Anesthesia for Noncardiac Surgery in Heart Transplanted Patients: 2 cases report / 대한마취과학회지

With the introduction of cyclosporine, heart transplantation has become a widely accepted treatment for patients with end-stage heart failure. Number of operation increased steadily during recent 6 years with many postoperative follow up cases. A number of survivors are now presenting for non-cardiac surgery. Cardiac transplanted patients present anesthesiologists with challenging problems related to the infection in immunosuppressed patients, rejection phenomena, denervated heart pathophysiology with altered hemodynamic function of their own and under circumstances of stress and drug therapies. We experienced 2 cases of general anesthesia for noncardiac surgery in heart transplanted patients without important hemodynamic changes. Preoperative evaluation including heart status, rejection, immunosuppressive drug therapy and its complications is mandatory. These patients present few problems during anesthesia if adequate hydration, aseptic technique, selection of proper vasoactive drugs are provided.

Temperature Changes in Hands and Feet during and after T3 Sympathicotomy for Palmar Hyperhidrosis / 대한마취과학회지

BACKGROUND: Recently a report was published about the cross-inhibitory effect of post ganglionic neuron between upper extremities. We tried to find the existence of the same effect in all extremities by comparing the changes of skin temperature (ST) of all extremities during and after sympathicotomy for palmar hyperhidrosis. METHODS: Twenty patients with palmar hyperhydrosis underwent bilateral video-assisted thoracoscopic sympathicomy. Right side T3 sympathicotomy was performed first, then left side T3 sympathicotomy was done. The ST of both hands and feet were compared with the ST before the surgery at 2, 4, 6, 10 minutes after first (right) sympathicotomy, 10 minutes after second (left) sympathicotomy and 4 hours after both sympathicotomy in the post anesthetic care unit (PACU) of our one-day surgery center. RESULTS: At 10 minutes after completion of first (right) sympathicotomy, ipsilateral increase of the ST (right hand, 2.73 +/- 2.01oC) and contralateral decrease of the ST (left hand, - 0.65 +/- 0.88oC) were observed (P < 0.05). After the second (left) sympathicotomy was done, the ST of both feet decreased (right, - 1.24 +/- 0.81oC and left, - 1.31+/- 0.77oC, P < 0.05) and the ST of both hands increased (right, 3.34 +/- 2.40oC and left, 2.11+/- 1.91oC, P < 0.05). There were increases of the ST in both hands (right, 4.93 +/- 2.51oC and left, 4.63 +/- 2.19oC) and decreases of the ST in both feet (right, - 3.38 +/- 1.85oC and left, - 3.09 +/- 2.03oC, P < 0.05) in the PACU. CONCLUSIONS: There may be a cross-inhibitory effect by the post ganglionic neurons innervating the blood vessels of the all extremities. Sympathicotomy causes the relief of the cross-inhibitory effect and result in vasoconstriction and a decrease of ST of contralateral hand and both feet.

Temperature Changes in Hands and Feet during and after T3 Sympathicotomy for Palmar Hyperhidrosis / 대한마취과학회지

BACKGROUND: Recently a report was published about the cross-inhibitory effect of post ganglionic neuron between upper extremities. We tried to find the existence of the same effect in all extremities by comparing the changes of skin temperature (ST) of all extremities during and after sympathicotomy for palmar hyperhidrosis. METHODS: Twenty patients with palmar hyperhydrosis underwent bilateral video-assisted thoracoscopic sympathicomy. Right side T3 sympathicotomy was performed first, then left side T3 sympathicotomy was done. The ST of both hands and feet were compared with the ST before the surgery at 2, 4, 6, 10 minutes after first (right) sympathicotomy, 10 minutes after second (left) sympathicotomy and 4 hours after both sympathicotomy in the post anesthetic care unit (PACU) of our one-day surgery center. RESULTS: At 10 minutes after completion of first (right) sympathicotomy, ipsilateral increase of the ST (right hand, 2.73 +/- 2.01oC) and contralateral decrease of the ST (left hand, - 0.65 +/- 0.88oC) were observed (P < 0.05). After the second (left) sympathicotomy was done, the ST of both feet decreased (right, - 1.24 +/- 0.81oC and left, - 1.31+/- 0.77oC, P < 0.05) and the ST of both hands increased (right, 3.34 +/- 2.40oC and left, 2.11+/- 1.91oC, P < 0.05). There were increases of the ST in both hands (right, 4.93 +/- 2.51oC and left, 4.63 +/- 2.19oC) and decreases of the ST in both feet (right, - 3.38 +/- 1.85oC and left, - 3.09 +/- 2.03oC, P < 0.05) in the PACU. CONCLUSIONS: There may be a cross-inhibitory effect by the post ganglionic neurons innervating the blood vessels of the all extremities. Sympathicotomy causes the relief of the cross-inhibitory effect and result in vasoconstriction and a decrease of ST of contralateral hand and both feet.

