Non-intubated video-assisted thoracoscopic biopsy surgery of a large anterior mediastinal mass via epidural anesthesia: A case report

Anesthesia for a patient with a large mediastinal mass is a challenge for anesthesiologists, given the risk of airway collapse and hemodynamic compromise. Moreover, there are very few reports on the anesthetic management of non-intubated video-assisted thoracoscopic surgery (VATS). Thus, in the following case report, we provide an account of the successful anesthetic management and excisional biopsy of a large anterior mediastinal mass (measuring 13 × 10 cm) utilizing non-intubated VATS. The patient was kept awake, maintaining consciousness and spontaneous respiration throughout the procedure, in order to prevent devastating airway collapse and pain control and cough prevention were achieved by thoracic epidural analgesia and lidocaine nebulization.

Carbon dioxide pneumothorax occurring during laparoscopy-assisted gastrectomy due to a congenital diaphragmatic defect: a case report / 대한마취과학회지

During laparoscopic surgery, carbon dioxide (CO2) pneumothorax can develop due to a congenital defect in the diaphragm. We present a case of a spontaneous massive left-sided pneumothorax that occurred during laparoscopy-assisted gastrectomy, because of an escape of intraperitoneal CO2 gas, under pressure, into the pleural cavity through a congenital defect in the esophageal hiatus of the left diaphragm. This was confirmed on intraoperative chest radiography and laparoscopic inspection. This CO2 pneumothorax caused tolerable hemodynamic and respiratory consequences, and was rapidly reversible after release of the pneumoperitoneum. Thus, a conservative approach was adopted, and the remainder of the surgery was completed, laparoscopically. Due to the high solubility of CO2 gas and the extra-pulmonary mechanism, CO2 pneumothorax with otherwise hemodynamically stable conditions can be managed by conservative modalities, avoiding unnecessary chest tube insertion or conversion to an open procedure.

The effect of multimodal approach with combination of antiemetics and total intravenous anesthesia on postoperative nausea and vomiting in very high-risk patients

BACKGROUND: Postoperative nausea and vomiting (PONV) is a long standing problem in both surgical patients and anesthesiologists, and the treatment of this problem is very important.The purpose of this study was to evaluate the effect of multimodal approach with combination of antiemetics and total intravenous anesthesia (TIVA) on PONV in very high risk patients identified by the Korean predictive model. METHODS: Between March 2008 and February 2009, we evaluated 96 patients who were considered to be at very high risk of PONV according to the Korean predictive model.Among the patients, those who received antiemetic combination of dexamethasone and ondansetron were allocated to treatment group (T) and, those who underwent operation without antiemetics were placed in control group (C).All patients were anesthetized using propofol and remifentanil.We evaluated the incidences of PONV in two groups during the first 24 hours after surgery. RESULTS: The overall incidence of PONV was 14 (29.17%) in C group and 4 (8.33%) in T group, respectively (P = 0.027). CONCLUSIONS: The overall incidence of PONV in T group was significantly lower than that of C group.This study shows that multimodal approach with combination of antiemetics and TIVA was effective in preventing PONV in patients with very high risk.

