Laryngo-tracheal perforation caused by the use of a stylet during tracheal intubation is a rare complication. We present a case of subcutaneous emphysema and connective tissue inflammation after tracheal intubation. The patient was a 41-year-old male undergoing general anesthesia for an appendectomy. The intubation was difficult during laryngoscopy (Cormack-Lehane Grade III). An assistant provided an endotracheal tube with a stylet inside while the laryngoscope was in place. During intubation, a short, dull sound was heard with a sudden loss of resistance after the distal tip of the endotracheal tube passed the rima glottis. A sonogram and computerized tomography revealed subcutaneous emphysema from the neck to the upper mediastinum and fluid collection between the trachea and the thyroid. This lesion appeared to have been caused by the protruded, loose stylet. Anesthesiologists should be aware of the damage a loose stylet protruding beyond the tip of the endotracheal tube can cause.
Adult ; Anesthesia, General ; Appendectomy ; Connective Tissue ; Glottis ; Humans ; Inflammation* ; Intubation ; Laryngoscopes ; Laryngoscopy ; Male ; Mediastinum ; Neck* ; Punctures* ; Subcutaneous Emphysema* ; Thyroid Gland ; Trachea

BACKGROUND: Acute renal failure is one of the leading causes of postoperative morbidity and mortality. The purpose of this study was to determine the risk factors that are associated with acute renal failure after colorectal surgery. MATERIALS AND METHODS: Five hundred seventy patients who operated colorectal surgery at the Yeungnam University Medical Center over three years from 2004 to 2006 were enrolled in this study. The effects of gender, age, ASA classification, concomitant disease, surgery type and duration, reoperation, urogenital manipulation, medication, hypotension, hypovolemia, transfusion, and postoperative ventilatory care on the occurrence of acute renal failure after colorectal surgery were studied. RESULTS: The major risk factors of acute renal failure after colorectal surgery were age of patients (P=0.003), ASA classification (P<0.001), concomitant disease (P<0.001), duration of the time surgery (P=0.034), reoperation (P=0.001), use of intraoperative diuretics (P=0.005), use of postoperative diuretics (P<0.001), intraoperative hypotension (P=0.018), intraoperative transfusion (P<0.001), postoperative transfusion (P<0.001), and postoperative ventilatory care (P=0.001). CONCLUSION: Multiple factors cause synergistic effects on the development of acute renal failure after colorectal surgery. Therefore, efforts to reduce the risk factors associated with acute renal failure are needed. In addition, intensive postoperative care should be provided to all patients.
Academic Medical Centers ; Acute Kidney Injury* ; Classification ; Colorectal Surgery* ; Diuretics ; Humans ; Hypotension ; Hypovolemia ; Mortality ; Postoperative Care ; Reoperation ; Risk Factors*

BACKGROUND: This study was performed to evaluate the dose-related effects of naloxone on morphine analgesia in the rat formalin test, and observe the correlation of pain behavior and spinal c-fos expression induced by a formalin injection. METHODS: Fifty rats were divided into five groups; control, morphine (morphine pre-treated, intra-peritoneal injection of 0.1 mg of morphine 5 min prior to formalin injection), and three naloxone groups, which were divided according to the administered dose-ratio of naloxone to morphine; 20: 1 (5microgram), 10: 1 (10microgram), and 1: 1 (100microgram) representing the low-, medium-, and high-dose naloxone groups, respectively, were injected intra-peritoneally 16 min after a formalin. A fifty ul of 5% formalin was injected into the right hind paw. All rats were observed for their pain behavior according to the number of flinches during phases 1 (2-3, 5-6 min) and 2 (1 min per every 5 min from 10 to 61 min). The spinal c-fos expression was quantitatively analyzed at 1 and 2 hours after the formalin injection using a real-time PCR. RESULTS: The morphine pre-treated (morphine and three naloxone) groups during phase 1, and the morphine, low- and medium-dose naloxone groups during phase 2, showed significantly less flinches compared to those of the control (P < 0.05). In the three naloxone groups, the numbers of flinches were transiently reduced following the naloxone injection in the low- and medium-dose groups compared to those of the morphine group (P < 0.05). The duration of the reduced flinches was longer in the medium-dose group (P < 0.05). The high-dose group revealed immediate increases in flinches immediately after the naloxone injection compared to those of the morphine, low- and medium-dose groups (P < 0.05 for each). The spinal c-fos expression showed no significant patterns between the experimental groups. CONCLUSIONS: Our data suggest that relatively low-dose naloxone (1/20 to 1/10 dose-ratio of morphine) transiently potentiates morphine analgesia; whereas, high-dose (equal dose-ratio of morphine) reverses the analgesia, and the spinal c-fos expression does not always correlate with pain behavior in the rat formalin test.
Analgesia* ; Animals ; Formaldehyde* ; Morphine* ; Naloxone* ; Pain Measurement* ; Rats* ; Real-Time Polymerase Chain Reaction

