One-lung Anesthetic Experience for Video-assisted Thoracoscopic Surgery in Two Children / 대한마취과학회지

Video-assisted thoracic surgery (VATS) has been increasingly used because of it is a less invasive procedure than the open thoracotomy. Neither commercially available double-lumen tubes nor the univent tube can be used in small children. An ordinary uncuffed tracheal tube was introduced into the main bronchus of the right lung. This technique proved to be a simple and effective method of isolating and ventilating the other lung. We describe our experience providing one-lung ventilation with ordinary endotracheal tube during VATS in two young children. (Korean J Anesthesiol 2001; 40: 824 ~ 828)

Anesthesia for Living Related Liver Transplantation in Homozygous Protein C Deficiency / 대한마취과학회지

Protein C exerts anticoagulant effects by inactivating factor Va and VIIIa and stimulating fibrinolysis. The homozygous protein C deficiency is extremely rare and often results in life threatening thrombosis and purpura fulminans with necrotic cutaneous lesions. A child with homozygous protein C deficiency was treated at 6 months by a living-related liver transplantaion. After induction of anesthesia, we started an FFP infusion for protein C replacement and a low molecular weight heparin continuous infusion to prevent thrombosis. A complete reconstitution of protein C activity and resolution of the thrombotic condition occured postoperatively. So we report this case with a brief review of the literature.

Hemodynamic Effects of Combination of General and Caudal Anesthesia in Children / 대한마취과학회지

BACKGROUND: Caudal anesthesia has gained wide acceptance in pediatric anesthesia as a technique for providing postoperative pain relief and reducing general anesthetic requirement for surgical procedures below umbilicus. Although blood pressure has been shown to be well maintained with caudal anesthesia in pediatrics, little is known about the change in hemodynamics with combined general and caudal anesthesia. This study was designed to investigate the hemodynamic changes of combined general and caudal anesthesia for lower abdominal surgery in children. METHODS: Sixty children scheduled for lower abdominal surgery were involved. They were randomly divided into 2 groups: group G (n = 30); anesthesia with enflurane and N2O, and the group GC (n = 30); anesthesia with combined caudal block using 1% lidocaine 1 ml/kg and enflurane. Systolic (SBP), diastolic (DBP), mean blood pressure (MBP), and heart rate (HR) were measured at the 6 different time periods; at before induction (T1), just before skin incision (T2), just after skin incision (T3), 5 min (T4), 10 min (T5), and 30 min (T6) after skin incision. RESULTS: There were no significant differences in variables of hemodynamics between both group. Compared with the values at T1, those of SBP, DBP, and MBP at T2, T3, T4, T5, and T6 were decreased in both groups. However, there were no difference in those values at the same time periods between the two groups. The values of SBP, DBP, and MAP at T3, T4, T5, T6 in group G were higher compared with those at T2. CONCLUSIONS: From these results, we concluded that there were no significant changes in hemodynamics by combined general and caudal anesthesia in pediatric patients.

Clinical Evaluation of Low-Flow Enflurane Anesthesia in Infants / 대한마취과학회지

BACKGROUND: The purpose of this study was to evaluate the safety and efficacy of low-flow anesthesia with a semi-closed circle anesthesia system in infants. METHODS: Twenty, ASA physical status 1 or 2, infants were randomly assigned into two groups: high-flow anesthesia (HFA) or low-flow anesthesia (LFA). An identical semi-closed Dr ger circle anesthesia system (Cato) was used to all patients. Initial fresh gas flow (FGF) was N2O 1.5 L/min and O2 1.5 L/min in both groups. This FGF of 3 L/min was maintained in the HFA group. After 10 min of HFA, the FGF was reduced to 500 ml/min (N2O 250 ml/min and O2 250 ml/min) in the LFA group. RESULTS: Hypoxic or hypercarbic gas concentrations were not observed in all patients. Enflurane consumption during LFA was about 1/3 of that during HFA (6.8 +/- 1.3 ml vs. 19.5 +/- 5.8 ml). The mean highest esophageal temperature was similar in both groups. The mean highest inspiratory gas and soda lime temperatures were significantly higher in the LFA group than in the HFA group. CONCLUSIONS: Low-flow anesthesia in a circle system with a fresh gas flow of N2O 250 ml/min and O2 250 ml/min could be performed safely and economically for infants.

