Endometriosis, defined as growth of endometrial stroma and glands outside the uterine cavity, is a chronic and recurrent disease that affects patients' quality of life. Ectopic endometrial tissue can proliferate at any location in the body, but the pelvic organs and peritoneum are the most frequent implantation sites. Among extrapelvic endometriosis, inguinal endometriosis is a very rare gynecologic condition usually associated with previous pelvic surgery. Endometriosis should be preoperatively distinguished from other inguinal masses using computed tomography, magnetic resonance imaging, or ultrasonography. Here, we report a case of right inguinal endometriosis in a patient with no previous history of gynecologic surgery; in addition, we have provided a brief review of relevant literature. Keywords: Endometriosis; Inguinal; Round ligament; Ultrasonography
Thyroid storm is characterized by rapidly increased circulation of T3, T4, or both with worsened hyperthyroidism, hyperthermia, tachycardia, and hypertension. Although many case reports have been presented on thyroid storm, which occurs during surgery [1], case reports on thyroid storm that occurs prior to the induction of anesthesia are rare [2]. We present a case where a patient underwent a thyroid storm during anesthesia induction, even though she had neither a history of hyperthyroidism, nor abnormal findings in the preoperative evaluation.
A 50 year-old female patient (height 156 cm, weight 59 kg) was diagnosed with a humerus fracture, and was, therefore, admitted for an open reduction and internal fixation. The examination findings upon being admitted were normal. Preoperative electrocardiogram showed tachycardia with a heart rate of 90-100 beats/min. Her past history showed no diagnosis of hypertension, diabetes mellitus, or thyroid disease. However, the patient had experienced 6 kg weight loss, intermittent palpitation, and hand tremors for the past 1 year. There were no abnormal laboratory findings. The patient had no history of past surgeries or experience with anesthesia.
Upon arriving on the operating table, her blood pressure was 125/85 mmHg, body temperature was 36.5℃ and her heart rate was about 90-100 beats/min. She did not complain of anxiety or discomfort. The patient did not receive premedication in the ward. While performing ECG and pulse oximetry monitoring, glycopyrrolate 0.2 mg was intravenously administered before general anesthesia induction. After injection of glycopyrrolate, her blood pressure increased from 120/80 mmHg to 200-220/110 mmHg, her heart rate also elevated from 100 beats/min to 170-190 beats/min, and a severe diaphoresis was observed. Respiration also weakened, and the patient was losing consciousness. Therefore, 100% oxygen was administered and assisted ventilation was performed, followed by an endotracheal intubation without muscle relaxants. Her body temperature increased to 39℃. At first, we suspected malignant hyperthermia. To reduce body temperature, ice packs were applied on the neck, axillar, and groin sites, and cooled lactated Ringer's solution was infused. Esmolol and labetalol were, intravenously, administered to reduce high blood pressure. In the pulse oxymetry, oxygen saturation was maintained at 97-100%. The end-tidal carbon dioxide level was maintained at around 40 mmHg. Physical examination showed no findings of muscle rigidity, including in the masseter muscle. We finally made an impression of the thyroid storm. After a 40 minute adjustment of blood pressure and heart rate, with labetalol and esmolol, the patient's consciousness returned and blood pressure was stable at 110-130/80-90 mmHg. The patient's body temperature stabilized at around 37.5℃.
The surgery was postponed. A thyroid hormone test showed TSH 6.64 ng/ml (normal: 0.60-1.81 ng/ml), and free T4 5.48 ng/dl (normal: 0.83-1.76 ng/dl). Anti-thyroid antibodies, thyroglobulin in Ab, were 1,116 IU/ml (normal < 115 IU/ml). These patterns corresponded to a thyroid storm. Anti-thyroid antibodies were positive and Graves' disease was confirmed with a thyroid function test. Thus, antithyroid drug, methimazole was administered to the patient. Euthyroid state was achieved and the patient received operation for humerus fracture after 1 month later.
In the past, thyroid surgery was the most common cause of thyroid storm and when a thyroid storm occurs with surgery, it commonly occurs 6-18 hr post-surgery [3,4]. However, recent preoperative medication creates a euthyroid state before performing surgery, although its occurrence is low [3]. The clinical sign of the thyroid storm, due to the abrupt release of T4 and T3 into the circulation. In this case, T3 and T4 levels abruptly increased. When surgery is performed, without the awareness of the patient having hyperthyroidism, the likelihood of a thyroid storm occurrence increases. To reduce the occurrence of thyroid storm, adequate premedication is needed, when performing anesthesia. Barbiturates or benzodiazepines should be administered to adequately sedate the patient. Anticholinergic drugs, especially atropine, are usually not administered because atropine deter the normal heat control mechanism and cause tachycardia.
In this case, the electrocardiogram from 6 months prior showed a heart rate of 70-80 beats/min, and in the tests after the patient was admitted into the hospital, the blood pressure was normal, the body temperature was 36.5℃, and the electrolytes test and blood test appeared normal. Therefore, the surgery was expected to be uneventful. However, the preoperative electrocardiogram showed tachycardia of 90-100 beats/min. Although the patient had no past history of a thyroid disease, it was confirmed that in the past 1 year, the patient had experienced a 6 kg weight loss, intermittent palpitation, and hand tremors. Therefore, although hyperthyroidism was not diagnosed, if there had been more appropriate history-taking, hyperthyroidism could have been suspected.
