제왕절개술을 위한 전신마취 중 각성

최성욱 대한마취통증의학회 2012 Anesthesia and pain medicine Vol.7 No.1

Awareness during general anesthesia or intraoperative awareness is defined as the unexpected recall of events that occur during anesthesia by patients who receive general anesthesia. The objectives of general anesthesia for cesarean delivery are to keep mother and fetus adequately oxygenated, while limiting drug transmission across the placenta and maintaining maternal comfort. Therefore, the obstetric population is considered at high risk of awareness and recall when undergoing general anesthesia for cesarean delivery. Today, the incidence of awareness during cesarean delivery was reduced to approximately 0.26%, but it remains an undesirable complication with potential for the development of posttraumatic stress disorder. This review examines the recent knowledge of definition, causes, and prevention of awareness during general anesthesia for cesarean delivery. 제왕절개술을 위한 전신마취의 경우 마취 중 각성의 고위험군에 속하지만 적절한 평가와 면담을 통해 환자에게충분히 설명하고, 마취 기계나 약물의 내용물과 용량을 수시로 점검하며 수술 중 주의 깊게 환자를 감시하는 등 마취의 기본적인 원칙을 잘 지키는 것만으로도 그 빈도를 감소시킬 수 있다. 흡입마취제 0.8−1.0 MAC 이하에서는 oxytocin에대한 자궁의 수축력은 잘 유지되므로 적절한 마취를 위해서 충분한 범위의 흡입마취제를 투여하는 것이 바람직하다. 하지만 불가피하게 마취 중 각성이 발생했다면이후 환자의 장기간의 후유증을 줄이기 위해 설명과 상담등을 통해 적절히 대처하는 것이 중요하다.

전신마취하 유양골삭개술시의 혈중 ADH (antidiuretic hormone)의 변화

김효은,박윤곤,진홍용,조민수,길혜금 대한마취통증의학회 2006 Korean Journal of Anesthesiology Vol.50 No.3

Background: Markedly reduced urine have been commonly observed during mastoidectomy under general anesthesia. The aim of study was to evaluate the surgery-related mechanism of reduced urine during mastoidectomy. Methods: 11 patients undergoing mastoidectomy were studied. Blood samples were drawn from CVP line inserted through right internal jugular vein just before drilling (Pre-D); at 15 min after drilling (D-15); at the time closest to the inner ear (CHP-1); at 15 min (CHP-2) and 30 min (CHP-3) after CHP-1 and just before emergence (End). MAP, HR, temperature, CVP, and urine output (UO) were recorded at each period. 0.9% normal saline with room temperature was used to irrigate surgical field. Serum ADH, and the osmolalities (serum and urine) were measured. In 6 patients, serum TSH and FSH were measured, simultaneously. Results: There were no significant hemodynamic changes during procedure. UO was decreased in 50% during and after the drilling. No differences showed in UO between before and after the drilling of CHP. Plasma ADH level after the CHP was increased 2-3 fold than before. Serum osmolality was unchanged throughout the periods, while the urine osmolality was significantly increased after the period of CHP. FSH was not changed during the periods and TSH was decreased slightly than in Pre-D. Conclusions: The reduced urine output during mastoidectomy may be influenced by the drilling-related vibration, which may affect the supraoptico-hypophyseal tract, resulting in ADH release. The irrigated isotonic saline with higher osmolality (308 mOsm/kgH2O) than plasma osmolality may partly contributed to the increased ADH. (Korean J Anesthesiol 2006; 50: 296~301) 전신 마취로 수술을 받는 유양골 삭개술 환자에서는 수술적 조작인 드릴의 진동 자체의 영향과 관주액에 의한 국소적 삼투질 농도의 변화가 후뇌하수체로부터의 ADH 분비증가에 영향을 줌으로써 소변량이 더욱 저하될 가능성이 있는 것으로 여겨진다. 그러므로 유양골 삭개술의 마취동안 적절한 약제 선택과 적정마취깊이, 충분한 수액 투여를 유지함으로써 체내 신경 내분비계 호르몬의 급격한 변화를 예방해야 하며 이에 대한 추 후 연구가 필요한 것으로 생각된다.

모니터 파형 해석과 생체 정보

심지연,안원식 대한마취통증의학회 2007 Korean Journal of Anesthesiology Vol.52 No.5

심전도나 이산화탄소 파형은 상대적으로 많은 정보를 임상가에게 주고 있다. 반면, 시간에 따른 변화를 압축하여 단순히 상수값을 사용하는 동맥압이나 맥박산소포화도는 상대적으로 적은 정보를 임상가들에게 제공한다. 그러므로, 이러한 파형에 대한 연구를 활성화하여 이들을 임상에 이용한다면 보다 정확하게 환자의 상태를 파악할 수 있어 양질의 진료를 수행하는 데 도움을 줄 수 있을 것으로 생각된다.저자: 심지연·안원식*울산대학교 의과대학 서울아산병원 마취통증의학교실,*서울대학교 의과대학 서울대학교병원 마취통증의학과서울시 종로구 연건동 28, 우편번호: 110-744E-mail: aws@snu.ac.kr

소아환자의 마취와 연관된 문제점들에 대한 마취통증의학과 전문의들의 의식조사

황태후 대한마취통증의학회 2008 Anesthesia and pain medicine Vol.3 No.3

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.

