Morphine의 血漿Corticosterone增加作用에 對한 Clonidine의 抑制效果에 미치는 Adrenoceptor 遮斷劑의 影響

田溶愛,全普權,申萬鍊 고려대학교 의과대학 1984 고려대 의대 잡지 Vol.21 No.1

Clonidine is a potent, centrally acting, antihypertensive that produces analgesia and suppresses the opioid withdrawal signs. Ganong et al. reported that catecholamine and clonidine inhibit the ACTH liberation from an anterior pituitary gland. In order to ascertain whether the suppression induced by clonidine of morphine-induced increase of plasma corticosterone level is related with the stimulation of alpha-s-adrenoceptor, the influences of phenoxybenzamine, yohimbine, and propranolol on the suppression induced by clonidine of morphine-induced increase of plasma corticosterone level in male mice. The results obtained were summarized as follows: 1. Clonidine 100㎍/㎏ or 500㎍/㎏ did not affect the basal plasma corticosterone level. 2. Plasma corticosterone level was slightly increased by phenoxybenzamine 10㎎/㎏ or yohimbine 5㎎/㎏. 3. Plasma corticosterone level was significantly increased by morphine 20㎎/㎏, ACTH 5㎍/㎏ and picrotoxin 4㎎/㎏. And the morphine-induced increase was not affected by the clonidine 100㎍/㎏ but significantly suppressed by the clonidine 500㎍/㎏. But the ACTH or picrotoxin-induced increase was not affected by even the clonidine 500㎍/㎏. 4. The suppressing effect of clonidine 500㎍/㎏ on the morphine-induced increase was not affected by the pretreatment of propranolol 5㎎/㎏ but significantly inhibited by the pretreatment of phenoxybenzamine 10㎎/㎏ or yohimbine 5㎎/㎏. The results suggest that clonidine dose not affect the basal level of plasma adrenal corticosteroid and suppression mechanism of clonidine on the morphine-induced increase of plasma corticosterone level is mediated through the stimulation of alpha-2-adrenoceptor.

上肢 外轉位에서 施行한 鎖骨上 上腕神經叢遮斷

田溶愛,朴澳,金晟烈 순천향대학교 1981 논문집 Vol.4 No.1

With the arm in hyperabduction, we have carried out 525 procedures of supraclavicular Brachial plexus block from Aug. 1976 to June 1980, whereas block with the arm in adduction has been customarily performed by other authors4,27,28). The anesthetic procedure is as follows: 1) The patient lies in the dorsal recumbent position without a pillow under his head or shoulder. His arm is hyperabducted more than a 90 degree angle from his side. and his head is turned to the side opposite from that to be blocked. 2) An "X" is marked at a point 1cm above the midclavicle, immediately lateral to the edge of the anterior scalene muscle. and on the pa1pab1e portion of the subclavian artery. The area is aseptically prepared and draped. 3) A 22 gauge 3. 5cm needle attached to a syringe filled with 2% lidocaine (7-8mg/kg of body weight) and epineprine (1 :200,000) is inserted caudally toward the second portion of the artery where it crosses the first rib and parallel with the lateral border of the muscle until a paresthesia is obtained. 4) Paresthesia is usually elicited while inserting the needle tip about 1∼2cm in depth. If so, the local anesthetic solution is injected after careful aspiration. 5) If no paresthesia is elicited. the needle is withdrawn and redirected in an attempt to elicit paresthesia. 6) If, after several attempts, no paresthesia is obtained, the local anesthetic solution is injected into the perivascular sheath after confirming that the artery is not punctured. 7) Immediately after starting surgery. Valium is injected for sedation by the intravenous route in almost all cases. The age distribution of the cases was from 11 to 80 years. Sex distribution was 476 males and 49 females (Table 1) . Operative procedures consisted of 103 open reductions, 114 skin grafts combined with spinal anesthesia in 14, 87 debridements, 75 repairs, i.e. tendon(41), nerve(32), and artery (2), 58 corrections of abnormalities, 27 amputations above the elbow (5). below the elbow (3) and fingers (17). 20 primary closures, 18 incisions and curettages, 2 replantations of cut fingers respectively (Table 2). Pareathesia was obtained in all cases. Onset of analgesia occured within 5 minutes, starting in the deltoid legion in almost all cases. Complete anesthesia of the entire arm appeared within 10 minutes but was delayed 15 to 20 minutes in 5 cases and failed in one case. Thus, our success rate was nearly 100%. The duration of anesthesia after a single injection ranged from ?? to ?? hoers in 94% of the cases. The operative time ranged from 0.5 to 4 hours in 92.4% of the cases(Table 3). Repeat b1ocks were carried out in 33 cases when operative times which were more than 4 hours in 22 cases and the others were completed within 4 hours (Table 4). Two patients of the 33 cases, who received microvasular surgery were injected twice with 2 % lidocaine 20 ml, for a total of ?? hours. The 157 patients who received surgery on the forearms or hands had pneumatic tourni-quets (250 torrs) applied without tourniquet pain. There was no pneumothorax, hematoma or phrenic nerve paralysis in any of the unila- teral and 27 bilateral blocks, but there was hoarseness in two, Horner's syndrome in 11 and shivering in 7 cases. No general seizures or other side effects were observed. By 20m1 of 60% urografin study, we confirmed the position of the needle tip to be in a safer position when the arm is in hyperabduction than when it is in adduction. And also that the humeral head caused some obstruction of the distal flow of the dye, indicating that less local anesthetic solution would be needed for satisfactory anesthesia. (Fig.3.4)

