Comparisons of Propofol, Enflurane, Sevoflurane, and Desflurane Anesthesia in Laparoscopic Cholecystectomy on Postoperative Liver Enzyme Levels / 대한마취과학회지

BACKGROUND: Many factors cause postoperative hepatic dysfunction, and anesthetic agents and type of surgery are belived to contribute to hepatic dysfunction. The authors planned this study to evaluate the effect of different anesthetic agents (sevoflurane, desflurane, enflurane or propofol) on liver enzymes in the patients who undergone laparoscopic cholecystectomy. METHODS: 80 patients were randomly selected from among those who had undergone cholecystectomy and divided into 4 groups; an enflurane group (n = 20), a sevoflurane group (n = 20), a desflurane group (n = 20) and a propofol group (n = 20). Preoperative values of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were compared with those on postoperative days 1 and 3 in all groups. RESULTS: In all groups, ALT and AST were significantly elevated after operation, and then showed a decrease 3 days after operation, but remainrd of above preoperative levels (P < 0.05). However, no differences were observed between the 4 groups (P < 0.05). CONCLUSIONS: We consider that propofol, sevoflurane, desflurane and enflurane are equally usable and that they have little effect on liver function after laparoscopic cholecystectomy.

Effects of Etomidate, Thiopental Sodium and Propofol on Intraocular Pressure Associated with Tracheal Intubation / 대한마취과학회지

BACKGROUND: During ophthalmologic surgery, various intravenous anesthetic induction agents are used to prevent an intraocular pressure (IOP) increase. This study was designed to compare the effects of etomidate on IOP with those of thiopental sodium and propofol in patients receiving vecronium bromide, and in whom tracheal intubation was performed. METHODS: Forty-five patients undergoing elective surgery were ramdomized to receive etomidate 0.3 mg/kg (E group, n = 15), thiopental sodium 5 mg/kg (T group, n = 15) or propofol 2.5 mg/kg (P group, n = 15). IOP, systolic arterial pressure (SAP) and heart rate (HR) were measured before induction (B), after the adminstration of the induction agents (I1), before intubation (I2) and at 1, 2 and 3 mins after intubation (T1, T2 and T3). RESULTS: The IOP after I1 and I2 in the E , T and P groups were significantly lower than in group B (P < 0.05). The IOP at T1, T2 and T3 in the E, T and P groups were not found to be significantly different from group B. The IOP, SAP and HR at T1, T2, and T3 in the E, T and P groups were significantly higher than at I1 and I2 (P < 0.05). No significant differences were observed between the groups in term of IOP. The SAP and HR at T1, T2 and T3 in the P group were significantly lower than in the other two groups (P < 0.05). CONCLUSIONS: We concluded that etomidate, thiopental sodium and propofol may be useful induction agents for general anesthesia in ophthalmologic surgery but that they do not prevent IOP elevation during endotracheal intubation.

The Effects of Neostigmine added to Ropivacaine for Intravenous Regional Anesthesia / 대한마취과학회지

BACKGROUND: Neostigmine has been added to local anesthetic regimen for epidural or intrathecal block, and this resulted in prolonged and improved analgesia, but evidence of its benefit in intravenous regional anesthesia (IVRA) is controversial. The purpose of this study was to evaluate the effects of neostigmine added to ropivacaine for IVRA. METHODS: Forty patients undergoing hand or forearm surgery were randomly assigned to two groups to receive IVRA: Group I received 40 ml of 0.2% ropivacaine plus 1 ml of normal saline, and group II received 40 ml of 0.2% ropivacaine plus 500microgram (1 ml) of neostigmine. Sensory block onset time, postoperative visual analogue scale (VAS) scores, recovery time from motor block after deflation, mean arterial pressure (MAP), heart rate (HR), and pulse oximeter saturation (SpO2) values were measured. The incidence of side effects was recorded. RESULTS: Group II had a shorter sensory block onset time, a prolonged motor block recovery time, and lower postoperative VAS scores. No significant difference was found between the two the groups in terms of MAP, HR, SpO2 and side effects. CONCLUSIONS: The addition of neostigmine to ropivacaine in IVRA is believed to be a useful effective method for outpatient arm surgery due to a shortened sensory onset time and improved postoperative analgesia.

