Assessment for the Quality of Recovery from General Anesthesia in Patients with Gynecologic Surgery / 대한마취과학회지

BACKGROUND: Quality of recovery, assessed by patients, is related to patients' satisfaction, and even to quality of life. Of numerous patient-based measures to evaluate the quality of recovery, a '40-item-quality of recovery (QoR-40)' has proved to be valid and reliable. Using this questionnaire, we evaluated the quality of recovery in the gynecological patients and tried to identify factors affecting the quality of recovery. METHODS: Patients undergoing gynecological surgery were asked to fill a questionnaire 8 to 9 p.m the day after the completion of anesthesia. Questionnaires were prepared after translation to Korean from 40-item-quality of recovery. From the anesthetic and recovery room records we collected data about patient's age, surgery types, anesthetic and surgical duration, recovery room stay, main anesthetic agents, and recovery room complications. RESULTS: A total of 383 patients completed the questionnaires. Patients aged under 40 got significantly lower QoR-40 scores than those aged over 40, especially in the dimension of pain (P < 0.05). Patients who had undergone laparoscopic surgery got higher scores than those had undergone non-laparoscopic surgery (P < 0.05). Patients who answered the questionnaires in more than 30 hours after the completion of anesthesia showed lower total scores than those who did in less than 30 hours, especially in the dimensions of emotional state and pain (P < 0.05). CONCLUSIONS: In gynecological patients, laparoscopic surgery improved quality of recovery. Quality of recovery was affected by age and survey time. Postoperative pain contributed to the decrease of the quality of recovery.

The effect of music on the effect-site concentration of propofol for loss of consciousness / 대한마취과학회지

BACKGROUND: Music reduces anxiety and the need for sedatives in preoperative patients. Currently, propofol is usually infused using target controlled infusion device. With the use of such a device, we investigated the effects of music on the effect-site concentration of propofol for loss of consciousness. METHODS: Sixty-five ASA 1 or 2 patients aged 35 to 55 years who were scheduled for general anesthesia were randomly allocated to either the control, music or headphone group. The control group patients were exposed to the ambient operating room atmosphere (n = 17), the music group patients listened to music (n = 25), and headphone group wore a headphone alone without listening to music (n = 23). Propofol was infused with a predetermined effect-site concentration and we determined loss of consciousness in patients by a verbal response and eyelash reflex for 3 minutes. Each concentration of propofol was predetermined by the up-and-down method with 0.4microgram/ml as the step size. RESULTS: Loss of consciousness was observed at a concentration of 4.20 +/- 0.25microgram/ml in the control group, 3.60 +/- 0.34microgram/ml in the music group, and 3.73 +/- 0.47microgram/ml in the headphone group. The effect-site concentration for loss of consciousness was significantly lower in the music group as compared to the control group (P < 0.05). The effect-site concentration in the headphone group, however, showed no statistical difference as compared to the control group (P = 0.117). CONCLUSIONS: Listening to music reduced overall propofol effect-site concentration for loss of consciousness that was required by patients.

Anesthesia for Surgical Fixation of the Fractured Neck of Femur in a Patient with Eisenmenger's Syndrome : A case report

Eisenmenger's syndrome consists of high pulmonary vascular resistance with reversed or bidirectional shunt at aortopulmonary, ventricular, or atrial level. Noncardiac surgery for a patient with this syndrome is challenging because both the perioperative morbidity and mortality are high. We describe the anesthetic management of a 66-year-old female patient with Eisenmenger's syndrome secondary to the tetralogy of Fallot (TOF), who was operated on for the fractured neck of her left femur. Anesthesia was induced with etomidate and sufentanil and was maintained with propofol and sufentanil without any inhalational anesthetics (total intravenous anesthesia). To maintain the systemic vascular resistance, we administered norepinephrine throughout the surgery and the postoperative care. The patient was discharged 20 days after the operation without any complications.

