Anesthesia for Multiple Cerebral Aneurysms in a 7 Year Old Child with Ventricular Septal Defect: A case report / 대한마취과학회지

Multiple cerebral aneurysms in children are rare lesions, occurring at a frequency of approximately 0.5% to 4.6%. In children, infective endocarditis from congenital or rheumatic heart disease are the important causes of cerebral mycotic aneurysms. Subarachnoid hemorrhage, most commonly caused by the rupture of an intracranial anurysm is associated with mortality and morbidity. We reported a case of multiple cerebral aneurysms in a 7 year old child with ventricular septal defect (VSD) in operation of the two times performed under general anesthesia. He was scheduled for elective surgery for clipping of cerebral aneurysm in ASA physical status II. For premedication, he was administered triflupromazine 10 mg (Veprin ) and glycopyrrolate 0.1 mg IM 1 hour prior to induction. Induction was established with thiopental, vecuronium after preoxygenation. N2O/O2 (2 L/min:2 L/min), isoflurane and vecuronium were administered for maintenance. For monitoring, ECG, direct arterial pressure, CVP, ETCO2 were performed. In second operation, we were performed the general anesthesia the same as the first operation. He had discharged in coma state on 4 day after the second operation hopelessly.

Anesthetic Management of Carotid Endarterectomy: A case report / 대한마취과학회지

Carotid endarterectomy is the preferred treatment for a patient with transient ischemic attacks (TIAs) in whom carotid artery stenosis is present. This patient was a 58-year-old male associated with 60 kg in body weight and 172 cm in height. He was scheduled for elective carotid endarterectomy in ASA physical status III. For premedication, he was administered triflupromazine (Veprin ) 10 mg and glycopyrrolate 0.2 mg IM 1 hour prior to induction. Induction was established with thiopental sodium, succinylcholine after preoxygenation. N2O/O2 (2:1), isoflurane and pancuronium were administered for maintenance. For monitoring, ECG, EEG, direct arterial pressure, ETCO2, CVP and rectal temperature were performed. A primary goal of the intraoperative management is the prevention of the cerebral ischemia. He was challenged to maintain adequate cerebral perfusion without causing myocardial ischemia. The EEG is the reliable indication of cortical function during general anesthesia. No signs of the cerebral ischemia were occurred at the time of the carotid occlusion. Minute ventilation was kept mild hypo-or normocapnia. He had no new neurologic deficits and myocardial ischemia, and discharged on 14 day postoperation.

Anesthetic Management of Carotid Endarterectomy: A case report / 대한마취과학회지

Carotid endarterectomy is the preferred treatment for a patient with transient ischemic attacks (TIAs) in whom carotid artery stenosis is present. This patient was a 58-year-old male associated with 60 kg in body weight and 172 cm in height. He was scheduled for elective carotid endarterectomy in ASA physical status III. For premedication, he was administered triflupromazine (Veprin ) 10 mg and glycopyrrolate 0.2 mg IM 1 hour prior to induction. Induction was established with thiopental sodium, succinylcholine after preoxygenation. N2O/O2 (2:1), isoflurane and pancuronium were administered for maintenance. For monitoring, ECG, EEG, direct arterial pressure, ETCO2, CVP and rectal temperature were performed. A primary goal of the intraoperative management is the prevention of the cerebral ischemia. He was challenged to maintain adequate cerebral perfusion without causing myocardial ischemia. The EEG is the reliable indication of cortical function during general anesthesia. No signs of the cerebral ischemia were occurred at the time of the carotid occlusion. Minute ventilation was kept mild hypo-or normocapnia. He had no new neurologic deficits and myocardial ischemia, and discharged on 14 day postoperation.

Modification of radiation induced lipid peroxidation by calmodulin antagonists.

It has been shown that calmodulin antagonists provide radio-protection in euoxic and sensitization in hypoxic conditions. This differential protection in euoxic conditions might have arisen from the interaction of calmodulin antagonists with oxygen free radicals. This possibility has been tested in the present communication. Radiation induced lipid peroxidation process in liposomes has been used for this purpose. Liposomes prepared from L-alpha-lecithin were irradiated with or without calmodulin antagonists. Calmodulin antagonists inhibited lipid peroxidation significantly. The inhibition was found to increase with increase in concentration of the drugs. These observations suggest that calmodulin antagonists have a capacity to scavenge oxygen free radicals involved in initiation and/or propagation of lipid peroxidation process. This may be the reason for their differential radioprotection in euoxic conditions in biological systems.

Anesthetic management for Surgery of the Ascending Aortic Aneurysm / 대한마취과학회지

Fifteen cases of corrective operation for the ascending aortic aneurysm performed under general anesthesia from 1979 to 1985 in Severance Hospital were studied retrospectively. There were ten male patients and 5 female and their average age were 36.6 years(range 25~50 years). Most of the patients showed aortic regurgitation. Thus the anesthetic management involved consideration for patients with aortic dissection combined with aortic incompetence(annuloaortic ectasia). Patients were premedicated with atropine or glycopyrrolate in 14 cases and a combination of triflupromazine, hydroxyzine, diazepam and pethidine in 13 cases or a combination of hydroxyzine and morphine in 2 cases. Anesthesia was induced with thiopental sodium and/or diazepam and/or midazolam and/or morphine IV. Morphine and a mixture of 50% nitrous oxide and oxygen was administered for maintenance of anesthesia. Supplementary volatile anesthetics were inhaled as needed. Vasodilating therapy and avoidance of bradycardia during anesthesia are the most importance considerations for the reduction of left ventricular wall tension and to maximize the myocardial oxygen supply while maintaining cardiac output. Operative complications were reoperation due to bleeding in four cases, myocardial infarction in two cases, pericardial tamponade and urethral track infection in one case each. One patient died of sepsis. Fourteen patients improved in their heart size and function.