Anesthetic Management with Mivacurium in the Myasthenic Patients: Two cases / 대한마취과학회지

We have used mivacurium in two myasthenic patients, a generalized myasthenia gravis (MG) patient presenting for thymectomy and a Lambert-Eaton myasthenic (LEM) patient for mediastinoscopic lymph node biopsy. Both of them received nitrous oxide/oxygen (1:1)-narcotic-enflurane anesthesia with mivacurium as a muscle relaxant and the neuromuscular blocking effect of mivacurium was monitored continuously through the operation as well as before the induction of anesthesia. The dose of mivacurium for MG patient was 5.5 mg and LEM patient was 12 mg, because MG patient showed more severe clinical symptoms. The response to train-of-four (TOF) ulnar nerve stimulation was recorded using accelography. The onset times to maximal block in MG and LEM patients were 30 and 120 sec, respectively after injection and the recovery times to 25% from maximal block were 117 and 76 min, respectively. Mivacrium would be safe and appropriate for use in myasthenic patients, with relatively small dose under the neuromuscular monitoring.

Effect of the K+ Channel Modulations on Glutamate and K+ Concentrations in Rabbit Hippocampus during Transient Global Ischemia / 대한마취과학회지

BACKGROUND: Cerebral ischemia causes an increase in extracellular potassium ([K+]e) through activation of the KATP channel. This increase in [K+]e could result in neuronal depolarization and a reversal of the glutamate uptake system in glia. This may further contribute to the excessive concentrations of glutamate and asparate in the extracellular space during ischemia. If the early rise in [K+]e during ischemia could be attenuated, less excitotoxic neuronal damage may be the result. However, activation of KATP channels has been shown to attenuate the anoxia induced depolarization in the hippocampus and may reduce the release of excitatory neurotransmitters during cerebral ischemia. In this study, we address the question of whether KATP channel modulation affects [K+]e and whether it is related with extracellular glutamate concentrations. METHODS: After approval by the Animal Care and Use Committee, 18 New Zealand white rabbits were anesthetized with halothane and mechanically ventilated to maintain normocarbia. Microdialysis catheters were inserted into the left dorsal hippocampus and perfused with artificial cerebrospinal fluid at 2 ml/min. K+ sensitive microelectrodes were inserted into the contralateral hippocampus. A pneumatic tourniquet was placed loosely around the neck. Animals were randomized to receive glibenclamide (n=5, KATP blocker, 3.7 mg/kg) or cromakalim (n=5, KATP opener, 0.5 mg/kg). The control group (n=6) had neither drug. Ten-minute period of global cerebral ischemia was produced by inflation of the tourniquet combined with induced hypotension. Hippocampal [K+]e was measured throughout the periischemic period and glutamate concentrations in dialysate were determined by high-performance liquid chromatography. Peak levels were compared by ANOVA. RESULTS: Glutamate concentration significantly increased during ischemia period for all groups (p<0.05). In glibenclamide treated animals, brain glutamate concentration increased markedly during early reperfusion (t=I+15) compared to other groups (p<0.05). There were no statistical differences on ischemia-induced increases in [K+]e among the three groups. CONCLUSIONS: Although it was not possible to demonstrate an effect of modulators of the ATP sensitive K+ channel on [K+]e, glibenclamide increased glutamate during reperfusion. This paradoxical increase in glutamate after administration of a K+ channel blocker suggests that the mechanism of glutamate release is not related to [K+]e change.