Lead fracture of peripheral nerve stimulator for brachial plexopathy -a case report-

최서정,채지선,김윤진,전진영,문호식 대한마취통증의학회 2018 Korean Journal of Anesthesiology Vol.71 No.5

Peripheral nerve stimulation (PNS) is a useful treatment for chronic pain, but it can cause damage depending on its application site. Here, we describe the case of a 54-year-old man who underwent PNS for brachial plexopathy in 2015. One lead was implanted on the left medial cord to stimulate the medial antebrachial cutaneous nerve, and the other was implanted on the radial nerve to stimulate the posterior antebrachial cutaneous nerve. Both leads were inserted near the shoulder joint but did not cross it. Before PNS, the patient did not move his shoulder and elbow because of severe pain, but the treatment greatly alleviated this pain. Twenty months after the operation, both leads were fractured, and the severe pain returned. Repetitive motion near the joint was closely related to the lead fractures. In conclusion, large joints as the insertion sites of PNS leads should be avoided to prevent lead fractures.

A bench study comparing between scalpel-bougie technique and cannula-to-Melker technique in emergency cricothyroidotomy in a porcine model

See Seong Chang,Qian Jun Tong,Zhi Yuen Beh,Kelvin Howyow Quek,Bun Hui Ang 대한마취통증의학회 2018 Korean Journal of Anesthesiology Vol.71 No.4

Background: The ideal emergency cricothyroidotomy technique remains a topic of ongoing debate. This study aimed to compare the cannula-to-Melker technique with the scalpel-bougie technique and determine whether yearly training in cricothyroidotomy techniques is sufficient for skill retention. Methods: We conducted an observational crossover bench study to compare the cannula-to-Melker with the scalpel- bougie technique in a porcine tracheal model. Twenty-eight anesthetists participated. The primary outcome was time taken for device insertion. Secondary outcomes were first-pass success rate, incidence of tracheal trauma, and technique preference. We also compared the data on outcome measures with the data obtained in a similar workshop a year ago. Results: The scalpel-bougie technique was significantly faster than the cannula-to-Melker technique for cricothyroidotomy (median time of 45.2 s vs. 101.3 s; P = 0.001). Both techniques had 100% success rate within two attempts; there were no significant differences in the first-pass success rates and incidence of tracheal wall trauma (P > 0.999 and P = 0.727, respectively) between them. The relative risks of inflicting tracheal wall trauma after a failed cricothyroidotomy attempt were 6.9 (95% CI 1.5–31.1), 2.3 (95% CI 0.3–20.7) and 3.0 (95% CI 0.3–25.9) for the scalpel-bougie, cannula-cricothyroidotomy, and Melker-Seldinger airway, respectively. The insertion time and incidence of tracheal wall trauma were lower when the present data were compared with data from a similar workshop conducted the previous year. Conclusions: This study supports the use of a scalpel-bougie technique for cricothyroidotomy by anesthetists and advocates a yearly training program for skill retention.

Effects of acute kidney injury after liver resection on long-term outcomes

Seiji Ishikawa,Manami Tanaka,Fumi Maruyama,Arisa Fukagawa,Nobuhiro Shiota,Satoshi Matsumura,Koshi Makita 대한마취통증의학회 2017 Korean Journal of Anesthesiology Vol.70 No.5

Background: To investigate the effects of acute kidney injury (AKI) after liver resection on the long-term outcome, including mortality and renal dysfunction after hospital discharge. Methods: We conducted a historical cohort study of patients who underwent liver resection for hepatocellular carcinoma with sevoflurane anesthesia between January 2004 and October 2011, survived the hospital stay, and were followed for at least 3 years or died within 3 years after hospital discharge. AKI was diagnosed based on the Acute Kidney Injury Network classification within 72 hours postoperatively. In addition to the data obtained during hospitalization, serum creatinine concentration data were collected and the glomerular filtration rate (GFR) was estimated after hospital discharge. Results: AKI patients (63%, P = 0.002) were more likely to reach the threshold of an estimated GFR (eGFR) of 45 ml/ min/1.73 m2 within 3 years than non-AKI patients (31%) although there was no significant difference in mortality (33% vs. 29%). Cox proportional hazard regression analysis showed that postoperative AKI was significantly associated with the composite outcome of mortality or an eGFR of 45 ml/min/1.73 m2 (95% CI of hazard ratio, 1.05–2.96, P = 0.033), but not with mortality (P = 0.699), the composite outcome of mortality or an eGFR of 60 ml/min/1.73 m2 (P = 0.347). Conclusions: After liver resection, AKI patients may be at higher risk of mortality or moderate renal dysfunction within 3 years. These findings suggest that even after discharge from the hospital, patients who suffered AKI after liver resection may need to be followed-up regarding renal function in the long term.

