Effects of Premedicants an Flow Rate during Cardiopulmonary Bypass / 대한마취과학회지

This study was performed to compare the effect of premedicant with triflupromazine, one of the phenothizine derivatives, and more common drugs such as morphine, hydroxyzine or atropine on flow rate and mean arterial pressure. A total of 54 cases who had open heart surgery for acquired or congenital heart diseases were divided into 3 groups depending on the main premedicants. Group l : 22 cases had triflupromazine, pethidine, hydroxyzine and atropine in divided doses. These cases were induced with a small amount of thiopental, morphine and succinylcholine and maintained with either nitrous oxide(50%), oxygen, gallamine and methoxyflurane in analgesic concentrations or with morphine fractionation. Group ll: 26 cases were given morphine, hydroxyzine and atropine as premedicants. Anesthesia was induced with thiopental, morphine and diazepam and maintained with morphine, nitrous oxide and oxygen. Group lll : 6 cases were premedicated with hydroxyzine and atropine only and maintained with halothane. After induction, surface cooling was begun using a blanket, combined with internal cooling during bypass. In group l and lll rectal temperature was maintained between 28 and 32 degrees C. in group ll, however, temperature was lower than other groups. After the main intracardiac procedures, rewarming was performed with combined surface and internal techniques. In most case a bypass time of longer than 1 hour was required with the longest times in group lll, 129.80+/-21.49 min. in duration. The longest anesthetic time was in the child group of group lll, 430+/-45.82min. in duration. Urine output during bypass in subgroup of methoxyflurane and morphine of group l was 8.95+/-0.33 and 12.15+/-0.36cc/kg/hr. In group ll the subgroup maintained with morphine in the adult and child and halothane, outputs were 11.63+/-0.14, 19.79+/-0.26 and 8.43+/-0.33 cc/kg/hr. respectively. In group lll maintained with halothane, output was 8.64+/-0.22mg/kg/hr. Mean arterial pressure(MAP) during bypass in most cases was maintained between 50 to 100 torr. In group l, the methoxyflurane subgroup, pressures were lower than in any other group, and higher flow rate was required than in any other group. Average MAP during cross clamp on the aorta of group l-methoxyflurane, group ll-morphine adult, group lll were 56.61+/-12.47, 78.79+/-17.33, and 74.06+/-19.09 mmHg respectively. MAP below 50 torr immediately after beginning bypass was more frequent in group ll(94.8%) than in other groups, and MAP above 100 torr after aorta clamping was observed more in group ll(65.2%) and in group lll(50%) than in group l(10.05%). Time to extubation was longer in group ll, the morphine subgroup, than in other groups 19.02+/-1.26 hours in the adult group and 20.05+/-2.69 hours in the child group. Post-op recovery in ICU averaged 4.17+/-0.65 days being longer in group l, the morphine subgroup, than in other groups. With this experience, we may conclude that group l with triflupromazine premedicants, as compared with the other groups, showed less esophageal and rectal temperature gradients during cooling and rewarming states, less acid base imbalance, better urine output, lower requirement of vasopressors or dilators to keep MAP with more flow rate in reasonable range during bypass and shorter time to extubation after surgery.

Endotracheal Anesthesisl with Thslamonal , Ketamine Infnsion , N2O and Relaxant / 대한마취과학회지

The dangers of explosion hazards and operation theater contamination by inhalation anesthetics have led to a renewed interest in intravenous anesthesia. without intubation. We have reported clinical studies of Thalamonal-ketamine anesthesia under room air breathing in non-abdominal surgery in a previous paper that discussed advantages, disadvantages and usefulness. Now, we report Thalamonal-N2O-Ketamine anesthesia with a microdrip technique and intubation in 63 patients undergoing various operations. These patients were divided into three groups by operation site: Group 1-upper abdominal, Group 2-lower abdominal and Group 3-non-aMominal surgery. These groups were subdivided, by muscle relaxants used, into pancuronium, d-tubocurarine and no relaxant groups. To minimize potential cardiovascular stimulation and postoperative sequelae, ThalamonaI was used at the beginning of anesthesia. The results were as follows: 1) The average duration of anesthesia was 153.9 minutes. The duration of anesthesia was 217.9 minutes in Group I, 121.9 minutes in Group 2 and 152.1 minutes in Group 3. 2) The average dose of ketamine-during induction was 1mg/kg/19 minutes. The average maintenance dose of ketamine was 1.8mg/kg/hr, 2.3mg/kg/hr in Group 1, 1.6mg/kg/hr in Group 2 and 1.8mg/kg/hr in Group 3. 3) The order of frequency of administration and total dose of pancuronium and d-tubocurarine was Group 1, Group 2 and Group 3. 4) The changes in vital signs after intubation and during anesthesia were insignificant clinically. 5) The average duration required from the end of operation to extubation was 10 minutes. 6) Arterial blood gas study performed preoperatively, during operation and in the recovery room in 11 patients revealed no significant changes. 7) The postanesthetic complications were pleasant dreams 18% (11), unpleasant dreams 6% (4), emergence delirium 3% (2), vomiting 6% (4) and shivering 3% (2).