We experienced a patient with unilateral visual loss after cervical spine surgery in the prone position. During the initial postoperative period, we were not been able to identify the patient's visual loss because of severe conjunctival edema in both eyes. Three days after surgery, the patient complained of right visual loss and was examined by an ophthalmologist. Ophthalmic artery occlusion was taken to be the presumptive cause, based on fluorescein angiography (FAG) and other evidence. He had several risk factors of ophthalmic artery occlusion, such as; prone position, compression of the eye-balls, anatomic abnormality, cervical spine and a long duration operation, intraoperative bleeding, hypotension and smoking, and a diabetic history. We concluded that attention must always be paid to a patients' eyes throughout the perioperative and postoperative period to prevent such a catastrophic postoperative complication.
Edema ; Fluorescein Angiography ; Hemorrhage ; Humans ; Hypotension ; Ophthalmic Artery ; Postoperative Complications ; Postoperative Period ; Prone Position* ; Risk Factors ; Smoke ; Smoking ; Spine*

BACKGROUND: This study was performed to evaluate the effects of pre-emptive subdiaphragmatic instillation of lidocaine before pneumoperitoneum on postoperative pain following a laparoscopic cholecystectomy (LC) and also to evaluate it's effect on the changes of blood pressure during an operation. METHODS: Thirty-three relatively healthy patients for an LC were allocated into the two groups. after the induction of general anesthesia with sodium thiopental, vecuronium, nitrous oxide and enflurane (1-2 vol%), 0.2% lidocaine 200 ml was subdiaphragmatically instilled 10 min before pneumoperitoneum in the lidocaine group (n = 15), and normal saline in the control group (n = 18). The changes of the systolic and mean arterial pressure (SAP and MAP), postoperative pain score, and the number of analgesics used during the postoperative 24 h were compared between two groups. RESULTS: The pain scores at postoperative 1, 3, 6, 12, 18 and 24 h and the number of analgesics used were significantly low in the lidocaine group compared to the control group (P<0.01). The elevations of SAP and MAP during pneumoperitoneum were significantly attenuated in the lidocaine group (P<0.01). CONCLUSIONS: This data suggests that subdiaphragmatic instillation of lidocaine before pneumoperitoneum is effective in the control of postoperative pain following an LC and also effective to attenuate the elevation of blood pressure during pneumoperitoneum. However, further study is needed to evaluate the safety of these methods before recommendation of routine use.
Analgesics ; Anesthesia, General ; Arterial Pressure ; Blood Pressure* ; Cholecystectomy, Laparoscopic* ; Enflurane ; Humans ; Lidocaine* ; Nitrous Oxide ; Pain, Postoperative* ; Pneumoperitoneum* ; Sodium ; Thiopental ; Vecuronium Bromide

BACKGROUND: Propofol has an antioxidant capacity and can be used for ischemia-reperfusion injury of the liver. However, the effects of propofol on the Kupffer cells have not been established. METHODS: Kupffer cells were isolated and cultured from male Sprague-Dawley rats. The effects of propofol on the Kupffer cells were evaluated by a phagocytosis assay, TNF-alpha gene expression, TNF-alpha production, and superoxide anion release after administering propofol in different concentrations on the cultured Kupffer cells. RESULTS: The latex bead phagocytosis by the Kupffer cells was suppressed when the Kupffer cells were exposed to propofol irrespective of concentrations. Higher propofol concentrations decreased the loss of Kupffer cells after latex bead phagocytosis. Propofol induced TNF-alpha mRNA expression in the Kupffer cells, but the mRNA expression level after 50microgram/ml of propofol decreased. The pattern of TNF-alpha mRNA expression induced by propofol was different to that induced by LPS: TNF-alpha mRNA was expressed continuously in the propofol-treated cells until 16 hours after exposure to propofol, whereas the level of TNF-alpha mRNA expression induced by LPS was evident after 2 hours and was not found thereafter. TNF-alpha production after propofol treatment was not higher than that of the control. Formazan precipitation did not show any qualitative differences between cells untreated or treated with propofol concentrations of 0.5, 5.0, and 50microgram/ml. CONCLUSIONS: These results showed that propofol might inhibit Kupffer cells. This suggests that propofol can be used for patients with ischemia-reperfusion injury of the liver.
Animals ; Gene Expression ; Humans ; Kupffer Cells* ; Liver* ; Male ; Microspheres ; Phagocytosis ; Propofol* ; Rats* ; Rats, Sprague-Dawley ; Reperfusion Injury ; RNA, Messenger ; Superoxides ; Tumor Necrosis Factor-alpha

