Acute and Critical Care

Case Report

Pharmacology/Anesthesiology
Lipid Emulsion in the Successful Resuscitation of Local Anesthetic Toxicity after Ankle Block: Sang Hee Park, Sang Hyun Kwak, Kyung Yeon Yoo, Hyun Jung Lee, Keun Bae Yook, Seok Jai Kim; Korean J Crit Care Med. 2014;29(3):234-236. Published online August 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.3.234

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Abstract PDF: Unexpected occurrence of local anesthetic toxicity is not rare and can cause fatal complications that do not respond to any known drug of intervention. Recently, the successful use of lipid emulsion for local anesthetic toxicity has been reported and recommended as a rescue method for cardiac or neurologic complications. We report a case of seizure attack and respiratory arrest successfully recovered with the use of intravenous lipid emulsion. Clinicians must be aware of the beneficial role of lipid emulsion in cases of local anesthetic toxicity.

Original Article

Comparison of Hemodynamic Changes by the Thoracic Electrical Bioimpedance Device during Endotracheal Intubation or Insertion of Laryngeal Mask Airway in General Anesthesia: Han Mok You, Jin Mo Kim, Jae Kyu Cheun; Korean J Crit Care Med. 1998;13(1):67-72.

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Abstract PDF: Introduction: we measured the hemodynamic changes by the thoracic electrical bioimpedance (TEB) device during induction of anesthesia, endotracheal intubation or insertion of layngeal mask airway (LMA). This TEB device is safe, reliable and estimate continuously and invasively hemodynamic variables.
METHODS
We measured the cardiovascular response of endotracheal intubation or that of LMA insertion in thirty ASA class I patients. General anesthesia was induced with injection of fentany 1 microgram/kg, thiopetal sodium 5 mg/kg and vecuronium 1 mg/kg intravenously. Controlled ventilation was for 3 minutes with inhalation of 50% nitrous oxide and 1.5 vol% of enflurane before tracheal intubation or LMA insertion in all patients. The patient was randomly assinged to either tracheal intubation group (ET group) or laryngeal mask airway group (LMA group). Heart rate (HR), mean arterial pressure (MAP), systemic vascular resistance (SVR), stroke index (SI) and cardic index (CI) were measured to pre-induction, pre-intubation, 1 minute after intubation, 2 minute, 3 minute, 5 minute, 7 minute.
RESULTS
MAP and SVR were decreased effectively LMA group than ET group during 1 minute after intubation, 2 minute, 3 minute, 5 minute, 7 minute (p<0.05). HR was decreased effectively LMA group than ET group between pre-induction and 1 minute after intubation, between 1 minute after intubation and 2 minute after intubation (p<0.05). But, SI and CI were no difference between ET group and LMA group during induction of anesthesia and intubation (p<0.05).
CONCLUSION
The insertion of LMA is beneficial for certain patients than endotracheal tube to avoid harmful cardiovascular response in the management of airway during anesthesia.

Case Reports

Pulmonary Embolism Detected in the Postanesthesia Care Unit Following Operation of Long Bone Fracture: A Case Report: Yun Jeong Chae, Young Ju Lee, Jin Soo Kim, Han Bum Cho; Korean J Crit Care Med. 2003;18(1):33-38.

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Abstract PDF: Clinical manifestations of pulmonary embolism are nonspecific during anesthesia. A 44 years old female received elective operation for right tibio-fibular fracture under spinal anesthesia. During operation, the patient received oxygen supply 5 L/min via mask with oxygen. On arrival of postanesthetic care unit, oxygen saturation of pulse oxymeter (SpO2) was 89% and with the 100% oxygen 10 L/min by mask, SpO2 went up rapidly to 100%. When the patient breathed under room air, SpO2 suddenly decreased to 80%. Chest x-ray at that time was non-contributory. Under the suspicion of pulmonary embolism, the patient was transferred to intensive care unit (ICU), and low molecular weight heparin (LMWH) treatment was started. LMWH was changed to regular heparin on the second day of ICU admission after conclusive diagnosis with spiral computed tomography and lung perfusion scan. The patient's oxygenation progressively improved and on the 10th day of ICU, the patient was transferred to general ward and she was discharged without any sequelae on the 23th day postoperatively.

Vagal Reflex Induced Bronchospasm: Tae Hyeong Kim, Yong Lak Kim; Korean J Crit Care Med. 2000;15(2):113-116.

