개심술시 Activated Clotting Time 을 이용한 Heparin 투여 조절에 관한 임상적 고찰

서충헌 대한흉부심장혈관외과학회 1983 Journal of Chest Surgery (J Chest Surg) Vol.16 No.3

Heparinization is an essential step in extracorporeal circulation for open heart surgery. But wide individual variation to heparin effect sometimes makes it difficult to anticoagulate safely or neutralize appropriately. Because the conventional set protocol of heparinization did not consider this individual variation, a new method of control of heparinization was proposed by Dr. Brian Bull in 1974. We compared the group in which a conventional set protocol was used [Control group] with the other in which a new protocol modified from that of Bull was used [ACT group], on the aspects of the dosages of heparin and protamine administered and postoperative bleeding. Our conventional protocol [Control group] consisted of: 1. Initial heparin was given at dose of 350U/Kg into the right atrium prior to bypass. 2. Additional heparin was given every hour during E.C.C., as much as a half of the Initial dose. 3. 600U of heparin was mixed into every 100ml. of priming solution. 4. The protamine dose was calculated by totalling the units of heparin given to the patient and giving 1 .8mg. of protamine per 100 units of heparin. ACT protocol [ACT group] consisted of: 1. Initial heparinization was same as that of conventional protocol. 2. ACT`s were checked before [A point] and 10 minutes after initial heparinization [B point]. With these 2 points, a dose response curve was drawn. 3. Heparin for the priming solution was same as in control group. 4. Every 30 minutes during E.C.C., ACT`s were checked with Hemochron [International Technidyne Corp.]. ACT between 450 and 600 seconds was regarded as safety zone. If ACT checked at a time was below 450 seconds, heparin dose was calculated on the dose-response curve to lengthen ACT to 480 seconds and was given into the oxygenator. 5. About 10 minutes before the term of E.C.C., ACT was checked to estimate the blood heparin level at the time. Then, protamine dose was calculated at dose of 1.Stag per 100 units of heparin. The calculated dose of protamine was mixed into 50 to lO0ml of 5% Dextrose Water and dripped intravenously during the period of 15 minutes. Compared these two groups mentioned above, results were obtained as follows: 1. Mean value of normal ACT checked with Hemochron on 30 preoperative patients was 124 seconds [range 95-145 sec.]. 2. Doses of heparin and protamine given to the patient were decreased in ACT group as much as 32.2% and 62.2% respectively. 3. Postoperative bleeding and transfusion were also decreased in ACT group in 60.5% and 67.1% respectively. 4. Our modified dose-response curve did not cause any problems in the control of heparinization. 5. Initial heparinization [Heparin 350U/Kg] was sufficient for the most patients until 60 minutes under extracorporeal circulation. 6. We used 1.5mg of protamine to neutralize 100 units of heparin. But smaller dose of protamine may be sufficient for appropriate neutralization.

경부 및 상부종격동에 발생한 낭상임파관종 1례

서충헌 대한흉부심장혈관외과학회 1980 Journal of Chest Surgery (J Chest Surg) Vol.13 No.4

A 37 year old male patient was suffered from severe labored breathing caused by post tracheostomy stenosis, which was localized at the mediastinal trachea [cuffed tracheal stenosis] and ranged 1.5 cm in length and approximately 3 ram. in diameter on tracheogram. After dilation of tracheal stenosis with dilator, endotracheal intubation was tried for induction of anesthesia and control of respiration during operation. A tube was placed just beyond the tracheal stenosis without respiratory difficulty. Under the endotracheal anesthesia, circumferential resection of the mediastinal trachea containing the stenosis, approximately 2 cm in length [4 tracheal rings}, was carried out and primary direct end to end anastomosis was performed with interrupted submucosal sutures [3-0 Dexon] and mobilization of trachea Postoperative tracheostomy was not performed. The patient was completely relieved from dyspnea immediately after operation. Post-operative convalescence was entirely uneventful and at present, about 3 months after operation, he is now conducting a usual life. From the literature and our experience, the etiology and treatment of post-tracheostomy stenosis were discussed.

