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Incidence of Venous Air Embolism Ddetected by Ultrasonic Doppler during Cesarean Section.

Jin Yong CHUNG ; Tae Hyeon LEE ; Woon Seok RHO ; Soung Kyung CHO ; Sang Hwa LEE

Korean Journal of Anesthesiology.1995;29(6):858-862. doi:10.4097/kjae.1995.29.6.858

Venous air embolism(VAE) can occur by the entry of air into open veins, being facilitated if the operative field is above the level of the heart. Among the many diagnostic methods, precordial ultrasonic Doppler is currently the more sensitive. Thus we have attempted to define the incidence of VAE using this device. 103 ASA physical status 1 or 2 parturients undergoing Cesarean section with general anesthesia in 73 parturients and epidural anesthesia in 30 parturients were studied with the ultrasonic Doppler transducer placed parasternally over the 4th right intercostal space. Total incidence of venous emboli was 31%(32/103) during surgery. In some parturients, embolism occurred more than once during operation and leaded to total 45 episodes of venous emboli. The incidence of venous emboli was 26%(19/73 ) during general anesthesia and 43.3%(13/30 ) during epidural anesthesia. No statistical difference existed in the incidence of venous emboli detected related to the type of anesthesia. Among the 45 episodes of venous emboli, 19 episodes(42.2%) were detected during repair of the hysterotomy. As even small air bubbles in the circulation are potentially harmful especially in patent foramen ovale and emboli events may occur at risk cases involving profound hypovolemia, abruptio placenta, or placenta previa, clinically insignificant venous air emboli, although low, is still worrisome. Thus above the cases, the use of additional precordial Doppler monitoring may be considered during cesarean section to detect VAE promptly, efficiently.
Anesthesia ; Anesthesia, Epidural ; Anesthesia, General ; Cesarean Section* ; Embolism ; Embolism, Air* ; Female ; Foramen Ovale, Patent ; Heart ; Hypovolemia ; Hysterotomy ; Incidence* ; Placenta ; Placenta Previa ; Pregnancy ; Transducers ; Ultrasonics* ; Veins

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Comparative Study of Heparinase Treated Activated Clotting Time with Hephrinase Treated Thromboelastography for Detecting Residual Heparin Effects Following Cardiopulmonary Bypass.

Sung WOO ; Cheol Hoi HUR ; Ky Sang SUNG ; Moon Cheol KIM ; Kang Hee CHO

Korean Journal of Anesthesiology.1995;29(6):850-857. doi:10.4097/kjae.1995.29.6.850

Residual heparin effects after protamine reversal is a potential bleeding disorder associated with cardiopulmonary bypass(CPB). To differentiate this from the other multiple factors causing coagulopathy should be initialized in the setting of management. The purpose of this study was to compare simple activated clotting time(ACT) and thromboelastography(TEG) with heparinase treated ACT and TEG for detecting residual heparin effects to distinguish rapidly the presence of heparin from the effects of other factors because the enzyme heparinase specifically neutralized heparin. After institution approval, 20 patients who required open heart surgery were studied. Baseline kaoline ACT, heparinase ACT, TEG and heparinase TEG(Haemoscope) were obtained before CPB on the same blood sample. The repeated tests were performed on the same blood samples 20 minutes after protamine reversal following CPB. Differences between heparinase treated tests and untreated tests were also evaluated at the same time. Wilcoxon signed ranked test was used to compare the results between before and after bypass. None of patients had significant postoperative bleeding complication. All tests before bypass were normal. Twenty minutes after protamine reversal, 3 patients showed kaoline ACT were extended above 10% of the value of heparinase ACT but all of them remained within normal range. However, nearly all patients showed heparin effects on TEG. The heparin effects on TEG were defined as significant differences in all of parameters, especially in alpha angle and R+K time between simple TEG and heparinase TEG. In Conclusion, heparinase treated ACT and native ACT are not sensitive to residual heparin effects after CPB. Their normal results did not preclude residual heparin effects on heparinase modified TEG. However, it might be further investigated to need additional protamine in the case of residual heparin effects on TEG.
Cardiopulmonary Bypass* ; Hemorrhage ; Heparin Lyase* ; Heparin* ; Humans ; Kaolin ; Reference Values ; Thoracic Surgery ; Thrombelastography*

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Onset and Duration of Succinylcholine and Vecuronium Neuromuscular Blockade at Laryngeal Adductor and Adductor Pollicis Muscles.