Clinical Status and Anesthetic Management of Very Low Birth Weight Premature Infants who underwent Surgical Closure of Patent Ductus Arteriosus / 대한마취과학회지

BACKGROUND: A delay in spontaneous closure of the patent ductus arteriosus (PDA) is frequent in premature infant and may lead to cardiopulmonary congestion and death. Surgical closure of the PDA in the premature infant can be a safe and effective procedure. Now, several centers prefer to eliminate the problem of transportation to operating room and adopt the policy of operating in the newborn intensive care unit (NBICU). So we investgated the anesthetic management and clinical status of premature infants who underwent surgical closure of PDA. METHODS: We analyzed retrospectively the anesthetic management and clinical status of eleven premature infants below 1,500 g birth weight. RESULTS: Range of gestational age of infants was 24-30 weeks. Most common cause of operation was failure of medical treatment. All infants had features of respiratory distresses and prematurity complications. Fentanyl, vecuronium, oxygen, and air constituted a anesthetic regimen. The body temperature remained stable. Systemic blood pressure with ligation of PDA increased to 66.3 17.4 mmHg (mean+/-SD). After operation, three infants died from complication of prematurity. There were no deaths directly related to operation. Four infants underwent operation in NBICU and also had no wound infections. CONCLUSIONS: Premature infants with PDA had associated complications of prematurity and were severely ill. If the infants did not respond to medical therapy, the PDA was closed by operation with adequate anesthesia. Furthermore, the operation can be performed safely and efficiently in the operating room or NBICU.

Knotting of Pulmonary Artery Catheter in Cardiac Transplantation: A case report / 대한마취과학회지

A pulmonary artery catheter (PAC) is a useful monitoring device for measuring pulmonary artery pressure, pulmonary capillary wedge pressure and cardiac output, but its insertion brings about many complications including pulmonary artery rupture, infarction, thrombosis and infection. This case concerns the knotting of a PAC in a 27 year-old female patient who had undergone cardiac transplantation due to dilated cardiomyopathy. The PAC was inserted via the right subclavian vein to the pulmonary artery and withdrawn to the superior vena cava before heart was removed. After the weaning of the cardiopulmonary bypass (CPB), we tried to reinsert the PAC, which was neither advanced nor withdrawn. Postoperative chest x-ray revealed that the PAC appeared to be knotted in the subclavian vein. Two days later, we loosened the knot of the PAC and removed it via femoral and bracheal cineangiography techniques guided by fluoroscopy without any complications. In this case, we thought the knotting of the PAC occurred at insertion due to severe tricuspid regurgitation, and its size was reduced at withdrawal before the CPB and wedging to the subclavian vein. Knotting of PAC is very rare and unpredictable, but once it or other complications of the PAC is suspected, we recommend that the manipulation of the PAC should be stopped and x-ray should be checked.

Pupil Changes during Hypothermic Cardiopulmonary Bypass Under Fentanyl Anesthesia / 대한마취과학회지