간농양에 병발한 심낭염 치험 2례

서충헌 대한흉부심장혈관외과학회 1981 Journal of Chest Surgery (J Chest Surg) Vol.14 No.2

Thymolipoma is extremely uncommon benign mediastinal tumor consisting of fatty and thymic tissue. Only 50 verified cases have been reported in the world literatures. This one case is the first reported example of surgically treated thymolipoma associated with spontaneous pneumothorax. A thirty-two year old male patient had been in good health until two days prior to admission, when he noted sudden dyspnea associated with an aching pain over the left precordium. The dyspnea and chest pain had become progressively worse. The physical examination revealed that left hemithorax was tympanic sound on percussion and absence of breathing sound on auscultation and point of maximal impulse was located on the 4th intercostal space at the left sternal border. Emergency closed thoracostomy was performed under the impression of tension type spontaneous pneumothorax of the left lung. After closed thoracostomy, point of maximal impulse was not changed inspire of full expansion of the left lung and chest X-ray was strongly suggested pericardial effusion or cardiomegaly which couldn`t account for by clinical course and hemodynamic evidence. EKG, echocardiogram, bronchofiberoscophy, bronchogram and diagnostic thoracentesis was performed. On Dec. 8, 1980, operation was performed under the impression of mediastinal tumor in the anterior mediastinum. At left posterolateral thoractomy, a large fatty mass, measuring 35 x 27 x 13 Cm in dimension and weighing 3350 gm, was resected and multiple bullae on the apicoposterior segment of the left upper lobe was resected and continuously sutured. The pathologic diagnosis of the fatty mass was thymolipoma. The postoperative course was uneventful and discharged in good general conditions.

실험쥐모델에서 이식전 제공자 전혈 수혈이 이식심장의 생존에 미치는 영향

서충헌,박만실 대한흉부심장혈관외과학회 1999 Journal of Chest Surgery (J Chest Surg) Vol.32 No.11

Background: Donor-specific blood transfusion(DSBT) before organ transplantation has been demonstrated to prolong allograft survival; the mechanism of this effect has remained unclear. Only a few researches have been performed on this subject in our country. Material and Method: To investigate the effect of DSBT, we selected 5 donor recipient combinations using rats of pure strain such as PVG, ACI, and LEW. One ml of donor whole blood was transfused to each recipient through the femoral vein 7 days prior to transplantation. The donor heart was transplanted to the recipient's abdominal vessels heterotopically using modified Ono and Lindsey's microsurgical technique. Five transplantations were done for each combination. Postoperatively, donor heart beat was palpated everyday through the recipent's abdominal wall. Rejection was defined as complete cessation of donor heart beat. Result: The allogeneic heart grafts transplanted from PVG strain to ACI strain(PVG ACI) without DSBT were acutely rejected(mean survival 10.2 days). With pretransplant DSBT, the cardiac allografts in PVG ACI and LEW PVG combinations survived indefinitely(more than 100 days), those in ACI PVG combination survived 12 to 66 days(mean 31.8 days), those in PVG LEW survived 8 to 11 days(mean 10.0 days), and those in ACI LEW survived 7 to 9 days(mean 8.0 days). In brief, DSBT prior to heart transplantation was definitely effective in PVG ACI and LEW PVG combinations and moderately effective in ACI PVG combination, but not effective in PVG LEW and ACI LEW combinations. Conclusion: DSBT prior to heart transplantation showed variable effects, but might prolong cardiac allograft survival indefinitely in some donor recipient strain combinations. The mechanism of this effect should be further investigated.

