Postoperative Residual Curarization either after Continuous Infusions or Intermittent Bolus of Rocuronium or Vecuronium / 대한마취과학회지

BACKGROUND: Although the incidence of postoperative residual curarization (PORC) following the use of intermediate-acting neuromuscular blocking agents is lower than that of longer-acting neuromuscular blocking agents, it has been reported in many studies. We compared the incidence of PORC following either rocuronium or vecuronium given by intermittent bolus or continuous infusion dosing. METHODS: Ninety-eight patients were included in this study. Neuromuscular blocking drugs were administered based solely on clinical criteria, and the reversal agent pyridostigmine was given to all patients. Residual block following rocuronium infusion (Group R-I), rocuronium bolus (Group R-B), vecuronium infusion (Group V-I), or vecuronium bolus dosing (Group V-B) was evaluated on arrival in the postanesthesia care unit. Neuromuscular function was assessed acceleromyographically (using TOF-Watch(R) to measure the train-of-four (TOF) ratio) and also clinically. PORC was defined as a TOF ratio of < 0.8. RESULTS: The incidence of PORC on arrival in the postanesthesia care unit was 20% in Group R-I, 23% in Group R-B, 42% in Group V-I, and 19% in Group V-B. Mean TOF ratio in Group V-I was less than those of the other groups (P < 0.05). CONCLUSIONS: PORC is still common following vecuronium or rocuronium, even after the block is antagonized, if neuromuscular blocking agents are administered according to clinical criteria alone.

Effects of Histamine on Nerve Block with Lidocaine / 대한마취과학회지

BACKGROUND: The failure to achieve satisfactory anesthesia following the administration of local anesthetic agents in acute inflammatory tissues is a recognized clinical phenomenon. Many inflammatory mediators can reduce the threshold of nociception during inflammation, and histamine, one of the most important inflammatory mediator, may attenuated local anesthetic effect during inflammation. The purpose of this study was to investigate if histamine can antagonize a lidocaine induced nerve block in vitro. METHODS: Recordings of the compound action potentials (CAP) of A-fiber components were obtained from the isolated sciatic nerves of male Sprague-Dawley rats. The nerve sheath of the sciatic nerve was removed and desheathed nerve was mounted in a recording chamber. Single pulse stimuli (0.5 msec, supramaximal stimuli) were repeatedly applied (2 Hz) to one end of the nerve and CAP recordings were made at the other. The effect of histamine on the suppression of CAP by lidocaine and the effect of histamine on the recovery time to the nerve block by lidocaine were measured. RESULTS: Compared with the baseline amplitude, the amplitudes of CAP were 11.7+/-4.1% for the lidocaine group, 18.3+/-4.6% for the lidocaine histamine 0.05% group, and 26.1+/-5.6% for the lidocaine histamine 0.5% group. Nerve block recovery times were: 38.6+/-3.5 min for the modified Krebs group, 29.8+/-4.2 min for histamine 0.05% in the modified Krebs group, and 19.2+/-1.1 min for histamine 0.5% in the modified Krebs group. CONCLUSIONS: Histamine shortened the recovery time induced by lidocaine. We suggest that histamine may significantly attenuate the effects of local anesthetics in inflammed tissue.

Evaluation of LMA Insertion with Sevoflurane 8% and N2O after Midazolam Administration / 대한마취과학회지

BACKGROUND: Sevoflurane is characterized by the lack of an unpleasant odor, airway irritation and its low blood/gas partition coefficient (0.68), which provides rapid and smooth induction. Inhaled induction with sevoflurane is commonly used in pediatric patients, but not in adult patients. This study was designed to investigate the time to completion of LMA insertion and end-tidal sevoflurane concentration during induction with sevoflurane 8% and N2O 50%, after midazolam administration, in adults. METHODS: Twenty eight patients, aged 20(-60) years, were administered intravenous midazolam 30 microgram/kg and after one minute, sevoflurane 8% and N2O 50% were inhaled with tidal-volume breathing. One minute after loss of consciousness, jaw thrust and mouth opening were checked and an LMA was inserted. The end-tidal concentration of sevoflurane, and the times to loss of consciousness and completion of insertion were recorded. The mean arterial pressure and heart rate were also recorded. RESULTS: From initiation of sevoflurane and N2O inhalation, it took 48 +/- 14 seconds until loss of consciousness, and 143 +/- 19 seconds until the completion of LMA insertion. The end-tidal sevoflurane concentration was 4.1 +/- 0.6% at loss of consciousness, 5.0 +/- 0.7% at one min after loss of consciousness, and 4.1 +/- 0.5% after LMA insertion. In all patients LMA insertion was successful and satisfactory. After LMA insertion, compared to baseline, the mean arterial pressure was reduced and the heart rate increased. CONCLUSIONS: After small-dose of midazolam, inhaled induction with sevoflurane 8% and N2O 50% allowed successful and satisfactory LMA insertion in adults.