Risk Factors for an Intraoperative Arrhythmia during Esophagectomy

PURPOSE: Arrhythmias after an esophagectomy (most commonly atrial fibrillation) are a significant contributing factor to patient morbidity. However, the significance of an intraoperative arrhythmia is not completely understood. The aim of this retrospective study was to determine the occurrence and risk factors for developing intraoperative arrhythmias in patients undergoing an esophagectomy. MATERIALS AND METHODS: We reviewed the records of 427 patients who underwent a transthoracic esophagectomy between 2001 and 2005. Variables such as age, sex, hypertension, diabetes, cardiac disease, preoperative pulmonary function test (PFT) results, cancer level, combined radiochemotherapy, intrathoracic cavity adhesions and anastomosis site, hemoglobin, central venous pressure (CVP), fluid balance, serum potassium level, dose of vasopressors, temperature, and combined general and epidural anesthesia were analyzed as risk factors for the occurrence of an arrhythmia. We defined this arrhythmia as one not originating from the sinus node. RESULTES: The incidence of intraoperative arrhythmia in this subset of patients was 17.1%, with a 37.2% reoccurrence rate during the first three postoperative days. Univariate and multivariate analysis revealed the presence of heart disease, poor PFTs, cervical anastomosis, elevated CVP, and higher ephedrine doses to be independent predictors of the development of an intraoperative arrhythmia. CONCLUSION: The incidence of intraoperative arrhythmia during esophagectomy was 17.1% with a 37.2% of reoccurrence rate.

Effect of Intraoperative 80% Inspired Oxygen on Postoperative Nausea and Vomiting in Patients undergoing Vitreoretinal Surgery / 대한마취과학회지

BACKGROUND: Most recently, the antiemetic effects of high inspired oxygen have been discussed and various results have been reported according to the types of surgeries and the groups of patients. In ophthalmic surgical patients, surgical procedures involving intraoperative manipulation of the eye and giving rise to residual eye discomfort were associated with the increased incidences of postoperative nausea and vomiting (PONV). The antiemetic effect of 80% inspired oxygen for the patients undergoing vitreoretinal surgery is unknown. Therefore, we examined the efficacy of 80% inspired oxygen in the decrease of the PONV incidences after vitreoretinal surgery under general anesthesia. METHODS: 170 adults under 70 years of age have received standardized sevoflurane anesthesia. After tracheal intubation, they were randomly assigned to two groups: 30% inspired oxygen in air (Group 30), and 80% inspired oxygen in air (Group 80). Postoperative nausea and vomiting were evaluated at the 2, 6, and 24 h postoperatively by an investigator unaware of patients' allocation. RESULTS: There was a significantly lower incidence of PONV during the first 2 h postoperatively in the Group 80 (22%) compared with the Group 30 (40%) (P = 0.024). The Group 80 (33.8%) showed the decreased incidence of PONV during the first 24 h postoperatively compared with the Group 30 (48.8%), but these differences were not statistically significant (P = 0.081). CONCLUSIONS: The use of 80% inspired oxygen during vitreoretinal surgery reduced the incidence of PONV during the first 2 h postoperatively.

Effects of Epidural Naloxone on Pruritus Induced by Hydromorphone Epidural Patient-Controlled Analgesia / 대한통증학회지

BACKGROUND: Opioid delivered by epidural patient-controlled analgesia (PCA) is effective in relieving pain after surgery, but it is associated with side effects, such as nausea, vomiting, pruritus, respiratory depression, and urinary retention. The purpose of this study was to compare hydromorphone related side effects and the quality of analgesia when naloxone was added to epidural PCA regimen. METHODS: Fifty-two thoracotomy patients with PCA were allocated blindly into two groups. Patients in group H (n = 26) received continuous epidural hydromorphone (16microgram/ml) in 0.1% bupivacaine; patients in group N (n = 26) received an epidural infusion containing naloxone (2 microgram/ml) and hydromorphone (16microgram/ml) in 0.1% bupivacaine. The basal rate of PCA was 4 ml/hr and the demand dose was 1.5 ml with a lockout time of 15 min. Pain intensity, sedation, pruritus, nausea and vomiting, respiratory depression were checked at 6, 12, 24 hours postoperatively. RESULTS: The Visual Analog Scale (VAS) scores were significantly lower in group H than in group N. There were no significant differences in the overall incidence of pruritus, nausea and sedation between the two groups. CONCLUSIONS: Continuous epidural infusion of naloxone combined with hydromorpho-ne is not effective in reducing the incidence and severity of pruritus induced by epidural hydromorphone.