There has not been a case report of considering glycopyrrolate, as an etiologic factor of thyroid storm. Psychological stress, among many other initiating factors, is considered to have another significant role in causing the thyroid storm. Even though the patient's heart rate was 90-100 beats/min on the operating table, the administration of glycopyrrolate, without premedication in the general ward, was not appropriate because it is an anticholinergic drug, which further increases the heart rate by stimulating the sympathetic nervous system. In conclusion, if abnormal findings, such as tachycardia, weight loss, and tremors are found, or if hyperthyroidism is suspected even though a patient does not have a history of hyperthyroidism, a preoperative thyroid function test should be performed. Also, an anesthesiologist should consider potential thyroid storm, due to intravenous glycopyrrolate administration in patient with hyperthyroidism or hyperthyroidism like symptoms.
Halothane, isoflurane and desflurane are metabolized to hepatotoxic trifluoroacetyl proteins.But sevoflurane is metabolized to hexafluoroisopropanol.Hexafluoroisopropanol has a low binding affinity for liver protein and is therefore rapidly converted to glucuronidate that are excreted in the urine.Thus sevoflurane has been considered to have a very low potential for hepatotoxicity.We report a case of a 67 years old woman who developed acute hepatic dysfunction after sevoflurane anesthesia.(
Background: Milrinone, phosphodiesterase III inhibitor, has been used effectively in patients with right heart failure, especially resulted from pulmonary hypertension.However, milrinone is often used with α-and β-adrenergic receptor agonist to prevent severe systemic vasodilation and unfavorable hypotension.Furthermore, structural and functional vasacular changes are associated with aging and are greatest in the aorta.We evaluated the vasodilatory effects of milrinone and sodium nitroprusside (SNP) on young and old rat aortic rings preconstricted with various catecholamines.Methods: Aortic rings of young and old rat were placed in 25 ml organ chamber and preconstricted with epinephrine (EPI, 10 -6 M), norepinephrine (NE, 10 -7 M) , phenylephrine 10 -7 M) , and U46619 (10 -8 M).Cummulative dose-responses to milrinone (10 -9 -10 -5 M) and SNP (10 -9-10 -5 M) were obtained to characterize vasodilatory effects.Results: Relaxation response to milrinone was markedly enhanced in both young and old aortic rings preconstricted with U46619 compared with other vasoconstrictors.The maximal response of the young rat aortic rings preconstricted with NE is significantly reduced, compared with that of EPI.The maximal vasorelaxant response of SNP in young and old aortic rings are nearly identical.Conclusions: We conclude that combined use of milrinone and epinephrine may be more useful in prevention and treatment of systemic hypotension.(Korean J Anesthesiol 2009; 57: 615∼21)
A new gerbera cultivar known as ‘Red Velvet’ was bred by the National Institute of Horticultural & Herbal Science in 2015. The scarlet-flowered cultivar ‘Rose’ with a semi-double flower type and green center and the red-flowered cultivar ‘Sabana’ with a semi-double flower type and dark center were crossed from October 2007 to February 2008. Among 187 offspring from this cross, ‘Red Velvet’ was selected, especially for cut flower production after investigating the phenotypic characteristics for eight years (2008–2015). ‘Red Velvet’ is a vigorous standard gerbera cultivar with brilliant red flowers (RHS R45B) and brown center disc florets; it is a semi-double flower type. Its average flower diameter is 12.6 ± 0.5 cm, and its inner ray floret and disc floret diameters are 5.7 ± 0.3 cm and 2.8 ± 0.2 cm, respectively. It has a thick peduncle width, with upper and lower parts being 5.4 ± 0.4 mm and 7.8 ± 0.7 mm, respectively; its long peduncle height is 60.0 ± 8.1 cm. The vase life of ‘Red Velvet’ is 9.8 ± 2.3 days, similar to the standard cultivar. It is a high-yielding cultivar, with an average yield of 48.3 ± 4.8 stems per plant.
Systemic injection of peptidoglycan (PGN) special polymers, which are the primary structural components of most bacterial cell walls, leads to acute inflammation and pain behavior. This study was conducted to confirm that an intraplantar injection of PGN evoked hindpaw inflammation and hyperalgesia, and to evaluate the effects of bee venom (BV) pretreatment of an acupoint on PGN induced inflammation and hyperalgesia.Inflammation and hyperalgesia were induced by injecting PGN into the plantar surface of one hindpaw of the rats. Inflammation and hyperalgesia were then evaluated by measuring the thickness of the hindpaw using a caliper and the paw withdrawal time (PWT) in response to noxious thermal stimulus (48degrees C hot water). In addition, spinal cord c-fos expression was quantitatively analyzed. The BV pretreatment was injected at the acupoint located 5 mm lower and 5 mm lateral to the anterior tubercle of the tibia in the hind limb.The PGN groups showed increased in paw thickness and spinal c-fos expression two hours after PGN injection, as well as decreased PWT in response to noxious thermal stimulus for each tested time. BV pretreatment of the acupoint was found to inhibit hindpaw thickness and led to a significant increase in PWT, but did not significantly inhibit spinal cord c-fos expression induced by PGN injection.These results indicated that BV pretreatment has both an anti-inflammatory and antinociceptive effect in PGN induced inflammatory pain, which suggests that peptidoglycan may be useful as an inflammatory agent for inflammatory pain models.
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