Extracranial Carotid-Vertebral Artery Bypass Technique and Surgical Outcomes

Vertebral artery (VA) occlusion is frequently encountered, usually without acute ischemic injury of the brain. However, when it is accompanied by hypoplasia or stenosis of the opposite VA, brain ischemia may develop due to insufficient collateral supply. Both hemodynamic instability and embolic infarction can occur in VA occlusion, which may cause severe symptoms in a patient. Extracranial carotid-VA bypass should be considered for symptomatic VA occlusion patients, especially when the patient has repeated ischemic brain injuries. In this report, the cases of three extracranial carotid-VA bypass patients are introduced, along with a brief description of the surgical techniques. All three cases were treated with different bypass methods according to their disease location.

Comparison between Combined Epidural-General Anesthesia and General Anesthesia for Total Hip Replacement / 대한마취과학회지

BACKGROUND: Surgical repair of a hip fracture and a total hip replacement (THR) are mostly performed in elderly patients. The overall perioerative mortality is 0.5 to 1.0%, for which one of the common causes is pulmonary embolism during the postoperative period. A number of studies have demonstrated reduction in both perioperative blood loss and incidence of postoperative thromboembolism after a total hip replacement with spinal or epidural anesthesia. However a regional technique is often inappropriate for the patient scheduled for a THR because of the long operating time, the positioning and the manipulation required during the procedure. Even though combined epidural-general anesthesia may offer advantages for the patient undergoing a THR, until now the effects of such a technique for a THR have not been reported. The aim of this study was to compare the effects of general anesthesia (GA) and combined epidural-general anesthesia (CEGA) on blood loss, incidence of postoperative thromboembolism and effective postoperative pain control on patients undergoing a THR. METHODS: Thirty cases of both GA and CEGA for a THR performed at the department of anesthesiology, Keimyung University Dongsan Hospital from Jan. to Dec. 1999 were selected. The surgical time, volume of intravenous fluid infusion during the operation, intraoperative and postoperative transfusion volume, preoperative and postoperative hemoglobin, postoperative blood loss, use of postoperative analgesics, and incidence of postoperative thromboembolism were measured. RESULTS: Surgical time, volume of intravenous fluid administration during the operation and the use of postoperative analgesics was significaltly less in the group CEGA (P < 0.05). Mean values of intraoperative and postoperative transfusion volume, differences between preoperative and postoperative hemoglobin and postoperative blood loss were less in the CEGA group than in GA group. However, the differences were not found to be statistically significant. No difference was found between the two groups in incidence of postoperative thromboembolism. CONCLUSIONS: CEGA decreases surgical time, volume of intravenous fluid administration during an operation and provides effective postoperative pain control in patients undergoing a THR. Therefore,it is suggested that CEGA offers some advantages over GA alone.

Hemodynamic Changes and Clinical Symptoms Resulting from Stellate Ganglion Block / 대한마취과학회지

BACKGROUND: Stellate ganglion block (SGB) is the most common nerve block procedure in pain clinics. To evaluate changes in the hemodynamics and peripheral blood flow on the affected extremity after SGB, SGB was performed unilaterally one at a time on the right and left stellate ganglions by injecting 1% mepivacaine 10 ml without epinephrine in a designated healthy man. METHODS: SGB was repeated 16 times in one subject (right side SGB: 8, left side SGB: 8) by the same clinician. The mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and peripheral blood flow were measured in the supine position before (control), and 3, 6, 9, 12, and 15 minutes after SGB using thoracic electrical bioimpedence (Bioz system A-10043, Cardiodynamics, USA), sphygomanometer, and flow meter. RESULTS: The values after SGB including MAP, HR, CI, and SVRI increased slightly compared to the control value. However, peripheral blood flow increased significantly (p < 0.05). The SGB did not affect systematic hemodynamics and the comparison between left and right SGB in hemodynamic changes were not clinically significant. Following SGB, ptosis (100%), nasal stiffness (100%), skin temperature elevation (100%), hoarseness (100%), numbness (81%), dizziness (25%), and swallowing difficulty (25%) were observed. CONCLUSIONS: We concluded that SGB showed to be a hemodynamically safe clinical technique.

