Evaluation of the Relationship between the Patient's Severity and the Presence of Heparin Effects with the Use of Heparinase-Guided TEG in Liver Transplantation / 대한마취과학회지

BACKGROUND: Endogenous heparinoid substances have been mentioned as one of the causes of coagulopathy during liver transplantation. Some reported that heparin effects after reperfusion increase with decreasing liver function, as assessed by the Child-Pugh classification. Comparisons of native and heparinase TEG can assess the quantity of heparin effects and distinguish the cause of coagulopathy. We investigated the heparin effects before reperfusion by heparinase-guided TEG and the correlation between heparin effects and the UNOS and Child-Pugh score. METHODS: 67 liver transplanted patients were studied and divided two groups. Two groups were control group that exist heparin effect and experimental group that does not exist heparin effect during preanhepatic period. Native and heparinase TEG are performed simultaneously after anesthetic induction. Present heparin effects were defined as coagulation time (gamma + kappa) differs more than 20% between native and heparinase TEG showing the native TEG's index is out of the normal range. RESULTS: Heparin effects were present before reperfusion in 29.8% of liver transplantation cases and these were related more with the Child-Pugh classification than UNOS (gamma = 0.31, P = 0.012). There were many transfusions of packed red cells and a large infusion amount through RIS in the group with heparin effects but there was no statistical significance. CONCLUSIONS: We could confirm that heparin effects appear already before reperfusion in 29.8% of the cases using heparinase-guided TEG and this correlates with the Child-Pugh classification

Anesthetic Management of Living Related Hepatorenal Transplantation / 대한마취과학회지

Kidney or liver transplantation is a standard therapeutic procedure if one of these organs fail. However, the need for transplantation of both organs may arise with deterioration of organ function especially in hepatorenal syndrome patients. Hepatorenal failure patients are at increased risk for management intraoperatively, because they have complex problems such as renal failure related to volume overload, hyperkalemia, and uremic syndrome. These days, intraoperative use of hemodialysis or ultrafiltration is feasible and achieves successful result in patients undergoing hepatorenal transplantation. Recently, we experienced one case of hepatorenal transplantation. After setting for operation, renal transplantation was done first, and then liver transplantation was also done successfully without any problems of volume overload, massive transfusion and severe electrolyte disturbance. Total required volume for transfusion was packed red cell 9 units, FFP 4 units and crystalloid solution 8,600 ml. Patient was carried to the ICU after 16 hours operation, followed by the extubation 16 hours later in ICU and sent to the ward after 7 days ICU stay.

Clinical Observation of Postreperfusion Heparine Effects with a Heparinase Guided Thromboelastogram in a Liver Transplanted Patient / 대한마취과학회지

Orthotopic liver transplantation is frequently associated with severe bleeding, especially after reperfusion of the grafted liver. Heparin or heparinoids are released from the grafted liver and cause additional blood coagulation disorders. Recently many investigators have used a heparinase guided thromboelastogram (TEG) to control and confirm heparin effects not only on liver transplantation but also cardiac surgery. We reported a clinical case using a heparinase guided TEG to observe the duration of postreperfusion heparin effects.

Effects of Epidural Naloxone on Intestinal Hypomotility Caused by Epidural Morphine after Gastrectomy / 대한마취과학회지