椎弓切除術時 小量의 Morphine과 局麻劑를 混注한 硬膜外麻醉 및 術後 鎭通效果

박욱,田容愛,金晟烈 순천향대학교 1981 논문집 Vol.4 No.1

From September 1979 through April 1980, we had carried out continuoua lumbar epidural anesthesia (2% lidocaine 20m1) with small dose of morphine and single dose caudal anest-hesia (2% lidocaine. 15-20m1) for 16 cases of lumbar laminectomy. And also we observed the effects of postanesthetic pain relief by administered morphine (2mg) into lumbar epidural space. The results of this study were as follows: 1. Age distribution was from 20 to 60 years, sex distribution was 14 in men and 2 in women, and physical states was in ASA class I in all cases. 2. The trite of herniated intervertebral disc was L4-5 in 15 cases and L3-4 in one. The epidural puncture site was selected 2-3 vertebral segments cephalad from the lesion. 3. The morphine amount administered with lidocaine into lumbar epidural space was 2mg in all cases. 4. The duration of pain relief from the induction of anesthesia was average 17.5 hours, and from the additional epidural injection of morphine (2mg) in ward was average 13.5 hours. 5. There was no neurological deficit or sequele except nausea in one case postoperatively. Therefore this anestihetic method was not only satisfactory for laminectomy but also safer and simpler in the fixation of spinal anesthetic level by patient's position change than spinal anesthesia, and faster in the postanesthetic ambulation thats general anestesia. Moreover. surgeon'a acceptability was excellent and anestesiologist's load was more reduced than general anestheia.

상복부 말기암 통증치료에 대한 연구

신양식,오흥근,전용애 대한마취과학회 1979 Korean Journal of Anesthesiology Vol.12 No.4

Celiac plexus block for upper abdominal cancer pain was performed on 26 patients from April, 1977 to April, ]979 at the Pain Clinic of Yonsei Medical Center. Patients were placed in prone position and the location of the tip of needles was conformed by fluoroscopy and on image intensifier. Immediately after the assesment of the effect of test blocks with 1% lidocaine, permaneat blocks with 50% aIcohol were performed. The results obtained were as follows: 1) Under flouroscopic control, the interval from the test to the permanent block was less than 15 min, thus economical in both time and expense. Also no patient refused the alcohol block after the test block and alcohel injection was painless. 2) The test and permanent blocks were effective in all cases, but repeated permanent block was neceessary in 7 cases within 2 weeks after the initial alcohol block. 3) As to complications, hypotension, nausea and face flushing developed in 10, 3 and 8 cases respectively. There were no postponements and no mortality. 4) These cases were discharged from hospital without pain 2 to 18 days after block. 5) Two cases with recurrent cancer pain had repeated alcohal block with exellent effect 3 and 6 months after the initial alcohol blocl. 6) The block to death interval was l to 4 months in 6 cases in which follow up was possible. From the above results. we may conclude that by using fluoroscopyic control with needle placement only once, the test and permanent blocks were performed safely, effectively and painlessly.