A Endotracheal Intubation in a Child with Mocopolysaccharidoses Using the Fiberoptic Laryngoscopy / 대한마취과학회지

Mucopolysaccharidoses are a group of inherited disorders of metabolism resulting in the deposition of mucopolysaccharide in various tissues. This leads to organ dysfunction and anatomical abnormalities which can be important to the anesthetist. These abnormalities result in airway difficulty and difficult intubation. We successfully performed endotracheal intubation in a case of mucopolysaccharidoses in a 9-year-old female patient using fiberoptic laryngoscopy.

Total Intravenous Anesthesia for Freeman-Shelden Syndrome / 대한마취과학회지

Freeman-Sheldon syndrome (FSS) is a rare congenital myopathy and dysplasia characterized by a whistling mouth and hand-foot anomalies. There are several anesthetic challenges like difficult airway and intravenous access, and the possibility of malignant hyperthermia. We controlled the anesthetic management of a patient with FSS undergoing contractured thumb correction. Intubation was done with a tracheal tube by direct laryngoscopy after three failed attempts. An anesthetic technique triggering malignant hyperthermia was not used. Anesthetic agents used were ketamine, propofol, fentanyl and nitrous oxide under spontaneous respiration. The child had an uneventful anesthetic course and no sign or symptoms of malignant hyperthermia.

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.

Anesthetic Management for Pediatric Living Related Liver Transplantation: Experience of 30 Cases / 대한마취과학회지

BACKGROUND: Living related liver transplantation (LRLT) was developed to alleviate the mortality resulting from the scarcity of suitable cadevaric grafts. The purpose of this study is to review 30 cases of pediatric living-related liver transplantation, and to find the proper anesthetic management for this operation. METHODS: We retrospectively analyzed the medical records of 23 cases (body weight < 15 kg) of liver transplantation from living related donors between August 1995 and May 1998. RESULTS: Mean age and body weight were 14 (range; 6-29) months, 8.7 (range: 5.4-12.2) kg, respectively. The most common cause of end stage liver disease was biliary atresia. After reperfusion there were significant decreases of mean arterial pressure and body temperature, and increases of central venous pressure (P< 0.05), whereas the change of heart rate was not significant. The incidence of postreperfusion syndrome was 26%. Serum Na levels increased significantly (P< 0.05) from 133 3 to 144+/-3 mEq/L, and K level decreased from 4.1+/-0.7 to 3.2+/-0.5 mEq/L during surgery. Hematocrit was 26+/-3.5%, platelet 10.3+/-7.2 x 104/mm3 at the time of peritoneal closure. Wide inter-individual RBC and FFP requirements were observed, 43+/-40 (range: 5-133) mL/kg, 108+/-82 (range: 22-300) mL/kg, respectively. CONCLUSIONS: We conclude that anesthetic management for pediatric LRLT and LRLT in recipients less than 15 kg in body weight can be carrid out, through with some precautions.

Estimation of the Optimal Depth of Subclavian Catheterizations in Pediatric Patients / 대한마취과학회지

BACKGROUND: The optimal depth of subclavian catheterization is not clearly and simply defined in the pediatric population. The aim of this study is to examine the relationship between the depth of the subclavian catheter and easily measured body-size variables, such as weight and height, and then to formulate a guide for the optimal depth of subclavian catheterization in the pediatric population. METHODS: We cannulated eighty-five pediatric cardiac patients via the left or right subclavian approach. The position of the catheter tip was determined by postoperative AP chest x-ray, and the length from the skin to the point of the border of superior vena cava and the right atrium (SK-SVCRA) was measured. RESULTS: Significant correlations with SK-SVCRA were found for weight and height. For the right approach, SK-SVCRA is calculated as 0.28xweight (kg) + 4.86 or 0.07 x height (cm)+1.70. For the left approach, SK-SVCRA is calculated as 0.22xweight (kg)+6.51 or 0.06xheight (cm)+3.94. CONCLUSIONS: Simple equations for the placement of the catheter tip at the border of the superior vena cava and right atrium as a function of patients' weight and height were formulated. These data may provide a useful guide to determine how deeply the subclavian catheter should be located.

Anesthesia for Renal Transplantation in Children: 4 cases / 대한마취과학회지

Despite significant advances in dialysis technology, kidney transplantation is accepted today as the optimal available treatment for end-stage renal disease (ESRD) in children and adolescents. Children undergoing renal transplantation pose many challenges to the anesthesiologist because ESRD has such adversely affects on the entire vital organ system as hypotension, hypovolemia, acidosis, atelectasis and pulmonary edema. Most importantly, hypotension and hypovolemia as results of large kidney transplantation should be corrected for normal renal function. In addition, ESRD alters the effects of various drugs used in anesthetic practice. We experienced 4 cases of general anesthesia for renal transplantation in children. Careful preoperative evaluation and preparation of the patients, as well as a knowledge of altered dry responses are essential in planning and managing anesthesia.

