Airway Obstruction due to Huge Dried Mucous Plug Discovered during Induction of Anesthesia : A case report

Endotracheal obstruction may cause serious complications, including cardiovascular instability, pneumothorax, pulmonary edema and even brain death. A 21-year-old man was scheduled to undergo an open reduction for an orbital fracture. The patient had tracheostomy with an 8.0 mm tracheostomy tube 3 weeks ago and was breathing well spontaneously. When the cuff of tracheostomy tube was inflated for assisted manual ventilation and the induction of anesthesia, signs of partial endotracheal obstruction were observed, including high airway pressure, low tidal volume and high ETCO2. Large dried mucous plug was impacted in the tracheostomy tube. After removing this plug with a sterile surgical forcep, effective ventilation was recovered without complications. The case like this nearly fatal obstruction by large dried mucous plug was rarely reported, but it should be considered cautiously when a patient uses tracheostomy tube as an airway before general anesthesia.

Nasogastric Tube Insertion using Savary-Gilliard Wire Guide(R) in a Comatose Patient : A Case Report / 대한구급학회지

The insertion of nasogastric tubes in comatose, obtunded or anesthetized patients is often difficult, frustrating and time-consuming. A large variety of methods inserting nasogastric tubes in those uncooperative patients have been reported. As a new effective method, we used Savary-Gilliard Wire Guide(R), which is designed for introducing Savary-Gilliard Dilator(R) into a strictured esophagus, for inserting a nasogastric tube in a comatose patient who was intubated with a ballooned tracheostomy tube. The insertion was successful in the first attempt and no complication occurred.

Neural Stem Cell Harvest and Culture using the High Speed Centrifugation from Rat Brain / 대한마취과학회지

BACKGROUND: During recent two decades of crucial revision of some cornerstone concepts has opened new horizons in neurosciences. Modern basic viewpoints include the idea of high CNS plasticity which means not only rearrangement of neurons and their interconnections, but also the formation of new neural cells in humans and animals during their whole life span. The purpose of this study is to harvest neural stem cell from the adult rat brain using the high speed centrifugation method and study the characteristics of these cell. METHODS: 60 rats (Fisher 344, 150-160 g) brain were saved under inhalation anesthesia and dissect the subventricular zone under the microscope. The brain tissue was digested with enzyme to make a cell suspension. The cell suspension was processed high speed centrifugation to separate the neural stem/progenitor cells according to the buoyancy. After 2 weeks culture, immuno-staining (O4, GFAP, Nestin, beta-tubulin III and DAPI) were performed and replated the cultured cells. RESULTS: The 2 weeks culture cells were positive 92.8% in Nestin, 91.5% in O4 and 87.6% in Gal-C. But only positive 1.4% in beta-tubulin III and 5.5% in GFAP. And replated cell culture shows similar results compared to the primary culture. CONCLUSIONS: With this high speed centrifugation method, authors can harvest neural stem/progenitor cells from the adult rat brain. Although we have many limitations using these cell in clinical trial, but we can afford to next step on neural stem cell research.

Bispectral Index Changes during Anesthesia Induction with Ketamine in Children / 대한마취과학회지

BACKGROUND: The bispectral index (BIS) is a processed EEG information that has been validated as a means to measure the hypnotic effect of anesthetic drugs. The aim of this study was to evaluate the BIS changes during anesthesia induction with ketamine in children. METHODS: Eighty-four ASA class I and II pediatric patients, aged 3-8 years, were enrolled in this study. In each patient the BIS value was recorded before anesthesia induction. Without premedication, eighty-four patients received ketamine bolus, 1.0 mg/kg (Group 1, n = 28) or 1.5 mg/kg (Group 2, n = 28) or 2.0 mg/kg (Group 3, n = 28). When unresponsiveness to verbal commands (UVC) and loss of eyelash reflex (LER) were ascertained, intubation was performed after administration of succinylcholine 1.5 mg/kg and anesthesia was maintained with 2.0% enflurane and 50% N2O-50% O2. RESULTS: Ketamine bolus induced UVC and LER at which the BIS values were, 92.5+/-5.6 and 93.9+/-3.0 for Group 1, 92.5+/-6.3 and 92.6+/-4.4 for Group 2, and 93.0+/-4.3 and 91.0+/-4.1 for Group 3. BIS from UVC and LER to three minutes after ketamine bolus remained above 90 for Group 1 and 2, whereas lower than Group 1 for Group 3 (P<0.05). However, the BIS for Group 3 showed above 85 as patient entered into clinical anesthetic state. CONCLUSIONS: Our study showed that there is a lack of correlation between the BIS and the anesthetic state induced by ketamine in children aged 3-8 years. Monitoring the depth of ketamine anesthesia remains difficulty.