Seung Ok HWANG ; Seok Kon KIM ; Nam Hoon PARK

Korean Journal of Anesthesiology.1995;29(6):843-849. doi:10.4097/kjae.1995.29.6.843

Adequate relaxation of the laryngeal adductor muscle is required to obtain good tracheal intubating condition. But we couldnt check rountinely laryngeal adductor muscle response, so we quantify the effects of succinylcholine and vecuronium at the laryngeal adductor muscles and the adductor pollicis. Twenty adult patients of ASA physical status 1-2 were studied during propofol-fentanyl anesthesia. The trachea was intubated without the use of muscle relaxants and the tube cuff placed between the vocal cords. Succinylcholine 1.5 mg/kg or vecuronium 0.1 mg/kg was given as a single bolus by random allocation. Muscular activity was evoked with supramaximal stimuli in a train-of-four sequence every 12 sec to the ulnar nerve and the anterior branch of the recurrent laryngeal nerve at the notch of the thyroid cartilage and forehead. Neuromuscular transmission was monitored at wrist by mechano-myography and laryngeal response was measured as pressure changes in the cuff of the tracheal tube positioned between the vocal cords. Pressure inside the cuff was measured with an air-filled transducer. TOF responses of both sites were continuously recorded on strip chart. Lag time and onset time were no statistically significant differences at the laryngeal adductor and adductor pollicis after succinylcholine or vecuronium bolus injection. Clinical durations were significantly shorter at the laryngeal adductor than at the adductor pollicis after succinylcholine and vecuronium injection. In one patient, onset of neuromuscular blocking effect with vecuronium was 125 sec slower at the laryngeal adductor than at the adductor pollicis. We recommand that if vecuronium is selected for gentle and smooth tracheal intubation, intubation will be delayed sufficient time after adductor pollicis relaxation.
Adult ; Anesthesia ; Forehead ; Humans ; Intubation ; Muscles* ; Neuromuscular Blockade* ; Random Allocation ; Recurrent Laryngeal Nerve ; Relaxation ; Succinylcholine* ; Thyroid Cartilage ; Trachea ; Transducers ; Ulnar Nerve ; Vecuronium Bromide* ; Vocal Cords ; Wrist

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Cardiac Arrhythmias under General Anesthesia Using Enflurane.

Seung Su KIM ; Soo Il LEE ; Young Dae KIM ; Na Kyung LEE ; Chang Ryul LEE ; Jung Hyun LEE

Korean Journal of Anesthesiology.1995;29(6):836-842. doi:10.4097/kjae.1995.29.6.836

The large part of pathophysiology of cardiac arrhythmias has been clarified but still arrhythmias have bothered anesthesiologists. This study was done in order to investigate the incidence and nature of arrhythmias using Holter monitor for complete study during enflurane anesthesia. The patients were randomly allocated to two groups. Group I received succinylcholine 1.5 mg/kg, and Group II vecuronium 0.1 mg/kg, intravenously for intubation. Continuous electrocardiographic recordings on magnetic tape were made in 34 patients undergoing tympanoplasty during general anesthesia (thiopental(5 mg/kg)-muscle relaxants induction, and N2O(50%)-O2-enflurane(1.2%)-pancuronium maintenance). After completion of the recordings, the tapes were scanned to detect changes in rhythm using the analyzer. Complexes were further studied by readouts on standard ECG paper. The results were as follows: 1) The number of patients(n=14) who exhibited arrhythmias during anesthetic maintenance was significantly greater than that(n=4) during induction. 2) The incidence of occurrence of cardiac arrhythmias was 64.7%. There was no difference between two groups. If sinus tachycardia included, the incidence reached at 94.1%. 3) The frequency of supraventricular arrhythmias was more than two times that of ventricular ones. The arrhythmias occuning at the AV junction were the most common, and VPCs the second most common 4) There was no effect on the frequency in arrhythmia occurrence, of age, gender, preoperative ECG findings, intraoperative serum K(+), and intraoperative PaCO2 The discrepancy in the incidence of arrhythmia occurrence between complete and incomplete studies tells that great caution should be paid perioperatively, especially to the patients who have cardiovascular disorders.
Anesthesia ; Anesthesia, General* ; Arrhythmias, Cardiac* ; Electrocardiography ; Enflurane* ; Humans ; Incidence ; Intubation ; Succinylcholine ; Tachycardia, Sinus ; Tympanoplasty ; Vecuronium Bromide

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The Effect of Physostigmine on Arousal and Respiration after General Anesthesia with Enflurane.