Effects of Non-selective NO Inhibition on Hypoxia-, Acetylcholine- and Bradykinin-induced Vasoconstriction in Septic Isolated Rat Lungs / 대한마취과학회지

BACKGROUND: Endotoxin stimulates nitric oxide synthase (NOS) and the free radical nitric oxide (NO) is produced by NOS, which vasodilates the smooth muscle of pulmonary vessels. Otherwise, endotoxemia stimulates the release of cyclooxygenase (COX) products, which may modify hypoxic pulmonary vasoconstriction (HPV). We also observed the effect of nonselective NOS inhibition by NG-nitro-L-arginine methyl ester (L-NAME) on receptor-mediated acetylcholine (Ach)/bradykinin (BK) induced vasoconstriction and receptor independent HPV in E.coli lipopolysaccharide (LPS) induced septic isolated rat lungs. METHODS: Four hours before surgical instrumentation for lung isolation, we administered saline (1 ml) to the control group (n = 15), E.coli LPS (20 mg/kg) to the LPS group (n = 14) and LPS (30 mg/kg) the nitric oxide synthase inhibitor, L-NAME (15 mg/kg) to the LPS + L-NAME group (n = 14), intraperitoneally. In 43 isolated rat lungs perfused with physiologic salt-albumin- blood mixture, angiotensin II 0.2 microgram was injected into the perfusion circuit, to confirm pulmonary vascular reactivity in each isolated lung. HPV responses were induced by three hypoxic challenges for 5 minutes separated by 5 minutes of ventilation with a normoxic gas mixture. We observed the pulmonary arterial pressure at each challenge, ten minutes after the last HPV, 0.01, 0.1, 1.0 microgram of Ach and 1, 3, 10 microgram of BK were injected. PAP and static lung compliance were measured. RESULTS: The baseline pulmonary artery pressure in the LPS group higher than in the controls and HPV in the LPS group was changed compared to the controls but in the LPS + L-NAME it was higher than in the controls. The administration of Ach 0.1, 1.0 microgram and BK 3, 10 microgram causedpulmonary vasoconstriction and the vasoconstrictions of BK were dosage-dependent. Lung stiffness in the LPS and LPS + L-NAME groups were higher than those of the controls. CONCLUSIONS: Vascular constriction of pulmonary vessels and increased lung stiffness by Ach and BK might be the result of the endothelial injury. But pulmonary vasoconstriction and stiffness by Ach and BK were similar in the LPS and LPS + L-NAME groups, showing that factors other rather than excessive NO production might be involved in endothelial injury.

The Clinical Investigation on Laryngeal Mask Airway Intracuff Pressure Monitoring / 대한마취과학회지

BACKGROUND: This study was undertaken to analyze the necessity of deflating cuff volume to maintain intracuff pressure of the laryngeal mask airway (LMA) under 44 mmHg in general anesthesia with propofol and N2O. METHODS: In 168 surgical patients, LMA was inserted (male: #5, female: #4) and the cuff was sealed with air under positive pressure ventilation with 7-8 ml/kg of tidal volume. After measuring the initial intracuff pressure (P0), the intracuff volume (V0) of LMA and peak inspiratory pressure (PIP0), N2O (50%) was administered, and the time for the intracuff pressure to reach a pressure of 44 mmHg (T44), the intracuff volume for the intracuff pressure to reduce to P0 (Vdef), the N2O inhaled time and the number of patients who needed deflation were recorded. RESULTS: P0, V0, PIP0 were 24+/-7.5 mmHg, 17+/-2.8 ml, 13+/-3.8 cmH2O in males and 27+/-8.2 mmHg, 14+/-2.3 ml, 13+/-4.0 cm H2O in females, respectively. The number of patients who needed cuff deflation after inhaling N2O was 17 (18.5%) in males and 36 (47.4%) in females. T44 and Vdef were 27+/-16 min, 1.9+/-0.8 ml in males and 26+/-21 min and 1.3+/-0.6 ml in females, respectively. The necessity for LMA cuff deflation was related to P0, V0, and the N2O inhaled time in males and to P0 and the N2O inhaled time in females (P <0.05). CONCLUSIONS: In anesthesia with N2O, if the initial intracuff pressure of LMA is high and the duration of anesthesia prolonged, careful monitoring of the intracuff pressure is necessary.