The Effect of Blood Transfusion on the Tissue Perfusion and Lung Injury during Cardiopulmonary Bypass / 대한구급학회지

BACKGROUND: The blood components of priming solution for cardiopulmonary bypass (CPB) may have opposite roles for tissue perfusion, which are the activation of inflammatory reaction and the improvement of oxygen carrying capacity. This study is aimed to investigate the effect of blood transfusion of priming solution on inflammatory response and tissue perfusion. METHODS: Twenty mongrel dogs randomly allocated and received hypothermic CPB with blood- containing (H group, n=10), or non-hemic (NH group, n=10) priming solution. Gastric intramucosal CO2 concentration (PrCO2), intramucosal pH (pHi), interleukin-8 (IL-8), blood gas and hemodynamic parameters were measured at 1) before CPB, 2) 1 hour during CPB, 3) the end of CPB, 4) 2 hours after CPB, 5) 4 hours after CPB. The ratio of wet to dried lung weight was measured. Statistical verification was performed using repeated measures ANOVA and unpaired t-test. RESULTS: PrCO2 increased and pHi decreased during the study without significant difference between the groups. IL-8 increased in both groups and IL-8 of H group increased higher than that of NH group during the study. The difference between PaCO2 and end-tidal CO2 of NH group was higher than that of H group at 4 hours after CPB. The ratio of wet to dried lung weight was not significantly different between the groups. CONCLUSIONS: We conclude that the allogenic blood in priming solution aggravates the CPB- induced inflammatory reaction, however, the CPB-induced impairment of gastric mucosal perfusion and the pulmonary edema are not significantly affected, compared to non-hemic solution.

Changes in Osteopontin Expression in the Rat Lumbar Spinal Cord Following the Avulsion of Lumbar Nerve Roots / 대한해부학회지

This study investigated the expression of osteopontin (OPN) in rat lumbar spinal cords after lumbar nerve root avulsion, using in situ hybridization histochemistry, immunocytochemistry and western blot analysis. Cells expressing OPN were motoneurons and interneurons in the ventral horn, but no signals were observed in neurons in the dorsal horn of the normal lumbar spinal cord. From day 1 after avulsion injury, OPN mRNA-labeled neurons increased in the ventral horn and the intermediate zone. By day 3, relatively strong OPN mRNA signals were found throughout the gray matter of the injured side of the spinal cord with OPN mRNA-labeled cells scattered in the superficial dorsal horn. By day 7, the labeling patterns for OPN mRNA were similar to those on day 3, but the numbers of OPN mRNA-labeled cells in the ventral horn and the intermediate zone peaked. At this point, these labeled cells were also more densely packed and the intensity of signals was stronger. Interestingly, these labeled cells were neurons, but not glial cells such as astrocytes or microglia. This OPN mRNA-labeled cell profile in the dorsal horn had nearly disappeared by day 14 after avulsion injury, and the labeling pattern became similar to that on day 1. By day 28, after avulsion injury, the numbers of OPN mRNA-labeled cells decreased further below control values. These results suggest that increased expression of OPN in the rat lumbar spinal cord after avulsion injury might play an important role in the pathogenesis of damaged neurons.

A Case of Paturient Bone Marrow Harvest Under General Anesthesia / 대한마취과학회지

Bone marrow transplantation is a curative therapeutic modality for the treatment of malignancy, marrow failure and of selected genetic diseases. Bone marrow is gained mainly by bone marrow harvesting under general or regional anesthesia. In anesthesia for paturients, teratogenic drugs, intrauterine fetal acidosis, hypoxia and premature labor must to be actively avoided. We report a case of bone marrow harvest under general anesthesia in a paturient, which was successfully managed without complication between fetus and mother.