Jae Jin LIM ; Dae Ja UM ; Yong Tak NAM ; Song Youn KIM

Korean Journal of Anesthesiology.1995;29(6):830-835. doi:10.4097/kjae.1995.29.6.830

Physostigmine has been used to counteract somnolence or coma induced by different types of pharmacological agent, such as anticholinergics, opioids, ketamine, tricyclic antidepressants and inhalational anesthetics. In this study, we have assessed the effect of physostigmine on arousal and respiration after 50% N2O-50% O2-enflurane general anesthesia under controlled condition such as no premedication, no neuromuscular blockade, same operative procedure and duration. Fifty healthy gynecologic patients scheduled for dilatation & curettage and cervical cone biopsy were divided randomly into two groups such as control group and physostigmine group. In physostigmine group, 0.02 mg/kg of physostigmine was administered intravenously at the end of operation. We evaluated the recovery time of pain response, eye opening on verbal command and orientation after the end of operation. We also checked the end-tidal enflurane concentration with SARACAP spectrometry. Blood pressure, pulse rate, respiration rate and tidal volume were checked at the end of operation and at the time of each recovery parameters returned. The results were as follows; first, pain response time was 5.1+/-2.4 min in control group compared with 3.5+/-2.1 min in physostigmine group. Second, on simple order to patients, eye opening time was 8.5+/-2.3 min in control group compared with 6.5+/-2.1 min in physostigmine group. Third, recovery of orientation to time, place and person was 9.7+/-2.8 min in control group compared with 7.5+/-2.1 min in physostigmine group. Fourth, there was no significant difference in respiratory parameters between the two groups. But there was no significant difference in end-tidal enflurane concentration between the two groups inspite of rapid recovery time in physostigmine group. In conclusion, 0.02mg/kg of physostigmine has the effect of early arousal after enflurane anesthesia without specific problems.
Analgesics, Opioid ; Anesthesia ; Anesthesia, General* ; Anesthetics ; Antidepressive Agents, Tricyclic ; Arousal* ; Biopsy ; Blood Pressure ; Cholinergic Antagonists ; Coma ; Dilatation and Curettage ; Enflurane* ; Female ; Heart Rate ; Humans ; Ketamine ; Neuromuscular Blockade ; Physostigmine* ; Premedication ; Reaction Time ; Respiration* ; Respiratory Rate ; Spectrum Analysis ; Surgical Procedures, Operative ; Tidal Volume

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Effect of Alternative Methods on Pain during Intravenous Administration of Propofol.

Seung Il KIM ; Keon Sik KIM ; Dong Ok KIM ; Ok Young SHIN ; Moo Il KWON

Korean Journal of Anesthesiology.1995;29(6):824-829. doi:10.4097/kjae.1995.29.6.824

Propofol is limited in clinical use for induction of anesthesia, because of its high incidence of pain on injection. We sought to determine whether different methods could prevent this pain. 150 patients were allocated randomly into five groups. Group 1 was received room-air temperature propofol 2.5 mg/kg. Group 2 was received room-air temperature propofol 2.5 mg/kg mixed with 1 ml of 1%(10 mg) lidocaine. Group 3 was received room-air temperature propofol 2.5 mg/kg just after the injection of l ml of 1%(10 mg) lidocaine. Group 4 was received room-air temperature propofol 2.5 mg/kg mixed with 1 ml of 0.5%(5 mg) lidocaine. Group 5 was received propofol 2.5 mg/kg cooled to 0-4degrees C. The pain was classified as none, mild, moderate, or severe. All patients were questioned the degree of pain in an identical manner both at induction of anesthesia and as recalled in the recovery room. There was a significant reduction in the incidnce and severity of pain in the Groups 2 and 3, which were used 10 mg of lidocaine. But 23.3% of patients in the Group 2 and 30.0% of patients in the Group 3 still suffered unpleasant pain during the induction, and 20.0% and 26.7% of patients, respectively recalled in the recovery room. From the above results, we concluded that the pain from injection of propofol can be prevented by 1 ml of 1%(10 mg) lidocaine mixed with propofol or preinjection before propofol.
Administration, Intravenous* ; Anesthesia ; Humans ; Incidence ; Lidocaine ; Propofol* ; Recovery Room

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The Study of Appropriate Sizes in Large-Volume, Low-Pressure Cuffed Tubes in Adults under General Anesthesia: With special reference to intracuff pressure changes.