Thalamonal-Ketamine Infusion without Intubation / 대한마취과학회지

Despite its many disadvantages ketamine may offer a partial answer to the pollution of the operating room by gases and vapours. It is a relatively long-acting drug with good analgesic action and does not require supplementation with nitrous oxide. This study was carried out to investigate the efficiency of the ketamine I.V. drip technique in patients undergoing operations not requiring tracheal intubation, muscle relaxation and controlled ventilation. The only contraindications to the use of its technique were hypertension, a history of a cerebrovascular accident or undetermined history of psychiatric upset. Twenty patients, ranging in age from 20 to 60 years, were premedicated with atropine and secobarbital, diazepam or hydroxyzine. Anesthesia was induced with 0.15mg/kg droperidol in Thalamonsl and was maintained with 0. 1% ketamine in 5% dextrose or balanced salt solution. The average dosage of ketamine was 1.175 mg/kg/hr for induction and 2. 33 mg/kg/hr for maintenance during operations with duration from 20 minutes to 5 hours and 35 minutes. No supplementary general anesthesia was given, but when the depth of anesthesia was :not adequate, the rate of the ketamine infusion was increased. After the induction with Thalamonal the respiration rates were decreased temporarily, but the tidal volume and arterial gas study were clinically within normal limits. The incidences of complications of anesthesia, namely increased B.P. (20mmHg above preoperative value), involuntary movements, dreams and hallucinations were 60, 40, 10 and 5% respectively. The verbal response time from the end of operation was within 30 minutes in 75% cases. It may be concluded that Thalsmonal and ketamine I.V. drip anesthesia without intubation can be used relatively satisfactorily in operations in which muscle relaxation, endotracheal intubation and controlled respiration are not needed.

Continuous Epidural Anesthesia for Transurethral Resection and Postoperative Pain Control / 대한마취과학회지

Thirty consecutive anesthesia records of transurethral resection (TUR) have been reviewed. Patient's physical status, anesthetic management and complications were also discussed. Operations in this series were classified as follows: 25 cases of TUR for carcinoma of the prostate, 3 cases of bladder tumor. In all the thirty cases of TUR, circulatory diseases, such as hypertension were encountered most frequently. (10 cases) The patients had the highest mean age(66.5 years old) and their physical status was almost all ASA class II or III. Hypotension occurred in 1 patient during TURP. There was no death associated with anesthesia and operation in this study. Pain control after operation with epidural block was satisfactory in nearly all cases. Continuous epidural anesthesia for TUR and pain control after operation was desirable.

Influence of Hypertonic Solution on Myocardial Contractility / 대한마취과학회지

The influences of osmolarity on the cardiac muscle contraction were investigated in cat papillary muscles. The muscle was immersed in the modified Krebs-Ringer-bicarbonate solutions containing various Ca ion concentrations and osmolarities and the resultant changes in maximum developed tension, rate of development of tension and time to maximum tension were analyzed. Following are the results. 1) Mean length of papillary muscle used was 9.3+/-0.60mm, end mean cross-sectional area was l. 73+/-0.07 mm2. Normal contraction amplitude at 5 mM Ca ion-K-R-B solution was 2. 46+/-0. 1 gram/mm. 2) Within the range of 2.5-10.0 mM Ca ion concentration, the contraction amplitude increased along with the increment of Ca concentration. 3) Osmolarity exerted dual effects on contraction; within the range of 300-400 mosm/I solution, the hypertonic solution exported a positive inotropic effect while 500 mOsm/1 solution exerted a negative inotropic effect upon papillary muscle. 4) Maximum rate of tension development increased in 350 mOsm/1 solution, but decreased in 400 mOsm/1 or more hypertonic solution. The time to maximum tension did not change within the range of 300 400 mOsm/1 osmolarity and in 500 mOsm/1 solution. 5) The difference in maxium developed tension between single and paired stimulation was 1. 99 gram/mm' at 300 mOsm/1 solution and was negligible in 450 mOsm/1 or more hypertonic solutions.

