Comparison of cardioprotection between sevoflurane-remifentanil and midazolam-sufentanil total intravenous anesthesia during off-pump coronary artery bypass surgery

BACKGROUND: Volatile agents have been reported to protect myocardium against ischemia. But, there were a few clinical reports about the myocardial protection of inhalation agents. So we investigated the cardiac protection of sevoflurane in comparison with total intravenous anesthesia (TIVA). The study is a retrospective unrandomized study via the medical record review. METHODS: The records of 102 patients who received off-pump CABG were reviewed. One patient group received TIVA by midazolam and sufentanil continuous infusion (TIVA group, n = 68), and the other patient group received an inhalational anesthesia by sevoflurane (sevoflurane group, n = 34). Except maintenance of anesthesia, two groups of patients received an identical surgical, anesthetical, and postoperative care. At arrival in the intensive care unit, and after 1, 2, 3 and 5 days, serum cardiac enzyme levels were measured. RESULTS: All the median values of cardiac enzyme concentrations were lower in the sevoflurane group than TIVA group. Moreover, there were the significant differences between groups at the immediate postoperative CK-MB (median 4.7 ng/ml versus 5.9 ng/ml (P = 0.049)), 1-5 days postoperative LD (1 day 271.5 U/L versus 292 U/L (P = 0.045), 2 day 227.5 U/L versus 270 U/L (P = 0.009), 3 day 215 U/L versus 250 U/L (P = 0.030), 5 day 218 U/L versus 231 U/L (P = 0.005)), and 1, 3 postoperative troponin I level (0.485 ng/ml versus 1.12 ng/ml [P = 0.029], 0.090 ng/ml versus 0.235 ng/ml [P = 0.047] respectively). CONCLUSIONS: Sevoflurane lowered cardiac enzyme levels in comparison with TIVA after off-pump CABG anesthesia. These data suggest a cardioprotective effect of sevoflurane during CABG.

The effect of low fresh gas flow rate on sevoflurane consumption / 대한마취과학회지

BACKGROUND: In an era of medical cost containment, cost-effectiveness has become a major focus in healthcare. The effect of a new policy on the use of low fresh gas flow during maintenance of general anesthesia with volatile anesthetics was evaluated. METHODS: The numbers and duration of general anesthesia cases using sevoflurane 5 weeks prior to and 15 weeks after policy implementation were retrieved from the electronic medical records database. The number of sevoflurane bottles consumed was also assessed. The anesthesia hours per bottle of sevoflurane were compared before and after policy implementation. RESULTS: The number of anesthesia hours performed per bottle of sevoflurane increased by 38.3%. The effect varied over time and tended to fade with time. CONCLUSIONS: The implementation of a low fresh gas flow rate policy effectively reduces the amount of sevoflurane consumed for the same duration of anesthesia.

Effects of sevoflurane on neuronal cell damage after severe cerebral ischemia in rats / 대한마취과학회지

BACKGROUND: The aim of this study was to investigate the neuroprotective effects of sevoflurane after severe forebrain ischemic injury. We also examined the relationship between the duration of ischemia and neuronal cell death. METHODS: Male Sprague-Dawley rats (300-380 g) were subjected to 6 (each n = 6) or 10 min (each n = 10) of near-complete forebrain ischemia while anesthetized with either 50 mg/kg of zoletil given intraperitoneally or inhaled sevoflurane (2.3%). Ischemia was induced by bilateral common carotid artery occlusion plus hemorrhagic hypotension (26-30 mmHg). Histologic outcomes were measured 7 days after ischemia in CA1 pyramidal cells of the rat hippocampus. RESULTS: The mean percentage of necrotic cells in the hippocampal CA1 area decreased in the sevoflurane group compared to the zoletil group (25% vs. 40% after 6 min ischemia, respectively: P = 0.004 and 44% vs. 54% after 10 min of ischemia, respectively P = 0.03). The percentage of apoptotic cells was similar in all groups. The percentage of necrotic cells in each anesthetic groups was significantly higher in the 10 min ischemia group compared to the 6 min ischemia group (P = 0.004 in the sevoflurane group, P = 0.03 in the zoletil group). CONCLUSIONS: The present data show that sevoflurane has neuroprotective effects in rats subjected to near-complete cerebral ischemia. Longer duration of ischemia is associated with more neuronal injury when compared to ischemia of shorter duration.