The Effect of the Level of Sedation on Recovery in Patients undergoing Target Controlled Propofol Infusion with a Bolus of Fentanyl for Strabismus Surgery / 대한마취과학회지

BACKGROUND: An immediate examination of ocular movement is required during strabismus surgery. The aim of this study was to determine the effect of the level of sedation on the recovery of patients undergoing a target controlled propofol infusion with a bolus of fentanyl for strabismus surgery. METHODS: Twenty-one outpatients scheduled to undergo strabismus surgery were assigned randomly to one of two groups. In both groups, sedation was induced with a bolus of fentanyl 1microgram/kg intravenously followed by an infusion of propofol with a target concentration of 1.0microgram/ml. The target concentration was increased or decreased by 0.1 microgram/ml steps until the patient reached and maintained the observer's assessment of alertness/sedation (OAA/S) scale score of 3 (group A) or 4 (group B). The supplemental analgesics consisted of fentanyl 25-50microgram bolus injection. The target concentration of propofol, the total dose of fentanyl, delayed awakening, and recovery time were recorded. RESULTS: The mean target concentration of propofol (mean +/- SD) in group A (1.8 +/- 0.4microgram/ml) was significantly higher than that of group B (1.3 +/- 0.4microgram/ml) (P<0.05). There were no significant differences in the total dose of fentanyl, delayed awakening and recovery time between the two groups. There was an an increasing trend in the recovery time with the total dose per kilogram of body weight of fentanyl (Spearman's correlation coefficient, r = 0.384, P = 0.086). CONCLUSIONS: The levels of sedation did not affect the recovery time in patients during target propofol infusion with a bolus of fentanyl. However, the addition of fentanyl tended to prolong the recovery time.

Assessment of Blood Glucose Values Measured by Blood Gas Analyzer or Portable Glucometer / 대한마취과학회지

BACKGROUND: A portable glucometer is commonly used to immediately check the blood glucose level. In the anesthetic field, some blood gas analyzers can also give a rapid indication of the blood sugar level but the accuracy is unknown. Therefore, this study assessed the accuracy of the blood glucose values measured by either a blood gas analyzer or portable glucometer. METHODS: Venous blood from diabetic patients was used to measure the glucose level with either a blood gas analyzer or a portable glucometer. The difference and 5% deviation from reference values was analyzed. These values were also assessed using a Bland-Altman plot and clinical significance was examined using a Clarke error grid. RESULTS: The differences from the reference values were smaller using the blood gas analyzer (1.3 +/- 7.8 mg/dl) than using the portable glucometer (-5.1 +/- 16.7 mg/dl)(P < 0.01). 73.4% of the values measured by the blood gas analyzer and 40.0% of those measured by the portable glucometer were within 5% of the reference value. The 95% limits of agreement in the difference ranged from -14.3 to 16.9 in the blood gas analyzer and -38.5 to 28.2 in the portable glucometer. Error grid analysis showed that 100% of the values measured by the blood gas analyzer were located in zone A. When locating the values measured using the portable glucometer, 95.6% were located in zone A, and the remaining 4.4% are located in zone B. CONCLUSIONS: The blood gas analyzer measures the blood glucose more accurately than the portable glucometer. However, the blood glucose values measured by the portable glucometer are clinically acceptable.

Anesthetic Management in a Patient with Charcot-Marie-Tooth Disease: A case report / 대한마취과학회지

A 35-year old woman was scheduled to undergo a total hystectomy due to uterine myoma. She had been diagnosed with Charcot-Marie-Tooth disease 2 years ago. In addition, she had previously received a Cesarean section under epidural anesthesia 10 years ago and reported a prolonged motor blockade at that time. General anesthesia was induced with propofol 120 mg in a divided dose and the intubating condition was achieved with vecuronium 3 mg. Anesthesia was maintained with 1.5-2.5% enflurane with air and O2. During surgery, the body temperature and end tidal concentration of CO2 were maintained within the normal range. Despite the continuous monitoring of the train-of-four (TOF) response, no more muscle relaxants were required during surgery and the patient recovered without a delay in awakening. In the management of patients with Charcot-Marie-Tooth disease, it is desirable to evaluate the patient carefully, select the appropriate anesthetics and adjust the dosage of the drug according to the patients requirements.

Atrial Fibrillation Developed during Recovery from General Anesthesia: A case report / 대한마취과학회지

Laparoscopic cholecystectomy was performed in a 69-year old woman due to perforated acute gangrenous cholecystitis. After completion of the surgery, we administered 10 mg pyridostigmine for the reversal of neuromuscular block and 4 mg ondansetron for the prevention of nausea and vomiting. Twenty minute after arrival in the recovery room, atrial fibrillation and tachycardia occurred. Even with the continuous infusion of esmolol and then administration of digoxin, atrial fibrillation and tachycardia continued in the recovery room. After transfer to the general ward, the heart rate was gradually decreased, and next morning, we could find the atrial fibrillation disappeared.

