Anesthesia for Heart Transplantation in Dilated Cardiomyopathy Patient with Delirium: A case report / 대한마취과학회지

Heart transplantation is the last method for the patients who are suffering from heart failure refractory to conventional medical treatment. Traditional contraindications of heart transplantation are irreversible pulmonary arterial hypertension, active infection, irreversible renal, hepatic dysfunction, coexisting neoplasm, psychosocial instability, substance abuse and so on. But these days, traditional contraindications have been changed because increased clinical experience allowed liberalization of patients who were previously considered contraindication. We experienced a case of successful heart transplantation in dilated cardiomyopathy patient with preoperative delirium.

Decrease in Arterial Oxygen Partial Pressure by Pleural Opening in Thoracotomy during One-Lung Ventilation / 대한마취과학회지

BACKGROUND: One-lung ventilation (OLV) is commonly used in the majority of thoracotomies and thoracoscopic surgeries. During OLV, a decrease in partial pressure of arterial oxygen (PaO2) occurs due to the right-to-left transpulmonary shunt that develops in the non-dependent lung, and is aggravated just after pleural opening. Here, we examined the occurrence, cause, and means of preventing drops in PaO2 caused by pleural opening. METHODS: Seventy patients, ASA PS I or II, who were scheduled for elective thoracotomy or thoracoscopic surgery, were prospectively examined. After OLV, patients were randomly allocated to one of four groups. In the Control group (n = 10), pleurae were not opened during studies. In the Open group (n = 20), pleurae were opened with the plug of the double-lumen endobronchial tube of the non-dependent lung opened. In the Closure group (n = 20), the plug was closed just before pleural opening. And in the continuous positive airway pressure (CPAP) group (n = 20), pleurae were opened after applying 5 cmH2O CPAP of medical air to the non-dependent lung. Arterial blood gas analyses, hemodynamics, end-tidal CO2, peak inspiratory airway pressure, lung compliance, and airway resistance were recorded 15 min after two-lung ventilation, 20 min after transition to OLV, just before pleural opening, and 1, 3, and 20 min after pleural opening. In the control group, data were recorded 15 min after two-lung ventilation and in seven intervals after transition to OLV (1, 3, 5, 10, 20, 25, and 45 min). RESULTS: A significant decrease in PaO2 was detected just after pleural opening in the Open and Closure groups. PaO2 decreased in the Open group more than in the Closure group. However, in the CPAP group, no significant PaO2 reduction was detected after pleural opening. CONCLUSIONS: We found that PaO2 decreased when pleurae were opened during OLV. This may be due to the sudden development of atelectasis in the non-dependent lung by exposure to atmospheric pressure. This decrease in PaO2 can be relieved by closing the double-lumen endobronchial tube's plug of the non-dependent lung or by applying CPAP to the non-dependent lung when pleurae are opened.

Central Anticholinergic Syndrome Confirmed with Physostigmine after Open Heart Surgery / 대한마취과학회지

Central anticholinergic syndrome (CAS) can be caused by many anesthetic drugs. Early diagnosis and treatment are very important because untreated CAS may result in a life-threatening condition. Physostigmine, though not available in Korea, is the only drug which can confirm and treat CAS. A forty five year old patient underwent open heart surgery due to patent foramen ovale. Anesthetic agents which were used for anesthetic induction and maintenance were midazolam, fentanyl and isoflurane. Following anesthesia, he showed irritated and excited behavior and delayed recovery from anesthesia more than 3 h after operation in the ICU, even though flumazenil and naloxone were given to rule out the residual anesthetic effect. After physostigmine 4 mg was administered intravenously, he calmed down and became more coherent. There was no evidence of neurologic deficit in the following brain MRI and neurologic examination. We report the first case of CAS confirmed with physostigmine in Korea.

Correlation between the Degree of Bradycardia in Strabismus Surgery with Linear and Nonlinear Analysis of Preoperative Electrocardiogram / 대한마취과학회지

BACKGROUND: Severe bradycardia occurring in strabismus surgery is unpredictable and may lead to cardiac arrest. If we identify patients who have risk of severe bradycardia during strabismus surgery, it is helpful to provide a more meticulous anesthesia. In this study, we investigated the correlation between the degree of bradycardia and indices of power spectral analysis and nonlinear dynamic data analysis of preoperative ECG. METHODS: ECG was collected for twenty minutes from strabismus patients (n = 93). No premedicants were administered. After administration of anesthesia and traction of extraocular muscle, the lowest heart rate was recorded. We calculated the correlation coefficient between the power spectral density, approximate entropy and correlation dimension of preoperative ECG and the difference between preoperative and lowest HR. RESULTS: As the difference between the preoperative heart rate and the intraoperative bradycardia increased, the preoperative ECG showed a low total power (r = 0.27, P = 0.016), low low-frequency power (r = 0.31, P = 0.049), low high-frequency power (r = 0.30, P = 0.007) and high ratio of low to high-frequency power (r = 28, P = 0.03). There was no correlation between bradycardia and approximate entropy and correlation dimension, respectively. CONCLUSIONS: There was a correlation between indices of power spectral analysis of preoperative ECG and degree of bradycardia during strabismus surgery. Therefore we take into consideration preoperative ECG and its analytic indices in order to provide careful preparation for high risk patients who exhibit a tendency to severe bradycardia.