The Comparison of Transfusion Practice and Prognosis according to Transfusion Guidelines of Packed Red Blood Cells in Off-Pump Coronary Artery Bypass Graft Surgery / 대한마취과학회지

10.0 g/dl in group B (minimum Hb 10.4 g/dl). The rate of bloodless OPCAB increased from 2% to 57%. There was a similar number of blood restorations and wastage, incidence of wound infections, bleeding, arrhythmias, myocardial infarctions, sudden death, length of the ICU stay and postoperative admissions in the two groups. CONCLUSIONS: With the new transfusion guideline, number of P-RBC preparations and transfusions was decreased significantly without an increase in the incidence of complications.

Effects of Isosulfan Blue and Methylene Blue on Oxygen Saturation by Pulse Oximetry in Sentinel Lymph Node Biopsy / 대한마취과학회지

BACKGROUND: In breast cancer, lymphatic mapping with blue dye has been used intraoperatively to identify the sentinel lymph nodes. Several blue dyes are known to cause spurious desaturation when measured by a pulse oximeter. This study examined the differential effects of isosulfan blue (IB) and methylene blue (MB) on the level of oxygen saturation by pulse oximetry according to the sites measured. METHODS: Forty women with breast cancer were divided into two groups according to the dyes used. The level of oxygen saturation by pulse oximetry was measured on the index finger of the unoperated arm and on the 2nd toe, respectively, before injecting the dye and, 5, 10, 15, 20, 25, 30, 60, 90, 120, and 150 minutes after. The color of the skin was evaluated on a 4 point scale. RESULTS: In the IB group, the level of oxygen saturation on the finger was significantly lower immediately after injection than the level of oxygen saturation on the toe, and remained at a significantly lower level for up to 150 minutes. In the MB group, there was no significant reduction in the level of oxygen saturation at both sites after injecting the dye. The lowest oxygen saturation in each group was 95.8 +/- 1.9%, 97.5 +/- 1.2%, 99.0 +/- 1.0%, and 99.4 +/- 1.0% in the IB-finger, IB-toe, MB-finger, and MB-toe, respectively. The color change in the skin according to the dye injection was significant in the IB group but, not in MB group. CONCLUSIONS: IB decreased the level of oxygen saturation as measured by pulse oximetry, and its effects were more pronounced on the finger than toe. MB did not decrease the level of oxygen saturation as measured by pulse oximetry at both sites. Oxygen saturation monitoring on the toe is more desirable in a sentinel lymph node biopsy using IB than the finger.

Prolonged Respiratory Failure after General Anesthesia for Cesarean Section in a Presumed Myotonic Dystrophy Patient: A case report / 대한마취과학회지

Myotonic dystrophy is the most common manifestation of mytonic disease. It is a systemic disease and its most serious complications after general anesthesia result from respiratory failure. We report a case of prolonged respiratory failure after general anesthesia for cesarean section in a presumed myotonic dystrophy patient. A 36-year-old parturient underwent emergency cesarean section under general anesthesia for premature rupture of the amniotic membrane with fetal distress. At the end of the operation, the recovery of respiratory muscle from paralysis was insufficient to maintain spontaneous ventilation despite the administration of reversel agents. Her TOF count was 3/4 and she was reintubated in the PACU. The patient was transferred to the ICU for proper respiratory care and her respiration fully recovered after 21 hours of conservative supportive care.

Analysis of Postoperative Liver Function and Complications versus Donor Hepatectomy Type for Living-Related Liver Transplantation / 대한마취과학회지

