EDTA 유발성 위혈소판감소증 환자의 마취경험

이승준,길호영,김태견,윤영준 대한마취과학회 1998 Korean Journal of Anesthesiology Vol.34 No.1

Pseudothrombocytopenia caused by platelet clumping is an in vitro phenomenon that occurs in ethylene-diamine-tetra-acetic acid(EDTA) anticoagulated blood at room temperature. Pseudothrombocytopenia may lead to erroneous diagnosis, unnecessary and costly additional laboratory examinations, and inappropriate medical or surgical therapy. experienced 75-year old female pseudothrombocytopenia patient scheduled for orthopedic surgery, who showed abnormal thrombocytopenia (35,000/mm3) in preoperative routine platelet count using EDTA anticoagulant, but showed normal platelet count in sodium citrate anticoagulant. (Korean J Anesthesiol 1998; 34: 213∼216)

Propofol-Fentanyl-N_2O 마취시 Fentanyl 농도가 마취유지, 회복 및 술후 통증조절에 미치는 영향

길호영,유홍성,김태견,이승준,윤영준,박영주 대한정맥마취학회 1999 정맥마취 Vol.3 No.3

서론: 피부절개는 술중 가장 강한 자극이 아니므로 외과적 자극의 대표적 지표로 사용하기 어렵다는 견해가 있다. 최근 평균동맥압이 외과적 자극에 대해 혈압변동을 상괘시킬 수 있는 propofol의 혈중농도와 유사하게 외과적 자극의 정도를 잘 반영할 수 있음이 보고되었다. 본 연구는 이러한 견해에 따라 propofol-fentanyl-N_2O 마취시 fentanyl 농도의 변화가 마취 및 회복에 미치는 영향을 알아보고자 fentayl의 농도응 등농도노모그램에 의거하여 0, 1.5, 3, 4.5 ng/㎖로 저절하면서 평균동맥압의 변화에 따라 propofol의 주입속도를 조절하여 술중 propofol 사용량으로 대변되는 각 fentanyl 농도의 마취유지효과 및 천장효과 여부, fentanyl과 propofol이 의식회복에 미치는 영향, 술후 통증 조절을 위한 술중 fentanyl 농도의 영향 등을 관찰하였다. 방법: 20∼55세의 척추융합이 예정된 미국마취과학회 신체분류 등급상 1 및 2에 해당되는 체중 50∼75㎏의 남녀환자 80명을 대상으로 등농도노모그램에 의한 fentanyl의 혈중 예상농도 1.5 ng/㎖(2군), 3.0 ng/㎖(3군), 4.5 ng/㎖(4군)로 투여되는 군으로 나누어 fentanyl을 사용하지 않은 1군과 비교 관찰하였다. Propofol 정주 속도는 술중 평균동맥압의 증감에 따라 0∼12 ㎎/㎏/hr의 주입속도 변화, 수액주입속도증가, 일시주입 중단 등으로 조절하였다. 예상 수술 종료 15분 전 propofol과 fentanyl 주입을 중단하였고 의식회복 후 통증을 호소할 때 fentanyl을 사용한 IV-PCA를 술후 통증조절에 이용하였다. 각 군간의 비교를 위해 술중 사용된 propofol의 총용량, fentanyl 주입중단 후 자발개안 시간 및 지남력 회복까지의 시간, IV-PCA 사용시 단추를 처음 누른 시간 및 처음 24시간동안의 fentanyl 사용량을 측정하였고 통증의 정도를 VRS (Verbal Rating Scale)에 따라 측정하였다. 결과: 술중 사용된 propofol의 평균주입속도는 1군에 비해 2, 3, 4군이 유의하게 감소하였으며, 자발개안 및 지남력 회복 시간은 1군에 비해 2, 3, 4군에서 유의하게 증가하였다. IV-PCA의 단추를 처름 누른 시간, fentanyl 사용량은 1군에 비해 2, 3, 4군에서 유의하게 차이가 있었고, 통증의 정도도 1군에 비해 2, 3, 4군이 유의하게 낮았다. 결론: 술중 fentanyl 혈중 농도 3∼4.5 ng/㎖ 사이에서 propofol 평균 주입속도, 의식회복, 술후 통증조절을 위한 24시간 fentanyl 사용량, VRS에서 천장효과를 보임으로써 Propofol-Fentanyl-N_2O마취시 fentanyl 농도를 3.0∼4.5 ng/㎖ 이하로 조절하고 propofol을 평균동맥압에 따라 조절하는 것이 적절한 약물주입을 위한 합리적인 방법으로 사료되었다. Background: Skin incision has been used as a standard stimulus in most concentration versus response relationship studies for anesthetics. However, skin incision is not the most intense stimulation and inconvenient method during operation. Mean arterial blood pressure, but not heart rate, is convenient and predicts surgical stress as well as propofol blood concentration. We evaluated the effects of different fentanyl concentration on propofol-fentanyl-N_2O anesthesia using mean arterial blood pressure as an indicator of surgical stress during operation. Methods: Eighty ASA Ⅰ or Ⅱ patients (age: 20~55 yrs) scheduled for spine fusion were randomly allocated to four groups according to expected fentanyl blood concentration (Group 1, 2, 3, 4: 0, 1.5, 3.1, 4.5 ng/ml respectively. n-20 for each group). Fentanyl was infused according to isoconcentration nomogram, and propofol infusion rate was titrated by changes of mean arterial blood pressure (0~12 ㎎/㎏/hr). Fifteen minutes before expected end of surgery, propofol and fentanyl infusion were discontinued. Thereafter Ⅳ-PCA using fentanyl was applied for postoperative pain relief. Average propofol flow rate, recovery of orientation, verbal scale were cheked. Results: Group 2, 3, 4 showed decreased average propofol flow rate, delayed recovery and decreased postoperative 24 hr fentanyl requirement for pain relief gradually compared with group 1. Group 4 showed ceiling effect in terms of average propofol flow rate, recovery of orientation and 24 hr fentanyl requirement for postoprerative pain relief compared with group 1~3. Conclusions: Keep the fentanyl concentration below 3.0~4.5 ng/ml and titrate propofol flow rate was reasonable method for adequate control of drug infusion during a propofol-fentany1-N_2O anesthesia.

