Upper extremity deep vein thrombosis (UEDVT) is relatively uncommon and superior vena cava (SVC) filter placements are not often encountered due to strict indication. A 33-year old male with underlying protein C/S deficiency and secondary liver cirrhosis was admitted because of hematemesis. The patient was conservatively managed, but underwent elective splenectomy to prevent aggravation of gastric varix. During postoperative care, the patient underwent cholecystectomy for acalculous cholecystitis. During the postoperative course, UEDVT was detected and heparinization was initiated. The patient experienced repeated attacks of severe dyspnea, which was accompanied by chest pain that lasted for 3 to 10 minutes. Repeated episodes of pulmonary thromboembolism were suspected and SVC filter was placed. Warfarin treatment was initiated and the SVC filter was removed about one month later. The case highlights the clinical significance of UEDVT and reports rare case of SVC filter placement. Intensivists should have comprehensive understanding of UEDVT and its management.
Acalculous Cholecystitis ; Chest Pain ; Cholecystectomy ; Dyspnea ; Esophageal and Gastric Varices ; Hematemesis ; Heparin ; Humans ; Liver Cirrhosis ; Male ; Postoperative Care ; Pulmonary Embolism ; Splenectomy ; Upper Extremity ; Upper Extremity Deep Vein Thrombosis ; Vena Cava Filters ; Vena Cava, Superior ; Warfarin

Left-sided gallbladder (LSGB) is a rare anomaly, but it is often associated with multiple combined variations of the liver anatomy. We present the case of a patient with LSGB who underwent successful resection of perihilar cholangiocarcinoma. The patient was a 67-year-old male who presented with upper abdominal pain and obstructive jaundice. Initial imaging studies led to the diagnosis of Bismuth-Corlette type IIIB perihilar cholangiocarcinoma. Due to the unique location of the gallbladder and combined multiple hepatic anomalies, LSGB was highly suspected. During surgery after hilar dissection, we recognized that the tumor was located at the imaginary hilar bile duct bifurcation, but its actual location was corresponding to the biliary confluence of the left median and lateral sections. The extent of resection included extended left lateral sectionectomy, caudate lobe resection, and bile duct resection. Since some of the umbilical portion of the portal vein was invaded, it was resected and repaired with a portal vein branch patch. Due to anatomical variation of the biliary system, only one right-sided duct was reconstructed. The patient recovered uneventfully without any complication. LSGB should be recognized as a constellation of multiple hepatic anomalies, and therefore, thorough investigations are necessary to enable the performance of safe hepatic and biliary resections.
Abdominal Pain ; Aged ; Bile Ducts* ; Biliary Tract ; Cholangiocarcinoma* ; Diagnosis ; Gallbladder* ; Hepatectomy* ; Humans ; Jaundice, Obstructive ; Liver ; Male ; Portal Vein

BACKGROUND: Palonosetron is a recently introduced 5-hydroxytryptamine-3 (5-HT3) receptor antagonist useful for postoperative nausea and vomiting prophylaxis. However, 5-HT3 receptor antagonists increase the corrected QT (QTc) interval in patients who undergo general anesthesia. This retrospective study was performed to evaluate whether palonosetron would induce a QTc prolongation in patients undergoing general anesthesia with sevoflurane. METHODS: We reviewed a database of 81 patients who underwent general anesthesia with sevoflurane. We divided the records into palonosetron (n = 41) and control (n = 40) groups according to the use of intraoperative palonosetron, and analyzed the electrocardiographic data before anesthesia and 30, 60, 90, and 120 min after skin incision. Changes in the QTc interval from baseline, mean blood pressure, heart rate, body temperature, and sevoflurane concentrations at each time point were compared between the two groups. RESULTS: The QTc intervals at skin incision, and 30, 60, 90, and 120 min after the skin incision during general anesthesia were significantly longer than those at baseline in the two groups (P < 0.001). The changes in the QTc intervals were not different between the two groups (P = 0.41). However, six patients in the palonosetron group showed a QTc interval > 500 ms 30 min after skin incision, whereas no patient did in the control group (P = 0.01). No significant differences were observed between the two groups in mean blood pressure, body temperature, heart rate, or sevoflurane concentrations. CONCLUSIONS: Palonosetron may induce QTc prolongation during the early general anesthesia period with sevoflurane.
Anesthesia ; Anesthesia, General* ; Arrhythmias, Cardiac ; Blood Pressure ; Body Temperature ; Electrocardiography ; Heart Rate ; Humans ; Incidence* ; Isoquinolines ; Laparotomy* ; Methyl Ethers ; Patient Safety ; Postoperative Nausea and Vomiting ; Quinuclidines ; Receptors, Serotonin, 5-HT3 ; Retrospective Studies ; Skin

Anesthetic management of pediatric liver transplantation in a patient with osteogenesis imperfecta (OI) requires tough decisions and comprehensive considerations of the cascade of effects that may arise and the required monitoring. Total intravenous anesthesia (TIVA) with propofol and remifentanil was chosen as the main anesthetic strategy. Malignant hyperthermia (MH), skeletal fragility, anhepatic phase during liver transplantation, uncertainties of TIVA in children, and propofol infusion syndrome were considered and monitored. There were no adverse events during the operation. Despite meticulous precautions with regard to the risk of MH, there was an episode of high fever (40degrees C) in the ICU a few hours after the operation, which was initially feared as MH. Fortunately, MH was ruled out as the fever subsided soon after hydration and antipyretics were given. Although the delivery of supportive care and the administration of dantrolene are the core principles in the management of MH, perioperative fever does not always mean a MH in patients at risk for MH, and other common causes of fever should also be considered.
Anesthesia, Intravenous ; Antipyretics ; Child ; Dantrolene ; Fever ; Humans ; Infant* ; Liver Transplantation* ; Malignant Hyperthermia ; Osteogenesis Imperfecta* ; Pediatrics ; Pharmacokinetics ; Propofol

BACKGROUND: The aim of this study was to investigate the clinical characteristics of complex regional pain syndrome (CRPS) in young male patients in South Korea, especially focusing on the association with military service. METHODS: From January 2007 to May 2017, we investigated the electronic medical records of 430 consecutive patients, aged 18 to 30 years, who visited Seoul National University Hospital Pain Center, with a suspected diagnosis of CRPS at the initial visit. The following patient details were available for analysis: demographic and disease-related variables, relevance to military service, medications, and the treatment modalities received. RESULTS: Out of 430 patients, 245 (57.0%) were diagnosed with CRPS, of which, 200 were male patients and 45 were female patients. Of the male patients, 95 (47.5%) developed CRPS during military service. CRPS during military service was more likely to result from sprain/strain, and the incidence of CRPS was significantly higher in the lower extremities in patients from the military service group than in those from the non-military service group. During the follow-up period, 37.9% of male CRPS patients (n = 61/161) were treated successfully. Patients with moderate to severe initial pain intensity, and diagnosed during their military service, showed better outcomes. CONCLUSIONS: Our results demonstrated that manifestation of CRPS in the young Korean population was more common in male and among those male CRPS patients, about half the cases developed during the military service period.
Chronic Pain ; Diagnosis ; Electronic Health Records ; Epidemiology ; Female ; Follow-Up Studies ; Humans ; Incidence ; Korea ; Lower Extremity ; Male ; Military Medicine ; Military Personnel ; Neuralgia ; Pain Clinics ; Retrospective Studies ; Seoul ; Stress, Psychological