Acute Respiratory Failure after General Anesthesia for Anal Fistulotomy in Unrecognized Congenital Hypertrophic Pyloric Stenosis: A case report / 대한마취과학회지

We had a 2 month, 5.8 kg male infant for a surgery of perianal fistula. He had no considerable past or family history or laboratory data except mild jaundice and abnormal liver function tests. He was intubated after intravenous injection of ketamine and vecuronium. Anesthesia was maintained with isoflurane-N2O and O2. The operation was over within just 10 minutes without any specific event. We found abdominal distension, then suctioned out about 100 ml of milkish, bloody, gastric juice. In recovery room, the patient was cyanotic and a hazziness of the whole lung field was found in the chest X-ray. Acute respiratory failure (ARF) developed and we suspected aspiration. The next day he was diagnosed with congenital hypertrophic pyloric stenosis (CHPS) in sonographic examination. His ARF improved and he recieved pyloromyotomy 2 weeks later. CHPS is a common gasrointestinal disorder requiring operation in the infant stage. We report the ARF of an infant with asymptomatic unrecognized CHPS for anal fistulectomy. The incidence and sonographic features of CHPS and problems associated with anesthetic concerns are discussed.

Effects of Caudal Bupivacaine, Bupivacaine/Morphine, and Intravenous Ketorolac for Postoperative Analgesia in Pediatric Day Surgery Patients / 대한마취과학회지

BACKGROUND: For outpatient pediatric anesthesia, pain has perhaps been the main cause of hospitalization. Caudal blocks have been used to treat postoperative pain after low abdominal surgery. The purpose of this study was to evaluate and compare the analgesic effect and the incidence of side effect of caudal bupivacaine alone, a bupivacaine-morphine mixture, and intravenous ketorolac in pediatric day surgery patients. METHODS: Forty three patients, aged 1 to 7 years, were divided into three groups after the induction of general anesthesia. Caudal blocks were performed with 0.2% bupivacaine 0.7 ml/kg alone (group B), 0.2% bupivacaine 0.7 ml/kg and morphine 0.03 mg/kg (group M), and normal saline 0.7 ml/kg (group K). Ketorolac 0.8 mg/kg (group K) or normal saline 2 ml (group B and M) was injected intravenously before incision. Postoperative pain/discomfort scales and 4-point patient sedation scores were assessed, and the incidences of side effects were observed after recovery. RESULTS: Pain/discomfort scores in the group B and K were significantly greater than in group M. There was no difference among the groups in the 4 point patient sedation score. The incidences of nausea/vomiting and urinary retention were more frequent in group M but discharge was not delayed by the side effect. CONCLUSIONS: The addition of morphine to bupivacaine for caudal block provides more effective postoperative analgesia than caudal block with bupivacaine alone and intravenous ketorolac administration in day surgery. Side effects such as nausea/vomiting and urinary retention must be considered after use of morphine during caudal block.

Effects of Caudal Bupivacaine, Bupivacaine/Morphine, and Intravenous Ketorolac for Postoperative Analgesia in Pediatric Day Surgery Patients / 대한마취과학회지

BACKGROUND: For outpatient pediatric anesthesia, pain has perhaps been the main cause of hospitalization. Caudal blocks have been used to treat postoperative pain after low abdominal surgery. The purpose of this study was to evaluate and compare the analgesic effect and the incidence of side effect of caudal bupivacaine alone, a bupivacaine-morphine mixture, and intravenous ketorolac in pediatric day surgery patients. METHODS: Forty three patients, aged 1 to 7 years, were divided into three groups after the induction of general anesthesia. Caudal blocks were performed with 0.2% bupivacaine 0.7 ml/kg alone (group B), 0.2% bupivacaine 0.7 ml/kg and morphine 0.03 mg/kg (group M), and normal saline 0.7 ml/kg (group K). Ketorolac 0.8 mg/kg (group K) or normal saline 2 ml (group B and M) was injected intravenously before incision. Postoperative pain/discomfort scales and 4-point patient sedation scores were assessed, and the incidences of side effects were observed after recovery. RESULTS: Pain/discomfort scores in the group B and K were significantly greater than in group M. There was no difference among the groups in the 4 point patient sedation score. The incidences of nausea/vomiting and urinary retention were more frequent in group M but discharge was not delayed by the side effect. CONCLUSIONS: The addition of morphine to bupivacaine for caudal block provides more effective postoperative analgesia than caudal block with bupivacaine alone and intravenous ketorolac administration in day surgery. Side effects such as nausea/vomiting and urinary retention must be considered after use of morphine during caudal block.

