Ventricular arrhythmia in patients with prolonged QT interval during liver transplantation: two cases report / 대한마취과학회지

QT interval prolongation is associated with an increased risk of ventricular arrhythmia in various conditions. Cardiac electrophysiologic abnormalities including QT interval prolongation are well documented in patients with advanced liver cirrhosis. We report two cases of patients with QT interval prolongation on preoperative electrocardiography who exhibited repetitive ventricular arrhythmias with significant hemodynamic deterioration during liver transplantation. For the treatment and prevention of ventricular arrhythmias during the intraoperative period, we performed intravenous administration of lidocaine and isoproterenol, corrected imbalances of electrolytes including potassium and magnesium, and prepared a defibrillator. These cases emphasize that preoperative recognition of QT interval prolongation and adequate management to prevent fatal arrhythmias are important in patients undergoing liver transplantation.

Cannulation of the dorsal radial artery: an underused, yet useful, technique / 대한마취과학회지

No abstract available.

Low-dose remifentanil to modify hemodynamic responses to tracheal intubation: comparison in normotensive and untreated/treated hypertensive Korean patients / 대한마취과학회지

BACKGROUND: Remifentanil has been shown to be effective at treating potentially adverse hemodynamic responses to tracheal intubation even at low doses (< 1 microg/kg/min), which needs to be evaluated in patients with diverse cardiovascular conditions. METHODS: A low-dose regimen of remifentanil (continuous infusion of 0.1 microg/kg/min, preceded by 0.5 microg/kg bolus) was given before induction with bolus propofol and rocuronium, and heart rate as well as systolic, diastolic, and mean arterial pressures were measured at 1 min intervals from before induction to 5 min after tracheal intubation in normotensive patients, untreated hypertensive patients, and patients with known hypertension. RESULTS: The low-dose regimen of remifentanil resulted in parallel hemodynamic responses in all three groups, and was effective at limiting hemodynamic responses to tracheal intubation without excessive cardiovascular depression. Hemodynamic responses in our study showed a similar pattern to that reported in previous investigations, except for elevations in heart rate and arterial pressures over the baseline values immediately after intubation. CONCLUSIONS: We suggest that the low-dose regimen of remifentanil in our study could be routinely used to modify hemodynamic responses to tracheal intubation in patients with diverse hemodynamic characteristics. However, the development of supplementary regimens is still needed to control the brief, but exaggerated responses to tracheal intubation, especially in untreated hypertensive patients.

Assessment of cerebral oxygen supply-demand balance by near-infrared spectroscopy during induction of anesthesia in patients undergoing coronary artery bypass graft surgery: comparison of midazolam with propofol / 대한마취과학회지

BACKGROUND: Near-infrared spectroscopy (NIRS) continuously measures regional cerebral oxygen saturation (rSO2) noninvasively and has been shown to detect even small changes in cerebral oxygen supply-demand balance. Although widely used, only the effect of midazolam on cerebral blood flow has been studied in humans and evidence is lacking about its effect on cerebral metabolic rate. We therefore evaluated the effect of midazolam on cerebral oxygen supply-demand balance with NIRS. METHODS: Sixty patients undergoing elective coronary artery bypass graft surgery were randomly allocated into either midazolam (n = 30) or propofol (n = 30) group. rSO2 was recorded before induction while patients were breathing room air as baseline, after pre-oxygenation with 100% oxygen, after administration of either midazolam or propofol, after completion of administration of sufentanil and after tracheal intubation. Hemodynamic variables including cardiac index and mixed venous oxygen saturation were recorded at the same time points. RESULTS: rSO2 and hemodynamic variables were similar between the groups throughout the study period. After pre-oxygenation, rSO2 significantly increased compared to baseline in each group, and did not show any additional increase after administration of either midazolam or propofol and sufentanil in both groups. CONCLUSIONS: Midazolam preserves cerebral blood flow-metabolism coupling to a similar degree to propofol as assessed by near infrared spectroscopy.

