The effect of administering colloid solution on the postoperative blood loss in patients who are undergoing total knee arthroplasty: Comparing Hextend with Voluven

BACKGROUND: Total knee arthroplasty (TKR) is associated with a significant loss of blood. Fluid substitution with crystalloid or colloid solutions to correct perioperative hypovolemia is essential. Colloid solutions, and especially hydroxyethyl starches (HES), are used to treat hypovolemia, but they may affect blood coagulation. The purpose of this study was to test the efficacy and the safety of colloid solutions in patients undergoing TKR. METHODS: The patients undergoing TKR were divided into a group that underwent fluid management with Voluven(R) (n = 22) and a group that was managed with Hextend(R) (n = 24). The blood loss, the autotransfused blood volume, the hemoglobin level, the allogenic blood requirement, the urine output and the complications were assessed. RESULTS: There were no significant differences in the amount of blood loss, the autotransfused blood volume, the allogenic requirement, the urine output and the complications between the two groups. CONCLUSIONS: Voluven(R) and Hextend(R) are equally efficacious plasma volume substitutes when performing TKR with an autotransfusion of drained blood.

Effect of Nicardipine on Hemodynamic Responses to Endotracheal Intubation / 대한마취과학회지

BACKGROUD: Laryngoscopy and tracheal intubation often provoke an undesirable increase in blood pressure and heart rate. This study was done to examine the blunting effect of nicardipine on the adverse hemodynamic changes following a direct laryngoscopy and tracheal intubation. METHODS: Thirty ASA physical status 1 adult patients were allocated into two groups; the control group (n = 15) and nicardipine group (n = 15). In the control group, normal saline, and in the nicardipine group, 20microgram/kg of nicardipine were given 2 minutes before endotracheal intubation. Blood pressure and heart rate were measured after arrival at the operating room, before endotracheal intubation and after intubation under anesthesia (enflurane-N2O-O2). RESULTS: Systolic, diastolic and mean arterial blood pressure were significantly lower in the nicardipine group than in the control group before and after intubation (P < 0.05). The heart rate showed significantly higher values in the nicardipine group than in the control group before and after intubation (P < 0.05). CONCLUSIONS: Compared with no pretreatment before the IV induction of general anesthesia, the peak increase in blood pressure after a laryngoscopy and tracheal intubation is blunted by nicardipine. However, the increase in heart rate is not blunted by nicardipine.

The Effects of Intravenous Thiopental Injection on Jugular Venous Oxygen Saturation (SjVO2) during Cerebral Aneurysm Surgery / 대한마취과학회지

BACKGROUND: Thiopental has a profound impact on the cardiovascular system. The effects of hemody namics after intravenous thiopental on the balance of cerebral metabolism with cerebral blood flow is unknown. The purpose of this study was to monitor hemodynamic change, cerebral arterial-jugular venous oxygen content difference (AVDO2) and jugular venous oxygen saturation (SjVO2) after a thiopental injection for brain protection during cerebral aneurysm surgery. METHODS: Twenty patients received a standard anesthetic consisting of isoflurane, vecuronium and fentanyl with a PaCO2 of 30 35 mmHg. Hemodynamics, arterial and jugular venous blood gases were measured at 3 time points:I; Just before thiopental injection; II; Electroencephalographic (EEG) burst suppression after a 4 5 mg/kg intravenous thiopental injection; and III; EEG recovery. RESULTS: Intravenous thiopental (4 5 mg/kg) induced an EEG burst suppression for 6.5 +/- 1.7 minutes. Hemodynamics and arterial blood gas analysis were not significantly different among the different time points, but mean arterial pressure (68.4 +/- 7.2 mmHg) and systemic vascular resistance (1027.0 +/- 300.9 dynes sec/cm5) in II were significantly (P < 0.05) decreased compared with I (84.3 +/- 9.6, 1169.1 +/- 304.5) and III (89.1 +/- 10.6, 1288.6 +/- 426.1). SjVO2 (71.6 +/- 11.8%) was significantly (p < 0.05) decreased within the normal value compared with I (75.1 +/- 5.6) and III (76.1 +/- 10.1), but AVDO2 was not significantly different among the 3 time points. There was no evidence of cerebral ischemia or infarction in computed tomographic (CT) findings of the 20 patients after surgery. CONCLUSIONS: Hemodynamics after 4 5 mg/kg intravenous thiopental do not modify the balance ofcerebral oxygen metabolism with cerebral blood flow in patients undergoing cerebral aneurysm surgery.

