The Effects of Epidural Anesthesia in Elderly Patients during Single-Level Lumbar Microdiscectomy

OBJECTIVE: To analyze the effect of epidural anesthesia in elderly patients with single-level lumbar discectomy. METHODS: Medical records of 28 patients aged between 60 and 90 years who had undergone single-level lumbar microdiscectomy by two surgeons from January 2004 to December 2008 were retrospectively reviewed. Patients were divided into 2 groups: Group I was comprised of patients with lumbar discectomy under epidural anesthesia and Group II was comprised of patients with lumbar discectomy under general anesthesia. Factors taken into account when comparing the effects of epidural and general anesthesia were surgical time, anesthetic time, starting time of ambulation after surgery, hospital stay, postoperative headache, nausea, vomiting, urinary difficulty, back pain and patient satisfaction. The score on the visual analogue scale(VAS) for back pain was measured after surgery. RESULTS: 15 patients(Group I) underwent discectomy under epidural anesthesia. The mean age of patients in Group I and II were 65+/-6.1 years and 67+/-6.7 years, respectively. 19 patients had underlying co-morbidities, such as cardiovascular, pulmonary, cerebrovascular diseases and cancer. Demographically, there was no statistical diffe- rence between the two groups. Surgical time, anesthetic time, starting time of ambulation after surgery and hospital stay were longer in patients in Group II. The incidences of urinary difficulty and VAS score for back pain were significantly lower in Group I. The incidences of headache, nausea and vomiting and patient satisfaction were not different between Group I and II. CONCLUSION: Epidural anesthesia was as efficacious and as safe as general anesthesia. Elderly patients who need to undergo single-level lumbar discectomy could be offered epidural anesthesia.

Cutoff of Percent Body Fat to Predict Obesity and Metabolic Risk in Children and Adolescents: 2007 Children and Adolescent Physical Growth Standard / 가정의학회지

BACKGROUND: Body mass index (BMI) for gender and age and percentage-weight-for-height (PWH) for gender and height have been frequently used to diagnose childhood obesity. However, few studies have examined the optimal cutoff of percent body fat (%BF) to predict metabolic abnormalities in obese children. METHODS: One thousand fifteen obese children aged 10 to 15 years were enrolled in this study. The %BF cutoff values were calculated by ROC analysis for metabolic abnormalities. We also calculated %BF cutoff values corresponding to a BMI of > 85th or 95th percentile for gender and age and a PWH of > 120% for gender and height based on the 2007 Korean children and adolescents growth standard chart. To define metabolic abnormalities in children, we used the criteria of metabolic syndrome recommended by International Diabetes Federation consensus for children and adolescents. RESULTS: The %BF cutoff corresponding to the group having more than one metabolic abnormality in this study population were 38.4% (sensitivity 40.1%, specificity 84.4%) in total, 38.4% (sensitivity 35.4%, specificity 84.8%) in boys and 39.5% (sensitivity 38.9%, specificity 90.9%) in girls. The %BF cutoff values corresponding to a BMI > or = 95 percentile were 38.1% (sensitivity 50.5%, specificity 72.7%), a BMI > or = 85 percentile were 34.5% (sensitivity 69.3%, specificity 74.2%), and a PWH > or = 120% were 36.4% (sensitivity 72.3%, specificity 64.4%) in total. CONCLUSION: The optimal cutoff value of percent body fat to predict metabolic abnormalities in obese children may be 38.4% (boys 38.4, girls 39.5%) and we suggest 34.5% as a cutoff value of %BF for screening childhood obesity.

The Effect of Intraoperative and Postoperative Music on Patients of Regional Anesthesia / 대한마취과학회지

BACKGROUND: Music influences the body and mental well-being of humans. Almost all patients undergoing surgery experience perioperative anxiety. This study was designed to determine the effect of music during surgery and the post-operation period under regional anesthesia on the level of anxiety, relaxation and fatigue. METHODS: Sixty-four patients who underwent orthopedic surgery under regional anesthesia were randomly assigned to Group 1 (listening to music) and Group 2 (no music). The premedication and anesthesia were standardized for both groups. The level of anxiety, fatigue and psychological well-being were examined as outcome variables. RESULTS: The level of anxiety and psychological well-being was significantly lower (anxiety: P = 0.012, psychological well-being: P = 0.006) in Group 1 than in Group 2. The level of fatigue was similar in both groups. CONCLUSIONS: The results suggested that music might be effective in reducing the level of intra and post-operative anxiety and improving the psychological well-being of patients undergoing surgery under regional anesthesia.

