A Case Report of Brachial Plexus Palsy after Laparascopy Assisted Vaginal Hysterectomy / 대한마취과학회지

Trendelenburg position has been used for the low abdominal and pelvic surgery or for the management of the hypotensive patients. But, various adverse effects can also occur in steep Trendelenburg position, of which brachial plexus injury has been known as the most common nerve injury during this position under the general anesthesia especiaUy when the shoulder braces are used. We experienced a case of brachial plexus palsy in a 53 year old woman who had a laparas-copy assisted vaginal hysterectomy(LAVH) under the general anesthesia for myoma uteri for four and a half hours. During the operation she was in a 30 degree-tilting Trendelenburg and combined lithotomy position with her arms tucked at her side with drawsheet and shoulder braces were placed over the acromioclavicular joints bilaterally. In the morning of the postoperative 1st day, she complained the right shouder pain and the right arm tingling sensation and weakness. After needle electromyography and nerve conduction study, it was decided that she got an intraoperative brachial plexus injury mainly involving the lateral cord of the brachial plexus, resulting from the nerve compression caused by shoulder braces in Trendelenburg position. The symptoms were improved after the physical therapy and she was recommended to take more physical therapy after discharge.

The Effects of Preloading Solution on Blood Glucose Levels of Newborn Baby during Epidural Anesthesia for Cesarean Section / 대한마취과학회지

It is common for patient undergoing cesarean section under epidural anesthesia to have lower blood pressure because of not only supine hypotension syndrome but vasodilation due to sympathetic blockade. So it is necessary to give large volume of fluid before perfarming epidural anesthesia to prevent hypotension. When we use the dextrose containing fluid for that purpose, newborn baby could have a high blood glucose at delivery and low blood glucose level due to high insulin level after birth. The authors examined the blood glucose level at delivery and two hours after birth following use of 5% dextrose in lactated Ringers solution(HD group, n=24) or lactated Ringers solution (HS group, n=24) for prevention of hypotension during epidural anesthesia for cesarean section The results were as follows; I) The total amount of fluid was 789.6+/-264.2 ml in HD group and 741.1+/-253.5 ml in HS group. 2) The glucose level of mother at delivery was 300.9+/-76.3 mg/dl in HD group and 98.7+/-24.6 mg/dl in HS group and there was statistical significance(p< 0.01). 3) In HD group, the glucose level of newborn baby was 212.2+/-57.2 mg/dl at delivery and 465.+/-20.3 mg/dl at 2 hours after birth. The change of amount during 2 hours after birth was highly related to the glucose level at birth. Higher level of glucose at birth, larger amount of change during 2 hours after birth. 4) In HS group, the glucose level of newborn baby was 66.8+/-10.2 mg/dl at birth and 67.0+/-12.1 mg/dl at 2 hours after birth. There was no significant change.

A Comparative Study of Inhalation Agent and Midazolam during Tracheal Intubation Using Nondepolaring N - M Blocker for The Anesthetic Induction / 대한마취과학회지

Because of various complicatins it's a trend to use non-depolarizing N-M blocker for the intubation, but oneset of action is delayed. So inhalation anesthetics are administered by mask until the onset time of action of N-M blocker which may cause pollution in operating room and it is possible for operating room personnel to bring up serious health problems. So, we used midazolam as adjuvant to induce general anesthesia and compared it with inhalation anesthetics for cardiovascular responses. Group E was given pentothal sodium 5mg/kg and inhaled 2% enflurane, group MP given midazolam O.lmg/kg and pentothal sodium 3mg/kg, and group M given only midazolam 0.3 mg/kg. As a N-M blocker O.lmg/kg of vecuronium bromide was given to all groups for endotracheal intubation. The results were as follows. 1. There was no significant difference in blood pressure and heart rate in each group. 2. Recovery time of consciousness at the end of anesthesia was longer in groups given midazolam. 3. The ratio of the patients who became asleep after the administration of O.lmg/kg of midazolam was 20% and 100% of patients became asleep with 0.3mg/kg of midazolam.