Seok Hee CHAH ; Guie Yong LEE

Korean Journal of Anesthesiology.1995;29(6):817-823. doi:10.4097/kjae.1995.29.6.817

Although cuffed tracheal tubes are available in various sizes(ranging from 5 to 11 mm I.D.), many anesthesiologists are apt to use a limited range of sizes in adult patients. In making a selection, we prefer the ease of insertion of a smaller tube and the better gas flow characteristics of a larger tube. However, when the tube in small perimeter of cuff or over-large cuffed tube is selected to seal the trachea, intracuff pressure exceeds tracheal capillary perfusion pressure and results in tracheal complication during prolonged general anesthesia with N2O-O2 mixture. This study was performed to determine the appropriate size of tubes for men(Group A, n=30) and women(Group B, n=30), using the large-volume, low-pressure cuffed tubes(Portex-Blue Line Tubes, U.K.) during prolonged general anesthesia with N2O-O2 mixture. They were subdivided into A-l(7.5 mm I.D.), A-2(8.0 mm I.D.), A-3(8.5 mm I.D.) in men and B-l(6.5 mm I.D.), B-2(7.0 mm I.D.), B-3(7.5 mm I.D.) in women. Each subgmup included 10 patients in number. They were compared in several factors; residual volume of each tube, sealing volume, sealing pressure and the intracuff pressure changes with time. The results were as follows 1) There were no significant differences in age, height, and weight among the subgroups in men and women respectively. 2) There were significant changes of intracuff pressure every 20 minutes in both groups and the changes of slope of pressure were significantly steep in 7.5 mm I.D. in men and 6.5 mm I.D. in women. 3) Although the values of sealing pressure of all groups were less than 22 mmHg, the intracuff pressure were increased and maintained over 22 mmHg after 100 minutes in 7.5 mm I.D. in men and 20 minutes in 6.5 mm I.D. in women. 4) The changes in volumes(delta V) after 2 hours among 6 subgroups were not statistically significant, but the changes in pressures(delta P) were higher in 7.5 mm I.D.in men and 6.5 mm I.D. in women. 5) According to Spearman's Correlation Coeffients, the smaller the residual volume of tube, the higher the sealing pressure to seal the trachea and the larger the pressure changes to volume changes. In conclusion, intracuff pressure of 7.5 mm I.D. in men and that of 6.5 mm 1.D. in women can easily exceed the tracheal capillary perfusion pressure during prolonged general anesthesia with N2O-O2 mixture and when considering the changes of intracuff pressure alone, it seems that 8.0, 8.5 mm I.D. in men and 7.0, 7.5 mm I.D. in women are preferable to seal the trachea.
Adult* ; Anesthesia, General* ; Capillaries ; Female ; Humans ; Male ; Perfusion ; Residual Volume ; Trachea

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Tracheal Tube Cuff Inflation in Oropharynx : An Useful Method in Blind Nasotracheal Intubation.

Byoung Chul KO ; Young Pyo CHEONG ; Kang Chang LEE ; Tai Yo KIM

Korean Journal of Anesthesiology.1995;29(6):811-816. doi:10.4097/kjae.1995.29.6.811

We designed a study to determine if the tracheal tube cuff inflation in the oropharynx improves the success rate of blind nasotracheal intubation in normal, paralyzed patients because of lacking of controlled study about it. In prospective, randomized fashion, 100 ASA I or II patients undergoing elective oral surgery were studied. The trachea was intubated once keeping the tracheal tube cuff deflated throughout the maneuver and once using the technique of tracheal tube cuff inflation in the oropbarynx. A maximum of two attempts was allowed for each technique. If the first attempt was failed, the second attempt was tried with an addition of application of thyroid cartilage compression in each technique. Witb the tracheal tube cuff inflated, the success rate was significantly higher than the cuff-deflated technique(p<0.05). A application of thyroid cartilage compression increased the success rate of the blind nasotracheal intubation in each technique, but it was more useful in the cuff inflation technique(p<0.05). Time taken to intubate the trachea was longer in the cuff inflation technique. We suggest that, in normal paralyzed patients, the tracheal tube cuff inflation in the oropharynx increases the success rate of blind nasotracheal intubation.
Humans ; Inflation, Economic* ; Intubation* ; Oropharynx* ; Prospective Studies ; Surgery, Oral ; Thyroid Cartilage ; Trachea

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Evaluation of Endotracheal Tube Positioning using a Lightwand : The Length of Endotracheal Tube from Upper Incisor to Suprasternal Notch in Adults.