A Comparison of the Efficacy and Safety of Tropisetron and Tropisetron Plus Dexamethasone as Antiemetics for Elective Thyroidectomy / 대한마취과학회지

BACKGROUND: Thyroidectomy is associated with a relatively high incidence of postoperative nausea and vomiting (PONV) ranging from 63% to 84%. In this study, we evaluated the safety and the antiemetic effects of tropisetron 30 microgram/kg or tropisetron 30 microgram/kg plus dexamethasone 5 mg in patients undergoing thyroidectomy under a standard anesthetic technique without narcotics. METHODS: Sixty-eight patients undergoing thyroidectomy were randomized to receive a placebo (Group C, n = 28), tropisetron 30 microgram/kg (Group T, n = 23) or tropisetron 30 microgram/kg plus dexamethasone 5 mg (Group T + D, n = 17) IV over 2 5 minutes immediately before the induction of anesthesia. The effects of these regimens on the development of PONV, adverse events and need for rescue antiemetics were analyzed for the 0 to 1 hour and 1 to 24 hours postoperative periods. RESULTS: In the 0 to 1 hour postoperative periods, the incidence of PONV in group C, T and T + D was 35.7%, 17.4% and 17.6% respectively, which showed no significant difference among the three groups (P > 0.05). In the same period, the incidence of retching or vomiting in Group C, T and T + D was 14.3%, 0% and 0% respectively, which showed a significantly lower incidence in Group T and T + D than Group C (P 0.05). During the first 24 hours postoperatively, the overall incidences of PONV was 67.9% for group C, 60.9% for group T and 58.8% for group T + D, which showed no siginificant difference among the three groups (P > 0.05). Group T + D patients had more headache compared to other groups, but there was no significant difference in theincidences of overall adverse events. CONCLUSIONS: Neither tropisetron or tropisetron plus dexamethasone was significantly different from the placebo for the prevention of PONV after thyroidectomy during the first 24 hour postoperative period. Only vomiting during the first 1 hour postoperatively was prevented in the tropisetron and combination of tropisetron plus dexamethasone groups compared to the control group.

Adequate Target Concentration of Propofol and Fentanyl for Total Intravenous Anesthesia by Target-controlled Infusion during Cesarean Section / 대한마취과학회지

BACKGROUND: Propofol has been used for the induction and maintenance of obstetric anesthesia for its potential benefit of rapid recovery and less post-anesthetic complications. In order to determine the safe application of target-controlled infusion of propofol and fentanyl during Cesarean section under general anesthesia, we have investigated the adequate target concentrations of each drug using the bispectral index and hemodynamic parameters. METHODS: Ninety-two pregnant women who received Cesarean section under general anesthesia were enrolled in this study. After preoxygenation, anesthesia was induced with thiopental 4 mg/kg and succinylcholine 1 mg/kg, and intubation was done. Vecuronium 0.1mg/kg I.V. was applied for muscle relaxation, and mechanical ventilation was maintained with N2O/O2 (2 L/2 L)-enflurane. EtCO2 was maintained between 30 35 mmHg. After delivery of the fetus, propofol and fentanyl was infused by a computer-assisted continuous infusion system with air/O2 (2 L/2 L). The bispectral index was monitored perioperatively. This study proceeded in three stages. In the first stage, thirty women were studied for titration of the target effect-site concentration of propofol that could maintain a bispectral index between 40 60 while maintaining the target concentration of fentanyl at 1.5 ng/ml. In the second stage, forty-two women were randomly assigned into the four different groups (F25, F50, F75, F100) at target fentanyl concentrations of fentanyl of 0.25, 0.50, 0.75 and 1.0 ng/ml for each group respectively. The adequate target concentration of fentanyl was titrated. In the third stage, twenty women were studied for assessment of the adequacy of target concentrations of propofol and fentanyl prospectively. RESULTS: The target effect-site concentrations (Ce, 95% confidence interval) that could maintain 50% and 95% of patients hemodynamically stable with the bispectral index within 40-60 were 2.41 (2.27-2.55) microgram/ml and 3.15 (2.95-3.50) microgram/ml for propofol, 0.32 (0.13-0.46) ng/ml and 0.84 (0.66-1.29) ng/ml for fentanyl. The pre-anesthetic bispectral index was 97.1+/-1.2 and it decreased maximally to 39.5+/-6.47 after thiopental injection and increased maximally to 83.6+/-6.3 before delivery and it was 80.6+/-6.9 for eye-open to verbal command during recovery. CONCLUSIONS: The adequate target effect-site concentrations of propofol and fentanyl for the maintenance of total intravenous anesthesia during Cesarean section were determined and these concentrations were validated prospectively.