Comparison of Meperidine and Meperidine with Ketamine for Postoperative Analgesia after Total Abdominal Hysterectomy / 대한마취과학회지

BACKGROUND: The purpose of this study was to compare meperidine and meperidine with ketamine for postoperative analgesia after total abdominal hysterectomy (TAH) and to establish a correlation between three types of pain: pain at rest, pain with movement and pain with coughing (maximal pain). METHODS: This present study compared the quality of pain during pain management in 65 patients undergoing TAH. Patients received i.v. meperidine as the loading dose in the recovery room and PCA with meperidine 600 mg, droperidol 5 mg, normal saline 35 ml for three days (Group 1, n = 36), or with meperidine 600 mg, ketamine 200 mg, droperidol 5 mg, normal saline 16 ml for three days (Group 2, n = 29). Patients were then interviewed on postoperative day 1, 2 and 3 (POD1, 2 and 3) to assess their pain on a visual analogue scale (VAS) of 0 (none) to 10 (worst imaginable) and to compare meperidine and meperidine with ketamine for postoperative analgesia. RESULTS: The mean VAS of pain at rest was 4.5 on POD and decreased to 1.8 on POD 3 for patients receiving meperidine with ketamine was lower than the VAS scores of patients receiving meperidine 5.4 to 2.5. Patients receiving meperidine with ketamine also had less difficulty with side effects, less headache, nausea and vomiting. CONCLUSIONS: IVPCA ketamine in combination with meperidine provides superior postsurgical pain relief, especially at rest and with movement and has fewer side effects than meperidine alone.

Ultrastructural Changes of Nerve Fibers Using a Neuropathic Pain Model in a Rat / 대한마취과학회지

BACKGROUND: Neuropathic pain is part of the symptom complex known as peripheral neuropathy. Sensory loss, muscle weakness, atrophy, and decreased tendon reflexes are more common than pain in neuropathic disease. Recently, Bennett and Xie reported that when the sciatic nerve of a rat is loosely ligated, the rat develops pain syndrome similar to that observed in neuropathic pain states in a human. Anatomical and physiological studies to date indicate that the major pathological finding in large diameter myelinated fibers distal to the ligatures was a complex loss of response while in small myelinated fibers there were was only subtle changes. However, a more extensive analysis of the various nerve fiber groups in the damaged sciatic nerve is required for a better understanding of the pathophysiology of the present neuropathy. METHODS: To evaluate the damage and regeneration of all caliber of peripheral nerve, we performed an electron microscopic analysis of the sciatic nerve after four loose ligatures were applied. Cross- sectional photomicrographies of regions distal to the ligatures were studied. A peripheral mononeuropathy was produced in adult rats by tying 4 ligatures loosely around the common sciatic nerve. The distal part of the ligated common sciatic nerve was severed in 2 rats of each group at 1 day, 3 days, 1 week, 2 weeks and 4 weeks respectively. The severed nerves were prepared for electron microscopic examination and pathologic changes were observed under the electron microscope. RESULTS: The ultrastructural changes after ligature application were as follows: At 1 day, the axon of A-beta fiber was shrunken and detached from the myelin sheath. C-fibers were mildly edematous and A-delta fibers appeared to be normal. On the 3rd day, the axoplasm of A-beta fibers was more shrunken, containing swelling of microorganelles and irregularly thickened myelin sheath. C-fiber showed some degrees of degeneration. A-delta fibers revealed mild degeneration and interstitial edema was also noted. At 1 week, the myelin sheaths of A-beta fibers were severely irregular in appearance with marked axonal loss. Many myelin fragments were phagocytosed in the cytoplasm of adjacent Schwann cells. At 2 weeks, A-beta fibers predominantly disappeared and many fragmented myelin sheaths were ingested in the Schwann cell. In some areas, A-beta fibers partially regenerated, which involved remyelination and an increase in the numbers of microorganelles of the Schwann cells. C-fibers were also regenerated. At 4 weeks after sciatic nerve ligation, A-beta fibers regenerated and myelin ovoids were noted within the axoplasm of the A-beta fibers. Myelin ovoids were found in the Schwann cell cytoplasm. A-delta fibers and C-fibers appeared ultrastructurally well-regenerated and had a relatively normal distribution. CONCLUSIONS: We found that maximal nerve degeneration was observed at 2 weeks after sciatic nerve ligation, thereafter, nerve regeneration was noted at 4 weeks after sciatic nerve ligation.