Comparison of Remifentanil and Fentanyl for Postoperative Pain Control after Abdominal Hysterectomy

PURPOSE: In this randomized, double-blind study, we investigated the analgesic efficacy and side effects of continuous constant-dose infusions of remifentanil after total abdominal hysterectomy and compared it to fentanyl. MATERIALS AND METHODS: Fifty-six adult female patients scheduled for elective total abdominal hysterectomy were enrolled in this study. Patients were randomly assigned to two groups according to fentanyl (group F, n=28) or remifentanil (group R, n=28) for postoperative analgesia. Patients in group F were given fentanyl intravenously with an infusion rate of fentanyl 0.5 microgram/kg/hr; group R was given remifentanil with an infusion rate of remifentanil 0.05 microgram/kg/min for 2 days. Pain intensity at rest, occurrence of postoperative nausea and vomiting (PONV), dizziness, pruritus, and respiratory depression were assessed 1 hr after arrival at the post-anesthesia care unit, at 6; 12; 24; and 48 hr post-operation and 6 hr post-infusion of the study drug. Pain was evaluated by using visual analogue scale (VAS; 0-10). The time that patients first requested analgesics was recorded as well as additional analgesics and antiemetics. RESULTS: There were no significant differences in VAS, time to first postoperative analgesics, and additional analgesics between the 2 groups. The incidences and severities of PONV and opioid related side effects were not different between the groups; however, there were 3 episodes (10.7%) of serious respiratory depression in group R. CONCLUSION: Continuous infusion technique of remifentanil did not reveal any benefits compared to fentanyl. Furthermore, it is not safe for postoperative analgesia in the general ward.

Anesthetic Management in a Patient with Severe Primary Pulmonary Hypertension with Right Ventricular Dysfunction: A case report / 대한마취과학회지

Primary pulmonary hypertension is characterized by progressive increase in pulmonary vascular resistance leading to right ventricular (RV) failure and death.The desirable goal of primary pulmonary hypertension is preserving coronary perfusion of RV while decreasing pulmonary arterial pressure with selective pulmonary vasodilators.We report a case in which anesthetic management was successfully performed in a 67 years old man, who had experienced ventricular tachycardia at the previous anesthesia induction, with severe pulmonary hypertension and right ventricular dysfunction.

A Questionnaire Survey of Domestic Anesthesiologists on the Ethics of Publishing / 대한마취과학회지

BACKGROUND: The importance of publication ethics has recently been emphasized.Therefore, inquiries regarding dual publications were analyzed to obtain basic data on whether domestic anesthetists recognized its importance and understood its practicalities. METHODS: The data for the questionnaire was collected from doctors who participated in a review workshop with full consent. A total of 15 questions were classified into 3 categories:a general interest regarding the ethics of publication, personal objective opinions and reactivity toward an illegal act in this regard. RESULTS: Thirty-eight participants responded spontaneously to the questionnaire.Thirty-six participants were aware of the principle of dual publications and 35 participants were aware of the contents in the home page.Twenty participants had contact with lectures or other media related to redundant publishing.Fourteen participants answered 'yes' regarding their colleague in an illegal action.However, 25 participants said that they were prepared to report an illegal act to the department or society.Only 5 participants tried to take into consideration ethical issues of dual publication while 15 participants were tempted regarding dual publication while writing a paper.Twenty-seven participants agreed with the principle of duplicate or illegal publication.Thirty participants were prepared to have a consistent attitude toward any individual that committed a violation against publication ethics.Nineteen participants worried about the possibility of exposure of an illegal publication. CONCLUSIONS: According to the development of a watch system, dual publication can easily be detected. Regular education regarding publication ethics and notification to members to prevent an illegal act is necessary.

