The Attitudes of Anesthesiologists towards the Problems Associated with Pediatric Anesthesia

BACKGROUND: Anesthesiologist must be aware of the common problems that occur in pediatric anesthesia. The purpose of this survey was to collect information to help improve the quality of pediatric anesthesia by comparing the opinions of anesthesiologists that treat children and those that do not treat children. METHODS: A questionnaire surveying the attitudes of 103 anesthesiologists with regard to pediatric problems was analyzed. The questionnaire inquired about the number of years worked in field, the form of work and the responsibilities with regard to the pediatric anesthesia. Each question was rated from 1 (very infrequent) to 5 (very common) for the frequency of problems and from 1 (not importance) to 5 (very important) for the importance of the problem. Then we calculated the average of each item and combined the scores to obtain an average frequency and an average importance. RESULTS: The list of problems had high combined scores for preoperative anxiety (10.62), incision pain (9.59), postoperative agitation (9.53), hypothermia (9.40), and vomiting (9.30) for the pediatric anesthesiologist group. In addition, the problem list had high combined scores for propofol injection pain (11.25), preoperative anxiety (10.92), vomiting (10.17), hypothermia (9.44), and postoperative agitation (9.42) for the non-pediatric anesthesiologist group. CONCLUSIONS: The results of this study showed a difference in the pediatric and non pediatric anesthesiologist groups for propofol injection pain. Differences were noted for the average importance (2.34 : 2.80) compared to the average frequency (3.93 : 4.01). The pediatric anesthesiologists regarded propofol injection pain to be less of a problem than did the anesthesiologists who did not care for pediatric patients.

Comparison between Remifentanil and Nicardipine with Esmolol Continuously Infused for Attenuation of Hemodynamic Changes during Total Knee Arthroplasty in Elderly Patient / 대한마취과학회지

BACKGROUND: The use of tourniquet is associated with severe hemodynamic changes, particularly in elderly patients. This study examined the effects of continuously infused remifentanil or nicardipine with esmolol on the attenuation of the hemodynamic changes with enflurane inhalation during total knee arthroplasty in elderly patients. METHODS: Thirty elderly female patients undergoing total knee arthroplasty were enrolled into this randomized, prospective study. Remifentanil (group R) or nicardipine with esmolol (group EN) was infused using a titration method to maintain a mean arterial pressure (MAP) of 90 mmHg to 70 mmHg during tourniquet inflation. In addition, the inhalation of enflurane was adjusted to guarantee a hypnotic state based on entropy. The hemodynamic variables, inhaled concentration of enflurane, recovery time, and postoperative pain characteristics were measured and compared. RESULTS: Following tourniquet inflation, the MAP was increased and maintained in the target since 20 min after that in both group. Following tourniquet deflation the MAP was decreased significantly in both groups and more patients in group R required a vasopressor. Group R inhaled a lower enflurane concentration and showed more rapid recovery than group EN. There were no significant differences in the level of postoperative pain between the two groups. CONCLUSIONS: These results suggest that remifentanil is more likely to be associated with hypotension after tourniquet deflation and require more attention than nicardipine with esmolol.

The Experience of One Day Surgery in Pediatric Patients

One day surgery in children has been practiced for last 10 years in this institution. This study is to examine its safety and effectiveness for patients younger than 15 years old treated at the Department of Pediatric Surgery, Asan Medical Center, from September. 1996 to December, 2005. A total of 3,709 patients, 37 % of the total pediatric operations, are included in this retrospective study. The most prevalent ages were between 1 and 3 years olds (1,199 patients). Twenty patients were younger than 6 months, and they all had one day surgery safely. Operations were herniorrhaphy in 3,126 patients,followed by excisional biopsy, chemoport removal, and OK 432 injection. There were 12 cases (0.32 %) of unplanned admissions, 7 occurred within 6 months of one day surgery. Perioperative fever was the most common cause of admission in 4 cases. The related conditions of unplanned admission were bleeding in 2 cases and radical surgery in 2. One day surgery in this institution was easily accessible and safe. This is to the result of appropriate selection of patients, cooperation with anesthesiologists, adequate control of postoperative pain, and home care programs.

