Myotonic dystrophy is the most common and serious form of myotonic disease. It is a multisystem disease, although skeletal muscles are principally affected. Its most common complication is postoperative respiratory failure. We report such a case in a patient undergoing total abdominal hysterectomy after inhalational anesthesia. The patient had preoperative muscular weakness, which was, we concluded, induced by hypothyroidism and an old lacunar infarction in left thalamus with mild cerebral atrophy by preoperative thyroid function testing and brain CT. We studied electromyographic results and more intensively queried family history after postoperative respiratory failure. It was confirmed that the patient had myotonic dystrophy.
Anesthesia ; Anesthesia, General* ; Atrophy ; Brain ; Humans ; Hypothyroidism ; Hysterectomy ; Muscle Weakness ; Muscle, Skeletal ; Myotonic Dystrophy* ; Respiratory Insufficiency* ; Stroke, Lacunar ; Thalamus ; Thyroid Function Tests

A 53 year old man with gastric cancer was admitted for radical subtotal gastrectomy. The patient received general anesthesia with epidural analgesia. Epidural catheterization was performed using an 18-gauge Tuohy needle at the T10-11 interspace, and the epidural space was confirmed after a repeated attempt. An epidural catheter was then advanced smoothly 5 cm in cephalad direction without bleeding or CSF leakage. The patient received a test dose of lidocaine and epinephrine and continuous infusion with morphine and lidocaine 30 minutes before operation finished. Vital signs during the operation were stable. Two days after the operation, the patient complained of an orthostatic headache, and relieved ketolorac. On the seventh day, the patient complained of bilateral diplopia. Diffuse pachymeningeal gadolonium enhancement was seen on the brain MRI, and his CSF pressure was 0 mmHg by spinal tapping. We suspected abducent nerve palsy due to CSF hypovolemia and performed an epidural blood patch with 15 ml of autologus blood at the previous puncture site. The patient is receiving regular examinations at the Neurology and Opthalmology department. Abducent nerve palsy completely recovered by the Hess Screen test 6 months after operation, and diplopia disappeared 10 months after the operation.
Abducens Nerve ; Analgesia, Epidural ; Anesthesia, General ; Blood Patch, Epidural ; Brain ; Catheterization* ; Catheters* ; Diplopia* ; Epidural Space ; Epinephrine ; Gastrectomy ; Headache ; Hemorrhage ; Humans ; Hypovolemia ; Lidocaine ; Magnetic Resonance Imaging ; Middle Aged ; Morphine ; Needles ; Neurology ; Pain, Postoperative* ; Paralysis ; Punctures ; Spinal Puncture ; Stomach Neoplasms ; Vital Signs

BACKGROUND: Lidocaine is used for suppressing circulatory responses to endotracheal intubation. In this study the investigated changes of middle cerebral artery blood flow velocity (Vmca) before and after intravenous lidocaine injection by transcranial doppler. METHODS: Fifteen healthy volunteers received a bolus dose of intravenous lidocaine 1.5 mg/kg. Vmca's were measured on the temple using a bidirectional 2-MHz transcranial doppler probe before and after lidocaine injection. Vmca's were recorded continually every 10 sec for 10 minutes after lidocaine injection. RESULTS: Mean Vmca was 67.6 +/- 7.6 cm/sec before lidocaine injection. Maximal Vmca's (70.7 +/- 7.5 cm/sec, P<0.05) occurred 35 +/- 16 sec after lidocaine injection, and then the Vmca decreased gradually. Minimal Vmca's (56.6 +/- 7.4 cm/sec, P<0.05) were measured at 164 +/- 40 sec after lidocaine injection. CONCLUSIONS: We suggest that lidocaine generally causes the decreases in Vmca, excepting the temporarily increase in Vmca about 35 sec after a single bolus administration of intravenous lidocaine.
Blood Flow Velocity* ; Healthy Volunteers ; Injections, Intravenous* ; Intubation, Intratracheal ; Lidocaine* ; Middle Cerebral Artery*

BACKGROUND: Thiopental anesthesia increases the seizure threshold of patients receiving electroconvulsive therapy. However, excessive neuronal suppression could result in an unacceptably short seizure duration. We sought to identify the correlation between the pre-ictal Bispectral index (BIS) score and seizure duration during electroconvulsive therapy (ECT) under thiopental anesthesia. METHODS: Thirty patients with major depressive disorders underwent ECT. Anesthesia was induced by a bolus injection of 2 mg/kg of thiopental. BIS was monitored continuously, and recorded at specific end points, i.e., before anesthesia, just before ECT (pre-ictal BIS), on awaking (eye opening), before discharge to the recovery room and before discharge to the ward. The durations of motor and electroencephalographic seizures were recorded. RESULTS: The BIS score just before ECT was 52+/-9. Both motor and electro encephalographic seizure durations were positively correlated with the pre-ictal BIS score (R = 0.59 and 0.60, respectively; P < 0.01). On eye opening, BIS showed 48+/-13 and slowly recovered but remained low until discharge to the ward, reflecting post-ictal suppression. CONCLUSIONS: Pre-ictal BIS score is positively correlated with seizure duration, but the BIS score may not accurately reflect the depth of sedation after ECT.
Anesthesia* ; Depressive Disorder, Major ; Electroconvulsive Therapy* ; Humans ; Neurons ; Recovery Room ; Seizures* ; Thiopental*