Successful Hemodialysis in Acute Phenobarbital Intoxication / 대한신장학회잡지

Phenobarbital is one of long-acting barbiturate with low lipid solubility and used frequently as an anticonvulsant. However, in severe intoxication, hypotension and respiratory arrest are the major causes of prehospital mortality. Mortality is 3M for blood levels over HO pg/mL and estimated lethal adult dose is 6-10g. No effective antidotes are available. We report a case of phenobarbital intoxication in a 29-year-old female, treated successfully with hemodialysis. She was found corhatose on the day of admission and was alleged to have taken 30g of phenobarbital. On physical examination, the blood pressure was 80/60mmHg, and pulse, 97/min. There was no respiration. Pupil was dilated fully. Corneal and deep tendon reflexes were absent. There was no response to painful stimuli. She was treated conservatively with mechanical ventilation, gut decontamination and forced diuresis. Hemodialysis was tried to remove excess phenobarbital for 13 hours. The blood phenobarbital level at admission was 162.2 pg/ mL, which was decreased to 114.4pg/mL after first session of hemodialysis. On the fifth hospital day, blood level decreased to 41.8 pg/mL and she regained her consciousness. She was discharged on the 10th hospital day without major sequelae.

A Comparison of Fentanyl, Lidocaine and Esmolol for Blunting the Hemodynamic Response during Rapid-Sequence Induction in the Hemodynamically Unstable Patients / 대한마취과학회지

BACKGROUND: Tracheal intubation is accompanied by varing degrees of sympathetic stimulation as reflected by increases in heart rate, and blood pressure and several clinical trials to reduce the effects on blood pressure and heart rate by pharmacologic agents such as and blockers, calcicum channel blockers, narcotics and lidocaine, have been reported. METHODS: To evaluate the effect of fentanyl, lidocaine, esmolol on the hemodynamic changes induced by intubation, we administered thiopental 5 mg/kg only (group 1, n=12), fentanyl 2 g/kg with thiopental 5 mg/kg (group 2, n=12), lidocaine 1 mg/kg with thiopental 5 mg/kg group 3, n=12) or esmolol 0.5 mg/kg with thiopental 5 mg/kg (group 4, n=12) for induction of anesthesia, and measured heart rate, systolic blood pressure, diastolic blood pressure, mean arteiral pressure, and rate-pressure products (RPP) before induction, after induction, after intubation and at 1, 2, 3, and 5 minutes after intubation. RESULTS: There was a significant increase in heart rate, systolic blood pressure and RPP after intubation and 1 min after intubation in all groups, but in group 2, group 3 and group 4, the cardiovascular responses were more attenuated compared to group 1. CONCLUSION: The preintubation intravenous injection of fentanyl, lidocaine and esmolol may offer important roles in the hemodynamically unstable patients because it attenuate cardiovascular responses with intubation.

A Case of Becker Muscular Dystrophy Associated With Dilated Cardiomyopathy / 대한내과학회지

Dilated cardiomyopaty is a rare occurrence in Hecker muscular dystropy. We report a case of Becken muscular dystrophy in 28 old man who presented with dyspnea, progressive muscle weakness, and dilated cardiomyopathy with severe left ventricular dysfunction which was detected by echocardiograpy. Muscle biopsy demonstrated diffuse degenerated changes consistent with progressive muscular dystropy, His brother has also Becker muscular dystrophy and dilated cardiomyopathy, The patient is on NYHA Class II~III with medical therapy.

Comparison of Open and Laparoscopic Cholecystectomies / 대한마취과학회지

Laparoscopic cholecystectomy, a surgical technique first performed in France, which has gained widespread acceptance among surgeons in Korea. The advantages of the laparoscopic technique include lesser patient discomfort, shorter hospitalization, and a shorter return interval to full activities after operation. It has been postulated that due to the minimal incisional discomfort of laparoscopic cholecystectomy, the postoperative pulmonary function following this procedure would be improved as compared to open cholecystectomy. Laparoscopic cholecystectomy uses carbon dioxide, a highly diffusable gas, for insufflation. With extended periods of insufflation, a patient's arterial carbon dioxide levels may be adversely altered. We performed 44 laparoscopic cholecystectomy in 1993. There were 22 women and 22 men, with a mean age of 50.0+/-11.9 years. The mean operative time was 86.7+/-24.3 minutes, reflecting a 62 percent decrease in operative time compared to the open cholecystectomy. The mean hospital stay was 4.6+/-2.0 days. To analyze the hemodynamic effects of carbon dioxide during laparoscopic cholecystectomy, the changes of pH, PaCO2, PaO2, and SaO2 were studied. The measurement showed significant increase of arterial carbon dioxide. Finally, during laparoscopic cholecystectomy patients may require careful intraopererative arterial blood gas monitoring of the absorbed carbon dioxide.

