Neuromuscular Blockade of Mivacurium Following the Duration of Isepamicin Intramuscular Injection in Rabbits / 대한마취과학회지

BACKGROUND: Isepamicin, a new aminoglycoside antibiotic, was usually administered to patients for prophylactic use. Mivacurium has a short duration of action. The current study was undertaken to evaluate the neuromuscular blockade of mivacurium following the duration of an intramuscular injection of isepamicin 20 mg/kg/d in rabbits. METHODS: In the first study, the dose-response relations of mivacurium were studied in forty rabbits during thiopental anesthesia. Rabbits were randomly assigned to four groups; group 1: normal saline 2 ml/d IM for 7 days; group 2: isepamicin 20 mg/kg/d IM for 1 day; group 3: isepamicin 20 mg/kg/d IM for 3 days; group 4: isepamicin 20 mg/kg/d IM for 7 days. They received mivacurium 10, 20 and 30ng/kg in groups 1, 2 and 3; mivacurium 20, 30 and 40ng/kg in group 4, respectively. In the second study, time courses of action of mivacurium 0.18 mg/kg in forty rabbits were evaluated in each group. RESULTS: The calculated ED50 for mivacurium in groups 1, 2, 3 and 4 were 19.2 +/- 3.1ng/kg, 15.4 +/- 3.7ng/kg, 20.1 +/- 3.5ng/kg and 31.2 +/- 4.4ng/kg, respectively and corresponding ED95 was 29.9 +/- 3.7ng/kg, 22.1 +/- 4.5ng/kg, 30.1 +/- 5.9ng/kg and 43.4 +/- 5.1ng/kg, respectively. There were significant differences between group 4 and the others (P < 0.05). In the second study, the times after mivacurium 0.18 mg/kg until 95% twitch recovery in groups 1, 2, 3 and 4 were 35.1 +/- 5.1 min, 42.2 +/- 6.2 min, 32.8 +/- 4.9 min and 24.9 +/- 3.6 min, respectively. There were significant differences between group 2 and others, and between group 4 and group 1 or 3, respectively (P < 0.05). CONCLUSIONS: Mivacurium when used as a bolus isepamicin therapy, has both an increased potency and a longer duration of action, but when used during concurrent isepamicin therapy, has both a decreased potency and a shorter duration of action.

Fos Expression in the Brain of Neuropathic Pain Rats / 대한마취과학회지

BACKGROUND: There have been some investigations regarding expression of c-fos, as a marker of altered neuronal expression in the spinal cord of neuropathic rats. However, the expression of c-fos in the brain of a neuropathic pain model has not yet been investigated. The purpose of this study was to evaluate the time course of c-fos expression in the brain of neuropathic pain rats. METHODS: The experimental rats were divided into two group; neuropathic pain (n = 16) and control (n = 16) groups. The left L5 L6 spinal nerves of the neuropathic pain group were ligated but those of the control group not ligated (sham operation). Two hours, 1st day, 3rd day and 7th day after the operation, we examined the expression of Fos in the cerebral cortex, the amygdala, the thalamus and the hypothalamus of the coronary sectioned brains of the rats. RESULTS: C-fos expressions in the cerebral cortex and the amygdala of the neuropathic pain group were greater at 2 hours, the 3rd and the 7th day than the control group, but those of the thalamus and hypothalamus of the neuropathic pain group were greater on the 3rd and 7th day than the control group (P< 0.05). In the neuropathic pain group, c-fos expressions of four brain regions were greater on the 3rd and 7th day than those at 2 hours and day 1, but there was no difference between the 3rd and 7th day's (P< 0.05). CONCLUSIONS: There were significant expressions of Fos protein in the brain of the neuropathic pain group at 2 hours, the 3rd day and 7th day of the operation, but the meaning of each expression was different. The expression of Fos at postoperative 2 hours resulted from acute pain but that at the 3rd and 7th day of the operation resulted from neuropathic pain.

