Dose fentanyl injection for blunting the hemodynamic response to intubation increase the risk of reflex bradycardia during major abdominal surgery? / 대한마취과학회지

BACKGROUND: Although supplemental fentanyl has been widely used to blunt the hemodynamic responses to laryngoscopic intubation, its residual vagotonic effect may increase the risk of reflex bradycardia. We compared the incidence and severity of significant reflex bradycardia after a bolus injection of equivalent doses of fentanyl and remifentanil (control drug). METHODS: In this prospective, randomized, double-blind study, 220 adult patients undergoing major abdominal surgery were randomly assigned to receive fentanyl (1.5 microg/kg) or remifentanil (1.5 microg/kg). No anticholinergic prophylaxis was administered. Symptomatic reflex bradycardia was defined as a sudden decrease in heart rate to < 50 beats per minute (bpm) or to 50-59 bpm associated with a systolic arterial pressure < 70 mmHg in connection with surgical maneuvers. If bradycardia or hypotension developed, atropine or ephedrine was administered following a predefined treatment protocol. RESULTS: In total, 188 subjects (remifentanil, 95; fentanyl, 93) were included. The proportion of subjects with symptomatic reflex bradycardia in the fentanyl group was similar to that in the remifentanil group (30.1% vs. 28.4%, respectively). Atropine and/or ephedrine were needed similarly in both groups. The differences between the group of 55 patients who presented with symptomatic reflex bradycardia were not statistically significant with respect to the lowest heart rate, anesthetic depth-related data (bispectral index and end-tidal sevoflurane concentration), or the proportion of causative surgical maneuvers. CONCLUSIONS: Fentanyl (1.5 microg/kg) administered intravenously during anesthetic induction is unlikely to increase the incidence and severity of significant reflex bradycardia in patients undergoing major abdominal surgery.

Remodeling and Changes of Systolic and Diastolic Functions of Left Ventricle after Acute Myocardial Infarction: Comparison according to Killip Class at Admission

BACKGROUND: Infarct size determines left ventricular (LV) systolic and diastolic dysfunctions after acute myocardial infarction, and also may affect the recovery from functional impairment. We studied the differences of LV remodeling and changes of systolic and diastolic functions of LV during two weeks after acute myocardial infarction, according to Killip class at admission. METHODS: Echocardiographic examinations were performed within two days (23.9+/-2.3 hours), and two weeks after the attack in 27 patients with acute myocardial infarction, and the results were compared with those of 19 controls. Patients were divided into two groups according to Killip class at admission; 18 patients in Killip class I (group I) and 9 patients in Killip class II to IV (group II). Group II had larger infarct, reflected by higher levels of peak serum cardiac enzymes. RESULTS: LV systolic function was more depressed in group II. Regional wall motion score index decreased in group I after two weeks, but not in group II. LV systolic and diastolic volume indexes increased after two weeks in group II but not group I. E/A ratio of mitral inflow was less than 1, and isovolumic relaxation time was prolonged in group I immediately after the attack. Group II had E/A>1 and shorter deceleration time (DT) of mitral inflow, and higher peak reverse flow velocity associated with atrial contraction (AR) of pulmonary venous flow than those of controls immediately after the attack. In group II, E/A ratio was greater, DT was shorter, peak systolic/diastolic flow velocity ratio of pulmonary venous flow was less, and AR was higher than those of controls after two weeks. CONCLUSION: Infarct size affected remodeling and changes of systolic and diastolic functions of LV after acute myocardial infarction. In patients with large infarct, LV was dilated and regional wall motion was not improved during two weeks. Restrictive pattern of LV filling, which was more aggravated during two weeks, was noted immediately after the attack. In patients with small infarct, LV was not dilated and regional wall motion was improved during two weeks. LV filling pattern showed relaxation abnormality.

Assessment of Left Atrial Appendage Flow Pattern Using Multiplane Transesophageal Echocardiography in Patients with Nonrheumatic Atrial Fibrillation and Ischemic Stroke