Bilateral Cortical Blindness Due to Parieto-Occipital Infarction after General Anesthesia: A case report / 대한마취과학회지

Cortical blindness is characterized by visual sensation loss with retention of pupillary reaction to light, and a normal fundoscopic examination. The suggested causes are emboli, profound hypotension, anemia, and infarction of watershed areas in the parietal or occipital lobe. We experienced a case of cortical blindness with severely reduced visual acuity after penile cancer surgery under general anesthesia. In the acute stage, visual acuity was slightly improved, but over the course of several months, no further improvement in visual acuity occurred. In this case there was no severe hypotension or anemia during the operation. Two days after the operation, electroencephalography (EEG) was performed during the period of blindness and the recording obtained was abnormal, with no alpha rhythm. Biparieto-occipital lucency was found by magnetic resonance imaging (MRI). Therefore parieto-occipital infarction due to seizure, embolus, or thrombosis could be considered a possible etiology. We concluded that cortical blindness can unexpectedly develop perioperatively and postoperatively, and that close monitoring of the patient and adequate management are essential.

Comparison of Postoperative Pain by Different Methods in the Removal of Gases after Laparoscopic Hysterectomy / 대한마취과학회지

BACKGROUND: Laparoscopic surgery has many advantages compared with conventional methods and may allow a significant reduction in postoperative pain and analgesic consumption. Nevertheless, some patients still experience significant pain. Therefore, many clinicians have tried various methods to reduce of postoperative pain. We investigated degrees of postoperative pain and the incidences of shoulder pain versus the different methods of gas removal after laparoscopic surgery. METHODS: Sixty ASA class I or II patients were included in this study. In Group A (Control group, n = 20), residual carbon dioxide was removed by the classic method without a drain tube. In Group B (Suction group, n = 20), residual carbon dioxide was removed using a suction device aggressively without a drain tube. In Group C (Drain group, n = 20), residual carbon dioxide was removed by the classic method with a drain tube. The intensities of abdominal and shoulder pain were assessed 1, 6, 24 and 48 hours after surgery using a visual analog scale (VAS) and a verbal rating scale (VRS). We also assessed the mean hospital stay for the three groups. RESULTS: The abdominal pain scores (VAS and VRS) at 1 hour after surgery and the incidence of shoulder pain, epigastria pain and flank pain were significantly higher in Group A than in the other groups for 1hour after surgery (P <0.05). Mean hospital stay was significantly longer for group C. CONCLUSIONS: After laparoscopic surgery, the active removal of residual carbon dioxide may be a simple and safe method that significantly reduces postoperative shoulder and abdominal pain.

The Changes in Lung Mechanics before and after the Nuss Operation in Pectus Excavatum Patients / 대한마취과학회지

BACKGROUND: Nuss et al introduced a less invasive method for inserting a stainless steel bar through the small incision on the lateral chest wall into the pectus excavatum. This study was undertaken to assess the effect of the Nuss operation on lung mechanics, CT-Index and hemodynamics. METHODS: Twenty patients (age 4 to 17 years) with severe pectus excavatum underwent the Nuss operation. CT-Index (the internal transverse distance of the thorax/the vertebral-sternal distance at greatest depression) was evaluated before operation. Lung mechanics (dynamic compliance [Cdyn], static compliance [Cstat] and airway resistance [Raw]), hemodynamic changes (heart rate [HR], systolic blood pressure [SBP], and diastolic blood pressure [DBP]), and gas exchange (arterial oxygen tension [PaO2], arterial carbon dioxide tension [PaCO2], pulse oximeter saturation [SPO2] and end-tidal carbon dioxide tension[PETCO2]) were measured before and after the operation. RESULTS: Cdyn and Cstat decreased significantly (P < 0.05), but Raw did not change. PaCO2 and PETCO2 decreased significantly (P < 0.05), and SBP and DBP increased significantly (P < 0.05) postoperatively. CONCLUSIONS: It is concluded that decreased compliance after the Nuss operation may result from reduced thoracic elastance, not to a change of lung parenchyma.

Anesthetic Clinical Observations on the Use of the intraventricular Sodium Nitroprusside for Treatment of Cerebral Vasospasm: A case report / 대한마취과학회지

Delayed type cerebral vasoconstriction (DCV) following aneurysmal subarachnoid hemorrhage is an important cause of permanent neurological injury and death. The mechanism of DCV remains unknown. Recently many investigators have used a new treatment for DCV involving the use of intraventricular sodium nitroprusside. We report upon a clinical case where a relatively large amount of sodium nitroprusside was intrathecally delivered by intraventricular catheter for the treatment for DCV.

