Anesthetic management for a pediatric patient with joubert syndrome: A case report / 대한마취과학회지

Joubert syndrome is a rare autosomal recessive condition in which there is complete or partial agenesis of the cerebellar vermis. The clinical features are hypotonia, ataxia, mental retardation, abnormal ocular movements, typical facial features and episodic tachypnea with alternating apnea. The abnormal respiratory pattern and hypotonia may be exacerbated by anesthetics, and especially, the apneic episodes may be prolonged by administering opioids. Joubert syndrome has been associated with various airway abnormalities such as a high and arched palate, a large or protruding tongue, laryngomalacia, a variable epiglottis and micrognathia. These abnormalities may cause difficulty with tracheal intubation. In this present case, direct laryngoscope-assisted, fiberscopic guided intubation was performed. This case is the first report of anesthetic management in a patient with Joubert syndrome and who underwent palatoplasty in Korea.

Effect of fentanyl on hemodynamic changes connected with a thigh tourniquet during knee arthroscopic surgery / 대한마취과학회지

BACKGROUND: The use of a tourniquet can produce pain and increase in blood pressure. It is known that fentanyl reduces central sensitization, however its effect on blood pressure increase due to tourniquet is unknown. So we investigated the effect of fentanyl on tourniquet-induced changes of mean arterial blood pressure (MBP), heart rate (HR), and cardiac index (CI). METHODS: ASA physical status I and II, who were scheduled for knee arthroscopic surgery using a tourniquet, were assigned into control (n = 30) and fentanyl group (n = 30). Anesthesia was maintained with enflurane, N2O and O2. Fentanyl was injected 1.5 ug/kg at 10 min before inflation of the tourniquet in the fentanyl group. Changes of the MBP, HR, CI were measured before and 10, 20, 30, 40, 50, 60 min after inflation of the tourniquet. RESULTS: There were no differences in the baseline values. MBP was increased at 40, 50, 60 min in the control group. At 60 min, MBP was lower in the fentanyl than the control group. HR was decreased at 10 min in the fentanyl group. CI was decreased in all groups after tourniquet inflation. At 60 min, CI was more decreased in the control than the fentanyl group. CONCLUSIONS: Fentanyl injection prior to tourniquet inflation can attenuate the tourniquet induced hemodynamic changes in the knee arthroscopic surgery patients.

The effect of cranial electrotherapy stimulation on preoperative anxiety and hemodynamic responses / 대한마취과학회지

BACKGROUND: Cranial electrotherapy stimulation is used as a treatment for depression, anxiety, insomnia, and adjunctive intervention for pain management. The aim of this study is to evaluate the effect of cranial electrotherapy stimulation pretreatment on the level of preoperative anxiety and the hemodynamic responses. METHODS: Sixty patients undergoing general anesthesia were randomly assigned into two groups to receive either no pretreatment (Control group, n = 30) or cranial electrotherapy stimulation pretreatment (CES group, n = 30). Anxiety score, systolic and diastolic blood pressure, and heart rate were measured in the preoperative holding area and the operating room. RESULTS: The anxiety score in the operating room compared with the preoperative holding area decreased in the CES group, but increased in the Control group. Systolic blood pressure and heart rate in the operating room were lower in the CES group compared with the Control group. CONCLUSIONS: Cranial electrotherapy stimulation pretreatment reduced the level of the preoperative anxiety and the hemodynamic responses.

The effect of methods of ondansetron administration on nausea and vomiting during intravenous patient-controlled analgesia in pediatric patients undergoing pectus excavatum repair

