Carbon Dioxide Retention after Non-Cardiac Surgery in a Patient with Cor Pulmonale

Regional anesthesia is generally recommended over general anesthesia for non-cardiac surgeries in patients with severe pulmonary hypertension (PH) caused by pulmonary disease. However, pre-, and intra-, postoperative management are critical for patients with severe PH even when regional anesthesia is performed. This is the first reported case of carbon dioxide retention and administration of the appropriate treatment during non-cardiac surgery performed under spinal/epidural anesthesia and analgesia in a patient diagnosed with chronic cor pulmonale accompanied by severe PH.

Comparison of the central venous pressure from internal jugular vein and the pressure measured from the peripherally inserted antecubital central catheter (PICCP) in liver transplantation recipients / 대한마취과학회지

BACKGROUND: Unlike its use during stable conditions, central venous pressure (CVP) monitoring from a peripherally inserted central venous catheter (PICC) has not often been used in surgeries with significant hemodynamic alterations. The aim of this study was to evaluate the feasibility of measuring PICC pressure (PICCP) as an alternative to measuring centrally inserted central catheter pressure (CICCP) in adult liver transplantation (LT) patients. METHODS: We measured PICCP and CICCP simultaneously during each main surgical period in adult LT. Statistical analysis was performed using simple linear regression analysis to observe whether changes in PICCP paralleled by simultaneous changes in CICCP. Correlation analysis and Bland-Altman analysis were used to determine the degree of agreement between the two devices. Differences were considered statistically significant when P values were less than 0.05. RESULTS: A total of 1342 data pairs were collected from 35 patients. The PICCPs and CICCPs were highly correlated overall (r = 0.970, P < 0.001) as well as at each period measured. The differences among each period were not clinically significant (0.33 mmHg for pre-anhepatic, 0.32 mmHg for anhepatic, -0.15 mmHg for reperfusion, and -0.10 mmHg for neohepatic periods). The overall mean difference was 0.14 mmHg (95% confidence interval: 0.09-0.19) and PICCP tended to give a higher reading by between 0.09 and 0.19 mmHg overall. The limit of agreement was -1.74 to 2.02 overall. CONCLUSIONS: These findings suggest that PICCP can be a reasonable alternative to CICCP in situations of dynamic systemic compliance and preload, as well as under stable hemodynamic conditions.

Unpredicted tachycardia and hypotension in a patient with medullary thyroid cancer and undiagnosed pheochromocytoma: A case report / 대한마취과학회지

A 35 year old woman with hypercalcitoninemia was scheduled for an operation to treat her medullary thyroid cancer (MTC). TIVA with propofol and remifentanil was planned, and about 3 minutes after the infusion of anesthetics, her heart rate was suddenly elevated to 180/min and the systolic blood pressure was lowered to nearly 50 mmHg. The blood pressure returned to normal after the injection of phenylephrine 100 microgram and a rapid infusion of 700 ml crystalloid solution. After the operation, bilateral pheochromocytoma and a RET proto-oncogene mutation related with multiple endocrine neoplasia 2A (MEN-2A) were found. Patients with MTC can present with peripheral vasodilation and relative hypovolemia that are related with hypercalcitoninemia. Patients with MEN-2A can be anesthetized for a MTC operation without the appropriate preparation for their pheochromocytoma. Therefore, we suggest that patients with MTC and hypercalcitoninemia should be cautiously anesthetized with TIVA. They also should be screened for pheochromocytoma and the RET proto-oncogene mutation to prevent deleterious hemodynamic events during anesthesia.

