The effects of remifentanil and lidocaine on the cardiovascular responses to tracheal intubation in hypertensive patients / 대한마취과학회지

BACKGROUND: Hypertensive patients are more prone to exhibit an exaggerated hemodynamic responses to laryngoscopy and tracheal intubation. We compared the effects of remifentanil and lidocaine on the cardiovascular responses during intubation in hypertensive patients. METHODS: Fifty adult hypertensive patients (>140/90 mmHg) were divided into 2 groups (remifentanil group; 1.0 microgram/kg, n = 25, lidocaine group; 1.5 mg/kg, n = 25). After 3 minutes'oxygenation, anesthesia was induced using 0.2 mg glycopyrrolate, 1.5 mg/kg propofol, and 1 of experimental drugs (30 seconds) bolus administration. Tracheal intubation was facilitated 90 seconds after administration of rocuronium; anesthesia was maintained with 2% sevoflurane and air in oxygen. Arterial blood pressure and heart rate were measured at the following times: resting state (baseline), after oxygenation; before intubation; just after intubation; and at 1, 3, and 5 minutes after intubation. RESULTS: There was significant attenuation of mean systolic and diastolic arterial blood pressures, after intubation of the remifentanil group compared to the lidocaine group at just after intubation and at 1 minute after intubation (P < .05). The difference in heart rate was not significant between both groups. CONCLUSIONS: Bolus administration of remifentanil was found to be superior to lidocaine in the attenuation of the blood pressure during intubation in hypertensive patients.

Effect of Normal Saline and Distilled Water Used for Dilution of 4% Plain Lidocaine in Epidural Anesthesia / 대한마취과학회지

BACKGROUND: Lidocaine blocks sodium channels in nerve membranes, which inhibits sodium influx and prevents development of an action potential. For epidural anesthesia, we usually use lidocaine diluted in normal saline or distilled water. However, diluents containing sodium ions may affect lidocaine activity. METHODS: Fifty patients, ASA physical status class I or II, scheduled for elective epidural anesthesia were randomly divided into two groups.For epidural anesthesia, we used 14 ml of 2% lidocaine solution made with 7 ml of 4% lidocaine plus an equivalent of distilled water (Group DW) or normal saline (Group NS).In the right lateral decubitus position, a 19 G Arrow catheter was inserted 3 cm in the cephalad direction in the L3-4 intervertebral space.In the supine position, 3 ml of 2% lidocaine was injected as a test dose, and the remaining 11 ml of lidocaine was injected 2 minutes later.We used a pinprick test for evaluation of sensory block levels and a Bromage grade for degrees of motor block every 2 minutes during the first 30 minutes. RESULTS: Levels of sensory block were higher in Group DW than Group NS at 12, 14 and 30 minutes. The degree of motor block was also higher in Group DW at 12 and 14 minutes. CONCLUSIONS: Diluent containing sodium ions reduces sensory and motor block compared to sodium-free solution in epidural anesthesia.

Optimal Dose of Remifentanil and Propofol TCI for Minimizing Cardiovascular Changes to Tracheal Intubation during Total Intravenous Anesthesia / 대한마취과학회지

BACKGROUND: The purpose of this study is to determine the optimal dose of remifentanil and propofol for minimizing the cardiovascular changes to tracheal intubation during total intravenous anesthesia (TIVA) using propofol target controlled infusion (TCI). METHODS: One hundred thirty five patients, aged 20-60 years, were randomly divided into three groups. Anesthesia was induced with remifentanil, propofol and rocuronium 1 mg/kg for intubation. Group I received remifentanil 0.1microgram/kg/min and a propofol target concentration 4microgram/ml. Group II received remifentanil 0.2microgram/kg/min and propofol 4microgram/ml. Group III received remifentanil 0.2microgram/kg/min and propofol 3microgram/ml. Remifentanil was infused continuously, and 2 minutes after remifentanil infusion, propofol was infused continuously. Mean arterial blood pressure (MAP) and heart rate (HR) were measured at pre-induction, 1 minute after remifentanil infusion, before propofol TCI, immediately before and after intubation and 1, 2, 3 minutes after intubation, respectively. RESULTS: Compared with pre-induction values, MAP at immediately after intubation was significantly increased in group I, but decreased in group II, with no change in group III. The HR immediately after intubation was significantly increased after intubation in all groups compared to the pre-induction values, but the rate of increase of HR in groups II, III were significantly lower than those of group I (p < 0.05). Hypotension was observed in 6 patients in group II and 3 in group III. CONCLUSIONS: Remifentanil 0.2microgram/kg/min and the propofol target concentration 3microgram/ml are optimal doses for minimizing cardiovascular changes and side effects to tracheal intubation during TIVA.

