Multiple Bronchoalveolar Lavages in a Patient with Acute Progressive Pulmonary Alveolar Proteinosis: A case report / 대한마취과학회지

We had performed six times (4 in right lung, 2 in left lung) bronchoalveolar lavages in a patient who has hypertension and suffered cerebral vascular accident previously. The diagnosis of PAP was confirmed by an open lung biopsy and multiple bronchoalveolar lavages were done for two and a half months. Even though she showed slight improvement in chest radiographs, she showed minimal improvement in her clinical course until the third lavage was done. She had to receive tracheostomy and prolonged ventilatory care because her PAP was progressed rapidly and complicated with superinfection. In addition, she sustained pneumothorax as a complication of the prolonged ventilatory care and the lavages. She was discharged one month after the last lavage and her clinical course has been uneventful 10 months thereafter.

Malignant Hyperthermia during General Anesthesia and Anesthetic Management for That Same Patient in Day Surgery Center: A case report / 대한마취과학회지

Malignant hyperthermia is a potentially fatal hypermetabolic syndrome characterized by hyperpyrexia and skeletal muscle rigidity. We experienced a case of malignant hyperthermia after general anesthesia with halothane and succinylcholine in day surgery center. 2 years old male patient arrived to get congenital ptosis operation. He was relatively healthy and had no considerable past or family history of hereditary disease. Anesthesia induced with halothane inhalation and succinylcholine. After induction, he abruptly showed masseter muscle rigidity, total body rigidity, elevation of end-tidal CO2 tension, tachycardia and hyperthermia. Under the suspicion of malignant hyperthermia, all anesthetics were discontinued and vigorous emergency treatment was attemped with dantrolene sodium. The patient survived without any sequele and discharged after 11 days. About 10 months later, that same patient comes to our hospital to take the operation. We experienced successful anesthetic management for malignant hyperthermia.

Comparison of the Cervical Spine Motion during Endotracheal Intubation with Lightwands and Macintosh Laryngoscopes / 대한마취과학회지

BACKGROUND: Endotracheal intubation with direct laryngoscope requires movement of the head, neck, and cervical spine. Spine movement may be limited for anatomical reasons or because of cervical spine injury. The lightwand requires less neck flexion and head extension than the conventional laryngoscope. The purpose of this study was to compare the extension of cervical spine obtained with lightwand and Macintosh laryngoscope. METHODS: Twenty patients requiring general anesthesia with endotracheal intubation were studied. Patients were placed on the operating table and anesthesia was induced. Intubation were performed on two occasions: with lightwands and Macintosh #3 laryngoscopes. Cricoid pressure was not applied. To determine cervical spine extension, five radiographs were taken in each patient (before induction, during mask ventilation, during intubation with lightwand, during laryngoscopy with the Macintosh blade: in the best glottic view or during intubation). RESULTS: Of 20 cases, we excluded 2 cases due to the technical error. Significant reduction of radiographic cervical spine extension were found in the lightwand compared to Macintosh blade at all cervical level. Mean atlantooccipital extension angles were 6.2o and 11.7o for the lightwand and Macintosh, respectively. There were no significant differences between mask ventilation and intubation with lightwand. CONCLUSIONS: Lightwand may be better than the conventional intubation in patients whose cervical spine movement is limited or undesirable, especially in the patients in whom awake intubation is not available.

General Anesthetic Experience of Resection & Anastomosis in a Distal Tracheal Tumor: A case report / 대한마취과학회지

A tracheal mass was detected in a woman who complained progressive cough and dyspnea developed 3 months ago. Tumor was located just 1 cm above carina almost obstructing the tracheal lumen and it was mobile with respiration. Curative tracheal resection & anastomosis was attempted with a right thoracotomy approach. In this patient, complete tracheal obstruction by the mass can occur during the induction of the anesthesia and the pre-resection period; therefore, we made cardiopulmonary bypass available before the induction. We successfully maintained the airway and provided the adequate ventilation during that critical period without using cardiopulmonary bypass. Here we report this case with a literature review.