Atrial Fibrillation Developed during Recovery from General Anesthesia: A case report / 대한마취과학회지

Laparoscopic cholecystectomy was performed in a 69-year old woman due to perforated acute gangrenous cholecystitis. After completion of the surgery, we administered 10 mg pyridostigmine for the reversal of neuromuscular block and 4 mg ondansetron for the prevention of nausea and vomiting. Twenty minute after arrival in the recovery room, atrial fibrillation and tachycardia occurred. Even with the continuous infusion of esmolol and then administration of digoxin, atrial fibrillation and tachycardia continued in the recovery room. After transfer to the general ward, the heart rate was gradually decreased, and next morning, we could find the atrial fibrillation disappeared.

The Effect of Ketamine for Pain on Rocuronium Injection Pain / 대한마취과학회지

BACKGROUND: Rocuronium can cause pain on injection in awake patients. We compared the effect of ketamine at three different small doses (0.1 mg/kg, 0.2 mg/kg, 0.3 mg/kg) and saline (placebo) for reducing pain on injection in awake patients. METHODS: 80 patients (aged 19-63 yr) scheduled for elective surgery were randomized to four groups in double-blind manner. Patients received the study drug intravenously, with venous occlusion for 20 seconds, followed by rocuronium 0.6 mg/kg into the dorsal vein over 10 seconds. Patient's response torocuronium injection was graded by four-point verbal rating scale. RESULTS: The incidence of pain was significantly less in patients receiving ketamine 0.3 mg/kg (55%) than in patients receiving saline (85%)(P < 0.05). But, No difference was found between ketamine 0.1 mg/kg, 0.2 mg/kg and saline groups. The pain score was significantly less in patients receiving ketamine 0.2 mg/kg and 0.3 mg/kg than in patients receving saline (P < 0.05). CONCLUSIONS: We concluded that pretreatment of ketamine 0.3 mg/kg with venous occlu-sion for 20 seconds, effectively decreases the incidence of pain caused by rocuronium injection.

Anaphylactic Reaction after an Intracervical Injection of Isosulfan Blue Dye: A case report / 대한마취과학회지

Isosulfan blue dye can be used to mark the sentinel lymph node during various surgeries. The dye was known to have minimal side effects, but recently a few cases of an anaphylactic reaction were reported in melanoma and breast surgery. We experienced an anaphylactic reaction during peritumoral injection of this dye in a patient with cervical cancer. Immediately after dye injection, the patient showed an anaphylactic reaction with cardiovascular collapse and oxygen desaturation. We resuscitated the patient and she recovered without complications.

Partial Endotracheal Tube Obstruction Due to Secretions: A case report / 대한마취과학회지

Endotracheal tube obstruction causes serious complications, including cardiovascular instability, pneumothorax, pulmonary edema and brain death. A 64 year old man was scheduled for a laminectomy and instrument fixation due to spinal stenosis. The patient was intubated with a 8.5 mm reinforced endotracheal tube and turned to the prone position. An hour later, signs of partial endotracheal obstruction were observed including high airway pressure and low tidal volume. Airway obstruction signs were aggravated as the operation proceeded. Two hour later, passage of a suction catheter was difficult and PaCO2 increased significantly, so we temporarily stopped the operation and turned the patient to supine. After that, we exchanged the tube with another tube and found the distal tip of the reinforced tube impacted with mucous secretions.

Acute Renal Artery Thromboembolism during Abdominal Aortic Bypass Graft Surgery / 대한마취과학회지

Acute occlusion of the artery to a single functioning kidney is a rare but surgically correctable cause of acute renal failure. A young-aged woman with acute renal failure and anuria due to a thromboembolism of the right renal artery was surgically treated 2 hours after the onset of anuria. Revascularization resulted in the reversal of renal failure and complete recovery of renal function. An aggressive diagnostic and therapeutic approach is important whenever occlusion of the renal artery is suspected during surgery in Takayasu arteritis patients.