BACKGROUND: Central nervous system dysfunction continues to be a major cause of morbidity after aorta and cardiac surgery under cardiopulmonary bypass (CPB). Pupillary reflexes are important component of the neurologic examination. The purpose of this study was to evaluate how the pupil reacts during hypothermic CPB under fentanyl anesthesia and its relation with postoperative neurologic deficits. METHODS: Fourteen patients undergoing ascending aortic dissection or aneurysm repair surgery under profound hypothermic CPB and circulatory arrest were enrolled. Pupil size and light reflex were evaluated at varying stages of CPB and temperatures. Temperatures were measured at different sites of perfusate, nasopharynx and rectum. Postoperatively neurologic assessments were performed to compare with the pupillary signs. RESULTS: Anesthetic induction with fentanyl decreased pupil size to pinpoint. Pupil dilated progressively under hypothermic CPB reaching fully dilated size at profound hypothermia. Rewarming returned the pupil to original size. Nasopharyngeal temperature correlated well with pupil size during cooling and rewarming. Light reflex was absent at any stage or temperature after anesthetic induction. Seven patients showed insignificant anisocoria and two died of other causes than neurologic deficit. One patient who was not in the anisocoria group exhibited delirium. CONCLUSIONS: Profound hypothermic CPB under fentanyl anesthesia dilates the pupil to a maximum size without light reflex overwhelming narcotic effect. Fully dilated pupil does not denote neurologic damage.

Changes in Arterial to End Tidal CO2 Difference during Pediatric Open Heart Surgery: Cyanotic vs Acyanotic Congenital Heart Diseases / 대한마취과학회지

BACKGROUND: The arterial to end-tidal carbon dioxide tension difference(Pa-ETCO2) can be increased in patients with congenital heart disease(CHD) and, therefore, end-tidal carbon dioxide tension(PETCO2) does not accurately approximates arterial carbon dioxide tension(PaCO2). The purpose of this study was to evaluate the stability of the Pa-ETCO2 in pediatric patients with congenital heart disease undergoing open heart surgery. METHODS: Forty three children with CHD were studied: twenty two were acyanotic and twenty one were cyanotic. Simultaneous PETCO2 and PaCO2 measurements, as well as pulse rate, blood pressure, pH and arterial oxygen tension(PaO2) were obtained for each patient during four intraoperative events: (1) after induction of anesthesia and before sternotomy, (2) after sternotomy and before cardiopulmonary bypass(CPB), (3) after weaning of CPB, and (4) after closure of sternotomy. RESULTS: The PETCO2 of cyanotic group were lower than that of acyanotic group throughout operation period, and did not change significantly after CPB. Cyanotic children demonstrated a greater Pa-ETCO2 difference before CPB as compared with acyanotic group. In acyanotic group, Pa-ETCO2 difference increased significantly after CPB(P <0.05), whereas it remained unchanged in cyanotic group. CONCLUSIONS: Since cyanotic children had higher Pa-ETCO2 differences intraoperatively and acyanotic children showed an increase in Pa-ETCO2 after CPB, the PETCO2 cannot be the alternative value to estimate reliably the PaCO2 during open heart surgery of pediatric CHD.

Analysis of the Right Ventricular Pressure/Volume Relationship and Contractility During Liver Transplantation / 대한마취과학회지

BACKGROUND: Hemodynamic instability is one of the main concerns for anesthesiologists during orthotopic liver transplantation (OLTX). The most troublesome event would be an increase of central venous pressure associated with sudden right ventricular (RV) filling without any change in heart contractility. An acute increase in RV outflow pressure depresses RV contractility and eventually causes overt RV failure. To avoid such disaster, it would be wise to evaluate right heart pressure/volume relationship and assess contractility when anticipating acute increase of pressure in right heart chamber. METHODS: RV function was assessed in 15 patients undergoing OLTX. RV function was monitored using an ejection fraction catheter and a monitor. Complete hemodynamic profile was obtained on regular intervals. Statistical analysis was performed using ANOVA for repeated measures. Correlation between variables were determined by simple regression analysis and ANCOVA. RESULTS: RV end-diastolic volume was in the range of supranormal values. No correlation was observed between right atrial pressure and RV end-diastolic volume index (RVEDVI). There was a significant correlation between stroke index and RVEDVI. RV ejection fraction and E-single were relatively constant throughout the procedure. There was weak negative correlation between E-signle and RVEDVI. CONCLUSION: RV function appeared to be well preserved during OLTX. However, RV contractility tends to decrease in response to RVEDV increase because RVEDV of endstage liver disease might increase to their maximal value. Right heart filling pressure was less reliable clinical indicator of RV preload.

