Background While some evidence indicates that propofol-based anesthesia has less postoperative pain than sevoflurane-based anesthesia, these results are controversial. We compared acute postoperative pain intensity and opioid consumption after total shoulder arthroplasty between propofol-remifentanil (PR) and sevoflurane-remifentanil (SR) anesthesia.
Methods Among 48 patients undergoing shoulder arthroscopic surgery anesthetized with PR or SR, postoperative pain intensity was assessed at 30 minutes and at 2, 6, 12, and 24 hours. The total patient-controlled analgesia volume and number of patients requiring rescue analgesics were assessed.
Results No significant difference in postoperative pain intensity was observed between the two groups. Postoperative opioid consumption and analgesic requirements were also comparable in the first 24 hours after surgery.
Conclusion PR and SR anesthesia for shoulder arthroscopic surgery provide comparable postoperative analgesia results.
Cardiac dysfunction after subarachnoid hemorrhage (SAH) is described as Takotsubo or reverse Takotsubo cardiomyopathy that shows transient left ventricular wall motion abnormalities with electrocardiogram (ECG) changes. ST change followed by T inversion is a common ECG finding complicated with these disorders, left bundle branch block (LBBB) may be a potential ECG pattern which is seen. In this case, we describe the clinical profile and outcomes of a patient with LBBB and reverse Takotsubo cardiomyopathy after anesthetic induction, which was scheduled as an emergent external ventricular drainage after SAH. This is the first report of an LBBB pattern in reverse Takotsubo cardiomyopathy.
Pulmonary alveolar proteinosis (PAP) is an uncommon disease characterized by progressive accumulation of lipoprotein material in the lungs due to impaired surfactant clearance. Whole-lung lavage (WLL) is the current standard treatment and consists of sequential lavage of each lung to mechanically remove the residual material from the alveoli. Although WLL is considered safe, unexpected complications can occur. Moreover, due to the rarity of the disease itself, this procedure is unknown to many physicians, and management of intraoperative complications can be challenging for anesthesiologists. Lung ultrasound (LUS) provides reliable and valuable information for detecting perioperative pulmonary complications and, in particular, quantitation of lung water content. There have been reports on monitoring the different stages of controlled deaeration of the non-ventilated lung during WLL using LUS. However, it has been limited to non-ventilated lungs. Therefore, we report the use of LUS in WLL to proactively detect pulmonary edema in the ventilated lung and implement a safe and effective anesthesia strategy. Given the limited diagnostic tools available to anesthesiologists in the operating room, LUS is a reliable, fast, and noninvasive method for identifying perioperative pulmonary complications in patients with PAP undergoing WLL.
The demand for drug-induced sedation for magnetic resonance imaging (MRI) scans have substantially increased in response to increases in MRI utilization and growing interest in anxiety in children. Understanding the pharmacologic options for deep sedation and general anesthesia in an MRI environment is essential to achieve immobility for the successful completion of the procedure and ensure rapid and safe discharge of children undergoing ambulatory MRI. For painless diagnostic MRI, a single sedative/anesthetic agent without analgesia is safer than a combination of multiple sedatives. The traditional drugs, such as chloral hydrate, pentobarbital, midazolam, and ketamine, are still used due to the ease of administration despite low sedation success rate, prolonged recovery, and significant adverse events. Currently, dexmedetomidine, with respiratory drive preservation, and propofol, with high effectiveness and rapid recovery, are preferred for children undergoing ambulatory MRI. General anesthesia using propofol or sevoflurane can also provide predictable rapid time to readiness and scan times in infant or children with comorbidities. The selection of appropriate drugs as well as sufficient monitoring equipment are vital for effective and safe sedation and anesthesia for ambulatory pediatric MRI.