Comparison of Arterial and End-Tidal CO2 Tension by Position and Time Changes during Hip Replacement Arthroplasty in Elderly Patients / 대한마취과학회지

BACKGROUND: Hip replacement arthroplasty (HRA) is highly traumatic and performed in a lateral position for several hours and dead-space ventilation may increase. So, the difference between arterial and end-tidal PCO2 was investigated depending on the changes in the patient's posture during HRA in elderly patients. METHODS: Forty-three patients scheduled for a HRA were divided into two groups; Adult Group (n = 21, A-Group) and Elderly Group (n = 22, E-Group). Mean arterial pressure (MAP), heart rate (HR), PaO2, PaCO2, and end-tidal carbon dioxide tension (P(ET)CO2) were simultaneously measured at 10 min after anesthesia in a supine position (S[10]), at 30 min intervals from 30 min (L[30]) to 180 min (L[180]) in a lateral position and at 10 min in a supine position after the end of surgery (ES[10]) in both groups. The PaCO2-P(ET)CO2 gradient (P[a-ET]CO2) and dead space ventilation (Vd/ Vt) were calculated. RESULTS: At S(10), P(a-ET)CO2 in the A- and E-Groups was 7.0 +/- 5.0 and 7.2 +/- 3.3 mmHg respectively. From L(30) to ES(10), the P(a-ET)CO2 and the ratio of Vd/Vt in both groups increased significantly and progressively (P < 0.05 vs the control value) and the slope in the E-Group rose two times as compared to that in the A-Group. The correlation coefficient between P(a)CO2 and P(ET)CO2 was very significant from S(10) to L(90) and ES(10) in the A-Group, and from S(10) to L (60) in the E-Group (P < 0.01). CONCLUSIONS: For maintaining adequate ventilation of the elderly patient during HRA, PaCO2 should be measured intermittently along with the position changes after anesthesia in addition to the constant monitoring of PETCO2.

The First Successful Heart-Lung Transplantation in Korea / 대한흉부외과학회지

The first heart-lung transplantation in Korea was successfully performed. The recipient was a 11 year old girl with pulmonary atresia with intact ventricular septum. She had been catheterized at the ages of 4 months, 3 years, 7 years and 10 years, which revealed that neither Fontan nor biventricular repair was feasible. The donor was a traffic accident victim, a 9 year-old boy with the same blood type. The donor was pronounced dead according to the guidelines of the Korean Medical Association's Brain Death Committee. The operation was performed on April 20, 1997. The native heart-lung block was explanted segmentally and donor one was placed above the phrenic nerve using the Arizona technique. After the tracheal anastomosis with single continuous 4-0 prolene, both vena cavae were anastomosed, followed by aortic anastomosis. The graft ischemic time was 145 minutes. The postoperative course was complicated by fever and tracheal stenosis at the anastomosis site. The fever was controlled by anti-tuberculous medications and the tracheal stenosis was relieved by stent (Palmaz 8 mm, 30 mm in length) placement on POD #71. The patient is doing well and is very active in her 7th postoperative month.

First Successful Dynamic Cardiomyoplasty in Korea / 대한흉부외과학회지

A 25-year-old man with viral cardiomyopathy and chronic active hepatitis successfully underwent dynamic cardiomyoplasty for the first time in Korea on July 30, 1996. The patient had been intermittently dyspneic for 5 years and was admitted to our center twice because of heart failure. For the past 2 years, he was NYHA functional class III status with a left ventricular ejection fraction (LVEF) of around 30%. The patient was born with scoliosis and showed a short stature. The liver function showed elevated liver enzymes, and hepatitis B antigen was positive. The liver biopsy revealed chronic active hepatitis. The preoperative echocardiogram showed decreased left ventricular function with grade II mitral and grade II tricuspid regurgitation with dilated left and right atrium. Recently his symptoms worsened and we decided to perform a dynamic cardiomyoplasty. The left latissmus dorsi muscle (LDM) was mobilized and tested with lead placement on his right lateral decubitus position. The patient was positioned into supine and, after median sternotomy, the heart was wrapped with the mobilized muscle. The Russian made cardiomyostimulator (EKS-445) and leads (Myocardial PEMB for heart and PEMP-1 for LDM) were used. The total operation time was 8 hours and there were no perioperative episodes. Postoperatively the LDM had been trained for a 10 week period and currently the stimulation ratio is maintained at 1:4. The postoperative LVEF did not increase with the value of 30-35%. However, the patient feels better postoperatively with slightly increased activity.

