Postoperative Epidural Analgesia using 0.1% Levobupivacaine or 0.1% Ropivacaine Combined with Sufentanil in Gynecologic Surgery / 대한마취과학회지

BACKGOUND: Ropivacaine and levobupivacaine are recently introduced amide local anesthetics that are structurally similar to bupivacaine. In this study, we compared the quality of postoperative analgesia and the side effects of 0.1% ropivacaine/sufentanil and 0.1% levobupivacaine/sufentanil. METHODS: Sixty patients scheduled for gynecologic surgery under general anesthesia were randomized to receive either 0.1% ropivacaine with sufentanil (ropivacaine group) or 0.1% levobupivacaine with sufentanil (levobupivacaine group) for postoperative epidural analgesia using a patient-controlled analgesia pump at a rate of 5 ml/h during the 48 hour period following surgery. Visual analogue scale (VAS) scores at rest and on coughing, sitting and movement, the degree of ambulation, additional analgesic requirements and side effects were assessed. RESULTS: In the levobupivacaine group, VAS scores at rest and on coughing, sitting and movement were lower than in the ropivacaine group (P < 0.05). In the ropivacaine group more patients were able to walk unaided (P < 0.05). There were no differences in local anesthetic consumption, additional analgesic requirements and side effects between the groups. CONCLUSIONS: Both 0.1% ropivacaine with sufentanil and 0.1% levobupivacaine with sufentanil provided effective postoperative epidural analgesia, but ropivacaine produced lesser motor block.

Effect of Combined Hyperventilation and Mannitol on Cerebral Blood Flow and Cerebral O2 Metabolism during a Craniectomy / 대한마취과학회지

BACKGROUND: There are therapies to lower intracranial pressure (ICP) including head elevation, hyperventilation, diuretics injection, intravenous mannitol, hypothermia, cerebrospinal fluid drainage, and cerebral resection in neurosurgical patients. However in recent reports, hyperventilation followed by mannitol administration may lead to cerebral ischemia. Therefore, we investigated the effect of 0.5-1.0 g/kg mannitol administration on jugular venous oxygen saturation (SjVO2) and cerebral arterial- jugular venous oxygen content difference (AVDO2) at PaCO2 25-30 mmHg and 35-40 mmHg in patients undergoing neurosurgery. METHODS: We studied 17 patients undergoing neurosurgery in the Ajou University Hospital. Anesthesia was induced with fentanyl, midazolam, thiopental, and vecuronium, and maintained with O2-Air-Isoflorane, a continuous infusion of fentanyl, and vecuronium. Patients were divided into two groups. Group 1 (n = 10) which is PaCO2 25-30 mmHg and Group 2 (n = 7) which is PaCO2 35-40 mmHg by controlling ventilator. Measurements of SjVO2 and AVDO2 in following time intervals: I = preinjection of mannitol, II = postinjection 20 minutes of mannitol, III = postinjection 40 minutes of mannitol were obtained for each group. 0.5-1.0 g/kg mannitol was administered intravenously just at duramater opening. RESULTS: Hemodynamics and hematologics were not significantly different among the two groups. SjVO2 of each group are as follows; Group 1; I (70.3+/-8.1%), II (66.3+/-6.9%), III (69.1+/-7.9%) and Group 2; I (78.6+/-7.4%), II (75.1+/-8.1%), III (76.0+/-11.2%). Hyperventilation significantly decreased SjVO2. AVDO2 was not significantly different but SjVO2 in II was significantly decreased compared with I and III in Group 1 (20% patients). CONCLUSIONS: Mannitol produced a change of SjVO2 and AVDO2 during hyperventilation. Therefore, intravenous mannitol during hyperventilation should be given cautiously according to the patients status because it may cause cerebral ischemia in critical patients.

Aspiration Pneumonia Due to Aspiration of Intestinal Fluid during Mechanical Ventilation in a Septic Patient / 대한마취과학회지

Pulmonary aspiration is one of the most common complications and leading cause of high morbidity and mortality from tracheal intubation under mechanical ventilation. We experienced a case of severe aspiration pneumonia leading to death in a sixty-year old male patient who was under mechanical ventilation due to sepsis after intestinal perforation. In his past history, he had undergone a radical total gastrectomy due to advanced gastric cancer, and this time, he got almost a total small bowel resection due to small bowel perforation and gangrenous change. He was admitted to the Surgical ICU for postoperative care due to sepsis. At first his condition was very poor. Aggressive therapy with hemodynamic monitoring was performed, and there had been much improvement in his condition. On the 8 th ICU day, there was a large amount out of greenish intestinal fluid and increased endotracheal secretions of the same color. At that time, there was no air leak around the trachea and his tidal volume on ventilator was the same as before. The pH of aspirated fluid was 6.8 and E. coli was cultured. Two days later, there was a diffuse ground glass appearance on the entire right lung field on his chest X-ray. On the 11 th ICU day, he expired.