Axillary approach versus the infraclavicular approach in ultrasound-guided brachial plexus block: comparison of anesthetic time / 대한마취과학회지

BACKGROUND: With ultrasound guidance, the success rate of brachial plexus block (BPB) is 95-100% and the anesthetic time has become a more important factor than before. Many investigators have compared ultrasound guidance with the nerve stimulation technique, but there are few studies comparing different approaches via the same ultrasound guidance. We compared the axillary BPB with the infraclavicular BPB under ultrasound guidance. METHODS: Twenty-two ASA physical status I-II patients presenting with elective forearm surgery were prospectively randomized to receive an axillary BPB (group AX) or an infraclavicular BPB (group IC) with ultrasound guidance. Both groups received a total of 20 ml of 1.5% lidocaine with 5 microg/ml epinephrine and 0.1 mEq/ml sodium bicarbonate. Patients were then evaluated for block onset and block performance time was also recorded. RESULTS: Group IC demonstrated a reduction in performance time vs. group AX (622 +/- 139 sec vs. 789 +/- 131 sec, P < 0.05). But, the onset time was longer in group IC than in group AX (7.7 +/- 8.8 min vs. 1.4 +/- 2.3 min, P < 0.05). All blocks were successful in both groups. CONCLUSIONS: Under ultrasound guidance, infraclavicular BPB was faster to perform than the axillary approach. But the block onset was slower with the infraclavicular approach.

Intravenous patient-controlled analgesia to manage the postoperative pain in patients undergoing craniotomy / 대한마취과학회지

BACKGROUND: This randomized controlled study evaluated the efficacy of intravenous patient-controlled analgesia (IV-PCA) with fentanyl and ketorolac for neurosurgical patients, and compared the effectiveness of IV-PCA with intermittent analgesics injection. METHODS: The patients undergoing craniotomy were randomly assigned to two groups. Patients of group P (n = 53) received fentanyl (0.2 microg/kg/hr) and ketorolac (0.3 mg/kg/hr) via IV-PCA, and those of group N (n = 53) received intermittent fentanyl or ketorolac injection as needed. Pain was evaluated using a 0-10 visual analogue scale (VAS) at postoperative 1, 4, and 24 hr. The amount of infused analgesic drugs, Glasgow Coma Scale (GCS) score, systolic arterial pressure, heart rate, respiratory rate, and the incidence of nausea and miosis were measured at the same time points. RESULTS: Although VAS of pain (VASp) was comparable at postoperative 1 hr (P = 0.168) between the two groups, the group P had significantly lower VASp at postoperative 4 hr (P = 0.007) and 24 hr (P = 0.017). In group P, less analgesic drugs were administered at postoperative 1 hr, and more analgesic drugs were administered at postoperative 24 hr. There were no differences between two groups with respect to nausea, GCS, systolic arterial pressure, and heart rate. IV-PCA did not further incur respiratory depression or miosis. CONCLUSIONS: IV-PCA with fentanyl and ketorolac after craniotomy is more effective analgesic technique, without adverse events, than the intermittent administration of analgesics.

Comparison of airwayscope to direct laryngoscope and lightwand for cardiovascular response in patients with difficult airway / 대한마취과학회지