Factors Affecting the Intracuff Pressure of an Endotracheal Tube during General Anesthesia Using Nitrous Oxide / 대한마취과학회지

BACKGROUND: It is recommended not to exceed an intracuff pressure of 22 mmHg. We evaluated many factors affecting the intracuff pressure of an endotracheal tube during general anesthesia using nitrous oxide. METHODS: Eighty adult patients undergoing surgery under general anesthesia using inhalation of nitrous oxide via a large-volume low-pressure cuffed standard tube (Vygon(R)) were enrolled. They were randomly divided into 4 groups according to sex and tube size; group M-1 (n = 20): male, 7.0 mm internal diameter (ID); group M-2 (n = 21): male, 7.5 mm; group F-1 (n = 21): female, 6.5 mm; group F-2 (n = 18): female, 7.0 mm. Specific cuff compliance of the tubes were 8.7 - 9.0nl/torr/ml and residual volumes of tubes of ID 6.5, 7.0 and 7.5 mm were 7.7 +/- 0.4, 11.1 +/- 0.5 and 10.9 +/- 0.5 ml, respectively. Sealing volume (SV), sealing pressure (SP), peak inspiratory pressure (PIP) and tracheal transverse diameter (TD) were measured. When the intracuff pressure reached 22 mmHg cuff volume (DV1) was deflated to SP and the elapsed time to the first deflation point (1-CP22) were recorded. Factors affecting the need for cuff deflation were analyzed. RESULTS: There were no correlations between SP or SV and TD. The incidence of need for cuff deflation was 30% and 38.1% in group M-1 and M-2, and 52.4% and 27.8% in group F-1 and F-2, respectively. The need for cuff deflation was significantly correlated with SP and duration of anesthesia in males and with SP in females (P < 0.05). CONCLUSIONS: Factors affecting the need for cuff deflation to maintain intracuff pressure below 22 mmHg were SP and duration of anesthesia in males, and SP in females and not SV/RV, TD or the size of the tube.

Effect of Continuous Infusion of Ketamine on the Cortisol and Hyperglycemic Response to Abdominal Surgery during General Anesthesia / 대한마취과학회지

BACKGROUND: The effect of a continuous infusion of ketamine on the cortisol and hyperglycemic response induced by surgery was studied in patients undergoing an abdominal hysterectomy under enflurane anesthesia. METHODS: Twenty adult female patients were randomly allocated to two groups receiving intravenous ketamine (0.3 mg/kg initially, followed by a continuous infusion at a rate of 0.15 mg/kg/h) (ketamine group, n = 10) or normal saline (control group, n = 10) 2 min after intubation. Hemodynamic responses, serum cortisol and glucose concentrations were measured before induction, 2 min after intubation, 2 min after incision, at closure of peritoneum and 5 min after extubation. Inspired and expired concentrations of enflurane were also evaluated. RESULTS: There were no significant differences in hemodynamic responses, inspired and expired concentrations of enflurane, serum cortisol and glucose concentrations between the two groups. As compared with the values before induction, significant increases were seen in serum cortisol (control: 2.3-2.6 times, ketamine: 2-2.2 times) and glucose concentrations (control: 1.2-1.3 times, ketamine: 1.3 times) at closure of peritoneum and 5 min after extubation in both groups (P<0.05). CONCLUSIONS: Continuous infusion of an analgesic dose of ketamine could not abolish the increases in serum cortisol and glucose induced by abdominal surgery under enflurane anesthesia.

The Effect of Maternal Supine or Lateral Tilt Position on Maternal and Neonate Outcome / 대한마취과학회지

BACKGROUND: An aortocaval compression by the gravid uterus in late pregnancy leads to acute hypotension in the mother and decreases uteroplacental blood flow which may affect neonatal outcome. The purpose of this study was to evaluate maternal hemodynamic changes, which affect neonatal outcome under general anesthesia for an elective cesarean section depending on the maternal position-supine or left lateral 15degrees tilting by wedge. METHODS: Forty women undergoing an elective cesarean section under general anesthesia delivered through the supine position or left lateral 15degrees tilting by wedge position randomly. The maternal brachial blood pressure and heart rate were recorded, and the maternal arterial blood, umbilical artery and vein blood were sampled. Induction-to-delivery time (IDT), uterine incision-to-delivery time (UDT), and Apgar scores were measured. RESULTS: The two groups had no maternal hypotension less than 100 mmHg, and there were no significant differences in brachial blood pressure and heart rate of the mother, or acid-base status and Apgar scores of the neonate. CONCLUSIONS: In conclusion, maternal position had no clinical significant effects on maternal brachial blood pressure and heart rate, and neonatal outcome.