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Abstract PDF: The parasympathetic nervous system has been considered to have an important role in bronchospasm. Although vagal reflexes are well documented in animal models of airway hyperresponsiveness, their importance in asthmatic attacks in man is less documented. We report a case of bronchospasm during sclera buckling operation and we believe that this patient's bronchospasm was induced by the vagal reflex.

Continuous Infusion of Ketamine in Mechanically Ventilated Patient in Septic Shock with Status Asthmaticus: Bon Nyeo Koo, Shin Ok Koh, Sung Yong Park, Jae Kwang Shim, Sung Sik Chon; Korean J Crit Care Med. 2000;15(2):108-112.

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Abstract PDF: Ketamine is well known for its analgesic, bronchodilating and sympathetic stimulating effect. Hence, it has been widely used for induction of patients with hypotension or asthma and also for analgesic and sedating purposes in the ICU. We presented a 62 year old female patient with ventilator support in septic shock with refractory asthma whom we managed successfully with continuous intravenous infusion of ketamine postoperatively in the ICU. The patient had a history of asthma but had been asymptomatic recently and was scheduled for an emergent explo-laparotomy under the diagnosis of acute panperitonitis. Before the induction of anesthesia, the patient was in septic shock but no wheezing could be auscultated. After the induction of general anesthesia and endotracheal intubation, wheezing was apparent in both lung fields with a high peak inspiratory pressure. Inotropics, vasopressors and bronchodilators were promptly instituted without any improvement of asthma and the patient had to be transferred to the ICU with intubated after the operation. Clinical symptoms of asthma continued throughout the first day despite using bronchodilators under mechanical ventilation but, after starting the IV infusion of ketamine, there were decrease in the peak inspiratory pressure and wheezing with a subsequent improvement in the arterial blood gas analysis findings. We could also achieve considerable analgesic and sedating effect without any decrease in the blood pressure. The patient's general physical status improved and weaning with extubation was successfully done on the 21st day and was transferred to the general ward on the 28th day.

The Use of Thiopental Sodium with BIS Monitoring in Hypoxic Brain Damage: Jae Young Kwon, Sul Ki Song, Kyung Hoon Kim, Sang Wook Shin, Seong Wan Baik; Korean J Crit Care Med. 2000;15(1):52-55.

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Abstract PDF: Hypoxemia is a common and potentially serious postoperative complication. Hypoxic encephalopahty may occur in prolonged hypoxemia. This condition needs brain protection. There are many brain protective methods. The primary cental nervous system protective mechanism of the barbiturates is attributed to their ability to decrease the cerebral metabolic rate, thus improving the ratio of oxygen (O2) supply to O2 demand. The electroencephalogram-derived bispectral index system (BIS) is a promising new method to predict probability of recovery of consciousness. We experienced two cases of hypoxic brain damage in recovery room. The patients were treated with thiopental and monitored with BIS. The use of thiopental as brain protection during complete global ischemia after cardiac arrest was not effective.

Anesthetic Management for Sequential Bronchoalveolar Lavage in a Patient with Pulmonary Alveolar Proteinosis: A case report: You Seong Jeong, Hee Joo Kim, Jae Hwan Kim, Myoung Hoon Kong, Mi Kyeong Lee, Nan Suk Kim, Young Seok Choi, Sang Ho Lim; Korean J Crit Care Med. 1998;13(2):243-248.

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Abstract PDF: Pulmonary alveolar proteinosis is a rare disease of unknown etiology characterized by the remittent or progressive accumulation of lipid-rich proteinaceous material within the alveolar space in the absence of inflammatory response. The removal of lipoproteinaceous material from the alveolar can the only means of effectively treating the progressive hypoxemia in pulmonary alveolar proteinosis. Bronchoalveolar lavage using a double-lumen endotracheal tube is an accepted modality for treatment of pulmonary alveolar proteinosis. We had utilized sequential bronchoalveolar lavage successfully for the treatment of a 51 year-old male patient with pulmonary alveolar proteinosis. There was no hypoxemia and unstable hemodynamics during the procedure. We conclude that the procedure will be safely performed by careful monitoring.

Original Articles

Effects of Intravenous Lidocaine on Intra-abdominal Pressure during Endotracheal Suctioning: Wha Ja Kang, Seok Hee Ham, Young Kyu Choi, Moo Il Kwon; Korean J Crit Care Med. 1998;13(2):224-228.