心筋 pH 測定에 관한 實驗的 硏究 : 術後 心臟機能 回復의 指標로서 心筋 pH의 意義 Significance of intramyocardial pH as an index of postoperative recovery of cardiac function

徐忠憲,金炯默 고려대학교 의과대학 1991 고려대 의대 잡지 Vol.28 No.1

It is widely recognized that adequate preservation of the ischemic myocardium is of primary importance in cardiac operations. Yet, there are no techniques available for intraoperative assessment of the adequacy of myocardial preservation during the period of aortic cross-clamp. With the use of cold cardioplegia, continuous intraoperative measurement of myocardial temperature has been found useful in monitoring the adequacy of the delivery of the cardioplegic solution to the ischemic myocardium. It is, however, more important to monitor the metabolic status of the ischemic tissues, since tissue acidosis can progress even in the presence of adequate myocardial hypothermia. The continuous measurement of intramyocardial pH was used to follow the progression of ischemia, and it was correlated to the recovery of left ventricular function following hypothermic global ischemia. New miniature intramyocardial probes with dual pH- and temperature-sensing capability were placed into the left ventricular free walls of 12 mongrel dogs undergoing ischemic arrest during tardiopulmonary bypass. All dogs underwent a single period of aortic cross-clamping for 90 minutes. Systemic moderate hypothermia (around 25℃ esophageally) was employed in all dogs. In six of them, modified St. Thomas hospital cardioplegic solutions at 4℃ was infused every 30 minutes during aortic cross-clamping and cold saline was also used for local myocardial cooling(Group Ⅰ). In other six dogs, only cold saline was used for myocardial protection without intermittent infusion of cardioplegic solution(Group Ⅱ). Intramyocardial pH and temperature were continuously monitored during cardiopulmonary bypass with PH & Thermo Monitor(Chemical Ins. Co. Model PT-501). To assess the degree of myocardial injury, CK-MB isoenzyme was measured before cardiopulmonary bypass(pre-CPB), and at 20 minutes(post-20), 40 minutes(post-40), and 60 minutes (post-60) after cardiopulmonary bypass. Postoperative recovery of left ventricular function was also evaluated by measuring cardiac output and dp/dt max. at the same times. Baseline intrarmyocardial pH before CPB averaged 7.49±0.12. Intramyocardial pH decreased following aortic cross-clamping. Decrease in intrarnyocardial pH was less in Group Ⅰ than in Group Ⅱ. The lowest intramyocardial pH during ischemia in Group Ⅰ ranged between 6.55 and 6.81, but those in Group Ⅱ ranged between 5.90 and 6.25. Mean lowest intramyocardial pH in both groups were significantly different, 6.70±0.09 in Group Ⅰ and 6.06± 0.14 in Group Ⅱ (p<0.01). As compared with baseline values, CK-MB isoenzymes at 60 minutes after CPB increased about 3.2 folds in Group Ⅰ and more significantly increased in Group Ⅱ by 14 folds(p<0.05). In Group Ⅰ, cardiac output and dp/dt max. at 60 minutes after CPB was recovered in average to 93.8±4.2% and 95.5±3.0% of baseline value, respectively. But in Group Ⅱ, postischemic myocardial recovery was significantly low as 65.8±7.3% and 61.8±7.5%, respectively(p<0.01). In conclusion, Group Ⅰ which employed cardioplegic solution and local iced saline cooling for myocardial protection demonstrated less decreased intramyocardial pH during ischemia and better postoperative recovery of myocardial function than Group Ⅱ. However, Group Ⅱ which employed only iced saline for myocardial protection demonstrated further decrease in myocardial pH during ischemia and poorer postoperative recovery of myocardial function than Group Ⅰ. These data indicate that continuous intraoperative measurement of intramyocardial pH is a practical and useful method for assessment of the adequacy of myocardial preservation during ischemia with aortic cross-clamp, and it may be valuable for further clinical use.