BACKGROUND: Airwayscope (AWS), which has been used successfully for difficult airway in general anesthesia, has been anticipated that hemodynamic response to tracheal intubation in the difficult airway may be attenuated. Also, there is a series of reports demonstrating the successful use of lightwand to open the difficult airway. Thus, we decided to conduct a survey to compare AWS to lightwand and to direct laryngoscopy of cardiovascular response to tracheal intubation. METHODS: Of 64 healthy patients without cardiovascular disease, 22, 21, 21 patients were randomly assigned to AWS group, lightwand group and direct laryngoscope group. After induction of general anesthesia, intubation was performed with manual in-line neck stabilization. During laryngoscopy, a modified Cormack-Lehane grade was assessed and time to intubation was measured. Systolic arterial pressure (SAP) and heart rate (HR) were recorded at the following timepoints: baseline, just before intubation, 1 min, 2 min, 3 min, 4 min and 5 min after intubation. RESULTS: There were no significant differences between the 3 groups in SAP, HR (P > 0.05). However modified Cormack-Lehane grade of all patients in the AWS group was I, while that in direct laryngoscope group was IIB or III. In addition, the mean time to intubation of the direct laryngoscope group was significantly longer than that of the AWS and lightwand (P < 0.05). CONCLUSIONS: In the difficult airway, AWS was very effective in improving laryngeal view and decreasing time to intubation compared to direct laryngoscopey. In addition, lightwand reduced the time to intubation. However we could not find any significant difference in hemodynamic response to tracheal intubation among the 3 groups.

Severe Neck Edema after Shoulder Arthroscopy : A case report

Although shoulder arthroscopy has provided a major advantage in the diagnosis and treatment of shoulder injuries, it is not free of complications. Several clinical reports have described patients who suffered life-threatening airway obstruction during arthroscopic shoulder surgery performed under regional or general anesthesia. We report a case of severe neck edema threatening airway after shoulder arthroscopy under general anesthesia.

Sniffing Position Improves the Laryngeal View Regardless of Body Mass Index / 대한마취과학회지

BACKGROUND: Most anesthesiologists universally recommend the sniffing position and consider it to be essential for improving the performance of orotracheal intubation. However, a recent investigation reported that the sniffing position does not aid the laryngoscope except under specific circumstances (i.e., obesity). Therefore, this study examined the impact of the BMI (body mass index) on the effectiveness of the sniffing position in improving the laryngeal view. METHODS: A video laryngoscopy imaging system and POGO (the percentage of glottic opening) scoring system were used to assess the laryngeal view in 79 adult patients undergoing a laryngoscopy. In each patient, the laryngeal view was videotaped continuously from simple head extension to the sniffing position by inflating a pressure bag as a pillow to obtain approximately 15o of flexion of the lower cervical spine on the chest. The variables assessed included the BMI, the POGO score in each position and the change in the POGO score. RESULTS: The POGO scores improved with the sniffing position (18.1 +/- 14.3%). However, the sniffing position did not improve the POGO score in 16/79 (20.3%) patients. The sniffing position did not worsen the POGO score in any patient. No significant correlation was found between the BMI and the change in the POGO score in the sniffing position (Pearson's correlation coefficient r = 0.075). CONCLUSIONS: The sniffing position has the potential to improve the laryngeal view in all intubations without needing to consider the BMI. Therefore, the sniffing position appears to be advantageous for orotracheal intubation compared with a simple head extension.

Severe Hypotension Following Spinal Anesthesia in a Patient Taking Risperidone: A case report / 대한마취과학회지

Antipsychotic medications are often continued throughout the perioperative period and may have significant interactions with anesthetics. Risperidone is an atypical agent used to treat both positive and negative symptoms of psychosis while producing fewer extrapyramidal symptoms. It's mode of action is related to dopaminergic and serotonergic antagonism. However, it also possesses a potent alpha-1 adrenergic antagonistic property. Here, we report a case of a 46-year-old man with major depressive disorder, controlled with paroxetine, clonazepam and risperidone, undergoing spinal anesthesia for open reduction of femur fracture. Eight minutes after induction of anesthesia, the patient developed exaggerated hypotension, unresponsive to ephedrine and rapid intravenous fluid administration. Eventually, hypotension was corrected after using large doses of phenylephrine. When planning spinal anesthesia to a patient taking risperidone, an alpha-1 agonist, such as phenylephrine, may be useful in treating possible exaggerated hypotension.