The Effects of Single Epidural Triamcinolone Injection on the Blood ACTH and Cortisol Level / 대한마취과학회지

BACKGROUND: Epidural steroids injections are often used for the treatment of low back pain but their effects on the endocrine system have not been determined. Few studies have quantified the degree or duration of the suppression of the hypothalamic-pituitary-adrenal (HPA) axis in humans given epidural triamcinolone injection (ETI) for low back pain. The evaluation of the blood adrenocorticotropic hormone (ACTH) and cortisol was undertaken to determine the extent of suppression of the HPA axis in patients given ETI. METHODS: Lumbar epidural triamcinolone injections were performed on the painful lumbar intervertebral space with patients in the lateral decubitus position. The injection consisted of 40 mg of triamcinolone acetonide diluted in 10 mL of 1% lidocaine. Patients remained in the lateral position for 10 min after the procedure. Basal blood sampling was performed at 30 min before ETI and tested blood sampling was obtained at 7 days, 10 days, and 14 days after ETI. RESULTS: The blood cortisol level was significantly decreased at 7 days and 10 days but at 14 days was not significantly decreased and the blood ACTH level was not significantly decreased at 7 days, 10 days, and 14 days. CONCLUSIONS: Above results demonstrate that blood ACTH and cortisol level normalize 7 days and 14 days, respectively, after epidural triamcinolone 40 mg injection.

The Ventilatory and Cardiovascular Changes during Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: Laparoscopic cholecystectomy has emerged rapidly as a popular alternative to tradidonal laparotomy and cholecystectomy in the management of cholelithiasis. The advantages of shorter hospital stay, more rapid return to normal activities are combined with less pain associated with the small limited incisions. But it has some disadvantages related to insufflation of a large amount of carbon dioxide into peritoneal cavity. METHODS: To investigate ventilatory and hemodynamic changes during laparoscopic cholecystectomy, we observed the changes in blood pressure (systole, diastole, mean), heart rate, end-tidal carbon dioxide tension (PerCO2), arterial carbon dioxide tension(PaCO2), and arterial oxygen tension(PaO2) at intervals during general anesthesia with controlled ventilation (tidal volume: 10 mg/kg, ventilatory rate: 10 breaths/min). RESULTS: Mean arterial pressure was increased significantly until 30 minutes after carbon dioxide insufflation(p<0.05). Heart rate was not changed significantly throughout the operation. End-tidal carbon dioxide tension and arterial carbon dioxide tension were increased significantly during carbon dioxide insufflation(p<0.01), but arterial oxygen tension was not decreased significantly throughout the operation. CONCLUSIONS: This study described 19 patients who underwent laparoscopic cholecystectomy and analyzed the changes in hemodynamic and ventilatory parameters. It is important for anesthesiologist to monitor ventilation and hemodynamics carefully because the patients with cardiac or pulmonary diseases may be adversely affected by the hypercarbia associated with carbon dioxide insufflation.

Effect of Pre-vs. Post-incisional Lidocaine Infiltration on Postoperative Pain after Inguinal Herniorrhaphy / 대한마취과학회지

BACKGROUND: Recently many studies reported that the postoperative pain was prevented or decreased from preoperative regional anesthesia by preventing the establishment of central sensitization(pre-emptive analgesia). Therefore, we evaluated the efficacy of preincisional lidocaine infiltration on the postoperative pain. METHODS: We conducted a study to compare preinfiltrating group with 1% lidocaine (30 ml), postinfiltrating group with 1% lidocaine (30 ml) and non-infiltrating group in 45 patients scheduled for elective inguinal herniorrhaphy. During operation, all patients received a general anesthesia with thiopental, isoflurane and nitrous oxide in oxygen. Postoperatively, pain scores on visual analogue scale (VAS) and on verbal rating scale(VRS) at rest, coughing and movement from supine into sitting position were assessed. Also the time to first request for an on-demand postoperative analgesics and the total dose of postoperative analgesics were assessed. And the number of patients who didn't require any analgesics during postoperative period was assessed. RESULTS: The VAS and VRS at rest, coughing, movement were low in preinfiltrating group than in non-infiltrating group and postinfiltrating group postoperatively, but it was statistically significant only in early postoperative period. The time to first request for an on-demand postoperative analgesics occurred later in preinfiltrating group than in non-infiltrating group and in postinfiltrating group and the total dose of supplemental analgesics (ketorolac) was smaller in the preinfiltrating group than in non-infiltrating group and postinfiltrating group, and the patients without analgesic treatment was less in the preinfiltrating group than in non-infiltrating group and postinfiltrating group, but it was not statistically significant. CONCLUSIONS: In patients with inguinal herniorrhaphy, we can not support the pre-emptive analgesia clinically with preincisional lidocaine infiltration.

