Anesthetic Management of a Patient with Type II Alexander Disease: A Case Report

Patients with type II Alexander disease have white matter dysplasia, which may cause various symptoms due to nerve conduction impairment. When providing anesthesia to a patient with Alexander disease, careful and patient-specific individualized risk evaluation must be preceded by planning the method of anesthesia and anesthetic drugs. This is the first case report of a patient with type II Alexander disease who underwent general anesthesia. We performed general anesthesia on a 45-year-old male with type II Alexander disease for laparoscopic cholecystectomy, using remimazolam, remifentanil, and rocuronium. Despite the use of reversal agents including flumazenil, naloxone, and sugammadex, the patient manifested a delay in emergence but successfully recovered from anesthesia without postoperative complications. In consideration of the possibility that leukodystrophy may have altered responses to anesthetics, the action of an anesthetic agent may be prolonged or delayed in patients with type II Alexander disease. We recommend using drugs with a short duration of action and which can be reversed immediately by a reversal agent.

Analysis of prognostic factors for postoperative complications and mortality in elderly patients undergoing emergency surgery for intestinal perforation or irreversible intestinal ischemia

Purpose@#Because the global geriatric population continues to increase, the assessment of emergency surgical outcomes in elderly patients with acute peritonitis will become more important. @*Methods@#A retrospective review was conducted on the data of 174 elderly patients who underwent emergency surgery for intestinal perforation or intestinal infarction between June 2010 and November 2022. We conducted an analysis of the risk factors associated with postoperative complications and mortality by evaluating the characteristics of patients and their surgical outcomes. @*Results@#In our study, most patients (94.3%) had preexisting comorbidities, and many patients (84.5%) required transfer to the intensive care unit following emergency surgery. Postoperative complications were observed in 84 individuals (48.3%), with postoperative mortality occurring in 29 (16.7%). Multivariate analysis revealed preoperative acute renal injury, hypoalbuminemia, and postoperative ventilator support as significant predictors of postoperative mortality. @*Conclusion@#When elderly patients undergo emergency surgery for intestinal perforation or infarction, it is important to recognize that those with preoperative acute renal injury, hypoalbuminemia, and a need for postoperative ventilator support have a poor prognosis. Therefore, these patients require intensive care from the early stages of treatment.

Contralateral complete L5 palsy following ipsilateral L4 selective transforaminal epidural block / 대한마취과학회지

No abstract available.

Antifibrotic effects of magnesium lithospermate B on hepatic stellate cells and thioacetamide-induced cirrhotic rats

Magnesium lithospermate B (MLB) is one of the major active components of Salvia miltiorrhizae. The anti-oxidative effects of Salvia miltiorrhizae have been previously reported. The aim of this study was to investigate the effect of purified MLB on hepatic fibrosis in rats and on the fibrogenic responses in hepatic stellate cells (HSCs). Hepatic fibrosis was induced in rats by intraperitoneal thioacetamide (TAA) injections over a period of 8 or 12 weeks. MLB was orally administered daily by gavage tube. Serum AST and ALT levels in TAA + MLB group were significantly lower than those in TAA only group at week 8. Hepatic fibrosis was significantly attenuated in TAA + MLB group than in TAA only group at week 8 or 12. Activation of HSCs was also decreased in TAA + MLB group as compared to TAA only group. Hepatic mRNA expression of alpha-smooth muscle actin (alpha-SMA), TGF-beta1, and collagen alpha1(I) was significantly decreased in TAA + MLB group as compared to TAA only group. Incubation with HSCs and MLB (> or =100 microM) for up to 48 h showed no cytotoxicity. MLB suppressed PDGF-induced HSC proliferation. MLB inhibited NF-kappaB transcriptional activation and monocyte chemotactic protein 1 (MCP-1) production in HSCs. MLB strongly suppressed H2O2-induced reactive oxygen species (ROS) generation in HSCs, and MLB inhibited type I collagen secretion in HSCs. We concluded that MLB has potent antifibrotic effect in TAA-treated cirrhotic rats, and inhibits fibrogenic responses in HSCs. These data suggest that MLB has potential as a novel therapy for hepatic fibrosis.

