Successful Hysterectomy and Therapeutic Hypothermia Following Cardiac Arrest due to Postpartum Hemorrhage / 대한중환자의학회지

Postpartum hemorrhage is a common cause of maternal mortality; its main cause is placenta accreta. Therapeutic hypothermia is a generally accepted means of improving clinical signs in postcardiopulmonary resuscitation patients. A 41-year-old pregnant woman underwent a cesarean section under general anesthesia at 37 weeks of gestation. After the cesarean section, the patient experienced massive postpartum bleeding, which led to cardiac arrest. Once spontaneous circulation returned, the patient underwent an emergency hysterectomy and was placed under therapeutic hypothermia management. The patient recovered without neurological complications.

Successful Hysterectomy and Therapeutic Hypothermia Following Cardiac Arrest due to Postpartum Hemorrhage / 대한구급학회지

Postpartum hemorrhage is a common cause of maternal mortality; its main cause is placenta accreta. Therapeutic hypothermia is a generally accepted means of improving clinical signs in postcardiopulmonary resuscitation patients. A 41-year-old pregnant woman underwent a cesarean section under general anesthesia at 37 weeks of gestation. After the cesarean section, the patient experienced massive postpartum bleeding, which led to cardiac arrest. Once spontaneous circulation returned, the patient underwent an emergency hysterectomy and was placed under therapeutic hypothermia management. The patient recovered without neurological complications.

Ankle-brachial blood pressure differences before and during anesthesia

BACKGROUND: In surgeries involving the upper extremities and breast, the blood pressure is frequently measured at the ankles. As the blood pressure is used as a pain indicator in the full surgical anesthesia, the ankle blood pressure higher than the brachial blood pressure may be misinterpreted by the anesthesiologist, in determining the depth of the anesthesia. This paper investigated whether the ankle blood pressure is significantly higher than the brachial blood pressure before the anesthesia induction, during induction, and after tracheal intubation. METHODS: Two hundred seventeen patients requiring general anesthesia for elective surgery were included in this study. Ankle and brachial blood pressure were simultaneously measured before the anesthesia induction, during induction, and after tracheal intubation. RESULTS: The ankle blood pressure was higher than the brachial blood pressure before induction, during induction, and after tracheal intubation. Ankle-brachial blood pressure differences were significantly higher before induction and after intubation as compared to that during induction. The correlation coefficient between the systolic ankle-brachial blood pressure difference before induction and that after tracheal intubation was 0.623. In 33 child patients with an ankle-brachial blood pressure index > or =1 before induction, there were no significant differences in the ankle-brachial blood pressure during induction. The brachial systolic blood pressure could be predicted by simple and multiple regression equations (R2 = 0.349-0.828). CONCLUSIONS: The results of the study suggest that the anesthesiologists need to consider the ankle-brachial blood pressure differences in monitoring the anesthesia, in cases where the brachial blood pressure cannot be measured during surgery.

Anesthetic Management of Cesarean Section in Human Immunodeficiency Virus (HIV)Positive Pregnant Woman : A case report

Anesthesiologists are encountering an increasing number of human immunodeficiency virus (HIV) infections in pregnant women. In HIV infected patients, the history should include an evaluation of opportunistic infections, malignancies and treatments with antiretroviral drugs. The anesthesiologist should be aware of the possible toxic side effects or interactions between the antiretroviral drugs and anesthetics. In addition, a HIV infection passing from patient to physician can occur. Therefore, safety measures must be taken when handling body fluid or blood. We report the anesthetic management of an elective cesarean section in a HIV positive pregnant woman who was treated with antiretroviral drugs to decrease the possibility of vertical transmission.