Analgesic Effects of Gabapentin on Post-hysterectomy Pain / 대한마취과학회지

BACKGROUND: The aim of the present study was to examine whether gabapentin, a new anti-epileptic agent with relatively low toxicities and side effects, could reduce postoperative pain. METHODS: Thirty-two patients scheduled for an elective total hysterectomy were investigated in this randomized, double blind, placebo-controlled study. The patients were randomized to receive either oral gabapentin 400 mg (gabapentin group, n = 16) or a matching placebo capsule (control group, n = 16) the night before and again 30 min before surgery as an adjunct to morphine patient-controlled analgesia (PCA). The visual analogue scale (VAS) for pain at rest and on movement, morphine consumption, overall satisfactions and postoperative side effects including sedation were recorded for 24 h after surgery. RESULTS: Total morphine consumption for 24 h after surgery was not significantly different between the two groups, but mean hourly morphine consumption during the period of 2 6 h after surgery was significantly greater in the control group. Movement VAS of gabapentin group measured at 6 h and 12 h after surgery was significantly lower than those of control group. There were no significant differences between the two groups with respect to the sedation score, patient's satisfaction and the frequencies of side effects. CONCLUSIONS: We observed that preoperatively administered oral gabapentin 800 mg reduced postoperative morphine consumption and incidental pain without increasing side effects. The addition of gabapentin to a morphine regimen may lower morphine consumption and provide better pain relief without increasing side effects.

Effects of Intrathecal Magnesium Sulphate in a Rat Model of Postoperative Pain / 대한마취과학회지

BACKGROUND: The mechanical hyperalgesia that follows peripheral tissue injury results from peripheral and central sensitization. Central sensitization is initiated and maintained by windup that can be prevented by N-methyl-D-aspartate (NMDA) antagonists. NMDA antagonists, therefore, have the potential to prevent and treat pain, although clinical uses are limited because of their side effects. This study was designed to evaluate the analgesic action of intrathecal (IT) magnesium sulphate in a rat model of postoperative pain and investigate the analgesic mechanism of magnesium. METHODS: Forty-two Sprague-Dawley rats (300 +/- 20 g) were prepared with a chronic IT catheter. Under brief enflurane anesthesia, a 1-cm incision including skin, muscle and fascia was made in the plantar aspect of the hind paw and closed. Normal saline, magnesium (30, 100, 300, 600 microgram), NMDA 50 ng or NMDA 50 ng with magnesium 300 microgram was administered via the IT catheter after recovery. Response frequency, using Von Frey filaments, cumulative pain scores and motor deficits were assessed. RESULTS: The mechanical hyperalgesia and nonevoked pain behaviors decreased significantly at 1 h or 1 h and 3 h after IT injection of magnesium 100 microgram or 300 microgram compared to the saline group without profound motor deficits in a rat model of postoperative pain. However, the rats administered with magnesium 600 microgram were lethargic due to severe motor weakness. Effective duration of magnesium decreased significantly in the group of NMDA 50 ng with magnesium 300 microgram compared to that of magnesium 300 microgram administered alone, but the initial effects were similar between the two groups. CONCLUSIONS: We conclude that IT magnesium sulphate can modulate nociceptive processing after tissue injury and the analgesic mechanism of magnesium is involved in NMDA receptors. Magnesium,therefore, may offer a therapeutic agent for postoperative pain and may be an agent that prevents postoperative pain from changing to persistent pathological pain.

Effect of Hemodilution on Brain Damage after Focal Cerebral Ischemia in Rabbits / 대한마취과학회지