The Role of Nitric Oxide Synthase Isoforms in Neuropathic Pain Induced by Nerve Injury in Rats / 대한마취과학회지

BACKGROUND: Peripheral nerve injury may generate pain hypersensitivity, characterized by enhanced nociceptive responses to noxious stimuli and decreased thresholds to innocuous stimuli, and may lead to a chronic neuropathic pain state resulting from an increase in central neuron excitability. This central sensitization is mediated via N-methyl-D-aspartic acid (NMDA) receptor and may involve the production of nitric oxide (NO). In this work, we investigated whether the action of NO and local nitric oxide synthase (NOS) expression play a role in neuropathic pain in a rat model. METHODS: Neuropathic pain was produced by resecting two branches of the sciatic nerve. N-nitro-L-arginine methyl ester (L-NAME) (a nonselective NOS inhibitor), or 7-nitroindazole (7-NI) (a neuronal NOS (nNOS) inhibitor), or aminoguanidine (AG) (an inducible NOS (iNOS) inhibitor) were administered locally for 2, 7, or 14 days via osmotic pumps. Behavioral tests for pain were conducted after nerve injury using mechanical and thermal stimuli applied to the hind paws. We used immunohistochemical methods to provide evidence for endothelial NOS (eNOS), nNOS, and iNOS expression. RESULTS: Following nerve injury, significant mechanical allodynia and thermal hyperalgesia were observed in rats treated with AG or 7-NI. In contrast, when L-NAME, a known potent inhibitor of eNOS was applied locally, no significant mechanical allodynia or thermal hyperalgesia was observed. No dependency on the route or duration of NOS inhibitor administration was noted. Increased immunoreactivities of the eNOS and nNOS isoforms were intense and discrete at 48 hour following nerve injury, unlike sham exposed intact nerves. In 14 day stumps, iNOS staining was observed in the endoneurium and perineurium. eNOS immunoreactivity at 2 days after nerve injury was not observed in L-NAME treated rats. At 14 days after nerve injury, iNOS immunoreactivity was rarely observed in AG and L-NAME treated rats. CONCLUSIONS: Our results indicate that an early eNOS expression plays a critical role in the development of neuropathic pain.

Survey of Central Venous Catheter Depth Using the Carina as a Radiologic Landmark in ICU Patients / 대한마취과학회지

BACKGROUND: There is no unique guideline as to how to determine the depth of a central venous catheter (CVC). In this study, we inspected the current practice of CVC placement and evaluated insertion depth using the carina as a radiologic landmark in intensive care unit (ICU) patients. METHODS: In 138 ICU patients with a CVC in the right subclavian (SCV group) or internal jugular vein (IJV group), a chest X ray was taken, and the radiographic vertical distance between the catheter tip and the carina level (D-CC) was measured in Picture Archiving and Communication System (PACS) view. The distance between the skin puncture site and the carina level (D-SC) was calculated by adding/subtracting D-CC to/from the actual CVC insertion length. In addition, we surveyed physicians using a questionnaire about the methods they used to determine CVC depth. RESULTS: Mean D-SC was 13.80 +/- 1.69 cm in the SCV group, 14.42 +/- 1.34 cm in the IJV group, but no correlation was found with any measured physical dimension. In males, D-SC was greater, but this difference was not statistically significant. Physicians determined required insertion depths using many different methods (e.g., height, sex......). CONCLUSIONS: Patient height, weight, body mass index (BMI), and sex were not found to be reliable for predicting a safe CVC length. We recommend that after CVC insertion, a chest X ray should be taken and the catheter tip repositioned if necessary to reduce catheter related fatal complications (e.g., cardiac tamponade).

Influence of Myoendothelial Gap Junction on the Regulation of Vasomotor Tone / 대한마취과학회지

