An Optimal Dose of Ketorolac during Patient-Controlled Analgesia (PCA) Using Morphine after Gynecologic Surgery / 대한마취과학회지

Background: The aim of this study was to determine an intravenous dose of ketorolac providing augmentation of analgesia and lowering adverse events for patients using postoperative intravenous patient-controlled analgesia (IV-PCA) with morphine Methods: One hundred and ninety eight patients who underwent an elective gynecologic operation were allocated to one of seven groups (ketorolac 180 mg K6, ketorolac 150 mg + morphine 10 mg K5M1, ketorolac 120 mg + morphine 20 mg K4M2, ketorolac 90 mg + morphine 30 mg K3M3, ketorolac 60 mg + morphine 40 mg K2M4, ketorolac 30 mg + morphine 50 mg K1M5, morphine 60 mg M6). After a loading dose of 3 ml, the PCA was started at a setting of 1 ml per demand, with a 8 minute lockout interval and 5-h limit. Results: The total PCA volume was lower in the K3M3, K2M4 and M6 groups. Visual analogue scale pain scores were higher in the K6 and M6 groups. More additional analgesics were required in the K6, K5M1, K1M5 and M6 groups. More antiemetics were required in the M6 group, although the incidence of nausea/vomiting and pruritus was similar among the groups. The sedation scores were lower in the K6 group and higher in the M6 group, 6 h postoperatively; and higher in the M6 and K1M5 groups, 24 h postoperatively. Conclusions: The combination of morphine 30 mg and ketorolac 90 mg, or morphine 40 mg and ketorolac 60 mg in IV-PCA with a total volume of 60 ml, is more effective in analgesia and has less adverse events.

A Comparison between Patient-Controlled Analgesia (PCA) alone and PCA with Basal Infusion after Gynecologic Surgery / 대한마취과학회지

BACKGROUND: Intravenous patient-controlled analgesia (IV-PCA) is widely used because it is a simple, safe, and effective method for postoperative pain control. Controversies exist over the use of a continuous basal infusion in IV-PCA regarding its effectiveness. We evaluated the analgesic efficacy and side effects of PCA with basal infusion after gynecologic surgery and compared these results with PCA alone. METHOD: Eighty women undergoing elective gynecologic surgery under general anesthesia were studied. These patients were randomly assigned to receive either PCA alone (group 1) or PCA with basal infusion (group 2). Analgesic consumption, visual analogue scale (VAS) pain score, and side effects were assessed at postoperative 6 hours and 24 hours. RESULTS: In group 1, the amounts of analgesic used during the postoperative 6 hours and 24 hours were 15 +/- 5 and 30 +/- 13 ml, the median VAS pain score at postoperative 6 hours and 24 hours were 50 and 35 respectively. In group 2, the amounts of analgesic used during the postoperative 6 hours and 24 hours were 19 +/- 7 and 43 +/- 1 ml, the median VAS pain score at postoperative 6 hours and 24 hours were 50 and 38 respectively. The analgesic consumption during the postoperative 6 hours and 24 hours was significantly higher in group 2 than in group 1. There was no significant difference in median VAS pain score between the groups. There were no significant differences in incidence of side effects between groups. CONCLUSIONS: The use of a PCA with basal infusion appears to offer no clinical advantage over PCA alone.

An Analysis of Blood Transfusion Practice in Total Knee Arthroplasty / 대한마취과학회지

BACKGROUND: Almost all of the blood loss occurring postoperatively in total knee arthroplasty (TKA) is due to the use of an intraoperative tourniquet in all cases. So we tried having blood transfusions done, not by anesthesiologists intraoperatively but by orthopedic surgeons postoperatively. The purpose of this study is to analyze postoperative blood loss and transfusion practice in TKAs. METHODS: We analyzed retrospectively the medical records of 64 TKAs in 40 patients between March, 1997 and February, 1999. RESULTS: Six male and fifty-eight female patients were enrolled. Their mean preoperative, immediate postoperative, and post-transfusion hematocrit were 37.1+/- 3.4, 34.4+/- 3.3, and 34.4+/-3.9, respectively. The preoperative and post-transfusion hematocrit were measured in all cases, but immediate postoperative hematocrit was measured in only 21 cases, and the hematocrit of 17 among the 21 cases was over 32 percent. Drainage amount, for the 1st postoperative day were 843 328 ml, and the total drainage amount was 993+/-362 ml. The blood transfusion amount was 2.6+/-0.9 units. There were no statistically significant differences in preoperative hematocrit, immediate postoperative hematocrit, postoperative drainage amount and postoperative transfusion amount between the general and regional anesthetic group; Preoperative hematocrit did not statistically affect the postoperative transfusion amount, but the postoperative drainage amount was statistically associated with an increased postoperative transfusion amount. CONCLUSIONS: Based on these results, it was concluded that postoperative blood transfusion in TKA was to be done on the basis of clinical impressions of orthopedic surgeons in which postoperative drainage amount was the most important consideration. Therefore, postoperative transfusion should be based on appropriate transfusion guidelines and a careful clinical examination of the patient.

Combined Spinal-Epidural Anesthesia for Transurethral Resection of the Prostate / 대한마취과학회지

BACKGROUND: The technique of combined spinal-epidural anesthesia (CSE) may offer theoretic advantages for the various surgeries, because it produces the rapid onset of spinal anesthesia, with the option to extend the blockade and postoperative pain control with an epidural catheter. In this study, we attempt to evaluate both advantages and disadvantages of the CSE for transurethral resection of the prostate (TURP). METHODS: Fifteen patients scheduled to undergo TURP were involved in our study. In all patients, a 17 G Tuohy needle was introduced into the epidural space at L3-4 or L4-5 interspace. Using the needle-through-needle technique, each patients received a subarachnoid injection of 8 mg hyperbaric bupivacaine through a 25 G Whitacre needle. After withdrawal of the Whitacre needle, an epidural catheter was inserted into the epidural space. The level of sensory blockade was checked by pinprick test every 1~2 minute for 30 minutes. Epidural postoperative pain control was done after operation. Postoperatively, we evaluated the adverse effects and the quality of postoperative pain control. RESULTS: The time from start of anesthesia to the time for a T10 sensory block and the time to start of surgery were 6+/-2 min and 21+/-3 min, respectively. At 5, 10, 15 and 20 minutes after spinal anesthesia, sensory blockade level was T10+/-1, T7+/-2, T6+/-2, and T5+/-1, respectively. In general, the quality of anesthesia was good, and most of the patients were satisfied with postoperative pain control. CONCLUSIONS: CSE provided reliable anesthesia and excellent postoperative analgesia for TURP.

A Case Report of Tracheoesophageal Fistula Found during General Anesthesia for Emergency Exploratory Laparotomy / 대한마취과학회지

Tracheoesophageal fistula (TEF) occurs in approximately 1 in 3,000 to 5,000 live births. TEF arises from failure of normal division of proximal foregut into separate respiratory and digestive tracts at 4 weeks' gestation. TEF and esophageal atresia are interrelated anomalies, and TEF usually occurs with esophageal atresia. These are usually diagnosed shortly after birth. However, the diagnosis is often delayed in TEF without esophageal atresia, because babies with this anomaly are usually normal in size and seldom have other anomalies. Therefore, sometimes TEF without esophageal atresia is found during operation for an unrelated condition when positive pressure ventilation causes massive inflation of the gastrointestinal tract. We report a case of TEF in adult patient found during general anesthesia for emergency exploratory laparotomy.