A Case Report of Asthmatic Attack after Supraclavicular Block / 대한마취과학회지

In recent years, it has been common to use bupivacaine for prolonged operation because of its long duration of action but, besides of this benefits, we always are cautious of using bupivacaine for its possible systemic, toxicity, such as convulsion, myocardial depression. We experienced a case of asthmatic attack right after injection of 0.5% bupivacaine 125 mg for BPB(brachial plexus block) in a 26 year old male patient with chronic renal failure for the revision of a-v fistula. With the administration of aminophylline and oxygen by mask the patient was anounced about delaying operation and the symptoms were gone. Next day with local infiltration of 2% lidocaine operation was done uneventfully.

A Case Report of Acute Hepatitis after General Anesthesia with Enflurane / 대한마취과학회지

A 55 years old female was admitted for nausea, vomiting and right upper quadrant pain. On the admission physical examination revealed icteric sclera and right upper quadrant tenderness. She had no history of surgery and alcoholic intake. The levels of bilirubin and liver enzyme(ALT, AST) were elevated without evidence of viral hepatitis. After abdominal sonography, CT and ERCP, diagnosis was cholelithiasis. The laparoscopic cholecystectomy was done under enflurane anesthesia for 90 minutes without transfusion of blood and blood products. On the 9th postoperative day, she was discharged with symptomatic improvement and almost normal laboratory data. On the 20th postoperative day, she was admitted for follow up study and elevated liver enzyme were found. On the 30th postoperative day, she had suffered from acute hepatitis with symptoms of nausea, vomiting, chilling and jaundice and marked elevation of ALT, AST and eosinophilia. There were no evidence of viral hepatitis and remnant stone. The liver function was more aggravated and more advanced parenchymal damage of liver was shown by liver scan and sonography but liver function was improved gradually after 55th postoperative day. She recovered gradually and went home in good health on the 105th postoperative day. Postoperative hepatotoxicity might be developed as a result of many causes and we had suspected enflurane but the exact causes in this case were still unknown.

Comparison of Epidural Buprenorphine and Morphine for Postoperative Pain Management in Gynecologic Lower Abdominal Surgery / 대한마취과학회지

In a double-blind randomized study of five groups of fifty patients scheduled for gynecologic lower abdominal surgery the analgesic efficacy and side effects of epidurai buprenorphine were tested and compared to epidural morphine. Single epidural injeetion of 0.15mg of buprenorphine in group B 0.15, 0.30 mg of buprenorphine in group B D.3, 0.45 mg of buprenorphine in group B 0.45, 3 mg of morphine in group M 3 or 6 mg of morphine in group M 6 mixed with 10 ml of normal saline was done when the patients complained of postoperative pain after general anesthesia with enflurane-N2O-O2. The results were as follows; 1) The onset of analgesia was the most rapid in group B 0.45(20.7+/-3.2 minutes), and appeared as following order: group M 6(29.3+/-14.3 minutes), group M 3(37.5+/-6.7 minutes), group B 0.3(39.3+/-8.7 minutes), and group B 0.15(60.7+/-20.2 minutes). 2) Additional requirement of analgesics during first 24 hours after epidural injection was more frequent in group B O.IS(70%) than in any other four groups. 3) The lowest pain score during 24 hours after epidural injection was the lowest in group M 6(1.6+/-0.5) and group B 0.45(1.8+/-0.4) and the increasing order of the lowest pain score were as follows; 2.2+/-0.4 in group M 3, 2.3+/-0.5 in group B 0.3 and 2.6+/-0.5 in group B 0.15. 4) The pain score measured 24 hours after epidural injection was significantly lower in group B 0.45(2.0+/-0.0) than in any other four groups. 5) Subjective rating of well-being for first 24 hours following epidural injection was better in group B 0.45(good in 60% of patients) than in group M 6(good in 10% of patients). 6) Subjective rating of sleep at the first postoperative night showed no significant differences among five groups. 7) Disturbance of micturition after removal of catheter was noted in group B 0.45 and group M 6(30% each) and spontaneous urination after removal of catheter was significantly delayed in group B 0.45(9.1+/-10.2 hours) and in group M 6(7.2+/-7.8 hours) comparing to other three groups. 8) Pruritus was noted only in the groups with epidural morphine(in group M 3 & M 6; 70% each) and there was no statistieal difference between group M 3 and group M 6. 9) The frequency of nausea or vomiting was the lowest in group B 0.45(30%) and the highest in group M 3(90%), and no significant differences were noted among other three groups. 10) Dizziness was noted in group B 0.45 and in group M 6(30% each), but there was no statistical significances among five groups. I I) No signs of respiratory depression were noted.