BACKGROUND: In addition to nitric oxide (NO) and prostacyclin (PGI2), there is another endothelium-derived mechanism of smooth muscle relaxation, which is associated with an endothelium-derived hyperpolarizing factor (EDHF). To assess the role of gap junctions in endothelium dependent hyperpolarization, we investigated the relationship between distribution of myoendothelial gap junction (MEGJ) and relative importance of the EDHF pathway in the regulation of vascular tone. METHODS: Immunohistochemistry and confocal microscopic examination of the mesenteric arterial wall of male Sprague-Dawley rat following treatment with specific antibodies were performed to delineate the distribution of connexin 43, a gap junctional protein. The standard dose-response curve for acetylcholine (10-9-10-5 M) of the mesenteric artery was regarded as the release of EDHF in the presence of the NO synthase inhibitor, Nomega-nitro-L-arginine methyl ester (L-NAME, 10-4 M) and indomethacine (10-5 M). The effects of the gap junction inhibitors such as 18alpha-glycyrrhetinic acid (18alpha-GA; (2 x 10-4 M)) and carbenoxolone (3 x 10-4 M) was assessed regarding relaxtion to acetylcholine, contraction to phenylephrine (5 x 10-6 M) in the proximal and distal mesenteric arteries. RESULTS: In the distal artery, gap junctional plaques were more prevalent, and the relaxation response to acetylcholine was augmented and the contraction response to phenylephrine was depressed compared with the proximal artery. In both the proximal and distal mesenteric arteries, acetylcholine-induced relaxations attributable to EDHF were near completely blocked by 18alpha-GA and carbenoxolone to the same degree. Regardless of the presence of L-NAME plus indomethacin, 18alpha-GA significantly augmented the contraction response to phenylephrine. CONCLUSIONS: The vasomotor regulatory response by EDHF in the rat mesenteric arteries may be explained by extensive heterocellular coupling through MEGJs. Moreover, the release of EDHF through MEGJ may have a essential role in the regulation of resistor arterial tone.

Analysis of Heart Rate Variability in Preoperative Diabetic Patients by Linear and Nonlinear Dynamics / 대한마취과학회지

BACKGROUND: The aim of this study was to investigate the underlying changes in heart rate variability (HRV) of preoperative diabetic patients using five analytical methods; SDNN (standard deviation of normal to normal intervals), SDANN (standard deviation of the mean of normal RR intervals for each 5 min period of the entire electrocardiographic recording), RMSSD (root mean square successive difference, the squre root of the mean of the sum of the squares of differences between adjacent normal RR intervals over the entire electrocardiographic recording), PNN50 (percent of difference between adjacent normal RR intervals that are greater than 50 ms computed over the entire electrocardiographic recording) for linear time domain analysis and approximate entropy for nonlinear complexity analysis. METHODS: HRV values analyzed by five different measures were compared between a control group of ten nondiabetics without any significant systemic disease and a diabetic group of ten patients from the preoperative ambulatory electrocardiographic recordings. RESULTS: Approximate entropy, SDNN and SDANN values were significantly lower in the diabetic group than those of the control group (P< 0.01). CONCLUSIONS: Significantly decreased approximate entropy, SDNN and SDANN could provide information about decreased cardiovascular complexity and sympathetic output, suggesting the nature of dysfunction of the diabetic cardiovascular system.

Linear and Nonlinear Analysis of Heart Rate Variability in Postoperative Myocardial Ischemic Patients: Time Domain Analysis versus Approximate Entropy / 대한마취과학회지

BACKGROUND: Postoperative myocardial ischemia has been regarded as one of the major predictors of adverse cardiac outcomes after noncardiac surgery in high risk patients. Many schemes have been proposed to stratify the potential risk of this patient group in more noninvasive and cost-effective ways and analysis of heart rate variability (HRV) is one of them. To uncover the underlying changes in HRV with postoperative myocardial ischemia five analytical methods were introduced; SDNN (standard deviation of normal to normal intervals), SDANN (standard deviation of the mean of normal RR intervals for each 5 min period of the entire electrocardiographic recording), RMSSD (root mean square successive difference, the squre root of the mean of the sum of the squares of differences between adjacent normal RR intervals over the entire electrocardiographic recording), PNN50 (percent of difference between adjacent normal RR intervals that are greater than 50 ms computed over the entire electrocardiographic recording) for linear time domain analysis and approximate entropy for nonlinear complexity analysis. METHODS: Sixteen vascular surgical patients were monitored by an ambulatory electrocardiogram preoperatively and during the first postoperative day (POD1). HRV values analyzed by five different measures were compared between a control group (C group) of eight patients with no postoperative ischemia and a postoperative ischemic group (PI group) of eight with ischemia on POD1. RESULTS: Approximate entropy was the only measure of HRV which was significantly lower in PI group than that of C group (P< 0.01) on POD1. CONCLUSIONS: Approximate entropy, a complexity measure could provide more sensitive information about the physiologic changes associated with postoperative ischemia which could not be obtained from the conventional HRV measures. Time domain analyses can be used as adjuvant measures providing information about the cardiac autonomic regulation.