BACKGROUND: Hemodilution after focal cerebral ischemia increases cerebral blood flow to ischemic brain tissue and reduces neurologic injury. With rare exceptions, most studies have reduced hematocrit (Hct) to no less than 30%. We studied the effect of moderate hemodilution (hematocrit 27%) on cerebral infarct volume after focal cerebral ischemia in rabbits. METHODS: Twenty rabbits were divided into a control group (n = 10) and a hemodilution group (n = 10). In the control group, cerebral infarction was induced by embolization of the middle cerebral artery using an autologous blood clot without hemodilution. In the hemodilution group (n = 10), hemodilution of around hematocrit 27% was achieved by exchanging arterial blood with 10% hydroxyethyl starch 1 hour before embolization of the middle cerebral artery in the hemodilution group. Seven hours after embolization, coronal brain slices were made with 2 mm thickness at 1 cm from the frontal pole and stained with 2% 2,3,5-triphenyltetrazolium chloride. The infarct volume was quantitated by image analysis of photography of the infarcted area. RESULTS: The infarct volume of the cerebral hemisphere (25.9 +/- 8.9%), subcortex (16.3 +/- 3.1%) in the hemodilution group was significantly smaller than in the control group (34.9 +/- 8.9%, 19.3 +/- 5.1%) (P<0.05), but, in the cortex, the difference of infarct volume is not statistically significant between the control group (23.5 +/- 11.9%) and the hemodilution group (15.6 +/- 2.7%). CONCLUSIONS: These results indicate that moderate hemodilution (hematocrit 27%) reduces neurologic injury after focal cerebral ischemia.

The Effects of Continuous Hyperthermic Peritoneal Perfusion (CHPP) on Cardiopulmonary Parameters in the Basis of Systemic Oxygen Balance / 대한마취과학회지

BACKGROUND: Intra-operative application of continuous hyperthermic peritoneal perfusion (CHPP) in advanced cancer has been introduced as an effective and safe method to lessen the complication and enhance the effectiveness of its treatment. But CHPP induced acute change of body temperature and intra-abdominal pressure would produce various abnormal physiologic response. Now, we investigated to evaluate and understand the trend of changes of cardiac and oxygen parameters during CHPP. METHODS: Closed peritoneal irrigation was done with perfusate at temperature 47oC for 90 min under general anesthesia. Cardiac and oxygen parameters were measured at 10 min before CHPP, 30, 60, 90 min after the initiation of CHPP, 30 min after the end of CHPP with Swan-Ganz catheter application. RESULTS: Hemodynamic parameters; Systemic vascular resistance index and mean arterial pressure were decreased trend during CHPP. Pulmonary capillary wedge pressure and cardiac index were increased during CHPP. Oxygen parameters; AaDO2 and shunt fraction were increased during CHPP and O2 index were decreased during CHPP. Oxygen balance; O2 consumption and delivery increased during CHPP. CONCLUSIONS: We confirmed that systemic oxygen consumption and delivery were increased during CHPP but AaDO2 and shunt fraction were increased which could decrease systemic oxygen delivery. We should need more careful monitoring and proper treatment for maintaining stable hemodynamics and systemic oxygen balance during and after CHPP.

Clinical Experience of Coagulation Management in Multiple Myeloma Patient with Thrombocytopenia Using Thromboelastography: A case report / 대한마취과학회지

Multiple myeloma is malignant proliferation of plasma cells whose pathologic condition is produced by bone marrow invasion as well as excessive production of immunoglobulin. Its invasion into bone marrow causes severe pancytopenia. Therefore these patients are susceptible to thrombocytopenia and have bleeding tendency, especially during surgery. We experienced an anesthetic management of meningioma operation in a patient with multiple myeloma who showed severe thrombocytopenia and excessive abonormal immunoglobulin.

Clinical Experience of Coagulation Management in Multiple Myeloma Patient with Thrombocytopenia Using Thromboelastography: A case report / 대한마취과학회지

Multiple myeloma is malignant proliferation of plasma cells whose pathologic condition is produced by bone marrow invasion as well as excessive production of immunoglobulin. Its invasion into bone marrow causes severe pancytopenia. Therefore these patients are susceptible to thrombocytopenia and have bleeding tendency, especially during surgery. We experienced an anesthetic management of meningioma operation in a patient with multiple myeloma who showed severe thrombocytopenia and excessive abonormal immunoglobulin.