제왕절개술 마취의 임상적 고찰

박광원,이희전,전용애,정순미 대한마취과학회 1979 Korean Journal of Anesthesiology Vol.12 No.1

To provide optimal obstetric anesthetic care, it is essential for the anesthetist to know well the maternal physiological alterations produced by pregnancy, labor and paturition, physiology and pharmacology of the fetal placental complex and how these are altered by analgesics and anesthetics (Bonica, 1972). Recently, the tendency to cesarean section has increased; the cesarean section rate was 8.1. (Lee et al., 1974) and 15% (Dripps et al., 1977). Choice of regional or general anesthesia for cesarean section depends on many factors. As, the paturient is considered to have a full stomach, regional anesthesia is advantageous. However, if the indication is fetal distress or maternal hemorrhage, the necessity for rapid delivery overrides all other considerations. For elective cesarean section the choice of anesthesia largely relates to patients condition and physicans preference, although the somewhat. longer time required for delivery in a repeated cesarean section may indicafes regional rather than general anesthesia (Dripps et al., 1977; James et al., 1977). The problem of anesthetic management of cesarean section was fetal depression due to sedatives, analgesics and anesthetics during delivery. In emergency cesarean section, the major problem in general anesthesia is aspiration of gastric contents and in regional anesthesia it is hypotension. Regarding fetal and neonatal depression associated with anesthesia, the effects of general or regional anesthesia or. the neonatal neurobehavioral status have been reported by many authors (Standley et al., 1974; Tronick et al., 1976; Hollmen et al., 1978). Thus we have made a clinical analysis of anesthesia for 300 cases by random sampling among 1725 cesarean sections. including emergency and elective operations, performed from July 1973 to June 1978 in Severance Hospital at Yonsei University College of Medicine. Clinical analysis was made of frequency of cesarean section, age distribution, parity, indication of cesarean section, physical status (A.S.A. classification), premedication, anesthetic method, relationship between Apgar seore and the type of anesthesia, relationship between induction to delivery time and one minute Apgar score, time to initial blood pressure drop after spinal anesthesia, blood loss, the methods of cardiopulmonary resuscitation of the newborn, perinatal mortality and neonatal neurobehavioral states. The result are as follows: 1) The incidence of cesarean aection was 18.4 percent of total deliveries and the tendency is increasing. 2) One minute Apgar score in spinal anesthesia is better than in general anesthesia (0. 01 $lt;p $lt;0 025). 3) Blood loss in spinal anesthesia (566±146ml) is less than in general anesthesia (796 ± 388ml). 4) Blood pressure showed a drop within ten minutes in 83 percent of cases after induction of spinal anesthesia. 5) Perinatal mortality of general anethesia (3. 9%) is more than spinal aneathesia (1.9%) Even tbough clinical results of spinal anesthesia seem to be more favorable than those of general anesthesia, from the above obrvation it may be concluded that choice of anesthesia for cesarean section depends on each maternal condition and only one anestbetic method should not be exclusively used.

기관내 삽관마취후 발생한 일측성 성대마비 : 1 례보고

김성열,박욱,전용애,조욱연 대한마취과학회 1982 Korean Journal of Anesthesiology Vol.15 No.4

We experienced a case of unilateral vocal cord paralysis following cuffed endotracheal intubation for abdominal surgery. The patient had have no laryngotracheal symptoms prior to the operation and anesthesia was uneventful. He complained of hoarseness post-operatively but no visible evidence of trauma secondary to the intubation was manifested on the indirect laryngoscopic examination, except left vocal cord paralysis. There were no obvious causes for the vocal cord paralysis and possible etiologic factors. Therefore, no specific treatment was done except for the bed rest, humidification and gurgling. Vocal cord function returned nearly normal after six months.

미량의 Morphine 과 국마취의 혼주에 의한 술후 진통효과에 대한 임상적 고찰

김성열,조욱연,박욱,전용애,김선종 대한마취과학회 1981 Korean Journal of Anesthesiology Vol.14 No.4

Behar et al reported that small doses of epidural morphine are effective in the treatment of acute and chronic pain by direct action on the specific receptors in the substantia gelatinosa of the posterior horn of the spinal cord. Brachial plexus blocks were performed in 217 cases in our hospital from Jun. 1979 to Aug. 1981. In an attempt to evaluate the postoperative pain relief, these cases were divided into two groups; the control and the evperimental group. The two groups were subdivided into three according to the method of approach-supraclavicular, interscalene, and axillary. The cases complaining of pain within 8 hours after the block were 71/112(63.4%) in the control group, and 26/105(24.8%) in the experimental group; and the cases complaining of pain or noticing no pain after 8 hours following the block were 41/112(36.6%) in the control group and 79/105(75.2%) in the experimental group. The postoperative pain relief was remarkable especially in the interscalene and supraclavicular approach in the experimental group. We thought this was probably due to anatomical variance of the interscalene and supraclavicular approach-nearer to the spinal cord and opiate receptors.