A Total Intravenous Anesthetic Experience of Pediatric Living Related Liver Transplantation with Propofol: A case report / 대한마취과학회지

We have experienced one case of anesthesia for living related liver transplantation with propofol. The recipient was 18-month-old girl and 10.5 kg. She was suffered from congenital liver disease (biliary atresia). We decided propofol as an anesthetic agent of the recipient with permission of the recipient's parents. Total anesthetic time was about 13 hours and anhepatic phase was 110 min. Careful attention was paid to prevent infection, hypothermia, hepatic artery thrombosis and to keep proper lung function. Hemodynamic changes were relatively stable throughout the operation and postoperative mechanical ventilatory support was required for about 2 days.

A Total Intravenous Anesthetic Experience of Pediatric Living Related Liver Transplantation with Propofol: A case report / 대한마취과학회지

We have experienced one case of anesthesia for living related liver transplantation with propofol. The recipient was 18-month-old girl and 10.5 kg. She was suffered from congenital liver disease (biliary atresia). We decided propofol as an anesthetic agent of the recipient with permission of the recipient's parents. Total anesthetic time was about 13 hours and anhepatic phase was 110 min. Careful attention was paid to prevent infection, hypothermia, hepatic artery thrombosis and to keep proper lung function. Hemodynamic changes were relatively stable throughout the operation and postoperative mechanical ventilatory support was required for about 2 days.

Effects of Preoperative Oral Fruit Juices on Gastric olume and pH in Children / 대한마취과학회지

Backgrounds: The purpose of fasting before surgery is to minimize the volume of gastric contents. A short fast after solid food increases gastric volume, but a small drink of clear fluid 2 to 3 hours preoperatively decreases gastric volume. This investigation examined the effects of a small drink of clear fruit juice 2 to 3 hours prior to anesthesia on gastric volume, gastric pH, thirst and hunger. METHODS: Two hundred eighty children whose ages were five to ten years, scheduled for elective surgery were randomly assigned to one of 7 groups. Group 1 continued to fast but in the other 6 groups the children drank 2 ml/kg, 3 ml/kg, or 4 ml/kg of clear fruit juice (orange or grape) 2 to 3 hours preoperatively. The degree of thirsty and hunger was checked. The volume of gastric contents was measured by syringe and the pH by pH meter. RESULTS: The children who drank fruit juice preoperatively had decreased gastric volume. The gastric pH was not significantly different with that of the control group. The degree of thirst and hunger was not significantly different with that of the control group. CONCLUSIONS: We conclude that a small drink of fruit juice 2 to 3 hours preoperatively is more preferable than 8 hours fasting.

Comparison of Intranasal, Oral, and Rectal Midazolam for Premedication in Children / 대한마취과학회지

BACKGROUND: When appropriate premedication is required for pediatric patients, the route of drug administration and the patient's age may affect the drug response. This study was designed to evaluate the premedicative effects of intranasal, oral, and rectal midazolam in preschool (1~6 year) and school (6.1~10 year) ages. METHODS: One hundred fourteen children aged 1~10 years were randomly allocated into three groups to receive midazolam via intranasal (0.3 mg/kg), oral (1.0 mg/kg), or rectal (1.0 mg/kg) route. Sedation scores were evaluated at the arrival in preanesthetic room, drug administration, 5, 10, 20 and 30 min after drug administration, separation from parent, mask application, and induction with inhalational agent. Time to sedation scores of 3 and 4 and time to complete recovery from general anesthesia were recorded. RESULTS: At the drug administration, the incidence of crying was significantly higher in nasal group than in oral and rectal groups, especially in pre-school age group (87.5, 23.5. 40.9% for nasal, oral and rectal groups, respectively). At 5, 10 and 20 min after drug administration, sedation scores were significantly higher in nasal and rectal groups than in oral group. At separation, mask application and inhalational induction, sedation scores were significantly higher in oral and rectal groups than in nasal group. Time to sedation score of 3 and time to complete recovery were significantly longer in oral group than in nasal and rectal groups. CONCLUSIONS: In pre-school age, almost all the children cried at drug administration in nasal group, and onset and recovery were prolonged in oral group, so rectal route was suitable. In school age, nasal route was appropriate because of the lower frequency of crying at the drug administration and rapid onset and recovery. In overall age, rectal route was better because of the lower frequency of crying and rapid onset and recovery. This study suggests that administration route should be considered according to the age of pediatric patient to obtain appropriate premedication for pediatric patients.