BACKGROUND: Postoperative nausea and vomiting remain troublesome problems, especially in pediatric patients receiving the opioid analgesics. This study was designed to evaluate the difference between bolus injection and continuous infusion of ondansetron for the prevention of postoperative nausea and vomiting in pediatric patients with intravenous patient-controlled analgesia (IV-PCA). METHODS: Sixty patients undergoing pectus excavatum repair were randomly assigned into three groups, no antiemetic (Group 1, n = 20), intraoperative ondansetron 0.1 mg/kg IV bolus (Group 2, n = 20), ondansetron 0.1 mg/kg mixed with IV-PCA (Group 3, n = 20). The incidence of nausea, vomiting, the need for rescue antiemetics, side effects and pain score were recorded for 48 hr postoperatively. RESULTS: The incidence of nausea in Group 2 (20%) and Group 3 (25%) was significantly lower than Group 1 (60%). There was no significant difference in the incidence of vomiting among the groups (Group 1:60%, Group 2:20%, Group 3:20%). The need for rescue antiemetics was significantly lower in Group 2 and 3 than Group 1. CONCLUSIONS: In pediatric patients undergoing pectus excavatum repair, bolus injection and continuous infusion of ondansetron were effective in preventing postoperative nausea during IV-PCA. And the need for rescue antiemetics was significantly decreased.

The Effect of Sufentanil on Myocardial Function and Coronary Flow in an Isolated-Heart Rat Model / 대한마취과학회지

BACKGROUND: Some opioids have been shown to attenuate an ischemia-reperfusion injury in an isolated-heart model. The aim of this study was to evaluate the effect of sufentanil on the cardiac function in isolated-heart models when given before and after prolonged periods of low flow ischemia. METHODS: Isolated rat hearts were stabilized for 30 minutes and subdivided into four groups (each n = 7). The control group was subjected to low flow ischemia (LFI 0.3 ml/min) of 5% dextrose water for 30 minutes, followed by perfusion with a modified Krebs solution at a constant pressure for 60 minutes. In the sufentanil groups, different sufentanil (12.5 mg/L, 25 mg/L, 50 mg/L) doses were administered with the modified Krebs solution after 30 minutes of stabilization until the end of the experiment with the exception of the LFI group. The left ventricular end systolic pressure (LVESP), dP/dt max, heart rate and coronary flow were measured. After reperfusion, the infarct size of all groups was measured. RESULTS: The control and the sufentanil groups had a lower LVESP, dP/dt max, coronary effluent flow and arrhythmia duration after ischemia and reperfusion than those before ischemia. The infarct sizes in the sufentanil groups were smaller than those in the control group. However the infarct sizes of the sufentanil groups were similar. CONCLUSION: Sufentanil reduces the infarct size but does not improve the post-ischemic functional dysfunction.

The Effect of Epidural Block on Renal Function in Patients Undergoing Subtotal Gastrectomy with General Anesthesia / 대한구급학회지

BACKGROUND: Epidural block is widly used for anesthesia or analgesia, so many researches has been done in the field of cardiovascular system. And we reported the effects of epidural block on renal function in patients undergoing total abdominal hysterectomy with general anesthesia. In this research I evaluated the effect of epidural anesthesia on renal function in patients undergoing subtotal gastrectomy with general anesthesia. The earlier was in lumbar level and the later was in thoracic level. METHODS: We studied 15 patient who were in ASA 1 or 2. The epidural catheter was inserted via 17 gauge Tuohy needle through the T10-T11 intervertebral space of the patients before general anesthesia. Anesthesia for all the patients were maintained with isoflurane, nitrous oxide and oxygen. We measured urine output and hemodynamic profiles such as mean arterial pressure, pulse, CVP, cardiac output during 2 hours of general anesthesia period. And then we injected 10ml of 0.15% bupivacaine to the epidural space and measured the same parameters as those of general anesthesia period during another 2 hours of epidural anesthesia combined with general anesthesia. We also compared urine output and renal function (creatinine clearance, Na clearance, fractional excretion of Na and free water clearance) between each of the two periods. RESULTS: Mean arterial pressure and pulse were lower after epidural injection than before (p<0.05), but Cardiac output and CVP were not significantly different between two periods. Renal function data were not significantly different between the two periods. CONCLUSIONS: Renal function was maintained during sympathetic block by thoracic epidural anesthesia combined with general anesthesia.

