Severe Postoperative Delirium Lasting for Three Weeks: A Case Report / 대한구급학회지

Postoperative delirium in the intensive care unit is a serious problem that has recently attracted much attention. We present a 73-year-old female patient who was admitted by multiple fractures induced by an accident. We started general anesthesia for the operation of open reduction and internal fixation. After the discontinuation of general anesthesia, the patient was transported to the intensive care unit. The symptoms of delirium were developed and controlled with medications including haloperidols, benzodiazepines, and vitamins. The patient was recovered three weeks after the management and received two other operations, but delirium did not be developed again. She was discharged from the hospital without complications.

Spinal Anesthesia for Lower Extremity in the Aged: Comparision of Isobaric 0.5% Bupivacaine and Hyperbaric 0.5% Bupivacaine / 대한마취과학회지

BACKGROUND: The purpose of this study is to compare the clinical effects of isobaric 0.5% bupivacaine 8 mg and hyperbaric 0.5% bupivacaine 8 mg on sensory and motor block in aged patients undergoing spinal anesthesia. METHODS: Thirty patients, aged 65 years or more, undergoing orthopedic surgical operation of the lower extremities were randomly assigned to two groups for spinal anesthesia. In the isobaric group (n = 15), isobaric 0.5% bupivacaine 8 mg was administered and in the hyperbaric group (n = 15), hyperbaric 0.5% bupivacaine 8 mg was administered. We measured the maximal sensory level, the time to maximal sensory block, the duration of sensory block, the time to complete motor block, degree of motor block and hemodynamic variables every 2 minutes for 10 minutes in lateral decubitus position and then every 5 minutes for 20 minutes in supine position after spinal anesthesia. RESULTS: The maximal sensory block level and the duration of sensory block were not significantly different between the two groups. The time to maximal sensory block was significantly shorter in the hyperbaric group than in the isobaric group in both lower extremities. The time to complete motor block was significantly longer in the hyperbaric group than in the isobaric group in the nondependent extremity. CONCLUSIONS: These results suggest that isobaric 0.5% bupivacaine 8 mg for spinal anestheisa is more suitable for orthopedic operations requiring rapid and complete motor block than hyperbaric 0.5% bupivacaine 8 mg and that it can be performed in lateral decubitus position with the operating site up.

Spinal Anesthesia with 0.5% Hyperbaric Bupivacaine in Elderly Patients : Influence of Aging on Spread of Analgesia and Blood Pressure / 대한마취과학회지

BACKGROUND: We have studied the influence of aging on the spread of analgesia and blood pressure with 0.5% hyperbaric bupivacaine in elderly patients compared to findings with a control group. METHODS: Forty-nine patients in two groups between 22-59 yr and 70-86 yr undergoing lower limb surgery were placed in a lateral position with the side to be operated on dependent. Five minutes after the injection of 1.4 ml of 0.5% hyperbaric bupivacaine, each patient was placed in the surgical position. Noninvasive mean arterial pressure (MAP) and levels of analgesia were measured for 30 minutes. RESULTS: The maximum sensory block level was T7.5+/-2.4 in the elderly group and T8.2+/-2.4 in the control group. There was no significant difference on the highest level of analgesia between groups. The time to reach maximum level was 17.4+/-8.6 minutes in the elderly group and 16.9+/-7.0 minutes in the control group. The maximum decrease in MAP was significantly greater in the elderly group (23.3+/-11.1% of the baseline value) than in the control group (10.7+/-0.2%). The incidence of hypotension (defined as a decrease of 25% or more MAP) was 48.0% in the elderly group and 4.2% in the control group. CONCLUSIONS: There was no significant effect on the highest level of analgesia with advancing age. Decreases in mean arterial pressure were more frequent and pronounced in the elderly group than in control group. It may be appropriate to monitor patients carefully and treat hypotension immediately if it occurs.