A photoelastic evaluation of stress distribution during distal movement of upper molar / 대한치과교정학회지

The purpose of this study was to photoelastically visualize the distribution of forces transmitted to the alveolus and surrounding structures using three different types of headgear for the distal movement of the upper molars. A photoelastic maxillary model was made and three different directional forces applied, which were high-pull, straight- pull, and cervical-pull. Stress distribution was recorded through circular polariscope, and two-dimensional photoelastic stress analysis was performed according to isochromatic fringe characteristics. The results were as follows: 1. In the case of high-pull headgear, bodily movement occurred in the medium-length outer bow, stress distribution in the apical region was 1st molar, 2nd premolar, 1st premolar in sequence and there was no apparent difference. 2. In the case of straight-pull headgear, bodily movement occurred in the long outer bow and stress distribution in the apical region was heavy in the 1st molar, 2nd premolar, 1st premolar in sequence. But, there were no apparent differences according to the length of the outer bow. 3. In the case of cervical-pull headgear, bodily movement also occurred in the long outer bow, and apical stress of the premolar region was heaviest among other cases and apical stress of the 2nd premolar was heaviest in the short outer bow. In clinical situations, to achieve bodily movement of the upper 1st molars without modifying outer bow height, applying an outer bow length as long as the inner bow length in high-pull headgear and applying an outer bow length longer than the inner bow length in straight-pull, cervical-pull headgear are recommended.

Comparison of Changes in Bispectral Index and Auditory Evoked Potential Index during Endotracheal Intubation / 대한마취과학회지

BACKGROUND: Depth of anesthesia monitoring needs a consistent and reliable measure in close to real time. The aim of this study was to compare auditory evoked potential (AEP) as determined using the autoregressive model with exogenous input (ARX-model) versus the bispectral index (BIS) by conventional averaging. The hypothesis of the present study was that since the ARX-model extracts AEP faster than BIS, the former should be able to detect changes during the brief, intense stimulus of endotracheal intubation. METHODS: Forty ASA physical status I or II patients scheduled for orthopaedic surgery were randomly assigned to 2 groups (group 1; BIS and group 2; AEP). Anesthesia was induced with target-controlled infusions of propofol. After the effect-site concentration of propofol was reached at 4 microliterml, vecuronium 0.1 mg/kg was administered. The trachea was intubated 3 min after the administration of vecuronium. AAI and BIS were compared during endotracheal intubation. RESULTS: During endotracheal intubation, the ARX-extracted AEP Index showed a significant increase (P < 0.05), the BIS did not change significantly. There is a significant difference between the ARX-extracted AEP and the BIS, in terms of response time. CONCLUSIONS: The ARX-extracted AEP Index increases during the brief, intense stimulus of endotracheal intubation. For tracing short-term changes at the hypnotic level, ARX-extracted AEP is considered as the more useful monitoring device in terms of a real time measure.

Clinical Efficacy of Serum PIVKA-II in the Diagnosis and Follow up after Treatment of Hepatocellular Carcinoma / 대한간학회지

BACKGROUND/AIMS: Protein induced by vitamin K absence or antagonist II (PIVKA-II) appears to be a useful tumor marker for the evaluation of patients with hepatocellular carcinoma (HCC). But the usefulness of PIVKA-II was not yet clear in Korea where hepatitis B-virus is endemic. We investigated the usefulness of PIVKA-II in the diagnosis and follow-up after treatment of HCC. METHODS: We studied patients with HCC which was pathologically confirmed. PIVKA-II was measured by enzyme immunoassay. PIVKA-II levels before and after treatment, in correlation with imaging studies, were analyzed for the comparison of treatment responses. Kappa index was obtained. RESULTS: A total of 129 patients were included. 93 patients (72%) were HBsAg positive. 86 patients (67%) were PIVKA-II >40 mAU/mL. 52 patients (40%) were AFP >20 ng/mL and 77 patients (60%) were AFP 40 mAU/mL. 68 of 129 patients were evaluated treatment response. On the basis of radiologic response, CR was 33, PR 17, SD 12, and PD 6. Of the 33 radiologic CR patients, 30 patients were CR and 3 patients were PR by means of PIVKA-II response. Of the 17 radiologic PR patients, 6 patients were CR and 7 patients were PR. Therefore, tumor responses by radiologic and PIVKA-II were well correlated (Kappa index was 0.59). CONCLUSIONS: PIVKA-II can be used as a useful tumor marker for patients with HCC, especially those with low levels of AFP, before and after treatment in Korea.