Anesthesia for Heart Transplantation in a Jehovah,s Witness: A case report / 대한마취과학회지

Jehovah,s Witnesses who require operation represent a challenge to the physician because of the patient,s refusal to accept blood transfusion. An orthotopic heart transplantation was succesfully performed in a 40-year old Jehovah,s Witness without use of any blood product. During the operation, cell saver was used for shed blood and aprotinin was administered intravenously. The use of blood conserving methods, meticulous operative technique and brisk postoperative diuresis has added to the efficacy of heart transplantation in this patient. Total postoperative drainage was 860 ml and the lowest hemoglobin level was 11.8 g%. The patient recovered uneventfully and discharged on the 60th postoperative day.

Anesthesia for Coronary Artery Bypass Grafting without Extracorporeal Circulation: One case report / 대한마취과학회지

Coronary artery bypass grafting (CABG) without extracorporeal circulation (ECC) is now an accepted technique of myocardial revascularization in selective cases of coronary arterial occlusive disease. We experienced a case of CABG without ECC in a 20 year old female patient with complete occlusion of the right coronary artery. Anesthesia was induced and maintained with fentanyl, midazolam and isoflurane. Nitroglycerine and dopamine were given to stabilize the hemodynamics during intra- and post-operative periods. And esmolol was administered with a loading dose of 30 mg over 1 min, followed by a continuous infusion of 50~100 g/kg/min to maintain the heart rate (50~60 beats/min) and systolic blood pressure (60~80 mmHg) during distal anastomosis. The patient was recovered uneventfully and discharged on the 8th postoperative day.

Cardiac Transplantation in a Jehovah's Wittness: A Case Report / 대한흉부외과학회지

An orthotopic cardiac transplantation was successfully performed in a 40 year-old Jehovah's witness without use of any blood product. Preoperatively, the patient had been on coumadin to prevent left atrial thrombi and the INR(Internation Normalized Ratio)of prothrombin time was 2.4. During the operation, cell saver was used for shed blood and aprotinin was administered intravenously for platelet function. Total postoperative drainage was 860cc and the lowest hemoglobin was 12.2 gm/dl. Postoperative course was complicated by central nervous system infection by Listeria monocytogenes and two episodes of rejection, both of which were effectively treated. The patient is on his 5th postoperative month and doing well.

Anesthetic Experience of Dynamic Cardiomyoplasty: A case report / 대한마취과학회지

Dynamic cardiomyoplasty is a recently introduced surgical method to improve myocardial performance. It consists of a placement of a skeletal muscle flap around the heart and stimulation of the flap in synchrony with ventricular contraction. We experienced a case of cardiomyoplasty in a 25 year old male patient with congestive heart failure. Anesthesia was induced and maintained with fentanyl, midazolam and isoflurane. The operation was performed for 8hrs without cardiopulmonary bypass and the patient was transferred to the intensive care unit. He was mechanically ventilated electively overnight and extubation was done 18hrs postoperatively. The patient was discharged home on the 40days after operation and improved in exercise tolerance. We report the anesthetic management and hemodynamic changes in a patient who underwent dynamic cardiomyoplasty.

Anesthetic management for Liver transplantatin : 4 cases / 대한마취과학회지

We managed four cases of anesthesia for liver transplantation from August, 1992 to January, 1993. Four recipients, all male patients and ages of 40th, were suffered from liver cirrhosis related to Chronic hepatitis B and one recipient (case 1) was diagnosed as combined hepatocellular carcinoma. Operation risks by Pugh's classification were 10 (case 1), 8 (case 2), 7 (case 3) and 12 (case 4). Duaration of anesthesia was in the range of 13 to 22.5 hours. Various hemodynamic monitorings were observed and anesthetic managements were uneveritful. C.O., SVR, temperature and coagulation factors were analyzed. 2 patients (case 1 & 4) were expired due to acute rejection (case 1) and primary non-function of the grafted liver (case 4) postoperatively.

Cardiovascular Responses of General Anesthesia with Nalbuphine - Diazepam - O2 - 1/2 MAC Halothane and Awareness during Operation for Adult Open Heart Surgery / 대한마취과학회지