Anesthetic Management during an Ex Utero Intrapartum Treatment (EXIT) Procedure of the Agnathic Fetus : A case report / 대한마취과학회지

We report our experience of the anesthetic management of an ex utero intrapartum treatment (EXIT) procedure that was performed on a fetus with a mandible anomaly (agnathia) for airway management. The EXIT procedure is a method for maintaining the feto-placental circulation during a cesarean section using deep inhalation anesthesia. In the EXIT procedure, the anesthetic goal is the profound relaxation of the uterus to maintain the feto-placental circulation. High dose inhalation agents are used maintain the level of uterine relaxation. Anesthesia was induced with rapid sequence intubation and maintained with 2 vol% isoflurane and nitrous in oxygen (50:50) combined with intermittent boluses of fentanyl and atracurium. The fetus was not given any drugs other than those as a result of placental transfer and was monitored with pulse oximeter. The mother and fetus were maintained hemodynamically stable with a preserved feto-placental circulation. After delivery, the uterine tone improved soon after discontinuing the isoflurane, and the pitocin infusion was begun. There were no signs of uterine atony in the postoperative period.

A Comparison of the Effect of Cold Crystalloid Versus Normothermic Blood Cardioplegia on the Postoperative Recovery in Valvular Heart Surgery / 대한마취과학회지

BACKGROUND: Recent interest in the use of normothermic blood cardioplegia is based on theoretical advantages over the traditional method of hypothermic myocardial protection. These reported advantages are a decrease in intraaortic balloon pump use, greater incidence of return to normal sinus rhythm, greater immediate cardiac outputs, and less time weaned from bypass after removal of the aortic cross-clamp. In addition to these advantages, normothermic blood cardioplegia offers the promise to resuscitate the ischemic myocardium and reduce the morbidity and mortality for patients with high-risk disease. This study was designed to compare the effects of cold crystalloid and normothermic blood cardioplegia on the postoperative recovery. METHODS: To evaluate the efficacy of cold versus normothermic cardioplegia, forty-four patients scheduled to undergoing valvular replacement surgery were selected to receive intermittent cold(4degrees C) crystalloid cardioplegia(n=22), group I or continuous normothermic(37degrees C) blood cardioplegia(n=22), group II. Cardiopulmonary bypass(CPB) and aortic cross-clamp(ACC) times were measured during the operation and patients were evaluated postoperatively for serum electrolytes, arterial blood gas analysis, blood pressure, heart rate, complications, ventilator periods and ICU stay. RESULTS: The ACC and CPB times were significantly longer in group II(165.9+/-44.8 min, 210.9+/-60.2 min) compared with group I(121.2+/-38.7 min, 149.7+/-38.1 min)(p<0.01). Group II patients had significantly higher serum potassium level(5.2+/-0.8 mEq/L) than group I(4.3+/-0.4 mEq/L) on the first postoperative day(p<0.01). ICU stay and ventilator period were not significantly different in two groups. There was no significant difference in postoperative complications and mortality rates between two groups. CONCLUSIONS: These results suggest that the continuous normothermic blood cardioplegia may be useful in myocardial protection during cardiac operation.

Incidence and Contributing Factors of Malpositioning of the Endotracheal Tube after Endotracheal Intubation with Chest X-ray / 대한마취과학회지

BACKGROUND: Malpositioning of the endotracheal tube within airway after intubation may results in serious complications, such as accidental extubation and inadvertent endobronchial intubation. Therefore, early detection of malposioning of the endotracheal tube is very impotant for deciding patient's prognosis. METHODS: We assessed the distance from the tip of the endotracheal tube to the carina according to the patient's age, sex, and the time, the location, and the route of intubation. The chest x-ray was taken for 333 patients (men, 226: women, 107) who were admitted to the intensive care unit of Wonju Christian Hospital from march 1, 1995 to February 28, 1996. Chest x-ray was obtained after intubation to verify endotracheal tube position. Appropriate endotracheal tube position on chest x-ray was defined as between 2 and 6 cm above the carina. RESULTS: Of the 333 intubations, 106 (31.8%) endotracheal tubes were inappropriately placed according to the chest x-ray. The percentage of malpositioned endotracheal tubes (<2 cm) was higher in women than in men (11.2% vs. 5.3%, p<0.05), with higher in night (7 PM to 7 AM) than in day (7 AM to 7 PM) (42% vs. 24%, p<0.05). Distance from the carina to the tip of endotracheal tube is 4.34 +/- 1.77cm in women and 5.23 +/- 1.64cm in men. Thus, position of the endotracheal tube in women is deeper than men (p<0.001). CONCLUSIONS: We conclude that the chest x-ray for confirmation of endotracheal tube position after endotracheal intubation may remain the standard of practice. And endotracheal tube position should be carefully assessed immediately after tracheal intubation, particularly in women and at night.