Appropriate Dosage of 8.4% Sodium Bicarbonate for Preventing Injection Pain of Rocuronium during Anesthetic Induction / 대한마취과학회지

BACKGROUND: The administration of rocuronium is associated with severe burning pain on injection that lasts for approximately 10-20 seconds. Injection pain is probably caused by the acidic pH of rocuronium. Mixing rocuronium with 8.4% sodium bicarbonate might neutralize the acidic pH thereby decrease the level of injection pain. This study investigated the appropriate sodium bicarbonate dose for preventing injection pain. METHODS: The study examined 250 patients (aged 20 to 60 years) from ASA I and II groups who scheduled for elective surgery. The patients were divided randomly into five groups. The control group (SB0) received rocuronium 50 mg (5 ml) only and the experimental groups received rocuronium 50 mg mixed with 8.4% sodium bicarbonate 1 (SB1), 2.5 (SB2.5), 5 (SB5), 7 (SB7) ml, respectively. The level of pain was evaluated as the withdrawal response as follows: no movement, 0; hand and wrist movement, 1 point; ipsilateral arm movement, 2 points; and general movement 3 points. RESULTS: The incidence of a withdrawal response was 68% in the control group (SB0). On the other hand, the incidence of a withdrawal response was 38%, 28%, 14% and 12% in the SB1, SB2.5, SB5 and SB7 groups, respectively. The withdrawal response was significantly lower in the experimental groups than in the control group (P < 0.01). In the experimental groups, a significant difference was observed between the SB1 and SB5, SB7 groups. However, there was no significant difference observed between the SB2.5, SB5 and SB7 groups. CONCLUSIONS: Mixing 5 ml of 8.4% sodium bicarbonate with rocuronium 50 mg (5 ml) is the most effective in preventing the injection pain associated with rocuronium during the induction of anesthesia.

The Analgesic Effects of Dose of Butorphanol Administered in Intravenous Patient Controlled Analgesia after Subtotal Gastrectomy / 대한마취과학회지

BACKGROUND: Butorphanol, a synthetic partial agonist-antagonist narcotic, produces adequate analgesia for postoperative pain. This study was designed to determine the appropriate dosage of butorphanol when administered with ketorolac by intravenous patient controlled analgesia (IV-PCA) after subtotal gastrectomy. METHODS: Ninety ASA physical status I or II patients undergoing subtotal gastrectomy were randomly allocated into one of three groups according to type of drug used (n = 30 for each group). The patients were divided into group B6 (butorphanol 6 mg), group B10 (butorphanol 10 mg) and group B14 (butorphanol 14 mg). Drugs for each group were mixed with 300 mg of ketorolac and normal saline (total amount: 100 ml) for infusion. Bolus dose, maintenance dose and lockout interval were 0.5 ml per each press, 1 ml/hr and 15 minutes, respectively. In each group, numerical rating scale (NRS) score, sedation score and incidence of side effect were checked. RESULTS: There were no significant differences in analgesic effects and sedation score among three groups but the NRS score of group B14 is lower than that of group B6 (P < 0.05) 3 hrs after the recovery room. CONCLUSIONS: We recommend 6 mg butorphanol, mixed with 300 mg of ketorolac, and normal saline for postoperative pain relief using IV-PCA.

