Comparison of Hemostatic Effects between Aprotinin and Tranexamic Acid during Open Heart Surgery in Adults / 대한마취과학회지

BACKGROUND: Antifibrinolytics such as aprotinin and tranexamic acid have been administered to reduce blood loss of cardiac surgery, but opinions differ regarding the efficacy of each drug. This study was performed to compare the hemostatic effects between aprotinin and tranexamic acid on adult open heart anesthesia and to evaluate their additive effects. METHODS: We randomly allocated 73 patients undergoing coronary artery bypass grafting or double valve surgery to 4 groups. Group I was non-medicated control(n=15), group II(n=21)patients were recipients of a high dose of aprotinin, group III(n=16) patients were recipients of a conventional dose of tranexamic acid, and group IV(n=21) were recipient of both drugs. Cardiopulmonary bypass time, total operation time, hematocrit, platelet count, transfusion amount and 6 hours of postoperative chest tube drainage were measured. RESULTS: The medicated three groups significantly demonstrated less amounts of blood transfusion and blood loss over the first 6 hours at ICU compared to the nonmedicated control group. Total operation times were shorter in group II, III, and IV compared to group I. Use of both agents together was more effective in reducing the total operation time and blood loss compared to tranexamic alone. CONCLUSIONS: We conclude that the use of aprotinin and tranexamic acid result in significant positive hemostatic effects but superiority of one agent vs. the others is not proved. Use of two agents together yield a more positive effective in reducing the operation time and the blood loss compared to single agent alone but further study would be needed to fully confirm.

Induced Hypotension And Bradycardia During General Anesthesia For Coronaray Artery Bypass Graft Without Cardiopulmonary Bypass: A case report / 대한마취과학회지

Coronary artery bypass grafting(CABG) without cardiopulmonary bypass is now an accepted technique of myocardial revasculization in terms of preventive method from various complications of cardiopulmonary bypass. Despite danger of myocardial ischemia, induced hypotension with bradycardia are sometimes necessary for the convenience of operative approach to beating heart. We report a case of induced hypotension with bradycardia during general anesthesia for CABG without cardiopulmonary bypass. After induction and maintenance of balanced anesthesia with fentanyl-midazolam-isofluranepiperocuronium for the 68 kg, 55 years old male stable angina patient, we induced controlled hypotension(systolic blood pressure: 70~80 mmHg) and bradycardia(heart rate: 50~60/min.) by bolus injections of verapamil 5 mg and esmolol 30 mg followed by continuous infusion of esmolol 0.1~0.3 mg/kg/min. during 50 minutes of main graft implantations without bypass. Any significant ischemic changes on EKG were not detected during induced hypotension and bradycardia. Patient was recovered without any signs of myocardial ischemia postoperativery and discharged 8 days after operation.

Experiences of Transesophageal echocardiography in Open Heart Surgery / 대한마취과학회지

Echocardiography has been the most widely applicable noninvasive cardiovascular imaging technique. Recent advances in this technique have extended its use into the operating room by development of transesophageal approach. Many anesthesiologists use transesophageal echocardiography (TEE) because it provides a more direct and rapid method of assessing cardiac anatomy and function. Intraoperative TEE done by anesthesiologists or cardiologists makes it possible for operation team to get useful informations such as cardiac filling, valvular function, cardiac contractility, intracardiac shunt, segmental wall motion abnormality and adequacy of coronary blood flow, etc. We analyzed our clinical experiences of forty six cases of TEE (6.0%) in 767 cases of anesthesia for open heart surgery at the Sejong General Hospital during the period from September 1993 to August 1994. 767 open heart surgical cases were divided into 4 groups by disease entity ; 498 cases of group I(congenital), 190 cases of group II(valvular), 63 cases of group III(ischemic) and 16 cases of group IV(miscellaneous). TEE was done for 22 cases of male patients and 24 cases of female patients. 32 cases of TEE were done for the age group between 21 to 30 years old. The number of TEE was 26 cases of group II, 11 cases of group I, 7 cases of group III and 2 cases of group IV, respectively. The main purpose of TEE in descending order was 27 cases for assessment of cardiac contractility, 18 cases for valvular function after valvuloplasty, 7 cases for the evaluation of low cardiac output syndrome(LCOS), and 7 cases for adequacy of coronary blood flow respectively. Two cases of Biopump in group I, 2 cases of Biopump in group II, 3 cases of intraaortic baloon pump(IABP) in group II, III and IV were applied after TEE. Two cases of mitral valvular replacement(MVR) were done immediately after confirmation of valvular insufficiency by TEE. These results have demonstrated that TEE is one of the useful monitoring devices for the anesthesia in open heart surgery by assessment of variable informations about patients' cardiac status.