Attenuating Effect of cAMP on Hypoxic Pulmonary Vasoconstriction in the Isolated Perfused Rat Lungs / 대한마취과학회지

BACKGROUND: Pulmonary vessels constrict when they are exposed to hypoxia, unlike other vessels. It is hypothesized that the decreased concentration of cAMP in the hypoxic condition causes this reaction, HPV (hypoxic pulmonary vasoconstriction). When cAMP concentration is increased by either activating adenylate cyclase, using adenosine, or inhibiting the cAMP hydrolysing enzyme, phosphodiesterase type 3, using amrinone, then HPV can be reversed. The aims of this study were to develop HPV in an isolated perfused rat lung preparation, and to investigate the vasodilating effects of adenosine and amrinone on HPV. METHODS: Isolated lungs from male rats (270 330 g) were ventilated with a normoxic gas mixture (21%O2-5%CO2-74%N2) or a hypoxic gas mixture (3%O2-5%CO2-92%N2) alternately, and perfused with calcium-containing perfusate solution. Adenosine (6 x 100-2 microgram, n = 6) and amrinone (5 x 101-3 microgram, n = 6) were mixed to perfusate solution, and the initial hypoxic pressor response { Pin = Pmax (maximum pulmonary artery pressure) - Pin (initial pulmonary artery pressure)} and hypoxic pressor responses after drug administration { Pdrug = Pmax (maximum pulmonary artery pressure) - Pbase (baseline pulmonary artery pressure)} were measured. Meclofenamate was used to block prostaglandin-mediated vasorelaxation. RESULTS: Adenosine did not decrease Pdrug compared to Pin. But amrinone inhibited HPV effectively a with a linear dose-response relationship (r = 0.842, P< 0.05). y = 26.72 x log (x) 35.79y: % relaxation = 100 [ Pdrug/ Pin] 100 , x: amount of drug, microgram, CONCLUSIONS: Amrinone attenuated HPV, and it can be concluded that increased levels of cAMP helpful to relax pulmonary vessels in hypoxic condition.

Preoperative Evaluation of Diabetic Autonomic Neuropathy by Power Spectral Analysis / 대한마취과학회지

Background: The aim of this study is to investigate the changes in the patterns of power spectra of R-R interval variability of diabetic patients who are subject to autonomic neuropathy. Methods: The changes in power spectra of eight diabetic patients were compared with those of eight normal persons while changing positions from supine to Trendelenburg and from supine to standing each. Results: Low, high and total frequency power densities of diabetic patient group were significantly lower than those of control group in resting supine position. Low frequency power density and ratio of low frequency power to high frequency power of control group increased significantly while changing position from supine to standing compared with those of diabetic patient group. And low frequency power density of control group decreased significantly compared with that of diabetic patient group while changing position from supine to Trendelenburg. Conclusions: The decrease in power densities of low, high and total frequency suggest depressed overall autonomic activities in diabetic patient group and significantly decreased changes in low frequency power and ratio of low frequency power to high frequency power while changing positions from supine to standing suggest attenuated sympathetic activity in diabetic patient group, reflecting autonomic changes in diabetic group rapidly.

Power Spectral Analysis of Heart Rate Variability during Acute Hypoxia in Fetal Lamb / 대한마취과학회지

BACKGROUND: The aim of the present study was to investigate the changes in the patterns of power spectrum of R-R interval variability on fetal lamb EKG during acute fetal hypoxia. METHODS: Acutely instrumented six fetal lambs during the third trimester of gestation(115 to 145 days) was subjected to reproducible hypoxia by reduction of maternal placental blood flow with complete obstruction of maternal abdominal aorta for 60 seconds. RESULTS: Power spectral density of low, middle and high frequency increased significantly on hypoxia compared to that of baseline state. Power density of high frequency was significantly higher than that of low and middle frequency in baseline state. And the power density of low and high frequency was significantly higher than that of middle frequency in hypoxic state and 1 minute of recovery. CONCLUSIONS: The conclusion is that an increase in power density of low frequency during hypoxia suggested increased sympathetic activity and increased power density of high frequency throughout the experimental procedures suggested active respiratory movements of fetal lambs close to term and increased parasympathetic activity, reflecting rapidly the autonomic nervous system changes of the fetal lambs.