Comparison of d-tubocurarine with vecuronium as the priming drug for vecuronium induced neuromuscular blockade / 대한마취과학회지

Administration of a subparalytic dose of a nondepolarizing muscle relaxant prior to intubating dose hastens the onset time of neuromuscular blockade. This study was designed to investigate the influence of a priming dose of vecuronium (0.015 mg/kg) and d-tubocurarine (0.05 mg/kg) on intubating dose of vecuronium (0.085 mg/kg). The authors measured TOF ratio using neuromuscular monitoring. This monitoring was carried out by stimulation of ulnar nerve at a frequency of 2Hz every 20 seconds using Datex relaxograph to measure the compound evoked electrographic response of hypothenar muscle. The patients were randomly divided into two groups as priming dose ; vecuronium and dtubocurarine (DTC) group respectively. Mixture of two different nondepolarizing muscle relaxant may produce synergism, although the reason for this synergism is unknown. It may be the results of the action of the drugs at different sites. In our study, we found the results as follows ;1) The rapid onset was occured with d-tubocurarine(0.05 mg/kg) as priming drug than vecuronium (0.015 mg/kg) 2) The duration was longer when d-tubocurarine was used (P<0.05) The authors conclude that the onset is more rapid and the duration is longer when other species of nondepolarizing muscle relaxant is used than same agent is used as priming drug.

Anesthetic Management for Coronary Artery Bypass Surgery with Coronary Artery Stenosis / 대한마취과학회지

This report is concerned with our clincal experiences of sixty one cases of anesthesia for coronary artery bypass grafting at the Dong San Medical Center during the period from Februry 1986 to September 1993. The results were as follows; 1) There were 41 men and 20 women with a mean age of 54 (25 to 79 years). 2) Among 61 cases, 17 cases (28%) were history of myocardial infarction. 3) Among 61 cases, single aortocoronary grafts were placed in 37 patients (60%), double or more grafts in 24 patients (40%). 4) The mean bypass time was 135+/-63.9 minutes and cross-clamp time was 45+/-23.5 minutes. 5) Glycopyrrolate, morphine or demerol, vistaril or lorazepam or veprin were used as premedicants. 6) 2% thiopental or 2% thiopental and fentanyl or midazolam and fentanyl were used as induction agents. 7) We have also used isoflurane and fentanyl as anesthetic agents in conjuction with nitrous oxide. 8) Succinylcholin and pancuronium or vecuronium were used for intubation. 9) Early mortality was 16.4% (10 patients) and poor ejection fraction was significantly associated with mortality rate. 10) perioperative myocardial infarction was most common complication.

Effects of Esmolol on Hemodynamic Responses to Laryngoscopy and Tracheal Intubation in Normotensive Patients / 대한마취과학회지

Laryngoscopy and endotracheal intubation undergoing general anesthesia cause hypertension and tachycardia with concomitant increases in plasma catecholamine concentration. These transient stress responses are greatly exaggerated in patients with hypertension and cardiovascular diseases and can lead to cardiac arrhythmia, pulmonary edema, cardiac failure and cerebral hemorrhage. Therefore, several attempts have been made to attenuate the hypertensive and tachycardiac responses, but none has been satisfactory. This study was made to alleviate the hemodynamic responses to tracheal intubation using ultra-short acting cardioselective beta-blocker, Esmolol. Following get informed consent in ASA physical status 1 and 2, 28 patients were randomly divided into two groups. Group 1(n=16), control group, and group 2(n=12), esmolol treatment group. Patients on alpha or beta-blockers or agonists were excluded from the study. 12 patients received an infusion of 500 mcg/kg/min esmolol loading dose for 3 min before induction with thiopental and 300 mcg/kg/min for maintenance for 6 additional minutes during the endotra- cheal intubation. The control patients, group 1(n=16), received 5% D/W infusion in place of esmolol with infusion pump. The patients received hydroxyzine 1 mg/kg, nalbuphine 0.1 mg/kg, and glycopyrroate 0.2 mg i. m. 60 minutes before anesthesia. Patients were induced with sodium thiopental 4-5 mg/kg until the disappearance of lid-refex. Succinylcholine 1.0 mg/kg i. v. was used to facilitate endotracheal intubation. As soon as relaxation was complete, laryngoscopy was initiated. After the completion of intubation, nitrous oxide/oxygen=2: 2 L/min with 0.5-1.5 % halothane or enflurane was administered. The blood pressure and heart rate were measured using noninvasive automatic blood pressure manometer Accutorr 1A (Datascope) for 30 minutes per l minute. Blood pressure and heart rate were evaluated at 6 key points; 1) baseline, 2) anesthetic induction, 3) tracheal intubation, 4) I minute postintubation, 5) 2 minutes postintu- bation, and 6) 3 minutes postintubation, Data were analyzed with paired t-tests within the groups. P<0.05 was considered significant. Esmolol infusion significantly prevented the increases in heart rate and rate pressure product caused by laryngoscopy and endotracheal intubation. Esmolol also moderated the increases in pressures. Esmolol infusion may offer an important role in patients in whom an increase in heart rate, blood pressure and/or rate pressure product should be avoided during the endotracheal intubation.