The Spectral Analysis of EEG according to Change in the Concentration of Isoflurane / 대한마취과학회지

BACKGROUND: Adequate depth of anesthesia requires a sufficient amount of the agent to secure unconsciousness and other components of anesthesia as needed for that particular surgical procedure, without jeopardizing vital organ functions. To evaluate the relationship of depth of anesthesia to EEG, we studied the effects of increasing minimum alveolar concentration (MAC) of isoflurane (arousal, 1, 1.3, 1.5 MAC) on power spectral analysis of the EEG. METHODS: To determine 1 MAC, we studied sixty patients undergoing general anesthesia who were randomly allocated to receive isoflurane at several predetermined end-tidal concentration. A minimum of 15 min was allowed between induction and skin incision to allow steady state condition. Patients were observed for gross purposeful movement for 60 seconds after incision. The MAC was calculated using maximum likelihood solution to a logistic regression model. Another forty patients were randomly allocated to have their EEGs recorded. General anesthesia was induced with oxygen and isoflurane only. After loss of consciousness, succinylcholine 1.5 mg/kg was given and intubation followed. The EEG was recorded awake and after 15 min at steady state conditions of 1, 1.3 and 1.5 MAC isoflurane had been achieved. Spectral edge frequency 95% (SEF95), median spectral frequency (MSF), total power (TP) and relative power in the delta, theta, alpha and beta band were calculated. RESULTS: The MAC of isoflurane was 1.21 vol% (20 - 40 years) and 1.09 vol% (40 - 60 years). The distribution of spectral EEG indices of the EEGs were established and compared. The threshold value of SEF95 14 Hz to differentiate between arousal and 1.3 and 1.5 MAC had a sensitivity of 60.5% (1.3 MAC), 71% (1.5 MAC) and specificity of 74.4% (1.3 and 1.5 MAC) and that of MSF 5 Hz had a sensitivity of 71% (1.3 MAC), 81.5% (1.5 MAC) and specificity of 48% (1.3 MAC), 48.8% (1.5 MAC). CONCLUSIONS: With regard to the dose-related decrease in SEF95 and MSF under increasing end- expiratory concentrations of isoflurane as described in the present study, future studies may have todetermine whether EEG feedback control of volatile anesthetic administration may be used successfully. It seems that if neglected parts by MSF and SEF95, which are really true values are considered in the future studies, those would increase the sensitivity and specificity of EEG could be used as tool for determining depth of anesthesia.

Effect of Different Concentration of Fentanyl on Maintenance, Recovery and Postoperative Pain Relief in Propofol-Fentanyl-N2O Anesthesia / 대한마취과학회지

BACKGROUND: Skin incision has been used as a standard stimulus in most concentration versus response relationship studies for anesthetics. However, skin incision is not the most intense stimulation and inconvenient method during operation. Mean arterial blood pressure, but not heart rate, is convenient and predicts surgical stress as well as propofol blood concentration. We evaluated the effects of different fentanyl concentration on propofol-fentanyl-N20 anesthesia using mean arterial blood pressure as an indicator of surgical stress during operation. METHODS: Eighty ASA I or II patients (age: 20~55 yrs) scheduled for spine fusion were randomly allocated to four groups according to expected fentanyl blood concentration (Group 1, 2, 3, 4: 0, 1.5, 3.0, 4.5 ng/ml respectively, n=20 for each group). Fentanyl was infused according to isoconcentration nomogram, and propofol infusion rate was titrated by changes of mean arterial blood pressure (0~12 mg/kg/hr). Fifteen minutes before expected end of surgery, propofol and fentanyl infusion were discontinued. Thereafter IV-PCA using fentanyl was applied for postoperative pain relief. Average propofol flow rate, recovery of orientation, verbal rating scale were cheked. RESULTS: Group 2, 3, 4 showed decreased average propofol flow rate, delayed recovery and decreased postoperative 24 hr fentanyl requirement for pain relief gradually compared with group 1. Group 4 showed ceiling effect in terms of average propofol flow rate, recovery of orientation and 24 hr fentanyl requirement for postoprerative pain relief compared with group 1~3. CONCLUSIONS: Keep the fentanyl concentration below 3.0~4.5 ng/ml and titrate propofol flow rate was reasonable method for adequate control of drug infusion during a propofol-fentanyl-N20 anesthesia.