The Influence of Patient Controlled Analgesia on the Recovery of Muscle Power and Respiratory Function following Intraoperative Muscle Relaxants / 대한마취과학회지

BACKGROUND: Residual muscle paralysis after anesthesia is reduced with the advent of intermediate-acting neuromuscular blocking drugs, yet the incidence is as high as about 10 percent. Opioids in patient-controlled analgesia (PCA) may cause respiratory depression and other problems after anesthesia. The purpose of this study is to evaluate the influence of PCA on the SPO2, TOF ratio, head-lift and tongue protrusion during recovery room stay following intraoperative muscle relaxants. METHODS: 120 patients aged from 20 to 65 in ASA class I and II were divided into control or PCA groups. All patients received rocuronium (0.9 mg/kg) or atracurium (0.5 mg/kg) for tracheal intubation, and maintenance of relaxation was done with atracurium 0.2 mg/kg/hr during inhalation anesthesia. Reversal of block was done with pyridostigmine 0.15 mg/kg and glycopyrrolate 0.2 mg. SpO2, TOF ratio, 5 sec-head lift, tongue protrusion tests were evaluated in the recovery room. RESULTS: IV-PCA did not influence the incidence of residual block, SPO2, TOF ratio during recovery room stay for 20 minutes, but influenced negatively 5 sec-head lift test, tongue protrusion test only immediately after arrival at the recovery room. CONCLUSIONS: Since IV-PCA decreased the ability to perform head-lift and tongue protrusion early postoperatively, it is recommended that patients with IV-PCA should be carefully managed against the risk of aspiration or upper respiratory obstruction during their early recovery room stay.

Effects of Lidocaine and Propofol on Production of Interleukin (IL)-2, IL-4, and Nitric Oxide in Mice / 대한마취과학회지

BACKGROUND: The possibility that anesthesia may alter the course of an infection has been under consideration for more a century. Alterations have been found in every component of the immune response during anesthesia and surgery. In this work, we have investigated the effect of lidocaine and propofol on interleukin-2 (IL-2), interleukin-4 (IL-4), and nitric oxide (NO) production in mice. METHODS: The culture supernatants of splenocytes exposed with anesthetics and lipopolysaccharide (LPS), or sera from mice injected with these agents were harvested to assay IL-2, IL-4, and NO. RESULTS: We detected that IL-2 productions of splenocytes culture supernatants and mice sera after exposure with lidocaine or propofol were decreased while IL-4 productions were increased. In addition, NO of mice sera was increased after lidocaine or propofol exposures. CONCLUSIONS: These findings suggest that lidocaine and propofol interfere with IL-2, IL-4, and NO production. This may explain the clinically well-recognized disturbance of human immunity after surgery and anesthesia.

The Evaluation of Predictability of Difficult Intubation Using Upper Lip Bite Test / 대한마취과학회지

BACKGROUND: The unexpected difficult endotracheal intubation is a significant contributor to mortality and morbidity in clinical practice. Although there are many methods to predict difficult intubation, modified Mallampati test (mMT) and airway score were popular tests. The authors wanted to compare upper lip bite test (ULBT) with those two tests and also explored the possibility that ULBT could be a good sole predictor for difficult intubation. METHODS: 322 patients who were ASA I or II, aged > 16yr were enrolled in this study. Three residents visited patients to obtain airway measurements such as 1) ULBT, 2) mMT, 3) airway score (inter-incisor gap, mMT, thyromental distance, head & neck movement, history of difficult intubation, buck teeth). They were not involved in the intubation of patients they evaluated. The accuracy, specificity, positive and negative predictive values were calculated from the data of three tests, and three tests were compared with patient's laryngoscopic view grade according to Cormack & Lehane criteria by using Chi-square test. RESULTS: The incidence of Cormack & Lehane grade III, IV was 14.6% (not applied external laryngeal pressure). ULBT showed significantly higher specificity, positive predictive value than mMT, but sensitivity was lower than other tests. There were significant correlations between ULBT class III and Cormack & Lehane laryngoscopic grade III, IV (P< 0.001). CONCLUSIONS: ULBT is good for predicting difficult intubation as a simple, single test. But because of it's low sensitivity, it seems better to incorporate ULBT as a factor of airway score tests for more reliable prediction.