Guie Yong LEE ; Rack Kyung CHUNG ; Kyung Ah YANG ; Choon Hi LEE

Korean Journal of Anesthesiology.1995;29(6):806-810. doi:10.4097/kjae.1995.29.6.806

It is well known that suprasternal notch is at the midpoint between the carina and vocal cords. We evaluated the distance from the endotracheal tube tip on the suprasternal notch to upper incisor using flexible lightwand. 97 male(height 155~187 cm) and 100 female(height 144~167 cm) patients of undergoing elective surgery were included in the study. After adjust the lamp of the tracheal lightwand at the tube tip, endotracheal tube was placed under anesthesia at the suprasternal notch using the light glow. The distance between upper incisor to suprasternal notch was recorded. The average distance from upper incisor to suprasternal notch was 20.0(+/-1.0)cm in males, 17.9(+/-0.7)cm in females. We demonstrated that the placing the tracheal tube at the suprasternal notch using lightwand was rapid and reliable method for identification of proper tube positioning. We have shown that securing endotracheal tube at upper incisor 23 cm in males and 21 cm in females are positioned distally.
Adult* ; Anesthesia ; Female ; Humans ; Incisor* ; Male ; Trachea ; Vocal Cords

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The Effects of Blood and Normal Saline on Laser-resistant Endotracheal Tube Combustion.

Dong Hee KIM ; Phil Sang JUNG ; Jong Seong KIM

Korean Journal of Anesthesiology.1995;29(6):798-805. doi:10.4097/kjae.1995.29.6.798

The protection afforded against CO2 and KTP(potassium titanium phosphate) laser-induced combustion by six different types of tracheal tubes was evaluated. Some of them were wrapped with aluminum foil. They were compared before and after the application of human blood to their external surfaces. The difference of protective efficacy against laser between normal saline filled and air filled cuff was evaluated, too. The tracheal tubes tested were laser-resistant tubes such as Bivona Fome-Cuf (Group 1), Xomed Laser-shield 11 (Group 2) and Mallincrodt Laser Flex (Group 3) tubes. Aluminum foil wrapped Rusch red rubber (RR) (Group 4) and Mallincrodt reinforced Polyvinylchloride (PVC) (Group 5) tubes and unwrapped Baxter plain PVC (Group 6) tubes were also tested. CO2 loser set to 38W in continuous mode and KTP laser set to 15W were directed at the shaft of the tracheal tube under study, which had 5L/min. of oxygen flowing through it. The laser was actuated for 90 seconds or until combustion or melting occurred. Bivona tubes (Group 1) resulted in combustion in 5 tubes before and after blood application with CO2 laser, but unaffected before blood and resulted in combustion in 4 of 5 after blood application with KTP laser. Laser-shield 11 tubes (Group 2) offered good protection form both laser before and after application of blood except 1 case. At one case in Group 2, combustion occurred after blood application with CO2 laser. A combustion occured in 1 of 5 prior to application of blood and 5 of 5 after blood in Laser Flex tubes (Group 3) with CO2 laser, but occurred no tube with KTP laser. Wrapped RR (Group 4) and reinforced PVC tubes (Group 5) were unaffected by both laser, but application of blood to the foil wrapped tube shaft resulted in melting in 4 of 5 tubes. Unwrapped PVC tube (Group 6) resulted in immediate combustion in all tubes tested with both laser. Saline inflated cuffs were not perforated only in Group 2 and 3 in KTP laser and perforated immediately in other groups, but there was no combustion with saline in all groups. Air filled cuffs were all perforated in both laser, and combustion occurred. The presence of blood on the surface of metallic foil wrapped or special laser-resistant tracheal tubes may make laser-induced combustion more likely during airway surgery. However, the Laser-shield 11 and aluminum foil wrapped tracheal tube provided good protection from even when covered with blood. In addition, Mallincrodt stainless steel Laser-Flex tube provided good protection from KTP laser only. The saline filling cuffs served as a heat sink that will absorb the lasers energy, thus preventing combustion of cuffs.
Aluminum ; Freezing ; Hot Temperature ; Humans ; Lasers, Gas ; Lasers, Solid-State ; Oxygen ; Rubber ; Stainless Steel ; Titanium

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