Intravenous Fentanyl Dose for Control of Postinguinal Herniorrhaphy Pain in Children / 대한마취과학회지

BACKGROUND: Postoperative pain control in children is a difficult problem for management. Fentanyl is one of the most commonly used narcotics in infants and children due to its rapid onset and brief duration. Infants older than 3 months had a lower incidence of apnea than adults given fentanyl; however, the dosage of fentanyl varies a great deal depending on the purpose and plan for the postoperative management. This study is designed to evaluate the effective dose of intraoperative intravenous fentanyl for pain control following inguinal herniorrhaphy in pediatric patients. METHODS: Sixty children for inguinal herniorrhaphy under general anesthesia were divided into four groups. Group I received no analgesics as a control. Group II, III and IV received intravenous fentanyl 0.5 microgram/kg, 1 microgram/kg and 1.5 microgram/kg respectively. Fentanyl was injected intravenously at the beginning of fascia closure. Extubation time and the degree of pain was evaluated. RESULTS: Our result showed that group III and IV had a lower pain score than that of the control group during the first 30 min in the recovery room (p<0.05), but no significant differences were found between the group III and group IV. The time interval from fascia closure to extubation was prolonged in the group II, III and IV compared to the control group (p<0.05). But no significant differences were found between the three groups. CONCLUSION: We suggest that intravenous administration of fentanyl 1 microgram/kg at the closure of fascia would be an easy, simple and effective means for relieving postinguinal herniorrhaphy pain in recovery room.

The Effect of Ultrafiltration in Pediatric Open Heart Surgery / 대한마취과학회지

BACKGROUND: Ultrafiltration is a method to reduce capillary leak and the accumulation of extravascular water associated with cardiopulmonary bypass(CPB). There are two techniques of ultrafiltration, conventional and modified techniques. The effect of the former is controversial. The author investigated the effect of ultrafiltration performed in pediatric open heart surgery in our institute. METHODS: The retrospective study was done in 18 children who received surgical correction of congenital heart disease associated with left to right shunt. Eight children undergone ultrafiltration(UF group) were compared with 10 children who did not receive ultrafiltration(non-UF group). Ultrafiltration was performed mainly during rewarming of CPB(conventional UF) with or without modified technique for about 5 minutes immediately after bypass. Hematocrit(Hct), mean arterial pressure(MAP) and platelet count, 24-h blood loss, the amount of transfusion, fluid requirement, time to extubation, duration of ICU stay and the postoperative hospital stay were compared between groups. RESULTS: The volume of ultrafiltrate was 149+/-88 ml and ultrafiltrate/total blood volume(UF/TBV) ratio was 8.6+/-5.3%. The increase of Hct(5.4+/-1.7%) and of MAP(14+/-5.9 mmHg) after rewarming in UF group were significantly greater than 1.5+/-1.7% and 4+/-8.9 mmHg in non-UF group, respectively(p <0.05). There were no significant differences in platelet count, 24-h blood loss, the amount of transfusion, fluid requirement, maximum body temperature, time to extubation, duration of ICU stay and the postoperative hospital stay between groups. CONCLUSIONS: Ultrafiltration performed during open heart surgery in children significantly increases Hct and MAP immediately after ultrafiltration, but does not affect 24-h blood loss, the time to extubation, duration of ICU stay and the postoperative hospital stay.

Caudal Epidural Morphine for Postoperative Analgesia in Children / 대한마취과학회지

BACKGROUND: The use of caudal morphine for postoperative analgesia has been increased in popularity since 1981. The purpose of this study was to compare the effect of analgesia and incidence of side effects of a mepivacaine-morphine mixture with mepivacaine alone. METHODS: Forty patients were randomly divided into two groups. In group 1, caudal block was performed with 1% mepivacaine 1 ml/kg alone. In group 2, caudal block was performed with 1% mepivacaine 1ml/kg-morphine 0.03 mg/kg mixture. Postoperative five-point pain scores and side effects were measured. RESULTS: There were no significant differences in sedation dose, incidence of side effects and supplemental analgesics. Pain scores were significantly lower at postoperative 2 and 3 hours in mepivacaine-morphine mixture group. CONCLUSIONS: Caudal epidural mepivacaine-morphine (0.03 mg/kg) mixture is effective in children for control of postoperative pain without significant side effects.