Analysis of Anesthesia-related Medical Disputes in the 2009-2014 Period Using the Korean Society of Anesthesiologists Database

노운석,김덕경,전영훈,김성협,이승철,고영권,이용철,이규홍 대한의학회 2015 Journal of Korean medical science Vol.30 No.2

Using the Korean Society of Anesthesiologists database of anesthesia-related medicaldisputes (July 2009-June 2014), causative mechanisms and injury patterns were analyzed. In total, 105 cases were analyzed. Most patients were aged < 60 yr (82.9%) and wereclassified as American Society of Anesthesiologists physical status ≤ II (90.5%). In 42.9%of all cases, the injuries were determined to be ‘avoidable’ if the appropriate standard ofcare had been applied. Sedation was the sec most common type of anesthesia (37.1% ofall cases), following by general anesthesia. Most sedation cases (27/39, 69.2%) showed acommon lack of vigilance: no pre-procedural testing (82.1%), absence of anesthesiarecord (89.7%), and non-use of intra-procedural monitoring (15.4%). Most sedation(92.3%) was provided simultaneously by the non-anesthesiologists who performed theprocedures. After the resulting injuries were grouped into four categories (temporary,permanent/minor, permanent/major, and death), their causative mechanisms wereanalyzed in cases with permanent injuries (n = 20) and death (n = 82). A ‘respiratoryevents’ was the leading causative mechanism (56/102, 54.9%). Of these, the mostcommon specific mechanism was hypoxia secondary to airway obstruction or respiratorydepression (n = 31). The sec most common damaging event was a ‘cardiovascular events’(26/102, 25.5%), in which myocardial infarction was the most common specificmechanism (n = 12). Our database analysis demonstrated several typical injury profiles (alack of vigilance in seemingly safe procedures or sedation, non-compliance with the airwaymanagement guidelines, and the prevalence of myocardial infarction) and can be helpfulto improve patient safety.

실험연구 : 실험견에서 Prostacyclin의 폐혈관 이완반응에 미치는 Propofol의 효과

노운석 ( Woon Seok Roh ),김유정 ( Yu Jung Kim ),전상훈 ( Sang Hoon Jheon ),김시오 ( Si Oh Kim ) 대한마취과학회 2003 Korean Journal of Anesthesiology Vol.45 No.2

증례보고 : 경막외마취 후 발생한 심한 저혈압을 동반한 당뇨병성 케톤산혈증

노운석 ( Woon Seok Roh ),이도석 ( Do Seok Lee ),이준석 ( Jun Seog Lee ) 대한마취과학회 2006 Korean Journal of Anesthesiology Vol.51 No.3

Morbidity and mortality are higher in diabetics undergoing surgery, which most often reflect various cardiovascular complications. Ketoacidosis is the most serious acute metabolic complications of diabetes perioperatively. Ketoacidosis has adverse effects such as decreased myocardial contractility and peripheral vascular tone, dehydration and electrolyte imbalances. We encountered a case of a 47 year-old man who presented with ketoacidosis and severe hypotension 15 minutes after being administered epidural anesthesia for femoro-popliteal arterial bypass surgery. This case highlights the need for anesthesiologists to consider the possibility that ketoacidosis can mimic severe hypotension due to epidural anesthesia or cardiogenic shock. (Korean J Anesthesiol 2006; 51: 391~4)

임상연구 : 한국 성인에서 전산화 단층촬영술을 이용하여 측정한 주기관지 길이

노운석 ( Woon Seok Rho ),신유식 ( Yoo Sik Sinn ),이준석 ( Jun Seog Lee ),박찬홍 ( Chan Hong Park ),박영찬 ( Young Chan Park ),정진용 ( Jin Yong Chung ) 대한마취과학회 2006 Korean Journal of Anesthesiology Vol.51 No.4

Background: Accurate knowledge of the mainstem bronchial lengths is essential in order to prevent malpositioning of the double lumen endobronchial tubes (DLT). It is believed that the lengths of the left and right mainstem bronchi measured by CT are more accurate than those measured using a fiberoptic bronchoscope. This study evaluated the length of the mainstem bronchus using a CT scan in Korean adults. Methods: One hundred twenty patients who underwent a chest CT scan without any anatomical changes due to a mass or inflammation were examined. Airway imaging with a minimum intensity projection of the oblique coronal section using multidetector CT was obtained and the lengths of the left and right mainstem bronchi were measured. Results: The lengths of the left mainstem bronchus of the males and females were 49.2 ± 4.8 mm and 44.6 ± 3.9 mm respectively, and the right mainstem bronchus of the males and females were 21.0 ± 4.8 mm and 18.0 ± 4.0 mm, respectively. There was no linear correlation between the height of the patients and the length of the left and right mainstem bronchi. Conclusions: These results provide reference data to help determine the precise margin of safety using a double lumen endobronchial tube for thoracic surgery. (Korean J Anesthesiol 2006; 51: 426~9)

상기도 감염이 있는 소아환자에서 기관내 삽관 후 발생한 점액감입(Mucous Impaction)

김유정,노운석,정진용 대한마취과학회 2001 Korean Journal of Anesthesiology Vol.41 No.2

제왕절개술시 Ultrasonic Doppler 에 의해 탐지된 정맥 공기 색전증의 발생빈도

이상화,노운석,조성경,정진용,이태현 대한마취과학회 1995 Korean Journal of Anesthesiology Vol.29 No.6

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.