Effects of Various Ventilatory Pattern of Upper Lung on Arterial Blood Gas Tension During Thoractomy / 대한마취과학회지

This study was understaken to observe the effects of various ventilatory patterns of the upper lung on pulmonary shunt fraction in the lateral decubitus position during thoractomy by assessing asterial blood gas. Twelve adult patients were intubated with Portex doube-lumen tube and the tidal volume, respiratory rare were maintained at 10ml/kg and 12/min, respectively, during anesthesia. Arterial blood gas was analyzed at 15min after beginning the following stages: 1) lateral decubitus position before the chest was opened: 2) surgical retraction of the upper lung after the chest was opened: 3) selective collapse of the upper lung while the lower lung is ventilated: 4) selective oxygen insuffiation to the upper lung(5L/min) with PEEP of 10 cmH2O. The results were as follows: 1) In stage 2, the value of PaO2 (173.6+/-21.4mmHg) was significantly decreased compared with that of stage 1 (267.5+/-32.6mmHg). 2) in the stage 3, the value of PaO2, PaCO2 and pH was 97.3+/-18.6mmHg, 48.85+/-3.33mmHg and 7.32+/-0.05, respectively, and showed a tendency toward respiratory acidosis. 3) In stage 4, the value of PaO2, was 129.8+/-18.6mmHg, and showed much improvement in arterial oxygenation compared with that of stage 3. 4) In all stages, there were no significant changes in blood pressure and heart rate except fro significant fall in blood pressure during stage 3.

Effects of 5 % Maltose in Lactated Ringers Solution on Blood. Glucose and pH during Operation / 대한마취과학회지

The purpose of this study is to compare the effects on blood glucose and pH of 5% maltose in lacated Ringer's solution with those of other solutions infused during operation. Ninety patients were divided into three groups according to the type of solutions: 5% maltose in lactated Ringer's solution(M/X Group, N=30), Lactared Ringer's solution(H/S Group, N=30) and 5% dextrose in lactated Ringer's solution (H/D Group, N=30). Blood sampling was done after each solution was infused at the rate of 5cc/kg/hr(N=15) and 10cc/kg/hr(N=15) for and hour. The results were as follows: 1) Blood glucose level following M/X solution infusion was slightly increased in contrast to the significant increase of blood glucose following H/D solution infusion(p<0.005). 2) Blood pH level following M/X solution infusion was not significantly changed regardless of infusion rate, but was significantly decreased following H/D solution infusion at the rate of 10cc/kg/hr(p<0.01).

Clinieal Effect of Thiopental-Thalamonal Induction During Intubation / 대한마취과학회지

Induction of general anesthesia with tracheal intubation has several advantages but also causes some cardiovascular side effects. Several approaches have been tried to reduce these side effects. As an attempt to reduce elevated blood pressure and increased heart rate during tracheal intubation, we used thiopental 3 mg/kg with Thalamonal 0.05 mg/kg (experimental group II, 30 cases) as an induction of general anesthesia inatead of the conventional use of thiopental 6 mg/kg(control group I, 30 caaes). The results are as follows:1. Blood pressure and heart rate changes between the 2 gruops at postintubation 30 sec. were statistically significant; 194+/-24 torr, 111+/-15/min. in control gruop and 166+/-29 torr (p<0.01), 102+/-14/min. (p<0.05) in experimental group. 2. There were no significant changes in blood pressure and heart rate at pre-intubation and post-extubation period. 3. The incidence of tachycardia and arrhythmia were more frequent in the control group, while hypotension and severe respiratory depression in experimental group.

The Effect of Cranial Pin Insertion on Blood Pressure and Heart Rate after Injecting Fentanyl and Esmolol or Thiopental Sodium and Esmolol / 대한마취과학회지

BACKGROUND: The placement of cranial pins into the periosteum is a acute noxious stimulation during intracranial surgery, which can result in sudden increases in blood pressure and heart rate, causing increases in intracranial pressure and other hemodynamic responses. We compared blood pressures and heart rates after injecting fentanyl and esmolol or thiopental sodium and esmolol to blunt hypertensive response. METHODS: Forty patients scheduled for a craniotomy were randomly divided into two groups: Intravenous (I.V.) bolus of fentanyl and esmolol group (n = 20) and the thiopental sodium and esmolol group (n = 20). After inducing general anesthesia with sevoflurane, nitrous oxide 50% and oxygen, an IV. bolus of either fentanyl and esmolol or thiopental sodium and esmolol was administered 2 minutes prior to the insertion of the cranial pin. Hemodynamic variables (systolic, diastolic, mean arterial pressure, and heart rate) were measured at 6 different time points; at baseline (drug administration), just before pinning, and at 30 seconds, and 1, 2, and 3 min after pinning. RESULTS: The fentanyl and esmolol group showed lower blood pressure and heart rate increases than the thiopental sodium and esmolol group at 30 sec and 1 min after cranial pin insertion compared with just before pinning. CONCLUSIONS: We conclude that I.V. fentanyl and esmolol 2 minutes prior to cranial pinning is more effective than I.V. thiopental sodium and esmolol at reducing blood pressure and heart rateincreases after cranial pinning.

