Epidural naloxone reduces postoperative nausea and vomiting in patients receiving epidural sufentanil for postoperative analgesia

BACKGROUND: Epidural opioids have excellent analgesic properties, but their side-effects limit their use in patient-controlled epidural analgesia. This study was designed to evaluate the effect of epidural naloxone on the side-effects of sufentanil, focusing on postoperative nausea and vomiting (PONV) in patients undergoing total knee replacement (TKR). METHODS: After obtaining Institutional Review Board approval and informed consent, 50 patients undergoing unilateral TKR were randomly assigned to receive either sufentanil in ropivacaine alone (Group C, n = 25) or the same solution with naloxone (Group N, n = 25) for their postoperative epidural analgesia. Episodes of PONV and five-point-scaled nausea scores were evaluated at 6, 12, and 24 h after epidural analgesia was started. Visual analogue scale (VAS) score for pain and the incidence of sedation, pruritus, hypotension, and respiratory depression were also evaluated at each of three time points. RESULTS: The nausea score in Group N was significantly lower than that in Group C. The VAS pain score at rest and on movement were significantly lower in Group N than in Group C at 24 h. Other opioid-induced side-effects were not significantly different. CONCLUSIONS: Epidural naloxone was effective in reducing PONV induced by epidural sufentanil and additionally enhanced the analgesic effect. Therefore, concomitant infusion of a small dose of epidural naloxone should be considered to reduce PONV, especially in patients at greater risk for PONV.ope

Conversion of orotracheal to nasotracheal intubation using a fiberoptic bronchoscope in a patient with intraoral hematoma

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Thrombus entrapped by patent foramen ovale in a patient with pulmonary embolism: a case report

Thrombus-in-transit appears to increase the risk of mortality compared to pulmonary embolism alone and can require alteration in therapeutic plan. We present the case of a biatrial thromboembolus caught in transit across a patent foramen ovale diagnosed by intraoperative transesophageal echocardiogram in a 69-year-old female with acute pulmonary embolism and subsequent acute cerebral infarction. We suggest that echocardiography should be performed in a patient with suspected pulmonary thromboembolism to evaluate right heart function and diagnose emboli in transit.ope

Efficacy of Sufentanil during Laryngeal Microscopic Surgery

BACKGROUND: Various anesthetic agents have been used in laryngeal microscopic surgery, because the airway is shared with the surgeon, there is a short operation duration and intense cardiovascular stimulation occurs during the surgery. Sufentanil is superior than other anesthetic agents in blocking the cardiovascular response to the airway stimulation and a short duration of effects. METHODS: Thirty patients undergoing elective laryngeal microscopic surgery were randomized to receive sufentanil 0.125 µg/kg (group 1, n = 10), sufentanil 0.25 µg/kg (group 2, n = 10) or sufentanil 0.5 µg/kg (group 3, n = 10). The bispectral index score, blood pressure, heart rate, recovery time from general anesthesia, the need for additional analgesics and naloxone and the postoperative complications associated with sufentanil were measured. RESULTS: The bispectral index, blood pressure and heart rate were similar in the three groups. Only four patients in group 3 required naloxone (P < 0.05). Three patients in group 1, one in group 2 and 0 in group 3 required an additional dose of sufentanil. Postoperative sore throat was detected in 6 patients in the immediate postoperative period and in 8 patients 6 hours after the end of anesthesia in group 1 (P < 0.05). CONCLUSIONS: Sufentanil is an effective analgesic for attenuating the cardiovascular responses of airway stimulation in laryngeal microscopic surgery. In addition, sufentanil 0.25 µg/kg is an appropriate dose for the rapid recovery and attenuation of the cardiovascular response in laryngeal microscopic surgery.ope

Unilateral pulmonary edema during an operation in patient with undiagnosed pheochromocytoma: A case report

Pheochromocytoma is a rare tumor, but it can cause severe hemodynamic disturbances during anesthesia, and particularly in patients whose pheochromocytoma was not diagnosed preoperatively. We report here on a case of unilateral pulmonary edema during laparoscopic adrenalectomy, and this edema was due to pheochromocytoma that was not diagnosed preoperativelyope

Heparin Resistance during Cardiopulmonary Bypass in Infective Endocarditis Patients

Appropriate anticoagulation is essential for safe cardiopulmonary bypass (CPB). Two patients with infective endocarditis were scheduled for valve replacement. After an intravenous heparin injection for the CPB, the increases in the activated clotting time (ACT) in both patients were less than expected. Subsequent additional heparin administration failed to maintain a sufficient ACT for the CPB, and antithrombin III (AT III) tests during the CPB revealed low activities in both patients. Heparin resistance, due to consumption of circulating AT III as a result of infective endocarditis or prior heparinization, was postulated. While fresh frozen plasma (FFP) could not be timely administered in the first patient, ACT was successfully prolonged after the administration of FFP in the second. It is strongly suggested that adequate management of heparin resistance should be prepared for patients with infective endocarditis who require CPB.ope