Respiratory Complications Due to Nitrous Oxide Impurities Six cases / 대한마취과학회지

The impurities potentially contained in nitrous oxide cylinders include NO, NO2, CO and NH3. The consequences of inahaling NO and NO2 are reflex breathing inhibition with laryngospasm and the rapid onset of intense cyanosis due to altered pulmonary gas exchange and methaemoglobinemia. Pulmonary edema may occur in the acute stage. Chronic chemical pneumonitis may follow with resultant pulmonary fibrosis and the respiratory and metabolic acidosis may also occur. Hypotension may be marked and results from the effects of nitrate and nitrite ions on vascular smooth muscle. Since certain clinical features provide clues that allow practicing anesthetists to recognize the toxicities of higher nitrogen oxides, six of our cases will be described in detail, whereas the remaining cases will be only commented. We examined a N2O cylinder at the National Metrology Institute, its NOX concentration was 2359 ppm. Another two cylinders were also abnormal with NOX concentrations of 547 ppm and 180 ppm. We recommend that medical gases be subjected to quality control on a national basis.

A Comparative Study of the Effective Infusion Method of Propofol for Patients That Prefer to be Sedated under Brachial Plexus Block / 대한마취과학회지

BACKGROUND: Patients who are scheduled for upper extremity surgery under brachial plexus block (BPB) prefer to have no memory of the surgical procedure and some form of sedation is therefore necessary. Because of this we have tried to find an adequate infusion method for propofol that would supply better sedation and less complications. METHODS: We divided 60 patients who were scheduled for upper extremity surgery under BPB into four groups according to loading dose and following continuous infusion rate of propofol (Group 1: 0.2 mg/kg, 8 microgram/kg/min, group 2: 0.4 mg/kg, 16 microgram/kg/min, group 3: 0.6 mg/kg, 33 microgram/kg/min, group 4: 0.8 mg/kg, 50 microgram/kg/min.). We evaluated the degree of sedation, amnesia, recovery, changes of blood pressure, heart rate, and respiratory effect of each group. RESULTS: According to the sedation score, groups 3 and 4 were sedated better than groups 1, 2 (P< 0.05). But the mean arterial pressure (MAP), heart rate and respiration were more depressed and recovery time prolonged in the higher dosage groups (P< 0.05). Three patients among group 4 developed severe respiratory depression, at which time infusion of propofol was stopped. CONCLUSIONS: The ideal infusion method of propofol for effective sedation was 0.4 0.8 mg/kg of loading dosage, followed by 16 50 microgram/kg/min of continuous infusion dosage. But the more dosages of propofol that were administered, the more complications appeared, so we must use care in administering propofol as a sedation adjuvant to BPB.

The Effect of Bupivacaine on Blood Coagulation In Vitro under Thromboelastography / 대한마취과학회지

BACKGROUND: Deep vein thrombosis (DVT) is a common complication following major surgical procedure. In regional anesthesia with local anesthetics, deep vein thrombosis is less frequent than in general anesthesia. Several studies have advocated that local anesthetics alter the function of platelets, the stability of vascular endothelium, and the hemodynamics of the blood flow in the epidural anesthetic region. We investigate the effect of the local anesthetic bupivacaine on blood coagulation in vitro under thromboelastography (TEG). METHODS: 16 Healthy volunteers who had no history of coagulation defect and anticoagulant use were evaluated. The patients were divided into 4 groups and each group was treated with bupivacaine in the following concentrations; the lower clinical level (1 microgram/ml, B1 group), the higher clinical level (2 microgram/ml, B2 group), the systemic toxicity level (4 microgram/ml, B3 group), and a control group which was treated with normal saline. We compared the TEG parameters of each group, reaction time (R), coagulation time (K), alpha angle (alpha), maximal amplitude(MA) and fibrinolysis index (lysis 60), respectively. RESULTS: As compared with the control group, there were no significant differences in the other 3 groups, especially in maximal amplitude. CONCLUSIONS: In the clinical concentration, bupivacaine had no effect on blood coagulation under TEG. Thus in the clinical concentration of bupivacaine, DVT is more influenced by several physiologic changes which are induced by epidural anesthesia, include stability of vascular endothelium, increased blood flow, and decreased catecholamine release rather than by the effect of bupivacaine on blood per se.

Quantification of Tranexamic Acid Reversal of Fibrinolysis Using Thromboelastography and Low Dose Tranexamic Acid Effect in Open Heart Surgery / 대한마취과학회지

