BACKGROUND: A tourniquet is often used during limb surgery to minimize surgical bleeding and to keep the clear surgical field. However the tourniquet is associated with severe hemodynamic changes and tourniquet-induced hypertension. We investigated the incidences of tourniquet-induced hypertension by tourniquet duration and anesthetic methods. METHODS: One hundred thirteen patients who underwent a total knee arthroplasty were assigned into four groups according to the types of anesthesia; general anesthesia (group I, n = 30), general anesthesia and intravenous adjuvants (group II, n = 30), general and epidural anesthesia (group III, n = 22), and spinal anesthesia (group IV, n = 31). Mean arterial pressure and heart rate were recorded at ward, before induction, one minute after tourniquet inflation and every 10 minutes until 60 mininutes. The extremity was exsanguinated and a tourniquet pressure of 350 mmHg (9 cm width) was applied in all groups. RESULTS: The mean arterial pressure increased in group I and II during the tourniquet inflation period. The incidence of tourniquet-induced hypertension was higher in group I (6.7%) than other groups but there was no statistical significance among the groups. Heart rates were not changed in any groups. CONCLUSIONS: We concluded that the shorter the tourniquet time the less the occurrence of tourniquet-induced hypertension under any type of anesthesia.
Anesthesia* ; Anesthesia, Epidural ; Anesthesia, General ; Anesthesia, Inhalation ; Anesthesia, Spinal ; Arterial Pressure ; Arthroplasty* ; Extremities ; Heart Rate ; Hemodynamics ; Hemorrhage ; Humans ; Hypertension* ; Incidence ; Inflation, Economic ; Knee* ; Tourniquets*

BACKGROUND: Modern studies have confirmed that interindividual pain threshold variability greatly exceeds intraindividual pain threshold variability. The purpose of this investigation was to compare the efficacy and safety of postoperative pain control by patient controlled analgesia (PCA) of two staged bilateral total knee replacements in the same patient. METHODS: Forty patients had two total knee replacements in separate sessions of anesthesia (a bilateral two stage procedure). They received postoperative pain treatment with patient-controlled epidural analgesia during the first postoperative 48 hours after total knee replacement. The procedures were assigned to the first operation (early group) and the second operation (late group) in the same patient. Visual analog scale (VAS) scores whilst at rest or during movement were used to assess pain. Total bupivacaine volume delivered, number of PCA requests, supplemental analgesics, overall satisfaction score and adverse events were evaluated. RESULTS: No significant differences were found between the two (early and late) groups in terms of effects and adverse events of postoperative pain control. CONCLUSIONS: Two staged bilateral total knee replacement appears to be a means of comparing postoperative pain control, and which significantly reduces interindividual variability.
Analgesia, Epidural* ; Analgesia, Patient-Controlled ; Analgesics ; Anesthesia ; Arthroplasty, Replacement, Knee* ; Bupivacaine ; Humans ; Pain Threshold ; Pain, Postoperative ; Passive Cutaneous Anaphylaxis ; Visual Analog Scale