Effects of Epidural Naloxone on Pruritus Induced by Epidural Sufentanil / 대한통증학회지

BACKGROUND: Postoperative pruritus following the administration of epidural narcotics is a very common and undesirable side effect. Therefore, we evaluated the use of a combination of naloxone and sufentanil via patient controlled epidural analgesia to determine if the incidence of pruritus was decreased when compared to the use of sufentanil alone. METHODS: Patients scheduled for subtotal gastrectomy under general anesthesia were enrolled in a prospective, double-blinded and randomized trial. All patients received a 20 microgram epidural bolus of sufentanil in 5 ml of 0.2% ropivacaine. Following administration of the epidural, patients in the sufentanyl group (S) received a continuous epidural comprised of sufentanil (0.75 microgram/ml) in 0.2% ropivacaine, whereas patients in the naloxone group (N) received an epidural infusion comprised of naloxone (4 microgram/ml) and sufentanil (0.75 microgram/ml) in 0.2% ropivacaine. The infusion rate, demand dose and lockout interval were 5 ml/hr, 0.5 ml and 15 minutes respectively. Next, the occurrence of postoperative analgesia and side effects were evaluated by blinded observers. RESULTS: The incidence of pruritus (47.4% versus 20.0%, P = 0.013) and nausea (42.1% versus 20.0%, P = 0.043) were lower in group N than in group S. In addition, there were no significant differences observed in the visual analogue scale, the incidence of vomiting or the incidence of sedation. Furthermore, epidural infusion of naloxone at 0.25-0.4 microgram/kg/hr did not affect the requirement for postoperative sufentanil. CONCLUSIONS: Epidural naloxone reduces epidural sufentanil induced pruritus and nausea without reversing its analgesic effects.

Airway Management for General Anesthesia in a Patient with Severe Trismus due to Temporomandibular Joint Ankylosis : A case report

An ankylosis of temporomandibular joint (TMJ) can cause severe trismus, thus it may bring on many difficulties in airway management such as orotracheal intubation or laryngeal mask airway insertion. Such difficulties may cause serious complications related to airway management because the trismus due to ankylosis of TMJ can not be improved by administration of muscle relaxants or deep anesthesia in most cases. We report a case of nasotracheal intubation guided by a fiberoptic bronchoscope in a male patient with severe trismus due to TMJ ankylosis, who was scheduled for undergoing ophthalmic surgery.

Effect of Preoperative Omitting Angiotensin-converting Enzyme Inhibitor on Hemodynamics in Patients Undergoing Off Pump Coronary Artery Bypass Surgery / 대한마취과학회지

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACE-I) have been widely used for cardiac patients. This study investigated the effect of omitting ACE-I medication on hemodynamics during induction of anaesthesia and operation in patients chronically treated with ACE-I undergoing off pump coronary artery bypass graft surgery (OPCAB). METHODS: Sixty patients scheduled for OPCAB were included in this study. Patients not treated with ACE-I were included in control group (Group 1, n = 20). And then, patients treated with ACE-I more than 4 weeks were randomly divided into two groups: continuing group including patients who continued ACE-I medication until the morning of surgery (Group 2, n = 20) and discontinuing group including patients who discontinued ACE-I one day before the surgery (Group 3, n = 20). Norepinephrine (8microgram/ml) was infused when systolic blood pressure decreased below 90 mmHg during induction and operation. Amount of norepinephrine infused and hemodynamic data were recorded. RESULTS: Significantly larger amount of norepinephrine was infused in Group 2 than in other two groups during obtuse marginal artery anastomosis. Total amount of norepinephrine infused during the all coronary anatsomosis was significantly larger in Group 2 than those values in other two groups. CONCLUSIONS: Continuing ACE-I treatment until the morning of surgery significantly increased the use of norepinephrine during the anastomosis. In contrast, there was no significant difference in the use of norepinephrine between Group 1 and Group 3. Discontinuing ACE-I before the surgery may helpful to maintain hemodynamics stable during coronary anastomosis in OPCAB.