Severe Hypokalemia Found during Operation: A case report / 대한마취과학회지

There has existed controversies concerning the relationship between hypokalemia and perioperative dysrhythmia. Definite lowest serum potassium level that guarantee safety has not been determined. We found accidentally severe hypokalemia (below than 2 mmol/L) after the induction of anesthesia in a 51-year-old man who had no systemic disease. This patient suffered from a traffic accident 18 years ago and has bed-ridden up to now. In addition, recently he had poor oral intake. The patient's serum potassium level was within normal range in blood chemistry taken 5 days before operation. Although no dysrhythmia developed, we administered potassium during operation. With the continuous potassium and magnesium replacement postoperatively, the serum potassium level returned to normal range. With the experience of this case, we had a chance to review the effect of hypokalemia on dysrhythmia and causes of hypokalemia.

Evaluation for Understanding and Satisfaction of Ambulatory Surgery and Anesthesia / 대한마취과학회지

BACKGROUND: During last 20 years, ambulatory surgery has been recognized as a convenient and highly efficient medical field due to improved medical skill and new anesthetics suitable for ambulatory patients. Therefore, it has become to popular in United States and Europe. Recently Korean doctors began to recognize the importance of ambulatory surgery and run Day Surgery Center(DSC) at several hospitals. The aim of this study is therefore to share our experience in management of DSC. METHODS: The analysis of information about DSC of Samsung Medical Center was based on questionnaire by 213 people(patients and their family) and 299 people who involved in our survey from August to September in 1995 and 1997, respectively. The contents of questionnaire were as follows: prerequisite knowledge of DSC, satisfactory levels of telephone visit, appointment and registration process, kindness of medical personnel, medical cost, medical technique and service of DSC, and problems to be improved. RESULTS: Prerequisite understanding of DSC was 30 and 32.8% in 1995 and 1997, respectively, indicating small increase in two years. however, 92.8% of people involved in the survey in 1997 showed positive response to the system of DSC and also 94% were content with the whole medical technique and service of DSC in 1997, comparable with 66% in 1995. CONCLUSIONS: We report that ambulatory surgery is a promising medical area by reducing medical cost, increasing efficiency of hospital management and conferring satisfaction to patients. We expect that such a qualified medical service as ambulatory surgery will be settled down in our country in near future.

Hematological Differences between Roller Pump and Centrifugal Pump in Cardiopulmonary Bypass / 대한마취과학회지

BACKGROUND: Prolonged extracorporeal circulation entails tremendous threats of red cell lysis, severe bleeding problems due to platelet injury and activation, and endothelial damages by sequestered leukocytes. In consideration of these problems, a new centrifugal pump was developed and tested clinically to evaluate its effectiveness. METHODS: We compared the effects of a centrifugal pump with those of a roller pump on hematological responses during cardiopulmonary bypass (CPB) in 20 coronary artery bypass surgery patients. The patients were divided into two groups of 10 each. The studied parameters included WBC counts, platelet counts, plasma Hb and D-dimer. Blood samples were taken after sternotomy, at 60 min, 120 min and 180 min after CPB start, and at 2 hr after CPB stop. RESULTS: No differences between the groups were found in bypass time, aortic cross clamp time, extracorporeal circulation flow and hematocrit. The centrifugal pump group demonstrated less platelet depletion (p<0.05), hemolysis (plasma Hb, p<0.05) and fibrinolysis (D-dimer, p<0.05). These differences were CPB time dependent and became statistically significant after 120 min bypass. CONCLUSION: We conclude that roller pump still can be safely used for standard cardiac procedures with bypass time less than 120 minutes and the centrifugal pump has significant potential to be safely applied to CPB for long ypass time in order to avoid postperfusion syndrome.