Air Way Instability due to Pulmonary Artery Sling combined with Diffuse Tracheal Stenosis / 대한마취과학회지

Pulmonary artery sling is a rare congenital condition in which the left pulmonary artery arises anomalously fmm the right pulmonary artery extrapericardially and encirdes the right main stem bronchus and passes between the trachea and esophaghus to reach the hilum of the left lung. Respiratory obstruction vesults from compression of the lower area of trachea and right main stem bronchus. It is rare cause of respiratory distress in the new bom and may be associated with significant morbidity and mortality. We experienced the case of pulmonary artery sling with diffuse trachea stenosis and congenital heart disease (pulmonary atresia and PDA) and confirmed the anomaly by bronchogram and MRI. The presumed cause of death was respiratory obsruction due to pulmonary artery sling.

A case of esophageal perforation during endotracheal intubation in ankylosing cervical rheumatoid patient / 대한마취과학회지

Adverse respiratory events during endotracheal intubation for general anesthesia are variable. These events frequently occur to difficult airway patients. Traumatic endotracheal intubation with poor glottic exposure and blind thrust can perforate the hypopharynx or cervical esophagus. We experienced a case of esophageal perforation during endotracheal intubation for general anesthesia of total hip replacement in a 50 year old female patient. Neck extension was almost impossible due to longstanding ankylosing rheumatoid cervical arthritis. We tried several times of endotracheal intubation but failed. Post-operative esophago-graphy after we found subcutaneous emphysema confirmed esophageal perforation. Emergency tube drainage and general supportive care were done. Fortunately she recovered uneventfully and discharged on post-op. 30th days.

A Study on the Elimination of Halothane after Cessation of Halothane Anesthesia / 대한마취과학회지

Complete consciousness may return Tery slowly following general anesthesia. Although most patiients appear to approach their preanesthetic state within minutes to tours, but there appears to be some changes in cognitive functions for the next 2 to 4 days after halothane anesthesia. For the evaluation of recovery time from halothane anesthesia, we studied 10 pediatric patients who received N2O-O2-halothane anesthesia, During the recovery after cessation of halothane inhalation, we administered N2O (2 l/min) and O2 (1 l/min) with Dameca anesth-esia machine. All the patients ware ventilated with Dameca ventilator. The minute ventil-ation was 145 ml/kg/min. Throughout the experiments, we measured inspired( l) and end-tidal (ET) O2, CO2, N2O, N2, and halothane concentrations with mass spectrometry. Control data were obtained just after cessation of halothane inhalation, and all the data after then were compared with control data and expressed as % response of control. The concentrations of O2, CO2, N2, and N2O were net changed significantly during the experiment. The inspired halothane concentration (C1 HAL) in control was 1.14+/-0.08 vol% and it sho- wed significant progreasive decrease by each minute, The most abrupt decrease in C1 HAL was noticed in 3 min and 6 min: 68.8% and 73.0% in 3 min and 6 min respectively. The endtidal halothane concentrations (CET HAL) were 1.06 vol%, 0.52 vo1%, 0.39 vol% and 0.32 vol% in control, 3 min, 6min and 9 min respectively. The end-tidal halothane concentrations were also significantly decreased progressively. CET HAL/C1 HAL ratio was 0.91+/-0.02 in centrol, but it wag alwayg more than 1.0 after cessation of halothane, which indicates continuous elimination of halothane from the body, The complete disappearance times of inspired and end-tidal halothane calculated from the linear regreasion equations were 60.26 min and 63.10 min, respectively.