Propofol-Fentanyl 완전정맥마취시 Isoconcentration Nomogram 을 이용한 Fentanyl 지속정주의 임상적 유용성

이승준,윤영준,길호영,김태견 대한마취과학회 1997 Korean Journal of Anesthesiology Vol.33 No.5

Background : To estimate real time concentration of drugs during TIVA is theoretical, but it is not easy and inefficient. To maintain designed target concentration with continuous infusion using methods that account for the multicompartmental pharmacokinetic profile of fentanyl, isoconcentration nomogram is one of the methods. We evaluated the clinical usefulness of the isoconcentration nomogram using two different expected concentration of fentanyl. Methods : Thirty ASA class I or II adult patients scheduled for spine fusion were randomly allocated into two groups according to 1.5 or 3 ng/ml of expected fentanyl concentration. Using isoconcentration nomogram, fentanyl concentration was adjusted and the propofol concentration was fixed to 3.5 g/ml according to Prys-Roberts method. Vital signs were titrated using variable flow rate of propofol. Fentanyl and propofol were discontinued 15 min before the end of operation. And, IV-PCA using fentanyl were applicated for postoperative pain control. The dosage of propofol and fentanyl, recovery time of consciousness and orientation were checked. Also, first buttoning time and 24hr fentanyl dosage in IV-PCA were checked. Results : Average flow rate of propofol used were 7.5 1.2 mg/kg/hr in group 1, 5.7 1.1 mg/kg/hr in group 2 which was significantly lower than group 1(P<0.05). Spontaneous eye opening and recovery of orientation was delayed 1.8 times in group 2. First buttoning time and 24hr fentanyl requirement for postoperative pain control using IV-PCA was delayed by 2 and decreased 60% in group 2, respectively. Conclusions : Isoconcentration nomogram was useful tool to control the expected concentration of fentanyl during TIVA and postoperative pain control using fentanyl IV-PCA. (Korean J Anesthesiol 1997; 33: 890∼895)