Anesthesia Induction with Propofol Using a Target Controlled Infusion (TCI) / 대한마취과학회지

BACKGROUND: Target Controlled Infusion (TCI) is designed to achieve a predicted target blood concentration based on population pharmacokinetics and it provides the closest approximation for any individual patients. This study determined which target is appropriate for propofol induction using a TCI in korean adullt patients premedicated with midazolam. METHODS: Sixty six patients (ASA I or II, 18~55 years) premedicated with midazolam were allocated randomly to receive an infusion to achieve and maintain a target blood concentration of 3, 4, 5 and 6 microgram/ml using a TCI. Induction time was measured as the interval from the start of the infusion to loss of verbal contact and induction within 3 min was considered as successful. Calculated concentration, induction dose, context sensitive decrement time, vital signs, pain score and side effects were checked and compared each other during induction period. RESULTS: The success rate when the target was 3 microgram/ml was 25%, 58.8%, 77.8% and 100% when targets were 4 microgram/ml, 5 microgram/ml and 6 microgram/ml respectively. EC50 for induction was 3.87 microgram/ml and EC95 was 5.71 microgram/ml. Calculated concentration, induction dose, context sensitive decrement time in 3, 4, 5 microgram/ml group showed no differences among groups, but 6 microgram/ml group showed statistically significant differences compared with other groups. Vital signs, pain score and side effects showed no differences among groups. CONCLUSIONS: Target concentration of 5~6 microgram/ml would successfully induce anesthesia in the majority of patients premedicated with midazolam without major hemodynamic changes.

Is the Administration of Fentanyl Useful for Hemodynamic Stability during Propofol Induction Using Target Controlled Infusion(TCI) Mode? / 대한마취과학회지

BACKGROUND: Because the propofol TCI software commands the syringe pump to deliver a rapid infusion at a rate of 1200 ml/hr until the pharmacokinetic model predicts that the selected target concentration has been reached, the hemodynamic changes are predicted. To this change, several methods could be considered and the fentanyl injection is one of them. METHODS: Sixty adult patients scheduled for orthopedic surgery were randomly alldegrees Cated into four groups according to amount of fentanyl injected during induction period(group 1: no fentanyl, group 2: 0.75 microgram/kg, group 3: 1.5 microgram/kg, group 4: 3.0 microgram/kg). Target plasma concentration of propofol was selected as 4.0 microgram/ml and this concentration was achieved using modification of Prys-Roberts method. We evaluated the hemodynamic effect of various doses of fentanyl that injected at Vdpeak effect time and determined the optimal dose of fentanyl during propofol induction using TCI mode. RESULTS: Induction dose(range: 1.25~1.31 mg/kg) of propofol and induction time(range: 46~76 sec) showed no difference among groups. Use of fentanyl was effective for blood pressure stability immediately after intubation, but not effective before and 3 min following intubation. The higher the dosage of fentanyl, the more stable the heart rate. CONCLUSION: It suggest that use of fentanyl for the prevention of abrupt hemodynamic change during propofol induction using target controlled infusion mode is not necessary.

An Anesthetic Experience in a Patient with EDTA-induced Pseudothrombocytopenia: A case report / 대한마취과학회지

Pseudothrombocytopenia caused by platelet clumping is an in vitro phenomenon that occurs in ethylene-diamine-tetra-acetic acid (EDTA) anticoagulated blood at room temperature. Pseudothrombocytopenia may lead to erroneous diagnosis, unnecessary and costly additional laboratory examinations, and inappropriate medical or surgical therapy. We experienced 75-year old female pseudothrombocytopenia patient scheduled for orthopedic surgery, who showed abnormal thrombocytopenia (35,000/mm3) in preoperative routine platelet count using EDTA anticoagulant, but showed normal platelet count in sodium citrate anticoagulant.