Effects of Atracurium in the Patients with Myasthenia Gravis Undergoing Thymectomy / 대한마취과학회지

BACKGROUND: Myasthenia gravis is an autoimmune neuromuscular disorder that shows increased sensitivity to nondepolarizing muscle relaxants. Atracurium is eliminated by Hofmann elimination and ester hydrolysis. We studied the onset and duration of atracurium in patients with myasthenia gravis. METHODS: Ten patients undergoing thymectomy for myasthenia gravis and ten patients of ASA Class I-II without liver, kidney and neuromuscular disease for orthopedic surgical procedures were assigned. Anesthesia was induced with thiopental (4~5 mg/kg) and maintained with inhalation of N2O:O2 (1:1) and enflurane (1.0~2.0 vol%). Atracurium (0.5 mg/kg) was given as a muscle relaxant and then intubation was performed after twitch response was depressed more than 80%. Neuromuscular relaxation was assessed by TOF (T1) at the adductor pollicis with supramaximal stimulation of ulnar nerve at 2 Hz every 12 seconds. The onset and the duration of 5, 25, 50, 75% recovery time of T1 and the recovery index were recorded. RESULTS: Onset of block was shortened and recovery time of 5, 25, 50, 75% and recovery index were prolonged in patients with myasthenia gravis. Conlusions: In patients with myasthenia gravis, atracurium induced rapid onset time and prolonged recovery time of 5, 25, 50, 75% and recovery index.

The Mechanism of Blood Flow Generation during Closed Chest Cardiac Massage: Transesophageal Echocardiographic Monitoring / 대한마취과학회지

The mechanism of forward blood flow during closed chest cardiac massage remains controversial. Two theories have been suggested: the cardiac pump theory and the thoracic pump theory. Case report is presented to illustrate the use of transesophageal echocardiography during cardiopulmonary resuscitation. The findings included right and left ventricular compression, closure of the mitral valve during compression, opening of the mitral valve during the release phase, and atrioventricular regurgitation during compression, indicating a positive ventricular-to-atrial pressure gradient. These findings suggest that direct cardiac compression was the predominant mechanism of forward blood flow during cardiopulmonary resuscitation in this patient. Transesophageal echocardiography offers a new approach for study of the flows and cardiac morphologic features during chest compressions in humans. An understanding of the actual mechanisms involved is necessary if improved cardiopulmonary resuscitative techniques are to be rationally developed for enhancing the outcome of resuscitation.

The Comparison of the Effect of Enflurane and Propofol on Arterial Oxygenation during One-Lung Ventilation / 대한마취과학회지

BACKGROUND: Controversy exists as to whether or not inhalation anesthetics and intravenous anesthetics impair arterial oxygenation (PaO2) during one lung ventilation (OLV). Accordingly, we examined the effect of enflurane and propofol on PaO2 and pulmonary vascular resistance (PVR) during OLV. METHODS: Forty patients, who had prolonged periods of OLV anesthesia with minimal trauma to the nonventilated lung were studied in a cross over design. Patients were randomized to four groups; Group 1 received 1 MAC of enflurane and oxygen from induction until the first 20 min after complete lung collapse, then were switched to propofol 100 g/kg/min (P100). In group 2, the order of the anesthetics was reversed. Group 3, Group 4 received the same order of the anesthetics as Group 1, Group 2, respectively but received propofol 200 g/kg/min (P200). RESULTS: During OLV, the PaO2 values were lower than those with two lung ventilation (TLV), there were no significant differences among each groups and between propofol and enflurane in PaO2, but in the selected patients (n=10, PaO2<120 mmHg during OLV), PaO2 in propofol group was higher than that of enflurane group (p<0.05). Conversion from TLV to OLV caused a significant increase in PVR, but there were no difference in PVR between propofol and enflurane group. CONCLUSIONS: These results suggest that the usual clinical dose of propofol affords no advantage over 1 MAC of enflurane anesthesia except low PaO2 patients during OLV. Propofol might be of value in risk patients of hypoxemia during thoracic surgery when OLV is planned.