The Effect of Sevoflurane on Myocardial Function and Coronary Flow in an Isolated-Heart Rat Model / 대한마취과학회지

BACKGROUND: Ischemic preconditioning (IPC) and some volatile anesthetics have been shown to attenuate ischemia-reperfusion injury in an isolated-heart model. The aim of this study was to determine whether sevoflurane has a cardioprotective effect on isolated-heart models when given before prolonged periods of global ischemia. METHODS: 48 male Sprague-Dawley rat hearts were randomly subdivided into four groups. Rats were anesthetized with 25 mg ketamine. After hearts had been removed, and perfused with a modified Krebs solution gassed with 5% CO2 balanced O2 at a constant temperature (37oC) and pressure (55 mmHg), a latex balloon was placed into the left ventricle to obtain isovolumetric contraction. After 20 min of equilibration, hearts were randomly allocated to 1) a control group, 2) an IPC group, two 5 min ischemic periods interspersed with 5 min normal perfusion, 3) an SPC (sevoflurane preconditioning) group, two 5 min sevoflurane periods interspersed with 5 min normal perfusion, 4) an SPC with Glibenclamide group. All groups were subjected to 30 min of global ischemia and 75 min of reperfusion. Left ventricular pressure, dP/dt max, and coronary flow were measured. Also flow responses to bradykinin were tested 15 min before IPC or SPC and 60 min after reperfusion. RESULTS: Sevoflurane administration before global ischemia was found to have protective effects like IPC on functional recovery, to reduce infarct size, and to conserve coronary endothelial function. LVP was less depressed in the SPC and IPC groups. dP/dt max in both the IPC and SPC groups recovered after global ischemia. Coronary flow was depressed in the control and in the SPC with Glibenclamide groups, but it was slightly depressed in the IPC and SPC groups. Smaller infarct sizes were observed in IPC and SPC groups. Flow increases due to bradykinin were greater after SPC and IPC. Moreover, these beneficial effects of sevoflurane were blocked by glibenclamide administration. CONCLUSIONS: Preconditioning with sevoflurane, like IPC, improves post ischemic contractility basal flow, and bradykinin-induced flow increases. Moreover, the protective effects of SPC and IPC were reversed by KATP channel antagonism.

Anesthetic Management of a Patient with Tuberous Sclerosis for Selective Arterial Embolization: A case report / 대한마취과학회지

A 39-yr-old female patient, diagnosed with tuberous sclerosis 10 years ago, presented for selective arterial embolization under general anesthesia. The symptoms of the patient were lower abdominal pain and gross hematuria. Renal arteriography showed multiple bilateral renal angiomyolipomas and ruptured aneurysms in right kidney. She had also pulmonary lymphangiomyomatosis, hepatic angiomyolipomas, and multiple subependymal nodules without mass effect in brain. We report the anesthetic management of this case with tuberous sclerosis for selective arterial embolization under general anesthesia.

Optimal Time Interval of Rocuronium Pretreatment for Prevention of Biochemical Changes, Fasciculations and Myalgia Following Succinylcholine Administration / 대한마취과학회지

BACKGROUND: The purpose of this study was to assess the optimal time interval between rocuronium pretreatment and succinylcholine for prevention of the rise in serum potassium and creatine kinase concentrations and the increased incidence of fasciculations and myalgia following succinylcholine administration. METHODS: We have studied 60 patients undergoing a minor elective surgery, in a prospective double blinded method. Three groups of 20 patients each were pretreated with saline 2 ml (Group C), 0.05 mg/kg rocuronium one min before (Group R1) or 3 min before (Group R3) 1.5 mg/kg succinylcholine administration. Serum potassium and creatine kinase were respectively measured 5 min after succinylcholine and 24 h after the operation. Fasciculations and myalgia on postoperative day 1 and day 2 were evaluated. RESULTS: The increase in the serum potassium concentration was not attenuated in any group. The increase in creatine kinase concentration, the incidence of fasciculations and the incidence of myalgia on postoperative day 1 and day 2 were highest in Group C; however, there was no difference between the Group R1 and R3. CONCLUSIONS: Either a 1 min or 3 min pretreatment time interval of the rocuronium has a similar effect on the prevention of the rise in serum potassium and creatine kinase concentrations and an increased incidence of fasciculations and myalgia following succinylcholine administration.