The Arteriovenous Differenees for Pco2 and pH during Ether, Methoxyflurane and Halothane Anesthesia / 대한마취과학회지

Arterial carbon dioxide partial pressure (PaCO2) and pH are basic indices of the adequacy of ventilation in anesthetized patients. Previous reports by us and by Frances et al indicate that peripheral venous Pco2 and pH approach values arterial blood during general anesthesia. The present study compares the arterial venous difference for Pco2 and pH during diethyl ether, methoxyflurane and halothane anesthesia in 20 cases each. After induction with thiopental, succinylcholine, the patient was intubated and maintained with N2O-O2 and one of above volatile agents. Venous blood was drawn from the back of the hand and an arterial sample was obtained from the radial artery of the other hand. The results were as follows: 1) The mean arteriovenous Pco2 differences in ether, methoxyflurane and halothane groups were -l. 25, -1. 425 and -0. 065 torr respectively. 2) The mean arterovenous pH differences in each group were 0. 031, 0, 017and 0. 014 respectively. We conclude from above results that the differences for the arteriovenous Pco2 and pH during halothane anesthesia were less than that of the ether or methoxyflurane groups.

Postoperative Pain Control with Intramuscular Injection of Thalamonal / 대한마취과학회지

Postoperative pain control is very important not only for the relief of pain. but in the prevention of respiratory acidosis, pulmonary complications, emotional disturbances and sleeping disturbances etc. Jn spite of its significance there are a few studies on postoperative pain control in medical literature. Techniques have been developed for postoperative pain control since the 19 century, for example analgesics, inhalational agents, regional block, hypnosis and accupuncture. However none of these techniques was satisfactory because of various complications. The intermittent intramuscular injection of narcotics (e.g. meperidine) has been used most widely pto the present. There have been many complications, induding addiction, from this method. Our study was done in the recovery room with intramuscular injections of Thalamonal to fully awake patients, with 20 cases each having operation done in the upper abdomen, lower abdomen, and in other sites. We evaluated the results for the requirement of meperidine after the adminstration of Thalamonal. This was compared with the control group. There were 85% of cases that did not require the injection of meperidine. One case was complicated by hypotension, but this patient was improved with routine management for , hypotension. Other complications were not found.

A Statistical Survey of the Patient of Intensive Care Unit in Severance Hospital / 대한마취과학회지

The concept of intensive care has developed from experience in recovery rooms, in anesthetic work, and in early specialized units in different fields of medicine. Between the First and the Second World Wars special units were created in some German hospitals. Intensive care often means a combination of recovery-room service and intensive therapy. Intensive care, especially respiratory care is an important part of the responsibility of the anesthesiologist. So, we have analyzed statistically 3, 072 I.C.U. patients who were admitted during a period of 7 years beginning October 18, 1968 when the I.C.U. at Severance Hospital was opened, The results are as follows: I. Cases admitted to the I.C.U. (March,1970-August, 1975 ) 1) For 5 and a half years, the total number of patients was 2, 479. These patients were 2.7% of 91,400 patients who were admitted into Severance Hospital. 2) The mortality rate was 20.0% . Mortality rate was highest in 1970 (23. 7%) and lowest in 1975 (13. 5%). It has gradually decreased every year. 3) Total occupied bed days were 9,840 days (average 4,0 days). The occupied bed days of the majority of the patients (83.6%) were below 5 days comprising 88.3% of the total expired patients. 4) 50% of the patients were in the 21 to 50 year age group. The highest mortality rate occurred in the 51 to 60 age group (24.3%). 5) The number of patients admitted in the department of internal medicine was 702 cases (28.3%) which was the highest among all departments. The mortality rates of the departments of pediatric and neurosurgery were 40. 3% and 34. 7% respectively and those were relatively high values. 6) All I.C.U. patients have been divided into two categories, operative and non-operative. The operative cases were 1, 264 (51. 0%) and non-operative 1, 215 (49. 0%,). The mortality ,The Journal of The Korean Society of Anesthesiologists VoI. 9, No. 2, 1976 rate of the non-operative cases (22. 5%) was higher than operative (17. 6%). 73 Cardiovascular disease was the commonest cause of death of I.C.U, patients (107 cases) admitted from March, 1974 to August, 1975 (30 cases, 28. 0%). Respiratory support cases (October 18, 1968-August 31, 1975) ;. During the 7 year period, of all I.C.U. admission cases (3,072) 423 cases (13.8%) received respiratory support. These patients gradually increased every year. 2) The mortality rate was 44. 0% which was more than twice the over-all mortality rate of. I.C.U. admission patients. 3) The mortality rate was highest in the 21 30 age group (18. 7%). 4) The department of internal medicine admitted the largest number of cases (153 cases, 36. 2%). 5) Of all conditions, cardiovascular disease was most frequent (126 cases, 29. 8%). Here we have discussed the definition of I.C.U., the responsibility and important role of the anesthesiologist in the I.C.U. by illustrating present situations and presenting problems at the I.C.U. in Severance Hospital.