BACKGROUND: Epidural morphine is usually associated with decreased bowel motility and increased transit time. Low doses of intravenous naloxone have been known to reduce morphine-induced side effects including intestinal hypomotility without reversing analgesia, but the effect of epidural naloxone has not been defined in any human study. Therefore, we evaluated bowel motility and analgesia when naloxone was administered via the epidural route. METHODS: Forty patients having epiduro-general analgesia for subtotal gastrectomy were randomly assigned to one of two study groups. As a means of postoperative pain control, all received 1.5 mg of epidural morphine bolusly 1 hour before the end of surgery, and a continuous epidural infusion was started using a two-day infusor containing 2.5 mg of morphine in 0.125% bupivacaine 100 ml with either no naloxone (control group, n=20) or 5 microgram/kg/day of naloxone (experimental group, n=20). We measured the time to the first postoperative passage of flatus and feces to evaluate the restoration of bowel function, and visual analog scales (VAS) for pain, during rest and movement. Scores were taken at 2 and 4 hours after the operation, 7 AM, 1 PM, and 7 PM of the 1st postoperative day and 7 AM and 1 PM of the 2nd postoperative day. RESULTS: The experimental group revealed less time to the first postoperative passage of flatus and feces. No significant difference was found in resting and movement VAS between two groups. CONCLUSION: This study suggests that epidural naloxone reduces epidural morphine-induced intestinal hypomotility without reversing analgesic effects.

Clinical Evaluation of Unplanned Extubation in Liver Transplant Patients / 대한마취과학회지

BACKGROUND: Unplanned extubation is a common occurrence in mechanically ventilated patients even in spite of careful attention. It is important to decide on reintubation or the retention of the extubated state especially in the critically ill patients. We tried to formulate general guideline for evaluation and safe management in unplanned extubated liver transplant patients with high risk of multiple organ failure and high mortality rate. METHODS: We reviewed all medical records of 5 unplanned extubated cases from 27 liver transplantation cases. We checked delayed extubation criteria which included United Network Organ Sharing (UNOS) class 1 or 2, preoperative Na (below 130 mEq) and albumin (below 3.0) level, transfusion amount in operating room, severity of postreperfusion syndrome (PRS) and need of vasopressor agents in the 5 unplanned extubated cases. We also checked direct intubation determining factors such as PaO2/FiO2 ratio, respiration rate and pattern, mental state and mode of ventilation. Finally, we reviewed additional factors influencing reintubation. RESULTS: We found a rate of 18 percent of unplanned extubation (5 of 27 events), and 80 percent of reintubation incidence (4 of 5 events). CONCLUSIONS: It is rational to reintubate immediately in unplanned extubated cases which meet 3 or more delayed extubation criteria. The direct reintubation determining factors are PaO2/FiO2 ratio (below 300) and the presence of paradoxical respiration with a high respiration rate (over 28/minute).

Evaluation of Clinical Factors Associated with Early Tracheal Extubation after Liver Transplantation / 대한마취과학회지

BACKGROUND: The timing of tracheal extubation in patients undergoing major intraoperative procedures is controversial. Immediate postoperative tracheal extubation after liver transplantation was not popularized. But in these days, early tracheal extubation has been safely performed in certain cases and routine use of mechanical ventilation is being questioned. We performed preliminary study of our 25 liver transplantation cases to evaluate factors affecting duration and indications of postoperative mechanical ventilation. METHODS: Our 25 cases were divided into two groups by periodic difference - early 13 cases (group 1) and late 12 cases (group 2). We evaluated preoperative UNOS (united network for organ sharing) scale, intraoperative transfusion and vasopressor requirement, postoperative multiple organ complications which would have influence upon tracheal extubation. RESULTS: We found great difference between two groups in duration of mechanical ventilation (Group 1: 94.4+/-7.12 hrs, Group 2: 36.1+/-28.3 hrs) and ICU stay (Group 1: 22.8+/-8.3 days, Group 2: 11.8+/-5.5 days). CONCLUSIONS: We concluded that early tracheal extubation in selected liver transplantation cases was safe and effective because it could shorten duration of ICU stay and reduce postoperative mortality. But more experience and knowledge may be needed to get more ideal guidelines for postoperative mechanical ventilation.