Clinical Use of Weaning Indices from Mechanical Ventilation in Surgical Intensive Care Unit Patients / 대한마취과학회지

BACKGROUND: A number of indices have been proposed as accurate predictors of weaning, but several studies have questioned the accuracy of these weaning indices in predicting the capability of independent breathing. The purpose of the study was to assess six standard bedside weaning indices and respiratory rate and tidal volume ratio (RRVT) of mechanically ventilated patients in the surgical intensive care unit (SICU). METHODS: The study was performed on 90 SICU patients who were mechanically ventilated. According to the outcome of weaning, they were divided into two groups, weaning success (n = 83) and weaning failure (n = 7). All subjects should have a PaO2 above 60 mmHg at an FiO2 of 0.4 and PEEP of 3 5 cmH2O and no PEEP in the extubated patients at the time of the weaning. Bedside weaning indices were respiratory rate (RR), tidal volume (VT), minute volume (VE), maximum inspiratory pressure (Pimax), vital capacity (VC), PaO2/FiO2 and RRVT. The predictive variables - sensitivity, specificity - of indices were calculated, and the data was also analysed with receiver-operating-characteristic (ROC) curves. RESULTS: Sensitivity was highest for VT (0.95), followed closely by the PaO2/FiO2 (0.94). Specificity was highest for Pimax (0.28). The VT was the best predictor of successful weaning, and Pimax was the best predictor of failure. The order of the area under the ROC curves was VC (0.761) followed by VE (0.636), VT (0.631), Pimax (0.546), PaO2/FiO2 (0.474), RR (0.457), and RRVT (0.339). CONCLUSIONS: Those weaning indices are good predictors of weaning success, but poor predictors of weaning failure. RRVT does not predict the weaning outcome.

The Effect of Pretreatment with Lidocaine for the Withdrawal Movement Associated with the Injection of Rocuronium in Children / 대한마취과학회지

BACKGROUND: The purpose of this study was two fold; first, to determine the incidence and type of withdrawal movement associated with IV injection of rocuronium in pediatric patients; and second, to determine whether pretreatment with IV lidocaine affects the incidence of movement associated with rocuronium administration in pediatric patients. METHODS: Forty-two pediatric patients were randomly assigned to two groups. After general anesthesia was induced with thiopental sodium 5 mg/kg and manual occlusion of venous inflow was performed, one group of patients received 0.1 ml/kg 1% lidocaine IV. A second group received 0.1 ml/kg of normal saline as a placebo control. Venous inflow occlusion was held for 5 seconds, and immediately followed by the injection of rocuronium 0.6 mg/kg IV. The patient's response to rocuronium injection was graded using a 5-point scale. RESULTS: We observed that the incidence of movement was 100% in the placebo group and was significantly decreased to 28.8% in the group pretreated with lidocaine (P<0.001). CONCLUSIONS: Withdrawal movement on injection of rocuronium in pediatric patients can be decreased or prevented by pretreatment with IV lidocaine.

Clinical Analysis of CA19-9 Positive Rate of Hepatobiliary Pancreas Disease

PURPOSE: CA19-9 is the most widely used pancreatic-tumor marker, and has become the standard against which other makers. However, the CA19-9 level is increased in conditions such as gallbladder cancer, cholangiocarcinoma, hepatocellular carcinoma, gallbladder polyp, acute cholangitis, and chronic pancreatitis. Therefore, this study aimed to determine the CA19-9 positive rate of the above diseases in Korea. METHODS: A positive result was considered if the upper limit of normal was 37~40 U/ml. The CA19-9 level was measured in 53 patients with pancreatic cancer, 72 with cholangiocarcinoma, 41 with common bile duct cancer, 27 with gallbladder cancer, 35 with hepatocellular cancer, 70 with acute pancreatitis, 93 with chronic pancreatitis, and 30 with a gallbladder polyp from September 1998 to December 2000 in the Severance hospital. RESULTS: When the cut-off value was >40 U/ml, a positive result was found in 79.2% (42/53) of pancreatic cancer patients, 58.3% (42/72) of cholangiocarcinoma patients, 37% (10/27) of gallbladder cancer patients, 31.7% (13/41) of common bile duct cancer patients, 19.7% (14/70) of acute pancreatitis patients, 14.2% (5/35) of hepatocellular cancer patients, 16% (5/93) of chronic pancreatitis patients, and the 3.3% (1/30) of patients with a gallbladder polyp. CONCLUSION: The highest positive rate was 79.2% in the pancreatic cancer patients. We confirmed that the Lewis phenotype distribution indieates that pancreatic cancer, cholangiocarcinoma, and chronic pancreatitis show high frequency in Le(a-b-) group when they were statistically compared with a healthy control group, but that acute pancreatitis showed a stastically higher frequency in the Le(a-b-) group than chronic pancreatitis.

Neurologic Sequelae Following Spinal Anesthesia / 대한마취과학회지

Spinal anesthesia is a safe anesthetic technique and relative easy to perform, but occasionally neurologic injuries after spinal anesthesia have been reported. A 53-year old female patient visited the emergency room due to abdominal pain and she was diagnosed with acute appendicitis. Thus, an emergent appendectomy was planned. During the preoperative evaluation, we noticed that she had a history of intermittent low back pain for the previous 5 years. However, because her stomach was not fully empty, we decided to administer spinal anesthesia. When the spinal needle passed the subarachnoid membrane, she suddenly complained of severe paresthesia on her right posterior thigh. However the parethesia subsided soon, and 2.2 cc of 0.5% bupivacaine was injected via a spinal needle, and aftewards, an appendectomy was done without any complications. As she recovered from the spinal anesthesia, she started complaining of shooting, stabbing and burning pain on her right buttock and posterior thigh Because a neurologic injury after spinal anesthesia was suspected, we inserted an epidural catheter to the same lumbar vertebral level for administering the mepivacaine and ketamine mixture and we also performed a right second sacral nerve root block and a lumbar sympathetic ganglion block. Magnetic Resonance Imaging showed spondylosis of lumbar spine and associated disc degeneration and a bulging disc at the L3-4, L4-5 and L5-S1 level. After treatments, her symptoms improved gradually. When she was discharged on the 16th hospital day, she complained of only minor discomfort on her right posterior thigh.