One thousand sixty-seven patients scheduled for elective an cesarean section, that have been NPO for more than 6 (6-48) hours were evaluated. They were premedicated with an H2 receptor blocker (ranitidine 50 mg i.m.) 1 hour before the operation. They were anesthetized with penthotal sodium (3-4 mg/kg), vecuronium (1 mg/10 kg i.m.) and then a 3 or 4 LMA was inserted after the mask ventilation with 100% oxygen for 1 min. The cuff was inflated with air 15.3 +/- 2.6 ml. On auscultation, air entry was good in both lungs. Anesthesia was maintained by 50% oxygen in N2O with 0.7 - 1.0% enflurane. Analgesics (tramadol 30 mg i.v.) was given incrementally after delivery of the baby. Manual assisted ventilation was used throughout the procedure. The number of insertion attempts, cuff volume and the incidences of complications were evaluated. RESULTS: In 1051 patients, the LMA was inserted on the first attempt. In 16 patients more than 2 attempts were needed and change to endotracheal intubation were needed in 7 cases. The mean cuff volume was 15 +/- 2.6 ml at insertion and increased to 18.5 +/- 3.2 ml after removal. The average airway pressure was 20 cmH2O during positive pressure ventilation, above that pressure air leakage was detected in 16 cases. Complications noted were mild sore throat in 5 cases, and blood tinged after removal of LMA in 3 cases but gastric distention was not detected. No incidence of aspiration was noted. CONCLUSIONS: In this study, the LMA proved to be a useful tool for the management of patients presenting for elective an cesarian section. There is the remote possibility of aspiration which did not happen in our study.
Analgesics ; Anesthesia ; Anesthesia, Obstetrical ; Auscultation ; Cesarean Section* ; Enflurane ; Female ; Humans ; Incidence ; Intubation, Intratracheal ; Laryngeal Masks* ; Lung ; Masks ; Oxygen ; Pharyngitis ; Positive-Pressure Respiration ; Pregnancy ; Sodium ; Tolnaftate ; Vecuronium Bromide ; Ventilation

BACKGROUND: Lidocaine is useful as a local anesthetic and antiarrhythmic agent perioperatively. It may augment a neuromuscular block from both nondepolarizing and depolarizing muscle relaxants. Cisatracurium is a new muscle relaxant as an isomer of atracurium. We investigated the interaction of cisatracurium and lidocaine on the dose-response curve in vitro. METHODS: Institutional approvement was obtained. Forty male Sprague-Dawley rats (150 - 200 gm) were divided into four groups (control, lidocaine 0.01, 0.1, or 1ng/ml). The animals were anesthetized with 40 mg/kg pentobarbital. The hemidiaphragm with the phrenic nerve was dissected and mounted within 5 minutes in a bath containing 100 ml Kreb's solution at 32degreesC. The phrenic nerve was stimulated at supramaximal intensity by a Grass(R) S88 stimulator through an SIU5 isolation unit. A twitch height was measured by a precalibrated Grass FT88 force displacement transducer and recorded with a Grass 79 polygraph. After stabilization of the twitch response, cisatracurium was added to the solution to obtain an initial concentration of 50ng/ml with saline 1 ml or lidocaine 0.01, 0.1 or 1ng/ml. When a stable 3 - 5 twitch inhibition was obtained after the first dose, additional cisatracurium was added to the Kreb's solution in increments of 25ng/ml to more than a 90% neuromuscular block. The data was analyzed by repeated measures of ANOVA. RESULTS: There was a significant decrease in the effective dose of cisatracurium needed to depress the twitch response in lidocaine 0.1ng/ml and 1ng/ml groups compared with the control group and with the lidocaine 0.01ng/ml group. CONCLUSIONS: We concluded that lidocaine will increase the sensitivity to cisatracurium in the hemidiaphragm preparation of rats.
Animals ; Atracurium ; Baths ; Humans ; Lidocaine* ; Male ; Neuromuscular Blockade ; Neuromuscular Depolarizing Agents ; Pentobarbital ; Phrenic Nerve ; Poaceae ; Rats ; Rats, Sprague-Dawley ; Transducers