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Abstract PDF: BACKGOUND: We evaluated the effect of intravenous lidocaine (1 mg/kg and 2 mg/kg) on intra-abdominal pressure (IAP) during endotracheal suctioning.
METHODS
We studied 40 patients undergoing endotracheal intubation during mechanical ventilation. Group I (1 mg/kg) and group II (2 mg/kg)were given lidocaine double fashion. The endotracheal suctioning (ETS) was done 1, 3, 5 and 7 min after the injection of lidocaine. IAP, systolic blood pressure (SBP), diastolic blood preassure (DBP), and heart rate (HR) during ETS were recorded, IAP was measured using a transurethral bladder catheters. The cough response to ETS was classified as " cough score".
RESULTS
Before administration of lidocaine, ETS produced significant increase in SBP, DBP, IAP and HR compared with baseline values in the two groups (p<0.05). Both groups showed no significant changes in SBP, DBP, and HR during the study. In group I, ETS produced a significant increase in IAP 5 and 7min after lidocaine treatment (p<0.05). There were significant differences between the two groups 5 and 7 min after lidocaine treatment (p<0.05). The score of cough decreased significantly in both groups 3 min after lidocaine treatment but there was a significant difference between the two groups at 7 min.
CONCLUSIONS
We concluded that lidocaine pretreatment significantly blunted the increase in IAP, SBP DBP and HR caused by ETS and this effect lasts for 3 min in group I and 7 min in group II.

The Effect of Clonidine Pretreatment on Bupivacaine-induced Cardiac Toxicity in Rabbit: Eun Ju Lee, Jin Young Chon, Yong Woo Choi, Se Ho Moon; Korean J Crit Care Med. 1998;13(2):205-211.

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Abstract PDF: BACKGOUND: Bupivacaine, an amide type local anesthetic, is frequently used for regional anesthesia. Bupivacaine overdose induces cardiac toxicity and directly depresses both cardiac electrophysiology and hemodynamic status. Clonidine, an imidazolin alpha-2-adrenoreceptor agonist, given prophylactically may delay the toxic manifestation of bupivacaine overdose and does not accentuate the subsequent hypotension. We studied the effect of clonidine pretreatment on bupivacaine induced cardiac toxicity.
METHODS
Fourteen rabbits (seven in each group) were anesthetized with ketamine and rompun, and tracheostomy was performed. Spontaneous ventilation with room air was continued throughout the experiment. Electrocardiogram, heart rate, and invasive arterial blood pressure were continuously recorded. Clonidine 5 microgram/kg (clonidine group) or saline (control group) was injected intravenously in randomized fashion. After 15 minutes, an intravenous infusion of bupivacaine was started at 0.3 mg/kg/min. The time of occurrence of the bupivacaine-induced toxic events: first dysrhythmia, 25% and 50% reduction in basal heart rate and mean arterial pressure, and asystole were recorded. At 5, 10, 15, and 20 minutes after bupivacaine infusion, 2 ml of whole blood were withdrawn via femoral arterial catheter for determination of bupivacaine concentration.
RESULTS
The threshold time at the first dysrhythmia was significantly greater in the clonidine group (27.2+/-4.5 min) than control group (19.9+/-1.2 min). The threshold times at the 25 and 50% reduction in basal heart rate were significantly greater in the clonidine group (23.7+/-5.8 min, 33.2+/-5.1 min) than control group (16.6+/-2.9 min, 22.9+/-2.8 min) and in basal mean arterial pressure were significantly greater in the clonidine group (15.6+/-2.6 min, 25.3+/-3.7 min) than control group (9.7+/-2.7 min, 16.3+/-5.8 min). The threshold time at the asystole was significantly greater in the clonidine group (38.2+/-7.7 min) than control group (28.7+/-3.4 min). At 5, 10, 15, and 20 minutes after bupivacaine infusion, there was no significant difference in the plasma bupivacaine concentration between two groups.
CONCLUSION
This study demonstrates that clonidine pretreatment delays the cardiac toxic manifestations of bupivacaine overdose. And plasma bupivacaine concentration was not influenced by clonidine pretreatment.

Volume Changes under Isotonic Condition Containing Thiopental in Brain Astrocytoma Cells: Young Seok Lee, Bong Ki Moon, Sang Gun Han, Young Joo Lee, Jeong Yeon Hong, Kyeong Jin Lee, Soo Han Yoon, Keum Hee Chung, Hyun Jue Gill; Korean J Crit Care Med. 1998;13(2):194-197.