Comparison of Initial Weaning Success Rates and Weaning Periods between Synchronized Intermittent Mandatory Ventilation and Pressure Support Ventilation / 대한구급학회지

BACKGOUND: SIMV (synchronized intermittent mandatory ventilation) mode is comprised of a ventilator that intermittently enters the volume assist/control mode in conjunction with circuitry that allows for spontaneous ventilation by a demand flow system. There is additional work of breathing caused by the endotracheal tube and demand valve in SIMV. However, PSV (pressure support ventilation) has the ability to decrease work of breathing and to augment spontaneous breaths with a variable amount of inspiratory positive pressure with a clinician-selected level of inspiratory airway pressure. METHODS: To compare the initial weaning success rates and weaning periods between SIMV and PSV, we reviewed medical records of 103 intensive care unit patients, who had received mechanical ventilatory support and performed weaning. We compared the patients' characteristics, initial weaning success rates and ventilatory periods, weaning periods, weaning periods/ventilatory periods, ICU stays according to the weaning process (SIMV and PSV). And then we compared the same variables as the above between the initial weaning success group and initial weaning failure group. RESULTS: Patients' characteristics, ventilatory periods, weaning periods, ICU stays were similar, but there was significantly shorter weaning periods/ventilatory periods on PSV group. Initial weaning success rates according to the weaning process were similar. Ventilatory periods, weaning periods, weaning periods/ventilatory periods, ICU stays were significantly shorter on initial weaning success group. CONCLUSIONS: PSV could be used effectively as one of the weaning modes, and further studies are required about weaning criteria, weaning start time and weaning methods.

Change of Body Impedance according to Loss of Total Body Water during Hemodialysis in Chronic Renal Failure Patients / 대한마취과학회지

BACKGROUND: In biological structures, application of a constant alternating low current results in an impedance to the spread of the current that is frequency dependent. The living organism consists of intra- and extracellular fluids that behave as electrical conductors, and cell membranes that act as electrical condensers. Body fluids and electrolytes are responsible for electrical conduction. METHODS: We studied body impedance and fluid loss during hemodialysis in 20 patients with chronic renal failure. Two pairs of electrodes with a thin layer of electrolyte gel were placed on the dorsal surfaces of the hands and feet. 50KHz 800uA current was applied via the distal electrodes of each pair and the voltage drop was measured by proximal electrodes and impedance was derived from Ohms law. We measured body impedance and fluid loss at every one hour during hemodialysis. RESULTS: Body impedance value according to weight before hemodialysis changed in inveise ratio. During hemodialysis the rate of increase of body impedance according to body fluid loss revealed individual variance, but it was nearly constant in each individual patient. CONCLUSIONS: The method assessing total body water by body impedance is very simple, safe, rapid and noninvasive. The change of total body water can be predicted with body impedance method in individual patient by continuous monitoring, and this method may be useful particularly in critically ill patient. Further validation of this method is required for clinical application.

Comparison of Respiratory Effects of Continuous Flow CPAP System with Demand Flow CPAP System / 대한마취과학회지