The Effects of Subarachnoid Fentanyl in Combined Spinal-Epidural Anesthesia for Cesarean Section / 대한마취과학회지

BACKGROUND: Combined spinal-epidural anesthesia (CSEA) for cesarean section has gained an increasing interest as it combines a reliability of spinal anesthesia and the flexibility of epidural anesthesia. The aim of this study is to compare the surgical analgesia and the frequency of side effects for cesarean section produced by CSEA using subarachnoid fentanyl or placbo. METHODS: The study was performed in a randomized, double-blined fashion in 40 (20 per group) healthy, full-term parturients presenting for elective cesarean section. We compared the effects of intrathecal fentanyl (20 microgram), and placebo when administered together with 0.5% hyperbaric bupivacaine 7 mg in combined spinal-epidural anesthesia (CSEA) for cesarean section. Patients' anesthetic levels, vital signs and intraoperative pain were recorded. If anesthetic level achieved by intrathecal injection was not sufficient for cesarean section (T4), additional 2% lidocaine 2 ml per segment was administered epidurally. Patients were asked to rate their severity of pain on a visual analog scale (VAS) score intraoperatively and intravenous fentanyl was administered if the patient experienced intraoperative discomfort. The quality and side effects of anesthsia and neonatal Apgar scores were compared between two groups. RESULTS: The number (percent) of patients achieved sensory block level above T4 by subarachnoid injection alone was significantly higher in the fentanyl group (17/18, 94.4%) than the control grop (10/16, 62.5%). The dose of epidural lidocaine was significantly less in the fentanyl group (p<0.05). The frequency of intraoperative pain was significantly less in the fentanyl group (17%) than in the control group (50%). CONCLUSION: We conclude that adding fentanyl into subarachnoid injection in CSEA for cesarean section significantly decreases the additional epidural local anesthetics and intraoperative pain.

Pharmacological Prevention of Post-Anesthetic Shivering: Clonidine Vs Meperidine: A Meta-Analysis of Randomized-Controlled Trials / 대한마취과학회지

BACKGROUND: Post-operative shivering is one of the potential complications for any surgical patient. Its incidence varies from 5% to 65%, and many preventive and treatment modalities have been reported. For the effective prevention of post-anesthetic shivering by using intravenous clonidine or meperidine, randomized controlled studies were reviewed. The overall incidence of shivering after clonidine or meperidine administration, and the anti-shivering effect of clonidine and meperidine were evaluated. METHODS: DATA SOURCES: Medline search from 1978 to March 1998. DATA SELECTION: We selected studies that had investigated the preventive anti-shivering effect of intravenous clonidine or meperidine by randomized controlled trials. Ten clinical trials were evaluated. RESULTS: The pooled odd ratio of the patients who received clonidine was 0.32 (95% confidence interval, 0.22~0.47) and it seemed to be effective. But these studies showed little evidence of significant homogeneity (P=0.01). In the subgroup analysis, the pooled odd ratio of group A (early administration or intra-operative infusion group) was 0.47 (95% CI 0.31~0.72) evidenced effectiveness but failed to prove homogeneity (P=0.047). But group B (the late intra-operative administration group) had a pooled odd ratio of 0.10 (95% CI 0.05~0.22) and showed homogeneity (P=0.98). In meperidine trials, the pooled odd ratio was 0.20 (95% CI 0.07~0.55). CONCLUSION: We present quantitative evidence based on a meta-analysis of pooled effect size from randomized trials that clonidine is more beneficial for the prevention of post-anesthetic shivering and more effective than meperidine when it is administrated during later period of surgery.