Central Venous Pressure and Its Effect on Blood Loss during Hepatic Lobectomy / 대한마취과학회지

BACKGROUND: Some studies reported that lowering central venous pressure (LCVP) during liver resection could significantly reduce the intra-operative blood loss, however it is still controversial concerning LCVP induced renal dysfunction, hypovolemia, hemodynamic instability. This study evaluated the association of low central venous pressure with blood loss during liver resection comparing the control group. METHODS: A total 62 patients aged 20 to 70 underwent hepatectomy by the same group of surgeon were randomized into group L (CVP 10 mmHg, n = 32) during dissection and lobectomy period. Data such as age, sex, concurrent disease, liver resection site (right or left), pre-, intra- and postoperative day 3 hemoglobin, blood urea nitrogen, creatinine, bleeding time, prothrombin time, activated partitial thromboplastin time, intraoperative blood loss, urine output, transfusion volume, length of hospital stay were collected and compared between the two groups and t-test was used for comparison of results. RESULTS: The difference of total blood loss between two groups was 193.6 +/- 432.2 ml (group L; 589.1 +/- 380.8 ml, group C; 782.7 +/- 316.7 ml), however statistically insignificant (P value = 0.1243). Additionally, there were no significant differences in other data including the length of hospital stay. CONCLUSIONS: Our results suggest maintaining CVP under 10 mmHg is not effective in reducing blood loss during liver resection.

Liver Function and Inhaled Anesthetics

The liver is the major site of endogenous and exogenous drug metabolism. The primary result of drug metabolism is the production of more water-soluble and therefore more easily excreted drug metabolites. Drugs are sometimes biotransformed into more reactive metabolites, which may lead to toxicity. Volatile anesthetics, like most drugs, undergo metabolism in the body and are sometimes associated with toxic reactions. Here, author will discuss the metabolism and hepatic toxicity of inhaled anesthetics. Toxicity and liver injury have been reported after repeated exposure on subsequent occasions to different fluorinated anesthetics. This phenomenon of cross-sensitization has also been reported with the chlorofluorocarbon(CFC) replacement agents, the hydrochlorofluorocarbons(HCFCs). Halothane, enflurane, sevoflurane, isoflurane, desflurane are all metabolized to trifluoroacetic acid, which have been reported to induce liver injury in susceptible patients. The propensity to produce liver injury appears to parrel metabolism of the parent drug: halothane(20%) >>>> enflurane(2.5%) >> sevoflurane(1%) > isoflurane(0.2%) > desflurane(0.02%). The use of any anesthetic must be based on its benefits and risks, how it may produce toxicity, and in which patients it may be most safely administered. Nonhalogenated inhaled anesthetics (nitrous oxide, xenon) chemically inert and not metabolized in human tissue. The perfect anesthetic agents dose not exist. But ongoing research attempts to uncover emerging toxicities. Xenon is not currently approved for clinical use. Other than the expense associated with its use, it may be the most ideal anesthetic agent. In general, surgical manipulation or disturbance of the surgical site appears to be more important in decreasing hepatic blood flow than current anesthetic agents such as isoflurane, sevoflurane, and desflurane or technique. However, the clinician is challenged to balance new information with current clinical practices and choice the safest, most effective agents for each patient.

Anesthesia for Living Related Liver Transplantation in Argininosuccinic Acidemia: A case report / 대한마취과학회지

We describe our initial experience of the perioperative anesthetic care provided to 8 years old female child with argininosuccinic acidemia undergoing living-related liver transplantation because it is the only available therapy for end-stage liver disease. Induction and maintenance of anesthesia has been conventional method. Arterial catheterized at radial and femoral arteries for continuous blood pressure monitoring and sampling. 18 G central vein catheterization was placed in left subclavian vein for fluid, drug infusion and CVP monitoring. EKG, pulse oxymetry, end-tidal CO2, urine output and body temperature were monitored. CBC, PT, aPTT, serum electrolyte were checked at preanhepatic, anhepatic phase and just after hepatic artery anastomosis. ABGA was checked every 1 hour. The level of serum ammmonia returned to normal range without protein restriction. We describe this case and a brief review of the literature.

Pneumomediastinum Following Routine Endotracheal Intubation: A case report / 대한마취과학회지

Tracheobronchial rupture is considered to be a life-threatening condition and most commonly occurs after blunt trauma to the neck or chest. However, single- and double-lumen endotracheal tubes can cause serious airway injury. The recognition of this complication and a knowledge of the possible contributory factors is critical, because failure to do so could result in lethal events. We report the case of a 63-year-old male patient who developed pneumomediastinum three days after routine orotracheal intubation.

