Heterotopic pregnancy is named when an extrauterine (ectopic) pregnancy coexists with an intrauterine pregnancy simultaneously by many causes such as PID (pelvic inflammatory disease), endometriosis, IUD (intrauterine device), previous pelvic surgery and others. This is very rare in general population, with a range of occurrence estimated between 1:7963 and 1:30000. But recently the incidence has increased as the uses of ARTs (assisted reproductive technologies) including ovulation induction, IVF-ET (in-vitro fertilization and embryo transfer) and GIFT (gamete intrafallopian transfer) increase. Because this has high maternal morbidity, mortality and fetal loss, early diagnosis and proper management is very important. We report a case of heterotopic pregnancy following IVF-ET with a brief review.
Early Diagnosis ; Embryonic Structures ; Endometriosis ; Female ; Fertilization ; Incidence ; Mortality ; Ovulation Induction ; Pregnancy ; Pregnancy, Heterotopic*

Uterine perforation and displacement of intrauterine device (IUD) are the most serious complications associated with insertion of that. An IUD may perforate through the uterine wall into the pelvic or abdominal cavity or into adjacent organs. We experienced a case of displacement of IUD into abdominal cavity by uterine perforation in early normal pregnancy and removed an IUD with laparoscopy. So we report one case with a brief review of the literature.
Abdominal Cavity ; Displacement (Psychology) ; Intrauterine Devices ; Laparoscopy ; Pregnancy ; Uterine Perforation

BACKGROUND: Sufficient accumulations of local anesthetics in the extrapleural space promotes effective access to several intercostal nerves and, consequently, analgesia. The total volume of leakage of these anesthetics from the space can depend on the technique of extrapleural catheter insertion which is chosen. METHODS: Twenty patients due for thoracotomy were randomly selected to be provided with postoperative pain relief by an extrapleural approach. Before the thoracic cavity was closed, appropriate spaces between parietal pleura and intercostal muscle were made with surgical dilators under direct vision. An epidural catheter was introduced at a longitudinal lie in a cephalad direction, before the thoracic cavity was closed. Bupivacaine 0.25%, with 1 : 200,000 epinephrine was injected in a 10 ml dose about 20 minutes before the end of anesthesia, and infused at a rate of 0.88 mg/kg/hour for 1 hour, 0.35 mg/kg/hour for 23 hours and 0.3 mg/kg/hour for the second day postoperatively. RESULTS: The degree of analgesia with coughing and deep breathing was satisfactory to patients and thoracic surgeons. The average numbers of analgesic dermatomes obtained by pinprick tests, VAS, and Prince Henry pain scores were 5.2 0.5, 2.0 0.5 cm and 1.6 0.6, respectively. Changes in mean arterial pressure were insignificant, and heart rate increased at the postoperative hours of 1, 4 and 8 (P value < 0.05). FVC and FEV1 were restored to levels up to 67.2 and 71.0% of their preoperative values at the postoperative hour of 48. CONCLUSIONS: These results suggest that the technique of a catheter introduced at a longitudinal lie in a cephalad direction was effective and clinically useful for pain relief following thoracotomy regardless of some leakage of bupivacaine.
Analgesia ; Anesthesia ; Anesthetics ; Anesthetics, Local ; Arterial Pressure ; Bupivacaine ; Catheters* ; Cough ; Epinephrine ; Heart Rate ; Humans ; Intercostal Muscles ; Intercostal Nerves ; Pain Management* ; Pain, Postoperative ; Pleura ; Respiration ; Thoracic Cavity ; Thoracotomy*

BACKGROUND: Sufficient accumulations of local anesthetics in the extrapleural space promotes effective access to several intercostal nerves and, consequently, analgesia. The total volume of leakage of these anesthetics from the space can depend on the technique of extrapleural catheter insertion which is chosen. METHODS: Twenty patients due for thoracotomy were randomly selected to be provided with postoperative pain relief by an extrapleural approach. Before the thoracic cavity was closed, appropriate spaces between parietal pleura and intercostal muscle were made with surgical dilators under direct vision. An epidural catheter was introduced at a longitudinal lie in a cephalad direction, before the thoracic cavity was closed. Bupivacaine 0.25%, with 1 : 200,000 epinephrine was injected in a 10 ml dose about 20 minutes before the end of anesthesia, and infused at a rate of 0.88 mg/kg/hour for 1 hour, 0.35 mg/kg/hour for 23 hours and 0.3 mg/kg/hour for the second day postoperatively. RESULTS: The degree of analgesia with coughing and deep breathing was satisfactory to patients and thoracic surgeons. The average numbers of analgesic dermatomes obtained by pinprick tests, VAS, and Prince Henry pain scores were 5.2 0.5, 2.0 0.5 cm and 1.6 0.6, respectively. Changes in mean arterial pressure were insignificant, and heart rate increased at the postoperative hours of 1, 4 and 8 (P value < 0.05). FVC and FEV1 were restored to levels up to 67.2 and 71.0% of their preoperative values at the postoperative hour of 48. CONCLUSIONS: These results suggest that the technique of a catheter introduced at a longitudinal lie in a cephalad direction was effective and clinically useful for pain relief following thoracotomy regardless of some leakage of bupivacaine.
Analgesia ; Anesthesia ; Anesthetics ; Anesthetics, Local ; Arterial Pressure ; Bupivacaine ; Catheters* ; Cough ; Epinephrine ; Heart Rate ; Humans ; Intercostal Muscles ; Intercostal Nerves ; Pain Management* ; Pain, Postoperative ; Pleura ; Respiration ; Thoracic Cavity ; Thoracotomy*

