Some Effects of Histamine Type 2 Blockers on the Nosocomial Pneumonia in Patients with Prolonged Intubation / 대한마취과학회지

Nosocomial pneumonia, which can develop in patients with prolonged intubation, may have in fatal consequences. The histamine type 2 blockers used for prevention of stress ulcers, increases gastric pH, and may increase the incidence of nosocomial pneumonia in patients with prolonged intubation by promoting bacterial overgrowth in the stomach and retrograde colonization in the trachea. We assessed the effect of histamine type 2 blockers on the incidence of nosocomial pneumonia in patients with prolonged intubation, who were admitted to the Intensive Care Unit, Young Dong Severance Hospital, Yonsei University College of Medicine from September 1992 to February 1993. The patients were divided into two groups Group 1 was the patients given histamine type 2 blockers and total parenteral nutrition, and Group 2 was the patients not given histamine type 2 blockers and with enteral feeding through the gastric tube. Gastric juice was aspirated for measurement of gastric pH. A culture of isolates was grown from endotracheal secretion and pharyngeal swab for identification of isolate cultured. Chest X-rays were taken for assess of pneumonic infiltrate, The results were as follows ;. 1. There were no difference of age, APACHE II scores at admission to ICU, duration of ICU stay and mortality between the two groups. 2. Gastric pH differed significantly between the two groups. In group 2, there was a significant difference between gastric pH before and after feeding. 3. The incidence of upper gastrointestinal bleeding did not differ between the two groups. 4. Colonization developed more frequently in the patients with enteral feeding. 5. The incidence of retrograde colonization was higher in patients with enteral feeding. 6. The incidence of nosocomial pneumonia were 30 and 40 percent, and there was no significant difference between the two groups. From our study, the incidence of nosocomial pneumonia was not different significantly between the two groups although gastric pH differed significantly.

Effect of Gastric pH on the Nosocomial Pneumonia in Long - term Intubated Patients / 대한마취과학회지

The retrograde microorganismal colonization in the pharynx from stomach may cause the nosocomial pneumonia and that may be more likely when the gastric pH is relatively high. We tried to find out the relationships between the gastric pH and the incidence of nosocomial pneumonia with twenty patients intubated for longer than 48 hours at ICU. We achieved following results: 1) The incidence of the nosocomial pneumonia was twenty percent. 2) All the patients developed nosocomial pneumonia showed the gastric pH above 4.0. 3) In the patients intubated for longer than 5 days, the incidence of nosocomial pneumonia was 33.3% in contrast to 9.0% for less than 5 days. 4) With the sputum culture, the incidence of colonization was higher in the patients with gastric pH above 4.0 than that in the patients with gastric pH below 4.0(84.6% vs 58.1%). 5) With regard to the duration of intubation, the incidence of colonization was higher in the patients intubated for longer than 4 days than that in the patients intubated for less than 4 days(90% vs 50%). 6) The most common pathognomic organisms were astreptoccus and Pseudomonas aeroginosa. It is conculded that the nosocmial pneumonia might develop more frequently in the patients with gastric pH above 4.0 than in the patients with gastric pH below establishment of the relationship between the treatment of the stress ulcer and the nosocomial pneumonia.

Incidence and Etiology of Pneumonia Acquired during Mechanical Ventilation / 대한마취과학회지

Nosocomial pneumonia is a common complication of mechanical ventilation. However the actual incidence of pneumonia associated with ventilator is not known. A total of 57 consecutive patients submitted to mechanical ventilation(MV) for mqre than 48 hours in ICU were studied to investigate the incidence, etiology and consequence of ventilator associated pneumonia. Pneumonia was diagnosed when new and persistent radiographic infiltration was detected together with more than two of the following criteria; (l) fever more than 38degrees C, (2) leukocytosis more than 12000/mm, (3) purulent sputum with s gram stain showing bacteria. The results are as following: l) Twenty-one(37.9%) patients developed bacterial pneumonia during mechanical ventilation 2) Ventilator associated pneumonia was developed after 4.6 days of machanical ventilation 3) The etiology of pneumonia were Gram(-) bacilli 65.8%, Gram(+) bacilli 31.7% and, Pseudomonas 27.9%, Streptococcus 16.5% and or, Staphylococcus 13.9%.

Incidence and Etiology of Pneumonia Acquired during Mechanical Ventilation / 대한마취과학회지

Nosocomial pneumonia is a common complication of mechanical ventilation. However the actual incidence of pneumonia associated with ventilator is not known. A total of 57 consecutive patients submitted to mechanical ventilation(MV) for mqre than 48 hours in ICU were studied to investigate the incidence, etiology and consequence of ventilator associated pneumonia. Pneumonia was diagnosed when new and persistent radiographic infiltration was detected together with more than two of the following criteria; (l) fever more than 38degrees C, (2) leukocytosis more than 12000/mm, (3) purulent sputum with s gram stain showing bacteria. The results are as following: l) Twenty-one(37.9%) patients developed bacterial pneumonia during mechanical ventilation 2) Ventilator associated pneumonia was developed after 4.6 days of machanical ventilation 3) The etiology of pneumonia were Gram(-) bacilli 65.8%, Gram(+) bacilli 31.7% and, Pseudomonas 27.9%, Streptococcus 16.5% and or, Staphylococcus 13.9%.

