Subcutaneous emphysema is a complication of the pneumoperitoneum necessary to perform laparoscopy and will be seen more often as laparoscopic techniques are applied to a growing number of intraabdominal procedures. We report a case of subcutaneous emphysema and hypercarbia without pneumothorax or pneumomediastinum during laparoscopic cholecystectomy, which was treated by multiple puncture with 18G needle on emphysematous site. The suspected cause is inadvertent subcutaneous insufflation of carbon dioxide through the trocar sites by increased intra-abdominal pressure for the establishment of pneumoperitoneum. Immediate recognition, evaluation, and treatment of subcutaneous emphysema is necessary since this can be life-threatening complication.
Carbon Dioxide ; Cholecystectomy, Laparoscopic* ; Insufflation ; Laparoscopy ; Mediastinal Emphysema ; Needles ; Pneumoperitoneum ; Pneumothorax ; Punctures ; Subcutaneous Emphysema* ; Surgical Instruments

BACKGROUND: Endobroncheal intubation or extubation may occur accidentally when the patient's neck is flexed or extended even in the appropriate endotracheal intubation. The purpose of this study is to examine the effect of fixation or unfixation of the endotracheal tube at the teeth level on the displacement of its distal end when the patient's neck is extended or flexed. METHODS: This study was conducted in 37 patients who underwent endotracheal general anesthesia. The patients with the evidence of pathology in head, neck and chest were excluded from the study. Individual patient's displacement in endotracheal tube tip compared unfixed cases with fixed cases when the change of neck position. The moved distance was measured by fiberoptic bronchoscope. The data were statistically analyzed by Student's paired t-test. RESULTS: The endotracheal tube moved away from the carina when the patient's neck was extended, while it moved toward the carina when flexed in all cases. When the patient's neck was extended the average distance displaced 1.2 0.7 cm in fixed cases and 1.1 0.9 cm in unfixed cases. when the neck was flexed, they were 1.2 0.5 cm and 1.0 0.8 cm respectively. There were not statistically significant between the fixed and the unfixed cases. CONCLUSIONS: It is concluded that the displacement of the endotracheal tube is not related to its fixation or unfixation at the teeth level and therefore, unfixation does not provide any benefits in terms of the displacement of the distal end of the tube in adult trachea.
Adult ; Anesthesia, General ; Bronchoscopes ; Head ; Humans ; Intubation ; Intubation, Intratracheal ; Neck* ; Pathology ; Thorax ; Tooth ; Trachea

PURPOSE: To understand the normal endosonographic anatomy of the perianal spaces, and to evaluate the diagnostic efficacy and limitation of endorectal sonography(EUS), correlative study with MRI, cadaveric sectional image and cadaveric MRI were performed. MATERIALS AND METHODS: EUS images of the normal 6 perianal spaces (pelvirectal, ischiorectal, intersphincteric, subcutaneous, central, submucous space) which were bounded by internal and external anal sphincters, rectal wall and levator ani muscle were correlated with MRI in 10 normal persons, cadaveric sectional images and cadaveric MRI in 2 cadavers. RESULTS: Pelvirectal space located superior to levator ani muscle could be demonstrable only on anterior wall scan but could not be visualized on lateral or posterior wall scan on EUS. Five perianal spaces located inferior to levator ani muscle were well seen on anterior, lateral, and posterior wall EUS. MRI was superior to EUS in the evaluation of pelvirectal and ischiorectal spaces but equal or inferior to EUS in the evaluation of intersphincteric, subcutaneous, central and submucous spaces. CONCLUSION: EUS was valuable in the evaluation of perianal spaces inferior to levator ani muscle but was limited in the evaluation of perianal spaces superior to levator ani muscle.
Anal Canal ; Cadaver* ; Humans ; Magnetic Resonance Imaging*

BACKGROUND: At present, epidural steroid injection is one of the most frequently used methods in the treatment for low back pain.. But this method is nonspecific and results in a widespread of injected agent around the target point. Therefore we thought direct injection to the nerve root is more specific and effective. METHODS: The authors evaluated the effects of lumbar paravertebral steroid injection in 39 patients with low back pain and radicular pain, retrospectively. We used triamcinolone 40mg(1ml) and 0.25% bupivacaine 3ml as injection agents and used pain relief scale(PRS) score for assessment of the effect. RESULTS: One week after injection, the patients of PRS score less than 5 were 65% in spinal stenosis and 85% in herniated intervertebral disc(HIVD). The patients of effective response more than 4 weeks after injection were 48% in spinal stenosis and 68% in HIVD, more than 12 weeks were 22% and 38%, respectively. The patients of PRS score less than 5 were 45% at the time of follow-up study. CONCLUSIONS: We think paravertebral steroid injection is effective in patients with low back pain and radicular pain. Therefore, this technique could be alternative method to epidural steroid injection.
Bupivacaine ; Follow-Up Studies ; Humans ; Low Back Pain* ; Retrospective Studies ; Spinal Nerve Roots* ; Spinal Nerves* ; Spinal Stenosis* ; Triamcinolone