흰쥐에서 급성심근경색 3일 후 흉부 대동맥 혈관 반응성의 변화

이섭,노운석,장재석,배지훈,박기성,이종태 대한흉부외과학회 2009 Journal of Chest Surgery (J Chest Surg) Vol.42 No.5

Background: The up-regulation of the nitric oxide (NO)-cGMP pathway might be involved in the change of vascular reactivity in rats 3 days after they suffer acute myocardial infarction. However, the underlying mechanism for this has not been clarified. Material and Method: Acute myocardial infarction (AMI) was induced by occluding the left anterior descending coronary artery (LAD) for 30 min (Group AMI), whereas the sham-operated control rats were treated similarly without LAD occlusion (Group SHAM). The concentration-response relationships for phenylephrine (PE), KCl, acetylcholine (Ach) and sodium nitroprusside (SNP) were determined in the endothelium intact E(+) and endothelium denuded E(−) thoracic aortic rings from the rats 3 days after AMI or a SHAM operation. The concentration-response relationships of PE in the E(+) rings from the AMI rats were compared with those relationships in the rings pretreated with nitric oxide synthase (NOS) inhibitor Nω-nitro-L-arginine methyl ester (L-NAME) or the cyclooxygenase inhibitor indomethacin. The plasma nitrite/nitrate concentrations were checked via a Griess reaction. The cyclic GMP content in the thoracic aortic rings was measured by radioimmunoassay and the endothelial nitric oxide synthase (eNOS) mRNA expression was assessed by real time PCR. Result: The mean infarct size (%) in the rats with AMI was 21.3±0.62%. The heart rate and the systolic and diastolic blood pressure were not significantly changed in the AMI rats. The sensitivity of the contractile response to PE and KCl was significantly decreased in both the E(+) and E(−) aortic rings of the AMI group (p<0.05). L-NAME completely reversed these contractile responses whereas indomethacin did not (p<0.05). Moreover, the sensitivity of the relaxation response to Ach was also significantly decreased in the AMI group (p<0.05). The plasma nitrite and nitrate content (p<0.05), the basal cGMP content (p<0.05) and the eNOS mRNA expression (p=0.056) in the AMI rats were increased as compared with the SHAM group. Conclusion: Our findings indicate that the increased eNOS activity and the up-regulation of the NO-cGMP pathway can be attributed to the decreased contractile or relaxation response in the rat thoracic aorta 3 days after AMI. 배경: Nitric oxide (NO)-cGMP 신호전달체계의 상향 조절(up-regulation)이 급성심근경색 3일 후 흰쥐의 혈관반응성의 변화에 관여한다고 알려져 있으나 그 기전에 대해서는 명확히 규명되지 않았다. 대상 및 방법: 좌전하행관상동맥을 30분간 폐쇄한 후 급성심근경색을 유도한 군을 AMI군으로, 동일한 모의 수술(sham operation)을 하였으나 관상동맥을 폐쇄하지 않은 군을 SHAM군으로 하였다. AMI 혹은 SHAM 수술 3일 후 흰쥐의 대동맥 고리절편(내피를 보존한 대동맥 절편을 E(+), 내피를 제거한 대동맥 절편을 E(−))에서 phenylephrine (PE), KCl, acetylcholine (Ach) 및 sodium nitroprusside (SNP)에 대한 농도-반응 관계를 측정하였다. AMI군의 E(+) 대동맥 절편에서 PE의 농도-반응 관계를 NO synthase (NOS) 억제제인 Nω-nitro-L-arginine methyl ester (L-NAME)와 cyclooxygenase 억제제인 indomethacin으로 각각 전처치한 대동맥 절편과 비교하였다. 혈장 nitrite/nitrate 농도는 Griess reaction으로 측정하였고, 방사면역 분석법을 이용한 흉부 대동맥 절편의 cGMP정량과 real time PCR을 이용한 endothelial nitric oxide synthase (eNOS) mRNA 발현양상 측정을 하였다. 결과: AMI군에서의 심근경색의 평균 크기는 21.3±0.62%였다. AMI군에서 심박수와 수축기 및 이완기 혈압은 의미 있는 변화가 없었다. E(+)와 E(−) 대동맥 절편에서 PE와 KCl에 대한 수축반응의 민감도는 AMI군 대동맥 절편에서 의미 있게 감소하였다(p<0.05). L-NAME은 이러한 수축반응을 완전하게 역전시켰으나 indomethacin은 효과가 없었다(p<0.05). 또한 AMI군에서 Ach에 대한 이완반응의 민감도가 의미 있게 감소하였다(p<0.05). AMI군에서 SHAM군에 비해 혈장 nitrite/nitrate 농도(p<0.05), 기저 cGMP 농도(p<0.05), 및 eNOS mRNA 발현양상(p=0.056)이 증가하였다. 결론: 이상의 결과들로 보아 eNOS의 발현 증가와 NO-cGMP 신호전달체계의 상향조절이 급성심근경색 3일 후 흰쥐 흉부대동맥에서의 수축 및 이완 반응성 감소의 원인으로 생각된다.