General Anesthesia for Cardiac Catheterization in Children / 대한마취과학회지

Cardiac catheterization in man was first deseribed by Forasmann in 1929 and introduced as a diagnostic procedure by Caurnand in 1941. The purpose of the catheterization is to evaluate the nature of cardiac abnormalities. The information from the ivnestigation includes pressure and oxygen content of blood in the various chamhers of the heart and the presence of abnormal communications between them. Most of the blood samplings and recordings of pressure at the various sites are not carried out simultaneously but are collected continuously. Therefore, a steady cardiorespiratory state is essential during the procedure in order to allow comparison of pressure and oxygen saturation observed at all stages of the procedure. Inhalation anesthesia used to provide a steady state in children might alter the pressures or oxygen saturatian because of its higher inspired oxygen content. Therefore room air breathing is essential far this investigation. In Yonsei Medical Center, from September 1964 to December 1974 we used thiopental (1964~1970) and ketamine (1971 ~1974) with spontaneous respiration in 170 children with congenital .heart disease, ranging in age from 50 days to 13 years. Thiopental was administered rectally (38 cases) intravenously (10 cases) and both together (10 cases), Ketamine was administered intravenously (13 cases), intramuscularly (8 cases) and both together 119 cases). For premedication, secobarbital was given orally one and a half hours before. Atropine was omitted. The rate of administration, time of operation, anesthesia and. recovery, and alteration in body temperature, blood pressure, pulse rate and respiratory rate were observed statistically. It was concluded that: In the ketamine groups. 1) General anesthesia was obtained satisfactorily without frequent administration and supplementary administration of meperidine or diazepam. Furthermore the drug is stable and requires no prior mixing. 2) Sleep occurs quickly after both intravenous ar intramuscular injection and analgesia is profound. Therefore investigation was begun quickly after injection, and time of operation and anesthesia was shorter. 3) Postoperative increase in body temperature was observed but less than when thiopental was administered. 4) Blood pressure, pulse rate and respiratory rate were increased 5~18% after induction. but returned to previous state after about 15 minutes. 5) Cardiovascular complication was minimal. Profuse salivation was seen in 0.8% of patients, but there were preservation of jaw tone and laryngo-pharyngeal reflexes, so maintenance of the airway was excellent if suction was available. In conclusion, general anesthesia using ketamine was superior to thiopental for cardiac catheterization in children.

Anesthesia for Diaphragmatic Eventration / 대한마취과학회지

Special problems face the anesthesiologist in anesthetizing patients with left diaphragmatic eventration. A 59 year old man was admitted for surgical repair of diaphragmatic eventration with cyanosis, dyspnea and abdominal discomfort. The patient was scheduled for operation after chest phyaiotherapy and I.P.P.B. for 15 minutes, 3 times a day, for a week. After this preoperative treatment, the patient's pulmonary function was slightly improved. He was premedicated with atropine. Induction of anesthesria was planed to give intravenous ketamine with lidocain spray, but the patient had discomfort and was iritable during preanesthetic oxygen inhalation. Therefore anesthesia was induced by thiopentothal and succinylcholine, and maintained with oxygen, N2O and methoxyflurane. After anesthesia, the patient was given intensive care with Bennett respirator Model P-R2. Both anesthetic management for surgical repair of diaphragmatic eventration is reviewed and the problem of respiratory care is discussed.

