This is a case of cervical cord injury which is a rare complication of endotracheal intubation. A 32 year old muscular male with a short neck had a laparotomy for panperitonitis. He was tranfered to the recovery room after surgery, and the anesthetic procedure wase completed uneventfully. Endotracheal intubation was attempted on several occations on an emergency basis because of unexpected cyanosis associated with hiccups and vomiting in the recovery room. Therefore, his respiration was controlled by the respirator, but he was not able to breath spontaneously for several days. The condition was due to a cervical cord injury with signs of paralysis of the respiratory muscles and upper extremities. The mechanism and process was described.
Adult ; Cyanosis ; Emergencies ; Hiccup ; Humans ; Intubation* ; Intubation, Intratracheal ; Laparotomy ; Male ; Neck ; Paralysis ; Recovery Room ; Respiration ; Respiratory Muscles ; Upper Extremity ; Ventilators, Mechanical ; Vomiting

Halothane is most easily blamed when a postoperative casef hepatitis occurs because it is most commonly used as an anesthetic agent and hepatitis has been intermittently reported for time. However, it is not easy to prove halothane induced the hepatitis clinically because there a long are many factors causing hepatitis. We had two cases of acute hepatitis developing following surgery. Case 1. A 49 year old male underwent surgery for femur fracture under halothane anesthesia. The preperative liver function tests were normal and the operation was uneventful. He developed epigastirc descomfor on the second postoperative day and jsundice with marked elevation of SGOT, SGPT, alkaline phosphatase and bilirubin on the 3rd day. Since the 7th postoperative day, the signs of acute renal failure with ascites became evident, therefore, dialysis was carried out. The died of acute respiratory and renal failure on the 20th postoperative day. We consider the nonA, nonB viral hepatitis infection as a possible cause in this case. Case 2. A 35 year old male had an operation for right femur fracture under repeated halothane anesthesia. On the 3rd day, he developed high fever of 39 degrees C. Liver function tests showed marked elevation of SGOT, SGPT, alkaline phosphatase and leukocytosis with eosinophilia, followed by gross jaundice. HBs Ag(-) and anti-HBs(+) were reported. He recovered gradually from the hepatitis and went home in good health on the 30th postoperative day. A possible cause of the hepatitis in this case was considered to be the halothane anesthetic.
Acute Kidney Injury ; Adult ; Alanine Transaminase ; Alkaline Phosphatase ; Anesthesia ; Ascites ; Aspartate Aminotransferases ; Bilirubin ; Dialysis ; Eosinophilia ; Femur ; Fever ; Halothane ; Hepatitis* ; Humans ; Jaundice ; Leukocytosis ; Liver Function Tests ; Male ; Middle Aged ; Renal Insufficiency

Acid-base balances in the CSF have been reported by a number of groups during the past 20 years. The CSF contains only neligilbe concentrations of buffer anions other than HCO3(-). Acid-base balances in the CSF depend mainly on arterial PCO2 because arterial CO2 diffuses easily into the blood-brain barrier to form H2CO2 in the CSF. This study was primarily undertaken to observe the changes of pH, CO2 and HCO3(-) values in the CSF in the acute stage of hyperventilation. We have studied relatively healthy patients who were scheduled for surgery for cerebral aneuryams. Prior to induction of anesthesia, the radial artery was cannulated for and arterial line and blood samples taken and lumbar tapping was performed at the level of L3-4 using at 14 gause long needle, then a 18 gauze catheter was inserted through the needle. Pre-operative samples for gases were taken, then the patient was anesthetized and his repiration was controlled and maintained at the PaCO2 of 30 torr. The samples in both blood and CSF for gases were obtained at intervals of 15, 30, 45 and 60 minutes and observed and compared. The results were as follows: The PCO2 in CSF decreased as rapidly as the arterial PCO2 decreased by hyperventilation. The data obtained after hyperventilation of 45 minutes showed a significant decrease of CO2 value in the CSF as compared to the control group. The pH in the CSF increased as rapidly as the pH of the arterial blood. The arterial HCO3(-) decreased significantly in the groups of 15, 30 and 45 minutes and it was highly significant in the 60 minutes group, despite this the HCO3(-) in the CSF showed no significant changes in any of the groups. In conclusion as a result of this study, no visible metabolic compensation in the CSF for respiratory alkalosis was observed in an acute stage of hyperventilation.
Alkalosis, Respiratory ; Anesthesia ; Anions ; Blood-Brain Barrier ; Catheters ; Compensation and Redress ; Gases ; Humans ; Hydrogen-Ion Concentration ; Hyperventilation* ; Needles ; Radial Artery ; Vascular Access Devices