BACKGROUND: Although pulmonary artery catheters are useful to monitor hydration, these devices may be associated with severe morbidity and are not routinely used in kidney transplantation. A central venous pressure (CVP) catheter is preferred rather than a pulmonary artery catheter. Noninvasive continuous blood pressure monitors may substitute for intraarterial catheters, thereby preserving the radial artery in kidney transplantation patients should it be needed later to create an arteriovenous fistula. If there is a relationship between central venous and radial arterial blood for acid-base (pH, BE, HCO3(-)), we can use the blood sample from a CVP catheter instead of arterial blood from aradial artery catheter for testing acid-base and it can help patients. METHODS: A central venous catheter and radial artery catheter was inserted in 67 patients while undergoing kidney transplantation. To assess arteriovenous differences in acid-base status at operation start, before reperfusion of the transplanted kidney, after reperfusion, we measured the pH, BE and HCO3(-) simultaneously from the arterial and central venous circulation. RESULTS: Aacid-base using arterial and central venous samples at operation start, before reperfusion and after reperfusionb was evaluated. We found the relationship as follows: pH between arterial (pHa) and central venous blood (pHcv) in each: linear regression equation; pHcv = 0.668 + (0.906 X pHa), pHcv = 0.225 + (0.965 X pHa), pHcv = 0.646 + (0.908 X pHa), determination coefficient; 0.908, 0.926, 0.888, P values < 0.001 in each period. Base excess (BE) between BEa and BEcv in each period: linear regression equation; BEcv = 0.483 + (0.952 X BEa), BEcv = 0.032 + (0.939 X BEa), BEcv = 0.008 + (0.954 X BEa), determination coefficient; 0.844, 0.954, 0.962 P values < 0.001 in each period. HCO3(-) concentration between HCO3(-)a and HCO3(-)cv in each period: linear regression equation; HCO3(-)cv = 2.434 + (0.937 X HCO3(-)a), HCO3(-)cv = 2.093 + (0.942 X HCO3(-)a), HCO3(-)cv = 1.755 + (0.954 X HCO3 a), determination coefficient; 0.950, 0.925, 0.932 P values < 0.001 in each period. CONCLUSIONS: The acid base status of arterial blood is similar to that of central venous blood. Central venous blood gas values (pH, BE, HCO3(-)) may be an acceptable alternative to arterial blood gas values in kidney transplantation patients.
Arteries ; Arteriovenous Fistula ; Blood Pressure Monitors ; Catheters ; Central Venous Catheters ; Central Venous Pressure ; Humans ; Hydrogen-Ion Concentration ; Kidney ; Kidney Transplantation ; Linear Models ; Pulmonary Artery ; Radial Artery ; Reperfusion

BACKGROUND: Wake-up tests may be necessary during surgery for kypho-scoliosis to ensure that spinal function remains intact. It is difficult to predict the time when patients can respond to a verbal command. We evaluated the effectiveness of the bispectral index (BIS) and its relation to patients' levels of consciousness in wake-up tests during desflurane and sevoflurane anesthesia. METHODS: Eighteen patients each were enrolled in the desflurane and sevoflurane groups for spinal correction surgery. We measured BIS values, blood pressure, heart rate, and consciousness state and time, at the points when patients responded during the wake-up test. RESULTS: The BIS values when patients made fists upon a verbal command (T3) were 86.7 +/- 7.5 for desflurane and 90.3 +/- 5.4 for sevoflurane. Patients in the desflurane group had significantly shorter wake up delays than those in the sevoflurane group (6.9 +/- 1.8 min vs. 11.8 +/- 3.6 min). However, there was no difference between the groups in the time between the response to a verbal command and the time when a patient moved their toes in response to verbal commands. No recall of the wake-up tests occurred in either group. CONCLUSIONS: The values obtained using the BIS index could to some extent predict the time of a patient's and would be informative during desflurane and sevoflurane anesthesia. Moreover, desflurane permitted faster responses to verbal commands than sevoflurane, and allowed the wake-up test to be performed sooner.
Anesthesia ; Blood Pressure ; Consciousness ; Dietary Sucrose ; Heart Rate ; Humans ; Isoflurane ; Methyl Ethers ; Toes

BACKGROUND: The changes in acid-base balance and serum electrolytes after infusion of 0.9% normal saline during renal transplantation are poorly characterized. In this study, the relationships between the infusion of fluids and the changes in arterial blood gas analysis, serum electrolytes and central venous pressure during renal transplantation were determined. METHODS: Sixty-seven patients undergoing elective renal transplantation were divided into two groups: group I (n = 33) was made up of patients who received a living related renal transplantation, while group II (n = 34) was made up of those who received a living unrelated renal transplantation. Blood gas analysis, central venous pressure and serum electrolytes were evaluated just after the beginning of the operation, just before reperfusion (unclamping of the renal artery and vein), just after reperfusion and 20 minutes after arriving in the recovery room. RESULTS: pH, base excess, HCO3 and Na+ concentration were decreased, but PaCO2 was not changed during the operation. Central venous pressure and K+ concentrations were elevated during the operation. CONCLUSIONS: The results of this study suggest that 0.9% normal saline and mannitol leads to dilutional acidosis. If a lot of fluids are required during transplantation, we need to consider that 0.9% normal saline can aggravate acidosis in a renal transplantation patient.
Acid-Base Equilibrium ; Acidosis ; Blood Gas Analysis* ; Central Venous Pressure* ; Electrolytes* ; Humans ; Hydrogen-Ion Concentration ; Kidney Transplantation* ; Mannitol ; Recovery Room ; Renal Artery ; Reperfusion