BACKGROUND: Although living related liver transplantation (LRLT) has several advantages over cadaveric liver transplantation, there still is considerable debate concerning donor safety. We analyzed postoperative liver function and complications versus type of donor hepatectomy for LRLT. METHODS: The charts, anesthetic records and computerized hospital data of 135 consecutive donors registered for LRLT from June 1996 to February 2003 were retrospectively reviewed. Donors were divided into three groups: a left lateral segmentectomy (group LLS; n = 37), a left lobectomy (group LL; n = 8), and a right lobectomy (group RL; n = 90). Volume and weight of the resected liver, volume of blood loss, fluids and blood administered, surgical time and anesthetic time, duration of hospital stay, complications, and perioperative changes in hemoglobin (Hb), aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and prothrombin time (PT) were investigated. RESULTS: No significant differences in donor characteristics, blood loss, and duration of hospital stay were observed. But surgical and anesthetic times in the group RL were longest. The postoperative peak level of AST and ALT in the group LLS were significantly higher than those of the other groups. Postoperative PT and total bilirubin in the group RL were highest. AST, ALT, and PT peaked on the first postoperative day and decreased gradually thereafter. None of the donors experienced a critical complication, including liver failure. CONCLUSIONS: Significant differences in surgical time, postoperative liver function and incidence of hyperbilirubinemia were observed according to the type of hepatectomy. But, serious complication occurred in any donor.

Airway Sealing Effect and Gastroesophageal Regurgitation of Laryngeal Mask Airway-Proseal in Laparoscopy / 대한마취과학회지

BACKGROUND: The laryngeal mask airway Proseal (LMA-Proseal) is a renewed airway device with a modified cuff to improve the mask seal around the larynx. The classic LMA is known to have an incomplete mask seal during high positive pressure ventilation. Therefore, we examined whether the ventilation via a LMA-Proseal during laparoscopic surgery may be adequate and also observed the complications associated with a LMA-Proseal. METHODS: Thirty four patients undergoing elective gynecological laparoscopies were studied. After the insertion of a LMA-Proseal, we measured the peak airway pressure, plateau airway pressure, oropharyngeal leakage pressure, and the leakage around the neck before and after intra-abdominal CO2 insufflation. After extubation, we observed the complications, including the gastroesophageal regurgitation using a methylene blue staining method. RESULTS: The peak and plateau airway pressures after pneumoperitoneum increased significantly (P<0.05), compared with those before insufflation. However, the oropharyngeal leakage pressure was not changed and leakages around the neck were not observed. After extubation, a cuff stained with methylene blue occurred in 10 of 34 patients. Sore throat and dysphagia occurred in 8 and 4 of 34 patients, respectively. CONCLUSIONS: A LMA-Proseal during laparoscopic surgery permits adequate airway pressure, but does not protect the gastroesophageal regurgitation.

Anesthetic Management and Analysis of Postoperative Morbidity of Donors in Living-Related Liver Transplantation / 대한마취과학회지

BACKGROUND: Living liver donor surgery will become more common because of a shortage of donor organs. Howerver, donor hepatectomy has a potentially significant risk to the donor and raises important issues about the safety of the procedure. Our experience in the anesthetic management of donors is discussed and complications encountered are recorded. METHODS: The charts, anesthetic records and computerized hospital data of 100 consecutive donors for living-related liver transplantations from June 1996 to March 2002 were retrospectively reviewed. Donor characteristics, blood loss, fluids and blood administered, surgical and anesthetic duration, hospital stay time, postoperative complications, and perioperative changes in hemoglobin (Hb), aspartate transferase (AST), alanine transferase (ALT), and prothrombin time (PT) were investigated. RESULTS: A graft type consisted of 31 left lateral segments, 8 left lobes and 61 right lobes. The average operating time was 401.3+/-79.0 minutes and total duration of hospital stay was 14.1+/-2.6 days. The mean blood loss was 731.3+/-481.2 ml and 9 donors received a transfusion of heterologous packed red blood cells. Seven donors developed postoperative complications, all of which were managed conservatively. The average Hb decreased significantly from a preoperative value of 14.2+/-1.6 g/dl to the lowest postoperative value of 11.6+/-1.5 g/dl. AST, ALT and PT reached their highest level on the first postoperative day and decreased rapidly afterwards. All of these values were significantly different from the preoperative values for the postoperative 30 days. CONCLUSIONS: Serious complications did not occur after a living donor hepatectomy at our hospital, but the risk to the donor cannot be completely eliminated. Therefore the donor's safety and quality of life as well as graft function should be considered in living donor operation.