Propofol-Fentanyl-N2O 마취시 Fentanyl 농도가 마취유지, 회복 및 술후 통증조절에 미치는 영향

이승준,윤영준,길호영,유홍성,김태견 대한마취과학회 1998 Korean Journal of Anesthesiology Vol.34 No.4

Background : Skin incision has been used as a standard stimulus in most concentration versus response relationship studies for anesthetics. However, skin incision is not the most intense stimulation and inconvenient method during operation. Mean arterial blood pressure, but not heart rate, is convenient and predicts surgical stress as well as propofol blood concentration. We evaluated the effects of different fentanyl concentration on propofol-fentanyl-N20 anesthesia using mean arterial blood pressure as an indicator of surgical stress during operation. Methods : Eighty ASA I or II patients(age: 20∼55 yrs) scheduled for spine fusion were randomly allocated to four groups according to expected fentanyl blood concentration(Group 1, 2, 3, 4: 0, 1.5, 3.0, 4.5 ng/ml respectively, n=20 for each group). Fentanyl was infused according to isoconcentration nomogram, and propofol infusion rate was titrated by changes of mean arterial blood pressure(0∼12 mg/kg/hr). Fifteen minutes before expected end of surgery, propof and fentanyl infusion were discontinued. Thereafter IV-PCA using fentanyl was applied for postoperative pain relief. Average propofol flow rate, recovery of orientation, verbal rating scale were cheked. Results : Group 2, 3, 4 showed decreased average propofol flow rate, delayed recovery and decreased postoperative 24 hr fentanyl requirement for pain relief gradually compared with group 1. Group 4 showed ceiling effect in terms of average propofol flow rate, recovery of orientation and 24 hr fentanyl requirement for postoprerative pain relief compared with group 1∼3. Conclusions: Keep the fentanyl concentration below 3.0∼4.5 ng/ml and titrate propofol flow rate was reasonable method for adequate control of drug infusion during a propofol-fentanyl-N20 anesthesia. (Korean J Anesthesiol 1998; 34: 839∼845)