Torsade de Pointes Caused by Cardiac Pacemaker Malfunction: A case report / 대한마취과학회지

Anesthesiologists are faced with a growing number of patients in need of cardiac pacing with symptoms of increasing complexity. Because intraoperative pacemaker malfunction can lead to sudden death, it is important for the anesthesiologists to possessthe information necessary to evaluate and treat such patients. On the other hand, torsade de pointes, a particular form of life-threatening polymorphic ventricular tachycardia, is known to be elicited in patients with cardiac pacemakers in the setting of abnormally long QT intervals, decreased heart rate and severe electrolyte disturbances, notably hypokalemia. We herein report a case of intraoperative torsade de pointes that was triggered by pacemaker malfunction-induced bradycardia in a patient with a VVI-type cardiac pacemaker, whose serum potassium and magnesium level were low preoperatively. (Korean J Anesthesiol 1999; 37: 164~167)

The Effect of Co-administration of Midazolam on Induction and Recovery Using Continuous Propofol Infusion / 대한마취과학회지

BACKGROUND: Previous reports have demonstrated the synergistic interaction of midazolam and propofol in the induction of hypnosis. But there haer been some different views expnrsscd as to whether the synergism extended to hemodynamic effects. So we studied the effect of the co-administration of midazolam on induction dose, hemodynamic response, and recovery with the use of continuous infusion of propofol for induction, and the maintenance of anesthesia. METHODS: Thirty-five patients undergoing elective surgery within 2 hours were randomly assigned to one of two groups formed according to the induction agents: Group P (continuous propofol infusion 1,200 mg/h), Group MP (midazolam 2 mg followed by continuous propofol infusion 1,200 mg/h). After induction, anesthesia was maintained with fentanyl (50 microgram), N2O (70%), andpropofol (5 15 mg/kg/h). Outcome measures were propofol doses (induction and maintenance), hemodynamic responses (heart rate, blood pressure) during the induction period, emergence time (eye-opening to command), postoperative nausea and dizziness. RESULTS: The induction dose of propofol was 29% less in Group MP compared to Group P but there was no significant difference in maintenance doses between the two groups. Heart rates showed no differences between the two groups, but the changes of mean arterial pressures from base line at 30 sec, 2 min and 5 min after intubation were greater and the emergence time was delayed in Group MP compared to Group P (P < 0.05). CONCLUSIONS: Midazolam potentiates the hypnotic action of propofol synergistically, but there was no evidence that the synergism extended to the blunting effect of propofol against the hypertensive response to intubation.

The Effect of Co-administration of Midazolam on Induction and Recovery Using Continuous Propofol Infusion / 대한마취과학회지

BACKGROUND: Previous reports have demonstrated the synergistic interaction of midazolam and propofol in the induction of hypnosis. But there haer been some different views expnrsscd as to whether the synergism extended to hemodynamic effects. So we studied the effect of the co-administration of midazolam on induction dose, hemodynamic response, and recovery with the use of continuous infusion of propofol for induction, and the maintenance of anesthesia. METHODS: Thirty-five patients undergoing elective surgery within 2 hours were randomly assigned to one of two groups formed according to the induction agents: Group P (continuous propofol infusion 1,200 mg/h), Group MP (midazolam 2 mg followed by continuous propofol infusion 1,200 mg/h). After induction, anesthesia was maintained with fentanyl (50 microgram), N2O (70%), andpropofol (5 15 mg/kg/h). Outcome measures were propofol doses (induction and maintenance), hemodynamic responses (heart rate, blood pressure) during the induction period, emergence time (eye-opening to command), postoperative nausea and dizziness. RESULTS: The induction dose of propofol was 29% less in Group MP compared to Group P but there was no significant difference in maintenance doses between the two groups. Heart rates showed no differences between the two groups, but the changes of mean arterial pressures from base line at 30 sec, 2 min and 5 min after intubation were greater and the emergence time was delayed in Group MP compared to Group P (P < 0.05). CONCLUSIONS: Midazolam potentiates the hypnotic action of propofol synergistically, but there was no evidence that the synergism extended to the blunting effect of propofol against the hypertensive response to intubation.