Anesthetic Experience of Adrenalectomy with Primary Aldosteronism / 대한마취과학회지

Primary aldosteronism is a clinical syndrome referring to increased and inappropriate production of aldosterone from adrenal gland due to a solitery adenoma, bilateral hyperplasia or an adrenal carcinoma and this syndrome is characterized by hypertension, hyporeninemia, and hypokalemia and its manifestations. Under the general anesthesia, operation was performed on a 34-year-old male, who was diagnosed as primary aldosteronism caused by aldosterone producing adenoma and we have experienced the anesthetic management of unilateral adrenalectomy during perioperative periods.

The Effect of Labetalol on the Hemodynamic Response to Endotracheal Intubation / 대한마취과학회지

Transient increases in blood pressure and heart rate following laryngoscopy and endotra- cheal intubation are common. These stress responses are greatly exaggerated in patients with hypertension and cardiovascular diseases and can lead to cardiac arrhythmia, pulmo- nary edema, and cerebral hemorrhsge. Many approaches have been tried to attenuate these potentially adverse circulatory responses but none has been satisfactory. This study was made to evaluate the hemodynamic responses to tracheal intubation using combined alpha-and beta-adrenoreceptor blocking agent, labetalol. We intravenously administered labetalol or placebo prior to laryngoscopy and tracheal intubation in adult patients with ASA class 1, or 2. Sixty patients were randomly assigned to one of three treatment groups. Group 1 patients (control group,n=20) received normal saline 3ml, Group 2 patients (n=20) received labetalol 0.3mg/kg, and Group 3 patients (n= 20) received labetalol 0.6mg/kg intravenously. These drugs were injected 3 minutes before induction with thiopental sodium (5mg/kg). Succinylcholine chloride 1.0mg/kg i.v. was used to facilitate endotracheal intubation. After the completion of intubation, nitrous oxide/oxygen with enflurane or isoflurane was administered. The blood pressure and heart rate were measured upon arrival in the operating room (baseline), immediately before intubation, immediately after intubation, 1 minutes after intubation and at 2, 3, 5, 7, 10 minutes after intubation. There were no significant differences in preinduction values of blood pressure and heart rate. A significant reduction in heart rate was observed in the group 3, group 2 in that order compared with the group 1. Similarly, systolic, diastolic and mean arterial pressure de- creased in labetalol groups, but was not significantly different in all groups. None of the patients experienced any untoward side effects, such as hypotension, aignificant bradycardia, bronchospasm or electrocardiographic ehanges. In conclusion, in patients with no history of hypertension or significant cardiac disease, labetalol 0.3 or 0.6mg/kg i.v. is better suited to blunting tachycardia than to blunting hypertension to laryngoscopy and intubation.

Study about Hypothermic - anesthesia during Intraperitoneal Hyperthermo - chemotherapeutic Perfusion Combined with Surgery in Far - advanced Stomach Cancer / 대한마취과학회지

Intraperitoneal hyperthermic perfusion(IPHP) is gaining popularity in the world as a method of prevention and treatment of peritoneal metastasis following gatrointestinal cancer. The procedure presents significant problems to the anesthegiologist with regard to tempera- ture control, fluid and electrolyte balance, acid-base change and postoperative care. During IPHP, there is a potential for heat gain from the peritoneal cavity. Several workers have reported a significant increase in core temperature. Therefore, it is true that accurate monitoring of temperature is essential. We studied that acid-base balance, electrolyte balance, level of blood suger following core temperature change in Intraperitoneal Hyperthermo-chemotherapeutic Perfusion patients.