Clinical Experience of the Anesthetic Management of Mucopolysaccharidosis / 대한마취과학회지

Mucopolysaccharidosis is characterized by the progressive accumulation of glycosaminoglycans in multiple organs. Valve and coronary involvement, upper airway obstructive disease, joint stiffness, and mental retardation are associated perioperative anesthetic risks. Nineteen patients and 23 anesthetic cases were presented for elective surgery. The mean patient age was 10.8 years. General anesthesia was administered in 21 cases and intubation was failed in two. Mask ventilation without intubation was performed in two cases in day surgery unit. In one case, spinal anesthesia was performed. Otolaryngologic procedures, i.e., tonsillectomy and adenoidectomy, and ventilation tube insertion were most common. Percutaneous endoscopic gastrostomy and herniorrhaphy were also frequent. Dexamethasone was given to all intubated cases and all patients were extubated in the postanesthesia care unit or in the intensive care unit. There was no perioperative mortality. Cautious airway management until intubation is recommended and mask ventilation with short-acting inhalation or intravenous anesthetics is enough to manage relatively short procedures. For herniorrhaphy, a spinal block could be used.

Alterations of the Ventilation-Perfusion Ratio Measured by Using a Multiple Inert Gas Elimination Technique (MIGET) in One Lung Ventilated Rabbit / 대한마취과학회지

BACKGROUND: In this study, we performed one-lung ventilation (OLV) in rabbits to assess the effects of OLV on the VA/Q ratio and the respiratory physiological changes using MIGET. METHODS: Ten male New Zealand white rabbits, weighing 3-4 kg were selected. To perform MIGET, six inactive gases (SF6, krypton, desflurane, enflurane, diethyl ether, acetone) in 500 ml normal saline were injected intravenously. During two-lung ventilation (TLV), and after OLV for 30 minutes, blood was sampled for blood gas analysis and MIGET, hemodynamic variables were measured. For MIGET, the concentrations of the injected inert gases were measured and converted to retention/excretion data; the VA/Q distribution curve was obtained using a computer. RESULTS: Systolic, mean, and diastolic pulmonary pressures were elevated significantly and pulmonary resistance was doubled (P<0.05) in OLV compared to TLV. Blood pH decreased in OLV. The calculated intrapulmonary shunt was 19% and 52%, TLV and OLV, respectively. The analysis of VA/Q using MIGET showed that the VA/Q distribution curve was wider and that the VA/Q area was larger in normal rabbits. And, that intrapulmonary shunt approximated to 11%. In the case of OLV, a significant increase in shunt was observed but no change in the amount of dead space at distribution area, (log SDQ, log SDV) remained the same, whereas the VA/Q distribution curve shifted toward the right. CONCLUSIONS: OLV in rabbits showed severe hypercapnia and hypoxemia leading to a considerable increase in shunt. Because of the wide range of VA/Q distribution in TLV, no significant changes in respiratory variables were observed during OLV.

The Effects of 0.45% and 0.9% Saline Solutions on Serum Sodium Concentrations in Chronic Renal Failure Patients / 대한마취과학회지