Various anesthetic agents have been recommended for pheochromocytoma surgery. However, in general, no ideal anesthetic agent has been accepted as yet. The use of the well known agents, halothane still remains a contraversial issue for pheochromocytoma surgery. According to our experience and a review of the literature, it is strongly suggested that halothane is the anesthetic agent of choice among the anesthetic agents currently available. We believe that the incidence of arrythmia from halothane is not higher than that from other anesthetic agents and arrthmia is not caused primarily by halothane, but results mostly from endogenous catecholamines during surgery. In addition to these advantages, it is a rapid induction agent accompained by a peripheral vessel dilating effect. Lidocaine also is readily available to counteract the disadvantages of the arrythmic effect of halothane. We have had two uneventful cases of pheochromocytoma surgery. One was prepared with phenoxybeaxamine preoperatively and anesthetized with halothane. The other was not prepared with phenoxybeaxamine, but was anesthetized with halothane. The patient prepared with phenoxybeaxamine had prolonged hypotension for two days postoperatively and was treated with Neo-Synephrine drip. However, the patient wihout preoperative phenoxybeaxamine had no problem with his blood pressure post operatively. As a result of this experience, we believe the preoperative use of phenoxybeaxamine is not necessary, plus it also creates more problems with postoperative hypotension. Halothane can act as a vasodilator in place of phenoxybeaxamine during anesthesia. Therefore, halothane is currently the ideal anesthetic agent of choice without phenoxybeaxamine preparation when lidocaine is available.
Anesthesia* ; Anesthetics ; Arrhythmias, Cardiac ; Blood Pressure ; Catecholamines ; Halothane* ; Humans ; Hypotension ; Incidence ; Lidocaine ; Phenylephrine ; Pheochromocytoma*

The term flail chest is used to describe the condition in which a portion of the chest wall moves in a direction opposite to the rest of the thorax. This condition generally results from multiple rib fractures caused by external thoracic compression. Most characteristically, this occurs as a result of bilateral rib fractures after a steering-wheel injury or a crushing chest injury. In this article, 3 cases of flail chest developed following cardiopulmonary resuscitation showing a typical paradoxical respiration. The first case, a 69 year old male, had cardiac arrest during direct laryngoscopy in the operating room and was successfully resuscitated with external heart compression. He was then found to have separation of all costochondral junctions with paradoxical respirations. He was intubated and his respirations were controlled with a volume controlled respirator. Two days later, surgical traction was applied to his sternum, and was maintained for three weeks. He went home in good health after removal of the traction. The second case, a 48 year old male in hypovolemic shock, had a cardiac arrest postoperatively. He was resuscitated and then found to have paradoxical respiration which was controlled by a volume controlled respirator. He died of brain damage resulting from insufficient C.P.R. on the third day after the incident. The third case, a 57 year old male, was admitted to this institution from a local clinic with a flail chest as a result of costochondral separation after C.P.R. had been performed. He was intubated and his respirations were controlled by a volume setting respirator. On the second day following admission, traction was applied surgically to his sternum, thereafter he had normal respirations. However, his consciousness never returned and he died fo suspected brain damage fifteen days following admission. Cardiopulmonary resuscitation is vitally important to maintain artificial circulation and respiration. Cardiac compression must be sufficient to force blood out of the ventricles between the sternum and the spin(Fig.3). Even though the most common complication of C.P.R. is rib fractures, a sufficient heart compression is still the most important factor. However, rib fractures may be avoided by proper placement of the hands over the sternum during manual heart compression(Fig. 2). Once flail chest occurs, it should be actively treated by a volume controlled respirator and traction.
Aged ; Brain ; Cardiopulmonary Resuscitation* ; Consciousness ; Flail Chest* ; Hand ; Heart ; Heart Arrest ; Humans ; Laryngoscopy ; Male ; Middle Aged ; Operating Rooms ; Respiration ; Rib Fractures ; Shock ; Sternum ; Thoracic Injuries ; Thoracic Wall ; Thorax ; Traction ; Ventilators, Mechanical