A Comparison of the Efficacy and Safety of Ondansetron, Droperidol and Ondansetron Plus Droperidol as Antiemetics for Elective Thyroidectomy / 대한마취과학회지

BACKGROUND: Thyroidectomy has been a surgical procedure associated with a high incidence of postoperative nausea and vomiting (PONV), and conventional antiemetics cannot prevent PONV effectively. In this study, we compared the efficacy and safety of ondansetron 70 microgram/kg, droperidol 10 microgram/kg and combination of both drugs to placebo in the prevention of PONV. METHODS: Seventy-six patients undergoing thyroidectomy were randomized to receive placebo (Group I, n=20), ondansetron 70 microgram/kg (Group II, n=19), droperidol 10 microgram/kg (Group III, n=18) and combination of both drugs (Group IV, n=19). The effects of these regimens on the incidence and severity of PONV and adverse events were analyzed for the 0 to 1 hour and 1 to 24 hours postoperative periods. RESULTS: In the 0 to 1 hour postoperative periods, the incidence of symptom free (no nausea and retching or vomiting) paients were 60% for placebo, 68.4% for ondansetron (p>0.05 versus placebo group), 88.9% for droperidol (p0.05 versus placebo group), 77.8% for droperidol (p0.05 versus placebo group), 77.8% for droperidol (p<0.05 versus placebo and ondansetron group), and 73.7% for combination of both drugs (p<0.05 versus placebo and ondansetron group). Also, there were no significant differences between the droperidol and droperidol plus ondansetron group. Among the side effects associated with antiemetics, headache and dizziness incidence was higher. CONCLUSIONS: Droperidol and combination of ondansetron plus droperidol was superior to placebo, and ondansetron for prevention of PONV during the first 24 hours postoperative period.

Volume Changes under Isotonic Condition Containing Thiopental in Brain Astrocytoma Cells / 대한구급학회지

BACKGOUND: Cell volume regulation is especially important in the brain because the brain is confined within a non-compliant vault and cannot tolerate significant perturbations in cell size. Cerebral cell volume regulation mechanisms are activated by sustained disturbances in plasma osmolality. The constancy of cell volume under physiological conditions is generally thought to reflex a balance between influx and efflux of solute and is therefore critically dependent on the properties of the plasma membrane. Cell volume regulation have not been described under isoosmotic solution. The object of the study was to know the effects of thiopental on cell volume change in isoosmotic condition. METHODS: We made isoosmotic solution without thiopental (Group 1) and isoosmotic solution with 22.9 mM (Group 2), 16.8 mM (Group 3), 13.3 mM (Group 4) thiopental, separately, in order to study changes in cell volume under isoosmotic solution. We put cultured human brain astrocytoma cells into isoosmotic solution for each group and calculated cell volume using Coulter Counter after 30 minutes. RESULTS: Cell volume was shown to be 5084+/-8580 (micrometer3)in Group 1, 501+/-854 (micrometer3) in Group 2, 1183+/-3839 (micrometer3) in Group 3, and 624+/-1100 (micrometer3) in Group 4. We discovered that cells in Group 2,3,4 were shrunk relative to cells in Group 1 (p<0.01). And there were significant differences in cell volume among thiopental groups. CONCLUSIONS: Thiopental may has an effect on cell membrane properties and decrease cell volume under isoosmotic solution in brain astrocytoma cell.

The Effects of Intravenous Anesthetics on Blood-Brain Barrier Disruption Induced with Mannitol in Rats / 대한마취과학회지