Effects of Propofol on Hypoxic Pulmonary Vasoconstriction after Pretreatment with L-NAME and Glibenclamide in Isolated Rat Lungs / 대한마취과학회지

BACKGROUND: It is generally accepted that propofol does not inhibit hypoxic pulmonary vasoconstriction (HPV). However, because the previous studies for the effects of propofol on HPV were established in vivo, the effects of physiologic variables could not be ruled out. Therefore, we investigated the effects of various concentrations of propofol on HPV at isolated rat lungs and the relationship of these effects of propofol on HPV and endothelium-derived relaxing factor (EDRF) and an ATP-dependent K+ channel which were candidates as the mechanism of HPV. METHODS: In 30 isolated rat lungs, after three hypoxic challenges for 5 minutes, we administered saline in the control group, N(G)-nitro-L-arginine methyl ester (L-NAME) in the L group and glibenclamide in the G group followed by three hypoxic challenges for 5 minutes. In addition, we studied the effects of various concentrations of propofol on HPV in the three groups. RESULTS: L-NAME and glibenclamide did not alter baseline pulmonary arterial pressure but L-NAME significantly enhanced HPV. Clinical concentrations of propofol did not affect HPV and high concentrations of propofol inhibited HPV. The pretreatment of L-NAME and glibenclamide did not alter the inhibition of HPV even at high concentrations of propofol. CONCLUSIONS: The EDRF and ATP-dependent K+ channel did not largely contribute to baseline pulmonary arterial tone but EDRF might be released and downregulate HPV. Clinical concentrations of propofol did not inhibit HPV but high concentrations of propofol inhibited HPV. In addition, the mechanism of inhibition of HPV at high concentrations of propofol did not relate to the EDRF pathway and ATP-dependent K+ channel.

Extension of Sensory Blockade after Thoracic and Lumbar Epidural Administration of a Test dose of Lidocaine / 대한마취과학회지

BACKGROUND: The distribution of solutions injected into the epidural space has not been well determined. The aim of this study was to compare the difference in extension of sensory blockade between the thoracic and lumbar regions in epidural analgesia. METHODS: Forty-five female patients scheduled for postoperative pain control were enrolled. In group 1 (n = 22), the Tuohy needle was inserted at T6 10 levels and in group 2 (n = 23), it was inserted at T12 L2 levels. The catheter was introduced 3 4 cm into the epidural space and 3 ml of 1.5% lidocaine with epinephrine (1:200,000) was injected. The extension of sensory anesthesia to loss of cold sensation and pinprick test was measured every 5 minute for 15 minutes. RESULTS: Fifteen minutes after epidural injection, the mean sensory block extension in group 1 (7.8 +/- 2.0 dermatomes) was significantly wider than in group 2 (4.7 +/- 2.2 dermatomes) but cranial and caudad spread of sensory blockade in relation to the puncture level was the same in both groups. CONCLUSION: The mean dose of local anesthetic required for analgesia was smaller in the thoracic region than in the lumbar region.

Hemodynamic Effect of Propofol and Esmolol under Isoflurane Anesthesia in Dogs / 대한마취과학회지

BACKGROUND: Propofol has gained widespread popularity but it should at least be questioned in the presence of heart rate lowering medications such as beta-blockers. Esmolol, due to its ultrashort action and cardioselective properties, has been shown to be safe and effective for use in intraoprative tachycardia and hypertension. The purpose of this study is to evaluate the hemodynamic effects of esmolol and propofol under isoflurane anesthesia in dogs. METHODS: Six-mongrel dogs were induced with thiopental, intubated and ventilated with a mixture of isoflurane (1-1.5 vol%) and oxygen. A pulmonary artery catheter was placed via femoral vein and the femoral artery was cannulated. After stabilization, baseline hemodynamic measurements (HR, MAP, CO, SVR) were obtained. Measurements were repeated 5 and 15 minutes after injection of propofol (2 mg/kg), esmolol (1 mg/kg), and additional esmolol (1 mg/kg) for 30 seconds. Data was analyzed by repeated measurement of ANOVA. P < 0.05 was considered significant. RESULTS: Propofol produced no change in heart rate, MAP, CO and SVR. Heart rate decreased significantly during esmolol administration and remained decreased up to 15 minutes after the injection whereas the MAP, CO and SVR showed no significant changes. CONCLUSIONS: We have demonstrated that the decrease in heart rate continued up to 15 minutes after esmolol administration. These findings suggest that concomittent administration of propofol and esmolol requires monitoring of the heart rate after a bolus intravenous injection of esmolol.