Protein C exerts anticoagulant effects by inactivating factor Va and VIIIa and stimulating fibrinolysis. The homozygous protein C deficiency is extremely rare and often results in life threatening thrombosis and purpura fulminans with necrotic cutaneous lesions. A child with homozygous protein C deficiency was treated at 6 months by a living-related liver transplantaion. After induction of anesthesia, we started an FFP infusion for protein C replacement and a low molecular weight heparin continuous infusion to prevent thrombosis. A complete reconstitution of protein C activity and resolution of the thrombotic condition occured postoperatively. So we report this case with a brief review of the literature.
Anesthesia* ; Child ; Factor Va ; Fibrinolysis ; Heparin, Low-Molecular-Weight ; Humans ; Liver Transplantation* ; Liver* ; Protein C Deficiency* ; Protein C* ; Purpura Fulminans ; Thrombosis

A 70-year-old female who was diagnosed as myxoid chondrosarcoma by fine needle aspiration of a pleural mass is described. She presented with left chest discomfort of 4 months' duration and aggravating dyspnea and chest pain for 2 months. Chest X-ray and CT scan revealed a large lobulated low density mass invading chest wall at the left pleural cavity and massive pleural fluid. Fine needle aspiration was done under the impression of mesothelioma or metastatic cancer. The aspirates from the mass were very cellular and composed of isolated or clustered forms of large plump cells. Abundant cytoplasm was bluish opaque and the margin was rounded in the isolated cells, whereas clustered cells show ill-defined cell borders and aggregating tendency. The nuclei were eccentric, round to ovoid, and had fine chromatin pattern and multiple small nucleoli. Cellular pleomorphism or mitotic figure was not definite. These findings were consistent with cytologic features of chondrosarcoma. Final diagnosis was confirmed as myxoid chondrosarcoma by mediastinoscopic biopsy and the tumor showed strong positivity for S-100 protein.
Aged ; Biopsy ; Biopsy, Fine-Needle ; Chest Pain ; Chondrosarcoma ; Chromatin ; Cytoplasm ; Diagnosis ; Dyspnea ; Eosinophils* ; Female ; Humans ; Mesothelioma ; Peritoneal Dialysis, Continuous Ambulatory* ; Peritonitis* ; Pleural Cavity ; S100 Proteins ; Thoracic Wall ; Thorax ; Tomography, X-Ray Computed

BACKGROUND: Changes in acid-base balance and serum electrolytes by infusion of lactated Ringer's solution in liver cirrhosis patienst during liver surgery are poorly characterized. In this study, we evaluated the effects of infusing large amount of lactated Ringer's solution on acid-base and serum electrolytes during liver surgery in cirrhosis patients. METHODS: Thirty-two patients were divided into two groups. Group I (n = 21) was made up of patients who had received liver lobectomy without cirrhrosis. Group II (n = 11) was made up of patients who had received liver lobectomy with cirrhosis above a moderate level. Arterial blood gas and serum electrolyte levels were checked 4 times during the study in each patient: just after the operation start, after infusing 3,000 ml and 6,000 ml of lactated Ringer's solution during operation, and 30 minutes after arrival at the postanesthesia care unit. RESULTS: pH and base excess decreased according to the amount of lactated Ringer's solution used in both groups and these results were significant. Serum electrolyte levels were not changed and only Ca2+ levels were significantly different in the two groups. The cause of changing of Ca2+ levels found out by intravenous infusion of Ca2+ solution. CONCLUSIONS: In liver surgery patients with or without liver cirrhosis decreased pH and base excess in serum by increased amount of used lactated Ringers solution during liver surgery but in serum electrolytes and others acid-base parameters, CVP, changes on there were not any statistical significant. When a large amount of LR solution is used in liver surgery, we recommend regular arterial blood gas analyses for acid-base balance and an infusing speed of 20 ml/kg/h.
Acid-Base Equilibrium ; Blood Gas Analysis ; Electrolytes ; Fibrosis* ; Humans ; Hydrogen-Ion Concentration ; Infusions, Intravenous ; Liver Cirrhosis ; Liver*