BACKGROUND: Prophylactic administration of tranexamic acid (TA) reduces bleeding and transfusion requirement after open heart operations. This study was performed to determine the relationship between inhibition of fibrinolysis and TA blood concentration. METHOD: In phase I, recombinant tissue plasminogen activator[r-tPA (0, 50, 100, 150 ng/ml)] was added to the blood of volunteer and induced fibrinolysis. In phase II, 4 thromboelastography (TEG) models of severe fibrinolysis in which TA was added to achieve blood levels (0, 0.72, 1.44, 2.88 mg/ml) were compared to determine the lowest effective dose. In phase III, the lowest dose (0.72 mg/ml) was mixed with the blood and evaluated on TEG in open heart operation. In phase IV, a placebo group and study group receiving TA in an loading dose of 5 mg/kg before bypass following infusion of 2 mg/kg/hour. Used analysis is Mann Whitney U test and Wilcoxon rank signed test. RESULT: In phase I, fibrinolytic inhibition at A30/MA (r=0.752) and A60/MA (r=0.735) were linearly correlated with the blood r-tPA concentration. In phase II, severe fibrinolysis (r-tPA 100 ng/ml) was reversed completely at all doses of TA. In phase III, the fibrinolysis index at 10 min. after starting bypass, aorta declamping, and 1 hour after operation were improved when the patient's blood was treated with TA (0.72 mg/ml). In phase IV, blood treated with TA showed less fibrinolysis and better TEG results than the placebo group. CONCLUSION: A small dose of TA (5 mg/kg), which was determined by an in vitro model of fibrinolysis on TEG, was effective in preventing changes in fibrinolytic index during cardiopulmonary bypass in open heart surgery.

Coagulation Effect of Lyophilized Fresh Frozen Plasma, and Platelet on Human Blood Diluted with Normal Saline: Thromboelastographic Assessment / 대한마취과학회지

INTRODUCTION: Recent availability of lyophilized fresh frozen plasma(Lyo-FFP) and lyophilized platelet(Lyo-PLT) on thromboelastography(TEG) may help to target therapy with the required blood product and thereby correct coagulopathy. This study was performed to assess the in vitro effect of LyoFFP and Lyo-PLT on human blood diluted with normal saline by TEG. METHODS: Venous blood from 8 healthy volunteers was diluted to 50volume%(D1) and 75volume%(D2) with 37degreesC normal saline for native TEG. Then, D1 and D2 were mixed with 0.5 ml citrate for citrate TEG(CD1 and CD2). The TEGs of CD1 and CD2 treated with Lyo-FFP and Lyo-PLT were compared with TEGs of D1, D2, CD1 and CD2 . All of blood samples were checked for hematocrit, platelet count and fibrinogen concentration. All the TEGs were compared for significance of differences by repeated measure ANOVA. RESULTS: D1 and D2 showed much lower hematocrit, platelet count and fibrinogen than control. In serial hemodilution there were significant changes in only maximal amplitude(MA) in D1 and all TEG parameters in D2 were depressed. Addition of Lyo-FFP and Lyo-PLT to D1 did not show any positive change in TEG parameters. However, addition of Lyo-FFP and Lyo-PLT to D2 showed significant improvements in reaction time and alpha angle, but not in MA. CONCLUSIONS: Lyo-FFP may be helpful in determining therapy for bleeding associated with coagulation factor deficiencies. However, the role of Lyo-PLT for the detection of platelet deficiency needs further evaluation.

Heparinase is More Reliable than Protamine for Detecting Heparin Effects on Thromboelastography on Reperfusion of Liver Transplantation / 대한마취과학회지

BACKGROUND: Heparin released from grafted liver immediately after declamping is one of causes of coagulopathy, and its presence has been diagnosed by comparing thromboelastography(TEG) of blood treated with 0.01% of protamine and untreated blood. However, protamine may affect coagulation if the amount of protamine is not optimal to heparin in the blood sample. Heparinase, an enzyme isolated from Flavobacterium Heparinum, neutralizes heparin without adversely affecting coagulation. Therefore we compared the TEGs of blood treated with heparinase and protamine to clarify the sensitivity and reliability of heparinase in reversing the heparin effect. METHODS: Differences in Reaction time(R time), Alpha angle, Maximal Amplitude(MA) between native and heparinase treated TEG on reperfusion in 8 cases of orthotopic liver transplantations were compared with those between native and protamine in 14 cases of OLT. RESULTS: On reperfusion, all of TEGs treated with heparinase showed more improved data rather than native one in R time, Alpha angle and MA. But, in protamine treated blood, R time and Alpha angle in 6 patients and MA in 3 patients were more depressed. The scattergram show that TEGs treated with heparinase on reperfusion have almost positive difference, but TEGs treated with protamine did not have positive results consistently. CONCLUSIONS: Heparinase is a more reliable reagent and activator than protamine on TEG for detecting heparin effects on reperfusion without showing in-vitro anticoagulation. Those results suggest that heparinase on TEGs can make diagnosis of coagulopathy developed immediately after reperfusion efficiently.