Anesthetic Management of an Infant with Nesidioblastosis: A case report / 대한마취과학회지

Nesidioblastosis, persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is a disorder characterized by diffuse pancreatic islet cell hyperplasia arising from the ductal epithelium. Patients usually present during the neonatal or infantile period with apnea, hypotonia, poor feeding, lethargy, or seizure. Despite of greater awareness, one in three has some degree of mental retardation by the time the diagnosis is made. The diagnosis is established by demonstrating high plasma insulin concentration during an episode of hypoglycemia. This hypoglycemia is initially managed medically, but these medical treatment modalities are failed in more than half of nesidioblastosis. Patient who failed to respond to optimal medical treatment should be referred for surgery early, if permanent neurologic damage is to be avoided. The surgical procedure of choice is near total pancreatectomy (95~98% resection). We herein discuss the anesthetic management of a patient with nesidioblastosis who presented for near total pancreatectomy.

Etiology of Failure in Epidural Anesthesia: Transforaminal Escape of Epidural Catheter: Two cases / 대한마취과학회지

One of the most common mechanisms of failure of epidural anesthesia is the misplacement of a catheter. We present two cases of transforaminal escape of catheter which occurred accidentally during lumbar epidural anesthesia. Epidural catheter was inserted to a depth of 4.5 cm and 3.5 cm respectively, then 2% lidocaine 25 ml were injected slowly into the catheter. No analgesia was found except anterior knee area, so Iohexol dye was injected through the catheter for X-ray determination. The epidurogram showed the catheter, which passed through the intervertebral foramen, was to lie outside the epidural space in the paravertebral tissue. Because of the random direction and migration of epidural catheter, we suggest an epidural catheter should be inserted 3cm into the epidural space. Epidurogram with a small dose of contrast material is advisable in the cases of unsatisfactory effect of epidural block, or when some adverse reactions are noted after block.

Arterial and Venous Differences of Thiopental Pharmacokinetics as an Intravenous Anesthesia Induction Agent and its Pharmacodynamic Inplication / 대한마취과학회지

The arterial and venous differences of thiopental. pharmacokinetics and its impact on the onset of pharmacologic effect were examined in 6 male surgical patients with normal renal and hepatic functions during short time period of 6hrs post-intravenous bolus injection over 5 second(5 mg/kg). Arterial and venous blood samples were withdrawn from radial artery and subclavian vein, respectively at the time of right before and after injection(0), 5, 10, 20, 30, 45 (sec), l, 2, 5, 10, 30(min), 1, 2, 3, 4, 5, 6(hrs). Serum concentrations of thiopental were determined by reverse-phase, high performance liquid chromatography and the clinical endpoint of anesthesia induction were interpreted as the time of loss of consciousness by observing spontaneous closing of eyes and loss of eyelash reflex. As the results, significant differences between arterial and venous concentrations were noted during early phase lasting up to 10 minutes. Arterial data was best fitted to tri-exponential decay model. In analysing pharmacokinetic parameters with serum data of 6 hrs duration, there were no significant differences in AUCo-(area under curve), AUCO-t, and clearance(P <0.05), but significant difference in peak concentrations(arterial: 103.97+/-12.15, venons:17.487+/-5.206ug/ml), and times to peak(arterial: 0.67+/-0.037, venous: 1.653+/-0.712min), AUMC O-t, MRT (mean residence time), apparent T 1/2(terminal half-life) and apparent Vdss(steady-state volume of distribution). Spontaneous eye closures were observed within 20 seconds(10-20sec) after the end of injection where arterial concentrations were at peak(n=3) or right after peak(n=3) and otherwise, venous concentrations were at low or even almost at zero(n=3), reflecting the fact that arterial eoncentrations are directly correlated to the clinical efficacy and more important in pharmaco-kinetic and dynamic aspect of drug.