The Comparative Effects of Dopamine and Dobutamine on Hemodynamics and Gastrointestinal Perfusion in Resuscitation of Hemorrhagic Shock / 대한마취과학회지

BACKGROUND: Preservation of intestinal perfusion is considered the goal of resuscitation because derangement of gut perfusion is the major factor in multi-organ dysfunction. Gut intramucosal pH measured by tonocap, has been proven to be the sensitive monitor of gut mucosal perfusion. The effects of vasoactive agents on regional blood flow and cellular metabolism remain unclear. This study was done to examine the effects of dopamine or dobutamine on systemic hemodynamics and splanchnic perfusion assessed by gastric intramucosal pH (pHi) during resuscitation of hemorrhagic shock. METHODS: Thirty anesthetized dogs were bled to 30 40 mmHg of mean arterial pressure (MAP) and maintained at the shock state for 90 minutes. Cardiac output and arterial and mixed venous blood gas data was measured for the global assessment of circulation and oxygenation. Gastric intramucosal pH (pHi) and CO2 tension (PrCO2) and the difference of arterial and gastric intramucosal CO2 tension (CO2 gap) were measured for the assessment of splanchnic perfusion. Dogs were resuscitated with shed blood and a crystalloid solution at the maintenance dose (control group, n = 10). Dopamine (4microgram/kg/min, dopamine group, n = 10) or dobutamine (7microgram/kg/min, dobutamine group, n = 10 ) was added from the start of volume replacement and maintained for a follow-up period of 180 minutes. RESULTS: Cardiac index and global oxygen delivery and consumption were increased after resuscitation in all groups. These parameters were significantly higher in the dopamine or the dobutamine groups than in the control group (P< 0.05), and significantly higher in the dopamine group than in the dobutamine group (P< 0.05). The pHi, PrCO2 and CO2 gap were not improved from the values of shock state after volume resuscitation in the control group. The pHi, PrCO2 and CO2 gap were significantly improved from the values of shock state after resuscitation in the dopamine group (P< 0.05), but not differentfrom the control group. The pHi, PrCO2 and the CO2 gap were significantly improved from the value of shock state after resuscitation in the dobutamine group and maintained significantly higher than in the control group for the follow-up period (P< 0.05). Compared to the dopamine group, the pHi increased early and was higher in the dobutamine group (P< 0.05). CONCLUSIONS: We conclude that dobutamine is effective in improving gut mucosal oxygenation during early resuscitation of hemorrhagic shock. Dopamine has little effect on the restoration of gut mucosal oxygenation. Considering the better recovery of cardiac index and global oxygenation parameters in the dopamine group, this finding could be explained by the redistribution of cardiac output or imbalance of oxygen metabolism occuring in the dopamine group.

The Value of Systemic Ketamine for Preemptive Analgesia in a Rat Model for ostoperative Pain / 대한마취과학회지

BACKGROUND: Pretreatment of systemic ketamine reduced pain behaviors in some animal models with persistent pain. However, a clinically relevant preemptive analgeisic effect of systemic ketamine is controversial. The purpose of this study was to examine the preemptive effect of systemic ketamine in rats undergoing a plantar incision. METHODS: Ketamine (10, 30, or 100 mg/kg) or a saline vehicle was administered subcutaneously 30 minutes before an incision was made. Withdrawal thresholds to calibrated von Frey filaments adjacent to the wound were measured before incision and from 2 hours to postoperative 6 days after incision. To evaluate the effectiveness of an extension of antinociceptive treatment into the initial postoperative period, 30 mg/kg ketamine or a saline vehicle 30 minutes before an incision was made was administered subcutaneously followed by injection of 5 more of the same drug or vehicle every 1 hour. The development of pain behavior was also evaluated before incision and from 30 minutes after last drug injection to postoperative 6 days. RESULTS: In saline vehicle-treated rats, mechanical hyperalgesia was persistent through day 1 after surgery and then gradually returned to the preincisional value. Thirty mg/kg ketamine increased the withdrawal threshold at 2 hours. One hundred mg/kg ketamine caused a motor block at 2 hours and increased the withdrawal threshold at 2.5 and 3 hours. A repeated injection of 30 mg/kg ketamine caused a motor block during the first 2 hours, and reduced hyperalgesia at 3 and 4 hours after the last drug injection. However, there were no significant differences in withdrawal thresholds among the groups at all subsequent times. CONCLUSIONS: Antinociceptive treatment of systemic ketamine covers the period of surgery and the initial postoperative period by reducing early pain behavior, but had no impact on subsequent measures of hyperalgesia. Therefore, a preemptive effect of systemic ketamine in postoperative pain seems unlikely.