Entropy Responses to Endotracheal Intubation during Anesthetic Induction Using Thiopental or Propofol and Succinylcholine / 대한마취과학회지

BACKGROUND: Thiopental and propofol are commonly used intravenous induction agents and entropy is a new method of assessing depth of anesthesia. In this study we evaluated the entropy responses to endotracheal intubation during anesthetic induction with thiopental or propofol. METHODS: Forty ASA class I and II adult female patients undergoing elective surgeries were enrolled into this randomized, prospective study. At 1 minute after fentanyl 2 microgram/kg, thiopental 5 mg/kg (group T) or propofol 2 mg/kg (group P) was administered for induction. And endotracheal intubation was performed following succiny choline 1 mg/kg. From pre-induction till post-intubation 10 minutes, the entropy and hemodynamic variables were measured and compared. RESULTS: The entropy following intubation increased significantly in both groups. But entropy changes in group T were greater than those in group P remained below 65. CONCLUSIONS: Our results using the entropy to monitor anesthetic depth during induction and intubation, suggest that thiopental 5 mg/kg is more likely to be associated with lighter planes of anesthesia and consequent risk of arousal reaction following endotracheal intubation than propofol 2 mg/kg.

Effects of Fluid Therapy on Serum Glucose Level in Pediatric Outpatients / 대한마취과학회지

BACKGROUND: Whether intraoperative fluid therapy should contain glucose for the pediatric outpatient surgery remains controversial. This study was designed to compare the effects of glucose and glucose-free solutions on perioperative blood glucose change. METHODS: Healthy pediatric outpatients (n = 130) for minor procedure were randomly assigned to one of two fluid therapy groups. Patients in the group H (n = 65) received lactated Ringer's solution, and patients in the group D (n = 65) received 5% dextrose perioperatively. Blood glucose was checked before infusion (a), 10 minutes after induction (b), 30 minutes after induction (c), and at the time of discharge (d). RESULTS: The preoperative fasting glucose concentrations were 97.6 +/- 12.1 mg/dl and 97.7 +/- 11.3 mg/dl for the group H and D, respectively. The patients in the group D showed significantly increased blood glucose level after induction (135.9 +/- 42.7, 150.3 +/- 36.0, 123.6 +/- 26.8 mg/dl). The patients in the group H also showed significantly increased blood glucose levels (112.2 +/- 14.0, 121.4 +/- 11.4 and 105.8 +/- 18.3 mg/dl). The glucose level of group D was significantly higher than the glucose level of group H at b, c and d. Seven patients in the group D showed hyperglycemia (> 200 mg/dl). CONCLUSIONS: Dextrose containing fluid therapy resulted dangerous hyperglycemia in the pediatric outpatient surgery. We recommend lactated Ringer's solution or other glucose-free crystalloid for the healthy outpatient pediatric population undergoing minor procedures.

Effects of Poly (ADP-ribose) Polymerase Inhibitor on Hypoxic-ischemic Injury in the Neonatal Rat Brain: 1H Magnetic Resonance Spectroscopic Study / 대한마취과학회지