Transfused Blood Volume in the Various Surgieal Operations / 대한마취과학회지

Blood transfusion is indicated the surgical patient to maintain circulating blood volume, provide adequate oxygenation, and maintain clotting factor levels. Anesthesiologists should known the time and vloume of blood transfusion in order to carry out transfusion effectively. We measure the amount of transfused blood and plasma expander used during general or spinal anesthesia surgery for four years(from Jan. 1977 to Dec. 1980) and obtained the following results. The total amounts of transfused blood were 6563 pints and those of plasma expander were 1769 bottles. The compansated amounts to blood loss were average 1044 ml in each case. The amounts of transfused blood used in each surgical dept. were different. The thoracic surgery department used the most averaging 4.76 pints and least in urologic dept. at 1.48 pints. The number of operations increased year after year but the average amount of transfused blood showed a decreasing tendency and that of plasma expander showed increasing tendency. The average compensated amounts for blood loss among the following operations were 831ml in a hysterectomy, 1089ml in a nephrectomy, 2244ml in a lobectomy, 1165ml in a craniotomy and 1313ml in a intramedullary nailing.

Effect of Preoperative Fasting on Blood Sugar and Blood Gas Analysis / 대한마취과학회지

Blood sugar and blood gas analysis changes caused by a 10 hour fast and a 15 hour fast were studied in sixtythree patients. In the 10 hour fast group, mean blood sugar level was 79.58+/-8.77mg/dl compared with the 15 hour fast group was 77.22+/-14.93 mg/dl. There were no remarkable changes on blood gas analysis for both the 10 hour fast group and 15 hour fast group. Neither age nor sex had any significant influence on blood sugar level or blood gas analysis. Thus, in order to make preoperative recommendations as well as to give appropriate intravenous fluids during and following operation, the anesthesiologist must be acquainted with the physiology of fasting.

Anesthetic Experience of Renal Transplantation / 대한마취과학회지

This report is of 81 anesthetic experiences of renal homotransplantation performed under general anesthesia from December 1984 to April 1988 at Kosin Medical Center. Our anesthetic procedures in the recipients were as follows: 1) Preanesthetic preparation with dialysis. 2) Premedication with Robinul and Demerol. 3) Thiopental and succinylcholine for anesthetic induetion. 4) N2O-O2-relaxant (pancuronium and/or norcuron) with halothane or enflurane for maintenance. 5) Antagonism against the relaxant with neostigmine or pyridostigmine. 6) Transfusion and fluid infusion with which CVP was maintained around 10 cm H2O. These patients had several common problems of significance to anesthesiologists, including anemia, coagulopathies, electrolyte imblance, acidosis, hytertension with associated therapy, previous therapy with steroids and immunosuppressants, and dialysis etc. As well as the problems listed above, we experienced a case of protrusion of a grafted kidney due to inadequate relaxation, several cases of bradycardia which did not respond to intravenous atropine during anesthesia, and 5 cases of delayed recovery of respiration.

Comparison of Sensory and Motor Blockade Effect of Tetracaine and Bupivacaine in Spinal Anesthesia / 대한마취과학회지

BACKGREOUND: Tetracaine has been the most commonly used spinal anesthetic agent. Recently bupivacaine has been found to be a useful agent, and has been reported not to cause neurologic complications as well as being a better quality anesthetic. The purpose of this study was to compare the anesthetic effects of bupivacaine with that of tetracaine. METHODS: Forty patients undergoing lower abdomen and lower limb operation were randomly allocated to two groups. Group I (n=20) received 15mg, 0.5% tetracaine in 10% dextrose, while Group II (n=20) received 15mg, 0.5% bupivacaine in 8% dextrose. After intrathecal injection of the agent at the level of L3-4 intervertebral space, the changes in sensory and motor block, blood pressure and heart rate were measured in two groups. RESULTS: The onset time of sensory block was more rapid in Group I than in Group II. Two segment regression time of sensory block was significantly longer in Group II than in Group I (p<0.05). The time for maximum motor block was shorter in group I than in Group II (p<0.05), but the duration of decreased motor block was significantly longer in Group I. The change of systolic blood pressure in Group II was less than the change in Group I. CONCLUSIONS: Bupivacaine has a longer sensory block duration, a weaker, shorter motor block duration and yields a less change in systolic blood pressure than tetracaine in spinal anesthesia.