BACKGROUND: Continuous positive airway pressure (CPAP) during spontaneous breathing has contributed greatly to the management of the neonatal respiratory distress syndrome and adult respiratory failure associated with acute lung disease. CPAP systems may be grouped into two general categories, demand flow CPAP system and continuous flow CPAP system. The purpose of this study was to evalute the respiratory effects of continuous flow CPAP system compared with demand flow CPAP system. METHODS: Cardiorespiratory values were measured in twelve respiratory failure patients on demand flow CPAP system and continuous flow CPAP system made by authors. CPAP level and FIO2 were maintained at the same level for both modalities. RESULTS: Changing from demand flow CPAP to continuous flow CPAP was associated with significant decrease in tidal volume(demand flow CPAP 450+/-153.0 ml, continuous flow CPAP 338+/-73.8 ml), airway pressure fluctuation(demand flow CPAP 6.4+/-1.2 cmH2O, continuous flow CPAP 2.4+/-0.7 cmH2O) and improvement in arterial oxygen partial pressure (demand flow CPAP 90.0+/-20.9 mmHg, continuous flow CPAP 105.9+/-24.6 mmHg). There were no significant changes in other cardiorespiratory values, such as arterial blood pressure, heart rate and respiratory rate. CONCLUSIONS: These results suggest that continuous flow CPAP system may be a beneficial modality in the management of respiratory failure patients compared to demand flow CPAP system.

Comparison of Cardiorespiratory Effects of Pressure Controlled Ventilation with Volume Controlled Ventilation in Severe Respiratory Failure / 대한마취과학회지

Pressure controlled ventilation has been proposed to recruit closed alveolar units and improve oxygenation through changing the inspiratory flow pattern from a square wave as used with volume controlled ventilation to a rapidly exponentially decaying curve and through maintaining airway pressure at a constant level throughout the inspiratory phase. The purpose of this study was to evaluate the cardiorespiratory efficacy of pressure controlled ventilation in severe respiratory failure. Cardiorespiratory values were measured in ten patients with severe respiratory failure on volume controlled and pressure controlled ventilation. Tidal volume, ventilatory rate, PEEP, inspiratory:expiratory ratio and FIO2 were maintained at the same level for both ventilatory modalities. Changing from volume controlled ventilation to pressure controlled ventilation was associated with significant improvement in PaO2 and decrease in peak inspiratory pressure. There were no significant changes in other cardiorespiratory values, such as arterial blood pressure, heart rate, inspiratory pause pressure and static compliance. These results suggest that pressure controlled ventilation may be a beneficial ventilatory modality in the treatment of severe respiratory failure compared to volume controlled ventilation.

The Effect of Physostigmine on Arousal and Respiration after General Anesthesia with Enflurane / 대한마취과학회지

Physostigmine has been used to counteract somnolence or coma induced by different types of pharmacological agent, such as anticholinergics, opioids, ketamine, tricyclic antidepressants and inhalational anesthetics. In this study, we have assessed the effect of physostigmine on arousal and respiration after 50% N2O-50% O2-enflurane general anesthesia under controlled condition such as no premedication, no neuromuscular blockade, same operative procedure and duration. Fifty healthy gynecologic patients scheduled for dilatation & curettage and cervical cone biopsy were divided randomly into two groups such as control group and physostigmine group. In physostigmine group, 0.02 mg/kg of physostigmine was administered intravenously at the end of operation. We evaluated the recovery time of pain response, eye opening on verbal command and orientation after the end of operation. We also checked the end-tidal enflurane concentration with SARACAP spectrometry. Blood pressure, pulse rate, respiration rate and tidal volume were checked at the end of operation and at the time of each recovery parameters returned. The results were as follows; first, pain response time was 5.1+/-2.4 min in control group compared with 3.5+/-2.1 min in physostigmine group. Second, on simple order to patients, eye opening time was 8.5+/-2.3 min in control group compared with 6.5+/-2.1 min in physostigmine group. Third, recovery of orientation to time, place and person was 9.7+/-2.8 min in control group compared with 7.5+/-2.1 min in physostigmine group. Fourth, there was no significant difference in respiratory parameters between the two groups. But there was no significant difference in end-tidal enflurane concentration between the two groups inspite of rapid recovery time in physostigmine group. In conclusion, 0.02mg/kg of physostigmine has the effect of early arousal after enflurane anesthesia without specific problems.