Hospital Admissions of Ambulatory Surgical Patients / 대한마취과학회지

BACKGROUND: The purpose of ambulatory facilities is to relieve the pressure on hospital beds and to make the process of surgery more convenient for the patient. One way of assessing the success of a ambulatory unit is to look at the number of patients requiring admission to hospital. Thus the author investigated the rate, distribution, and cause of admission cases to get help to reduce the admission rates. METHODS: Total ambulatory surgeries were 15,512 cases for the period from March 1995 to January 1998. The medical records were reviewed and the patients admitted to hospital instead of being discharged home were analyzed retrospectively. RESULTS: The overall mean rates of admissions for the period was 0.76 percent. The principal reasons for admissions were requestion by surgeon (0.53%), wish of patients (0.12%), surgery related admissions (0.08%) and anesthesia related admissions (0.03%), respectively. CONCLUSIONS: With proper assessment and selection of patients and surgical procedures, the admission rates of ambulatory surgery will be reduced acceptably low. Thus the efficiency of ambulatory unit will be increased. But it will reduce the use rate of ambulatory unit. For increasing the use rate of ambulatory unit, our hospital is broadening the patients' selection criteria.

The Hemodynamic Changes of Alcohol Sclerotherapy in Patients with Congenital Peripheral Arteriovenous Malformation / 대한마취과학회지

BACKGROUND: Arteriovenous malformations (AVMs) are increasingly treated by radiologists using various embolic materials. Because of pain and significant hemodynamic changes that may be associated with this treatment, anesthesiologists are frequently asked to provide anesthesia and supportive care. We evaluated the hemodynamic changes that occurred after absolute alcohol embolization. METHODS: Fourteen patients between 15 and 50 years of age who had arteriovenous malformation were included in this study. 2 to 4 ml of alcohol was injected each time. The hemodynamic parameters were measured before alcohol injection (control) and after 1st to 10th alcohol injection. RESULTS: Blood pressure, heart rate, and cardiac output were significantly increased after 1st to 10th alcohol injection compared with control value. Central venous pressure, pulmonary capillary wedge pressure and systemic vascular resistance were not significantly changed. But pulmonary vascular resistance was significantly increased after 9th and 10th alcohol injection. Systolic pulmonary artery pressure was significantly increased after 4th, 8th, 9th and 10th alcohol injection. CONCLUSIONS: Bolus injection of absolute ethyl alcohol induces short-term significant increases in blood pressure, heart rate and cardiac output probably by severe pain and sympathetic activation that appear to be centrally mediated. The underlying mechanism of cardiovascular event and other systemic effects of intravascular ethanol in this setting need further study.

Delayed Tension Pneumothorax Complicating Subclavian Vein Catheterization and Positive Pressure Ventilation: A case report / 대한마취과학회지

Pneumothorax is the most common complication after central venous catheterization and routinely assessed by a chest X-ray within 4 hours after catheter placement. The diagnosis of pneumothorax may be delayed for hours or days because of minimal clinical symptoms or radiologic signs on initial evaluation. Pneumothorax may progress to tension pneumothorax after positive-pressure ventilation with a potentially fetal outcome. We report a case in which a patient developed a tension pneumothorax while positive-pressure ventilation for general anesthesia 1 day after subclavian vein catheterization, although initial post-insertion chest X-ray was normal.

Acute Blindness of Right Eye after Cervical Spine Surgery in the Prone Position: A case report / 대한마취과학회지

We observed a patient who had central retinal artery occlusion with severely reduced visual acuity and characteristic retinal changes after cervical spine surgery under general anesthesia. In acute stage, visual acuity was slightly improved. But over course of several months, there was no improvement in visual acuity and central scotoma was remained. There were no evidences of hypotension or anemia during operation. The only presumptive cause was direct external ocular compression by horseshoe headrest. It is necessary to pay attention to eyes when prone positioning in the patients of cervical spine surgery.

Usefulness of PAR Score and Modified PADSS as Patient Discharge Criteria in Ambulatory Surgery / 대한마취과학회지

Background: Although an ambulatory surgical practice continues to increase, there is a few data exist about patient discharge criteria. This study was undertaken to evaluate the usefulness and safety of Aldrete PAR (postanesthetic recovery) score and modified PADSS (modified postaneathesia discharge scoring system) on ambulatory surgery patients for recovery in Korea. Methods: Demographic, anesthetic data, Aldrete PAR score and modified PADSS on 279 patients were recorded. The time to dicharge, from recovery room and postoperative complications were evaluated, also. Results: PAR score and modified PADSS are correlated to length of stay in ambulatory surgery center. 24hr after discharge, 16% patients complained postoperative complications. Pain was most frequent postoperative complication. The PAR score was correlated with the occurrence of the complication. Conclusion: PAR score and modified PADSS are useful scoring systems to evaluate patients and make a decision to discharge the patients from ambulatory surgery center in safe.