Severe Bradycardia & Hypotension during Spinal Anesthesia / 대한마취과학회지

Spinal anesthesia has been widely used for operations performed in the lower abdomen, inguinal regions, lower extremities, and perineum. When patient have aevere systemic disease and a full . stomach, spinal anesthesia is may be more safe than general aneethesia. Bradycardia and hypotension have been accepted to be the most common complications in cardio-vascular system during spinal anesthesia. The mechanisms are a decrease in total peripheral vascular resistance, a decrease in cardiac output or a combination of both. Accessory factors include bradycardia resulting from block of accelerator impulses to the heart or decrease in endogeneous release of norepinephrine from sympathetic nerve endings, thereby reducing myocardial contractility. We report 2 cases of sudden extreme bradycardia and hypotension in patients who had received spinal anestesia. Although the exact pathophysiology of this phenomenon is unknown, the etiology is probably vagal effect. Thus the patient who receives spinal anestbesia should be required constant monitoring and vigilance throughout all procedures.

The Comparison of Vecuronium with Succinylcholine for Endotracheal Intubation / 대한마취과학회지

Depolarizing muscle relaxant, succinylcholine, has a rapid onset of action, allowing early endotracheal intubation. Succinylcholine, however, has a number of undesirable side effects. Therefore, some methods using nondepolarizing muscle relaxants for rapid endotracheal intubation have been tried, i.e. single large bolus, priming principle, timing principle, but their results were not enough to satisfy. In this study, there were administered vecuronium prior to anesthetic induction in order to shorten the intubation time, and compared intubation time and intubating condition in succinylcholine and vecuronium groups respectively. Sixty adult patients were adminstered succinylcholine 1mg/kg(group 1, 30 patients) or vecuronium 0.15 mg/kg(group 2, 30 patients), and measured intubation time and intubating condition. As a result, intubation time and intubation condition was not different in both groups significantly. It is concluded that vecuronium administered prior to induction agent for the endotracheal intubation is a reliable alternative in cases where succinylcholine is contraindicated.

The Comparison of Vecuronium with Succinylcholine for Endotracheal Intubation / 대한마취과학회지

Depolarizing muscle relaxant, succinylcholine, has a rapid onset of action, allowing early endotracheal intubation. Succinylcholine, however, has a number of undesirable side effects. Therefore, some methods using nondepolarizing muscle relaxants for rapid endotracheal intubation have been tried, i.e. single large bolus, priming principle, timing principle, but their results were not enough to satisfy. In this study, there were administered vecuronium prior to anesthetic induction in order to shorten the intubation time, and compared intubation time and intubating condition in succinylcholine and vecuronium groups respectively. Sixty adult patients were adminstered succinylcholine 1mg/kg(group 1, 30 patients) or vecuronium 0.15 mg/kg(group 2, 30 patients), and measured intubation time and intubating condition. As a result, intubation time and intubation condition was not different in both groups significantly. It is concluded that vecuronium administered prior to induction agent for the endotracheal intubation is a reliable alternative in cases where succinylcholine is contraindicated.

Anesthetic Management in Patient with Myasthenia Gravis / 대한마취과학회지

Myasthenia gravis is a disease characterized by muscle weakness upon exertion of an involved muscle group and partial return of function eithe with rest or the administration of anticholinesterase. It is generally thought that myasthenia gravis is caused by an autoimmune response associated with the thymus gland and thymectomy is considered to be the treatment of choice for countering this autoimmune process. It is a well known fact that perioerative nticholinesterase therapy, muscle relaxant administration during operation and postoperative respiratory management are in dispute. We described a case of a 42 year old male myasthenic patient with mild symptoms who needed 4 days of artificial ventilatory support following thymectomy.