Esmolol is a cardioselective beta-blocker with a very rapid onset of action and a short half-life. Labetalol is a combined alpha- and beta-adrenoceptor blocking agent. It is a nonselective antagonist at beta-adrenoceptors and a competitive antagonist of postsynaptic alpha 1-adrenoceptors. A 51 year old female patient was transferred to the operating room for performing spinal fusion under general anesthesia. She had no operation and medication history. The initial heart rate was 150 beats/min. Despite administering several bolus injections of esmolol, the heart rate was not decreased to under 130 beats/min. But the heart rate was decreased to 100 beats/min after the administration of labetalol 5 mg and this rate was maintained without an additional injection. The vital signs were stable until the operation was finished and the patient recovered uneventfully in the recovery room. The postoperative laboratory findings revealed that she had hyperthyroidism. We report here on an anesthetic experience of effective labetalol treatment for esmolol-resistant tachycardia in a patient who was under general anesthesia.
Anesthesia, General ; Female ; Half-Life ; Heart Rate ; Humans ; Hyperthyroidism ; Labetalol ; Operating Rooms ; Propanolamines ; Recovery Room ; Spinal Fusion ; Tachycardia ; Vital Signs

BACKGROUND: Even though careful techniques is utilized and proper concentration of local anesthetics are used, tissue toxicity is common. METHOD: The fibroblast cell lines (NUGM) was exposed with each concentration of 10(-6), 10(-5), 10(-4) M lidocaine and bupivacaine in culture media for 24 hours. Glucose consumption rate and LDH activity in cultured media were measured for using as indicator of cellular damage on 0. 24, 48, 72 hours. By using that, we calculated the trend lines of the change of glucose consumption rate and LDH (lactic dehydrogenase) activity. On the trend lines, we searched out for decreasing time to 1/2 of glucose concentration and increasing time to 2 times of LDH activity compared to control. RESULTS: 1) In control group, Decreasing time to 1/2 of glucose concentration was 236.0 hours (p<0.05) and increasing time to 2 times of LDH activity was 1168.6 hours (p<0.05). 2) At each concentration of 10 6, 10 5, 10 4 M lidocaine, decreasing time to 1/2 of glucose concentration was 873.7 (370%), 938.7 (398%), 1101.6 (467%) hours compared with 236.0 (100%) hours of control (p<0.05) and then increasing time to 2 times of LDH activity was 135.1 (12%), 85.6 (7%), 93.9 (8%) hours when compared with 1168.6 (100%) hours of control (p<0.05). 3) At each concentration of 10(-6), 10(-5), 10(-4) M bupivacaine, decreasing time to 1/2 of glucose concentration was 706.7 (299%), 948.1 (402%), 1018.2 (431%) hours when compared with 236.0 (100%) hours of control (p<0.05) and then increasing time to 2 times of LDH activity was 111.6 (10%), 69.5 (6%), 59.1 (5%) hours when compared with 1168.6 (100%) hours of control (p<0.05). 4) On light microscopy, cells are showed destruction in each concentration of 10(-6), 10(-5), 10(-4) M lidocaine and bupivacaine with dose dependent fashion. CONCLUSIONS: 1) Glucose consumption rate and LDH activity in cultured media could be used as a useful index of cellular destruction by toxic effect on cultured cell. 2) Even at any concentration of lidocaine and bupivacaine could be toxic on cell. With all of above results, cell-line on 3 demensional cultured method could be use as another method for determining of cellular toxicity of local anesthetics.
Anesthetics, Local* ; Bupivacaine* ; Cell Line ; Cells, Cultured* ; Culture Media ; Fibroblasts ; Glucose* ; Lidocaine* ; Microscopy ; Oxidoreductases*