Efficacy of the Laryngeal Tube in General Anesthesia

Background: A prototype airway management device, a laryngeal tube, has been recently introduced in Korea. This study was designed to assess the efficacy of the laryngeal tube for airway management under general anesthesia. Methods: We studied thirty-six ASA physical statusⅠ and Ⅱ patients undergoing general anesthesia. Anesthesia was induced with sleep dose propofol 2.0 ㎎/㎏ i.v., supplemented with fentanyl 1 ㎍/㎏, and maintained with 50% nitrous oxide and propofol. After inserting the laryngeal tube, its cuff was inflated using a balloon cuff gauge until the intracuff pressure reached approximately 65 ㎝H₂O. Adequacy of ventilation was assessed by observing the end tidal carbon dioxide wave form, chest wall movement and by stethoscope auscultation. Oropharyngeal leak pressure was also measured. Changes in heart rate, blood pressure, end-tidal carbon dioxide, airway pressure and oxygen saturation before induction, before insertion, 2, 5 and 10 minutes after insertion and 5 minutes after incision were recorded. Results: The first time success rate at achieving an effective airway was 30 in 36 (83%). The mean leak pressure was 22.9 ± 4.6 mmHg. Heart rate, blood pressure, oxygen saturation, end-tidal carbon dioxide and airway pressure values remained stable during laryngeal tube insertion and during the surgical procedure. Conclusions: We conclude that the laryngeal tube is easy to place, allows adequate ventilation and has a lower incidence of complications. It may offer an alternative device for the oxygenation of non-intubated patients undergoing general anesthesia.ope

Clinical Characteristics of the Patients Who Died Despite of Low APACHE II Score after Intensive Care

BACKGROUND: The acute physiology and chronic health evaluation (APACHE) II score is considered to be a precise predictor of mortality and a useful basic research tool. A lower APACHE II score means a better prognosis of patients, which means that these relatively low risk patients are more likely to benefit from the improved patient management than the higher predicted mortality admissions. Therefore, these patients are obvious targets for intensive care and for decreasing the level of intensive care unit (ICU) mortality. METHODS: This study reviewed the medical records of 729 patients, whose APACHE II scores on the ICU admission day were 10 or less, from June 1, 2001 to May 31, 2002 in University Hospital. The data of the patient's age, gender, disease category, first admission or readmission, APACHE II score, length of stay at the ICU and the hospital were reviewed. RESULTS: The average mortality rate of the patients who had an APACHE II score of 10 or less was 4.1%. The mortality of the cancer patients (8%) was significantly higher than the other disease groups. The mortality of the readmitted patients was significantly higher than the mortality of the patients who were admitted to the ICU for the first time. CONCLUSIONS: Among the patients in the ICU with a low APACHE II score, the mortality of cancer patients was high. The mortality of the readmitted patients was significantly higher than in those on the first admission.ope

Effects of steep head-down position on pulse pressure variation

Background:The effects of head-down position on dynamic hemodynamic variables remain without full understanding. We evaluated the effects of steep head-down position on the pulse pressure variation (PPV).Methods:Forty patients were positioned at 30o head-down position after anesthesia induction. We measured the heart rate (HR), arterial blood pressure (BP) and PPV before and 2 minutes after the position change.Results:PPV and HR decreased (9.3 ± 3.2% to 4.6 ± 1.8%, 67.2 ± 11.4 to 62.4 ± 7.8, respectively) after steep head-down position, whereas the BP increased. Baseline PPV was related with decreases of PPV (r2 = −0.83, P ＜ 0.0001). An 8% PPV threshold discriminated the patients with more than 5% decreases of absolute PPV value. The area under the receiver operating characteristic curve was 0.98 (95% CI = 0.88 to 1.00, P ＜ 0001). Conclusions:Steep head-down position caused decreases in PPV. Higher PPV at the supine position decreased more after the position change. Further investigations are required to assess the significance, the duration and the relationship with fluid responsi-veness of this change.ope

Facial paralysis after spine surgery : A case report

diopathic facial nerve paralysis after surgery is not common but has clinical significance. We report a case of facial nerve paralysis in the immediate postanesthetic period after cervical spine surgery. A 41-year-old man with cervical herniated disc was scheduled for cervical laminectomy. After uneventful surgery, he suffered from left facial numbness and weakness. Imaging study and audiogram couldn't reveal any anatomic abnormality except Thornwaldt cyst. Conservative treatment with steroids and antivirals resolved his symptoms until 16th day after surgeryope