Recently, nalbuphine has been used for reversal of opioid indueed respiratory depression. Because of its structural chsracter, nalbuphine has been known as a better nareotic antagonist with keeping analgesic potency and without considerable cardiovascular responses. Some investigators reported nalbuphine can decrease minimum alveolar concentration(MAC) of major inhalation anesthetic agents and can be a intravenous anesthetic adjuvant but can accompany several adverse reactions such as hypertension and tachycardia etc. To evaluate the eligibility and efficacy of nalbuphine as a intravenous narcotic adjuvant for cardiac anesthesia, we selected 24 adult cardiac patients and divided them into 3 groups. Valvular surgerys were performed for group I patients, aorto-coronary-bypass surgerys(CABG) for group II and correction of congenital heart disease for group III, respectively, All patients were inducted general anesthesia with 0.3 mg/kg nalbuphine+0.1 mg/kg diazepam+2 mg/kg thio- pental sodium and maintained with intermittent injection of 0.3-0.5 mg/kg nalbuphine and O.l mg/kg diazepam just before the time of most stressful surgical stimuli with 1/2 MAC halothane inhalation under vecuronization for muscle relaxation. We measured heart rate(HR), systolic blood pressure(BP), central venous pressure(CVP) at pre-induction as a control data, and just after endotracheal intubation, skin incision, sternotomy, and skin closure respectively to compare basic cardiovascular responses of patients at surgical stimuli with control data. We also checked recovery time of consciousness and presence of awareness during operation. The results were as follows: 1) Significant HR changes occurred in group I at just after intubation time from 104+/-18.6 to 134+/-25.9 and in group II from 83+/-10.5 to 115+/-32.3 respectively. 2) There were few significant changes of systolic blood pressure during anesthesia of all groups except just after intubation in group II from 135+/-32.8 torr to 168+/-37.9 torr.3) A significant CVP decrease occurred only in group I at the time of skin closure from 13+/-3. 5 cmHO to 10+/-3.8 cmH2O because of operative correction of tricuspid regurgitation of group I patients rather than anesthesia effects. 4) Recovery of consciousness needed average 1 hr 30 mins in group I and 2 hr 45 mins in group II. None of patients complained awareness during operations. Above results demonstrate that Nalbuphine-Diazepam-O2-1/2 MAC Halothane can be a anesthetic method for open heart surgery without any significant cardiovascular responses at surgical and anesthetic stimuli except intubation stimulus, but for more evaluation study of Nalbuphine-Diazepam-O2 Anesthesia will be needed.

The Changes of Serum Cholinesterase Activity in Term-Pregnant: In the Cesarean Section Patients / 대한마취과학회지

The serum cholinesterase level is influenced by a variety of disease states, especially in pregnancy as is well established now, although the reasons for the fall in the enzyme in certain conditions and its clinical significance are less clear. This known decrease in plasma cholinesterase activity could lead to the conclusion that the duration of paralysis from succinylcholine will be prolonged in pregnant patients. The purposes of this study were to evaluate the serum cholinesterase activity in nonpregnant women of the child-bearing age group and pregnant women and to evaluate the changes of serum cholinesterase following succinylcholine administration. The results were as follows: 1) The mean value of serum cholinesterase in 60 nonpregnant women of the child-bearing age group was 992.29-1,112.27 U/L. 2) The mean value of serum cholinesterase in 60 pregnant women was 769.40-826-27 U/L. 3) Pregnant women had a diminution of serum cholinesterase activity compared with nonpregnant women of the child-bearing age group, and this diminution was statistically very significant (p<0.01). 4) In Cesarean section patients treated with succinylcholine, there was further diminution of serum cholinesterase activity (P<0.01). With the above results, the possible clinical importance of marked diminution of a serum cholinesterase activity in pregnant women is outlined.

The Effects of Glycopyrrolate-Pyridostigmine Mixture on Heart Rate and Blood Pressure during Halothane and Enflurane Anesthesia / 대한마취과학회지

Anesthesiologists should have close relationship with muscle relaxants and their reversals in clinical practice. Nowadays, the nondepolarizaing blocker is interested more than the depolarizing blocker and its reversibility. The composition of atropine, neostigmine and glycopyrrolate has been investigated for many years in korea. This study was undertaken to investigate the effects of glycopyrrolate(7ug/kg) and pyridostigmine(200ug/kg) mixture for pancuronium reversal on the heart rate and the blood pressure during halothane and enflurane anesthesia. The results were as follows: 1) In the halothane group: significantly increased mean blood pressure as compared with the enflurane group at 2,4,6 minutes and no significant difference was found after 8 minutes. 2) In the halothane group: significantly increased pulse rate at 2 and 4 minutes and decreased after 12 minutes. 3) In the Enflurane group: significantly increased pulse rate at 2,4 and 6 minutes and no increase after 8 minutes. 4) In the halothane group: significantly decreased pulse rate as compared with the enflurane group after 6 minutes and thereafter. 6) There was no significant arrhythmia but 2 cases of the bradycardia were observed in the halothane group at 14 minutes which were treated by atropine.