Anesthesia for Cesarean Section in a Parturient with Peripartum Cardiomyopathy / 대한마취과학회지

Peripartum cardiomyopathy (PPCM) is defined as the onset of acute heart failure without demonstrable cause during the last trimester of pregnancy or within the first 6 months after delivery, which may have devastating consequences upon maternal and fetal outcome. PPCM is often unrecognized as symptoms of normal pregnancy commonly mimic those of mild heart failure but can rapidly progress to cardiac failure. We experienced a shock patient who had cardiac arrest during surgery for emergency cesarean section and the diagnosis of PPCM was made postoperatively. Her postoperative course was complicated by an embolic stroke four months after delivery. We suggest that close peripartum monitoring is essential in the management of PPCM. Thromboembolic complication as a major risk should be considered.

L2-3 versus T12-L1 Administration of Meperidine and Bupivacaine Using Patient-Controlled Epidural Analgesia after Obstetric and Gynecologic Surgery / 대한마취과학회지

BACKGROUND: A combined administration of epidural opioid and local anesthetic using patient- controlled epidural analgesia (PCEA) produces effective postoperative analgesia, but often causes profound motor and sensory blockade. The purpose of this study is to investigate the effect the location of the catheter insertion site has on total dose requirements and troublesome side effects including motor and sensory blockade after surgery. METHODS: 140 patients who had undergone obstetric and gynecologic surgery were randomly assigned to receive either L2-3 (Group L2-3) or T12-L1 (Group T12-L1) epidural catheter. All patients received meperidine and bupivacaine by PCEA. Patients were assessed with respect to total dose requirements, visual analogue scores and side effects. RESULTS: Total dose requirements, motor and sensory blocks were significantly lower in group T12-L1 compared with group L2-3. There were no significant differences in VAS, pruritus, nausea/vomiting, or patient's satisfaction. CONCLUSIONS: When the epidural placement level is closer to the dermatomes of the surgical incision in lower abdominal surgery, the total dose requirements can be reduced, and motor blocks that interfere with early ambulation and sensory block can also be reduced.

Anesthetic Management during Laparoscopic Splenectomy in a Third Trimester Pregnant Patient with Idiopathic Thrombocytopenic Purpura / 대한마취과학회지

Anesthetic management during a laparoscopic splenectomy in a third trimester pregnant patient with idiopathic thrombocytopenic purpura (ITP) is critical because of the possibility of massive intra- and postoperative bleeding either maternal, fetal, or both. Laparoscopic surgery may be beneficial in pregnant patients compared to open laparotomy, but the safety of laparoscopic operations in pregnant women is under investigation. Pregnancy, especially in the third trimester, has been considered a contraindication of a laparoscopic procedure because the effect of CO2 pneumoperitoneum on the fetus and uterine blood flow is unclear. However, the benefits of laparoscopic surgery such as less stress response and a shorter hospital stay are postulated. The careful anesthetic management and close hemodynamic monitoring of patient and fetus will be helpful in making laparoscopic surgery safer in pregnant patients. We report on the anesthetic management during a laparoscopic splenectomy in a third trimester pregnant patient with ITP. We monitored the intestinal mucosal CO2 using Tonocap because we considered it could sensitively represent the uterine perfusion and intestinal CO2 status, and we also monitored the noninvasive cardiac output by using NICO . Although the arterial and intestinal mucosal CO2 tension, PrCO2 and CO2 gap increased gradually during the operation, hypercapnia was not remarkable. Tonocap represented the earliest changes which made us control intraabdominal gas inflation pressure by detecting fluctuations of CO2 gap and pHi even though other respiratory and monitored hemodynamic parameterswere quite stable during the procedure in this case. The patient was maintained well postoperatively and discharged with an improved condition. She had preterm labor at 36 weeks and 4 days of eventful gestation, but safely delivered a healthy baby by a normal spontaneous method.