The Effects of Oral Clonidine on the Cytokines and Stress Hormone Responses in Patients Undergoing Abdominal Hysterectomy / 대한마취과학회지

BACKGROUND: Surgery cause alterations in immune and neuroendocrine responses. Cytokines and stress hormones are importanat mediators which modulate the various immune reactions. The aim of present study is to investigate whether clonidine premedication can affect on the concentrations of cytokines and stress hormones in abdominal hysterectomy patients. METHODS: Twenty two healthy women undergoing abdominal hysterectomy were randomly allocated to two groups: eleven control patients and eleven clonidine(0.15 mg) pretreated patients. Variations in blood cytokines, Interleukin-1beta(IL-1beta), IL-2, IL-6 and tumor necrosis factor-alpha(TNF-alpha), and stress hormones, cortisol and ACTH were studied. Blood sampling were conducted 4 times in each patient: after induction, after incision, after surgery 1 h and 3 h. Cytokines assays were carried out with commercially available ELISA kits, and cortisol with radioimmunoassay and ACTH with immunoradiometric assay. RESULTS: IL-1beta increased early and the concentrations of IL-1beta in clonidine treated group were significantly lower than control. The mean concentrations of IL-2 at 1 and 3 h after surgery were slightly higher than after induction in clonidine treated group. IL-6 increased significantly at 3 h after surgery in both groups. Clonidine lowered IL-6 during the whole period. TNF-alpha, and cortisol and ACTH concentraitons were not affected by clonidin. CONCLUSIONS: Clonidine pretreatment decreased IL-1beta and IL-6 concentrations, but not stress hormones in response to abdominal hysterectomy.

Bile Duct Reconstruction without T-Tube at Liver Transplantation / 대한이식학회지

BACKGROUND/AIMS: Biliary complication after orthotopic liver transplantation(OLT) continue to be a significant cause of surgical morbidity, occurring in 10~50% of patients. Bile duct obstruction and biliary leaks account for the majority of these complications. An end-to-end choledochocholedochostomy(CD) with or without T-tube or a Roux-en-Y choledochojejunostomy(CDJ) have been the standard methods of biliary reconstruction following OLT. We reviewed our experiences of OLT to assess whether or not use of the T-tube leads to increased biliary tract complications. MATERIALS AND METHODS: From May 1996 to Feb 1998, 34 consecutive liver transplantation in 33 patients were performed at our hospital, including 12 living related liver transplantaiton. Nineteen patients were male and twenty-two patients were adult. The main indication of OLT was hepatitis B virus related cirrhosis(14 cases)in adult and biliary atresia(7 cases) in child. Four ABO incompatible cases were included in living related liver transplant. Biliary tract complications were categorized as bile leak, stenosis, or obstruction that required therapeutic intervention. Retrospective review of clinical recordings and laboratory findings were done. The median follow up periods was 10 months(range: 3~24 month). RESULTS: The methods of biliary reconstruction in cadaveric liver transplant were CD with T-tube(n=2), CD without T-tube(n=18) and Roux-en-Y HJ(n=2), respectively. In living related liver transplant(LRLT), all 12 cases were reconstructed by Roux-en-Y CDJ without stent. Biliary tract complications were observed in one case of child LRLT patient that biliary fistula occurred at exposed bile duct on cut surface of liver. This patient underwent reoperation for constructed another HJ and progressed without complication. T-tube related complication was observed in one adult patient. T-tube was impinged at cystic duct that obstructed bile flow, intermittently. This patient was treated with insertion of PTBD catheter and removal of T-tube. No other biliary complications were detected in our series. CONCLUSION: Performing an end-to-end CD without T-tube was a safe and effective method of reconstructing the biliary tract following hepatic transplantation in adult patients, comparing with T-tube splintage method. We concluded that routine placement of the T-tube at hepatic transplantation was considered to some selective cases, but more large scale and long -term studies were needed.