Rocuronium and Lidocaine Pretreatment for Prevention of Biochemical Changes, Fasciculations and Myalgia following Succinylcholine Administration / 대한마취과학회지

BACKGROUND: The purpose of this study was to assess the changes in serum potassium and creatine kinase concentrations and the incidence of fasciculations and myalgia when rocuronium and lidocaine were used in combination and separately as pretreatment before succinylcholine. METHODS: We studied 60 patients undergoing a minor elective surgery, in a prospective double blinded method. Three groups each with 20 patients were pretreated before a 1.5 mg/kg succinylcholine administration with 0.05 mg/kg rocuronium three min before (group R), 1.5 mg/kg lidocaine 30 sec before (group L), or both rocuronium and lidocaine (group RL). Serum potassium and creatine kinase were respectively measured 5 min after succinylcholine administration and 24 h after the operation. Fasciculations and myalgia on postoperative day 1 and day 2 were evaluated. RESULTS: The increase in creatine kinase and incidence of myalgia on postoperative day 1 was less in the RL group than in the R group and L group. The incidence of fasciculations was higher in the L group than in the R group and RL group. There was no increase in serum potassium in any group. CONCLUSIONS: The combined use of rocuronium and lidocaine was more effective in reducing creatine kinase and postoperative myalgia than when they were used separately. However, the fasciculations were only reduced by the use of rocuronium.

The Effect of Epidural Block on Renal Function in Patients Undergoing Total Abdominal Hysterectomy with General Anesthesia / 대한마취과학회지

BACKGROUND: There are many documents about the hemodynamic changes during sympathetic blockade produced by epidural anesthesia, but few reports have addressed the effects of epidural anesthesia on renal blood flow and function. We evaluated the effects of epidural anesthesia on renal function in patients undergoing total abdominal hysterectomy with general anesthesia. METHODS: Thirty patients were randomized to groups I (n = 15) or II (n = 15). The epidural catheter was inserted via 17 gauge Tuohy needle through the L2-L3 intervertebral space of the patients in both groups, only in group II, the patients received 15 ml of 0.125% bupivacaine. All the patients were anesthetized with enflurane, nitrous oxide and oxygen. We measured mean arterial pressure and urine output, creatinine clearence, Na clearence, fractional excretion of Na and free water clearance during operation and compared the data between the two groups. RESULTS: Mean arterial pressure was lower in group II than in group I (P < 0.05), but other data were not different significantly between the two groups. CONCLUSIONS: Renal function was maintained even though epidural anesthesia reduced mean arterial pressure.

Does Perioperative Monitoring of the Train-of-Four Response Influence the Frequency of Postoperative Residual Curarization in Propofol Anesthesia? / 대한마취과학회지

BACKGROUND: Sometimes hypoxemia occurs in the postoperative recovery room because of postoperative residual curarization (PORC). Some reports show that postoperative residual curarization is common. PORC occurs after the use of the long-acting muscle relaxants. It has been recommended to use intermediate-acting muscle relaxants and a TOF monitor to decrease PORC. The purpose of this study was to examine whether the use of the TOF monitor during propofol anesthesia affects the incidence of postoperative residual curarization. METHODS: 38 ASA I or II patients were divided randomly into two groups of 19 each. They received propofol-fentanyl-nitrous oxide for anesthesia. Pancuronium (80 100 microgram/kg) was used to facilitate tracheal intubation and additional doses were used to maintain surgical relaxation. The requirement for incremental doses of pancuronium and adequacy of recovery following reversal were assessed, either with (control group:n = 19) or without (experimental group:n = 19) TOF monitoring. Fifteen minutes after the arrival at the recovery room, neuromuscular function was assessed clinically and by using TOF. RESULTS: There were no statistical differences in body weight, age, or duration of operation between the two groups. There was no statistical difference in the total dose of pancuronium and total dose of pancuronium relative to body weight and duration of operation. There were statistical differences in TOF ratio in the recovery room (0.73 vs. 0.86). The incidence of PORC was 47% in the control group and 5% in the experimental group. CONCLUSIONS: Though the monitoring of TOF did not effect the dose of muscle relaxant, it may have reduced the incidence of PORC. However, the PORC had no clinical significance because the mean TOF ratio in the two groups was over 0.7 and there were no clinical signs of residual muscle weakness.