Relationship Between Pain Threshold and Postoperative Morphine Requirement / 대한마취과학회지

BACKGROUND: Variability in pain sensitivity is a well known phenomenon. The variability also extends to experimental stimuli and postoperative opioid requirement. But the report of the relationship between pain threshold and postoperative opioid requirement is very rare. METHODS: We investigated prospectively the association between pressure pain threshold and postoperative morphine requirement. We estimated pressure pain threshold by using pressure algometer and adopted PCA to treat postoperative pain. RESULTS: In this study the relationship between pain threshold and postoperative opioid requirement was significant. But the correlation was weak negative (Pearson r = -0.273, P < 0.05). CONCLUSIONS: Considering other associated factors which affect postoperative pain, although correlation between pain threshold and postoperative opioid requirement was significant but we concluded that clinical relevance of pain threshold is uncertain.

Metastsectomy a Feasible Treatment in Selected Patients with Gynecologic Malignancy / 대한산부인과학회잡지

To report cases of metastasectomy for metastatic gynecologic malignancies, we reviewed the medical records of all patients who have undergone metastasectomy for metastatic gynecologic malignancies in Center for Uterine Cancer from June 2001 to October 2002. Six patients were identified with median age of 55 years (range 52-66 years). The metastatic sites and primary sites were as follows: 3 liver metastasis from ovary; 1 abdominal wall metastasis from uterus (endometrial cancer), 1 brain metastasis from ovary, 1 lung metastasis from uterus (sarcoma). The median disease free interval was 48 months (range 10 months-13 years). There was no perioperative mortality. Postoperative morbidity was tolerable with 1 case of bile leakage. In three patients with hepatectomy, one patient was dead of disease after 15 months, one patient is alive with disease at 20 months of follow up, one patient have no evidence of recurrence at 7 months follow up. The patient with brain metastasis was dead due to lung metastsis after 9 months later postoperatively. Remaining two patients with abdominal wall and lung metastasis have no evidence of tumor recurrence at 4, 7 months follow up respectively. Metastasectomy for metastatic gynecologic malignancies can be performed safely and may help prolong survival in carefully selected patients.

Comparison of Pseudocholinesterase Activity between Nonpregnant and Term-pregnant Women with the Genotypically Normal Enzyme / 대한마취과학회지

BACKGROUND: Many reports on the change of pseudocholinesterase activity in pregnant women showed that it declines during pregnancy and in the immediate postpartum period. In Korea, there are two papers that show dissident results. However, they didn't prove that the subjects in their studies had genotypically normal enzyme. So, we compared the pseudocholinesterase activities between nonpregnant and term-pregnant women who have the genotypically normal enzyme. METHODS: We measured the dibucaine, fluoride, chloride number as well as the pseudocholinesterase astivity using butyrylthiocholine as substrate by automatic analyser, urea and scoline numbers using benzoylcholine as substrate by manual technique in nonpregnant(n=15) and term-pregnant(n=15) women aging 20 to 40 years old before induction of anesthesia. RESULTS: The dibucaine, fluoride, chloride, urea and scoline numbers(mean+/-SD,%) in female subjects were 86+/-1.2, 50+/-5.2, 5+/-2.4, 47+/-2.8 and 92+/-2.0, respectively. There were two subjects showing low pseudocholinesterase activity(<4.8 U/ml) and the one(3.9 U/ml) was in nonpregnant group, the other(4.5 U/ml) in term-pregnant group. We found that they had genotypically normal enzymes because their inhibition numbers were within normal ranges. Pseudocholinesterase activity(mean+/-SD) in term-pregnant group(7.04+/-1.30) was significantly decreased compared with that in nonpregnant group(9.15+/-2.01)(P<0.01). CONCLUSIONS: We conclude that in subjects with the genotypically normal enzyme, term-pregnant women had significantly lower pseudocholinesterase activity than nonpregnant ones did.