Comparison of Hemodynamic Data obtained from a Pulmonary Artery Catheter vs. Esophageal Doppler during Liver Transplantation / 대한마취과학회지

BACKGROUND: The measurement of cardiac output is an essential part of anesthetic practice in patients undergoing liver transplantation. A thermodilution technique, using a pulmonary artery catheter is currently accepted as the gold standard in clinical practise. However, its use is associated with several limitations. METHODS: An esophageal doppler monitor was compared with the thermodilution technique in 22 patients undergoing split graft transplantation from a living donor. Six measurement were taken during liver transplantation, 1) control, 2) dissection phase, 3) anhepatic phase, 4) reperfusion phase, 5) after hepatic artery anastomosis, and 6) end of surgery. RESULTS: Significant difference were observed between the two measurement at all times studied with a strong correlation, except at the end of surgery (r > 0.4). CONCLUSIONS: The use of esophageal doppler monitor results in cardiac output measurements which are considerably different from those obtained using thermodilution, but a strong correlation exists between two methods. Thus the use of esohageal monitoring can be recommended in patients undergoing liver transplantation for trend monitoring.

Effects of Reactive Oxygen Species on ATP-induced intracellular Ca2+ Activity in Osteoblasts / 대한마취과학회지

BACKGORUND: The physiological activity of osteoblsts is known to be closely related to increased intracellular Ca2+ activity ([Ca2+ ]i) in osteoblasts. The cellular regulation of ([Ca2+ ]i) in osteoblasts is mediated by Ca2+ movements associated with Ca2+ release from intracellular Ca2+ stores, and transmembrane Ca2+ influx via Na Ca2+ exchanger, and Ca2+ ATPase. Reactive oxygen species, such as H2O2, play an important role in the regulation of cellular functions, and act as signaling molecules or as toxins in cells. METHODS: Osteoblasts were isolated from the femurs and tibias of neonatal Sprague-Dawley rats, and cultured for 7 days. The cultured osteoblasts were loaded with a Ca2+ -sensitive fluorescent dye, Fura-2 AM ester, and fluorescence images were monitored using a cooled CCD camera. Ca-spike changes upon ATP application were checked for (1) osteoblasts in Ca2+ -free and 2.5 mM CaCl2 normal Tyrode solution, (2) osteoblasts in which the Ca2+ of the endoplastic reticulumin had been depleted with ryanodine, thapsigargin ord caffein, and (3) osteoblasts pretreated with H2O2, in which the expression of iP3 receptor was checked by Western blotting. RESULTS: ATP increased intracellular free Ca2+ regardless of extracellular Ca2+ concentration. When the intracellular Ca2+ store was depleted, the level of increased Ca2+ activity by ATP was suppressed. H2O2 sustained the Ca2+ increase induced by ATP. The expression of iP3 receptor was enhanced by H2O2. CONCLUSiONS:H2O2 modulates intracellular Ca2+ activity in osteoblasts by increasing Ca2+ release from the intracellular Ca2+ stores.