Production and Accumulation of Plasma Carboxyhemoglobin in Minimal Flow Anesthesia / 대한마취과학회지

BACKGROUND: Minimal flow anesthesia (total inflow rate 0.5 L/min) has been known to increase carbon monoxide production and accumulation in the breathing circuit. We tried to investigate the differences that minimal flow anesthesia shows in the production and elimination of plasma carboxyhemoglobin as compared with high-flow anesthesia. METHODS: Fifty patients were divided into smokers and non-smokers. The smokers were allocated into two groups; high flow (Hs, n = 10) or minimal flow (Ms, n = 13). Non-smoker were also allocated the same way; high flow (Hns, n = 12) or minimal flow (Mns, n = 15). The values (%) of COHb were measured at the preanesthetic baseline, 50 min (30 min after reducing inflow rate in minimal flow), 80 min and 140 min. All values along the time were compared with their baseline within a group. RESULTS: Non-smokers showed a COHb level that didn't change at each time interval as compared with the baseline in group Mns (p = 0.91) and group Hns (p = 0.365). Smokers showed a decreased COHb level at 50 min which increased at 80, 140 min compared with the baseline in group Ms (p = 0.004), but decreased at 50, 80 and 140 min as compared with baseline in group Hs (p < 0.001). CONCLUSIONS: Minimal flow anesthesia does not produce plasma COHb more than high flow anesthesia, but an increase of COHb would be expected in risky groups such as heavy smokers because elimination of carbon monoxide in the breathing circuit was slower than with high flow anesthesia.

Mental Depression after General Anesthesia Caused by Unknown Intracranial Tumor: A case report / 대한마취과학회지

Slowly growing brain tumors may not present specific symtoms or signs related to increased intracranial pressure due to volume-spacial compensation. So we may not find brain tumors in patients in preoperative evaluations. But patients with unknown brain tumors may have severe complications after anesthesia. We experienced a patient whose emergence was delayed from general anesthesia for laparascopic urinary incontinence surgery (Burch's operation). The patient had such neurologic signs as deeply confused mentality, loss of pupil reflex and anisocoria. A large brain tumor in the left parietal lobe was revealed by brain MRI and it was resected. After further evaluation we found that it had originated from pulmonary adenocarcinoma, so the patient was designated for radiation therapy.

The Effect of Lung Disease in the Arterial to End-Tidal Carbon Dioxide Tension Difference / 대한마취과학회지

BACKGROUND: The purpose of this study was to evaluate the effects of lung disease on the difference between arterial and end-tidal carbon dioxide tension by placing patients from the supine to the lateral decubitus position and by the changes from two lung ventilation (TLV) to one lung ventilation (OLV) during thoracic surgery. METHOD: Fifteen patients who had no parenchymal lung disease were selected for control group and 15 patients who had parenchymal lung disease on non-dependent lung were selected for disease group. All patients had been intubated with double lumen endobronchial tubes and respiration was controlled with a rate of 14-15 breaths per minute and tidal volume 8 ml/kg. End-tidal and arterial carbon dioxide tension were measured at three different measurement periods (supine plus TLV, lateral decubitus plus TLV, lateral decubitus plus OLV). RESULTS: The arterial to end-tidal carbon dioxide tension difference was more increased in disease group than control group. But there was no significant difference in arterial to end-tidal carbon dioxide tension with position change, ventilation method change in each groups. CONCLUSION: We conclude that the arterial to end-tidal carbon dioxide tension difference is increased in lung disease, but it does not changed with position and ventilation method change.

Effects of Concentration of Preoperatively Administered Epidural Bupivacaine on Postoperative Pain Control / 대한마취과학회지