BACKGROUND: Preemptive analgesia may prevent nociceptive input generated during surgery from sensitizing central neurons and, therefore, may reduce postoperative pain. The purpose of this study is to examine the effect of epidural fentanyl between preincisional (preemptive) and postincisional groups on postoperative morphine requirements. METHODS: Sixty patients (ASA physical status 1 or 2) scheduled for elective total abdominal hysterectomy under general anesthesia were allocated randomly to one of two groups and prospectively studied in a double-blind manner. Group 1 received epidural fentanyl(2 g/kg in 15 ml normal saline) before surgical incision followed by epidural normal saline (15 ml) 15 minutes after skin incision. Group 2 received epidural normal saline(15 ml) before surgical incision followed by epidural fentanyl(2 g/kg in 15 ml normal saline) 15 minutes after skin incision. No additional analgesics were used before or during the operation. Postoperative visual analogue pain scores, PCA morphine requirements and side effects were assessed. RESULTS: Postoperative PCA morphine requirements in preincisional group were significantly less (p<0.05) than those in postincisional group between 6 and 24 hours postoperatively. VAPS was also significantly less (p<0.05) in preemptive group than in postincisional group 12 hours after surgery. CONCLUSIONS: Preemptive analgesia with epidural fentanyl is more effective in reducing the postoperative morphine requirements and VAPS than analgesia with postincisional epidural fentanyl in patients with total abdominal hysterectomy.
Analgesia ; Analgesics ; Anesthesia, General ; Fentanyl* ; Humans ; Hysterectomy ; Morphine ; Neurons ; Pain, Postoperative* ; Passive Cutaneous Anaphylaxis ; Prospective Studies ; Skin

BACKGROUND: Pulse oximetry has been recommended as a standard of care for ICU, CCU, Post Anesthetic Care Unit as well as general anesthesia. The device provides valuable data regarding blood oxygenation. But there are some limitations and inaccuracies of pulse oximetry. The purpose of the present study is to assess the knowledge of pulse oximetry in the doctors and nurses who frequently use pulse oximeter in their practice. METHODS: We investigated 29 doctors(resident) and 41 nurses who answered a structured questionnaire about pulse oximetry. Questions were given about the knowledge of equipment, factors affecting readings, normal values in various patients, values in hypothetical clinical situations, education experience and source of information about pulse oximetry. RESULTS: Only 20% of doctors understood how a pulse oximeter worked and about 60% of doctors and 80% of nurses were confused about factors influencing readings. About 30% of doctors and 12% of nurses had received formal training about the pulse oximetry. Sources of information about pulse oximetry were operating manual, senior, books and journal. CONCLUSION: Our survey revealed that most of resident doctors and nurses using pulse oximeter were untrained, lacked knowledge of the basic principles and factors influencing saturation values in pulse oximetry. Therefore the systematic training program is important for doctors and nurses to use of pulse oximeter.(Korean J Anesthesiol 1996; 31: 791~796)
Anesthesia, General ; Education ; Humans ; Oximetry* ; Oxygen ; Reading ; Reference Values ; Standard of Care

BACKGROUND: Pulse oximetry has been recommended as a standard of care for ICU, CCU, Post Anesthetic Care Unit as well as general anesthesia. The device provides valuable data regarding blood oxygenation. But there are some limitations and inaccuracies of pulse oximetry. The purpose of the present study is to assess the knowledge of pulse oximetry in the doctors and nurses who frequently use pulse oximeter in their practice. METHODS: We investigated 29 doctors(resident) and 41 nurses who answered a structured questionnaire about pulse oximetry. Questions were given about the knowledge of equipment, factors affecting readings, normal values in various patients, values in hypothetical clinical situations, education experience and source of information about pulse oximetry. RESULTS: Only 20% of doctors understood how a pulse oximeter worked and about 60% of doctors and 80% of nurses were confused about factors influencing readings. About 30% of doctors and 12% of nurses had received formal training about the pulse oximetry. Sources of information about pulse oximetry were operating manual, senior, books and journal. CONCLUSION: Our survey revealed that most of resident doctors and nurses using pulse oximeter were untrained, lacked knowledge of the basic principles and factors influencing saturation values in pulse oximetry. Therefore the systematic training program is important for doctors and nurses to use of pulse oximeter.(Korean J Anesthesiol 1996; 31: 791~796)
Anesthesia, General ; Education ; Humans ; Oximetry* ; Oxygen ; Reading ; Reference Values ; Standard of Care

