A 75-year-old male patient with a left intertrochanteric fracture underwent emergency total hip arthroplasty under spinal anesthesia. He had an operation for laryngeal cancer about 10 years ago. Bronchiectasis and atelectasis were noticed in his preoperative roentgenogram. He underwent spinal anesthesia with 13 mg of 0.5% isobaric tetracaine. The level of spinal anesthesia was T7. The SpO2 (oxygen saturation of pulse oxymeter) decreased to 55% at 1 hour after start of operation. Breath sounds on the right lung were diminished. Tracheal intubation was performed for endotracheal suction. A large amount of yellowish secretion was aspirated through suction catheter. The SpO2 returned to 98%. We report a case of severe hypoxemia due to inability of expectoration in patient with bronchiectasis who underwent spinal anesthesia.
Aged ; Anesthesia, Spinal* ; Anoxia* ; Arthroplasty, Replacement, Hip ; Bronchi* ; Bronchiectasis* ; Catheters ; Emergencies ; Humans ; Intubation ; Laryngeal Neoplasms ; Lung ; Male ; Pulmonary Atelectasis ; Suction ; Tetracaine

BACKGROUND: Clonidine, an 2-adrenergic agonist, shows the analgesic effect and potentiates the analgesic effect of opioid. However, when it is injected with bolus technique, it reveals the short duration of inadequate analgesia and induces hypotension, bradycardia or sedation. We examined the analgesic and side effects of clonidine administered by continuous epidural infusion over 24 hrs, following epidural morphine injection. METHODS: Sixty parturients, scheduled for elective cesarean section under epidural anesthesia were randomly allocated into three groups. They received an infusion of saline alone (group 1, n= 20), clonidine 20 g/hr (group 2, n= 20), or 40 g/hr (group 3, n= 20) respectively, following epidural morphine 3 mg injection at the end of operation. The total doses and number of request for supplemental analgesic, blood pressure, heart rate, and degree of sedation were measured during 24 hrs. RESULTS: There were significant differences in pain relief between clonidine groups and group 1. The total doses and number of patient's request for supplemental analgesic in clonidine groups, compared to group 1 were significantly decreased (p<0.05), but no significant differences between the two clonidine groups. The diastolic pressure of group 3 was significantly lower than that of group 1 over 24 hrs, and that of group 2 at 18 hr, 24 hr (p<0.05). However, there was no severe hypotension, bradycardia or sedation in the three groups. CONCLUSION: Clonidine administered by continuous epidural infusion over 24 hrs enhances the analgesic effect of epidural morphine, and the infusion of clonidine with 20 g/hr rather than 40 g/hr shows minimal changes of blood pressure. Therefore, administration of epidural clonidine (20 g/hr) following epidural morphine may be considered as a regimen for pain management after cesarean section.
Analgesia* ; Anesthesia, Epidural ; Blood Pressure ; Bradycardia ; Cesarean Section* ; Clonidine* ; Female ; Heart Rate ; Hypotension ; Morphine ; Pain Management ; Pregnancy

"Background: In using the Double-lumen tube (DLT), knowing the minimum bronchial cuff volume (MCV) for an effective air-tight seal will be useful; to provide a collapse of the lung; and to avoid pressure damage. The aims of the present study are thus three-fold: to measure the MCV; to measure the diameter of left main bronchus (LMBD); and to prove any relationships between two parameters. METHODS: One hundred men and forty women who needed intubation of left-sided DLT were enrolled in this study. 37 Fr DLTs were used in male patients, and 35 Fr DLTs were used in female patients. We evaluated the MCV by air bubble method and measured the LMBD in chest PA. We also evaluated the pressure/volume characteristics of the bronchial cuffs by control inflator. RESULTS: 29 patients of 100 patients (29%) exhibited persistent air leakage in 2.5 ml cuff volume in male patients (group of MCV >2.5). On the contrary, 18 patients of 40 patients (45%) did not require any cuff volume in female patients (group of MCV 0). The mean LMBD were 13.23 1.45 mm in male and 11.09 0.96 mm in female. There were significant positive correlations between MCV and LMBD in both sex and their respective correlation coefficients were 0.264 (P=0.008) in male and 0.484 (P=0.002) in female. The equations of linear regression were: LMBD = 12.394 0.429xMCV in male, LMBD = 10.725 0.438xMCV in female. CONCLUSIONS: The MCV of the brochial cuffs in left-sided DLTs has significant relationships with the LMBD measured in chest PA.
Bronchi ; Female ; Humans ; Intubation ; Linear Models ; Lung ; Male ; Thorax