BACKGROUND:Administration of a rapid or large dose of remifentanil (>1.0microg/kg for 30?60 s) should be avoided due to its association with side effects such as muscle rigidity. The present study determined the infusion rate and dosage of remifentanil administered using target-controlled infusion (TCI) varies with the modality selected and the target concentration. METHODS: Data including the age, sex, weight, and height of 10 patients undergoing elective surgery in a university hospital were randomly used for a 3-min simulation of TCI-remifentanil Minto model. In every simulation, TCI targeting both plasma (Cp) and the effect-site (Ce) was performed repeatedly with varying target concentrations (2, 3, 5, 10, and 20 ng/ml). The rate of administration and the cumulative dosages of remifentanil (per min) in all of the TCI simulations were recorded and analyzed. RESULTS: The rates of Ce TCI were significantly greater than those of Cp TCI using the same concentration. The cumulative dosage in the first-minute TCI simulation with Cp 20 ng/ml, and Ce 3, 5, 10, 20 ng/ml exceeded 1.0microg/kg/min. CONCLUSIONS: The target concentration and the infusion modality should be selected carefully to avoid rapid infusion and an overdose of remifentanil.
Humans ; Muscle Rigidity ; Piperidines ; Plasma

BACKGROUND:Administration of a rapid or large dose of remifentanil (>1.0microg/kg for 30?60 s) should be avoided due to its association with side effects such as muscle rigidity. The present study determined the infusion rate and dosage of remifentanil administered using target-controlled infusion (TCI) varies with the modality selected and the target concentration. METHODS: Data including the age, sex, weight, and height of 10 patients undergoing elective surgery in a university hospital were randomly used for a 3-min simulation of TCI-remifentanil Minto model. In every simulation, TCI targeting both plasma (Cp) and the effect-site (Ce) was performed repeatedly with varying target concentrations (2, 3, 5, 10, and 20 ng/ml). The rate of administration and the cumulative dosages of remifentanil (per min) in all of the TCI simulations were recorded and analyzed. RESULTS: The rates of Ce TCI were significantly greater than those of Cp TCI using the same concentration. The cumulative dosage in the first-minute TCI simulation with Cp 20 ng/ml, and Ce 3, 5, 10, 20 ng/ml exceeded 1.0microg/kg/min. CONCLUSIONS: The target concentration and the infusion modality should be selected carefully to avoid rapid infusion and an overdose of remifentanil.
Humans ; Muscle Rigidity ; Piperidines ; Plasma

Anesthetic management for aortic arch aneurysm (AAA) surgery employing deep hypothermic circulatory arrest in a Jehovah's Witness (JW) patient is a challenge to anesthesiologist due to its complexity of procedures and their refusal of allogeneic transfusion. Even in the strict application of intraoperative acute normovolemic hemodilution (ANH) and intraopertive cell salvage (ICS) technique, prompt timing of re-administration of salvaged blood is essential for successful operation without allogeneic transfusion or ischemic complication of major organs. Cerebral oximetery (rSO2) monitoring using near infrared spectroscopy is a useful modality for detecting cerebral ischemia during the AAA surgery requiring direct interruption of cerebral flow. The present case showed that rSO2 can be used as a trigger facilitating to find a better timing for the re-administration of salvaged blood acquired during the AAA surgery for JW patient.
Aneurysm ; Aorta, Thoracic ; Brain Ischemia ; Circulatory Arrest, Deep Hypothermia Induced ; Disulfiram ; Hemodilution ; Humans ; Oximetry ; Spectrum Analysis ; Wit and Humor as Topic