BACKGROUNDS: Epidural anesthesia before surgical stimulus may reduce or prevent subsequent pain by preemptive analgesia. We studied the effect of varied concentration of a local anesthetic agent administered through epidural catheter before operation on preemptive analgesia after an abdominal hysterectomy. METHODS: Fourty-five patients scheduled for abdominal hysterectomy were blindly randomized to receive 10 ml of 0.5% bupivacaine (group I), 0.25% bupivacaine (group II) or saline (group III) respectively before induction of anesthesia. For postoperative pain control all patients received the same analgesic regimen which was 10 ml of 0.125% bupivacaine and buprenorphine 0.15 mg after resection of the uterus. Then the epidural catheter was connected with infusion pump containing 100 ml of 0.125% bupivacaine and buprenorphine 0.45 mg. Its infusion rate was 2 ml/hour. Pain was assessed using the Visual Analogue Scale (0 = no pain to 10 = intolerable pain) on rest, motion, cough and verbal rating scale at 1, 3, 6, 24 and 48 hour after operation. Side effects were recorded at the same time intervals. RESULTS: Using the ANOVA on ranksum test, pain scores 1 hour after operation differed between groups I and III (P<0.05). In VAS in motion, the pain scores 24 hours after operation differed between groups I and III (P<0.05). In VRS, the pain scores 3 hours after operation differed between groups II and III (P<0.05), and those 24 hours after operation differed between groups I and III (P< 0.05). The incidence of motor weakness using Chi-square test in group I differed from groups II, III (P< 0.05). CONCLUSIONS: Among the 45 patients who had a postoperative pain control after abdominal hysterectomy with initial bolus injection and then continuous infusion of epidural bupivacaine and buprenorphine, postoperative pain scores of patients who had preoperative epidural injection of 10 ml of 0.5% bupivacaine (n = 15) were lower than those of saline injected patients (n = 15), but those of patients with a preoperative epidural injection of 10 ml of 0.25% bupivacaine (n = 15) were not lower than those of saline injected patients.

The Effects of Epidural Anesthesia on the Renal Blood Flow and Renal Function in Dogs / 대한마취과학회지

BACKGROUND: There are many documents about the hemodynamic changes according to sympathetic blockade produced by epidural anesthesia, but a few reports have addressed the effects of epidural anesthesia on renal blood flow and function. We evaluated the effects of epidural ane.sthesia on the renal blood flow and function in 6 dogs under general anesthesia. METHODS: The dogs were anesthetized with halothane 1.0-1.5 volume %, nitrous oxide 2L/min and oxygen 2L/min. Epidural catheter was inserted via 17 gauge Tuohy needle through L2-L3 intervertebral space. The abdominal wall was opened and the left renal artery was dissected to measure the blood flow with the electromagnetic flowmeter. We measured mean arterial pressure, cardiac output, central venous pressure, pulmonary capillary wedge pressure and renal blood flow at the interval of 20 minutes for 2 hours during general anesthesia (control period). Urine had been collected for the control period, and then blood was sampled for the measurement of serum creatinine concentration from the femoral artery. Under the general anesthesia, epidural anesthesia was established using 10ml of 0.5% bupivacaine, and we measured same parameters for the same time sequence as in the control period (experimental period). RESULTS: Mean arterial pressure and cardiac output decreased significantly after epidural anesthesia (p<0.05). Central venous pressure and pulmonary capillary wedge pressure were not changed comparing to those in the control period. Renal blood flow decreased significantly after epidural anesthesia (p<0.05) but creatinine clearance and urine output were maintained. CONCLUSION: renal blood flow was decreased but renal function was maintained when epidural anesthesia reduced mean arterial pressure and cardiac output.

Pulmonary Edema due to Upper Airway Obstruction after Neck Mass Excision of the Patient with Cerebral Palsy / 대한구급학회지

Because the emergence from anesthesia may be delayed in the patient with the cerebral palsy, extubation must be delayed until consciousness is recovered completely. Postoperative pulmonary edema has several causes and one of them, upper airway obstruction is rare. We had experienced pulmonary edema due to upper airway obstruction after neck mass excision in the patient with cerebral palsy, who was 21-year-old, 50 kg, male and normal preoperative laboratory data. There was no significant change in blood volume during operation for 1 hour. After operation, the patient breathed spontaneously and the endotracheal tube was extubated in the operating room. When the patient was transfered to the recovery room, he had cyanosis, intercostal and substernal retraction, and the pulse oximeter showed very low oxygen saturation. We supplied oxygen to the patient and reintubated him, and recognized the pinkish frothy sputum by suction of the endotracheal tube. On the portable chest X-ray film of the patient at the moment, hazy increased density on both lung fields indicating pulmonary edema, but the heart size was not increased. By routine treatment for pulmonary edema, the symtoms and signs of the patient were improved. He had stayed for 1 day in the SICU and then transfered to the general ward.