BACKGROUND: Lidocaine is a useful local anesthetic and antiarrhythmic agent perioperatively. It may augment a neuromuscular block from both nondepolarizing and depolarizing muscle relaxants. Cisatracurium of benzylisoquinoline derivatives and rocuronium of aminosteroid derivatives are new nondepolarizing muscle ralaxants. We investigated interactions of cisatracurium or rocuronium with lidocaine in vitro. METHODS: Institutional approvement was obtained. Eighty male Sprague Dawley rats (150 - 200 g) were divided into 8 groups (control, lidocaine 1, 10 and 100microgram of both cisatracurium and rocuronium groups). The animals were anesthetized with phentobarbital 40 mg/kg I.P.. The hemidiaphragm with the phrenic nerve was dissected and mounted within 5 minutes in a bath containing 100 ml Kreb's solution at room temperature. The phrenic nerve was stimulated at supramaximal intensity by a Grass S88 stimulator through an SIU5 isolation unit. A twitch height was measured by a precalibrated Grass FT88 force displacement transducer and recorded with a Grass 79 polygraph. After stabilization of the twitch response, cisatracurium (50microgram), and rocuronium (100microgram) were added to the Kreb's solutions. After 10 minutes, we measured twitch height, and saline 1 ml or lidocaine 1, 10 or 100microgram was added to the Kreb's solution. After 10 minutes, we again measured twitch responses. The data was analyzed by repeated measures of ANOVA. RESULTS: There were significant depressions in the twitch response of cisatracurium in lidocaine 10microgram and 100microgram groups compared with the control group and lidocaine 1microgram group. In addition, the lidocaine 100microgram group was significantly depressed compared with the lidocaine 10microgram group. There were no significant depressions of the twitch response of rocuronium in lidocaine 1microgram, 10microgram, and 100microgram groups compared with the control group. CONCLUSIONS: We concluded that lidocaine will increase the sensitivity to cisatracurium in the hemdiaphragm preparation of rats. Lidocaine will be able to cause recurarization. There was not a statistically significant change in the rocuronium group but it was clinically significant.
Animals ; Baths ; Depression ; Humans ; Lidocaine* ; Male ; Neuromuscular Blockade* ; Neuromuscular Depolarizing Agents ; Phrenic Nerve ; Poaceae ; Rats ; Rats, Sprague-Dawley ; Transducers

BACKGROUND: Three isoforms of the neuronal acetylcholine receptors (AChRs) have been described in muscle epsilonAChRs, gammaAChRs and alpha7AChRs. The adult neuromuscular junctions are composed of epsilonAChRs. During immobilization, new AChRs with subunit compositions of gammaAChRs and alpha7AChRs appear in the perijunctional and extrajunctional area. This study evaluated the contribution of these isoforms to neurotransmission during immobilization, by using waglerin-1 which selectively blocks the epsilonAChRs. METHODS: Male mice (n = 20) were used and each group was divided into sham operated or immobilized. A leg was immobilized in mice for 14 days by pinning, after which nerve-evoked twitch tension was examined under anesthesia in tibialis muscle of both legs, with the contralateral leg serving as control. Neuromuscular transmission was monitored by using a peripheral nerve stimulator with the tibialis muscle and sciatic nerve. Electrical stimuli of 0.2 msec duration were applied to sciatic nerve 2 Hz for 2 sec every 30 sec. After administration of waglerin-1, the evoked twitch was recorded. The percent depression of T1 relative to baseline was transformed to probit scale to determine the effective dose of waglerin-1 for 5%, 50%, and 95% twitch depression. RESULTS: The twitch tension in the control group was higher than immobilized group, confirming the efficacy of immobilization. Waglerin-1 produced 99% twitch suppression on the control group. But on the immobilized group, waglerin-1 produced only 70% twitch suppression even at 37 pg. CONCLUSIONS: The functional role of epsilonAChRs in neurotransmission decreases during immobilization while that of gammaAChRs and alpha7AChRs increases.
Adult ; Anesthesia ; Animals ; Depression ; Hindlimb ; Humans ; Immobilization ; Leg ; Male ; Mice ; Muscles ; Neuromuscular Junction ; Neurons ; Peripheral Nerves ; Protein Isoforms ; Receptors, Cholinergic ; Salicylamides ; Sciatic Nerve ; Synaptic Transmission

BACKGROUND: Myasthenia gravis is an autoimmune neuromuscular disorder that shows increased sensitivity to nondepolarizing muscle relaxants. Atracurium is eliminated by Hofmann elimination and ester hydrolysis. We studied the onset and duration of atracurium in patients with myasthenia gravis. METHODS: Ten patients undergoing thymectomy for myasthenia gravis and ten patients of ASA Class I-II without liver, kidney and neuromuscular disease for orthopedic surgical procedures were assigned. Anesthesia was induced with thiopental (4~5 mg/kg) and maintained with inhalation of N2O:O2 (1:1) and enflurane (1.0~2.0 vol%). Atracurium (0.5 mg/kg) was given as a muscle relaxant and then intubation was performed after twitch response was depressed more than 80%. Neuromuscular relaxation was assessed by TOF (T1) at the adductor pollicis with supramaximal stimulation of ulnar nerve at 2 Hz every 12 seconds. The onset and the duration of 5, 25, 50, 75% recovery time of T1 and the recovery index were recorded. RESULTS: Onset of block was shortened and recovery time of 5, 25, 50, 75% and recovery index were prolonged in patients with myasthenia gravis. Conlusions: In patients with myasthenia gravis, atracurium induced rapid onset time and prolonged recovery time of 5, 25, 50, 75% and recovery index.
Anesthesia ; Atracurium* ; Enflurane ; Humans ; Hydrolysis ; Inhalation ; Intubation ; Kidney ; Liver ; Myasthenia Gravis* ; Neuromuscular Diseases ; Orthopedic Procedures ; Relaxation ; Thiopental ; Thymectomy* ; Ulnar Nerve