An Analysis of the Social and Clinical Status of Organ Donation from Brain Death Donors / 대한이식학회지

BACKGROUND: Since the first successful kidney transplatation from a brain death donor(BDD) in 1979, organ transplantations from BDD have steadily increased. The legal definition of brain death has not yet been. However the number of BDDs have been increasing year by year. The purpose of this study is to analyze the social and clinical status of organ donation from BDDs. METHODS: We analyzed retrospectively the status of BDDs registerd for organ transplant program in Asan Medical Center from January, 1992 to March, 1997. RESULTS: The male to female ratio was 3:1, and the age distribution was the highest in twenties. Occupation distribution was the highest in students and distribution of religion was the highest in these who were non-believers. The distribution of cause of brain death was the highest in motor vehicle accidents. The blood type distribution was the highest in type A+, type B+, O+, and AB+ in order. The distribution of days stayed in ICU before organ donation was the highest in 3D, 2D, and 4D in order. The failure of organ donation was mainly very poor organ condition. CONCLUSIONS: We wish that these results were made use of bases of status of organ donation from BDDs.

An Anesthetic Experience for Automatic Implantable Cardioverter Defibrillator Implantation: A case report / 대한마취과학회지

Automatic implantable cardioverter defibrillator(AICD) is a device that senses ventricular tarchycardia and ventricular fibrillation and responses with counter-shocks to the heart. We experienced a case of AICD implantation to prevent sudden cardiac death. A-22-year-old male was operated under O2, N2o, fentanyl, low dose enflurane anesthesia. The diagnosis was familial long QT syndrome. Lead was introduced to the right ventricular apex through left subclavian vein and generator was placed between pectoralis muscles. Then defibrillation threshold testing was performed. Ventricular fibrillation was induced with Twave shock of 3 joule and defibrillation with 5 joule terminated ventricular fibrillation successfully. After ventricular fibrillation, his blood pressure decreased to 30mmHg. When ventricular fibrillation was converted to normal rhythm, it retured to normal range. After operation, patient was transferred to the ICU and stayed there for 3 days.

The Effect of Thiopental on Jugular Venous Oxygen Saturation during Rewarming in Cardiopulmonary Bypass / 대한마취과학회지

BACKGROUND: We examined the ability of thiopental known to have protective effect on brain to prevent brain damage resulting from cerebral ischemia due to global imbalance in cerebral metabolic rate for oxygen and cerebral blood flow during rewarming period in cardiopulmonary bypass. METHODS: Jugular venous oxygen saturation(SjO2) was used as a reflection of cerebral oxygen balance. Thiopental 20 mg/kg(thiopental 10 mg/kg bolus and 10 mg/kg continuous infusion) was received during rewarming from hypothermic cardiopulmonary bypass of 27~30.5degrees C to 36degrees C and SjO2 compared with control group. RESULTS: In 8 patients of the 25 control group(32%) and 7 patients of the 24 thiopental group(29.2%), SjO2 were < or =50% with no difference between groups. Artery-jugular vein oxygen content differences (C(a-j)O2) and O2 extraction ratios increased significantly in SjO2 < or =50% patients suggesting increased oxygen consumption. Awake time prolonged significantly with thiopental. CONCLUSIONS: Thiopental(20 mg/kg) administration during rewarming in cardiopulmonary bypass for cerebral protection is not recommended.

Acute Pulmonary Hypertension Associated with Protamine Neutralization of Systemic Heparinization during Open Heart Surgery / 대한마취과학회지

Protamine sulfate, a strong polycationic polypeptide, combined with acidic heparin to form a neutral salt, eliminates the anticoagulating properties of heparin. Heparin reversal with protamine after cardiopulmonary bypass may complicate with adverse hemodynamic effects including systemic hypotension, decreased cardiac output, changes in systemic and pulmonary vascular resistances, anaphylaxis and noncardiogenic pulmonary edema. We recently observed a case of severe pulmonary vasoconstriction with right ventricular failure after protamine administration in 37-year-old woman with mitral stenosis who underwent mitral valvuloplasty. After uneventful termination of cardiopulmonary bypass, administration of protamine was associated with sudden elevation of pulmonary arterial pressure with profound right ventricular distension and systemic hypotension by which heparin-protamine reaction is suspected. After intravenous epinephrine infusion and cardiac massage, these changes were reversed. Although the mechanism of this protamine-heparin induced response is unclear, complement activation and thromboxane release may play a role in the development of pulmonary vasoconstriction.