BACKGROUND: In the anesthetic state, various anesthetic agents may effect on hyperosmolar blood-brain barrier disruption. Therefore, the effects of intravenous anesthetics, pentobarbital, ketamine and propofol, on the mannitol induced blood brain barrier disruption (BBBD) of 21 Spague-Dawly rats were evaluated. METHODS: Intravenous anesthetics, pentobarbital (group 1), propofol (group 2) and ketamine (group 3), were administrated before right intracarotid artery infusion of mannitol in three groups. BBBD was estimated by the calculation of the ratio of radioactivity between plasma and brain tissue using 99MTC-human serum albumin and Evans blue staining in cerebral hemisphere. Also cerebral blood flow (CBF) was monitored with laser doppler flowmetry. RESULTS: Percent albuminal space of right and left cerebral hemisphere was showed 9.01 +/- 3.47%, 1.65 +/- 1.25% in group 1, 8.02 +/- 2.19%, 1.61 +/- 1.06% in group 2 and 5.63 +/- 1.79%, 1.10 +/- 0.94% in group 3 respectively. Evans blue dye staining was showed 2+~3+ in the right and 0 in the left cerebral hemisphere in all groups. Right cerebral hemisphere showed significantly more blood brain barrier disruption than left cerebral hemisphere in all groups (p<0.01). And there was no significant difference in BBBD among three groups. However, the degree of BBBD of group 3 was drop down to nearly 70-80% of group 1 and 2. The CBF of group 3 was significantly higher than that of group 1 and group 2 after intracarotid infusion of mannitol (p<0.05). CONCLUSIONS: The results suggest that pentobarbital, propofol and ketamine could be used to be anesthetics for BBBD in rats, but some caution should be paid to use ketamine in mannitol induced BBBD.

A Comparison of Hemodynamic Indices Derived by Invasive Monitoring and Transesophageal Echocardiography in Patients with Aortic Stenosis / 대한마취과학회지

BACKGROUND: Intraoperative fluid management should be aimed at maintaining appropriate left-sided filling pressures. The pulmonary capillary wedge pressure (PCWP) will overestimate the left ventricular end-diastolic volume (LVEDV) when ventricular compliance is markedly reduced in patients with aortic stenosis. Intraoperative transesophageal echocardiography (TEE) is useful for monitoring global left ventricular function and change of preload. This study was undertaken to evaluate preload derived by conventional invasive monitoring technique compare with preload obtained simultaneously from TEE in patients with aortic stenosis. METHODS: Fifteen patients with aortic stenosis who underwent aortic valve replacement were examined. The preload was examined by the short axis view of left ventricle with TEE at the level of the papillary muscles. For each patient, simultaneous measurements of PCWP, thermodilution cardiac output and left ventricular end-diastolic area (LVEDA) measured by TEE were made after the induction of anesthesia and after surgery. RESULTS: The correlation between echo-derived LVEDA and thermodilution cardiac index (CI) (r=0.53, p<0.05) or stroke index (SI) (r=0.56, p<0.05) was good after surgery, but the correlation was not found after induction of anesthesia. No correlation was observed between PCWP and CI or SI. CONCLUSIONS: The PCWP did not provide a reliable estimate of preload and did not allow good prediction of cardiac index. These findings demonstrate that, in patients with aortic stenosis who underwent aortic valve replacement, TEE provides a better index of left ventricular preload than conventional invasive hemodynamic monitoring particularly after surgery.

Development of Pressure Gradient between Radial and Femoral Artery due to Aortic Cannula Malposition in Pediatric Cardiac Surgery / 대한마취과학회지

BACKGROUND: Appropriate placement of aortic and venous cannulas is important to ensure effective systemic perfusion. The malposition of the aortic cannula may promote preferential flow down the aorta or induce flow to aortic arch vessels causing pressure gradient between mean radial arterial pressure (RAP) and femoral arterial pressure (FAP). In this study we compared mean radial to femoral artery pressure gradient before and immediately after aortic cannulation and during cardiopulmonary bypass (CPB). METHODS: Ninety two pediatric patients undergoing open heart surgery were examined. After induction of anesthesia RAP and FAP were measured. The pressure gradient was measured before and after aortic cannulation, 15, 30 and 60 minutes after aortic cross clamping (ACC). When the pressure gradient of more than 10 mmHg developed, the surgeon was recommended to manipulate position of the aortic cannula. If the pressure gradient returned to pre-CPB level after manipulation, the pressure gradient was considered to develop due to aortic cannula. The age, presence of cyanosis, adjustment of shape of aortic cannula tip before cannulation and side of radial artery cannulation as factors developing pressure gradient were examined. RESULTS: Fifteen patients (16.3%) developed pressure gradient due to position of aortic cannula. Two patients (2.2%) developed immediately after aortic cannulation and fourteen patients (15.2%) during CPB. There was no statistically significant factor developing pressure gradient except non-cyanotic disease. CONCLUSIONS: The pediatric patient could develop pressure gradient due to malposition of aortic cannula frequently during CPB. Therefore, the simultaneous monitoring of RAP and FAP may be beneficial for managing CPB in pediatric cardiac surgery.