H2O2 Enhances Ca2+ Release from Osteoblast Internal Stores

The physiological activity of osteoblasts is known to be closely related to increased intracellular Ca2+ activity ([Ca2+]i) in osteoblasts. The cellular regulation of [Ca2+]i in osteoblasts is mediated by Ca2+ movements associated with Ca2+ release from intracellular Ca2+ stores, and transmembrane Ca2+ influx via Na+-Ca2+ exchanger, and Ca2+ ATPase. Reactive oxygen species, such as H2O2, play an important role in the regulation of cellular functions, and act as signaling molecules or toxins in cells. In this study, we investigated the effects of H2O2 on cellular Ca2+ regulation in osteoblasts by measuring intracellular Ca2+ activities using cellular calcium imaging techniques. Osteoblasts were isolated from the femurs and tibias of neonatal rats, and cultured for 7 days. The cultured osteoblasts were loaded with a Ca2+-sensitive fluorescent dye, Fura-2, and fluorescence images were monitored using a cooled CCD camera, and subsequently analyzed using image analyzing software. The results obtained are as follows: (1) The osteoblasts with lower basal Ca2+ activities yielded a transient Ca2+ increase, a Ca2+ spike, while osteoblasts with higher basal Ca2+ activities showed a continuous increase in [Ca2+]i leading to cell death. (2) Ca2+ spikes, generated after removing Na+ from superfusing solutions, were blocked by H2O2 and this was followed by a sustained increase in Ca2+ activity. (3) ATP- induced Ca2+ spikes were inhibited by pretreating with H2O2 and this was followed by a continuous increase of [Ca2+]i. When cells were pretreated with the exogenous nitric oxide (NO) donor S-Nitroso-N-acetylpenicilance (SNAP, 50 microM), treatments of ATP (1 mM) induced a Ca2+ spike-like increase, but [Ca2+]i did not return to the basal level. (4) The expression of inositol- 1,4,5-triphosphate receptor (IP3R) was enhanced by H2O2. Our results suggest that H2O2 modulates intracellular Ca2+ activity in osteoblasts by increasing Ca2+ release from the intracellular Ca2+ stores.

The changes in delivered oxygen fractions using laerdal resuscitator bag with different types of reservoir

One of the disadvantages of the Laerdal resuscitator bag is that it does not deliver a high concentration of oxygen without a reservoir and an appropriate technique of ventilation. With a specific device that is able to compress a resuscitator bag mechanically at a regular volume, ventilator rate, and speed, we evaluated the effects of various factors (the tidal volume, the ventilator rate, the oxygen flow rate, the type of reservoir) of the Laerdal resuscitator bag during positive pressure ventilation that affect the delivered oxygen fraction (FDO2) and also whether 250 mL and 500 mL corrugated tubes could be used as substitutes for the reservoir bag. The 250 mL corrugated tube increased the FDO2 to over 96% with an oxygen flow rate of 15 L/min. The 500 mL corrugated tube increased the FDO2 to over 96% with an oxygen flow rate of 10 L/min regardless of the ventilator rate at a fixed tidal volume of 500 mL. At the identical fixed tidal volume of 500 mL, the 1,600 mL reservoir bag increased the FDO2 to over 92% with an oxygen flow rate of 5 L/min and to over 96% at 7.5 L/min regardless of the ventilator rate. We concluded that the FDO2 of the Laerdal resuscitator bag depends on various factors such as tidal volume, ventilator rate, oxygen flow rate, and type of reservoir and both the 250 mL and 500 mL corrugated tubes can be used as substitutes.

Anesthetic Management for Nutcracker Syndrome Patient / 대한마취과학회지

Nutcracker syndrome consists in the compression of the left renal vein by an aortomesenteric clamp. This results in left renal venous hypertension leading to the development of collateral veins with intrarenal and perirenal varicosities which can cause hematuria. The main presenting symptom is hematuria with or without left flank pain. It responds successfully to surgical treatment. We report a case of anesthesia for a nutcracker syndrome patient.

Retrial of Anesthetic Management for a Patient with Malignant Hyperthermia during Previous General Anesthesia / 대한마취과학회지

Malignant hyperthermia is a subclinical myopathy, usually triggered by anesthetics and associated with a mortality rate of up to 70%, when left untreated. But with early diagnosis using capnography and with the advent of dantrolene, the mortality rate could be reduced to less than 5%, which implies the significance of early diagnosis and proper treatment. Owing to the reduced mortality rate, anesthesiologists get more chances to encounter patients with a previous history of malignant hyperthermia and knowledge to provide proper anesthetic management become essential. We present a case in which malignant hyperthermia was detected in a 67 year old female patient with gastric cancer and a thyroid mass during the first operation and successfully treated with promptly initiated supportive measures based on capnography finding without dantrolene which was not available at the time and the same patient rescheduled for subsequent gastrectomy in which we chose non-triggering agents in adjunct to epidural anesthesia without provoking malignant hyperthermia.