BACKGROUND: Two results have been conflict regarding the pH of gastric contents in obese and lean surgical patients. Obese patients have been considered to have lower pH of gastric contents than lean surgical patients since the study by Vaughan, whereas Harter reported no significant difference in the pH's of obese and lean surgical patients. The author wanted to investigate whether gastric content pH differs or not between obese and lean surgical patients aged from 20 to 60 years. METHODS: Forty patients scheduled for elective abdominal hysterectomy under general endotracheal anesthesia were studied. Group I (n = 20) was composed of lean patients whose body mass indices (BMIs) were between 20 and 25, whereas Group II (n = 20) was composed of obese patients whose BMIs were above 30. Every patient was fasted between 8 and 14 hours preoperatively. Within 10 minutes of endotracheal intubation, gastric contents were withdrawn with a 20 cc syringe connected to a 16F nasogastric tube placed in the stomach. pH and the incidences of pH <2.5, and pH <1.8 were compared. RESULTS: No significant difference in pH (P = 0.199) or in the incidences of pH less than 2.5 (P = 0.23) or 1.8 (P = 0.52) were observed between obese and lean patients. CONCLUSIONS: Obese and lean patients have similar fasting gastric pH's, as long as the obesity is not too severe (BMI under 40).
Anesthesia ; Fasting ; Humans ; Hydrogen-Ion Concentration* ; Hysterectomy ; Incidence ; Intubation, Intratracheal ; Obesity ; Stomach ; Syringes

BACKGROUND: A lateral tilt position can affect the size of the femoral vein (FV) due to increased venous blood volume in the dependent side of the body. METHODS: Forty-two patients, aged 20–60 years, were enrolled in this study. The crosssectional area (CSA), anteroposterior, and transverse diameters of the FV were measured 1 cm below the left inguinal line using ultrasound. The value of each parameter was recorded in the following four positions: (1) supine, (2) supine + 10° left-lateral tilt (LLT), (3) 10° reverse Trendelenburg (RT), and (4) RT + LLT. RESULTS: CSAs of the left FV in the supine, supine + LLT, RT, RT + LLT positions were 0.93 ± 0.22, 1.11 ± 0.29, 1.17 ± 0.29, and 1.31 ± 0.32 cm2, respectively. Compared to the supine position, there was a significant increase in CSA and anteroposterior diameter according to the three changed positions. The transverse diameter of the left FV was significantly increased in supine + LLT, RT, RT + LLT positions compared to that in the supine position (P = 0.010, P = 0.043, P = 0.001, respectively). There was no significant difference in the transverse diameter of the left FV between the supine + LLT and RT positions (P = 1.000). CONCLUSIONS: Adding LLT to the supine and RT positions increased the CSA of the unilateral FV significantly.
Adult* ; Blood Volume ; Catheterization ; Femoral Vein* ; Humans ; Posture ; Supine Position ; Ultrasonography

BACKGROUND: Most terminal cancer patients suffered from intractable pain. For the treatment of these patients, opioids, via various routes, are usually administered. Continuous epidural opioid, especially morphine, administration is a good method for the management of intractable cancer pain. METHODS: We retrospectively analyzed 347 terminal cancer patients, who had been treated with continuous epidural morphine infusion, between 1999 and 2004. For the epidural infusion, an epidural catheter was inserted, tunneled subcutaneously and exited from the anterior chest or abdomen. Multiday Infursor(R) (Baxter, 0.5 ml/h) was used for the continuous infusion. RESULTS: Of the 347 patients studied, there were 211 males and 136 females. The mean treatment time was 54.7 days, ranging from 5 to 481 days. The mean starting and termination doses of morphine were 32.4 (for 5 days) and 100.0 mg, respectively. The doubling time of the morphine dose was 26.3 days, corresponded to a 3.8 percent increase per day. Incidental catheter removal was the most common side effect, which occurred 130 times in 61 cases. CONCLUSIONS: The procedure of epidural catheterization, with subcutaneous tunneling, was simple and inexpensive. Despite the disadvantages, such as incidental catheter removal, it is a useful method for the control of terminal cancer pain.
Abdomen ; Analgesics, Opioid ; Catheterization ; Catheters ; Female ; Humans ; Male ; Morphine* ; Pain Management* ; Pain, Intractable ; Retrospective Studies ; Thorax