BACKGROUND: The efficacy of oral anticoagulant therapy in reducing the risk of stroke and systemic embolism has been demonstrated in patients with nonrheumatic atrial fibrillation, but anticoagulation may introduce the risk for serious complications or adversely affect the patient's usual activities. Because the left atrial appendage(LAA) is the most likely site of thrombus formation in patients with nonrheumatic atrial fibrillation, evaluation of the LAA function with transesophageal echocardiography(TEE) may be helpful to deterrnine the high risk group for ischemic stroke. METHODS: Twenty patients with nonrheumatic atrial fibrillation(group I ), eighteen patients with rheumatic atrial fibillation(group II ) and twenty subjects in normal sinus rhythm without valvular heart disease(group III ) were underwent multiplane TEE examination. We measured maximal and minimal areas, ejection-fraction, and peak contraction and relaxation velocities of LAA. We also observed the presence or absence of thrombus and spontaneous echo contrast (SEC) in the left atrium or LAA. RESULTS: Maximal area of LAA was larger in group I and II compared with group III but there was no difference between group I and group II. Ejection fraction of LAA was much decreased in group I and II compared with group III. Peak contraction and relaxation velocities of LAA were over 45cm/sec in all cases from group Ill, but there was nearly negligible flow measurable in cases from group II. Patients from group I showed two distinct LAA flow patterns, either well defined saw tooth flow pattem(9 cases) or very low flow pattern like that of group II (11 cases). Therefore, patients from group I could be divided into two subgroups according to LAA flow profile. High flow profile subgroup had clear saw tooth flow pattern and revealed over 20cm/sec of peak contraction and relaxation velocities. The other low flow profile subgroup showed under 20cm/sec of both velocities. LAA ejection fraction was more increased in high flow profile subgroup but not significantly. Ischemic stroke occurred in six patients from group I, and all were in the low flow profile subgroup(p<0.05). SEC was observed in eight cases(73%) of the low flow profile subgroup but in only one case(11%) of the high profile sbugroup(p<0.05). All three cases with LAA thrombus belonged to the low flow profile subgroup. CONCLUSIONS: The assessrnent of LAA function by TEE may be helpful to discriminate the high risk group for the potential ischemic stroke in patients with nonrheumatic atrial firillation.

Two Cases of Bilateral Emphysematous Pyelonephritis / 대한비뇨기과학회지

Emphysematous pyelonephritis is a life-threatening, severe renal infection characterized by the presence of gas in the renal parenchyma or perirenal space. Bilateral involvement is rarely seen, with only 17 cases reported in the iterature. We herein report two cases of bilateral emphysematous pyelonephritis. One is occurred subsequently in a patient with diabetic cystopathy, the other is developed simultaneously and shows bilaterally-communicated gas pattern on computerized tomography. The theories on pathogenesis of the disease are reviewed and the modes of disease progression in our patients are discussed.

Renal Trauma, 80 cases / 대한비뇨기과학회지

Recently, renal traumas caused by traffic and industrial accidents have risen sharply due to rapid industrialization and an increase in automobiles. Renal traumas in such a modem industrialized era show different aspects compared with those in the past. We reviewed the charts and x-ray films of the 80 patients who had been hospitalized due to renal trauma during the period January 1988 to June 1993 to examine the causes and the extents of trauma, methods of imaging study, their treatments and results. According to the review, the ratio of men to woman was 66:14. with 46 cases in the active 21 to 50 age group. By cause, traffic accidents comprised 41 cases or 51.3%, falls marked 20 cases, followed by 16 cases of assault and 3 cases of stab injury. 5 patients died among the 28 cases suffering serious renal trauma associated with multiple injuries, for a high mortality rate of 19%. The reason for this high rate was that the degree of multiple injuries with renal trauma was most severe in traffic accidents and falls. We are of the opinion that close and prompt cooperation with other associated medical departments is mandatory in order to reduce morbidity and mortality caused by multiple injury.

Clinical Observation on the Cryptorchidism / 대한비뇨기과학회지

A clinical observation was made on 116 patients of cryptorchidism who had been admitted to the Department of Urology, Gil Genersl Hospital during 34 months from March, 1992 to January l995. The results were as follows: 1. The age distribution varies from to 1 to 33 years and the most frequent group was l to5 years old(62%). 2. Bilateral cryptorchidism was found in 22 cases(19%), and in the case of unilatera1, right in 52 cases(44.8%) and left in 42 cases(36.2%). 3. Of the 138 testes, most frequent location was in the inguinal canal in 123 testes(89.1%). 4. Orchiopexy was perrormed on 130 testes(94.2%) by subdartos pouch technique and 7 testes were performed the orchiectomy 5. Among the associated anomalies, the most common anomaly was inguinal hemia in 131 cases and others were contralateral hydrocele, hypospadias, congenital heart disese and syndactyly.

Renal trauma on horseshoe kidney, 2 cases / 대한비뇨기과학회지

It has been suggested that diseased and anomalous kidneys are more susceptible to injury. While horseshoe kidney is the most common congenital anomaly of renal fusion, occurring in about one in every 400-500 births, reports of the horseshoe kidneys associated with renal trauma are rare. Herewe now report our experiences with two cases of renal trauma on horseshoe kidney.