The Clinical Comparative Stndy on Liver Function with Enflurane and Halothane Anesthetics / 대한마취과학회지

Halothane was introduced in 1956. It has been used worldwidely as a relatively safe inhalation anesthetic but it is generally accepted that it can cause decrease of liver function. But the causative factor has not yet been pinpointed. Enflurane also seems to decrease liver function but the exact cause is not yet known. In order to study the effects of enflurane and halothane on liver function, we used 10 cases of spinal anesthesia as a control group, and 20 cases each of enflurane and halothane anesthesia respectively as experimental group. We then checked serum GOT, GPT, total bilirubin, alkaline phosphatase, and eosinophil count in peripheral venous blood before oeration and 6 days after operation and looked for the existence of high fever of more than 39 degrees C 3 days postoperatively. The results are as follows: 1) We found statistical significant change of serum GOT, GPT, total billirubin alkaline phosphatase and eosinophil count in spinal, enflurane, or halothane anesthesia beofre and after operation. There was no statistically significance between the control and experimental groups. 2) No patient developed high fever of more than 39 degrees C until 3 days after anesthesia in any group. 3) No significant change of mean arterial blood pressure was observed before and during anesthesia in each group. In this study no definite conclusion that enflurane and halothane might have affected the liver function.

Clinical Observation of the Patient who recieved Blood Transfusion / 대한마취과학회지

It is a well known fact that the best method of determinign need ofr transfusion is the accurate measurement of blood loss related to the patient's status and surgical maneuvers during operation. There are many complications of blood transfusion and their pathophysiologic mechanism, and theprevention and management has been discussed. Among the complications of blood transfusion, urticaria is the most common symptom. The pathophysiologic mechanism of urticaria is understood in some degree at the present time but there are many different opinions as to its prevention and management. Furthermore antihistamine has been widely used for the prevention of urticaria but there are many debatable events about the use of antihistamine. This study was undertaken to investigate the recent reports concerning the use of antihistamine for the prevent in and management of urticaria. Two hundred eighty eight transfused patients among the total of six thousand four hundred forty eight surgical cases done at the Hanyang University hospital from January 1st to December 31th 1983. were reviewed. The result are as follows: 1) The incidence of urticaria was 28 cases (9.72%) among the 288 transfused cases and there was no sex difference. 2) The age distribution was 10 cases (12%) in the 2nd decade and 9 cases(11.3%) in the 4th decade. 3) The lowest incidence of urticaria was 5 cases (5.3%) with A blood type and high of incidence with B, O and AB blood type. 4) The physical status of class 3 was seem in 10 cases(43.5%) as the most common occurrence of urticaria. 5) The highest incidence of urticaria was observed in 9(45%) of 20 obstetric cases. 6) There was no significant differnece of urticaria incidence between the groups which did and did not use antihistamine. Also in the group which received histamine 10 minutes before treansfusion there was a significant decreases 6 cases (3.41%) among the 178 transfused cases. 7) There was no significant statistical difference between blood loss and transfused blood volumes. 8) There was no significant statistical change in the mean values of hemoglobin and hematocrit which were measured preoperatively, in recovery room and 24 hours after operation. 9) In the patient's who were tranfused with more than 10 oints of whole blood, urticaria developed in 9 cases (50%) among 18. From the results of this study, I consider the most effective method for the prevention of urticaria to be the administration of histamine 10 minutes before transfusion. Further investigation of this method will be carried out.

