Analysis of Cause for Cancellation of Elective Operation / 대한마취과학회지

BACKGROUND: Cancellations of elective operations are due to various reasons, which can be categorized into those initiated by patients or their guardians and those initiated by hospital staff. Cancellations of elective operations result not only in time and economic loss but also in negative psychological effects for patients and guardians and operational inefficiency for hospitals among other problems. As such, by studying and analyzing the causes of such cancellations, one may categorize them into involuntary ones and preventable ones, with the aim to reduce the occurrence of the latter that will lead to reduction in cancellation of elective operations. METHODS: 11,082 cases of elective operation were reviewed and analyzed retrospectively from January 2002 to December 2006. Total number, department, anesthetic type and cause of cancellation were recorded daily. Emergency operation and operation under local anesthesia were excluded. RESULTS: Total number of cancellation was 762 cases and mean cancellation rate was 6.9%. The most common cause of cancellation was co-existing disease or abnormal laboratory finding (25.3%). Especially in urology the most common cause of cancellation was the relief from diseases or symptoms. Plastic surgery showed the highest cancellation rate among all at 12%. CONCLUSIONS: Setting up standards that help determine the driving factors behind cancellations of elective operations within anesthesiology departments and utilizing a patient evaluation system, after categorizing the causes of cancellations into involuntary and preventable ones and analyzing them, will lead to reduction in cancellation of operations and solve problems faced by patients and guardians, and hospitals and their staff.

Changes of Serum ADH Level during Matoidectomy under General Anesthesia / 대한마취과학회지

BACKGROUND: Markedly reduced urine have been commonly observed during mastoidectomy under general anesthesia. The aim of study was to evaluate the surgery-related mechanism of reduced urine during mastoidectomy. METHODS: 11 patients undergoing mastoidectomy were studied. Blood samples were drawn from CVP line inserted through right internal jugular vein just before drilling (Pre-D); at 15 min after drilling (D-15); at the time closest to the inner ear (CHP-1); at 15 min (CHP-2) and 30 min (CHP-3) after CHP-1 and just before emergence (End). MAP, HR, temperature, CVP, and urine output (UO) were recorded at each period. 0.9% normal saline with room temperature was used to irrigate surgical field. Serum ADH, and the osmolalities (serum and urine) were measured. In 6 patients, serum TSH and FSH were measured, simultaneously. RESULTS: There were no significant hemodynamic changes during procedure. UO was decreased in 50% during and after the drilling. No differences showed in UO between before and after the drilling of CHP. Plasma ADH level after the CHP was increased 2-3 fold than before. Serum osmolality was unchanged throughout the periods, while the urine osmolality was significantly increased after the period of CHP. FSH was not changed during the periods and TSH was decreased slightly than in Pre-D. CONCLUSIONS: The reduced urine output during mastoidectomy may be influenced by the drilling-related vibration, which may affect the supraoptico-hypophyseal tract, resulting in ADH release. The irrigated isotonic saline with higher osmolality (308 mOsm/kgH2O) than plasma osmolality may partly contributed to the increased ADH.

Cardiac Arrest after Complete Intratracheal Obstruction by an Aspirated Blood Clot in a Patient with Upper G-I Bleeding: A case report / 대한마취과학회지

Fatal airway obstruction due to the presence of blood clot occurs in a variety of clinical settings. Initial efforts to remove an airway clot, if warranted, involve suctioning, lavage, and forceps extraction through a flexible bronchoscope. If unsuccessful, further management options include rigid bronchoscopy, balloon-tip embolectomy catheter dislodgement, and the application of topical thrombolytic agents. We report a case of complete airway obstruction that developed after the aspiration of a blood clot during emergency operative vessel ligation in a 86-year-old female patient with gastric ulcer bleeding. Initial conventional suctioning was unsuccessful, in this case, due to a large firmly adherent clot. Therefore we peformed the alternative suctioning technique using suction attached directly to the existing tracheal tube in situ, with the cuff deflated. However, repeated direct tracheal suctioning alone failed to prevent cardiac arrest. Thereafter, simultaneously with several CPR chest compressions, large cylindrical clots were sucked up by direct tracheal suctioning. Presumably simultaneous chest compression has the potential advantage of creating higher airway pressures that provide effective kinetic energy to obstructing object.