BACKGROUND: Hemodilution reduces the concentration of clotting factors in blood and this may induce some degree of impairment of coagulation. But there are some evidence that hemodilution may induce a hypercoagulable state. The goal of this study is to investigate the changes of coagulation status during progressive hemodilution. METHODS: Whole Blood was diluted by 10% increment to 80% with 0.9% normal saline. At each 10% dilution blood coagulation status was analysed using thrombelastography (TEG) and was compared with that of an undiluted control specimen obtained concurrently from the same patients. RESULTS: Hemodilutions up to 40% decrease r and K times and increase values of MA and angle. Hemodilutions more than 70% increase r and K times and decrease values of MA and angle. CONCLUSIONS: Hemodilutions up to 40% increase coagulability and hemodilutions more than 70% decrease coagulability of whole blood in vitro.
Blood Coagulation ; Hemodilution* ; Humans ; Thrombelastography

BACKGROUND: Prolonged extracorporeal circulation entails tremendous threats of red cell lysis, severe bleeding problems due to platelet injury and activation, and endothelial damages by sequestered leukocytes. In consideration of these problems, a new centrifugal pump was developed and tested clinically to evaluate its effectiveness. METHODS: We compared the effects of a centrifugal pump with those of a roller pump on hematological responses during cardiopulmonary bypass (CPB) in 20 coronary artery bypass surgery patients. The patients were divided into two groups of 10 each. The studied parameters included WBC counts, platelet counts, plasma Hb and D-dimer. Blood samples were taken after sternotomy, at 60 min, 120 min and 180 min after CPB start, and at 2 hr after CPB stop. RESULTS: No differences between the groups were found in bypass time, aortic cross clamp time, extracorporeal circulation flow and hematocrit. The centrifugal pump group demonstrated less platelet depletion (p<0.05), hemolysis (plasma Hb, p<0.05) and fibrinolysis (D-dimer, p<0.05). These differences were CPB time dependent and became statistically significant after 120 min bypass. CONCLUSION: We conclude that roller pump still can be safely used for standard cardiac procedures with bypass time less than 120 minutes and the centrifugal pump has significant potential to be safely applied to CPB for long ypass time in order to avoid postperfusion syndrome.
Blood Platelets ; Cardiopulmonary Bypass* ; Coronary Artery Bypass ; Extracorporeal Circulation ; Fibrinolysis ; Hematocrit ; Hemolysis ; Hemorrhage ; Humans ; Leukocytes ; Plasma ; Platelet Count ; Sternotomy

BACKGROUND: Ambulatory surgery has the advantages of reduced demand for postoperative medications, faster recuperation, less disruption to personal life and reduced hospital costs. At present, 60-70% of surgery in North America is performed on an ambulatory basis. DSC (day-surgery center) was opened on March 1995 in our hospital. We want to introduce an experience in anesthesia for ambulatory surgery. METHODS: Ambulatory surgeries were reviewed from March 1995 to July 1996. Total ambulatory surgeries were 5,593 cases. The medical records of 1,816 patients who were anethetized by anesthesiologists for ambulatory surgery were an alyzed retrospectively (3,777 patients who were operated under local anesthesia were excluded). RESULTS: The rate of utility was 14.1% on March 1995 and 27.7% on January 1996. The mean rate of utility was 22.2% per month in DSC. The overall mean rate of delayed discharge for the period was 2.9% and the overall mean rate of admission for the period was 1.9%. The principal reasons for the both were requestion by surgeons without surgery and anesthesia-related complications. CONCLUSIONS: The increase of demands of patients for ambulatory surgeries, new technological developements for surgery and anesthesia and increased experiences of surgeons will stimulate the utility of day surgery center.
Ambulatory Surgical Procedures* ; Anesthesia* ; Anesthesia, Local ; Hospital Costs ; Humans ; Medical Records ; North America ; Retrospective Studies

BACKGROUND: Although degree of motor blockade during high thoracic spinal anesthesia is difficult to determine, pulmonary function may reflect the level of motor blockade. So we checked pulmonary function during spinal anesthesia with two different local anesthetic agents. METHODS: 50 patients, ASA PS 1-2, were randomly divided into two groups. After basal pulmonary function test (FVC: forced vital capacity, FEV1: forced expiratory volume in one second, PEFR: peak expiratory flow rate, PEP: peak expiratory pressure, PIP: peak inspiratory pressure.), the patients received spinal anesthesia with either 0.5% hyperbaric bupivacaine or 0.5% hyperbaric tetracaine. Thirty minutes after injection, level of sensory blockade was checked by pinprick test and pulmonary function test was performed. RESULTS: Almost all the values of pulmonary function reduced after spinal anesthesia, but the degrees of reduction were not differ in two groups except PEP, which reduced more profoundly in tetracaine group than bupivacaine group. CONCLUSIONS: It is more desirable that we use bupivacaine rather than tetracaine as spinal anesthetic agent in the patient with poor pulmonary function.
Anesthesia, Spinal* ; Anesthetics ; Bupivacaine* ; Forced Expiratory Volume ; Humans ; Peak Expiratory Flow Rate ; Respiratory Function Tests ; Tetracaine* ; Vital Capacity