Anesthetic Management of 10 Heart Transplantation cases / 대한마취과학회지

BACKGROUND: For 3 years since November, 1992, when first heart transplantation was performed in Asan Medical Center, total of 16 heart failure patients underwent that operation with succesful results. We are describing anesthetic management of former 10 cases. METHODS: Retrospective study by reviewing patients' medical records. RESULTS: Recipients had severe heart failure and pulmonary hypertension. Their age distribution was between 22 and 50 years and ratio of male to female was 8:2. Careful administration of midazolam and fentanyl was the preferred induction method and vecuronium was used for both intubation and maintenance in most of the cases. High dose narcotic technique(fentanyl 100 microgram/kg) was satisfactory for the induction and maintenance of anesthesia. Sterile technique was used placing endotracheal tubes and catheterizations. After transplantation, dobutamine, dopamine, isoproterenol and isosorbide dinitrate(Isoket) were required to support venticular performances. At ICU, postoperative courses were uneventful. Average duration of ICU stay was 10 days. There was no mortality. CONCLUSIONS: Anesthetic management of heart transplantation patients regarding fentanyl anesthesia, sterile technique,inotropic drug usages were described.

Effect of Chloral Hydrate on Sedation and Arterial Oxygen Saturation in Children with Congenital Heart Disease / 대한마취과학회지

BACKGROUND: To study the effect of chloral hydrate oral premedication on sedation and arterial oxygen saturation in noncyanotic and cyanotic congenital heart disease children. METHODS: 18 noncyanotic congenital heart disease patients and 18 cyanotic congenital heart disease patients scheduled for cardiac surgery were premedicated orally with chloral hydrate 50 mg/kg. Arterial oxygen saturations were measured with pulse oximeter before and after oral premedication and sedation effects evaluated. RESULTS: In noncyanotic group oxygen saturation decreased from 98.7+/-0.95% (mean+/-?SD) before premedication to 97.8+/-1.15% after premedication with statistical significance but without meaning. 16 of the 18 patients (89%) were adequately sedated without airway obstructions. In cyanotic group oxygen saturation increased with statistical insignificance from 73.5+/-10.9% before premedication to 74.0+/-13.9% after premedication. 15 of the 18 patients(83%) were adequately sedated. Effects on oxygen saturation in cyanotic group patients were quite variable with 3 of the patients revealing more than 10% decrease in oxygen saturation. CONCLUSIONS: Chloral hydrate has a good sedative effects on congenital heart disease children but its effects on oxygen saturation were variable and close monitoring followed by oxygen administration is recommended in cyanotic heart patients.

Airway Management by Bougienation in Tracheal Stenosis: A case report / 대한마취과학회지

The incidence of tracheal stenosis is increased because of the longterm respiratory care with endotracheal intubation and tracheostomy. Present therapeutic modalities for the relief of an tracheal or bronchial stenosis include laser resection, radiotherapy, cryotherapy, bougienation, stent insertion, dilatation with balloon catheter and finally reconstruction surgery. However, reconstruction surgery have some problems in ventilation during anesthetic management. Small sized tube insertion through lesion, high frequency jet ventilation, cardiopulmonary bypass are served to resolve ventilatory problem. We experienced a case of severe tracheal stenosis due to tracheostomy. The stenotic lesion was 2.5 cm above the carina, 3 mm in diameter and length of the stenotic segment was 1 cm. We used bougienation with endotracheal tube replace obturator for the ventilation before the reconstruction surgery and the patient was successfully managed without complications.