BACKGORUND: To choose optimal potassium free solutions in chronic renal failure patients, we studied the effects of 0.45% or 0.9% saline solutions on the serum sodium concentrations of patients undergoing kidney transplantation surgery. METHODS: Sixty two patients, ASA physical status iii iV, undergoing kidney transplantation surgery, were allocated to receive either 0.45% saline (n = 26) or 0.9% saline solutions (n = 36). The patients received 2 L of 0.45% or 0.9% saline solutions with a CVP of 10 mmHg prior to a renal vein anastomosis. Serum sodium and potassium concentrations were measured before (Na0, K0) and after the administration of 2 L of 0.45% or 0.9% saline solutions (Na2, K2), respectively. RESULTS: Serum sodium concentrations decreased after the administration of 0.45% saline solutions, and after administrating 2 L of 0.9% saline, the serum sodium concentrations increased in patients with baseline serum sodium concentrations lower than 136 mEq/L. When we administered 0.9% saline, which had a sodium concentration lower than the serum sodium concentration, the serum sodium concentration measured after 2 L of 0.9% saline infusion proportionally decreased in patients with baseline serum sodium concentration greater than 136 mEq/L (P<0.001). CONCLUSiONS: For ideal fluid selection in chronic renal failure patients, this study suggests a 0.45% saline solution for chronic renal failure patients with a baseline serum sodium concentration below the normal range and a 0.9% saline solution for patients with a baseline sodium concentration within the normal range.

Influence of Thoracic Epidural Analgesia on Postoperative Respiratory Complications in Esophageal Cancer Patients / 대한마취과학회지

BACKGROUND: Respiratory complications have been the main cause of death after a resection of esophageal cancer. This retrospective study was conducted to investigate the effect of thoracic epidural analgesia on respiratory complications after a resection of esophageal cancer. METHODS: This study enrolled two groups of patients undergoing an esophageal resection during a 7-year period. The first group (control group) was comprised of 105 patients in whom thoracic epidural analgesia was not used. The second group (epidural group) was comprised of 121 patients in whom thoracic epidural analgesia was done routinely. The latter group received an initial bolus of 0.1% bupivacaine 10 ml with 2 mg of morphine at the end of surgery and an infusion of 2 ml/hr of the solution comprised of 0.1% bupivacaine with 0.2 mg/ml morphine for 3 days. The incidence of respiratory complications and the duration of ventilator care and ICU stay were investigated by reviewing of charts. RESULTS: There were no significant differences in the incidence of respiratory complications and the duration of ventilator care and ICU stay in both groups. CONCLUSIONS: The results of this study suggest that the routine use of thoracic epidural analgesia did not reduce the incidence of respiratory complications after resection of esophageal cancer.

Is the Effect on Elimination of Apparatus Dead Space Different according to Ventilation Modes? / 대한마취과학회지

BACKGROUND: The objective of this study was to observe that the effect on the elimination of apparatus dead space was different according to modes of ventilation. METHODS: In 30 patients undergoing esophageal surgery, we placed a double-lumen endobronchial tube in the midtrachea and used the bronchial lumen with a conventional Y connector while the tracheal lumen was clamped for conventional ventilation (CV) or used both lumens with special connectors that separated the inspiratory limb and the expiratory limb for separated ventilation (SV). Four ventilation modes were used in each patient. Type CV10 is a mode with 10 ml/kg of tidal volume, and a frequency of 10/min, and type CV5 is a mode with 5 ml/kg of tidal volume, and a frequency of 20/min. Except for the special connectors, type SV10 and SV5 are the same as CV10 and CV5, respectively. RESULTS: The means standard deviations of PaCO2 in CV10, SV10, CV5, and SV5 were 34.8 +/- 5.7 mmHg, 32.3 +/- 5.1 mmHg, 39.2 +/- 6.6 mmHg, and 34.9 +/- 5.9 mmHg, respectively. The PaCO2 in SV10 and SV5 decreased significantly when compared with that seen in CV10 and CV5, respectively (P <0.001), showing the effect of the elimination of apparatus dead space. Moreover, the PaCO2 difference observed between CV5 and SV5 (4.4 +/- 4.1 mmHg) was significantly greater than that observed between CV10 and SV10 (2.5 2.4 mmHg) (P = 0.014). CONCLUSIONS: The elimination of apparatus dead space to improve CO2 removal can be more beneficial in a ventilation mode with 5 ml/kg of tidal volume, and a frequency of 20/min rather than in 10 ml/kg of tidal volume, and a frequency of 10/min.