BACKGROUD: To study the prevalence of abnormalities found in routine preoperative eletrocardiograms (ECGs) and to analyze abnormal ECG findings in different age groups. METHODS: 9,709 patients undergoing elective surgery requiring anesthesia at Busan Paik Hospital from January to December 2002 were retrospectively studied. Preoperative ECGs were analyzed in terms of age, sex and specific abnormal ECG findings that might alter anesthetic management. RESULTS: 1,683 of 9,709 patients (17.3%) had abnormal electrocardiogram findings. The incidences of ventricular hypertrophy, bundle branch block, myocardial ischemia, arrhythmia, myocardial infarction and atrioventricular block were 5.3%, 4.1%, 3.9%, 2.5%, 1.0% and 0.5%. Those over 75 years, 43% had abnormal findings and the incidence of myocardial ischemia, arrhythmia and ventricular hypertrophy were 11.7%, 9.7% and 8.7%. CONCLUSIONS: The prevalence of unexpected preoperative ECG abnormalities among elective surgery patients is high, especially among older patients. Given the wealth of information provided by preoperative ECG at low cost, ECG is necessary to establish the components of routine preoperative assessment for cardiovascular disease, especially for older adults.
Adult ; Anesthesia ; Arrhythmias, Cardiac ; Atrioventricular Block ; Bundle-Branch Block ; Busan ; Cardiovascular Diseases ; Electrocardiography* ; Humans ; Hypertrophy ; Incidence* ; Mass Screening* ; Myocardial Infarction ; Myocardial Ischemia ; Prevalence ; Retrospective Studies

BACKGROUND: Rocuronium has a high incidence of vascular pain when injected intravenous by, and diverse methods have been examined to reduced this pain. The aim of this study was to evaluate the effect of ketamine pretreatment on vascular pain during the injection of rocuronium in pediatric patients. METHODS: Sixty ASA physical status 1 patients scheduled for elective surgery were randomly divided into three groups; a control group (placebo: normal saline, n = 20), group 1 (ketamine 0.5 mg/kg pretreatment, n = 20), and group 2 (ketamine 1 mg/kg pretreatment, n = 20). The ketamine pretreatment was injected in the preanesthetic room. After being moved into the operation room, general anesthesia was induced using thiopental sodium 5 mg/kg in control group. All groups were followed during and after injecting rocuronium 0.9 mg/kg IV. Vascular pain was graded using a 4-point scale. RESULTS: The incidence of vascular pain diminished significantly in the ketamine pretreated group, as follows: 17 (85%) in control group, 4 (20%) in group 1 and 7 (35%) in group 2. CONCLUSIONS: Intravenous ketamine pretreatment at 0.5-1 mg/kg may effectively reduce or prevent vascular pain on injecting rocuronium in pediatric patients.
Anesthesia, General ; Humans ; Incidence ; Ketamine* ; Thiopental

OBJECTIVE: To analyze the clinical characteristics of intrauterine fetal death. METHODS: A retrospective cross sectional analysis was done on 269 cases of intrauterine fetal death, among 44,453 deliveries over 20 weeks of gestation or weighs more than 500gm, at Ghil Hospital, Gacheon Medical School from April 1994 to December 2001. RESULTS: The incidence of intrauterine fetal death was 0.06$. The average maternal age was 28 +/- 4.6 years old. There were 52 cases(19.3%) with previous history of spontaneous abortion and 3 cases(1.1%) with previous history of intrauterine fetal death. There were 28 cases(10.4%) of fetal anomaly, and of which central nervous system defect, hydrops fetalis, abdominal anomaly were common. The maternal disease was accompanied by 69 cases(25.7%) and most common maternal disease was preeclampsia. In 74 cases(27.5%), we could not find the suspected cause of intrauterine fetal death. The suspected causes of intrauterine fetal death were intrauterine growth retardation(13.8%), cord complication(12.6%), preeclampsia(11.5%), fetal anomaly(10.4%), and placental abruption(8.2%). There were 12 cases(4.5%) of peripartum maternal complications. CONCLUSION: Intrauterine growth retardation and cord complications were the most common suspected causes, we could not find the cause of intrauterine fetal death in 74 cases(27.5%) out of 269 cases.
Abortion, Spontaneous ; Central Nervous System ; Cross-Sectional Studies ; Female ; Fetal Death* ; Fetal Growth Retardation ; Humans ; Hydrops Fetalis ; Incidence ; Maternal Age ; Peripartum Period ; Pre-Eclampsia ; Pregnancy ; Retrospective Studies ; Schools, Medical