Anesthetic Experience of the Patient with Nemaline Myopathy: A case report / 대한마취과학회지

Nemaline rod myopathy is an autosomal dominant disease characterized by nonprogressive symmetric skeletal muscle weakness affecting principally proximal skeletal muscles. Anesthesia of the patient with this disease is known to present some problems:difficult intubation due to facial dysmorphism, delayed onset of succinilcholine, reduced vital capacity on pulmonary function test and skeletal deformity. We anesthetized 19 year old male patient with nemaline myopathy for the operation of cryptochidism. Because of the possibility of difficult intubation, we produced epidural anesthesia with 20 G Tuohy needle at L5-S1 intervertebral space successfully. There were no problems in the course of operation and recovery except transient airway obstruction due to sedative.

The Effect of Acute Hypervolemic Hemodilution on Blood Loss and Mononuclear Cell Counts during Bone Marrow Harvesting / 대한마취과학회지

BACKGROUND: Hypervolemic hemodilution (HHD) seems to be a good alternative to acute normovolemic hemodilution to reduce transfusion requirements because it requires less time and effort. In a prospective study in healthy donors, we studied the effects of HHD on blood loss and mononuclear cell counts of aspirated bone marrow which were transplanted. METHODS: After induction of anesthesia and positioning to prone, donors of the HHD group (n = 25) were administered 7.5 ml/kg of pentastarch and the same amount of Hartmann's solution prior to aspiration, but those of the control group (n = 25) were administered only 2 ml/kg/h of Hartmann's solution. Bone marrow was aspirated at the iliac spine and blood loss was replaced with pentastarch and Hartmann's solution for both groups. Hemoglobins and hematocrits were counted after induction, after hemodilution and the end of aspiration. Hemoglobins and mononuclear cell counts of aspirated bone marrow were also counted. RESULTS: HHD decreased hemoglobin from 13.2 +/- 1.1 g/dl to 10.7 +/- 1.0 g/dl significantly (P < 0.01). Even though hemoglobins of both groups at the end of aspiration were not different (9.3 +/- 2.3 g/dl at control vs 9.5 +/- 1.1 g/dl at HHD), calculated blood loss based on body weight through aspirated bone marrow was less in the HHD group (18.0 +/- 1.8% at control vs 16.3 2.0% at HHD, P < 0.05). There was no difference in counted mononuclear cell counts between the two groups (1.8 +/- 0.7 x 10(7)/ml at control vs 1.8 +/- 0.7 x 10(7)/ml at HHD). CONCLUSIONS: During bone marrow harvesting in healthy donors, HHD reduced blood loss through aspirated bone marrow, but does not affect transplanted bone marrow mononuclear cell counts.

An Experience of Right Pneumonectomy in a Lung Cancer Patient with Poor Pulmonary Function Test within the Conventional Criteria of Contraindication to Surgery: Intraoperative Re-evaluation of Pulmonary Function: A case report / 대한구급학회지

Usually FEV1 lower than 1 liter is considered as a contraindication to pneumonectomy. Therefore sometimes, the curative operations of the resectable lung cancer can not be performed in case of poor pulmonary functions. The usual criteria on the performance of pneumonectomy on high risk patients based on the preoperative assessment of pulmonary function may not predict the operative outcome with accuracy in the postoperative period. Nowadays, there are some arguing points about applying the values of preoperative PFTs to pulmonary resection surgery. We performed a right pneumonectomy for stage IIIb lung cancer in a patient with poor lung function test; FVC 2.17 L, FEV1 0.97 L, FEV1/FVC 44%, FEF 25~75% 0.42 L/sec, MVV 28 L/min, TLC 5.18 L, RV 2.99, DLCO 13.46. After the temporary ligation of right main pulmonary artery during 30 minutes, arterial blood gas and percutaneous oxygen saturation with the controlled ventilation with room air (FiO2=0.21) confirmed the hemodynamic and oxygenation stabilities, twice. After successful surgery, the patient was tolerated for 4 months. And the follow up PFTs at postoperative 3 months and 18 days showed as follows; FVC 1.20 L, FEV1 0.63 L, FEV1/FVC 53%, FEF 25~75% 0.31 L/sec, MVV 25 L/min, TLC 3.80 L, RV 2.33 L, DLCO 8.04. Through the intraoperative re-evaluation of pulmonary function in a patient with poor preoperative PFTs,had been conventionally considered as a contraindication to pneumonectomy, we report a successful surgery and anesthetic management with the literatures reviewed.