Pulmonary Embolism Associated with Total Hip Replacement for the Fracture of Femur Neck / 대한마취과학회지

Orthopedic surgical procedures are associated with a variety of complications due to em- bolic phenomena. Fat embolism syndrome is associated with multiple trauma injuries and surgery involving longbone fractures. The pathogenesis of syndrome is not clear and treatment remains supportive. We experienced a case of pulmonary embolism associated with total hip replacement. We suspected embolism on pulmonary perfusion scan and diagnosed fat embolism with criteria for diagnosis of fat embolism syndrome by Gurd.

A Clinical Survey of Patients of the Intensive Care Unit in Wonju Christian Hospital / 대한마취과학회지

We analyzed 5,504 ICU patients who were admitted between Mar. 1985 and Feb. 1989 to obtain better guidance and management in the ICU. The results of analysis are as follows ; 1) The total number of patients was 5,504; 792 patients in 1981, 771 patients in 1986, 1,036 patients in 1987, 1.393 patients in 1988, and 1.512 patients in 1989. There were continual increment annually since 1986, and 95% increment in 1989 compared to 1985. 2) The male patients were 3,681 and female patients were 1,823, and the ratio of male to female patients was about 2:1. The most frequent age group was 40-49 and the rate of which was 23.%. 3) The mean admission day was 5.9 days. There were continual increment annually and 13.3 % increment in 1989 compared to 1985, The number of patients stayed in the ICU for 1-2 days was highest and the rate of which was 36.1%. 4) The number of patients of neurosurgical department was 49.5% being the highest among all the patients. 5) The mortality rate was 10.4% and shows decreasing tendency annually. The mortality rate of 1-2 admission day was highest (13.3%). In age distribution, the mortaUty rate under the 10 years old was highest (17.4%) and in distribution by department, highest in the pediatric patients (24.5%). From the above results, we can conclude that in spite of increase in number of patients and admission days, the mortality rate has decreased annually due to improved equipments, support of nursing care, and specially qualified staffs.

Roentgenographic Confirmation of Central Venous Catheter Tips / 대한마취과학회지

To compare the rate of success and incidence of complications associated with currently popular routes of percutaneous central venous cannulation, we studied 131 patients in whom central venous catheterization was attempted. Right or left external jugular veins were used in 67 cases, and success rate was 9796. Right internal jugular veins were used in 27 cases, and success rate was 100%. Right or left basilic veins were used in 21 cases, and success rate was 76%. Right or left subclavian veins were used in 16 cases, and 75% of success rate. Non-J-wire type catheters were utilized in 60 cases, and success rate was 88%. J-wire type catheters were used in 71 eases, and success rate was 94%. We found 2 cases of catheter curling in Non-J-wire type catheters.

Movement of Double - lumen Endobronchial Tubes During Position Change / 대한마취과학회지

Accurate placernent of double-lumen endobronchial tube is essential for successful one lung anesthesia We studied 58 adult patients (38 males and 20 females) undergoing thoracic surgery under one lung anesthesia. We used the fiberoptic bronchoscope as an "introducer" over which the double lumen tube was advanced under direct vision. Correct position of the left side double-lumen endobronchial tube at supine position was determined by direct vision of cephalad surface of the bright blue bronchial cuff immediately below the carina. Correct position of the right side double lumen endobronchial tube at supine position was determined by direct vision of the right upper lobe bronchial orifice through the right upper labe ventilation slot. After the patient was repositioned, the position of the double lumen endobronchial tube was rechecked by fiberoptic bronchoscope. The results were as follows; 1) There was a significant correlation of correct depth of left and right double lumen endobronchial tube at supine position with height for both male and female patients. 2) Left side double lumen endobronchial tube: 58% of total cases (20 Case of 38 Case) were displaced by turning of the patient from supine to the lateral decubitus position. 3) Right side double lumen endobronchial tube: 65% of total cases (13 Case of 20 Case) were displaced by turning of the patient from supine to the lateral decubitus position.