Effect of Bilateral Superior Cervical Sympathectomy on Focal Cerebral Infarction Induced by Autologous Blood Clot in Rabbits / 대한마취과학회지

BACKGROUND: Many reports suggest that cervical sympathectomy improves cerebral blood flow. But the basal & medial areas of brain are innervated bilaterally, so unilateral sympathectomy may not improve the outcome of infarction of those areas effectively. Actually it was reported that only bilateral, not unilateral cervical sympathectomy increased the blood flow of thalamus which known to be innervated bilaterally, and also reported that unilateral sympathectomy did not reduce the infarct size of caudate nucleus. So we studied the effect of bilateral superior cervical sympathectomy on focal cerebral infarction. METHODS: Twenty rabbits were divided into two groups. In the sham-operated control group (n=10), focal infarction was achieved by administering an autologous blood clot into the internal carotid artery after exposure of bilateral superior cervical sympathetic ganglia. In the sympathectomy group (n=10), bilateral superior cervical sympathetic ganglia were excised following embolization. Seven hours after embolization, brains were sliced into 2 mm coronal sections, stained with 2,3,5-triphenyltetrazolium chloride, and infarct sizes were determined via image analysis. RESULTS: There were no differences in the physiologic variables between two groups. The percentage of infarct size was significantly greater in the control group as compared to the sympathectomy group in both cortex (23+/-8% vs 12+/-5%, respectively; P<0.05) and subcortical area (35+/-8% vs 17+/-8%, respectively; P<0.05). CONCLUSIONS: These results suggest that bilateral superior cervical sympathectomy may reduce the infarct size of subcortical area as well as of cerebral cortex measured at 7 hours following induction of focal cerebral infarction.

Effects of Cervical Sympathectomy on Mechanical Allodynia and Cold Allodynia in a Rat Model of Neuropathic Pain / 대한마취과학회지

BACKGROUND: The pathophysiologic mechanism of the neuropathic pain is still unclear. We designed this study to evaluate the effect of bilateral cervical sympathectomy on allodynia and the relationship of neuropathic pain with sympathetic nerve system of supraspinal level in rats experiencing neuropathic pain. METHODS: Neuropathic pain was produced by tight ligating the left 5th and 6th lumbar spinal nerves of male Sprague-Dawley rats. Mechanical allodynia was quantified by measuring the foot withdrawal frequency to stimuli with two von Frey filaments of 14.5 mN and 53.9 mN applied to the affected left hind paw, and cold allodynia was quantified with the same manner using 100% acetone. We divided the neuropathic pain models into experimental group (bilateral cervical sympathectomy) and control group (sham operation), and then measured the foot withdrawal frequency 1, 3, 5, 7, 14, 21 and 28 days postoperatively. RESULTS: In experimental group, the foot withdrawal frequency to mechanical stimuli with 14.5 and 53.9 mN of von Frey filament and cold stimuli with 100% acetone was significantly lower than that of control group for all postoperative observation points. Also, the experimental group showed decrease in foot withdrawal frequency compared with preoprative value over the course of the study. CONCLUSIONS: Bilateral cervical sympathectomy reduced mechanical allodynia and cold allodynia in the rat model of neuropathic pain suggesting that neuropathic pain, although the lesions are localized in low extremities, may be correlated with functional disturbance of sympathetic nerve fibers of supraspinal or brain level and help explain the mechanism of neuropathic pain.

Anesthestic Experience for Hepatic Retransplantation: A case report / 대한마취과학회지

Orthotopic liver transplantation has been an established medical therapy for almost any end-stage liver disease. In spite of improved survival rates following transplantation, acute or chronic allograft failure requiring hepatic retransplantation still occurs with an incidence of 9% to 22%. We experienced one case of anesthesia for liver retransplantation in 30-year-old male patient with posttransplantation hepatic arterial thrombosis. He had taken primary liver transplantation due to hepatocelluar carcinoma 15days before retransplantation. The operation was finished successfully after 10hours of anesthesia with anhepatic time of 65 minutes. Careful attention was paid to eletrolyte balance, blood coagulation function as well as cardiovascular and respiratory function. Hemodynamic value was relatively stable throughout the operation and postoperative mechanical ventilatory support was required for about 15 hours.