Bile Duct Reconstruction without T-Tube at Liver Transplantation / 대한이식학회지

BACKGROUND/AIMS: Biliary complication after orthotopic liver transplantation(OLT) continue to be a significant cause of surgical morbidity, occurring in 10~50% of patients. Bile duct obstruction and biliary leaks account for the majority of these complications. An end-to-end choledochocholedochostomy(CD) with or without T-tube or a Roux-en-Y choledochojejunostomy(CDJ) have been the standard methods of biliary reconstruction following OLT. We reviewed our experiences of OLT to assess whether or not use of the T-tube leads to increased biliary tract complications. MATERIALS AND METHODS: From May 1996 to Feb 1998, 34 consecutive liver transplantation in 33 patients were performed at our hospital, including 12 living related liver transplantaiton. Nineteen patients were male and twenty-two patients were adult. The main indication of OLT was hepatitis B virus related cirrhosis(14 cases)in adult and biliary atresia(7 cases) in child. Four ABO incompatible cases were included in living related liver transplant. Biliary tract complications were categorized as bile leak, stenosis, or obstruction that required therapeutic intervention. Retrospective review of clinical recordings and laboratory findings were done. The median follow up periods was 10 months(range: 3~24 month). RESULTS: The methods of biliary reconstruction in cadaveric liver transplant were CD with T-tube(n=2), CD without T-tube(n=18) and Roux-en-Y HJ(n=2), respectively. In living related liver transplant(LRLT), all 12 cases were reconstructed by Roux-en-Y CDJ without stent. Biliary tract complications were observed in one case of child LRLT patient that biliary fistula occurred at exposed bile duct on cut surface of liver. This patient underwent reoperation for constructed another HJ and progressed without complication. T-tube related complication was observed in one adult patient. T-tube was impinged at cystic duct that obstructed bile flow, intermittently. This patient was treated with insertion of PTBD catheter and removal of T-tube. No other biliary complications were detected in our series. CONCLUSION: Performing an end-to-end CD without T-tube was a safe and effective method of reconstructing the biliary tract following hepatic transplantation in adult patients, comparing with T-tube splintage method. We concluded that routine placement of the T-tube at hepatic transplantation was considered to some selective cases, but more large scale and long -term studies were needed.

High Fever Due to Sulprostone after Cesarean Section: A case report / 대한마취과학회지

A 30-year-old female underwent emergency cesarean section with general anesthesia. In the past history, she has no specific problem. After delivery of fetus and placenta, there was continuous uterine bleeding due to uterine atony. Surgeon injected 1 mg of sulprostone (prostaglandin E2) into the uterine muscle and 1 mg of sulprostone was injected intravenously. One hour after sulprostone injection, high fever was detected. Sulprostone has been known to have side effects such as nausea, vomiting, uterine rupture, pulmonary edema and fever. Therefore, when we inject sulprostone into the uterine atonic bleeding patient, it is necessary to pay attention to fever for it's complication, in giving overdose.

Effects of Clonidine on Blood pressure and Heart rate, and Anesthetic Requirement During Laparoscopic Cholecystectomy / 대한마취과학회지