Study on the Impurities in Anesthetic Diethyl Ether / 대한마취과학회지

The impurities of diethyl ether are mainly acetic aldehyde and ether peroxide. Other impurities are sulfuric acid, sulphur dioxide, mercaptane and ethyl ester. It was believed that these impurities are produced during production and storage. When we use ether containing impurities, inhalation of excessive peroxide can cause salivation, profuse bronchial secretion, lung edema and pneumonia. Excessive aldehyde also irritates the mucous membrane and can cause lacrimation, photophobia, conjunctivitis, an oppressive feeling of the chest, severe cough, headache, unconsciousness, bronchitis and pneumonia. It is well known that the deterioration of ether is favoured by contact with air, heat and sunlight. There are two opposite opinions on reuse of ether. Baskerville(1910) claimed that it should not be used for anesthesia twenty-four hours after the container is opened. However Harry and David Gold(1934) showed that, in ordinary anesthetic ether cans which were opened many times and stoppered with cork, the contents remaining pure by very delicate chemical tests for the usual impurities, aldehyde and peroxide, during a period of months. In order to measure the impurities of ether, four brands of ether for anesthesia were randomly selected for analysis. Type of containers and date of production in each group are as follows: Group I: Kong Shin Pharmaceutical Co. LTD., so called Korean made ether, 140 ml in brown, bottle one month old. Group II: May & Baker LTD., made in England, 100g(140 ml)can. Group III: Mallinckrodt Chemical Works, made in U.S.A., (1/4)lb(113.4 gm) can. Group IV: Showa Co., so called Japan made ether, 160 ml in brown bottle, fourteen months old in three samples and four years and six months old in another three samples, They were analysed by chemical tests for peroxide, aldehyde and acetic acid just after the containers were opened(zero day) and one, two, four, six and eight days later. Ethyl alcohol was analysed by gas chromatography. The results were as follows; Ether peroxide: Threshold limit value for U.S.P. is 7. 1 microgram/10 ml ether (0.025 mg of hydrogen peroxide/25 gm ether), In group I and III, they were within this value from zero to eight days but in group II and IV, they exceed this value already on zero day. Aldehyde: Threshold limit value in U.S.P. is 0.007mg/20ml ether(formaldehyde 0.0005%). In group I, there was nothing on zero day but after twenty-four hours it exceed threshold limit value and increased day by day up to eight days. In groups II, III and IV, they exceeded this value already on zero day, and increased day by day up to eight days but were below maximum allowable concentration for U.S.P. Acidity: The incidence was slightly increased day by day up to eight days but all were within normal range. By gas chromatography, analysis showed 4% ethyl alcohol in group III and IV. On the other hand, to ascertain the interrelationship between the production of impurities and the existence of alcohol or H2O2 in ether, 3% alcohol(group A), 6% alcohol(group B), H2O2 (600 microgramg%)(group C), and H2O2 with 3% alcohol together(group D) were added to ether respectively. In four groups, immediately after one, two, four, six and eight days after the containers were opened, they were analysed for peroxide, aldehyde and acidity. Peroxide: This was increased in all groups just after adding, and increased furthur day by day up to eight days when the increase was marked. Especially in group D, it increased sharply. Aldehycte: It was increased in all groups just after acding, and there after increased or decreased irregularly day by day up to eight days by which time it had increased markedly. Acidity: It was increased in all groups up to one and/or two days, there after decreased day by day up to eight days. However none of the groups exceeded the threshold limit value of 0.4 ml of N/50 NaOH. It was concluded that: 1. Impurities in ether for anesthesia are influenced by type of container for storage, date of its production, and duration after container is opened. 2. Ether for anesthesia should not be used for this purpose, if the original container has been opened longer than twenty four hours. 3. The production of impurities in ether was influenced by the presence of alcohol in ether. 4. It would be better to analyse the ether for impurities by chemical tests prior to clinical use.

Clinical Experience of Ketamine for Burned Patients / 대한마취과학회지

The severely burned patient, when first seen by the anesthesiologist, is usually in the "high-risk" category, envincing malnutrition and protein defficiency, combined with toxicity, dehydration and oliguria. Since homeostatic controls are markedly impaired, the cardiovascular system may be unable to respond to the changes in body position frequently necessary during surgical procedures. Especially when the burn involves the head, neck, and upper chest, the mucous membrane of the respiratory tract may be edematous and pulmonary atelectasis may be present. Inhalation agents such as ether, halothane, methoxyflurane, cyclopropane and nitrous oxide have serious disadvantages in anesthesia for burned patients, because: 1) the use of endotracheal tube to ensure an unobstructed airway is mandatory, but use of succinyl-choline for intubation may be dangerous, 2) there is a danger of introducing pathogenic organisms into upper respiratory tract with repeated intubation. 3) inhalation agents may impair the function of liver, kidney, and hemopoietic system. In the course of our clinical experience of ketamine in 45 burned patients, it became apparent that ketamine may be the anesthetic of choice for burn surgery, particularly for children, since the drug offers several distinct advantages over conventionally employed anesthetic agents. Protective reflexes are peserved, thereby rendering unnecessary an endotracheal tube. Also cardiovascular homeostasis, ease and simplicity of administration, rapid onset of anesthetic action, short duration, relatively quick recovery, virtual absence of postanesthetic nausea and vomiting and of toxicity for vital organs, and the absence of clinically detectable respiratory depression seemed to provide optimal conditions for surgery in burns.