Clinical Effects of Addition of Clonidine to Ldegrees Cal Anesthetics in Hypertensive Patients Undergoing Senile Cataract Surgery / 대한마취과학회지

BACKGROUND: Although the effect of clonidine, an alpha2 adrenoreceptor agonist, is well established, there is no study to evaluate the effects of addition of clonidine to ldegrees Cal anesthetics in elderly hypertensive patients. The aim of this study is to evaluate the effects of addition of clonidine to ldegrees Cal anesthetics in elderly hypertensive patients undergoing senile cataract surgery. METHODS: Forty elderly hypertensive patients who scheduled for elective senile cataract surgery were divided into two groups. The control group (n=20) received oral diazepam 0.1 mg/kg 60 min before surgery and the clonidine group (n=20) did not received premedication. A mixture of 2% liddegrees Caine and 0.5% bupivacaine with normal saline 0.7 ml (control group) or clonidine 100 ug (clonidine group) was used as a ldegrees Cal anesthetics. Perioperative blood pressure, heart rate, sedation score, and intradegrees Cular pressure were measured. RESULTS: After anesthesia, there was a significant fall in blood pressure and intradegrees Cular pressure in clonidine group, and increase in sedation score in clonidine group than control group. There was no difference in the perioperative heart rate between the two groups. CONCLUSIONS: The above results show that addition of clonidine to ldegrees Cal anesthetics in elderly hypertensive patients undergoing senile cataract surgery produced reduction in blood pressure, intradegrees Cular pressure and produced intraoperative sedation.

Comparison of the Frequency of Postoperative Delirium in Elderly between General Anesthesia and Regional Anesthesia / 대한마취과학회지

BACKGROUND: Elderly patients often have postoperative psychiatric disorders compared with young patients. METHODS: This study was undertaken to compare the effects of general or regional anesthesia on postoperative psychiatric disorders in 31 elderly patients with elective orthopedic and urological surgery. Mini Mental States Examinations(MMSE) was done to find out postoperative delirium at preoperative, postoperative 6hours, 1st, 3rd, and 7th days. RESULTS: Mean changes in MMSE score after general anesthesia were significantly decreased compared with preoperative score and with in regional anesthesia at postoperative 6 hours and 1st day. Postoperative MMSE scores were decreased below 17 points in 17 patients among 22 patients in general anesthesia and 3 patients among 26 patients in regional anesthesia. Hospital admission duration were significantly prolonged in general anesthesia compare with regional anesthesia. CONCLUSIONS: The incidence of postoperative delirium is more common after general aneshtesia than after regional anesthesia. Therefore regional anesthesia is recommeded in elderly patients to decrease postoperative delirium.

Clinical Evaluation of Anesthesia for Surgical Repair of Hip Fracture in the Elderly / 대한마취과학회지

BACKGROUND: The incidence of hip fractures in the elderly is increasing because of the expanding elderly population. These patients usually have accompanying chronic illness. We have reviewed 108 cases for hip fracture surgery to determine the factors which influence the intraoperative and postoperative outcome. METHODS: One hundred eight patients, aged 65 year or more, undergoing surgery for hip fracture were reviewed retrospectively according to age, sex, preoperative laboratory findings, pre-existing concomittent disease, type of anesthesia, amount of estimated blood loss during operation, changes of blood pressure, heart rate during anesthesia and postanesthesia care unit, one month morbidity and mortality. RESULTS: Seventy-one patients had pre-existing concomittent disease. Decrease in mean arterial pressure and tachycardia were less frequent in combined spinal epidural anesthesia than spinal anesthesia. Increase in mean arterial pressure was less frequent in combined spinal epidural anesthesia than epidural and general anesthesia during surgery. There was a significantly high postoperative morbidity among patients with concomittent disease. One month mortality increased with increasing age. CONCLUSIONS: We recommend the combined spinal epidural anesthesia in patients who could aggravate the pre-existing concomittent disease when hypotension, hypertension or tachycardia occurs during operation. One month morbidity was related to pre-existing concomittent disease, whereas mortality was related to age. More studies are needed to focus on well-defined risk groups in the elderly patients.