Dexamethasone alone versus in combination with intra-operative super-hydration for postoperative nausea and vomiting prophylaxis in female patients undergoing laparoscopic cholecystectomy: a randomized clinical trial

Eman A. Ismail,Sayed Kaoud Abd-Elshafy,Mohamed H. Bakri 대한마취통증의학회 2017 Korean Journal of Anesthesiology Vol.70 No.5

Background: Dexamethasone has a prophylactic effect on postoperative nausea and vomiting (PONV) and perioperative hydration is believed to play a role in PONV prophylaxis. This study was performed to examine the combined effects of pre-induction dexamethasone plus super-hydration on PONV and pain following laparoscopic cholecystectomy (LC). Methods: A total of 100 female patients undergoing LC were enrolled and randomized equally into two groups. Group DF received 5 mg dexamethasone (pre-induction) plus 30 ml/kg Ringer’s lactate (intraoperative) and group D received 5 mg dexamethasone (pre-induction) alone. Anesthetic and surgical managements were standardized for all patients. The incidence and severity of PONV, and intra and post-operative analgesic and postoperative antiemetic consumption, were assessed during the first 24 h postoperatively. Post-anesthesia care unit (PACU) stay and aggregated 24 h pain scores were calculated. Results: Group DF had significantly lower PONV than group D (P = 0.03). The number of patients with the lowest PONV score was significantly increased in group DF (P = 0.03). Ondansetron consumption was significantly lower in group DF (P < 0.0001). The mean accumulated 24 h pain scores were significantly lower in group DF compared to group D (P < 0.0001). The time to first analgesic request was significantly longer in group DF than group D (P < 0.0001). In addition, total meperidine consumption during the first postoperative 24 h was significantly lower in group DF than group D (P = 0.002). Conclusions: In female patients undergoing LC, pre-induction with 5 mg dexamethasone plus intraoperative 30 ml/kg Ringer’s lactate solution decreased PONV and pain during the first 24 h postoperatively compared to 5 mg dexamethasone alone.

Role of WhatsApp-based discussions in improving residents’ knowledge of post-operative pain management: a pilot study

Sumitra G. Bakshi,Pranay Bhawalkar 대한마취통증의학회 2017 Korean Journal of Anesthesiology Vol.70 No.5

Background: To provide a platform for the dissemination of basic knowledge of pain management, a WhatsApp group was created by residents and consultants. Common clinical scenarios, resident queries, and important instructions to be followed by residents with respect to running the Acute Pain Service were discussed in the group. This study evaluates the benefits of this interaction. Methods: This study was approved by the hospital ethics board and was registered with the Clinical Trial Registry of India. Second- and third-year anesthesia residents were included in a WhatsApp group, along with consultants (board certified anesthesiologists with a special interest in pain). Pain knowledge assessment was performed pre- and postdiscussion using a standard 22-point questionnaire. A feedback form, which included self-rated confidence scores (1–10, 10-most confident) and opinions about the 3-month WhatsApp discussion, was collected. Improvements in the documentation in clinical sheets post-discussion were also analyzed. Results: A total of 38 residents were included in the WhatsApp group. An improvement in the percentage of correct answers from 69.1% (pre-discussion) to 73.6% (post-discussion) was observed (P = 0.031). Improvements in the self-rated residents’ confidence levels were also noted (P < 0.05). A total of 37 residents felt that the WhatsApp-based discussion was useful. Documentation of the details of epidural blockade in clinical sheets improved from 30% to 100%. Conclusions: The WhatsApp discussion improved residents’ knowledge and confidence levels, and also resulted in improved documentation of essential details in the clinical notes. This form of education is promising and should be explored in future studies.

A comparison of palonosetron and dexamethasone for postoperative nausea and vomiting in orthopedic patients receiving patient-controlled epidural analgesia

김병건,양춘우,김현주,임현경,오소라,이병욱 대한마취통증의학회 2017 Korean Journal of Anesthesiology Vol.70 No.5

Background: Postoperative nausea and vomiting (PONV) is one of the major concerns after anesthesia and surgery, and it may be more frequent in orthopedic patients receiving patient-controlled epidural analgesia (PCEA). The purpose of this study was to compare the effect of palonosetron and dexamethasone on the prevention of PONV in patients undergoing total joint arthroplasty and receiving PCEA. Methods: Patients scheduled for total hip or knee arthroplasty under spinal anesthesia/PCEA were randomly allocated to receive either intravenous palonosetron (0.075 mg, n = 50) or dexamethasone (5 mg, n = 50). Treatments were administered intravenously to the patients 30 min before the beginning of surgery. The total incidence of PONV and incidence in each time period, severity of nausea, need for rescue anti-emetics, pain score, and adverse effects during the first 48 h postoperatively were evaluated. Results: The total incidence of PONV was lower in the palonosetron group compared with the dexamethasone group (18.4% vs. 36.7%, P = 0.042), but there were no statistically significant differences in incidence between the groups at all time points. No significant intergroup differences were observed in the severity of nausea, use of rescue anti-emetics, pain score, and adverse effects. Conclusions: Although there were no significant differences in the incidence of PONV between the treatment groups at all time points, intravenous palonosetron reduced the total incidence of PONV in orthopedic patients receiving PCEA compared with dexamethasone.