Heparinase is More Reliable than Protamine for Detecting Heparin Effects on Thromboelastography on Reperfusion of Liver Transplantation / 대한마취과학회지

BACKGROUND: Heparin released from grafted liver immediately after declamping is one of causes of coagulopathy, and its presence has been diagnosed by comparing thromboelastography(TEG) of blood treated with 0.01% of protamine and untreated blood. However, protamine may affect coagulation if the amount of protamine is not optimal to heparin in the blood sample. Heparinase, an enzyme isolated from Flavobacterium Heparinum, neutralizes heparin without adversely affecting coagulation. Therefore we compared the TEGs of blood treated with heparinase and protamine to clarify the sensitivity and reliability of heparinase in reversing the heparin effect. METHODS: Differences in Reaction time(R time), Alpha angle, Maximal Amplitude(MA) between native and heparinase treated TEG on reperfusion in 8 cases of orthotopic liver transplantations were compared with those between native and protamine in 14 cases of OLT. RESULTS: On reperfusion, all of TEGs treated with heparinase showed more improved data rather than native one in R time, Alpha angle and MA. But, in protamine treated blood, R time and Alpha angle in 6 patients and MA in 3 patients were more depressed. The scattergram show that TEGs treated with heparinase on reperfusion have almost positive difference, but TEGs treated with protamine did not have positive results consistently. CONCLUSIONS: Heparinase is a more reliable reagent and activator than protamine on TEG for detecting heparin effects on reperfusion without showing in-vitro anticoagulation. Those results suggest that heparinase on TEGs can make diagnosis of coagulopathy developed immediately after reperfusion efficiently.

Central Neurocytoma: A Case Report

A rare case of intraventricular central neurocytoma in 17-year-old male is reported. The patient had diffuse headache and diplopia. Radiologic findings displayed obstructive hydrocephalus and a large, well-demarcated intraventricular mass lesion obstructing the foramen of Monroe. The tumor arouse from the splenium of corpus callosum. It was removed successfully using two different approaches after extraventricular drainage of the cerebrospinal fluid(CSF). Histologically, the tumor showed pathological features as that of oligodengroglioma on the light microscope. In immunohistochemical examination, glial fibrillary acidic protein(GFAP) was negative and synaptophysin, positive. Numerous neurosecretory granules were found and no typical synapsis was noticed on the electron microscope. No shunt operation was needed. Postoperative radiotherapy or chemotherapy was not performed and no tumor recurrence was detected during the one year follow-up period. We present the case together with a review of the literatures.

Heparin Independent Coagulation Monitoring during Open Heart Surgery / 대한마취과학회지

Thromboelastography(TEG) is a useful monitor for assessing coagulation function in patients undergoing open heart surgery. However, whole blood clotting patterns on TEG are not able to obtain during the cardiopulmonary bypass(CPB) with heparin anticoagulation. When pretreating TEG sample with heparin antidote, heparinase or protamine (heparinase-modified TEG or protamine modified TEG) can make possible assessing the changes of clotting on TEG during the CPB. In this study, data from heparinase(N=50) and protamine(N=26) modified TEG were obtained before, during and after CPB in 76 open cardiac patients, which are presented to describe their usefulness concerning about prediction for coagulation after weaning of CPB. Heparin neutralized TEG revealed that all of depressed values initially after starting bypass were returning back to the values of before starting bypass on weaning CPB. These results suggested that function of the fibrinogen and platelet were relatively well maintained during the bypass. The fibrinolysis during the bypass were commonly developed in 51.2% without affecting by time course of CPB. Even though initial dose of protamine reversal after bypass, there were obviously residual heparin effects on heparinase-modified TEG as simultaneously comparing with native TEG. Regarding correlation of TEG findings in cases excluding fibrinolysis between before and after bypass, R time and MA before bypass were significantly correlate with R time and MA on heparinase-modified TEG after bypass but not on native TEG. (R time: R 0.46, MA: R=0.54). The data gathered in this study suggested heparin independent TEG assay can be useful to assess the coagulation function during the bypass and to predict the values of TEG after bypass, but residual heparin effect must be initially excluded to avoid underestimating the coagulation status after protamine reversal.

A case of asphylaxiating thoracic dystrophy type II

No abstract available.

A case of pneumoperitoneum secondary to pulmonary airleak and a similar case of abdominal subcutaneous emphysema

No abstract available.

Vesicoureteral Reflux Associated with Urinary Tract Infection in Children

No abstract available.

Computed tomographic evaluation of adrenal gland tumors

CT findings of twenty-four patients with adrenal gland tumors were analyzed to evaluate their location, size,shape, density etc. The post-surgical confirmation was made in 17 cases. The findings were as follows: 1. 4-10cmsized tumor messes were most common (42%). 2. Round or oval shaped forme were most common (59%). 3. Functionaltomors were 71% (17/24) including Cushing's syndrome of 10 cases, pheochromocytomas of 6 cases and aldosteronismof 1 case. 4. Abnormal adrenal glands were delineated in 88%(21/24), most effectively by CT. We concluded that CTwas the valuable study in the evaluation of the adrenal gland tumors and in the determination of surgicaloperation.