This is a case of an accidental prolonged tourniquet application on the lower extremity. A 31 year old, well developed male had an open reduction for a clavicle fracture and nerve graft of the injured arm. To obtain the nerve from the leg, a tourniquet was applied and remained on the right lower extremity for 4hours. Post-operatively, he developed severe edema with paralysis of that leg. Thereafter, progressively he had signs of acute tubularnecrosis with oliguria, myoglobinuria, elevation of BUN and creatinine, and finally pulmonary edema. He recovered graually from the renal failure, pulmonary edema and paralysis of the leg as he received intermittent peritoneal dialysis for renal failure and intensive respiratory care for pulmonary edema. He went home in good condition only with a slight residual sensory loss of the injured leg 90 days after his admission.
Adult ; Arm ; Clavicle ; Creatinine ; Edema ; Humans ; Leg* ; Lower Extremity ; Male ; Myoglobinuria ; Oliguria ; Paralysis* ; Peritoneal Dialysis ; Pulmonary Edema ; Renal Insufficiency* ; Tourniquets* ; Transplants

Cauda equina syndrome is characterized by urinary retention, loss of sexual function, loss of sensation in the perineal region and incontinence of feces. It had been reported by Courville, Kennedy, et al early in 1950. Since then Dripps, Vandam, Philips and others have reviewed many thousands of cases for evalustion of neurologic complications following spinal anesthesia, but there has not been a single case of permanent neurologic sequels reported. This 32 year old male with this postspinal neurologic complication was admitted to this institution on the twelveth post-operative day. His surgery had been carried out under spinal anesthesia for removal of an exostosis of the left knee at a local clinic. According to the history at the local clinic, a lumbar tap was performed at the level between L4-5, then 5% lidocaine in 5% D/W was injected into the subarachnoid space and the surgery was finished untevenfully. He developed pain in his buttocks and coccygeal region 6 hours after the surgery was done, so morphine sulfate was injected into the epidural space. After that, the pain was relieved for a while but he again started having the same pain associated with loss of sensation of the lower extremities, urinary retention, constipation and penile impotence on the 10th post-operative day. He came to this institution for 3 months with the above symptoms on the twelveth post-operative day. A cystoscopy and cystometry was done and showed a neurogenic bladder. He was treated with Urecholine for urinary retention and Dexamethasone for arachnoiditis for 2 months. He also had enemas intermittently for severe constipation and a Foley catheter was inserted. He was trained to void by himself by pressing his lower abdomen. He went home with the same symptoms after the Foley catheter was removed. The possible complications and preventions were listed in tabel l and ll. We will follow the patient.
Abdomen ; Adult ; Anesthesia, Spinal ; Arachnoid ; Arachnoiditis ; Bethanechol Compounds ; Buttocks ; Catheters ; Cauda Equina* ; Constipation ; Cystoscopy ; Dexamethasone ; Enema ; Epidural Space ; Erectile Dysfunction ; Exostoses ; Feces ; Humans ; Knee ; Lidocaine ; Lower Extremity ; Male ; Morphine ; Polyradiculopathy* ; Sacrococcygeal Region ; Sensation ; Subarachnoid Space ; Urinary Bladder, Neurogenic ; Urinary Retention

Urinary retention has been well documented as a complication of spinal anesthesia. This occurs somewhat more frequently than after general anesthesia because the bladder wall, supplied by the parasympathetic system is paralysed by local anesthetics and its fibers from S2 are very susceptihle to analgesic solution. For 5 years since 1974, 127 cases of urinary retention were recorded from 4733 cases of spinal analgesia performed at the Dong San Medical Center. The incidence of urinary retention is 2.7% in our data. In this article, two cases of prolonged urinary retention due to spinal anesthesia are described. Case l A 44 year old female was scheduled for a vaginal hysterectomy because of a prolapse of the uterine cervix. Spinal tapping was performed at L(4~5), and 16 mg of 0.4% Pontocaine was administered. The surgery was uneventful and the patient slept from Nembutal during the whole procedure. Postoperatively the patient developed retention of urine without any abnormality observed by cystoscopy, so that she was treated with urecholine orally and recovered on the 14 th postoperative day. Case ll The patient was a 39 year old female, scheduled for a cholecystectomy. Spinal analgesia was performed and the patient was put to sleep by Nembutal and the surgery was uneventful during the whole procedure. She complained of the difficulty of voiding postoperatively. She was started on urecholine 20 mg tid orally from the 7th postoperative day, then she started voiding on the 10th postoperative day. Since then there have been no problems. The mechanism and the precipitating factors are described.
Analgesia ; Anesthesia, General ; Anesthesia, Spinal* ; Anesthetics, Local ; Bethanechol Compounds ; Cervix Uteri ; Cholecystectomy ; Cystoscopy ; Female ; Humans ; Hysterectomy, Vaginal ; Incidence ; Pentobarbital ; Precipitating Factors ; Prolapse ; Spinal Puncture ; Tetracaine ; Urinary Bladder ; Urinary Retention*