경막외 Morphine 주입으로 대장포진의 동통관리 : 일례보고 A Case Report

김순임,김성열,박욱,전용애,김선종 대한마취과학회 1980 Korean Journal of Anesthesiology Vol.13 No.4

Herpes zoster is characterized by multiple grouped erythematous vesicular eruption on the skin with severe pain. Therefore diagnasis of herpes zoster is clinically easy but effective control of its severe pain is not clear yet. Recently, Behar suggested that morphine which was injected into the epidural space reached subarachnoid space and produced potent analgesic effect by direct action on the specific opiate receptors in the substantia gelatinosa of the posterior horn cell of the spinal cord. On the basis suggestion, we have attempted to treat the severe pain of herpes zoster which was developed on right shoulder, right upper anterior and posterior chest, and posterior auricular area. At the initial block, we inserted the catheter into the 6th cervical intervertebral space and the tip of the catheter was placed in epidural space to 3cm cephalad. Then 3mg of morphine mixed with 10ml of normal saline was adminietered and also right stellate ganglion block with 0.25% bupivacaine 7ml was combined, therefore effective pain relief was obtained for 11 hours. At second block, additional dose of 2mg of morphine mixed with 10ml of normal saline was administered through the inserted epidural catheter at the initial block without stellate ganglion block, and effective pain relief was obtained for 15 hours. After then, whenever the pain was developed, additional dose of 2mg of morphine was administered as the same procedure of the second block, and the duration of pain relief was extended gradually by the each procedure (for 24 hours after third block and for 49 hours after fourth block). At 5 days after initial block, severe pain was completely subsided. Side effects such as postural hypotension, motor weakness and dizziness was not developed except slightly motor weakness after initial block. This result showed that small dose of morphine injection into the epidural space is effective control of severe pain of herpes zoster.

수술후 및 암말기 환자의 동통관리 : 주로 경막 외강에 미량의 몰핀 주입으로

황경호,김선종,김성열,전용애,김순임,박욱 순천향대학교 1981 논문집 Vol.4 No.2

Pert and his co-workers(1976) reported that opiate receptors were identified autoradiogr- aphically in the brain and the substantia gelatinosa of the posterior horn of the spinal cord. In recent stuffy of Behar (1979), small doses of morphine administered directly into the lumbar epidural space produced potent analgesia. The results of above authors prompted us to study the effect of epidurally applied sma11 doses of morphine in patient suffering from postoperative and pathologically intractable pain. In an attempt to relieve postoperative pain after lumbar epidural, caudal and brachial plexus b1ock, there were divided into two groups for study; One of these groups is control group which was injected with 2% lidocaine only and another of theme groups is morphine group which was injected with 2% lidocaine and small doses of morphine (3.5∼5.5mg). The postoperative pain relief more than 12 hours from induction in morphine group was 86.1% in lumbar epidural anesthesia and 82. 5% in caudal anesthesia. And these effective-ness was more prolonger than control groups. In the cases of pathological intractable pain relief, Case I was a patient of herpes zoster which was developed on right shoulder, upper anterior and posterior chest, and posterior auricular area with the severe pain. At 5 days after initial block, severe pain was completely subsided with 5 times of small doses of morphine injection into the epidural space. Case Ⅱ was a patient of lung cancer with severe pain and this effective pain relief was obtained for two and half days with 3 times of above same method. But after discharge from hospita1, the severe pain was developed again and above method was ineffective. Complications of this method were same with ordinarily epidural block in cases which used 2% lidocaine and slightly over came, but no loss of motor appeared in cases of morphine alone to be used. Impairment of spontaneous voiding after this method is still remained in prob1em of further study. The advantage of this method would be to provide predictab1e relief from pain without attendant lose of motor or sensory function. It is tempting to speculate that this technique may be used for postoperative pain and intractable pathological pain except cancer pain. However, further studies are needed to estab1ish the clinical applicability of epidural inject-ions of morphine, espicially with regard to the effects on longterm control of pain.

추궁절제술시 소량의 Morphine 과 국마취를 혼주한 경막외마취 및 술후 진통효과

황경호,김성열,박욱,문광진,전용애 대한마취과학회 1980 Korean Journal of Anesthesiology Vol.13 No.4

From September 1979 through April 1980, we had carried out continuous lumbar epidural anesthesia(2% lidocaine, 20ml) with small dose of morphine and single dose caudal anesthesia(2% lidocaine, 15-20ml) for 16 cases of lumbar laminectomy,And also we observed the effects of postanesthetic pain relief by administered morphine(2mg) into lumbar epidural space, The results of this study were as follows: 1) Age distribution was from 20 to 60 years, sex distribution was 14 in man and 2 in woman, and physical status was in ASA class I in all cases. 2) The site of herniated intervertebral disc was L4~5 in 15 cases and L3~4 in one, The epidural puncture site was selected 2~3 vertebral segments cephalad from the lesion, 3) The morphine amount administered with lidocaine into lumbar epidural space was 2mg in all cases. 4) The duration of pain relief from the induction of anesthesia was average 17. 5 hours, and from the additional epidural injection of morphine(2mg) in ward was average 13.5 hours. 5) There was no neurological deficit or sequele except nausea in one case postoperatively. Therefore this anesthetic method was not only satisfactory for laminectomy but also safer and simpler in the fixation of spinal anesthetic level by patient's position change than spinal anesthesia, and faster in the postanesthetic ambulation than general anesthesia. Moreover, surgeon's acceptability was excellent and anesthesiologist's load was more reduced than general anesthesia.