Bronchospasm Caused by N-Acetylcysteine Intratracheal Instillation in a Patient with Bronchial Asthma: A Case Report / 대한마취과학회지

We report of a successfully treated case of fatal bronchospasm, which developed after N-acetylcysteine bolus intratracheal instillation in a 49-year-old female patient with bronchial asthma undergoing laparoscopic cholecystectomy. N-acetylcysteine has been widely used as a potent mucolytic agent since 1963, with few reported adverse reactions. Its mucolytic action is due to the breakage of disulfide bonds in mucus mucoproteins. Most adverse reactions to N-acetylcysteine are usually mild and respond to the termination of the medication and symptomatic treatment with antihistamine. However, several cases of fatal bronchospasm have been reported in asthmatic patients after inhaled or intravenous N-acetylcysteine. N-acetylcysteine induced bronchospasm could be avoided in most asthmatic patients if its concentration is not allowed to exceed 10%, and concomitant beta2-selective bronchodilators are utilized. Nevertheless, asthma is still a potent risk factor and requires special precautions, including careful risk-versus-benefit assessment, close observation and the immediate availability of resuscitation equipment and staff in the event of life-threatening bronchospasm.

Comparison of Epidural Anlagesia with Morphine-Bupivacaine Versus Fentanyl-Bupivacaine after Cesarean Section / 대한마취과학회지

Background: This study was aimed to compare the analgesic effect and side effects of morphine- bupivacaine mixture with those of fentanyl-bupivacaine mixture after Cesarean section. Methods: Eighty patients who were taken continuous epidural catheterization after Cesarean section were divided into two groups. In group 1 (N=40) the mixture of 1% lidocaine 10 ml and morphine 1mg was firstly injected via epidural catheter, and then two day infusor (Baxter(R)) which contained the mixture of 0.15% bupivacaine 100 ml and morphine 6mg was connected to epidural catheter. In group 2 (N=40) the mixture of 1% lidocaine 10 ml and fentanyl 100 mcg was firstly injected via epidural catheter, and then two day infusor (Baxter(R)) which contained the mixture of 0.15% bupivacaine 100 ml and fentanyl 850 mcg was connected to epidural catheter. Mean arterial pressure (MAP) and heart rate (HR) were checked preoperatively, and at post-injection 10, 20, 30 and 60 minutes. The visual analogue scale (VAS) was checked at postoperative 1/2, 1, 6, 12, 24 and 48 hours. The side effects of epidural analgesia were evaluated. Results: In group 2 MAP was significantly decreased at post-injection 20 minute. VAS was significantly increased at post-injection 1/2 and 1 hour in group 1. The most frequent side effect was pruritus in both groups. Conclusions: The first bolus injection of the mixture of 1% lidocaine 10 ml and fentanyl 100 mcg has more rapid analgegic effect than the mixture of 1% lidocaine 10 ml and morphine 2 mg, but because of shorter duration of action of fentanyl it seems to be better to increase the dosage of fentanyl or replace fentanyl by morphine for more effective epidural analgesia after Cesarean section.

Total Intravenous Anesthesia with Fentanyl and Propofol / 대한마취과학회지

BACKGROUND: Total intravenous anesthesia(TIVA) with various kinds of sedatives and synthetic analgesics has many advantages such as no air pollution, no hepatic or renal toxicity and good postoperative pain relief compared with inhalation anesthesia. METHODS: TIVA with fentanyl and propofol was applied to the 25 patients in ASA class I and II. The changes of hemodynamics, arterial blood gas, blood sugar level, hepatorenal function and complications were evaluated perioperatively. RESULTS: Systolic blood pressure and mean arterial pressure decreased after induction, but intraoperatively systolic blood pressure became preoperative value while mean arterial pressure increased compared with preoperative value. Heart rate increased after induction and intraoperatively. At recovery room there were no clinically significant changes in the data of arterial blood gas. The blood sugar level slightly increased during postoperative period. There were no clinically significant changes in hepatic or renal function test of postoperative 3rd day compared with preoperative one. The chief complications of TIVA during anesthesia were pain on injection site and slight movement, while nausea or vomiting, dizziness and urinary retention were the major complications at postoperative period. CONCLUSIONS: TIVA with fentanyl and propofol is considered to have good controllability and it can be applied as one of the general anesthesia methods in the case of contraindications to N2O and volatile anesthetics, but further study will be required to quantify the appropriate dosage of propofol or fentanyl to minimize perioperative hemodynamic change and respiratory depression.