BACKGROUND: In most brain operations, the endotracheal tube is kept in postoperatively for airway maintenance during radiologic examinations. But the endotracheal tube causes tracheal irritation and hemodynamic changes. Inhalation anesthetics can not be administered during transport, and minimal concentration is exhaled for several hours after the end of inhalation. The present study was designed : (1) to determine the end tidal isoflurane concentration after the end of administration ; (2) to investigate the effects of intravenous anesthetics in patients with tracheal intubation during radiologic examination postoperatively. METHODS: We selected forty adult patients who were scheduled for elective neurosurgical operation with postoperative brain CT (computerized tomography). The study was performed in 2 steps; in the step 1 (n = 10), end tidal isoflurane concentration was checked after ending inhalation. In the step 2 (n = 30), patients were divided into one of three groups according to anesthesia method; group I (using isoflurane), group P (change from isoflurane to propofol about an hour before operation end), group M (using midazolam instead of propofol, compared to group P). In each group, the frequency of bucking and incidence of hypertension were checked during postoperative radiologic examinations. RESULTS: Minimal concentrations of isoflurane were detected in exhaled gas for about 2 hours after the end of isoflurane inhalation. The frequency of bucking was significantly lower in the group P and M than in group I (P = 0.002). In group P, the incidence of hypertension was significantly reduced compared to group M and I (P = 0.031). CONCLUSIONS: These results suggest that the change of anesthetic technique (from inhalation to intravenous) in the late period of operation, provides postoperative hemodynamic stability, a more comfortable state and minimal environmental pollution in comparison to inhalation anesthesia only.
Adult ; Anesthesia ; Anesthesia, Inhalation ; Anesthesia, Intravenous* ; Anesthetics, Inhalation ; Anesthetics, Intravenous ; Brain ; Environmental Pollution ; Hemodynamics ; Humans ; Hypertension ; Incidence ; Inhalation ; Intubation ; Isoflurane ; Midazolam ; Propofol

BACKGROUND: In most brain operations, the endotracheal tube is kept in postoperatively for airway maintenance during radiologic examinations. But the endotracheal tube causes tracheal irritation and hemodynamic changes. Inhalation anesthetics can not be administered during transport, and minimal concentration is exhaled for several hours after the end of inhalation. The present study was designed : (1) to determine the end tidal isoflurane concentration after the end of administration ; (2) to investigate the effects of intravenous anesthetics in patients with tracheal intubation during radiologic examination postoperatively. METHODS: We selected forty adult patients who were scheduled for elective neurosurgical operation with postoperative brain CT (computerized tomography). The study was performed in 2 steps; in the step 1 (n = 10), end tidal isoflurane concentration was checked after ending inhalation. In the step 2 (n = 30), patients were divided into one of three groups according to anesthesia method; group I (using isoflurane), group P (change from isoflurane to propofol about an hour before operation end), group M (using midazolam instead of propofol, compared to group P). In each group, the frequency of bucking and incidence of hypertension were checked during postoperative radiologic examinations. RESULTS: Minimal concentrations of isoflurane were detected in exhaled gas for about 2 hours after the end of isoflurane inhalation. The frequency of bucking was significantly lower in the group P and M than in group I (P = 0.002). In group P, the incidence of hypertension was significantly reduced compared to group M and I (P = 0.031). CONCLUSIONS: These results suggest that the change of anesthetic technique (from inhalation to intravenous) in the late period of operation, provides postoperative hemodynamic stability, a more comfortable state and minimal environmental pollution in comparison to inhalation anesthesia only.
Adult ; Anesthesia ; Anesthesia, Inhalation ; Anesthesia, Intravenous* ; Anesthetics, Inhalation ; Anesthetics, Intravenous ; Brain ; Environmental Pollution ; Hemodynamics ; Humans ; Hypertension ; Incidence ; Inhalation ; Intubation ; Isoflurane ; Midazolam ; Propofol