Anesthetic management for aortic arch aneurysm (AAA) surgery employing deep hypothermic circulatory arrest in a Jehovah's Witness (JW) patient is a challenge to anesthesiologist due to its complexity of procedures and their refusal of allogeneic transfusion. Even in the strict application of intraoperative acute normovolemic hemodilution (ANH) and intraopertive cell salvage (ICS) technique, prompt timing of re-administration of salvaged blood is essential for successful operation without allogeneic transfusion or ischemic complication of major organs. Cerebral oximetery (rSO2) monitoring using near infrared spectroscopy is a useful modality for detecting cerebral ischemia during the AAA surgery requiring direct interruption of cerebral flow. The present case showed that rSO2 can be used as a trigger facilitating to find a better timing for the re-administration of salvaged blood acquired during the AAA surgery for JW patient.
Aneurysm ; Aorta, Thoracic ; Brain Ischemia ; Circulatory Arrest, Deep Hypothermia Induced ; Disulfiram ; Hemodilution ; Humans ; Oximetry ; Spectrum Analysis ; Wit and Humor as Topic

BACKGROUND: The impact of volatile induction using large-dose sevoflurane (VI-S) on cerebral blood flow has not been well investigated. The present study compared the changes in cerebral blood flow of middle cerebral artery using transcranial Doppler (TCD) during VI-S and conventional induction using propofol. METHODS: Patients undergoing elective lumbar discectomy were randomly allocated to receive either sevoflurane (8%, Group VI-S, n = 11) or target-controlled infusion of propofol (effect site concentration, 3.0 microg/ml; Group P, n = 11) for induction of anesthesia. The following data were recorded before and at 1, 2, and 3 min after commencement of anesthetic induction (T0, T1, T2, and T3, respectively): mean velocity of the middle cerebral artery (V(MCA)) by TCD, mean blood pressure (MBP), heart rate, bispectral index score (BIS) and end-tidal CO2 (ETCO2). Changes in V(MCA) and MBP from their values at T0 (DeltaV(MCA) and DeltaMBP) at T1, T2, and T3 were also determined. RESULTS: BISs at T1, T2 and T3 were significantly less than that at T0 in both groups (P < 0.05). DeltaVMCA in Group VI-S at T2 and T3 (18.1% and 12.4%, respectively) were significantly greater than those in Group P (-7.6% and -19.8%, P = 0.006 and P < 0.001, respectively), whereas ETCO2 and DeltaMBP showed no significant intergroup difference. CONCLUSIONS: VI-S using large-dose sevoflurane increases cerebral blood flow resulting in luxury cerebral flow-metabolism mismatch, while conventional propofol induction maintains cerebral flow-metabolism coupling. This mismatch in VI-S may have to be considered in clinical application of VI-S.
Anesthesia ; Blood Pressure ; Diskectomy ; Heart Rate ; Humans ; Middle Cerebral Artery ; Propofol*

BACKGROUND: Renal dysfunction is an independent risk factor of cardiac dysfunction and one of common complications after cardiac surgery. This study was designed to evaluate the relationship between serum creatinine (s-Cr) and cardiac troponin I (cTnI) in off-pump coronary artery bypass graft surgery (OPCAB). METHODS: Data, from 13 patients underwent OPCAB, were analyzed in prospective fashion. The levels of s-Cr and cTnI were evaluated before and after OPCAB. The correlations of s-Cr and TnI were analyzed in the patients with cardiac dysfunction assessed by low cardiac output or stroke volume at end of surgery. RESULTS: Patients with preoperatively elevated s-Cr (female, > or =1.2 microg/L; male, > or =1.5microg/L) showed higher incidence of elevated s-Cr and elevated cTnI (> or =0.68microg/L) on arrival at intensive care unit (POD-0), postoperative 12 hours (POD-1) and postoperative 36 hours (POD-2) (P< 0.05). Patients with preoperatively elevated cTnI showed higher incidence of elevated cTnI at POD-0, POD-1 and POD-2 (P< 0.05). In 7 patients with low cardiac index (< 2.0 L/min/m2) or stroke volume index (<40 mL/beat/m2) at end of surgery, the increases of s-Cr and cTnI showed positive correlation at POD-0, POD-1 and POD-2 (correlation coefficient 0.818, 0.864 and 0.785, respectively). CONCLUSIONS: The increases of s-Cr and cTnI showed positive correlation in low cardiac output after OPCAB. The results suggested that elevated s-Cr may be an independent predictor of elevated cTnI representing perioperative myocardial injury.
Cardiac Output, Low ; Coronary Artery Bypass, Off-Pump ; Creatinine ; Humans ; Incidence ; Intensive Care Units ; Male ; Prospective Studies ; Risk Factors ; Stroke Volume ; Thoracic Surgery ; Transplants ; Troponin ; Troponin I