A Case of Brachial Plexus Block in a Patient with Multiple Sclerosis / 대한마취과학회지

Multiple sclerosis is an acquired, demyelinating disease of the central nervous system Clinically, it is characterized by episodes of focal disorder of the optic nerves, spinal cord, and brain, which remit to a varying extent and recur over a period of many years. Because of the possibilities of neurologic exacerbation, general anesthesia is usually recommended, while spinal anesthesia is discouraged. Epidural anesthesia may be less of a risk than spinal anesthesia, because the concentration of local anesthetic in spinal cord white matter is lower. Other regional anesthesia is not likely to predispose postoperative exacerbation of multiple sclerosis, but a controlled study has not been performed. A 17 year-old female patient with advanced multiple sclemsis was successfully managed for internal fixation of ulnar fracture using brachial plexus block. The patient recovered well after block without any aggravation of neurologic symptoms.

The Influence of Deep Breathing and Encouraged Cough on the Arterial Oxygen Saturation in Patients Following Upper Abdominal Surgery / 대한마취과학회지

To investigate the effect of deep breathing and encouraged coughing on the arterial oxygenation in patients following upper abdominal surgery under general anesthesia, 80 patients were chosen and divided into 4 groups according to the therapy modalities given during the recovery mom care ; group 1: spontaneous recovery, group 2: oxygen, group 3: cough with deep breathing, and group 4: oxygen plus cough with deep breathing. Oxygen saturation (SpO2 by pulse oximeter) was monitored before anesthesia (control) and over a 24 hour period after operation. S values decreased on arrival in the recovery room after anesthesia in all groups (p<0.05). As patients awakened from anesthesia in the recovery room, SpO2 values were progressively increased to near preanesthetic values in the non-oxygen groups (Group 1, 3) and increased even above preanesthtic values in the oxygen groups (Group 2, 4) SpO2 values at 24-hours after operation were 97.0% in Group 1, 96.9% in Group 2, 97.8% in Group 3, and 97.5% in GRoup 4; therefore Group 3 had the highest value of SpO2 (p<0.05), In conclusion, deep breathing with cough encouragement in the recovery room seemed to be associated with better oxygenation 24 hours postanesthetically than supplemental oxygen or natural recovery groups.

Anesthetic Experience for Resection of Pheochromocytoma with Nitroprusside / 대한마취과학회지

Two cases of anesthetic experience for excision of pheochromocytoma were presented, one was diagnosed by abdominal computed tomography and urinary VMA level checked after cardiac arrest during previous anesthetic induction for gastric polypectomy at private clinic. The other case was diagnosed by upper GI series and abdominal sonography. Anesthesia was managed with glycopyrrolate and meperidine for premedication, thiopental for induction, isoflurane-nitrous oxide-oxygen for maintenance, pancuronium and vecuronium for muscle relaxation, and nitroprusside for controlling severe hypertensive episode. We experienced marked fluctuation of blood pressure during anesthetic course. Severe hypotension followed removal of tumor, which was corrected by rapid transfusion and infusion of crystalloids. Postanesthetic recovery and course were uneventful.

Anesthetic Experience for Resection of Pheochromocytoma with Nitroprusside / 대한마취과학회지

Two cases of anesthetic experience for excision of pheochromocytoma were presented, one was diagnosed by abdominal computed tomography and urinary VMA level checked after cardiac arrest during previous anesthetic induction for gastric polypectomy at private clinic. The other case was diagnosed by upper GI series and abdominal sonography. Anesthesia was managed with glycopyrrolate and meperidine for premedication, thiopental for induction, isoflurane-nitrous oxide-oxygen for maintenance, pancuronium and vecuronium for muscle relaxation, and nitroprusside for controlling severe hypertensive episode. We experienced marked fluctuation of blood pressure during anesthetic course. Severe hypotension followed removal of tumor, which was corrected by rapid transfusion and infusion of crystalloids. Postanesthetic recovery and course were uneventful.