Effect of Cervical Sympathectomy on Ischemic Brain Damage Induced by Focal Cerebral Infarction in Rats / 대한마취과학회지

BACKGROUND: Recently Umeyama et al. reported that cerebral blood flow is definitely increased on the ipsilateral side after the blockade of stellate ganglion. Considering that the most obvious solution to the problem of poor cerebral blood flow is to augment the flow, cervical sympathectomy may reduce the volume and extent of the brain damage by increasing the cerebral blood flow. We studied the effects of cervical sympathectomy on ischemic brain damage in a middle cerebral artery occlusion model in rats. METHOD: The experimental animals were divided into three groups. In the sham-operated control group (n=7), middle cerebral artery was occluded without cervical sympathectomy. In the experimental group I (n=7), cervical sympathectomy was performed 5 minutes before middle cerebral artery occlusion. In the experimental group II (n=7), cervical sympathectomy was performed 5 minutes after middle cerebral artery occlusion. The neurological grade of each experimental animal was evaluated at 24 hours post occlusion and then the animals were sacrificed. The brain was cut into coronal sections. The volume of infarct was computed and the edema volume was calculated. RESULTS: 1. There were no differences in the physiological variables in all groups. 2. Cervical sympathectomy, compared with the controls, significantly reduced the volume of infarct (P<0.05). 3. There was no significant difference in ischemic brain edema between each group. 4. The neurologic deficit was less severe in sympathectomized groups compared with the control group (P<0.05). And neurological grades were significantly correlated with the volume of infarction (P<0.05). CONCLUSION: These results suggest that cervical sympathectomy may improve the neurologocal deficit and reduce the infarct volume measured 24 hours following induction of focal cerebral infarction.

The Effect of Hypothermic Cardiopulmonary Bypass on Gastric Mucosal pH / 대한마취과학회지

BACKGROUND: It has been postulated that the derangement of gut perfusion is a factor of the development of multi-organ dysfunction and increasing postoperative morbidity. Gastric mucosal pH (pHim) correlates with splanchnic perfusion and the persistent gastric mucosal acidosis has been supposed to be a predictor of complications after cardiac surgery. The purpose of this study is to measure the change of pHim induced by hypothermic cardiopulmonary bypass (CPB). METHODS: Twelve patients undergoing cardiac surgery were anesthetized with fentanyl and isoflurane. Gastric mucosal PCO2 (PrCO2) and pHim were measured by Tonocap. Temperature was maintained about 28oC during CPB and arterial blood gas tension was managed by alpha-stat mode. Measurement was made at: (1) baseline, after induction of anesthesia, (2) 30 minutes after starting CPB, (3) 60 minutes after starting CPB, (4) at the end of CPB, (5) at the end of operation and (6) at 24 hours after CPB. Statistical analysis was performed using one-way ANOVA and Student t test. RESULTS: The PrCO2 and the CO2 gap (PrCO2 - PaCO2) increased at the end of CPB and maintained the increased state for 24 hours after CPB. The pHim decreased during CPB and maintained the decreased state for 24 hours after CPB. The difference between pHim and pHa increased significantly after CPB. CONCLUSION: We conclude that the hypothermic CPB induces gastric mucosal acidosis and it did not recover for 24 hours after CPB.