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Awareness during general anesthesia occurs in approximately 0.1–0.2% of cases; nevertheless, particular attention is required because it can lead to critical complications including insomnia, depression, anxiety, and post-traumatic stress disorder. To prevent these complications, bispectral index (BIS) and end-tidal anesthetic gas (ETAG) concentration monitoring are commonly used to examine patient consciousness during surgery. In the present case, an 80-year-old man was scheduled for total gastrectomy. Anesthesia was maintained using desflurane 4.0–5.0% vol, oxygen, and nitrous oxide. The authors simultaneously monitored BIS, which was maintained between 37 and 43, and ETAG, which was maintained between 0.9 and 1.2 minimum alveolar concentration (MAC). After the operation, however, the authors were surprised to learn that the patient complained of awareness during anesthesia. Although BIS and ETAG concentration monitoring are useful in preventing awareness during anesthesia, they cannot be completely trusted. Even though BIS was maintained at approximately 40 and ETAG at 0.7–1.3 MAC, awareness during anesthesia occurred.
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Background The type and regimen of anesthesia may affect perioperative hyperglycemia following major surgical stress. This study compared the effects of sevoflurane and propofol on the incidence of hyperglycemia and clinical outcomes in diabetic patients undergoing lung surgery.
Methods This retrospective study included 176 patients with type 2 diabetes mellitus who had undergone lung surgery. Blood glucose levels and clinical outcomes from the preoperative period to the first 2 postoperative days (PODs) were retrospectively examined in patients who received sevoflurane (group S, n= 87) and propofol (group P, n=89) for maintenance of general anesthesia. The primary endpoint was the incidence of persistent hyperglycemia (2 consecutive blood glucose levels >180 mg/dL [10.0 mmol/L]) during the perioperative period. The secondary composite endpoint was the incidence of major postoperative complications and 30-day mortality rate after surgery.
Results Blood glucose levels similarly increased from the preoperative period to the second POD in both groups (p=0.857). Although blood glucose levels at 2 hours after surgery were significantly lower in group P than in group S (p=0.022; 95% confidence interval for mean difference, -27.154 to -2.090), there was no difference in the incidence of persistent hyperglycemia during the perioperative period (group S, 70%; group P, 69%; p=0.816). The composite of major postoperative complications and all-cause in-hospital and 30-day mortality rates were also comparable between the two groups.
Conclusion Sevoflurane and propofol were associated with a comparable incidence of perioperative hyperglycemia and clinical outcomes in diabetic patients undergoing lung surgery.
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Background Carotid endarterectomy (CEA) has been performed under regional and general anesthesia (GA). The general anesthesia versus local anesthesia for carotid surgery study compared the two techniques and concluded that there was no difference in perioperative outcomes. However, since this trial, new sedative agents have been introduced and devices that improve the delivery of regional anesthesia (RA) have been developed. The primary purpose of this pilot study was to compare intraoperative hemodynamic stability and postoperative outcomes between GA and ultrasound-guided superficial cervical plexus block (UGSCPB) under dexmedetomidine sedation for CEA.
Methods Medical records from 43 adult patients who underwent CEA were retrospectively reviewed, including 16 in the GA group and 27 in the RA group. GA was induced with propofol and maintained with sevoflurane. The UGSCPB was performed with ropivacaine under dexmedetomidine sedation. We compared the intraoperative requirement for vasoactive drugs, postoperative complications, pain scores using the numerical rating scale, and the duration of hospital stay.
Results There was no difference between groups in the use of intraoperative antihypertensive drugs. However, intraoperative inotropic and vasopressor agents were more frequently required in the GA group (p<0.0001). In the GA group, pain scores were significantly higher during the first 24 h after surgery (p<0.0001 between 0-6 h, p<0.004 between 6-12 h, and p<0.001 between 12-24 h). The duration of hospital stay was significantly more in the GA group (13.3±4.6 days in the GA group vs. 8.5±2.4 days in the RA group, p<0.001).
Conclusion In this pilot study, intraoperative hemodynamic stability and postoperative outcomes were better in the RA compared to the GA group.