The Discrepancy between Pulmonary Capillary Wedge and Left Atrial Pressures during the Continuous Administration of Lidocaine with Verapamil / 대한마취과학회지

Simultaneous measurements of pulmonary capillary wedge and left atrial pressures as well as other hemodynamic effects of lidocaine with verapamil infusion were investigated in six dogs given fentanyl-nitrous oxide anesthesia. They were an initial bolus of lidocaine 3 mcg/kg/min. After 30 minutes of lidocaine infusion, Verapamil 0.2 mg/kg was given initially, followed by infusions of 3, 6, 9 and 12 mcg/kg/min respectively. Each infusion of verapamil lasted 30 minutes. Hemodynamic measurements were taken every 30 minutes following each infusion. We found that the pulmonary capillary wedge pressures were significantly higher than the left atrial pressures in each of the cases in which verapamil 6.9 and 12 mcg/kg/min(p<0.05) were respectively injected. The discrepancy between pulmonary capillary wedge and left atrial pressures may be due to an increase in pulmonary vascular resistance index. This may be related to an increase in mean pulmonary arterial pressures and a decrease in left ventricular stroke work index. We concluded from this data that the left atrial pressure reflects more accurately left ventricular filling. Therefore, The left atrial pressure should be used instead of pulmonary capillary wedge pressure to monitor the hemodynamics of depressed ventricular performance.

Cardiovascular Effects of Verapamil during Nalbuphine - Nitrous Oxide Anesthesia / 대한마취과학회지

Cardiovascualar effects of a verapamil infusion were investigated in six dogs given nalbuphine-nitrous anesthesia. Verapamil 0.2 mg/kg was given followed by an infusion of 3 and 6 mcg/kg per minute. Verapamil significantly reduced the systemic vascular resistanee index and mean arterial pressure. The decrease in afterload led to an increase in cardiac index, since was little change in myocardial contractility(LV dp/dt). Administration of calcium chloride, 20 mg/kg, did not reverse tbe hemodynamic effects of verapamil. The data indicate that in dogs verapamil be even in high concentrations, during nalbuphine-nitrous oxide anesthesia without serious adverse hemodynamic sequences.

The Changes of Plasma Concentration of Lidocaine Associated with Epidural Anesthesia / 대한마취과학회지

Epidural anesthesia is widely practiced for lower aMominal surgery and painless delivery in many hospitals and its complications are much lower than that of spinal anesthesia, Lidocaine is a most commonly using local anesthetic in clinics and it has been used exten-sively for epidural anesthesia with very good results. It has a rapid onset of acton with a good analgesic effect and a reasonable duration of action (about l - 11/2 hr). The primary purpose of this study is to observe toxic levels of plasma lidocaine concentration in patients who receive different doses of lidocaine epidurally. Twenty-two adult patients were divided into three groups. With patients in a sittng position, single epidural anesthesias were perfomed with a 17 gauge Tuohy needle. The 2% lidocaine mixed with 1: 200,000 epinephrine was used as a local anes- thetic. Of these, 7 patients in group l were given 400 mg and 8 patients in group 2 were given 500 mg and 7 patients in group 3 were given 600 mg. The plasma concentrations of lidocaine were measured by immunofluorescence assay at the intervals of 5, 10, 15, 30, 45 and 60 minutes. The peak plasma concentrations in the group 1, 2 and 3 were 2.24+/-0.51, 3.84+/-0.90 and 4.36+/-1. 16ug/ml (mean+/-SD) respectively. The peak plasma concentrations were measured 15 and 30 minutes after the epidural injection in group 1, 2 and 3 respectively. The maximum peak plasma concentration among 22 patients was 6.48ug/ml. These results indicate that the injection of 2% lidoeaine 500, 600mg with epinephrine is considered dangerous to some extent because the plasma concentrations of lidocaine exceed toxic levels occasionally.