Anesthetic Management during Laparoscopic Cystectomy in a Third Trimester Pregnancy: A case report / 대한마취과학회지

Pregnancy, especially in the third trimester, has been considered a contraindication of laparoscopic procedure because the effect of CO2 pneumoperitoneum on the fetus and uterine blood flow was unclear. However, the benefits of laparoscopic surgery such as less stress response and shorter hospital stay are postulated. Laparoscopic surgery may be beneficial in pregnant patients compared to open laparotomy, and the safety of laparoscopic operations in pregnant women is under investigation. The careful anesthetic management and close monitoring of patient and fetus will be helpful in making laparoscopic surgery safer in pregnant patients. We report the anesthetic management for laparoscopic surgery in a third trimester pregnant patient with torsion of an ovarian cyst. We monitored the intestinal mucosal CO2 using Tonocap, because we considered it could represent the uterine perfusion and intestinal CO2 status. Although the arterial and intestinal mucosal CO2 tension increased gradually during the operation, hypercapnia was not remarkable. The respiratory and monitored parameters were stable during the laparoscopic procedure. The patient has maintained uneventful pregnancy and delivered a healthy baby at 41 weeks of gestation.

The Effect of Clonidine Pretreatment on Bupivacaine-induced Cardiac Toxicity in Rabbit / 대한구급학회지

BACKGOUND: Bupivacaine, an amide type local anesthetic, is frequently used for regional anesthesia. Bupivacaine overdose induces cardiac toxicity and directly depresses both cardiac electrophysiology and hemodynamic status. Clonidine, an imidazolin alpha-2-adrenoreceptor agonist, given prophylactically may delay the toxic manifestation of bupivacaine overdose and does not accentuate the subsequent hypotension. We studied the effect of clonidine pretreatment on bupivacaine induced cardiac toxicity. METHODS: Fourteen rabbits (seven in each group) were anesthetized with ketamine and rompun, and tracheostomy was performed. Spontaneous ventilation with room air was continued throughout the experiment. Electrocardiogram, heart rate, and invasive arterial blood pressure were continuously recorded. Clonidine 5 microgram/kg (clonidine group) or saline (control group) was injected intravenously in randomized fashion. After 15 minutes, an intravenous infusion of bupivacaine was started at 0.3 mg/kg/min. The time of occurrence of the bupivacaine-induced toxic events: first dysrhythmia, 25% and 50% reduction in basal heart rate and mean arterial pressure, and asystole were recorded. At 5, 10, 15, and 20 minutes after bupivacaine infusion, 2 ml of whole blood were withdrawn via femoral arterial catheter for determination of bupivacaine concentration. RESULTS: The threshold time at the first dysrhythmia was significantly greater in the clonidine group (27.2+/-4.5 min) than control group (19.9+/-1.2 min). The threshold times at the 25 and 50% reduction in basal heart rate were significantly greater in the clonidine group (23.7+/-5.8 min, 33.2+/-5.1 min) than control group (16.6+/-2.9 min, 22.9+/-2.8 min) and in basal mean arterial pressure were significantly greater in the clonidine group (15.6+/-2.6 min, 25.3+/-3.7 min) than control group (9.7+/-2.7 min, 16.3+/-5.8 min). The threshold time at the asystole was significantly greater in the clonidine group (38.2+/-7.7 min) than control group (28.7+/-3.4 min). At 5, 10, 15, and 20 minutes after bupivacaine infusion, there was no significant difference in the plasma bupivacaine concentration between two groups. CONCLUSION: This study demonstrates that clonidine pretreatment delays the cardiac toxic manifestations of bupivacaine overdose. And plasma bupivacaine concentration was not influenced by clonidine pretreatment.

Tracheal Agenesis: A case report / 대한마취과학회지

Agenesis of trachea is a rare congenital anomaly. The main signs are respiratory distress, cyanosis, inability to vocalise and impossible tracheal intubation. There is no long-term surgical solution at present, therefore the condition is ultimately fatal. We report a case of tracheal agenesis. We anesthetized a 2.25 kg neonate for endoscopic examination, who was intubated successfully. Beyond 2.5 cm from the vocal cord, there was no trachea and we can only see esophageal lumen with fistula opening. After the endoscopic examination, exploratory thoracotomy was done, but surgical correction was impossible. After the surgery, she died from progressive ventilatory failure. Autopsy revealed a Floyd's type II tracheal agenesis with tracheo-esophageal fistula.