A Comparison Study on the Effects of the Variable Combination of Drugs Through Thoracic Epidural Catheter with General Anesthesia / 대한마취과학회지

Comparing with the simple general anesthesia, the combined thoracic epidural and general anesthesia generally provide with more improved regional endocardial perfusion, reduced myocardial oxygen consumption, eventually reduced postoperative morbidity and mortality. Patients undergoing thoracotomy have severe pain and related cardio-respiratory impairment postoperatively, so large amount of the analgesics are usually administered systemically. Recently, the method using epidural injection of the local anesthetics and/or analgesics is prefered during and after the operation because of its excellent analgesic action and advantage of lowering the need for anesthetics and systemic analgesics but has remaining problems such as eardiopulmonary and CNS depression and reduced motor function and so on. So, in an attempt to reduce the untoward effects of epidural injection, we planned to evaluate the validity of the mixing local anesthetic, bupivacaine, and narcotic analgesic, fentanyl, in a given concentration and infusion rate and randomized 70 patients undergoing thoracotomy into 4 groups. Group A(n=20): Intermittent intramuscular injection of nalbuphine hydrochloride in a dose of 0.2 mg/kg Group B(n=15): Continuous epidural infusion of fentanyl citrate, 2-5 ml/hr of 5 mcg/ml solution Group C(n=15): Continuous epidural infusion of bupivacaine hydrochloride, 2-5 ml/hr of 0.15% solution Group D(n=20): Continuous epidural infusion of mixtures of fentanyl and bupivacaine, 2-5 ml/hr of same concentrations We observed the visual analogue pain scale perioperatively and measured the hemodynamic parameters such as cardiac output, cardiac index, systemic vascular resistance, stroke volume, mean arterial pressure and heart rate. The results were as follows: I) The postoperative analgesic outcome was best in group D as compared with other groups. 2) The cardiac output decreased postoperatively in group A, B and C while group D showed an increase but there was no statistical significance. 3) The cardiac index decreased significantly in group B and sbowed a trend of decreasing in group C, increasing in group D, and no change in group A. 4) The stroke volume decreased postoperatively in group A and B but the significance was only in group A. 5) The systemic vascular resistance showed significant postoperative increase in group B. 6) The mean arterial pressure decreased in group D and increased in other groups. 7) The heart rate increased during and immediate after the operation in group B.