Changes of Lung Compliance in Pediatric Patients after Surgical Correction of Left to Right Shunt / 대한마취과학회지

BACKGROUND: Low values of lung compliance have been reported in patients with increased pulmonary blood flow due to intracardiac left to right(L-R) shunt. The compliance had returned to within normal limits 4 to 6 weeks after surgical correction of the shunt. We investigated whether lung compliance was improved immediately after surgical correction of the shunt. METHODS: Fifty four pediatric patients who were undergoing repair of intracardiac L-R shunt were evaluated. Lung compliance, arterial oxygen tension(PaO2) and arterial to end-tidal carbon dioxide tension difference(Pa-ETCO2) were measured after induction of anesthesia and at the completion of surgery. Left atrial pressure(LAP) was monitored. Lung compliance and end-tidal carbon dioxide tension were measured by monitoring system built in Cato anesthetic ventilator system. RESULTS: Lung compliance was significantly lower after surgery(6.57+/-6.46 ml/mbar) than after induction of anesthesia(7.71+/-7.18 ml/mbar). After surgery, PaO2 was significantly decreased and Pa-ETCO2 significantly increased than after induction of anesthesia. The decrease in lung compliance after surgery significantly correlated with a decrease in PaO2(r=0.43) and an increase in Pa-ETCO2 (r=0.47) but not correlated with LAP. CONCLUSIONS: Although surgical correction of intracardiac L-R shunt reduces pulmonary blood flow, the lung compliance decreases in immediate postoperative period. Therefore a deterioration of postoperative lung compliance may need judicious management for pulmonary and hemodynamic instability.

Anesthetic Management of the Patient with Paraneoplastic Pemphigus: A case report / 대한마취과학회지

Paraneoplastic pemphigus is a distinct and rare autoimmune disease characterized by extensive and painful mucosal ulcerations and polymorphic desquamated skin lesions in the setting of an underlying neoplasm, typically of lymphoreticular origin. Thus difficulties in the management of anesthesia can be expected. A 66-years-old man was scheduled for removal of intraabdominal sarcoma associated with paraneoplastic pemphigus. Physical examination showed multiple erythematous bullae, crusts, plaques and target-like lesions on the whole body and desquamated erythematous skin lesions on the back and extremities. In the operating room, his right femoral artery was cannulated with a 20 G, 12.7 cm CVP catheter and left femoral and subclavian veins with 14 G, 20 cm CVP catheters, respectively. After application of 4 % lidocaine spray, his oropharynx and supraglottic area were evaluated under direct laryngoscopy and revealed multiple ulcerations on oral mucosa, but no distinct lesion on supraglottic area. Anesthesia was induced by rapid-sequence method with fentanyl, thiopental sodium and succinylcholine followed by endotracheal intubation. The endotracheal tube was held by a roll gauze around the neck and its cuff was minimally inflated to avoid overpressure against his tracheal wall. After the end of surgery, his oral cavity was suctioned with no remarkable bleeding, and tracheal wall including cuff-contacted area was evaluated under fiberoptic bronchoscopy, revealed intact wall without any bulla or ulceration. The patient was transferred to intensive care unit for proper postoperative management after extubation of endotracheal tube.

The Influence of the Second Gas Effect on the Alveolar Concentration of the Inhalational Anesthetics that have the Different Solubility / 대한마취과학회지

One hundred and three patients with strabismus who were undergoing extraocular muscle surgery were studied to compare the incidence of arrhythmia following the traction of ex- traocular muscles under halothane and sevoflurane anesthesia. Fifty four patients were anesthetized with O2-halothane(halothane group) and forty nine patients with O2-sevoflurane (sevoflurane group). The incidences of arrhythmia were 74.1% and 71.4% in halothane and sevoflurane group, respectively. There was no significant change of blood pressure in either group when arrhythmia occurred. The incidence of arrhythmias in female patients of the sevoflurane group was higher than that in male patients, while not in the halothane group. In the sevoflurane group, the incidence of arrhythmia followed by the traction of medial rectus muscle was significantly higher than that of lateral rectus muscle. In conclusion, there was no significant difference in the incidence of arrhythmia following the traction of extraocular muscles between halothane and sevoflurane anesthesia, and sinus bradycardia was the most common arrhythmia with either anesthetic.