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Various changes in ocular position are possible during general anesthesia as opposed to the awakening state. However, unexpected ocular deviation under general anesthesia is a disconcerting event as it can lead to difficult complications intraoperatively. To date, sudden fixed upward ocular deviation has been rarely reported previously. This phenomenon was observed in an 8-year-old boy during strabismus surgery. Suddenly fixed upward ocular deviation occurred when the speculum was inserted into the right eye. When the eyeball was pulled down, using forceps, there was some resistance, such as contracture of superior rectus. The eyeball sprang back into the upward position when the forceps was released. These changes could hamper the good exposition of the surgical field, leading to significant intraoperative difficulties and complications. Surgeons should be aware of this possibility, despite general anesthesia; if it occurs, proceed with the surgery as planned preoperatively, and both ophthalmic and anesthetic interventions should be used to solve this problem.
One of the most popular types of vaporizer mounting sytems is Selectatec, as it possesses a simple detachment mechanism. Detachable units can loosen between the vaporizer and anesthetic machine, which can cause vapor leakage. A locking system was subsequently developed to prevent this issue; however, we report a case of an unexpected vapor leakage from a locked vaporizer.
Idiopathic peripartum cardiomyopathy is an uncommon malady disease. Making the diagnosis is often difficult and it is always necessary to exclude other prior heart disease and other causes of left ventricular dysfunction in pregnant women. Heart failure in these women ensues when the cardiovascular demands of normal pregnancy are further amplified when the common complications of pregnancy complications superimposed upon these underlying conditions that cause compensated ventricular hypertrophy. This may be aggravated by making a late diagnosis and providing inappropriate treatment. We experienced a 38-year-primigravida who has diagnosed with idiopathic peripartum cardiomyopathy and underwent elective cesarean section with general anesthesia.
We present here the case of a 13-year-old male patient with Alexander's disease who underwent surgical correction of a femur fracture. Alexander's disease is a rare and fatal disorder that affects the white matter in the brain and it causes developmental delay, psychomotor regression, spasticity, megaloencephaly and seizure. The patient had the possibility of a seizure attack during the perioperative period. We discuss the anesthetic management of a patient with Alexander's disease and we review the relevant literature.
Brugada syndrome is characterized by an ECG pattern of right bundle branch block and ST segment elevation in the right precordial leads (V(1)-V(3)) without structural heart disease. It is also characterized by sudden cardiac death that's caused by ventricular fibrillation. This is a familial syndrome with an autosomal dominant inheritance pattern and it may be considerably more common in Southeast Asia. Many factors during anesthesia can precipitate malignant dysrrhythmia in these patients, so careful choice of anesthetics is required. We experienced a case of Brugada syndrome in a 59-year-old male patient who was under general anesthesia for trans-sphenoidal surgery to treat a pituitary adenoma, and the patient was diagnosed as having Brugada syndrome without any untoward cardiovascular events.
A 67-year-old woman with severe congestive heart failure (New York Heart Association, NYHA class IV) was set to receive general anesthesia for cardiac surgery. For several months, she had been in a constant sitting position from which the slightest change evoked dyspnea. A patient in such a condition is rarely considered a candidate for general anesthesia, because such patients are never eligible for any type of surgery other than that used to fix the heart problem itself. We report this case to explain how anesthesia was induced with the patient sitting in a crouching position and discuss other methods of induction that can probably be used in similar situations.
Lesch-Nyhan syndrome is an inborn error of purine metabolism resulting from hypoxanthine-guanine-phosphoribosyltransferase (HGPRT) deficiency and leading to excess purine production and uric acid over-production. It is a very rare X-linked recessive disorder, characterized by movement disorder, cognitive deficits, and self-injurious behavior. However, because of the high incidence of calculi, patients may present for surgery of urinary tract, and have increased risk of difficult intubation, aspiration pneumonia, renal insufficiency or sudden death. We report the case of a 5-year-old boy with Lesch-Nyhan syndrome who underwent successive extracorporeal shockwave lithotripsy under general anesthesia.
Regional anesthesia, an attractive choice of anesthesia for the patients with systemic illness such as pulmonary/heart diseases or endocrine dysfunctions, is generally accepted as a safe anesthetic method. However, there are various kinds of complication annoying the physician and the patient following a regional anesthesia. Therefore, physicians and patients must understand the risks in addition to the benefits of regional anesthesia to make an informed consent of anesthetic technique. 1) This review will give an overview of delayed complications following a regional anesthesia.