BACKGROUND: Myasthenia gravis is an autoimmune neuromuscular disorder that shows increased sensitivity to nondepolarizing muscle relaxants. Mivacurium chloride is a short acting nondepolarizing neuromuscular blocker and a benzylisoquinolin diester that is hydrolized rapidly to inactive metabolites by plasma pseudocholinesterase. The onset and duration of mivacurium in patients undergoing a thymectomy with myasthenia gravis was studied. METHODS: Fifteen patients undergoing a thymectomy for myasthenia gravis and fifteen patients of ASA class I, II without liver, kidney or neuromuscular disease undergoing orthopedic surgical procedures were included in this study. Anesthesia was induced with thiopental 4 5 mg/kg and maintained with inhalation of N2O:O2 (1:1) and enflurane 1.0 2.0 vol%. Mivacurium 0.2 mg/kg was given as a muscle relaxant and then intubation performed after the twitch response was depressed more than 90%. Neuromuscular relaxation was assessed by TOF (T1) at the adductor pollicis with supramaximal stimulation of the ulnar nerve at 2 Hz every 12 seconds. The onset and duration of 5%, 25%, 50%, 75%, and 95% recovery time of T1 and recovery index were recorded. RESULTS: Onset of block was shortened but recovery time of 5%, 25%, 50%, 75%, 95% and recovery index were prolonged in patients with myasthenia gravis. CONCLUSIONS: In patients with myasthenia gravis, mivacurium induced rapid onset time and prolonged recovery time of 5%, 25%, 50%, 75%, 95% and recovery index.
Anesthesia ; Enflurane ; Humans ; Inhalation ; Intubation ; Kidney ; Liver ; Myasthenia Gravis* ; Neuromuscular Blockade ; Neuromuscular Diseases ; Orthopedic Procedures ; Plasma ; Pseudocholinesterase ; Relaxation ; Thiopental ; Thymectomy ; Ulnar Nerve

BACKGROUND: The precise measurement of body temperature during anesthesia is important to prevent hypothermia.The aim of this study was to compare the urinary bladder temperature to the esophageal, nasopharyngeal, rectal and skin temperatures, and to compare three heating methods during spine surgery. METHODS: Forty-two patients with ASA physical status I-II, who were scheduled to undergo spine surgery in the prone position, were included in this study.The patients were randomly divided into 4 groups:Group I was treated without any heating methods; group 2, with fluid-warmers; group 3, with forced air-warmers; and group 4, with a combination of both heating methods.After the induction of anesthesia, the esophageal, nasopharyngeal, rectal, urinary bladder and skin temperature was monitored every 15 minute for 3 hours.The urinary bladder temperature was compared to the esophageal, nasopharyngeal, rectal and skin temperatures. RESULTS: The urinary bladder temperature was found to be higher than the esophageal and the nasopharyngeal temperatures (P < 0.01).The urinary bladder temperature of group 3 was higher than that of group 1 at 180 minutes after induction of anesthesia (P < 0.05).The urinary bladder temperature of group 4 was higher than that of group 1 at 150 minutes (P < 0.05), as well as at 165 and 180 minutes (P < 0.05).The skin temperatures of groups 3 and 4 were higher than group 1 (P < 0.001). CONCLUSIONS: The urinary bladder temperature was higher than the esophageal temperature and correlated with the esophageal, nasopharyngeal and rectal temperatures.During spine surgery in the prone position, a forced air-warmer was found to be the most effective but a combination of all the methods tested was found to be even more effective.
Anesthesia ; Body Temperature ; Heating ; Hot Temperature ; Humans ; Prone Position ; Skin ; Skin Temperature ; Spine ; Urinary Bladder

BACKGROUND: The number of elderly patients undergoing orthopedic surgery is steadily growing. Aging modifies the physiology, pharmacokinetics and pharmacodynamics, and co-morbidity is common in the elderly. Therefore, it is important and necessary to evaluate the anesthetic management for orthopedic surgery in elderly patients. METHODS: Four hundred and twenty two patients, older than 80 yr, who underwent orthopedic surgery, between September 1996 and March 2004, were retrospectively reviewed according to age, sex, operation site, preexisting concomitant disease, anesthetic techniques, postoperative complications and mortality. RESULTS: Three hundred and fifty seven patients had a pre-existing concomitant disease. There were no meaningful differences in the postoperative morbidity and mortality according to the anesthetic technique employed, although there was a clearly reduced incidence of deep vein thrombosis with regional anesthesia. There were significantly higher postoperative morbidity and mortality among patients with a pre-existing concomitant disease. CONCLUSIONS: Appropriate anesthetic management is suggested for patients older than 80 yr undergoing orthopedic surgery, which will require proper preoperative evaluation, sufficient vigilance of their hemodynamics and an awareness of impaired circulatory function, as well as other age related concerns.
Aged ; Aging ; Anesthesia* ; Anesthesia, Conduction ; Hemodynamics ; Humans ; Incidence ; Mortality ; Orthopedics* ; Pharmacokinetics ; Physiology ; Postoperative Complications ; Retrospective Studies ; Venous Thrombosis