Inhibition Numbers of Pseudocholinesterase in Korean Adults / 대한마취과학회지

Pseudocholinesterase is an essential enzyme for hydrolysis of succinylcholine and some people has low activity. The pseudocholinesterase from a normal individual has a greater apparent affinity for the cholinester substrate than the enzyme from succinylcholine-sensitive individuals, who has genetic variants. The ideal situation would be one in which a single, simple test would detect and identify all the variant forms of enzyme, but no such test currently exsits. The inhibitors frequently used to identify variants are dibucaine, fluoride, chloride, urea or succinylcholine as inhibition numbers. The authors found that dibucaine, fluoride and chloride numbers in Korean adults (mean+/-SD, %) are 85.8+/-1.83, 46.5+/-2,05 and 3.53+/-1.64, respectively (substrate is butyrylthiocholine).

Influence of age and sex on pseudocholinesterase activity of Korean adults / 대한마취과학회지

Serum pseudocholinesterase activities, using butyrylthiocholine as substrate, measured in 639 employees of Korea Cancer Center Hospital in 1993. Overall mean value of pseudocholinesterase was 9.38+/-2.10 U/ml, 10.6+/-2.10 U/ml in male, and 8.58+/-1.67 U/ml in female, respectively. Male in the first five decades of life had higher pseudocholinesterase activity than female, and after the age of 50 tbere was no intersexual difference. These findings suggest that adults before the age of 50, male has higher pseudocholinesterase activity than female.

Silicone Covered vs. Non-covered Endotracheal Self-expandable Metallic Stent: An Experimental Study

PURPOSE: To evaluate pathologic changes of the trachea and the lung after insertion of silicone covered and non-covered Gianturco stent in the trachea of dog. MATERIALS AND METHODS: Silicone covered(covered) and non-covered(bare) Gianturco stents, six in each, were inserted into the tracheal lumen of six consecutive dogs. After 1--10 week observation, the dogs were sacrificed and their tracheas and lungs were examined grossly and histopathologically. Serial chest radiographs were performed to evaluate pneumonia and stent migration every 3--5 days. RESULTS: Pneumonia was observed in one of bare stent group and five of covered stent group. Stent migration was noted in three of covered stent group. In bare stent group, the epithelium of the trachea was markedly thickened by hyperplasia and stent was covered by granulation tissue from 6 weeks after stent insertion. Inflammation was focal at contact site between the stent and the trachea. In covered stent group, the epithelium was denuded at multiple areas and there were multifocal squamous metaplasia of the mucosa. Inflammatory reaction of the trachea was diffuse. CONCLUSION: Inflammatory reaction was more severe and stent migration was more frequent in covered stent group. The use of covered stent in the trachea should be studied further.

Anesthesia for Myasthenia Gravis following preoperative plasmapheresis / 대한마취과학회지

Myasthenia gravis is believed to be an autoimmune disease involving morphologic and electrophysiologic disturbances of motor end plates brought about by circulating antibodies against acetylcholine receptors. Its treatment includes the use of steroids, anticholinesterase, immunosuppression and plasmapheresis. Plasmapheresis, in particular, is used either as a stand-alone temporary measure for its often dramatic, though short-lived, effect, or as an adjunctive treatment. Plasmapheresis is considered to be essential not only in preventing and treating myasthenic crisis but in preoperative management of myasthenia gravis, usually before thymectomy. the authors here report a case of myasthenia gravis that underwent preoperative plasmapheresis followed by the use of atracurium for muscle relaxation during anesthesia for thymectomy.

The comparison among Mechanical, Electromyographic and Accelerographic responses during recovery from vecuronium induced neuromuscular blockade / 대한마취과학회지

As the use of muscle relaxants routinize in the clinical general anesthesia, the proper estimation of neuromuscular blockade and recovery is needed for the more safe anesthetic management. Three recording methods of measurement in recovery are available; measurement of the evoked mechanical responses (mechanography), measurement of the evoked electrical responses (electromyography), and measurement of the acceleration of the muscle responses, The purpose of this study was to evaluate the correlations among mechanomyographic, electromyographic and accelerographic responses during recovery from vecuronium induced neuromuscular blockade. 15 ASA class 1 adult patients were studied. Measurements were as follows: 1) Recovery time of T(1)/Tc, of 25%, 50%, 75%, 90% and 100% in each device. 2) Recovery index in each device 3) The values of T(1)>Tc, in EMG and ACC corresponding ta that of MMG. 4) The values of TOF ratio in EMG and ACC corresponding to that of MMG. The results were as follows: 1) Recovery time of T(1).