Difficult Weaning from Long Term Mechanical Ventilation - A case report / 대한마취과학회지

Inability to tolerate discontinuation of mechanical ventilation or the need for reintubation has been reported .s much as 20% in mechanically ventilated patients. Many factors may be responsible for the .nsuccessful weaning outcome such as hypoventilation secondary to decreased respiratory c,nter output, respiratory muscle fatigue, impaired pulmonary gas exchange and excessive ventilatory requirements. We experienced a patient who was very difficult to wean from long term mechanical ventilation. The patient was 36 years old male with Guillain Barre syndrome. After 7 days admission, tracheostomy was taken and mechanical ventilation continued to 332 days. There was not any chance of pneumonia during the 11 months ventilation. His respiratory parameter improved to TV of 350 ml and VC of 1300 ml and he was able to breath himself without mechanical ventilator during day time. But he could not sleep without ventilator for fear of dying during sleep. We made him sleep with diazepam injection and carefully observed the patient with pulse oximetry and Sara capnography. We tried this method many times and the patient got the confidence that he cauld alive during sleep without mechanical ventilator. We could wean from long term mechanical ventilation during sleep by carefully observing patients respiratory pattern. Therefore we report here this successful weaning from long term ventilator in anxious and nervous patient.

Anesthetic management for Surgery of the Ascending Aortic Aneurysm / 대한마취과학회지

Fifteen cases of corrective operation for the ascending aortic aneurysm performed under general anesthesia from 1979 to 1985 in Severance Hospital were studied retrospectively. There were ten male patients and 5 female and their average age were 36.6 years(range 25~50 years). Most of the patients showed aortic regurgitation. Thus the anesthetic management involved consideration for patients with aortic dissection combined with aortic incompetence(annuloaortic ectasia). Patients were premedicated with atropine or glycopyrrolate in 14 cases and a combination of triflupromazine, hydroxyzine, diazepam and pethidine in 13 cases or a combination of hydroxyzine and morphine in 2 cases. Anesthesia was induced with thiopental sodium and/or diazepam and/or midazolam and/or morphine IV. Morphine and a mixture of 50% nitrous oxide and oxygen was administered for maintenance of anesthesia. Supplementary volatile anesthetics were inhaled as needed. Vasodilating therapy and avoidance of bradycardia during anesthesia are the most importance considerations for the reduction of left ventricular wall tension and to maximize the myocardial oxygen supply while maintaining cardiac output. Operative complications were reoperation due to bleeding in four cases, myocardial infarction in two cases, pericardial tamponade and urethral track infection in one case each. One patient died of sepsis. Fourteen patients improved in their heart size and function.

A Clinical Evaluation of Hypotensive Anesthesia for Intracranial Aneurysm Surgery / 대한마취과학회지

Deliberately induced hypotension reduces bleeding in operative fields, therby facilitating the surgical manipulation of a highly vascularized lesion and enabling a better dissection to be made. Hypocapnia is a technique by which the regional cerebral blood flow is reduced, effecting a decrease in the intracranial volume. The monitoring of end-tidal CO2 tension(PECO2) is widely done since the amount of end-tidal CO2 tension reflects indirectly the value of the degree of arterial CO2 tension(PaCO2). During hypotension, increased physiologic dead space my produce the widened PaCO2-PECO2 gradient and this large gradient makes PECO2 an unreliable indication of PaCO2. There are many reports on hypotensive agents and techniques. Induced hypotension with halothane has been reported to be a relatively safe and useful method by Murtagh(1960) and Schettini, et al (1967). We reported 100 cases of halothane induce hypotensive anesthesia for intracranial aneurysm surgery in 1979. The present study reports concerning the hypotensive anesthesia for 259 cases of intracranial aneurysm surgery, which were performed at Severance Hospital of the Yonsei University College of Medicine from 1972 to 1985. We evaluated prospectively the PaCO2-PECO2 gradient with modern infrared capnographs during the induced hypotension of 25 cases, which was performed for intracranial aneurysm surgery at this hospital. The result of the retrospective and prostpective studies were as follows. A. Retrospective study 1) Halothane and enflurane were used as the primary anesthetics in 246 and 13 cases, respectively. Hydralasine, nitroprusside, and trimetaphan were supplementarily used for inducing hypotension in 29, 19 and 15 cases, respectively. 2) The mean arterial blood pressure of the lowest blood pressure in the induced hypotension group was 57.2+/-9.3 mmHg, and the mean arterial blood pressure of the highest blood pressures during the induction fo anesthesia was 111.3+/-20.8mmHg. 3) There was no significant difference in the perioperative hemoglobins, hematocrits, and serum electrolytes. 4) In the introperative period gas analysis revealed respiratory alkalosis(arterial CO2 tension and pH were 29.7+/-6.7mmHg and 7.485+/-0.078, respectively). In other values there was no significant change. 5) The mortality rate in 259 cases of intracranial aneurysm surgery was 6.2%. B. Prospective study There was no significant difference in the PaCO2-PECO2 gradients between in the hypotensive period (5.5+/-3.8 mmHg) and in the normotensiveperiod(4.3+/-3.4mmHg). In conclusion, the technique of using induced hypotension with the inhalation anesthetics, halothane or enflurane, is a safe and useful one to use in performing surgery for intracranial aneurysm, and end-tidal carbon dioxide tension can be used as an indirect measure of arterial carbon dioxide during the induced hypotension.