Clinical Usefulness of Isoconcentration Nomogram for Continuous Infusion of Fentanyl in Propofol-Fentanyl Total Intravenous Anesthesia (TIVA) / 대한마취과학회지

BACKGROUND: To estimate real time concentration of drugs during TIVA is theoretical, but it is not easy and inefficient. To maintain designed target concentration with continuous infusion using methods that account for the multicompartmental pharmacokinetic profile of fentanyl, isoconcentration nomogram is one of the methods. We evaluated the clinical usefulness of the isoconcentration nomogram using two different expected concentration of fentanyl. METHODS: Thirty ASA class I or II adult patients scheduled for spine fusion were randomly allocated into two groups according to 1.5 or 3 ng/ml of expected fentanyl concentration. Using isoconcentration nomogram, fentanyl concentration was adjusted and the propofol concentration was fixed to 3.5 g/ml according to Prys-Roberts method. Vital signs were titrated using variable flow rate of propofol. Fentanyl and propofol were discontinued 15 min before the end of operation. And, IV-PCA using fentanyl were applicated for postoperative pain control. The dosage of propofol and fentanyl, recovery time of consciousness and orientation were checked. Also, first buttoning time and 24hr fentanyl dosage in IV-PCA were checked. RESULTS: Average flow rate of propofol used were 7.5 1.2 mg/kg/hr in group 1, 5.7 1.1 mg/kg/hr in group 2 which was significantly lower than group 1 (p<0.05). Spontaneous eye opening and recovery of orientation was delayed 1.8 times in group 2. First buttoning time and 24hr fentanyl requirement for postoperative pain control using IV-PCA was delayed by 2 and decreased 60% in group 2, respectively. CONCLUSIONS: Isoconcentration nomogram was useful tool to control the expected concentration of fentanyl during TIVA and postoperative pain control using fentanyl IV-PCA.

Comparison of Intraoperative Patient-Controlled Sedation and Anesthesiologist-Controlled Sedation using Midazolam / 대한마취과학회지

BACKGROUND: Because of wide individual variations in response to sedative and the level of sedation desired by different patients, inadequate sedation is frequent during surgery. Patient-controlled sedation is a logical extension of patient-controlled analgesia to find and maintain their own steady-state of sedation by self-administration of sedatives during surgery. The purpose of this study was to evaluate the feasibility of patient-controlled sedation compared with anesthesiologist-controlled sedation during surgical spinal anesthesia. METHODS: Unpremedicated forty adult patients who received spinal anesthesia for lower extremity surgery were randomly allocated into two groups (n=20 for each group). After selection of target state of sedation according to sedation scale, patient-controlled sedation (PCS) group self-administered 0.5 mg (1 ml) intravenous midazolam in increments using a Walkmed PCA infusor and anesthesiologist- controlled sedation (ACS) group administered by the anesthesiologist as the same manner to achieve previously selected sedation state. Sedation score, vital signs, SpO2 were checked 5, 10, 20, 30, 40min after start of drug injection. RESULTS: The sedation scores patient desired were 4.4 +/- 0.8 in PCS group and 4.3 +/- 0.7 in ACS group. These scores were achieved 20min after start of injection in PCS group and 40 min in ACS grou p (p<0.05). Degree of satisfaction was higher in PCS group compared with ACS group (1.5 +/- 0.6 vs 2.1 +/- 0.8, p<0.05). No complications were detected in two groups. CONCLUSIONS: PCS using midazolam was better than ACS in terms of early achievement of sedation state patient desired and degree of satisfaction.