BACKGROUND: Carotid endarterectomy is a very high risk operation, combined with high incidence of stroke and myocardial infarction. We experienced 36 cases of carotid endarterectomies during the last two years. We reviewed these cases with anesthetic management and neurologic monitoring. METHODS: All of the operations were performed under general anesthesia. 33 cases were monitored by EEG and SEP. We maintained cerebral perfusion during cross-clamping and shunt by normothermia, normocarbia and mild hypertension. RESULTS: 33% of the patients had severe coronary artery stenosis and 41% had severe contralateral carotid artery stenosis preoperatively. During the operation, 10 patients showed transient EEG changes without SEP change or neurologic sequele. The major postoperative complication was myocarial infarction in one patient. There were 3 cases of postoperative cerebral infarction in radiologic findings. One case occurred after myocardial infarction and the other two cases showed no clinical evidence of neurologic deficit. CONCLUSIONS: In anesthetic management of carotid endarterectomy patients, maintaining cerebral perfusion, preventing perioperative myocardial infarction are important and monitoring neurologic function with EEG and SEP should be considered to prevent neurologic deficits.
Anesthesia, General ; Carotid Stenosis ; Cerebral Infarction ; Coronary Stenosis ; Electroencephalography* ; Endarterectomy, Carotid* ; Humans ; Hypertension ; Incidence ; Infarction ; Myocardial Infarction ; Neurologic Manifestations ; Perfusion ; Postoperative Complications ; Stroke

The Portland intensive insulin therapy effectively controls acute hyperglycemic change after graft reperfusion during liver transplantation. However, the time-consuming sophistication acts as a barrier leading to misinterpretation and decreasing compliance to the protocol; thus, we newly introduced an application software “Insulin protocol calculator” which automatically calculates therapeutic bolus/continuous insulin doses based on the Portland protocol. Methods: Of 144 patients who underwent liver transplantation, 74 patients were treated before the introduction of “Insulin protocol calculator” by using a paper manual, and 70 patients were treated by using the application. Compliance was defined as the proportion of patients treated with exact bolus/continuous insulin dose according to the Portland protocol. Results: Compliance was significantly greater in app group than in paper group regarding bolus dose (94.5% and 86.9%, P < 0.001), continuous dose (88.9% and 77.3%, P = 0.001), and both doses (86.6% and 73.8%, P < 0.001). Blood glucose concentration was significantly lower in app group at 3 h (125 ± 17 mg/dl vs. 136 ± 19 mg/dl, P = 0.014) and 4 h (135 ± 22 mg/dl vs. 115 ± 15 mg/dl, P = 0.029) after graft reperfusion. Acute hyperglycemic change during 30 min was more prominent in app group while hyperglycemia incidence was 71.4% vs. 54.1% (P = 0.031). However, hyperglycemia risk was comparable at 2 h (31.4% vs. 31.1%, P = 0.964), and even insignificantly lower in app group at 3 h (7.1% vs. 19.5%, P = 0.184). Conclusions: Compliance to the Portland protocol was significantly improved after introducing the application software; post-reperfusion hyperglycemia was better controlled. “Insulin protocol calculator” is cost-effective and time-saving with potential clinical benefits

BACKGROUND: Even though the effect of prehydration on the spinal anesthesia-induced hypotension has not yet been concluded, prehydration prior to spinal anesthesia is recommended in order to reduce the incidence and severity of hypotension. We investigated the effects of prehydration on hemodynamic change during spinal anesthesia with isobaric 0.5% tetracaine. METHODS: We prospectively performed this study on 96 patients who underwent elective transurethral surgery from October 2002 to January 2004. Patients were randomly allocated to receive either no prehydration or 10 ml/kg crystalloids administered over 10 15 min prior to spinal anesthesia. We compared dermatomal spreads of spinal anesthesia, hemodynamic parameters (blood pressure, heart rate), incidences of hypotension and bradycardia between two groups. RESULTS: Hemodynamic parameters, incidences of hypotension and bradycardia showed no statistically significant differences during spinal anesthesia between two groups. There were statistically significant differences in the dermatomal spread of sensory levels between two groups from 5 to 90 min after spinal anesthesia. Sensory block levels in prehydration group were statistically lower than no prehydration group. CONCLUSION: We hypothesized that prehydration can be one of factors that influence on dermatomal spread of local anesthetics in isobaric spinal anesthesia. The difference of dermatomal spread between two groups may be caused by brain blood barrier (BBB)-freely passing crystalloids, which may influence on the volume and density of cerebrospinal fluids. To verify this phenomenon found in our study, further investigation is still warranted.
Anesthesia, Spinal* ; Anesthetics, Local ; Blood-Brain Barrier ; Bradycardia ; Cerebrospinal Fluid ; Heart ; Hemodynamics ; Humans ; Hypotension ; Incidence ; Prospective Studies ; Tetracaine