APACHE II Score and Evaluation of Intensive Care Unit Patients / 대한마취과학회지

To deterrnine the applicability of the Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system in ICU, 552 ICU patients who had been admitted from March 1, 1992 to February 28, 1993 were analysed. The mean APACHE II score of nonsurvivors was significantly higher than that of survivors (p<0.01) and there was significant relationship between mortality rate and APACHE II score [Mortality rate(%) =2.994XAPACHE II score-14.987 (r=0.97, p<0.001)). However, the majority of postoperative patients had scores less than 20 points and the postoperative patients were more unevenly distributed. These results suggest that the APACHE II score may be useful for analyses of ICU patients but its application in postoperative patients must take into consideration the patient's clinical condition.

Midazolam Infusion for Sedation in the ICU Patients / 대한마취과학회지

Problems related to agitation in the ICU patients include cardiorespiratory instability, ina bility to cooperate with nursing care, failure to maintain op timal positioning in bed, dis- ruption of life sustaining tubes and catheters, and injuries to patients and hospital person- nel. Thus, the ability to provide safe, controllable, and reversible sedation can be important in the care of critically ill patients. Midazolam is a water soluble imidazobenzodiazepine with a rapid onset of ac tion and short elimination half life compared with diazepam or lorazepam. We evaluated the use of midazolam by continuous infusion for prolonged sedation of critically ill adult patients. The results were as follows ; 1) Midazolam infusion effectively controlled severe agitation in all patients. 2) No episodes of cardiovascular depression due to midazolam occur red during the study period. 3) In one patient, tolerance was developed 6 days after infusion. 4) Mean time to alertness was 2.23 hours. 5) In a renal failure patient, there was no significant prolongation of time to alertness. These results suggest that midazolam infusion provides safe, controllable, and reversible sedation in the care of critically ill patients.

The Changes of Serum Triiodothyronine(T3) and Thyroxine(T4) Levels during General Anesthesia with Enflurane and Propofol / 대한마취과학회지

Serum Ta and T were measured in 34 patients scheduled elective surgery with general anesthesia, who were divided into two groups (enflurane group' 12, propofol group' 22). No clinical signs of thyroid disturbances could be observed preoperatively in the patients. Anesthesia was induced with thiopental 5 mg/kg in enflurane group; propofol 2 mg/kg in propofol group, and maintained with Oz 2 L/min, NH 2 L/min, enflurane (1.0-2.596) in enflurane group,' 2 L/ min, N 4 L/min and continuous controlled infusion of pmpofol (50-150 mcg/kg/min) in propofol group. Blood samples were collected 5 minutes after arrival in operating room, 1 minute after induction, 5 minutes after intubation, 1 minute after skin incision, during operation and 10 minutes after extubation. Blood samples were centrifused and serum was taken from each sample. Determinations of Ta and T4 were performed using enhanced chemiluminescence immunoassay (ELIA). Comparisons of our results were made using repeated measuves analysis of variance, paired students t-test and statistically significant when p value was less than 0.05. The results are summarized as follows' 1) In enflurane group, serum Ta levels showed a decreasing tendency after extubation compared to baseline. Decreasing serum T4 after administration of thiopental could be considered statistically significant and serum T levels showed a decreasing tendency after extubation compared to baseline. 2) In propofol gnup, serum Tz levels showed a decreasing tendency after extubation compared to baseline. Rises in serum Te after incision and extubation could be considered statistically significant. Based on these results, no direct negative influence of propofol need be expected on Tg metabolism in euthyroid patients. However, the changes in these hormones, although with in the physiological range here, indicate that propofol may adversely influence their levels in the presence of manifested thyroid disease.

Accidental Insertion of Entire Guide - Wire in the Inferior Vena Cava During Central Venous Catheterization / 대한마취과학회지

Complications during central venous catheterization are well recognized and include infection, air emboliam, hemorrhage, pneumothorax and extravascular migration of central venous .catheter. The over-wire technique is usually considered safe. However, the wire itself can eause complications by looping knotting and retention. We ecperienced a case of accidental insertion of entire guide-wire during central venous catheterization via the right interal jugular vein. The right femoral vein was cannulated and the guide-wire was removed by a PIG TAIL catheter under the fluoroscopy.