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Abstract PDF: BACKGOUND: Cell volume regulation is especially important in the brain because the brain is confined within a non-compliant vault and cannot tolerate significant perturbations in cell size. Cerebral cell volume regulation mechanisms are activated by sustained disturbances in plasma osmolality. The constancy of cell volume under physiological conditions is generally thought to reflex a balance between influx and efflux of solute and is therefore critically dependent on the properties of the plasma membrane. Cell volume regulation have not been described under isoosmotic solution. The object of the study was to know the effects of thiopental on cell volume change in isoosmotic condition.
METHODS
We made isoosmotic solution without thiopental (Group 1) and isoosmotic solution with 22.9 mM (Group 2), 16.8 mM (Group 3), 13.3 mM (Group 4) thiopental, separately, in order to study changes in cell volume under isoosmotic solution. We put cultured human brain astrocytoma cells into isoosmotic solution for each group and calculated cell volume using Coulter Counter after 30 minutes.
RESULTS
Cell volume was shown to be 5084+/-8580 (micrometer3)in Group 1, 501+/-854 (micrometer3) in Group 2, 1183+/-3839 (micrometer3) in Group 3, and 624+/-1100 (micrometer3) in Group 4. We discovered that cells in Group 2,3,4 were shrunk relative to cells in Group 1 (p<0.01). And there were significant differences in cell volume among thiopental groups.
CONCLUSIONS
Thiopental may has an effect on cell membrane properties and decrease cell volume under isoosmotic solution in brain astrocytoma cell.

Case Reports

Atelectasis Due to Epistaxis Aspiration during Awake Fiberoptic Nasotracheal Intubation: Ju Tae Sohn, Sang Jung Lee, Kyung Il Hwang, Heon Keun Lee, Sang Hwy Lee, Young Kyun Chung; Korean J Crit Care Med. 1998;13(1):91-96.

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Abstract PDF: Indication for fiberoptic intubation in an awake patient include almost any abnormality that may hinder the expeditious placement of an endotracheal tube during anesthetic induction. An epistaxis is the most frequent complication of nasotracheal intubation. The patient was admitted for open reduction and internal fixation due to severe mandible fracture. We experienced a case of atelectasis due to epistaxis aspiration during awake fiberoptic nasotracheal intubation in the conscious patient regionally anesthetized by both superior laryngeal nerve block and translaryngeal anesthesia, which is treated by saline irrigation, suction, active coughing and chest percussion.

A Case of Pulmonary Aspiration during the Anesthetic Induction in the Post Total Gastrectomy Patient: Yoon Hee Kim, Sang Soo Kim, Moon Hee Park, Seok Hwa Yoon; Korean J Crit Care Med. 1998;13(1):85-90.

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Abstract PDF: Pulmonary aspiration of gastric contents is a feared complication of anesthetic procedures. But aspiration of intestinal contents is rare, the influences of the aspirated contents and/or the consequnt events in the airway have not been fully settled in its provacative role for causing an acute pulmonary reaction. We experienced a case of pulmonary aspiration of intestinal content. The patinet who had undergone previous total gastrectomy was planed emergency operation due to intestinal obstructon. Aspiration during anesthetic induction occurred accidentally. Immediate endotracheal intubation and suction were followed. Right chest breathing sound was coarse and then it was getting better. Although supplement of O2 by Y-piece, arterial blood gas analysis of patient revealed pH 7.30, PaCO2 36 mmHg, PaO2 58 mmHg after emegence from anesthesia in the recovery room. Chest X-ray showed the focal air space consolidation in right lower lung and ill defined pulmonary opacity in left mid lung and retrocardiac area. The measured pH of aspiration content was 7.8 and nonpathogenic Gram negative bacilli species were cutured. Frequent suction, encouraging expectoration, antimicrobial agents therapy and O2 supplementation by Y-piece were performed in the ICU. Patient normalized following 24 hrs after the episode of aspiration.

Original Article

Clinical Study of Diffusion Hypoxia in Early Period after Nitrous Oxide Anesthesia: Hae Keum Kil, Won Oak Kim, Sung Jin Lee, Woo Kyung Lee; Korean J Crit Care Med. 1998;13(1):55-60.