A Clinical Study on Anesthesia in Infants and Children with Congenital Heart Disease during Open Heart Surgery / 대한마취과학회지

To evaluate anesthetic experience during open heart surgery, 145 cases of patients under 15kg of body weight from January 1980 to June 1982 were analyzed according to age, sex, technique of anesthesia, anesthetica, premedicants, muscle relaxants, flow rates and mortality. The results were as follows: 1) Premedicants were mainly atropine, meperidine, hydroxyzine, triflupromazine and morphine. 2) Induction agents were thiopental in acyanotic group, but cyanotic group were mainly used ketamine. 3) The inhalation anesthetica that were halothane, methoxyflurane, N@O and enflurane were used in acyanotic group but cyanotic group did not used. 4) Early stage of open heart surgery, gallamine were mainly used but now, pancuronium were used. 5) During cardiopulmonary bypass, the lowest temperature were mean 27 degrees C and flow rate were 80~100ml/kg/m(2). 6) Overall mortality was 17.2%.

Nitroglycerine in the Anesthetic Management of Pheochromocytoma / 대한마취과학회지

A 41 year-old male underwent resection of a pheochromocytoma under general anesthesia. The patient was treated with phenoxybenzamine for 14 days preoperatively and premedicated with triflupromazine, diazepam, pethidine and hydroxyzine in combination. Following induction of anesthesia with intravenous morphine, thiopental sodium and alcuronium, endotracheal intubation was performed. As soon as intubation, tachycardia(143/min) and hypertension(170/100 mmHg) developed, but were controlled by intravenous injection of propranolol. Anesthesia was maintained with nitrous oxide, oxygen and enflurane, and alcuronium. Blood pressure during manupulation of tumor mass was 160/100 mmHg without arrhythmia but gradually was controlled to the range of 120-130/80-85 mmHg after intravenous infuaion of nitroglycerine at the rate of 0.5-2 ug/kg/min. After removal of the tumor mass, the blood pressure dropped to 100/70 mmHg. Blood pressure was controlled by I.V. low molecular weight dextran, and Hartmanns solution, but a vasoconstrictive agent was not needed. There was no marked tachycardia or arrhythmia during anesthesia. The importance of preoperative preparation, premedication, selection of anesthetics and nitroglycerne for controling the episodic hemodynamic pressure response is discussed.

Triflupromazine , Methoxyflurane and Alcuronium for Pheochromocytoma Anesthesia / 대한마취과학회지

A 21 year-old female underwent resection of a pheochrocytoma under general anesthesia. The patient was treated with phenoxybenzamine for 5 days preoperatively and premedicated with triflupromazien, Librium, Seconal, pethidine, hydroxyzine and atropine in combination. Following indution of anesthesia with intravenous morphine and thiopental sodium, succinylchoine was administered intravenously and endotracheal intubation was performed. Anesthesia was maintained with nitrous oxide, oxygen and methoxyflurane, using a semiclosed carbon dioxide absorption circle system, and alcuronium was injection intermittently. Blood pressure during manipulation of tumor was increased up to 190/130 torr without arrhythmia and transiently dropped to 70/50 torr immediately after removal. Blood pressure was controlled by i.v. Hartmann's solution and whole blood with Solucortef and Effortil but not norepinephrine was needed. There was no marked tachycardis or arrhythmia during anesthesia, so a beta-adrenergic blocker(Inderal) was not used. The importance of preoperative preparation, premedication and selction of anesthetics is discussed.

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.

Deep Hypothermia for Total Correction of Tetralogy of Fallot / 대한마취과학회지

Early correction of congenital cardiac defects has been facilitated by the use of deep hypothermia and cardiorespiratory arrest. Simple deep hypothermia has a number of advantages for infant open heart surgery, such as a quiet heart and bloodless operative field, reduced blood requirement, elimination of pulmonary and coagulation problems following cardiopulmonary bypass, elimination of cannulation, simple anesthetic technique, no neccessity of complicated facilities, and stable postoperative course. Deep ether anesthesia is the ideal agent for induction of deep hypothermia by surface cooling, especially when combined with ganglionic blocking agents in large quantities to elimiminate some of the undesirable effects of ether, thus improving and maintaining good peripheral perfusion. We have performed a total correction of TOF on March, 1979. Anesthesia was induced with intravenous thiopental and succinylcholine for intubation and maintained by a tight closed circuit system with ether. As soon as routine EKG, direct intra-arterial pressure, esophageal and rectal temperature monitoring devices were installed, slow intravenous administration of triflupromazine was followed by surface cooling. Surface cooling was done by the technique of covering the child with bags of crushed ice after placing the infant on an ice water blanket. After cooling, the intracardiac procedure was performed under circulatory occlusion and cardiac arrest, following cardioplegic infusion, for 45 minutes. After the intracardiac procedure, cardiac resuscitation and rewarming were accomplished by cardiopulmonary bypass technique. The patient recovered satisfactorily and was discharged on POD14 without any complication.