Acute fatty liver of pregnancy is a uncommon complication of late pregnancy which may progress to hepatic failure, encephalopathy, disseminated intravascular coagulopathy, and death. A 65 kg 29-yr-old female at 35 weeks gestation complained of epigastric discomfort and jaundice 5 days before adimission. She had icteric sclera but other physical findings were non-specific. Anesthetic induction was achieved with thiopental, succinylcholine and vecuronium and the trachea was easily intubated. Maintenance of anesthesia was accomplished with oxygen : nitrous oxide (3 : 2) and 0.8% isoflurane. The Apgar scores were 8 and 10 at 1 min and 5 min, respectively. After the end of surgery, the patient was awakened and she was extubated after she followed verbal commands. She remained stable during her immediate postoperative course, but her vital signs were worse suddenly on postoperative day 3. On postoperative day 5, she was supported by artificial ventilation. The prothrombin time and the partial thromboplastin time were prolonged. Dopamine, dobutamine and norepinephrine were administered for maintaining her cardiovascular function. After that she was managed with artificial ventilation, cardiovascular drugs, fluid and blood products due to multi-organ failure. On postoperative day 25, she expired due to an acute cardiac arrest which was suspected to be due to multi-organ failure.
Anesthesia ; Anesthesia, General ; Cardiovascular Agents ; Cesarean Section ; Dobutamine ; Dopamine ; Fatty Liver* ; Female ; Heart Arrest ; Humans ; Isoflurane ; Jaundice ; Liver Failure ; Nitrous Oxide ; Norepinephrine ; Oxygen ; Partial Thromboplastin Time ; Pregnancy* ; Prothrombin Time ; Sclera ; Succinylcholine ; Thiopental ; Trachea ; Vecuronium Bromide ; Ventilation ; Vital Signs

BACKGROUND: In intravenous administration of a depolarizing neuromuscular blocker, succinylcholine is reported to produce activation of the electroencephalogram and increase cerebral blood flow and intracranial pressure. In this point, rocuronium was recently introduced as a non-depolarizing relaxant, and recommended as a safe alternative to succinylcholine. The purpose of this study was to evaluate the effects of rocuronium and succinylcholine on cerebral blood flow velocities during anesthetic induction. METHODS: Forty patients were randomly assigned into two groups. Group 1 was administrated rocuronium 0.6 mg/kg and group 2 was administrated succinylcholine 1 mg/kg for tracheal intubation after each group had intravenous administration of thiopental 5 mg/kg. The author observed changes of mean arterial pressure, arterial carbon dioxide tension, and middle cerebral arterial blood flow velocities at 5 times: before induction (control), 30 sec after thiopental administration, 30 sec, 60 sec and 90 sec after muscle relaxant administration. RESULTS: Mean arterial pressure decreased more at 30 sec after thiopental administration compared with the control (P<0.05). Middle cerebral arterial blood flow velocities were reduced at 30 sec after thiopental administration and 60 sec after rocuronium administration compared with the control (P<0.05). Middle cerebral arterial blood flow velocities were reduced at 30, 60, 90 sec after rocuronium administration compared with succinylcholine administration (P<0.05). CONCLUSIONS: We conclude that rocuronium has little effects on increasing cerebral blood flow. These result suggest that rocuronium have a less effect on increase in cerebral blood flow during neurosurgical anesthesia.
Administration, Intravenous ; Anesthesia ; Arterial Pressure ; Blood Flow Velocity* ; Carbon Dioxide ; Electroencephalography ; Humans ; Intracranial Pressure ; Intubation ; Neuromuscular Blockade ; Succinylcholine* ; Thiopental

BACKGROUND: Neurologic and neuropsychologic dysfunction after cardiopulmonary bypass is frequent and can be caused by inadequate cerebral perfusion and oxygenation. A decrease of SjvO2 suggests a situation in which the oxygen supply to the brain is insufficient to meet metabolic demands. This study investigated the effects of normocapnia and hypercapnia on changes in SjvO2 and lactate levels during rewarming from hypothermic cardiopulmonary bypass. METHODS: Anesthesia was induced and maintained with bolus and continuous infusion of fentanyl, midazolam and vecuronium. Patients were assigned to a normocapnic (PaCO2: 35 - 40 mmHg, n = 10) or hypercapnic (PaCO2: 45 50 mmHg, n = 10) group during rewarming. SjvO2 and lactate levels at the jugular bulb were measured at 30, 34 and 37degrees C nasopharyngeal temperature. RESULTS: There was not a reduction in SjvO2 to < 50% in normocapnic and hypercapnic group during the rewarming period, and there was no significant difference in lactate levels at the jugular bulb. However, the hypercapnic group had a higher SjvO2 than the normocapnic group at 30, 34 and 37degrees C nasopharyngeal temperature during rewarming (P<0.05). CONCLUSIONS: Hypercapnia is more effective increasing SjvO2 than normocapnia and may contribute to the prevention of postoperative neurologic dysfunction, especially in patients having a low SjvO2.
Anesthesia ; Brain ; Cardiopulmonary Bypass* ; Fentanyl ; Humans ; Hypercapnia* ; Lactic Acid* ; Midazolam ; Neurologic Manifestations ; Oxygen* ; Perfusion ; Rewarming* ; Vecuronium Bromide