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.

The Effect of Three Different Doses of Intravenous Oxytocin on Patients Undergoing Elective Cesarean Section / 대한마취과학회지

BACKGROUND: Oxytocin is used for uterine contraction after delivery in cesarean sections. Doses of oxytocin vary widely, ranging from 5 20 IU by slow IV infusion. The aim of this study was to compare the effect of three different doses of oxytocin (5, 15, 25 IU) during elective cesarean section. METHODS: Thirty patients (ASA 1 and 2) undergoing elective repeated cesarean section were assigned to one of three groups. Group I received 5 IU, group II 15 IU, and Group III 25 IU of oxytocin after clamping of the umbilical cord. Linear analog scale (LAS) of 0 to 10 assessed by the surgeon for degree of uterine contraction was used at 5, 10, 15, 20, 25 and 30 min after delivery. Blood pressure (BP) and pulse rate (PR) of the patients, volume of blood mixed with amniotic fluid in suction jars (Vol in S.J.), weight of all gauzes soaked with blood (Wt of gauzes), difference in pre- and postoperative hematocrit (Change in Hct), induction to delivery (I-D) and delivery to closure of uterus (D-C) interval were also recorded. RESULTS: There were no significant differences in the degree of uterus contraction, BP and PR of the patients, Vol in S.J., Wt of gauzes, Change in Hct, I-D and D-C interval, in the three groups. CONCLUSIONS: Five IU of oxytocin is as effective as more doses in healthy parturients undergoing elective cesarean section with general anesthesia.

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.

Effects of Pneumoperitoneum and Posture on Ventilation Monitored with Continuous Spirometry under General Anesthesia / 대한마취과학회지

BACKGROUND: To evaluate the effects of pneumoperitoneum and posture on total respiratory compliance, peak inspiratory airway pressure and inspiratory minute ventilation during laparoscopic pneumoperitoneum and pelviscopic surgery we monitored continuously with continuous spirometry. METHODS: 20 patients were anesthetized and paralyzed, tracheally intubated and mechanically ventilated at te rate of 12/min and at a tidal volume of 10 ml/kg. Measurements were made before surgery, just before insufflation and 5, 10, 20, 30, 60 min after insufflation under position changed (10o reverse Trendelenburg position in laparoscopic cholecystectomy; group C, 10o Trendelenburg and lithotomy position in pelviscopic surgery; group P), and 5, 10 min after deflation under horizontal position. Compliance, peak inspiratory airway pressure and inspiratory minute volume were monitored continuously with side stream spirometry. RESULTS: Compliance of respiratory system decreased 39.8% and 39.1%, peak inspiratory pressure increased 43.5% and 61.3%, inspiratory minute volume decreased 10.9% and 9.1% under pneumoperitoneum in group C and group P. CONCLUSION: Increased intrabdominal pressure and posture during laparoscopic cholecystectomy and pelviscopic surgery cause significant decreased respiratory compliance and inspiratory minute volume and a significant increased airway pressure. On-line monitoring of respiratory volume, pressure and compliance may be helpful during general anesthesia to avoid the potential harmful effects of increased airway pressure occurring with increased intra-abdominal pressure.

Clinical Consideration of Headache Following Accidental Dural Puncture / 대한마취과학회지

BACKGROUND: Puncture of the dura can lead to a severe and often incapacitating headache. There is a report that the frequency of headache following accidental dural puncture with a 17 or 18 gauge needle is 86.7%. We reviewed the records to evaluate the efficacy of management for all patients whose epidural for postoperative pain control was complicated by dural puncture during a 3-year period. METHODS: The subject of patients in whom dural puncture occurred (35 cases in 1574 epidurals) was divided into two group. Group W5 consisted of 16 patients who received epidural saline and drugs in a rate of 5 ml/hr. Group W10 consisted of 19 patients who received epidural saline and drugs in a rate of 10 ml/hr. All patients were monitored daily by the pain control resident for occurrence of headache. RESULTS: The frequency of accidental dural puncture was 2.2% (35 cases of 1574 epidurals). In group W5, 6 of 16 patients (38%) experienced headache. In group W10, 6 of 19 patients (32%) experienced headache. There were no significant differences between both groups. CONCLUSIONS: The results of this study suggest that the epidural infusion with high volume of 0.9% saline and drugs should be considered as an alternative effective method of managing postdural puncture headache.