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Abstract PDF: Introduction: Anesthesiologists have been aware of the dangers of diffusion hypoxia in the early postoperative period after nitrous oxide anesthesia, but it was suggested of a little clinical significance in healthy patients. Goal of this study is to re-evaluate the possibility of diffusion hypoxia.
METHODS
Eighty patients who were scheduled for vitrectomy were allocated to two groups by normal and abnormal chest X-ray findings and each group was divided into two subgroups by N2O concentration (1-a, 2-a; 50%, 1-b, 2-b; 60%). One and half hours after anesthesia, end-tidal alveolar concentration of oxygen (et-O2), N2O (et-N2O), and PaO2 were measured for 10 minutes after the inspired gases were changed to room air 2 L/minute with controlled ventilation in group 1-a. Those parameters were re-measured after re-administration of O2 and N2O of 50% of each for an hour and the inpired gases were changed to room air again.
RESULTS
In group 1-a, there was no significant differences of et-N2O and PaO2 after 5 minutes by air flow. And there was no differences of et-N2O and PaO2 between group 1-a and 1-b by et-N2O after 4 minutes. In group 1-b, PaO2 was in normal range at 10 minutes after, although et-O2 was decreased to 14.9%. However, group 2-b showed peripheral arterial saturation lower than 96% after 6 minutes and mild hypoxemia (PaO2 75.3 mmHg) at 10 minutes.
CONCLUSIONS
We suggest that hypoxemic episode during spontaneous breathing of room air in early postoperative period after nitrous oxide anesthesia may be occur due to decreased ventilatory function rather than diffusion of nitrous oxide. However, in patients with minimal abnormal chest X-ray findings even without clinical symptoms, it would be better to avoid high concentration of nitrous oxide.

Case Report

Profound Hypothermia and Circulatory Arrest for Adult PDA Surgery: Case report: Seung Hun Baek, Sang Wook Shin, Hae Kyu Kim, Seong Wan Baik, Inn Se Kim, Kyoo Sub Chung; Korean J Crit Care Med. 1997;12(2):187-191.

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Abstract PDF: Correction of a calcified patent ductus arteriosus (PDA) is a difficult surgical procedure. Simple ligation or division of PDA is not possible if diffuse circumferential calcification is present. Several techniques using cardiopulmonary bypass and closure of PDA from within the aorta or pulmonary artery have been introduced. And the surgical procedure is performed under profound hypothermia and circulatory arrest. Total ischemia time should be less than 30 minutes, which is free from the organ damage by the circulatory arrest. Barbiturates, calcium channel blockers and steroids are used for brain protection. We experienced successful use of these techniques for adult female patch closure of PDA and reviewed the anesthetic considerations of the profound hypothermia and circulatory arrest for cardiac surgery.

Original Article

The Effect of Cervical Sympathetic Nerve Block on Blood-brain Barrier Disruption with Mannitol Infusion in Rats: Bong Ki Moon, Soo Han Yoon, Young Joo Lee, Chul Ryung Hur, Chang Ho Kim, Sung Jung Lee, Young Seok Lee; Korean J Crit Care Med. 1997;12(1):69-74.

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Abstract PDF: BACKGOUND: The barrier can be altered by a number of insults to the brain (e.g., hypertension, freezing, trauma, drug). But the effect of the blood brain barrier distruction immediately after the neural change is unknown. In the present study, we focused on the BBBD after cervical sympathetic chain block.
METHODS
13 male Sprague-Dawley rats were divided into 2 groups. Group 1 (N=7) was blocked with 0.5% bupivacaine on the right cervical sympathetic chain and group 2 (N=6) was blocked with 0.5% bupivacaine on the bilateral cervical sympathetic chain. All rats received 37degrees C, 25% mannitol (1.75 g/kg) via right carotid artery and then, the effect of cervical sympathetic chain block on blood-brain barrier disruption of four cerebral compartment using 99mTc-human serum albumin and Evans blue was evaluated.
RESULTS
Both groups showed blood-brain barrier disruption and there was no significant difference between group 1 and group 2 in the anterior and posterior hemisphere of the right side brain. But group 2 showed significant blood-brain barrier disruption than group 1 in anterior and posterior hemisphere of the left brain (p<0.01).
CONCLUSIONS
This results suggest that cervical sympathetic chain block can increase the degree of mannitol-induced blood-brain barrier disruption via neural arch or blood flow change.

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