BACKGROUND: Poly (ADP-ribose) polymerase (PARP) has been described as an important candidate for mediation of neurotoxicity after brain ischemia. This study was purposed to evaluate the effects of a PARP inhibitor on hypoxic-ischemic injury in the neonatal rat brain. In this study, a highly potent inhibitor of PARP, 3, 4-Dihydro-5-[4-(1-piperidinyl) butoxy]-1 (2H)-isoquinolinone (DPQ) was investigated. METHODS: Seven-day old Sprague-Dawley rat pups were used. The right common carotid artery was ligated under halothane anesthesia. After a recovery period of 3 hours, they were exposed to 8% oxygen at 37degreesC for about 120 minutes. The animals were divided into four groups: the pre-treatment group (n = 13) and post-treatment group (n = 21) were given DPQ 10 mg/kg and the pre-control group (n = 7) and post-control group (n = 14) were given a vehicle for controls. Pre-treatment and pre-control groups were injected 30 minutes prior to the hypoxic injury while post-treatment and post-control groups were injected 30 minutes after the hypoxic period intraperitoneally. The right cerebral hemisphere of the rats were examined with localized (1)H magnetic resonance spectroscopy on day 1 and 7 after the hypoxic insult. Lipid/N-acetyl aspartate (Lip/NAA) and lipid/creatine (Lip/Cr) ratios were used as apoptotic markers. On day 14, the degree of brain injury was scored by morphological changes. RESULTS: In the DPQ treated groups, the Lip/NAA and Lip/Cr ratios were lower than those of the control groups on day 1 after the hypoxic-ischemic injury (P < 0.05). However on day 7, only the ratios of the pre-treatment group were lower than those of the control group (P < 0.05). The degree of morphological changes of the brain injury on day 14 were lower in the DPQ treated groups (P < 0.05). CONCLUSIONS: These results suggest that DPQ exerts a neuroprotective effect in cerebral hypoxic-ischemic injury probably by inhibiting apoptosis especially in the early stage after an insult. Acute inhibition of PARP can have a therapeutic value in preventing ischemic brain injury.

The Relation between Tourniquet Hypertension and Bispectral Index in Patients Undergoing a Total Knee Arthroplasty / 대한마취과학회지

BACKGROUND: Tourniquet hypertension (TH) may develop from an autonomic reflex consequent to the sensitization of the central nervous system (CNS) due to ischemia of the affected limb and noxious surgical stimulation. TH could be preventable when anesthetic depth is sufficient enough to block plastic changes of the CNS during an operation. This study was aimed to evaluate the efficacy of the bispectral index (BIS) to predict development of TH by assessing correlations between BIS changes and hemodynamic changes during the skin incision. METHODS: Sixty patients who had undergone a total knee arthroplasty with a pneumatic tourniquet during isoflurane anesthesia were selected, and the samples were randomly divided into two groups: BIS 30 (30 - 39) and BIS 40 (40 - 49). Several variables such as BIS, mean arterial pressure (MAP), heart rate (HR) and end tidal concentraion of isoflurane were monitored during the operation. TH was defined as more than a 30% increase in MAP compared with the baseline values during the skin incision. The correlation between BIS changes and MAP and HR changes, and the incidence of TH between BIS groups were compared. RESULTS: The MAP and HR were meaningfully increased in both the BIS 30 and the BIS 40 groups (P < 0.05), but no significant correlations were found between the BIS changes and the MAP and HR changes during the skin incision. The incidence of intraoperative hypertension was not different between the BIS groups. The BIS of the patients who had TH was not different from those who did not have TH. CONCLUSIONS: BIS may not reflect the changes of the CNS and autonomic nervous system induced by noxious surgical stimulation during an operation, and BIS changes during a skin incision cannot be a predictor of TH.

Hemodynamic Response to a Rapid Fluid Challenge in End-Stage Liver Disease / 대한마취과학회지

BACKGROUND: Patients with end-stage liver disease have a hyperdynamic circulatory state complicated by a high right ventricular end-diastolic volume index (RVEDVI) and a low ventricular performance. These changes often make if difficult to evaluate volume status and preload. In this study, we analyzed hemodynamic profiles after a rapid fluid challenge in the recipients of a liver transplant. METHODS: Hemodynamic responses were evaluated before and after 200 ml of a 5% albumin challenge in forty patients, recipients of a liver transplant with a Swan-Ganz right-heart ejection fraction oximetry thermodilution cathether. Patients were divided into two groups, group A (responders, n=12, >or= 10% increase in stroke volume index (SVI) after fluid challenge) and group B (non-responders, n = 28, decrease or < 10% increase in SVI after fluid challenge). We analyzed hemodynamic data obtained from the two groups before and after the fluid challenge. RESULTS: Group B had a lower baseline right ventricular ejection fraction (REF) (49.9+/-5.9% vs 42.8+/-5.7%), a higher RVEDVI (120.8+/-19.4 ml/m2 vs 143.6+/-26.3 ml/m2), and a higher right ventricular end-systolic volume index (RVESVI) (60.8+/-14.0 ml/m2 vs 82.8+/-20.5 ml/m2) than group A. In group B, the cardic index (CI) and right ventricular stroke work index (RVSWI) were not increased after the fluid challenge. There was a mild decrease in the mean arterial pressure (MAP) in group B after the fluid challenge. There was a moderate negative correlation between the fluid-induced change in SVI and the baseline RVEDVI in all patients (r =-0.40, P<0.05). CONCLUSIONS: Our study suggests that there is no improvement of hemodynamic profiles after a rapid fluid challenge in many patients with end-stage liver disease, especially those with a high RVEDVI.

