We report a case of cardiac arrest in a 71 year old male during the Valsalva maneuver that had been performed immediately after completing a pneumonectomy. The patient had a subclinical atrial septal defect (1.08 cm sized) and he previously undergone a left upper lobectomy of the lung without complications 11 months earlier. He underwent a left completion pneumonectomy due to recurrent lung cancer. After surgery a Valsalva maneuver was performed with 35 cmH2O to relocate the mediastinum. During this procedure, the patient experienced a cardiac arrest and was resuscitated with difficulty. It is believed that the cardiac arrest was due to pulmonary hypertension, right ventricular failure and right to left shunt caused by several factors, such as the pneumonectomy, subclinical atrial septal defect (1.08 cm sized), and Valsalva maneuver. In addition, the hypovolemia caused by fluid restriction and the epidural injection of local anesthetics might have contributed to this incident. Although it is a rare complication, it is suggested that subclinical ASD can cause severe hypoxemia, dyspnea even cardiac arrest after pneumonectomy. In order to avoid these complications, ASD should be treated with percutaneous closure or surgical intervention. If these are not possible, care must be taken when anesthetizing the patient, and anything that can increase the pulmonary vascular resistance and right to left shunt should be avoided.
Anesthetics, Local ; Anoxia ; Dyspnea ; Heart Arrest ; Heart Septal Defects, Atrial ; Humans ; Hypertension, Pulmonary ; Hypovolemia ; Injections, Epidural ; Lung ; Lung Neoplasms ; Male ; Mediastinum ; Pneumonectomy ; Valsalva Maneuver ; Vascular Resistance

Epiglottic tuberculosis without pulmonary involvement is an uncommon disease that has rarely been described in Korea. We report here a case of a 36 year-old man with a recurrent tuberculosis abscess in his thigh. He had been treated with steroids for systemic lupus erythematosus, and he suffered from recurrent tuberculosis abscess in the thigh where he had received total hip replacement arthroplasty. When inducing general anesthesia for incision and drainage, we noticed a destroyed epiglottis. After consultation with an otolaryngologist, we concluded that the patient has had epiglottic tuberculosis and precautions against tuberculosis infection were taken. The surgery ended without event. The patient recovered safely and was transferred from the operating room directly to the general ward. In this paper, we also discussed the epiglottic tuberculosis and precautions that were taken to prevent tuberculosis infection of the healthcare workers in the operating theater.
Abscess ; Anesthesia, General ; Arthroplasty ; Arthroplasty, Replacement, Hip ; Delivery of Health Care ; Drainage ; Epiglottis ; Humans ; Korea ; Lupus Erythematosus, Systemic ; Operating Rooms ; Patients' Rooms ; Steroids ; Thigh ; Tuberculosis

We report here the successful use of the Airtraq(R) optical laryngoscope (AOL) as a rescue device following failed awake flexible fiberoptic nasotracheal intubation of a patient with severe mandibular microsomia. We attempted awake fiberoptic nasotracheal intubation following topical anesthesia with 4% lidocaine spray three times to induce general anesthesia for distraction osteogenesis of mandibular bone. However, due to a shallow pharyngeal cavity and cranially displaced larynx, we failed to locate the larynx each time and were therefore not able to intubate the patient. Awake orotracheal intubation using the AOL allowed us to easily intubate the patient. Therefore, we recommend that the AOL be used as a rescue airway device for intubation of difficult airways.
Anesthesia ; Anesthesia, General ; Humans ; Intubation ; Laryngoscopes ; Larynx ; Lidocaine ; Osteogenesis, Distraction

A 26-year-old male who had no underlying disease, including coagulopathy, underwent thoracotomy and bleeding control due to hemothorax. On the fifth postoperative day, paralysis of both lower limbs occurred. Urgent spine magnetic resonance imaging showed a massive anterior spinal epidural hematoma from C2 to L1 level with different signal intensities, which was suspected to be staged hemorrhage. Hematoma evacuation with decompressive laminectomy was performed. The patient's neurologic deterioration was recovered immediately, and he was discharged without neurological deficits. A drug history of naftazone, which could induce a drug-induced platelet dysfunction, was revealed retrospectively. To our knowledge, this is the first report of whole spontaneous spinal epidural hematoma in a young patient, with a history of hemorrhoid medication.
Adult ; Blood Platelets ; Hematoma ; Hematoma, Epidural, Spinal* ; Hemorrhage ; Hemorrhoids ; Hemothorax ; Humans ; Laminectomy ; Lower Extremity ; Magnetic Resonance Imaging ; Male ; Paralysis ; Retrospective Studies ; Spine ; Thoracotomy

Myotonic dystrophy is the most common manifestation of mytonic disease. It is a systemic disease and its most serious complications after general anesthesia result from respiratory failure. We report a case of prolonged respiratory failure after general anesthesia for cesarean section in a presumed myotonic dystrophy patient. A 36-year-old parturient underwent emergency cesarean section under general anesthesia for premature rupture of the amniotic membrane with fetal distress. At the end of the operation, the recovery of respiratory muscle from paralysis was insufficient to maintain spontaneous ventilation despite the administration of reversel agents. Her TOF count was 3/4 and she was reintubated in the PACU. The patient was transferred to the ICU for proper respiratory care and her respiration fully recovered after 21 hours of conservative supportive care.
Adult ; Amnion ; Anesthesia, General* ; Cesarean Section* ; Emergencies ; Female ; Fetal Distress ; Humans ; Myotonic Dystrophy* ; Paralysis ; Pregnancy ; Respiration ; Respiratory Insufficiency* ; Respiratory Muscles ; Rupture ; Ventilation