BACKGROUND: Laparoscopic cholecystectomy has become popular in the recent year. However, CO2 insufflation and patient's position changes during laparoscopic surgery can create severe hemodynamic changes, and increase anesthetic requirement. The major aim of this study is to assess the effect of oral clonidine on the cardiovascular lability during the operative and post-operative periods and enflurane requirement during operative period. METHODS: 43 patients(ASA I or II) undergoing elective laparoscopic cholecystectomy were selected for this study. The patients were randomly allocated into 3 groups: group 1(n=14) received no clonidine, group 2(n=15) 0.2 mg of clonidine and group 3(n=14) 0.3 mg of clonidine. Blood pressure and heart rate were continuously monitored during both the operative and post-operative periods. The enflurane concentration was also continuously adjusted to maintain blood pressure and heart rate within the range of 20% changes of baseline values. RESULTS: Since enflurane concentration was controlled to maintain systolic blood pressure within 20% of baseline values, there was no statistically significant difference in vital signs in the three groups during anesthesia. However, vital signs including systolic and diastolic blood pressure during their time in PACU (post anesthesia care unit) between the control and the clonidine treated groups were significantly different. The results of the blood pressure for the groups were found as follows. group 1) 134.9 +/-22.3 mmHg and 77.1 +/-12.4 mmHg, group 2) 116.8 +/-11.1 mmHg and 68.9 +/-12.2 mmHg and group 3) 113+/- 9.2 mmHg and 65.9+/- 9.2 mmHg for systolic and diastolic blood pressure respectively. Also, both the clonidine 0.2 mg and 0.3 mg treated groups, showed significantly decreased anesthetic requirement compared with the control group (P<0.05). There were dose dependent changes between 0.2 mg and 0.3 mg clonidine pretreated groups. CONCLUSIONS: Preoperative clonidine administration was effective in decreasing anesthetic supplement during laparoscopic cholecystectomy, and lessening the severity of hemodynamic changes during PACU.

An Experience in Anesthesia for Ambulatory Surgery / 대한마취과학회지

BACKGROUND: Ambulatory surgery has the advantages of reduced demand for postoperative medications, faster recuperation, less disruption to personal life and reduced hospital costs. At present, 60-70% of surgery in North America is performed on an ambulatory basis. DSC (day-surgery center) was opened on March 1995 in our hospital. We want to introduce an experience in anesthesia for ambulatory surgery. METHODS: Ambulatory surgeries were reviewed from March 1995 to July 1996. Total ambulatory surgeries were 5,593 cases. The medical records of 1,816 patients who were anethetized by anesthesiologists for ambulatory surgery were an alyzed retrospectively (3,777 patients who were operated under local anesthesia were excluded). RESULTS: The rate of utility was 14.1% on March 1995 and 27.7% on January 1996. The mean rate of utility was 22.2% per month in DSC. The overall mean rate of delayed discharge for the period was 2.9% and the overall mean rate of admission for the period was 1.9%. The principal reasons for the both were requestion by surgeons without surgery and anesthesia-related complications. CONCLUSIONS: The increase of demands of patients for ambulatory surgeries, new technological developements for surgery and anesthesia and increased experiences of surgeons will stimulate the utility of day surgery center.

Reperfusion Injury in Glial Cells: The Phenomenon and Mechanism of "Calcium Paradox" / 대한마취과학회지

BACKGROUND: Mechanisms of secondary injury(post-ischemic injury) in the central nervous system have recently reported in a vast of amount of experiments. Among many factors which give rise to post-ischemic neuronal damage, glial deterioration probably mediated by calcium paradox, could be another of the aggravating deleterious factors to the already ischemic neurophil. METHODS: here we have designed experiment to investigate calcium paradox in astroglial cell line, human astrocytoma U1242MG. Intracellular calcium alterations in experimental cells were monitored by using calcium indicating dye fura-2 and epifluorescent photometry system. RESULTS: Intracellular free calcium changes during reperfusion phase after exposure to low calcium led to a prompt increase in intracelluar calcium level after 10 and 30 minutes. The way of calcium entry during the reperfusion phase was mediated by the reverse mode of NA+/Ca2+ exchanger. Cells that had a reduction of reperfusate calcium to 10uM increased cell viability. Also we observed an inverse relationship between major enzymatic activity in the astrocytoma cells(i.e., gultamine synthetase activity) and the duration of reperfusion in the the same protocols. CONCLUSIONS: A relatively small amount of intracellular clcium increase by the reverse mode of Na+/Ca2+ exchanger during the reperfusion period is related to a limitation of enzyme activity and viability 24hours later.

Intracellular Calcium Alterations Induced during Reperfusion Injury are Altered by Local Anesthetics and Hypothermia / 대한마취과학회지

No abstract available.