BACKGROUND: There are many factors which cause postoperative hepatic dysfunction. Anesthetic agents are not the most common factor and there aremany other factors such as preoperative condition of the patients, site and duration of the operation, operation per se and so on. The purposeof this study is to evaluate postoperative liver function with respect to different types of surgery. METHOD: Fourty three patients were classified into three groups; 11 patients for tympanoplasty with mastoidectomy (Group 1), 16 patients for total abdominal hysterectomy (Group 2), 15 patients for subtotal gastrectomy (Group 3). All patients were anesthesized with about 2 vol% of enflurane combined with 50% nitrous oxide. Serum glutamic oxalacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and alkaline phosphatase (ALP) were measured before anesthesia, 1, 3 and 7 days after surgery in all group, respectively. RESULT: In Group 1 and 2, postoperative SGOT and SGPT levels were maintained with preoperative level during the 7days, but in Group 3, those levels were increased in the 1st day but below upper limit (p<0.05) and decreased thereafter. Alkaline phosphatase level was maintained within the normal range for all the group during the 7 days. CONCLUSION: We consider that postoperative liver functioin may be influenced by different types of surgery, and also may be influenced by anesthetic time.
Alanine Transaminase ; Alkaline Phosphatase ; Anesthesia ; Anesthesia, Inhalation* ; Anesthetics ; Aspartate Aminotransferases ; Enflurane* ; Gastrectomy ; Humans ; Hysterectomy ; Inhalation* ; Liver* ; Nitrous Oxide ; Reference Values ; Tympanoplasty

BACKGROUND: Recently there have been several contradictory reports about the analgesic effects of opioids applied to peripheral tissues. To confirm the peripheral analgesic effects of opioids, this study compared the analgesic effects by observing the pain behavior in rats using the formalin test following infiltration of the commonly used opioids: morphine, meperidine and fentanyl. Furthermore, to confirm the mechanism of this analgesia, it also contrasted the differences of the analgesic effects between local infiltration and intraperitoneal injection of each opioid, and the reversal of peripheral analgesia of morphine by the administration of naloxone. METHODS: One hundred rats were divided into ten groups. The groups were a SHAM group(injection of normal saline 5 min before the formalin injection), infiltration groups(MSLO; 0.1 mL of 0.1% morphine 5 min before the formalin injection, DMLO for 1% meperidine, FTLO for 0.001% fentanyl), intraperitoneal groups(MSIP, DMIP, FTIP), reversal groups(MSLONAIP, MSLONALO) and a naloxone group(NALO). Under inhalation anesthesia, all animals were injected with an opioid according to their allocated group followed by the injection of 0.1 mL of 5% formalin in the plantar area of the hind paw. After recovery from anesthesia, all animals were observed for the number of flinches during phase 1(2~3 min, 5~6 min) and phase 2(every 1 min from 10 to 61 min) after the formalin injection. RESULTS: The flinches were significantly less in the infiltration groups(MSLO, DMLO, FTLO) than in the SHAM group(p<0.05). In addition, there were significantly different peripheral analgesia according to the type of opioid(p<0.05): morphine had a weak, prolonged but delayed onset of peripheral analgesia; meperidine had a potent, prolonged, rapid onset of analgesia but the number of flinches increased in the latter stages of the test; and fentanyl had a rapid, potent but very short duration of analgesia. Differences between peripheral and systemic analgesia were observed; the numbers of flinches in the DMLO, MSLO and FTLO groups were less than in the DMIP, MSIP and FTIP groups respectively(p<0.05). The reversals by naloxone applied locally or intraperitoneally did not increase the number of flinches in the groups of local infiltration of morphine. Furthermore, local infiltration of naloxone alone had less flinches than in the SHAM group(p<0.05). CONCLUSIONS: In this study, peripheral analgesia of opioids are readily present. Local infiltration of opioids such as morphine, meperidine and fentanyl has more potent analgesia than in systemic injection and the characteristics of these peripheral analgesia are different by the type of opioid. Moreover, these effects are not reversed by naloxone.
Analgesia ; Analgesics, Opioid ; Anesthesia ; Anesthesia, Inhalation ; Animals ; Fentanyl* ; Formaldehyde* ; Injections, Intraperitoneal ; Meperidine* ; Morphine* ; Naloxone ; Pain Measurement* ; Rats*