Pulseless electrical activity refers to a heterogeneous group of cardiac rhythm disorders, all characterized by pulselessness in the presence of some type of electrical activity other than ventricular tachycardia or ventricular fibrillation. We experienced a case of sudden pulseless electrical activity and cardiac arrest during hetastarch infusion in general anesthesia in an adult who had total gastrectomy. We report this experience with a brief review of literature.
Adult ; Anesthesia, General ; Gastrectomy* ; Heart Arrest ; Humans ; Hydroxyethyl Starch Derivatives ; Tachycardia, Ventricular ; Ventricular Fibrillation

Benign primary headaches are common during the postpartum period. However, there are several other kinds of headaches caused by specific underlying pathologies like post-dural puncture headache (PDPH), pregnancy induced hypertension, cortical vein thrombosis, posterior reversible encephalopathy syndrome (PRES), subarachnoid hemorrhage, intracranial hemorrhage, brain tumor, and so on. These headaches are rare but each can be life threatening conditions when diagnosis is delayed. If a patient was treated for another type of headache, like a PDPH, the diagnosis would be even more difficult. We report on the case of a 24 year-old woman who suffered with PDPH followed by postpartum eclampsia with PRES.
Diagnosis ; Eclampsia ; Female ; Headache ; Humans ; Hypertension ; Hypertension, Pregnancy-Induced ; Intracranial Hemorrhages ; Pathology ; Post-Dural Puncture Headache ; Posterior Leukoencephalopathy Syndrome* ; Postpartum Period ; Pregnancy ; Seizures ; Subarachnoid Hemorrhage ; Thrombosis ; Veins

A 26-year-old male undergoing thoracotomy and bleeding control received a preoperative thoracic epidural for postoperative analgesia. On the fifth postoperative day, paralysis of both lower limbs occurred and urgent magnetic resonance imaging showed massive anterior epidural hematoma. During laminectomy and decompression, platelet dysfunction was diagnosed and preoperative non-steroidal anti-inflammatory drugs medications were supposed to the cause of platelet dysfunction. After infusion of ten units of platelet concentrate, coagulopathy was improved. We should be more careful to drugs with antiplatelet effect when using regional analgesia.
Adult ; Analgesia ; Analgesia, Epidural* ; Blood Platelets ; Decompression ; Hematoma* ; Hemorrhage ; Humans ; Ketorolac* ; Laminectomy ; Lower Extremity ; Magnetic Resonance Imaging ; Male ; Mefenamic Acid* ; Paralysis ; Thoracotomy

BACKGROUND: The aim of this study was to estimate the minimum effective volume (MEV) of 1.5% mepivacaine for ultrasound-guided supraclavicular block by placing the needle near the lower trunk of brachial plexus and multiple injections. METHODS: Thirty patients undergoing forearm and hand surgery received ultrasound-guided supraclavicular block with 1.5% mepivacaine. The initial volume of local anesthetic injected was 24 ml, and local anesthetic volume for the next patient was determined by the response of the previous patient. The next patient received a 3 ml higher volume in the case of the failure of the previous case. If the previous block was successful, the next volume was 3 ml lower. MEV was estimated by the Dixon and Massey up and down method. MEV in 95, 90, and 50% of patients (MEV95, MEV90, and MEV50) were calculated using probit transformation and logistic regression. RESULTS: MEV95 of 1.5% mepivacaine was 17 ml (95% confidence interval [CI], 13-42 ml), MEV90 was 15 ml (95% CI, 12-34 ml), and MEV50 was 9 ml (95% CI, 4-12 ml). Twelve patients had a failed block. Three patients received general anesthesia. Nine patients could undergo surgery with sedation only. Only one patient showed hemi-diaphragmatic paresis. CONCLUSIONS: MEV95 was 17 ml, MEV90 was 15 ml, and MEV50 was 9 ml. However, needle location near the lower trunk of brachial plexus and multiple injections should be performed.
Anesthesia, General ; Brachial Plexus ; Forearm ; Hand ; Humans ; Mepivacaine ; Needles

To compare the postoperative outcome according to the type of anesthesia, formerly prematured and high-risk infants who had received and weaned ventilator care preoperatively and had undergone inguinal herniorrhaphy were enrolled in this study. Immediate pre- and post-operative respiratory data which contained the lowest respiratory rates, SpO2, heart rates and the incidence of hypoxemia and bradycardia were collected with the incidence of ventilator care, application of continuous positive airway pressure (CPAP), application of oxygen, hospital stay, and respiratory mortality by chart review, retrospectively. Among the twenty-nine infants, fourteen received the general anesthesia (GA group), and fifteen received the spinal anesthesia (SA group). Postoperatively, the infants in the GA group had lower SpO2 (77.1 +/- 20.9% vs. 93.0 +/- 5.5%), higher incidence of hypoxemia (6 vs. 0), ventilator care (5 vs. 0) and application of CPAP (4 vs. 0) than the infants in the SA group. One infant in the GA group died because of acute respiratory failure caused by respiratory syncythial virus pneumonia. We concluded that spinal anesthesia reduces postoperative oxygen desaturation and respiratory morbidity in formerly prematured and high-risk infants who underwent inguinal herniorrhaphy.
Anesthesia, General ; Anesthesia, Spinal ; Hernia, Inguinal/*surgery ; Human ; Infant, Newborn ; *Infant, Premature ; Infant, Premature, Diseases/surgery ; Oxygen/metabolism ; Postoperative Period ; Respiration ; Respiratory Insufficiency ; Treatment Outcome