Total Intravenous Anesthesia with Propofol and Fentanyl / 대한마취과학회지

Total intravenous anesthesia(TIVA) with ketamine and fentanyl has many advantages such as no air pollution, no hepatic or renal toxicity and good postoperative pain relief compared with inhalational anesthesia, but this anesthetic method also has several disadvantages such as hypertension, delayed recovery and emergence delirium. For improvement of this problems, the authors tried new TIVA method with propofol and fentanyl to the 20 patients in ASA class I or II and compared this method with 20 patients in ASA class I or II who had been anesthetized with enflurane-N2O from March to May 1992. The results were as follows; 1) Systolic blood pressure decreased after induction from 127+/-12mmHg to 105+/-17mmHg in propofol-fentanyl group(p<0.05) and mean arterial pressure decreased after induction from 93 9 mmHg to 799 mmHg in propofol-fentanyl group and from 98+/-10 mmHg to 83+/-11 mmHg in enflurane-N2O group(p<0.05), but they became preoperative values during operation in both groups. RPP(rate-pressure product) and heart rate decreased about 28-39% after induction and during operation in propofol-fentanyl group(p<0.05) but there was no change in enflurane- N2 group. 2) The data of arterial blood gas had no clinically significant changes in both groups. 3) The blood sugar level increased during operation(p<0.05) but it became preoperative value from postoperative 30 min in both groups. 4) There were no clinically significant changes in hepatic or renal function test of postoperative 3rd day compared with preoperative one. 5) There were no postoperative complications except 2 cases of nausea in propofol-fentanyl group. 6) Emergence time and recovery time had no difference in both groups but the duration from arrival on recovery room to postanesthetic recovery score of 10 was shorter in propofol- fentanyl group(7.5+/-7.3 min) than in enflurane-N2O group(16.7+/-l0.3 min)(p<0.05). Therefore TIVA with propofol and fentanyl is considered to have good controllability nearly equal to enflurane-N2O anesthesia and it can be applied as one of general anesthetic methods in the case of contraindication to N2O and volatile anesthetics, but futher study will be required to quantify the appropriate dosage of propofol or fentanyl to minimize perioperative hemodynamic changes and respiratory depression.

Clinical Analysis of Anesthesia for Emergency Operation / 대한마취과학회지

We analyzed 1468 cases of anesthesia for emergency operation which were performed at the department of anesthesiology, Yongsan hospital from January 199l to December 1992. The patients were evaluated according to clinical department, age, sex, disease, ASA classification of physical status, day month, beginning time of operation, anesthetic method, duration of operation or anesthesia, perioperative patient care, past history of operation, operator and insurance. The results were as follows; 1) The percentage of anesthesia for emergency operation was 17.8 % of total anesthetic cases. 2) The departmental distribution was general surgery(47.3%), obstetrics and gynecology(19.0%), neurosurgery(14.6%) and orthopedic surgery(l1.2%). The greatest number of patients was found in the 20-29 years of age consisting of 30.9% of the patients. The male patients comprised of 51.6% while the female patients comprised of 48.4 % of the patients. 3) Most common diseases were appendicitis(57.8%) in general surgery, Cesarean section(50.2%) and ectopic pregnancy(30.8%) in obstetrics and gynecology, ICH(38.3%), EDH(20.1%) and SDH(20.l%) in neurosurgery, tendon rupture(11.0%) and tibia frature(9.8%) in orthopedic surgery. 4) The majority of patients were classified as ASA 2E comprising of 58.6% of the patients. 5) The greatest number of emergency operations was performed on Saturday(16.8%) and in August(10.3%). 6) 45% of emergency operations was performed during 12-18 oclock. 7) The anesthetic methods for emergency operation were inhalational anesthesia(94.3%), regional anesthesia(4.6%) and intravenous anesthesia(l.1%). 8) The percentage of duration of anesthesia and operation which was less than one hour was 70.1% and 77.7%, respectively. 9) 81.1% of patients who underwent the emergency operation was cared in the emergency room preoperatively, and 78.3% of operated patients was transferred to ward. 10) Concerning the past operation history 66.3% of patients never had the operation history, and 26.0% of them underwent operation once, 11) 84.6% of emergency operations was performed by staff doctors, arid 15.4% of them was performed by residents. 12) Concerning the classification of insurance the percentage of medical insurance was 83.4%, and 10.1% of the patients didnt reeeive favors of any type of insurance. Conclusively, in proportion as patients for emergency operation are incresing, the importance of anesthetic management for them is being emphasued. Therefore anesthesiologists have to focus on perioperative anesthetic management and postoperative care in recovery room and ICU to decrease the incidence of complications, morbidity and mortality of emergency operation.