Effects of Diltiazem on cardiovascular functions and oxygenation during sevoflurane anesthesia in dogs / 대한마취과학회지

Diltiazem was administered by two different dosages with 200 ug/kg 1V+10 ug/kg/min infusion, 400 ug/kg 1V+20 ug/kg/min infusion, in order to assess the interaction between sevoflurane and diltiazem on the cardiovascular function and oxygenation in dogs during inhalation of 1.0 MAC of sevoflurane. Significant decrease in heart rates, mean arterial pressure, pulmonary vascular resistance, systemic vascular resistance, coronary perfusion pressure were observed. Subsequently rate pressure product, as a parameter of myocardial oxygen consumption, decreased with no significant changes of oxygen extraction ration in 1.0 MAC of sevoflurane anesthesia with the above dosages of diltiazem in dogs. The author concludes that concomittent use of diltiazem in clinical doses induced tolerable hemodynamic depression and no untoward effects on oxygenation during maintenance of anesthesia with 1 MAC of sevoflurane. These combination would be safe for anesthetic cares in patient with ischemic heart diseases and coronary arterial diseases in which adequate oxygen supply in the heart is essentially necessary.

The relationship between hyperthermia and duration of action of muscle relaxants / 대한마취과학회지

This project is based on the hypothesis that induced hyperthermia may prevent or treat the prolonged muscular relaxation caused by intraoperative hypothermia or by unknown origin. In some researches, one of the causes of postoperative respiratory depression is residual curarization which is usually resulted from hypothermia. But, there is no articles about the twiteh response in hyperthermia. The 10 mongrel dog with no muscular, renal or hepatic disease were classfied into 3 groups according to the type of muscle relaxants, atracurium group, pancuronium group and norcuron group. In each case, induced hyperthermia was applied on one side and normothermia was maintained on the other side. Muscular twitch response from the TOF stimulation was recorded. This experiment was repeated with tourniquet application in order to avoid the effect of systemic circulation. The muscular twitch response appeared faster in hyperthermia group than in normothermia group regardless of the type of muscle ralaxants. Now, therefore, we can utilize the results by inducing hyperthermia to treat and prevent the postoperative hypoxia caused by intraoperative hypothermia as well as excessive use or inade- quate reverse of muscle relaxants.

A Clinical Study on Respiratory Intensive Cares in Critically Ill Patients (The Third Report) / 대한마취과학회지

A clinical study was analyzed on respiratory care of 919 critically ill patients who admitted between 1976 and 1979, which was 4.3% of 16,617 patients in post-operative recovery room of Seoul National University Hospital. 1) The patients who need respiratory cares were annually increased 76 in 1979, 115 in 1977, 289 in 1978 and 439 in 1979, and their overall mortality was 16.8%. 2) Among 439 patients, male were 267(60.8%), and female 172(39.2%) in 1979. 3) The highest age group was 1 to 10 year of age, 142 patients in number(32.4%). 4) The duration of ventilatory assistance was the longest(144.02 hours) for patients of abdominal surgery and 17.5 hours for patients of open heart surgery. 5) Major causes of deaths(84cases) in respiratory care patients of respiratory intensive care units were brain injuries(29 cases) and low cardiac output syndromes(28cases). 6) Types of airway in ventilatory assistance were orotracheal routes(345 cases) and tracheostomy routes(81 cases). 7) Importances of hemodynamic monitorings including Swan-Ganz catheterizations and blood gases and measurements of colloid osmotic pressure for critically ill patients in respiratory care units were literarily discussed.