Clinical Survey of Anesthetic Experiences with Geriatric Patients / 대한마취과학회지

To evaluate geriatric anesthetic experiences, the clinical record of 970 cases out of total 13,324 anesthetic cases perfomed at Korea university Anam hospital from January 1991 to December 1992 were reviewed according to age, sex, department, operation site, preoperative physical status, preoperative chest X-ray findings, preoperative electmcardiography readings, preoperative pulmonary function test, preoperative concurrent disease, type of anesthesia, duration of operation, intraoperative event, postoperative complication, and mortality. The result were as follows; 1) The number of the cases older than age 65 years was 970 accounting for 7.3% of 13,324 anesthetic cases from the year 1991 to 1992. 2) There were 566 (58.4%) males and 404 (41.6%) females. 3) There were 417 (43.0%) cases between the age of 65 and 69; 323 (33.3%) between the age of 70 and 74; 133 (13.7%) between the age of 75 and 79; 73 (7.6%) between the age of 80 and 84; 15 (1.5%) between the age of 85 and 89; 7 (0.7%) between the age of 90 and 94; 1 (0.1%) between the age of 95 and 100; 1 (0.1%) cases was 103 years of age. 4) In preoperative physical status according to the calssification of American Society of Anesthesiologist, 34 (3.5%) cases were class I, 471 (48.9%) class II, 465 (48.6%) class III, and 10 (1.0%) calss IV. 5) Emergency operation was performed in 107 (11.0%) cases. 6) There were 365 (37.6%) general surgery, 156 (16.1%) orthopedic surgery, 153 (15.8%) genitourinary surgery, 101 (10.4%) otolaryngologic surgery, 66 (6.8%) neurosurgery, 59 (6.1%) chest surgery, 40 (4.1%) gynecologic surgery, and etc. 7) The most frequent operation site was upper abdominal region in 242 cases (24.9%) and lower abdominal region in 184 (19,0%), upper and lower extremities in 165 (17.0%), head and neck in 126 (12.9%) and so on. 8) The findings of preoperative chest X-ray revealed that 502 (51.7%) cases were within normal limits. The most frequent abnormal finding was hypertensive heart changes in 128 (13.2 %). Another findings were arteriosclerotic changes in 72 (7.4%), inactive pulmonary tuberculosis in 37 (3.8%), emphysematous changes in 34 (3.5%), bronchiectasis in 19 (2.0%) and so on. 9) The preoperative electrocardiographic findings revealed that 452 (46.6%) cases were within normal limits. The abnormal findings were as follows ; left ventricular hypertrophy in 113 (11.6%), sinus bradycardia in 67 (6.9%), myocardial infarction in 45 (4.6%), myocardial ischemia in 32 (3.3%), and so on. 10) Preoperative pulmonary function test was performed in 702 (72.6%) cases. Two hundred sixity five cases (37.5%) showed abnormal results consisting of obstructive type in 34.7%, restrictive type in 24.9%, mixed type in 21.5%, and small air way disease in 18.9%. 11) Three hundred sixty one (37.3%) of the total cases had preoperative concurrent illness consisting of hypertension in 158 (16.3%), chronic obstructive pulmonary diseases in 66 (6.8%), myocardial infarction in 37 (3.8%), myocardial ischemia in 34 (3.5%), diabetes mellitus in 32 (3.3%), and so on. 12) The type of anesthesia used in these case were 678 (69.9%) general anesthesia, 96 (9.9%) spinal anesthesia, 84 (8.7%) combined anesthesia, 82 (8.4%) epidural anesthesia, and 30 (3.1%) brachial plexus block. 13) The duration of operation was 1~2 hours in 329 (33,9%) cases, 2~3 hours in 267 (27.5%), 3~4 hours in 126 (13.0%), and so on. 14) The most frequent intraoperative envent was hypertension in 155 (16.0%) cases. And hypotension in 72 (7.4%), premature ventricular contraction in 12 (1.2%), ohguria in 9 (0.9%), bradycardia in 8 (0.8%), myocardial ischemia in 8 (0.8%), myocardial ischemia in 7 (0.7%), and hyperglycemia in 7 (0.7%) were noted, 15) One hundred six cases (10.9%) were sent to intensive care unit for postoperative care. 16) The most frequent postoperative complication was hypertension in 154 (15.9%) cases. Hypotension in 21 (2.2%), myocardial ischemia in 13 (1.3%) and etc, were noted. 17) Overall mortality rate was 1.2%. The mortality rate was 0.2% in elective cases, and 9.3% in emergency ones.

A Case Report of Anesthesia for Subtotal Pancreatectomy in a Patient with Nesidioblastosis / 대한마취과학회지

Nesidioblastosis is a rare disease characterized clinically by persistent hypoglycemia with inappropriately elevated circulating insulin concentration. Adequate early diagnosis should be established and subtotal pancreatectomy performed before itreversible cerebral damage caused by glucose deficit. The authors got a chance to anesthetize 56-day-old male patient for subtotal pancreatectomy because of nesidioblastosis, Following an induction of anesthesia with intravenous thiapental sodium 5 mg/kg and succinylchohne 1 mg/kg, endotracheal intubation was performed and anesthesia was maintained with pancuronium bromide and O2-N2O-enflurane. Intravenous fluid was maintained with 1-2-3 solution 30 ml and 15% D/W 40 ml mixed with 20 ml of 20 mEq/L NaCI.