다한증의 제한적 교감신경절단술

박만실,서충헌,심재천,최봉춘,이영철 대한흉부심장혈관외과학회 1999 Journal of Chest Surgery (J Chest Surg) Vol.32 No.9

배경: 국소적 다한증의 흉강경을 이용한 통상적인 흉부교감신경절제술이나 교감신경절차단술은 효과적인 치료법이기는 하나 수술 후 심한 보상성 다한증이 많이 발생 하고 수장부 다한증의 경우 수술 후 얼굴에서 땀이 나지 않는 부작용이 발생한다. 저자들은 기존의 수술법을 개량해 제한적 흉부교감신경절단술을 고안하였다. 본 연구는 제한적 교감신경절단술의 결과를 분석하였다. 대상 및 방법: 1998년 5월부터 8월 까지 17명의 환자들에게 제한적 흉부교감신경절단술을 시행하였다. 9명의 안면부 다한증인 환자들에게 두 번째 교감신경절 위 아래의 교감신경을 절단하던 기존의 방법과는 달리 첫번째 와 두 번째 흉부교감신경절 사이의 신경절간신경만을 절단하였다. 8명의 수장부 다한증 환자에 대해서는 두 번째와 세 번째 흉부 교감신경절간신경을 절단하였다. 결과: 17명의 환자들 중 16명의 환자에서 수술 후 원하던 부위의 땀이 나지 않았으나 1명의 환자는 수술 1달 후 얼굴의 땀이 재발하였다. 안면부 다한증으로 수술을 받았던 9명의 환자들 보상성 다한증으로 4명이 심하게, 4명이 중등도로, 1명은 경미하게 불편을 호소 하였다. 그러나 수장부 다한증으로 수술을 받았던 8명의 환자들 중에서는 보상성 다한증을 3명에서 중등도로, 1명이 경미하게 호소하였으며 4명은 보상성 다한증이 없었다. 결론: 제한적 흉부교감신경절단술은 최소 침투 수술법으로 효과적인 치료법이며 특히 수장부 다한증에서는 수술 후 체간에서 발생하는 보상성 다한증의 발생을 줄이고 얼굴의 무한증을 막을 수 있을 것으로 사료된다. Background: Conventional thoracoscopic thoracic sympathectomy or sympathicotomy is an effective method in treating localized hyperhidrosis; however, this may result in a postoperatively embarrassing compensatory hyperhidrosis or facial anhidrosis in the treatment of palmar hyperhidrosis. We modified the conventional sympathicotomy by limiting the extent of nerve transection. The purpose of this study was to assess the result of the limited thoracoscopic sympathetic nerve transection in hyperhidrosis. Material and Method: From May to August 1998, 17 patients underwent limited transection of the sympathetic nerve. For 9 patients with facial hyperhidrosis, we transected only the interganglionic fiber between the first and the second ganglion, whereas the conventional method cuts two interganglionic fibers. Eight patients with palmar hyperhidrosis underwent limited transection of the interganglionic fiber between the second and third ganglion. Result: Sixteen patients had improved symptom postoperatively. There was a recurred facial sweating in 1 patient 1 month after the operation. Among the 9 facial hyperhidrosis patients, postoperative compensatory hyperhidrosis was severe in 4, moderate in 4 and minimal in 1. But in 8 cases of palmar hyperhidrosis compensatory hyperhidrosis was moderate in 3, and minimal in 1, none in 4. Facial sweating was not disturbed postoperatively in all of the palmar hyperhidrosis patients. Conclusion: Limited sympathetic nerve transection is a practical and less invasive method for the treatment of localized hyperhidrosis and may reduce the incidence of compensatory truncal hyperhidrosis and facial anhidrosis in case of palmar hyperhidrosis.

좌총장골 동맥에 스트레커 스텐트 삽입후 대퇴-대퇴동맥 우회로이식술로 치료한 하지 죽상경하 질환 2예

강신재,최재웅,오영배,송창섭,임진우,서충헌,박만실 대한순환기학회 1996 Korean Circulation Journal Vol.26 No.6