Clinical Study of Electrical Stimulation of the Peripheral Nerve / 대한마취과학회지

Recent studies in western countries have reported that the mechanism pf pain are concorded with gate control opiage receptor binding sites and the release of intrinsic morphine like substances, sodium glutamate and also with bradykinin, seroconin, histamine and prostaglandin E. Otherwise the mechanism of the stimulstion producing analgesia has been reported to involve a neurophysiologic and neurohumoral inhibitory effect at the level of spinal cord, brain stem, thalamus and cortex. This has been clarified but further study should improve the chance of understanding the mechanism of pain. From the standpoint of pain management, medications used to manage pain have some unfortunate side effects. nerve blocks cause anesthesia toxicity, major neurosurgical procedures have many complications. Subarachnoidal and epidural analgesics have unknown irritation pneumonia and drug toxicity, and plexus or pituitary gland block with phenol or alcohol has uneventful complication. From January 1980 to December 1982, electrical acupuncture stimulation has been used on 210 cases at HANYANG university hospital in the pain clinic. I found it useful in relieving pain which has not responded to various conventional methods which included medications, nerve blocks, neurosurgical intervantion and neuropolytics. The results are as follows: 1) There are two kinds of treated patients: One is consultation case-12 from internal medicine, 16 from orthopedic surgery, 10 from neurosurgical and 2 from psychiatry. Another 170 cases were patients who directly to the clinic. And the age distribution shows the highset number of patients in the 3rd decade(21%) and in the 4th decade(24.8%). 2) The region of pain was 21% lumbar, 13.8% shoulder, 10% lower leg and head or face with 9.5%. 3) The duration of the pain showed 10 days 25.7%, 1~2 month 18.6%, one year 11.4% and the longest up to 20 years. 4) Patients who were able to walk into the clinic were 19.5%, moderate cases who to be accompanied were 58.6% and bedridden cases were 21.9%. 5) Treatment was conducted mainly on low frequency stimulation with various waves that included the general dynamic activity point plus reactive electro permeable point (REPP) 81.9% and REER plus head in situ needle 18.1%. 6) In 16.7% only one treatment was administered, in 46.1% 2~5 treatments were given, in 28.6% 6~10 treatments were given and in 3 cases more than 100 treatments were administered. 7) Of the 210 cases, 43.3% showed marked improvement, 41.4% were improved, 13.8% showed translent improvement and there were 3 cases of no improvement. The total confidence was 84.7%. 8) There are no serious complications except hypertensive shock case, submucosal hemorrhagic petechia 7 cases and generalized fatigue 18 cases. In conclusion, electrical acupuncture stimulation of the peripheral nervous system can be used to relieve pain replacing such conventional means as medications, nerve blocks, major neurosurgical procedures, neuroytics and physiopsychic therapy which are generally less effective.

Influence of Flunitrazepam on the Adverse Effects of Succinylcholine Chloride / 대한마취과학회지

Intravenous succinylcholine is often associated with adverse effects, including muscle fasciculation, postoperative myalgia, increased intraocular and intragastric pressure, along with potassium and creatinine phosphokinase, myoglobinuria, and disturbances in cardiac rate and rhythm. Several methods have been used to modify these side effects, the most popular of which has been the of subparalyzing doses of nondepolarizining relaxants prior to injection of succinylcholine. With such pretreatment however satisfactory muscular relaxation is often not achieve, necessitaing use of larger doses of succinylcholine becauses pretreatment renders the endplateless sensitive to succinylcholine; hence large doses of succinylcholine are necessary to ensure adquate degress of relaxation. The present investigation was undertaken to determine the effects of flunitrazepam on the adverse effects of succinylcholine. This paper covers the period from March, 1981 to March, 1982 in the Department of Anesthesiology, Hanyang University Hospital. The 45 subjects were divided into 3 groups: 1) propanidid (8mg/kg) with succinylcholine 2) flunitrazepam(0.03mg/kg) with succinylcholine 3) flunitrazepam(0.06mg/kg) with succinylcholine. None had existing neuromuscular disease nor were any patients receiving diazepam or any drug known to influence myoneural blocking agent. Patients with burns, muscle injury of muscle atrophy were excluded. In each group, the plasma concentration of potassium and creatinie phosphokinase was observed before and 10 minutes after use of succinylcholine. Also succinylcholine in duced myalgia, fasciculation, onset of loss of eyelid reflex and relaxation were observed and compared. The conclusions are as follows: 1) There were no significant changes of plasma concentration of potassium and creatinine phosphokinase in presuccinylcholine and 10 minutes postsuccinylcholine. Also any statistically significant changes were not observed in the comparison of the propanidid group and the flunitrazepam groups. 2) Flunitrazepam significantly diminished the incidence of postoperative muscle pain and it was shown that the degree of fasciculation has no relationship with succinylcholine induced muscle pain. 3) In the propanidid group, the onset of loss of eyelid reflex was most rapid(22+/-13 second). In the flunitrasepam 0.03mg/kg group, the onset of loss of eyelid reflex was statistically significant (p<0.05), as compared with the 0.06mg/kg group(42+/-27 second). 4) In all groups, excellent conditions of intubation were observed. Propanidid and flunitrazepam did not affect the magnitude nor duration of the succinylcholine neuromuscular block.