Endotracheal Intubation, but not Laryngeal Mask Airway Insertion, Produces Reversible Bronchoconstriction / 대한마취과학회지

BACKGROUND: Intubation of the trachea frequently results in a rise in respiratory system resistance (Rrs) that is reversed by inhaled bronchodilators. In asthmatics, this reflex may occasionally result in profound bronchoconstriction, and anesthesiologists often try to avoid tracheal intubation if possible in asthmatics. The hypothesis of this study was that insertion of a laryngeal mask airway (LMA) would be less likely to result in reversible bronchoconstriction than would insertion of an endotracheal tube (ETT). METHODS: A total of 52 (45 male, 7 female) patients were randomized to placement of a 7.5 mm (females) or 8.0 mm (males) endotracheal tube or a #4 (females) or #5 LMA (males). Anesthesia was induced with 2 microgram/kg fentanyl and 5 mg/kg thiopental and airway placement facilitated with 1 mg/kg succinylcholine. After ensuring that a seal to greater than 20 cmH2O existed, Rrs was measured immediately following airway placement using the isovolumic method during positive pressure ventilation with oxygen. Correction was made for the resistance of the ETT but not for the resistance of the LMA, which was insignificant at the flows used. Inhalation anesthesia was then begun with isoflurane (ISF) to achieve an end-tidal concentration of 1.0% for ten minutes. Rrs was then measured again under identical conditions. In the LMA patients, fiberoptic laryngoscopy was then performed to ensure that the scope could be passed to the level of the cords without epiglottic obstruction. RESULTS: Among LMA patients, the initial Rrs was significantly lower than among ETT patients (9.2 0.7 vs 13.4 1.9 cmH2O/L/s, P <0.05). After 10 minutes of ISF, the resistance declined to 8.6 0.7 in the ETT group but remained unchanged at 9.1 0.7 cmH2O/L/s in the LMA group. The decline in Rrs in the ETT group of 4.7 1.4 cmH2O/L/s was highly significant compared to the lack of change in the LMA group (P <0.01). CONCLUSIONS: Despite the inclusion of the resistance of the LMA and the laryngeal resistance, Rrs in LMA patients was still clearly lower than in ETT patients. Furthermore, resistance dropped rapidly only in ETT patients after ISF, a potent bronchodilator, suggesting that reversible bronchoconstriction was present in ETT patients but not LMA patients. We conclude that an LMA is a better choice of airway to minimize airway reaction.

Endotracheal Intubation, but not Laryngeal Mask Airway Insertion, Produces Reversible Bronchoconstriction / 대한마취과학회지

BACKGROUND: Intubation of the trachea frequently results in a rise in respiratory system resistance (Rrs) that is reversed by inhaled bronchodilators. In asthmatics, this reflex may occasionally result in profound bronchoconstriction, and anesthesiologists often try to avoid tracheal intubation if possible in asthmatics. The hypothesis of this study was that insertion of a laryngeal mask airway (LMA) would be less likely to result in reversible bronchoconstriction than would insertion of an endotracheal tube (ETT). METHODS: A total of 52 (45 male, 7 female) patients were randomized to placement of a 7.5 mm (females) or 8.0 mm (males) endotracheal tube or a #4 (females) or #5 LMA (males). Anesthesia was induced with 2 microgram/kg fentanyl and 5 mg/kg thiopental and airway placement facilitated with 1 mg/kg succinylcholine. After ensuring that a seal to greater than 20 cmH2O existed, Rrs was measured immediately following airway placement using the isovolumic method during positive pressure ventilation with oxygen. Correction was made for the resistance of the ETT but not for the resistance of the LMA, which was insignificant at the flows used. Inhalation anesthesia was then begun with isoflurane (ISF) to achieve an end-tidal concentration of 1.0% for ten minutes. Rrs was then measured again under identical conditions. In the LMA patients, fiberoptic laryngoscopy was then performed to ensure that the scope could be passed to the level of the cords without epiglottic obstruction. RESULTS: Among LMA patients, the initial Rrs was significantly lower than among ETT patients (9.2 0.7 vs 13.4 1.9 cmH2O/L/s, P <0.05). After 10 minutes of ISF, the resistance declined to 8.6 0.7 in the ETT group but remained unchanged at 9.1 0.7 cmH2O/L/s in the LMA group. The decline in Rrs in the ETT group of 4.7 1.4 cmH2O/L/s was highly significant compared to the lack of change in the LMA group (P <0.01). CONCLUSIONS: Despite the inclusion of the resistance of the LMA and the laryngeal resistance, Rrs in LMA patients was still clearly lower than in ETT patients. Furthermore, resistance dropped rapidly only in ETT patients after ISF, a potent bronchodilator, suggesting that reversible bronchoconstriction was present in ETT patients but not LMA patients. We conclude that an LMA is a better choice of airway to minimize airway reaction.