Beta Blocker Sensitive Idiopathic Ventricular Tachycardia / 대한마취과학회지

A 31-year-old female patient suffering from hemoptysis was scheduled for a lobectomy. Her preoperative electrocardiogram was normal sinus rhythm and electrolytes were within normal range. During mask ventilaton a short run of ventricular tachycardia appeared, but she returned to normal sinus rhythm after lidocaine 60 mg was injected. However, after intubation, sustained ventricular tachycardia developed and did not respond to additional lidocaine immediately. Blood gases and electrolytes were in acceptable range and severe hypotension did not occur during the attack. Several minutes later, the rhythm changed spontaneously to sinus rhythm with intermittent premature ventricular contractions. However, stimuli such as position change and endotracheal suctioning caused another paroxysmal ventricular tachycardia. Idiopathic ventricular tachycardia was suspected and esmolol 30 mg was injected. Ventricular tachycardia terminated abruptly and changed to sinus rhythm so that the lobectomy was done successfully with a continuous infusion of esmolol. We are going to report this clinical experience with review of its mechanism, treatment, and long term prognosis.

Electrocardiographic and Hemodynamic Changes during Recovery from Bupivacaine Toxicity in Anesthetized Dogs / 대한마취과학회지

BACKGROUND: Severe cardiac arrhythmia after accidental intravascular injection of bupivacaine in the practice of regional anesthesia has been reported and is known to be difficult to treat. We evaluated the electrocardiographic and hemodynamic changes during recovery from bupivacaine-induced cardiac toxicity. METHODS: In eight male dogs receiving pentobarbital, after baseline recordings were obtained, 0.5% bupivacaine was infused at a rate of 0.5 mg/kg/min intravenously until cardiac output decreased to 50% or less(1/2 CO), which was defined as the point of cardiac depression in this study. The hemodynamic and electrocardiographic parameters were recorded at 1/2 CO, and 5, 10, 15, 20, 30 and 40 min after 1/2 CO. The following electrocardiographic parameters were measured: duration of QRS complex and T wave, PR interval and the corrected QT interval, all determined on the lead II. RESULTS: Mean arterial pressure was significantly decreased throughout the experimental period after 1/2 CO, and cardiac output and SO2 were significantly decreased until 20 min after 1/2 CO in comparison with those at baseline. All dogs had serious changes on the ECG. Heart rate and ECG changes returned to baseline within 20 min after 1/2 CO, but QRS duration remained increased until 30 min after 1/2 CO. Systemic vascular resistance, pulmonary vascular resistance and serum electrolytes were not changed with time. CONCLUSIONS: In the absence of hypoxia, acidosis, and hyperkalemia, QRS duration returned to control values more slowly than other variables on the EKG after bupivacaine cardiac toxicity. MAP and PCWP recovered the slowest of all hemodynamic variables.

Administration of Atracurium in a Patient Recovering from Organophosphate Poisoning / 대한마취과학회지

A 67-year-old woman accidentally ingested insecticide 3 months ago and received ventilator care for 1 month. Thereafter, she developed tracheal stenosis combined with a tracheal-esophageal fistula, and she was scheduled to receive a tracheal resection anastomosis. We anesthetized her with atracurium under the monitoring of an accelerograph and she did not represent any prolonged respiratory paralysis postoperatively. We administered atracurium 10 mg twice initially and then gave additional 5 mg boluses when the TOF ratio became greater than 0.5. The total dose of administered atracurium was 40 mg and total duration of anesthesia was 360 minutes. We did not extubate her in the operating room in spite of complete recovery from atracurium to preoperative status because her lung condition was not very good preoperatively and severe necK flexion was done for the anastomosis. In the intensive care unit, the patient's condition progressively deteriorated with the development of adult respiratory distress syndrome and acute renal failure. Despite vigorous organ specific support, she discharged hopelessly 24 days after the operation.