Clinical Investigation of Laryngeal Mask Airway Use in Geriatric Patients / 대한마취과학회지

BACKGROUND: The laryngeal mask airway (LMA) has many advantages including easy insertion, less trauma, minimal cardiovascular changes. And the elderly have many problems such as poor dentition, limited cervical extension and age related cardiovascular changes, so endotracheal intubation in geriatric patient is sometimes difficult and harzardous. This clinical study was designed to investigate availability and problems of LMA insertion in geriatric patients. METHODS: 60 geriatric patients undergoing elective surgery were induced with intravenous injection of pentothal sodium or propofol, vecuronium or atracurium and inhalation of O2, N2O, enflurane or isoflurane. After deep anethesia and full muscle relaxation LMA was inserted and cuff was inflated. When blind insertion was failed, laryngoscope was used. Anesthesia was maintained with inhalation of O2, N2O, enflurane or isoflurane under positive pressure ventilation. Thereafter, we observed peak inspiratory pressure and any incident including gas leakage, stomach distension, regurgitation of stomach content intraoperatively and then any complication postoperatively. RESULTS: LMA placement was successful in 98.8%, but LMA insertion in geriatric patient had some difficulty because patient's tongue slided down with LMA due to oropharyngeal dryness, teeth loss. Intraoperatively LMA was well maintained under positive pressure ventilation. There was no critical incident associated with LMA use. CONCLUSIONS: LMA is safe and may have a useful role in the anesthetic management of geriatric patients who have many problems such as poor dentition, limited cervical extension and age related cardiovascular changes.

The Effects of Combined Spinal Epidural Anesthesia for Hip Surgery in the Elderly / 대한마취과학회지

BACKGROUND: With recently increase in geriatric population, hip surgery of the aged is increasing likewise as one of the major surgical procedures for orthopedic surgeons. It is the purpose of this paper to study the effects of combined spinal epidural anesthesia on blood pressure, heart rate, pulse oxygen saturation, level of blockade, postoperative pain control and complication in geriatric hip surgery. METHODS: Combined spinal epidural anesthesia was performed with a 27G Whitacre spinal needle through a 18G Weiss epidural needle in 30 patients undergoing elective hip surgery of geriatric patients. 0.5% heavy bupivacaine 2 ml (10 mg) was injected intrathecally. Prolonged anesthesia over 2 hours of operation was accomplished by adding 0.5% bupivacaine through epidural catheter. Onset of sensory anesthesia and motor blockade were measured at frequent intervals. Blood pressure, heart rate and pulse oxygen saturation were checked in preoperative state, 1, 2, 3, 4, 5, 7, 9, 11, 13, 15 minute after injection, and then every 3 minute until the operation was finished. 0.125% bupivacaine 110 ml with morphine 3 mg was provided by Baxter infusor (Baxter Healthcare CO. Deerfield, USA) for postoperative pain control. RESULTS: All 30 patients had adequate anesthesia. Sensory block level was at least above T10 dermatome and motor blockade of lower extremity was Bromage 3 in all patients. Systolic blood pressure and diastolic blood pressure were significantly different (P<0.05) after 3 minutes compared to preoperative state, but any patient had no specific problem. Postoperative pain control was excellent with no significant complication. CONCLUSIONS: Combined spinal epidural anesthesia provided reliable anesthesia for hip surgery of geriatric patients without significant complication.

Direction of Catheter Insertion and Spread of Sensory Block during Lumbar Epidural Anesthesia / 대한마취과학회지

BACKGROUND: Endoscopic urologic surgery including transurethral resection of prostate (TURP) requires adequate sacral analgesia for insertion of resectoscope. But epidurally administered local anesthetic does not produce anesthetic effects uniformly. Failure to completely block S1 during epidural anesthesia because of the large size of nerve root has been noted. The purpose of this study to compare the relation between catheter direction and sensory anesthesia. METHODS: Thirty patients scheduled for endoscopic urologic surgery were enrolled. The epidural catheter was inserted at L3-4 using a standard 18 gauge Tuohy needle. In group A (n=15), the Tuohy needle with bevel pointed in a cephalad direction during catheter insertion. In group B (n=15), it pointed caudally. And the catheter was introduced 3 cm into the epidural space. After test dose, 2% lidocaine 5 cc, 0.5% bupivacaine 5 cc and 2% lidocaine 3 cc were administered with fractionate dose through it. The extent of the sensory anesthesia to loss of cold sensation and pin prick test was measured every 5minute for 30 minutes. RESULTS: Analgesia spread to loss of cold sensation and pin prick test was no significant statistical difference between the two groups. In 15 minutes after injection of surgical dose, complete blockade in L5, S1 dermatome was present in both groups. CONCLUSION: Our results conclude that epidural catheter direction is not significantly influence the epidural anesthetic spread including sacral area in continuous lumbar epidural anesthesia in elderly patients.