Anesthetic Management of Open Heart Surgery of the Patient with a Permanent Pacemaker / 대한마취과학회지

A 49-year-old man was admitted to Baptist Hospital on September 1, 1990. For mitral valve replacement due to mitral regurgitation. He has been treated by implantation of artificial pacemaker due to complete heart block for 1 year ago. We have experienced anesthetic management above patient who was scheduled of MVR. The patient with a cardiac pacemaker (VVI type) could give anesthesiologist many associated problems during the operation and anesthesia. During anesthesia an anesthesiologist should be able to manage the problems which might occur because of a cardiac pacemaker by various origins. Authors report this case with evaluation of references.

A Case Report of Asthmatic Attack in the Postoperative Recovery Room / 대한마취과학회지

Anesthetic managment of bronchial asthmatic patient requires understanding of the patho- physiology of the disease and the drug interaction with anesthetics and the drugs related to the treatment. A 53-year old male patient with hemorrhagic pancreatitis had been operated for exploratory laparotomy. He had history of the bronchial asthma. After the operation was completed, patient was transfered to recovery room after extubation. Sudden airway obstruction signs and patients agitation were noted 5 minutes after arrival in the recovery room. Asthmatic attack was relieved with salbutamol, corticosteroid, aminophylline, and isoproterenol intravenously. We have experienced one case of severe asthmatic attack in the postoperative recovery room. We report this case and review the anesthetic managements and drug interactions.

Lumbar Epidural Anesthesia for Cesarean Section : Lidocaine Dose and Its Plasma Concentration / 대한마취과학회지

The effects of lumbar epidural anesthesia for eleetive Cesarean section with 2% 1idocaine containing 1: 200,000 epinephrine on newborn Apgar scores, maternal vein, umbilica1 vein, and umbilical artery plasma concentration of lidocsine at delivery were studied in 9 parturients. With patients in a sitting position, single epidural anesthesias were performed with a 17 gauge Tuohy needle. 25ml of 2% lidocaine with 1: 200,000 epinephrine was used as a local anesthetic. Maternal venous blood samples for the measurement of plasma concentrations of lidocaine were obtained from an indwelling venous catheter at the time of delivery. In addition, blood was collected from a doubly clamped section of umbilical cord for the measurement of lidocaine plasma levels. Neonates were evaluated by Apgar scores at 1 and 5 min, Apger scores were assigned by the pediatricians. Maternal venous lidocaine concentrations at the time of delivery(mean+/-SD) were 3.00+/-0.45ug /ml, and the ratio between umbilical and maternal venous levels was 0.535+/-0.163. All newborns had Apgar scores of 7 or more at 1 min and 5 min, and the was no significant difference between the 1 min and 5 min Apgar scores. It is concluded that epidural anesthesia using 25ml of 2% lidocaine with 1: 200,000 epinephrine for Cesarean section has no adverse effects on both mothers and neonates.

Anesthetic Management for Repair of Congenital Diaphragmatic Hernia / 대한마취과학회지

A 2600 gm term female baby was born through Caesarean section at Baptist Hospital to 29-year-old, primigravda woman who had pregnancy induced hypertension(PIH), HBsAg carrier, and chronic glomerulonephritis. Apgar scores were 5 at one minute and 7 at five minutes. There was extreme respiratory distress in the nursery and she was diagnosed as congenital diaphramatic hernia. At operation, there was a left sided foramen of Bochdalek hernia with hypoplasia of left lung. The diaphragmatic hernia was reduced and cardiac evaluation revealed no evidence of congenital heart disease (CHD) by clinical examination. There also noted no right to left shunt via patent ductus arteriosus. After operation, endotracheal tube was left in place and the patient returned to the nursery where she received respiratory care with infant ventilator. The major determinants of outcome in patients with CHD are the extent of pulmonary hypoplasia and the degree of pulmonary hypertension. So pre- and postoperative management of the pulmonary hypertension is as important as surgical correction of the CHD. The patient tolerated anesthesia and surgery well, and was discharged one month later.

Recurrent Laryngeal Granuloma Following Endotracheal Anesthesia / 대한마취과학회지

Complications related to tracheal intuation are many, but intubation granuloma is a rare complication. The authors experienced a case of recurrent intubation granulomas in spite of removal of granuloma with CO2 LASER under suspension laryngosoopy. We used neuroleptic analgesia for the third operation in order to avoid tracheal intubation. The result was excellent after the third operation, and there was no recurrence noted for 8 months.