Recently several reports have described the usefulness of meperidine as a sole agent for spinal anestaeaia. In this study, meperidine mixed with a 10% dextrose solution was used for a spinal anesthetic agent for Cesarean sections in twenty cases. The results from the meperidine spinal anesthesia were compared with lidocaine spinal anesthesia. The specific gravity was 1.043 with 5% lidocaine solusion and 1.029 with meperidine solution. Both were hyperbaric and very similar in baricity. Hypotension over 20% decre-ase in systolic blood pressure due to spinal aneshesia was found in nine out of 20 cases in the lidocaine group and eleven out of 20 cases in the meperidine group. A dose of ephed- rine used for hypotension was 14.+/-3.mg in the lidocaine group and 20.6+/-10.2mg in the meperidine group. The Apgar score was 10 in both groups at 5 minutes. The duration from the administration of the drug until the development of severe pain postoperatively was checked as 481.8+/-197.8 minutes in the meperidine group and 89.0+/-21.8 minutes in the lidocaine group (P<0.001) . As a result of thin study, it was concluded that meperidine can serve as an alternative agent for spinal anesthesia for a Cesarean section. The motor recovery from meperidine spinal anesthesia is shorter than lidocaine and the postoperative analgesic effect was very efficient and much longer than lidocaine, and no clinical signs of fetal depression with a good Apgar score were observed.
Anesthesia, Spinal* ; Apgar Score ; Blood Pressure ; Cesarean Section* ; Depression ; Female ; Glucose ; Hypotension ; Lidocaine ; Meperidine* ; Pregnancy ; Specific Gravity

Voiding difficulty has been well documented as a complication after spinal anesthesia. This occurs somewhat more frequently after spinal anesthesia than after general anesthesia. However, the cause and mechanism of postspinal voiding difficulty has not been clarified, so in this study we have attempted to discover the mechanism of the voiding difficulty. Cystometry was performed on 30 healthy women who were scheduled for simple hystrectomy and the results were compared in three different groups. In the first group, cystometry was performed on 30 cases under only the premedication before the induction of anesthesia. In the second group, it waa performed on 14 cases under general anesthesia and in the 3 rd group, performed on 16 cases under spinal anesthesia. The results were as follows: 1) In the first group of 30 cases before anesthesia, the first voiding desire starts at approximately 150-250 ml (24 cases) and the average pressure of the bladder at the first voiding desire is approximately 5-10 cm H2O(19 cases). The volume at the maximum voiding desire is about 450-550ml(20 cases) and its pressure was 16-20cm H2O(12 patients). The average pressure tension curve of the cystometry was very similar to the normal one. 2) In the 2nd group of 16 cases under general anesthesia, measurement was not obtainable at the first and maximum voiding desire because they were under the effect of the anesthesia. The average pressure tension curve of the cystometry was lower than Group I (Fig. 1) and the critical volume which is designated as the volume at the point where the pressure of the bladder increased sharply in cystometry, was about 700ml which was larger than Group I. 3) In the 3 rd group of 16 cases, the cystornetry showed on the average pressure tension curve that the increase of the pressure was proportional to the volume in the bladder and no critical volume seems to be observed. It means that there is no contraction of the bladder muscle due to the paralysis of the sacral parasympathetic nerves which innervate the detrusor muacle of bladder. As a result of this study, we came to the conclusion that a cause of post-spinal urinary retension is the residual effect of local anesthetics prolonging the depression of the autonomic parasympathetic innervation system. These fibers from S2-S4 are very susceptible to analgesic solutions.
Anesthesia ; Anesthesia, General ; Anesthesia, Spinal* ; Anesthetics, Local ; Depression ; Female ; Humans ; Paralysis ; Premedication ; Urinary Bladder