An Analysis of the Process to Organ Donation in Brain-dead Patients / 대한이식학회지

Organ procurements were performed in 9 brain-dead patients at our hospital since 1995. They were 7 males and 2 females. The causes of brain death were trauma in 7 patients and CVA in 2 patients. When brain death was confirmed, hypernatremia over 145 mEq/L was showed in 6 and hypothermia in all. Blood transfusion was done in 6 patients for correction of anemia preoperatively. The time intervals from brain death confirmation to organ procurement were from 1 hour to 2 days. Multi-organ harvests were done in 4 patient, 60 year-old female and 2 patients who received the cardioversion before harvest were given up to procure liver and heart preoperatively. And 2 patients were not procured heart and liver because of pathologic findings of intraoperative frozen biopsy. Among 22 recipients, 1 kidney recipient died postoperatively. We conclude that the intensive care should be performed in the brain dead donor for multi-organ harvest and better results of organ transplantations. Beside the organ procurement and transplantation team, another intensive care team for brain dead donor should be composed if possible.

Analgesic Interaction of Epidural Fentanyl and Clonidine for Pain Control after Perianal Surgery / 대한마취과학회지

BACKGROUND: The spinal opioid is one of the excellent analgesic methods for acute postoperative pain and intractable terminal cancer pain, but some side effects limit its use. Many studies had been continued to decrease the frequency and severity of these side effects and to reinforce the analgesic potency of spinal opioid by administering of other drugs. METHODS: Ninety healthy patients who received perianal surgery were divided into 3 groups randomly and we observed VAS, sedation score, blood pressure, pulse rates and SpO2 after epidural clonidine (Group 1), fentanyl (Group 2) and combination of two drugs (Group 3) were injected. The ED50 of epidural clonidine and fentanyl were evaluated from VAS of Group 1 and 2 using the linear regression on log dose versus %MPE(Percent Maximal Possible Effect). We injected epidurally 1/4, 1/2, full dosage of ED50 to Group 3 patients and isobologram was constructed for evaluating the interaction of two drugs. RESULTS: The ED50 and 95% confidence limit of clonidine were 119 mcg, 78~161 mcg and those of fentanyl were 105 mcg, 68~204 mcg. At the ED95 level, the isobologram is nearly straight, suggesting additive interaction. At the lower level, the isobologram was bent toward the origin, a sign of synergy, the interaction below the ED80 was synergistic. CONCLUSION: At the large dose(ED95) to achieve nearly complete pain relief, epidural fentanyl and clonidine showed additive interaction and the other hand, at the smaller dose(below the ED80)which relieves most pain but not all pain, they showed synergistic interaction.

Comparison of Butorphanol with Morphine in Intravenous Patient Controlled Analgesia (PCA) for Postoperative Pain Relief / 대한마취과학회지

BACKGROUND: Morphine for the intravenous patient controlled analgesia (IV-PCA) provides effective postoperative pain control, but it has side effects such as itching, nausea and vomiting. Meanwhile, butorphanol, a synthetic potent agonist-antagonist narcotic with low incidence of adverse side effects and minimal addiction, produce adequate analgesia for postoperative pain. The purpose of this study was to compare the suitability of butorphanol combining with or without morphine with that of morphine in terms of relieving postoperative pain and incidence of side effects. METHODS: Sixty ASA physical status I or II female patients undergoing total abdominal hysterectomy were randomly allocated into one of three groups according to type of drug used (n=20 for each group). The groups were divided to group M (morphine 100 mg), group M B (morphine 50 mg+butorphanol 10 mg) and group B (butorphanol 20 mg). Drugs for each group mixed with 90 ml of normal saline (total amount: 100 ml) for infusion. Loading dose, PCA dose, lockout interval, mode of infusion was 0.05 ml/kg, 0.02 ml/kg, 8 minute, and PCA only, respectively. In each group, visual analog scale (VAS), pain score, sedation score, degree of satisfaction, total amount of drug used, history of attempt/injetion and incidence of side effects were checked. RESULTS: There were no significant differences in analgesic effects and degree of satisfaction among three groups, but incidence of side effects (especially pruritis) were less in group M+B and B compared with group M (p<0.05). CONCLUSIONS: Butorphanol showed comparable postoperative pain relief and marked less side effects compared with morphine. Butorphanol was considered as a useful drug for postoperative pain relief using IV-PCA.