Study for Emergency Patients Transportation System in Korea / 대한마취과학회지

The pre-and interhospital transportation of emergency patients has growing during the recent years to be al full-fledged component of medical practice. With this grow has arisen a need for discussion of the emergency patients transportation system required to carry out the transportation in Korea. All patients to transferred by transportation system have a common feature: the need during transportation for high-level intensive care and monitoring by specialized medical teams and equipments. This article reviewed the emergency medical service system of France (SAMU), West Germany and Japan, we proposed the following preliminary guidelines for emergency patients transportation system in Korea. 1) Emergency medical service system 2) Emergency medical hospitals 3) Emergency service area 4) Emergency transportation vehicles (ambulance, helicopter) 5) Communication system 6) 119 ambulance service system 7) Education and training of the emergency medical persons 8) Care for mass accidents.

Effect of Leukotriene C4 on Glandular Kallikrein Activity in Bronchial Wash of Guinea Pig / 대한마취과학회지

The involvement of plasma kallikrein-kinin system in some pathological states such as bronchial asthma and coughing induced by captopril has been suggested, LTC, and LTD, have been well reported to have a potent activity of bronchoconstriction and mucous secretion. The author tried to confirm whether leukotrienes increase glandular kallikrein activity in bronchial wash or not, and if it is true, to investigate the possible mechanism of leukotrienes-induced increase of glandular kallikrein activity. Bronchial wash was collected from excised lungs of guinea pig, and incubated with synthetic substrate (Pro-Phe-Arg-MCA), and released amount of AMC was measured by fluorescence spectrophotometer as the amidase activity (glandular kallikrein activity). In order to confirm that glandular kallikrein can release kinin, bronchial wash was also incubated with purified LMW- kininogen in the presence of kininase inhibitor (o-phenanthroline), and the amount of kinin was measured by enzyme immunoassay as the kinin releasing activity of glandular kallikrein. The results were as follows: 1) The glandular kallikrein activity (control: 2.98 x 10(-11) mole/min/ml wash) was increased by pilocarpine (12-120 umole/kg, i.v.), and the increased glandular kallikrein activity by pilocarpine (41 nmole/kg, i.v.) was inhibited by atropine (4-43 nmole/kg, i.v.). 2) LTC(4) (1-10 nmole/kg, i.v.) or LTD(4) (1-10 nmole/kg, i.v.) increased the glandular kallikrein activity, but the potency of LTD, was about 1/3 of that of LTC,. The increased glandular kallikrein activity by LTC, (3 nmole/kg, i.v.) was inhibited by ONO-1078 (20-203 nmole/kg, i.p.). 3) The increased glandular kallikrein activity by LTC, (3nmole/kg, i.v.) was inhibited by in- domethacin (8-83 nmole/kg, i.p.), OKY-046 (11-113 nmole/kg, i.v.), atropine (4-43 nmole/kg, i.v.), scopolamine (9-88 umole/kg, i.v.) and Thi-D-Phe-BK (100-1000 nmole/kg, i.v.). 4) STA, (6-60pmole/kg, i.v.) increased the glandular kallikrein activity, and the increased glandular kallikrein activity by STA, (20 pmole/kg, i.v.) was inhibited by atropine (14 umole/kg, i.v.) (p < 0. 001). 5) The increased glandular kallikrein activity by pilocarpine (41 urnole/kg, i.v.) was not inhibited by indomethacin (83 umole/kg, i.p.), but it was inhibited by Thi-D-Phe-BK (300 nmole/kg, i.v.) (p< 0. 001). 6) Bradykinin (3-30 nmole/kg, i.v.) increased the glandular kallikrein activity, and the increased glandular kallikrein activity by bradykinin (30 nmole/kg, i.v.) was inhibited by indomethacin (83 umole/kg, i.p.) or atropine (14 umole/kg, i.v.) (p<0.001). 7) The kinin releasing activity by glandular kallikrein in bronchial wash was 24 x 10 " mole/min/ ml wash in control group, and it was markedly increased in pilocarpine-pretreated group (124 x 10 mole/min/ml wash) (p<0.05), and in LTC4-pretreated group (164x10 mole/min/ml wash) (p<0. 01). The increased kinin releasing activity by LTC, (3 nmole/kg, i.v.) was completely inhibited by aprotinin (5000IU/ml, i.v.). I could conclude that i ) LTC, and LTD, increased glandular kallikrein activity in bronchial wash of guinea pig, ii) the most possible mechanism of LTC,-induced increase of glandular kallikrein activity in bronchial wash may be as follows; LTC,TXA,aeetyleholineinerease of glandular kallikrein acitivity, and iii) kinin released by glandular kallikrein may enhance the action of TXA, or acetylcholine to increase the glandular kallikrein activity.