목표농도조절주입 ( Target Controlled Infusion ) 을 이용한 Propofol 마취유도

길호영,양정화,유홍성,김태견,이성익,이승준,윤영준,박영주 대한정맥마취학회 1999 정맥마취 Vol.3 No.2

서론: 목표농도 조절주입은 약물의 정주방법을 단순하고 향상된 조절 방법으루 투여할 수 있는 새로운 약물투여 방법이다. 주입된 약물의 효과는 작용처의 농도에 의해 결정되는 이는 혈중농도와 밀접한 관련이 있다. 본 연구는 TCI를 이요한 propofol 마취유도를 위해 다양한 목표농도를 설정하고 이에 따른 마취유도 여부를 용량-반응 연구를 통해 분석함으로서 한국인에서 midazolam으로 전처치 한 경우 propofol 마취유도 시 적절한 목표 농도를 설정하는 동시에 활력징후의 변화 및 부작용에 대해 관찰하였다. 방법: 계획수술이 예정된 미국마취과학회 신체분류 등급상 1, 2에 속하는 체중 45∼100㎏, 연령 18∼55세의 남녀환자 66명을 대상으로 하였으며 심, 신 간장 질환이 있는 경우는 대상에서 제외하였다. 마취전처치로 마취유도전 1시간에 glycopyrrolate 0.2 ㎎ 및 midazolam 0.07 ㎎/㎏을 근주한 후 마취유도 시 목표농도를 3, 4, 5, 6 ㎍/㎖로 하는 네 개의 군으로 나누어 각각 15∼18명씩 임의로 배정하였다. 마취유도의 성공 여부는 약물주입 시작부터 3분이내에 눈을 떠보라는 요구에도 반응이 없는 경우로 정하였고 약물 주입동안 1분 간격으로 혈압 및 맥박, 10초 이상 지속되는 무호흡의 여부를 관찰하고 동시에 약물주입으로 인한 통증의 정도를 관찰하였다. 또한 마취유도 성공 시 마취유도 시간, 컴퓨터 주입기 화면에 표시된 마취유도 용량, 측정용량, 각성농도를 1.2 ㎍/㎖로 하였을 때의 상황민감성감소기를 관찰하였다. 결과: 목표농도 3 ㎍/㎖로 설정된 경우 환자의 25, 4 ㎍/㎖시 5.8.8%, 5 ㎍/㎖시 77.8%, 6 ㎍/㎖시 100%에서 성공적인 마취유도를 보여 목표농도 증가와 강한 상관관계를 보였다(r^2=0.98). Propofol의 마취유도를 위한 효과농도에서 EC_50은 3.87 ㎍/㎖, EC_95은 5.71 ㎍/㎖을 나타내었다. 각 군의 마취유도시간은 139∼166초로 각 군간의 차이를 보이지 않았으며 혈압, 맥박, 말초산소포화도와 주입 시 통증의 정도, 무호흡의 빈도, 부작용의 관찰도 각 군간에 차이를 보이지 않았다. 결론: Midazolam 전처치한 한국 성인의 경우 TCI를 이용한 propofol 마취유도는 목표농도 5∼6 ㎍/㎖에서 대부분의 대상환자가 활력징후의 개선이나 부작용 감소 등의 장점을 보이면서 성공적인 마취유도를 보였다. Background: Target Controlled Infusion (TCI) is designed to achieve a predicted target blood concentration based on population pharmacokinetics and it provides the closest approximation for any individual patients. This study determined which target is appropriate for propofol induction using a TCI in korean adult patients premedicated with midazolam. Methods: Sixty six patients (ASA Ⅰ or Ⅱ, 18~55 years) premedicated with midazolam were allocated randomly to receive an infusion to achieve and maintain a target blood concentration or 3, 4, 5 and 6 ㎍/ml using a TCI. Induction time was measured as the interval from the start of the infusion to loss of verbal contact and induction within 3 min was considered as successful. Calculated concentration, induction dose, context sensitive decrement time, vital signs, pain score and side effects were checked and compared each other during induction period. Results: The success rate when the target was 3 ㎍/ml was 25%, 58.8% and 100% when targets were 4 ㎍/ml, 5 ㎍/ml and 6 ㎍/ml respectively. Effective Concentration (EC)50 for induction was 3.87 ㎍/ml and EC95 was 5.71 ㎍/ml. Calculated concentration, induction dose, context sensitive decrement time in 3, 4, 5 ㎍/ml group showed no differences among groups, but 6 ㎍/ml group showed statistically significant differences compared with other groups. Vital signs, pain score and side effects showed no differences among groups. Conclusions: Target concentration of 5 ㎍/ml would successfully induce anesthesia in the majority of patients premedicated with midazolam without major hemodynamic changes.

목표농도조절주입(Target Controlled Infusion)을 이용한 Propofol 마취유도

이승준,윤영준,길호영,양정화,유홍성,김태견,이성익 대한마취과학회 1998 Korean Journal of Anesthesiology Vol.34 No.5

Background : Target Controlled Infusion(TCI) is designed to achieve a predicted target blood concentration based on population pharmacokinetics and it provides the closest approximation for any individual patients. This study determined which target is appropriate for propofol induction using a TCI in korean adullt patients premedicated with midazolam. Methods : Sixty six patients(ASA I or II, 18∼55 years) premedicated with midazolam were allocated randomly to receive an infusion to achieve and maintain a target blood concentration of 3, 4, 5 and 6 g/ml using a TCI. Induction time was measured as the interval from the start of the infusion to loss of verbal contact and induction within 3 min was considered as successful. Calculated concentration, induction dose, context sensitive decrement time, vital signs, pain score and side effects were checked and compared each other during induction period. Results : The success rate when the target was 3 g/ml was 25%, 58.8%, 77.8% and 100% when targets were 4 g/ml,5 g/ml and 6 g/ml respectively. EC50 for induction was 3.87 g/ml and EC95 was 5.71 g/ml. Calculated concentration, induction dose, context sensitive decrement time in 3, 4, 5 g/ml group showed no differences among groups, but 6 g/ml group showed statistically significant differences compared with other groups. Vital signs, pain score and side effects showed no differences among groups. Conclusions : Target concentration of 5∼6 g/ml would successfully induce anesthesia in the majority of patients premedicated with midazolam without major hemodynamic changes. (Korean J Anesthesiol 1998; 34: 944∼950)