Central Pontine Myelinolysis after Liver Transplantation: A case report / 대한마취과학회지

Central pontine myelinolysis (CPM) is a demyelinating disorder that almost exclusively affects the central portion of basis pontis and occurs in patients with malnutrition, chronic debilitating disorders and electrolyte abnormalities. CPM after liver transplantation is considered that had the relationship to rapid correction of hyponatremia and shift in osmolality. Our first case of 4 liver transplantations altered consciousness at the 5th day after transplantation and did not recover fully until 14 months. At first, atrial fibrillation and atelectasis due to left main broncheal obstruction were thought the causes of impaired consciousness as postoperative hypoxic event. At that time, CT scan showed diffuse brain atropy that suggested previous hepatic encephalopathy and/or hypoxic ischemic encephalopathy. After that, MRI revealed CPM and diffuse cortical atropy. We concluded that CPM associated with rapid correction of hyponatremia perioperatively alter patient's consciousness with hypoxic brain injury.

Clinical Evaluation of One: Syringe Total Intravenous Anesthesia ( TIVA ) / 대한마취과학회지

BACKGROUND: In TIVA, it was controversy which was more appropriate to increase the concentration of the analgesic or of the hypnotic according to the intensity of the surgical stimulus. We used preset infusion dose of propofol and fentanyl mixed with pancuronium through a single syringe for expected better control of hemodynamics. METHODS: Vital signs and recovery scores were observed in thirty patients undergoing total abdominal hysterectomy using one-syringe TIVA in which we used premixed fentanyl(150mcg), propofol(450mg) and pancuronium(2 mg) in one syringe. Induction of anesthesia was performed by injection of propofol 1.5~2 mg/kg, fentanyl 1.5~2 mcg/kg, pancuronium 0.1 mg/kg and ventilated with 100% oxygen after endotracheal intubation. Infusion was started by 1 ml/kg/hr of mixed solution immediately after intubation. If the vital sign changed more than 15% compared with preoperative value, flow rate either increased or decreased by 50%. If stable vital signs were maintained for more than 15 minutes, the flow rate decreased by 20% every 15 min, but were maintained above 0.5 ml/kg/hr. Two to four minutes before skin incision and peritoneal traction, an additional 10 ml of mixed solution was infused. Solution without fentanyl and pancuronium was infused after peritoneal closure for early recovery. Ten to fifteen minutes before the operation was completed, infusion was discontinued and neuromuscular block was reversed. RESULTS: Blood pressure and pulse rate were stable and did not significantly change even after intubation or peritoneal traction compared with preoperative value. And, recovery from anesthesia was prompt 15 min after extubation except 2 cases of respiratory depression. CONCLUSIONS: One-syringe TIVA may be an feasible alternative method to replace conventional multi-syringe TIVA.

Effects of Propofol in Combination with Ephedrine on the Hemodynamic Effects during Anesthesia Induction / 대한마취과학회지

BACKGROUND: Propofol is a useful induction agent, but it can cause hypotention and bradycardia. Meanwhile, ephedrine has alpha-vasoconstriction and beta-cardiac stimulant effect. The purpose of this study was to assess the hemodynamic effects of adding various doses of ephedrine to propofol to obtund adverse hemodynamic response and to determine the optimal dose. METHODS: Unpremedicated 120 ASA physical status I adult patients (20~50yrs) scheduled for elective surgery were randomly allocated into four groups according to the doses of ephedrine added to propofol (1%, 20 ml). Group 1 (control group) was given propofol alone and 10, 15 and 20 mg of ephedrine was added to propofol in Group 2, 3 and 4, respectively (n=30 for each group). Propofol was loaded at 150 ml/hr using a syringe pump and no response to verbal command was ascertained as the end-point of induction. Vital signs and SpO2 were checked every 1 min during the induction period. RESULTS: In group 1, there was a significant decrease in both systolic and diastolic pressure prior to intubation. Group 2 and 3 showed relatively stable hemodynamic changes and significant systolic or diastolic changes occured only in the pre or post 1 min periods of intubation. But, in pulse rate, group 3 showed significant change 1 and 2 min after intubation, in contrary to group 2. Group 4 showed significant changes in systolic and diastolic pressure 1 and 2 min after intubation, and in pulse rate throughout the postintubation period. CONCLUSIONS: Ephedrine 10mg may be safely employed to reduce the hemodynamic changes during induction preiod with propofol.