Anethetic Management of Diabetic Patient / 대한마취과학회지

No abstract available.

The Effects of Atropine and Neostigmine on Heart Rate / 대한마취과학회지

To confirm the effects of atropine and neostigmine on heart rate in balanced anesthesia with tramadol (Tridol) two groups of patients who were included in class I by A.S.A. classification were studied. In group I, only atropine(1.0 mg) was given to 8 patients at the end of operation. Group 2, a mixture of atropine(1. 0 mg) and neostigmine (2.0 mg) was given to 16 patients under the same condition as group 1. The heart rate was checked every 15 seconds for 10 minntes in each group. The results were as followes:1) In group 1, about 16% increase in heart rate was manifested at 11/4 minutes after injection. After that the was no significant change in heart rate. 2) In group 2, about 19% increase in heart rate was observed at 1 minute after injection. After that 28% decrease in heart rate was noted 6 minutes after injection. After that there was no significant change in heart rate. 3) There was no significant difference between the two groups at 1 minute after injection. 4) When a mixture of atropine and neostigmine was given, atropine effect appeared earlier than neostigmine. Therefore if a mixture of atropine and neostigmine is used, we don't need to inject it very slowly in anticipation of bradycardia.5) Even though the IV route is uncertain, neostigmine triggered bradycardia can be controlled by using it mixed with atropine. because shortly after infection of the mixture no bradycardia occurs, the operator has sufficient time to correct it should it be set in later.

The Use of Sodium Nitroprusside to Induced Hypotension during Anesthesia / 대한마취과학회지

SNP given by intravenous drip has been used to control hypertensive crisis since 1929. Its rapid action makes it suitable for controlled hypotension during general anesthesia. Experience of its use in three cases is described, which undergoing surgery for A-com aneurysm. The results are as follows: 1) The fall in MAP produced by the SNP was directly proportional to the doses of the infusion. (P<0. 01). 2) Increased doses of the SNP caused further rise in pulse rate, but not occurred tachycardia. (P<0.05). 3) The CVP by the SNP decreased consistantly. (P<0.05). 4) When SNP 4ug/kg/min was administered, 2 cases of respiratory acidoses and one case of mild metabolic acidosis were noticed. 5) No CN toxicity was seen, and recovery to normal level of blood pressure was noticed.

A Case of Massive Hemoptysis after Extracorporeal Circulation for Open Heart Surgery / 대한마취과학회지

Hemoptysis is quite common in primary pulmonary disease, including tyberculosis and carcinoma, as well as in congenital heart disease. Rescently the authors had experienced a case of massive hemoptysis soon after extracorporeal circulation during open heart surgery. The patient had been diagnosed as pulmonary tuberculosis and triology of Fallot. After surgical procedure for pulomonary stenosis and A.S.D, massive hemoptysis occurred abruptly through the endotracheal tube and B.P. took a sudden fall by 40 Torr/systolic pressure. Bleeding source was proved to be on the left upper lobe. So left upper lobetomy had to be performed to control this massive hemoptysis.

Intraluminal Partial Obstruction of Endotracheal Tube due to Cuff Ballooning / 대한마취과학회지

This is a ease report of intraluminal partial obatructian of an endotracheal tube after cuff ballooing, a complication of a malfunctioned endotracheal tube, This 18 year old female patient with herniated intervertebral disc of L4-5 was anesthetized for archotomy and removal of disc. Aneethesia was maintained with N2O-O2-halothanepancuronium after endotracheal intubation with a Murphy tube. (Porges-Latex-tube No. 7), manufactured in France. A few minutes later, airway obstruction signs such as sudden hypertension, tachycardia, resistance of the researvoir bag in inspiration, and delayed filling time of the reservoir bag in expiration appeared. We suspected kinking of the tube, tubal obstruction from secretions, bronchospasm etc, but we could not find the exact cause of airway obstruction in spite of detailed checking. After recovery of the patient from anesthesia we checked the extubated tube. There was intraluminal partial obstruction of the endotracheal tube according to increase of intracuff volume and pressure because of the thin walled, flexible tube and diffusion of N2O into the cuff. After extubation the patient returned to normal. We surmmerized this case and also reviewed with the literature.