Cerebral Hemorrhage Following Anesthesia for a Patient with Takayasu's Arteritis: A case report / 대한구급학회지

Takayasu's arteritis is a nonspecific inflammatory arteritis involving the aorta and its major branches. Stroke may be an important and predictive complication for the prognosis in such patient. A 48-year-old woman got a bypass operation 3 months ago because of both subclavian artery and left common carotid artery occlusion, but she still suffered from headache, dizziness and tingling sensation and had no pulse of right arm. So, she got a bracheoaxillary bypass reoperation. Anesthesia was performed with enflurane-N2O-O2. At the recovery room, her mental state was deep drowsy and she revealed high blood pressure and abnormal neurological sign. Her brain computed tomography revealed cerebral hemorrhage at left frontotemporal basal ganglion area. Emergent hematoma removal of brain was done. Post- operatively this patient sustained an intracerebral hemorrhage in the initial hemorrhagic site despite immediate reoperation. She was discharged home without improvement at postoperative 5 days. This report is a description of Takayasu's arteritis with massive cerebral hemorrhage following a reoperation of occluded bypass surgery.

Renovascular Hypertension Associated with Pheochromocytoma: A case report / 대한마취과학회지

The coexistence of pheochromocytoma and renal artery stenosis has been recognized since 1958, but it is rare. We have experienced an anesthetic management of 43-year-old female patient of renovascular hypertension associated with right adrenal pheochromocytoma. Proper preoperative preparation, sufficient sedation, smooth induction, complete analgesia and good muscle relaxation were very important. Relative cardiovascular stability was achieved with sodium nitroglycerine, sodium nitroprusside and verapamil during tumor manipulation. After the tumor was removed, we could control the hypotension with dopamine, dobutamine, crystalloid and colloid. On the operative field there was no definite anatomic stenosis of renal artery and it was suggested that leakage of catecholamines from pheochromocytoma causes functional, reversible spasm of renal artery and thus renovascular hypertension.

A Comparison of the Postanesthetic Recovery of Cognitive and Psychomotor Function between Propofol Anesthesia and Enflurane Anesthesia / 대한마취과학회지

BACKGROUND: For out-patient anesthesia a safe and rapid postoperative recovery, especially, the full recovery of psychological function for "street fitness" has become increasingly important. Up to the present, the scoring system - Steward postanesthesia recovery score - has been frequently used for the decision of discharge. But this system focuses on recovery of vital signs, other objective tests are needed to investigate cognitive and psychomotor function which is suitable for estimation of "street fitness". METHODS: The propofol group(n=70) received fentanyl 0.8 ug/kg followed by propofol I mg/kg for anesthesia induction. Continuous propofol infusion was initiated upon induction. Ventilation was supported with N2 O-O2 mixture. The enflurane group(n=70) was induced with sodium thiopental 4 mg/kg. 2.0 vo1% of enflurane with N2 O-O2 mixture was initiated immediately upon induction. Both group received vecuronium 0.08 mg/kg as muscle relaxants. We measured Steward postanesthesia recovery score as scoring system and seven kinds of parameters as cognitive and psychomotor function test. The tests were performed at three measurement points; the day before the operation and 30, 60 minutes after extubation. RESULTS: By the scoring system, no difference in recovery score at postop. 60 min. could be found between two groups. But by the cognitive and psychomotor function test, propofol group showed significantly better recovery than enflurane group at all tests, reaching control values at postop. 60 min. CONCLUSIONS: The scoring system is not suitable method for decision of discharge, thus cognitive and psychomotor function test should be performed for "street fitness" after outpatient anesthesia. Propofol was associated with less impairment in cognitive and psychomotor function than enflurane.