Delirium after Combined Epidural-General Anesthesia in a Elderly Patient: A case report / 대한마취과학회지

Postoperative delirium is defined as an acute change with cognitive status characterized by fluctuating consciousness and unattention occurring within 30 days after operation. Postoperative delirium is a common complication of surgery in elderly people, but have been often unrecognized, under-diagnosed, under-treated, and under-investigated. We present a case of postoperative delirium in elderly patient who should have been treated with psychotherapy and antipsychotic drugs in psychiatric department after combined epidural-general anesthesia with continuous epidural bupivacaine and fentanyl infusion for postoperative pain control.

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.

Continuous Epidural Analgesia after Cesarean Section; a Comparison of L2-3 Versus T12-L1 Epidural Route / 대한마취과학회지

BACKGROUND: A combination of epidural fentanyl and bupivacaine has been used for many years for the management of postoperative pain. The aim of this study was to compare the analgesia and side effects according to the site of epidural puncture on L2-3 or T12-L1 followed by infusion of fentanyl and bupivacaine after cesarean section. METHODS: Sixty female patients scheduled for cesarean section were assigned randomly to receive fentanyl and bupivacaine via an epidural catheter inserted at L2-3 (group I) or a T12-L1 (group II) for postoperative analgesia. Visual analogue scales (VAS) for pain were recorded at 1, 6, 12, 24 and 48 hr postoperatively and side effects and degree of satisfaction were noted. RESULTS: Rest pain scores at 1 hr and dynamic pain scores at 6 hr postoperatively in group II were significantly less than in group I. Rest pain scores in group II at 24 hr and 48 hr postoperatively were significantly more than in group I. Leg numbness and weakness occurred significantly less in group II than in group I. The average pain scores using VAS in two groups were less than 3. There were no significant differences in other side effects and degree of satisfaction between the two groups. CONCLUSIONS: The continuous epidural infusion of fentanyl and bupivacaine provides good postoperative analgesia and high degree of satisfaction after cesarean section. However, leg numbness and weakness occurred significantly less in T12-L1 group than in L2-3 group. We conclude that epidural analgesia performed on T12-L1 is a more advisable method for the cesarean patients in need of early ambulation.

Serum Lidocaine and Mepivacaine Level during Axillary Brachial Plexus Block / 대한마취과학회지

BACKGROUND: The maximum recommened dose for lidocaine and mepivacaine with epinephrine is about 500 mg regardless of the injection site. But this dose is insufficient for brachial plexus block and it is known that mepivacaine is safer than lidocaine. So the purpose of this study was to determine whether the serum concentrations of 1.5% lidocaine 600 mg with epinephrine and 1.5% mepivacaine 600 mg with epinephrine are within a safe range and to know any differences between them during axillary brachial plexus block. METHODS: Fifteen ASA physical status class I-II patients were selected. They were randomly divided into two groups. Group L patients (n=8) were anesthetized with 40 ml 1.5% lidocaine (600 mg) with epinephrine and group M patients (n=7) with 40 ml 1.5% mepivacaine (600 mg) with epinephrine. The serum concentrations were measured at the 5, 15 and 30 minutes after injection. RESULTS: The serum concentrations were 1.99 +/- 1.47, 2.66 +/- 1.03 and 2.41 +/- 1.41 microgram/ml in group L, and 3.03 +/- 0.64, 4.07 +/- 0.93 and 3.99 +/- 1.02 microgram/ml in group M at the 5, 15 and 30 minutes after injection. There were no symptoms or signs of local anesthetic toxicity, and serum levels of lidocaine and mepivacaine remained below the level that usually caused toxic symptoms. CONCLUSIONS: Although the serum concentration of mepivacaine group was higher than that of lidocaine group at each time, 1.5% lidocaine 600 mg with epinephrine and 1.5% mepivacaine 600 mg with epinephrine can be safely administered into the axillary sheath because the serum concentrations are within a safe range.