Protective Effect of Etomidate on Kainic Acid-induced Neurotoxicity in Rat Hippocampus / 대한마취과학회지

BACKGROUND: The present investigation was undertaken to evaluate the neuroprotective effect of etomidate against kainic acid (KA) induced neurotoxicity in rats by using the immunoreactivity of heat shock protein-70 (HSP-70) and the acid-fuchsin stain. METHODS: Administration of etomidate (20 mg/kg, I.P.) was performed in sequence; first being just one hour after a KA (10 mg/kg, I.P.) injection, then three more times at one hour intervals. Neuronal damages in the hippocampus were evaluated by using the acid-fuchsin stain to detect cell death and HSP-70 induction as an index of cell injury at 24 h after the administration of KA. RESULTS: HSP-70 induction and acid fuchsin positive neurons were increased in the CA1 and CA3 regions of the hippocampus after a KA injection but significantly decreased by an injection of etomidate (P < 0.01). CONCLUSIONS: These results suggest that the etomidate has a potential effect on the protection of neurons against KA-induced neurotoxicity.

Effects of Pentoxifylline on Hemorrhagic Shock in Cats / 대한마취과학회지

It was reported that pentoxifylline(PTX) improved tissue oxygenation and increased survival rate in animal models of hemorrhagic shock. The authors investigated the salutary effects of PTX on hemodynamics, oxygen transport and tissue metabolism in animal models of hemorrhagic shock. 18 anesthetized cats were subjected to hemorrhage to MABP of 40-45 mmHg and this pressure was maintained for 120 minutes. After this period, normal saline was administered in a volume double the original shed blood volume over 30 minutes. Thereafter the cats were observed for 120 minutes. Drug-treated cats received at 25 mg/kg i.v. bolus of PTX at the beginning of hemorrhage, followed by a continuous infusion of 25 mg/kg/hr throughout the experiment. PTX had no effect on MABP, pH(a-cv), P(cv-a) CO2 and lactic acid value but, PTX group had more rapid HR and higher PcvO, than placebo group(P<0.05). In addition, we found that pH(a-cv) and P(cv-a) CO2 changes occurred more rapidly than lactic acid changes(P<0.05) after hemorrhagic shock. So, pH(a-cv) and P(cv-a) CO2 changes might be considered as useful parameters for early detection of derangement of tissue oxygenation in shock states. It was concluded that PTX had no effects on indices of representing tissue oxygenation except improvement of central venous oxygen tension in this feline hemorrhagic shock model. Further studies are needed.

Guideline for the Optimal Blood Ordering for Elective Surgery / 대한마취과학회지

In this study, the authors would like to establish the guideline for effective utilization of blood and blood components in various elective surgeries. We investigated the amount of tansfused blood and blood components units, C/T ratio (crossmatching to transfusion ratio), disused rate of blood ordered in 861 elective surgery cases during the period from October I990 to September 1991. overall mean units of transfusional units per patient were 5.3 units and overall C/T ratio was 1.14. Of all the transfusional units the ratio of whole blood was 51.5%, packed red blood cell was 7%, fresh frozen plasma was 41% respectively. From this study, the guideline for the optimal blood ordering for each elective surgery was made.