Femoral and sciatic nerve blocks for total knee replacement in an obese patient with a previous history of failed endotracheal intubation −A case report−

김종해,노운석,정진용,송석영,김정은,김백진 대한마취통증의학회 2011 Anesthesia and pain medicine Vol.6 No.3

Peripheral nerve block has frequently been used as an alternative to epidural analgesia for postoperative pain control in patients undergoing total knee replacement. However, there are few reports demonstrating that the combination of femoral and sciatic nerve blocks (FSNBs) can provide adequate analgesia and muscle relaxation during total knee replacement. We experienced a case of successful FSNBs for a total knee replacement in a 66 year-old female patient who had a previous cancelled surgery due to a failed tracheal intubation followed by a difficult mask ventilation for 50minutes, 3 days before these blocks. FSNBs were performed with 50 ml of 1.5% mepivacaine because she had conditions precluding neuraxial blocks including a long distance from the skin to the epidural space related to a high body mass index and nonpalpable lumbar spinous processes. This case suggests that FSNBs can provide a good alternative anesthetic method for total knee replacement. (Anesth Pain Med 2011; 6: 270∼274)

제왕절개술을 위한 경막외마취시 국소마취제의 Alkali 화가 마취작용에 미치는 영향

이상화,노운석,조성경,백승희,김건수 대한마취과학회 1995 Korean Journal of Anesthesiology Vol.29 No.1

Several studies have indicated that the addition of sodium bicarbonate and opioid to solutions of lo?? anesthetics shortens the onset time, increases the intensity and prolongs the duration of neural blockade. This study was performed to compare onset times and duration of neural blockade in each groups. Eighty-two parturients scheduled for cesarean section at term unter epidural anesthesia were assigned to three groups. Group 1 (n=19) received 1.5% lidocaine hydrochloride (pH 6.32±0.01), group 2 (n=26) received 1.5% lidocaine hydrochloride plus fentanyl 50 mcg (pH 6.27±0.02) and group 3 (n=37) received 1.5% lidocaine hydrochloride plus fentanyl 50 mcg plus 8.4% sodium bicarbonate (sodium bicarbonate 1 mEq/lidocaine 10 ml)(pH 7.32±0.03). All groups were given 22-28 ml of local anesthetic solutions according to their height. Onset times and duration of sensory blockade were evaluated using pin prick test at two minutes interval after epidural injection at L2, T6, T4 dermatomes. Onset times (time between the completion of anesthetic injection and loss of pin prick sensation at each dermatome) of sensory blockade at L2 dermatome were 3.1±0.2 minutes in Group 3, which were shorter than 5.0±0.3 minutes in Group 1 and 4.7±0.4 minutes in Group 2 (p<0.05). At T6 dermatome, onset times of sensory blockade were 6.9±0.6 minutes in Group 3, which were shorter than 15.4±1.2 minutes in Group 1 and 12.9±1.0 in Group 2 (p<0.05). At T4 dermatome, onset times of sensory blockade were 10.1±0.2 minutes in Group 3, which were shorter than 22.3±1.2 minutes in Group 1 and 18.8±1.1 in Group 2 (p<0.05). The duration (time between loss of pin prick sensation and complete recovery of pain at each dermatome) of sensory blockade at T4 dermatome in Group 3 were 74.0±3.8 min, which were longer than 52.9±2.4 minutes in Group 1 and 52.7±1.4 minutes in Group 2 (p<0.05). The duration of sensory blockade at L2 dermatome in Group 3 were 119.6±4.4 minutes, which were longer than 78.6±4.8 minutes in Group 1 and 81.6±2.5 minutes in Group 2 (p<0.05). The above results seggested that alkalinization of lidocaine solution is an effective way to shorten the latency and to prolong the duration of epidural block for cesarean section. (Korean J Anesthesiol 1995; 29: 106~111)

Hypotensive bradycardic events during shoulder arthroscopic surgery under interscalene brachial plexus blocks

송석영,노운석 대한마취통증의학회 2012 Korean Journal of Anesthesiology Vol.62 No.3

Sudden, profound hypotensive and bradycardic events (HBEs) have been reported in more than 20% of patients undergoing shoulder arthroscopy in the sitting position. Although HBEs may be associated with the adverse effects of interscalene brachial plexus block (ISBPB) in the sitting position, the underlying mechanisms responsible for HBEs during the course of shoulder surgery are not well understood. The basic mechanisms of HBEs may be associated with the underlying mechanisms responsible for vasovagal syncope, carotid sinus hypersensitivity or orthostatic syncope. In this review, we discussed the possible mechanisms of HBEs during shoulder arthroscopic surgery, in the sitting position, under ISBPB. In particular, we focused on the relationship between HBEs and various types of syncopal reactions, the relationship between HBEs and the Bezold-Jarisch reflex, and the new contributing factors for the occurrence of HBEs, such as stellate ganglion block or the intraoperative administration of intravenous fentanyl.