항암치료를 받고있는 환자의 마취관리

채병국 대한마취과학회 1995 Korean Journal of Anesthesiology Vol.29 No.6

氣管內 揷管을 위한 d-Tubocurarine chloride(d-Tc)의 定量에 대한 臨床的 考察

蔡秉國,吉燦一,辛正順 고려대학교 의과대학 1982 고려대 의대 잡지 Vol.19 No.1

Administration of succinylcholine for endotracheal intubation may cause untoward reactions such as elevation of intraocular pressure, increased plasma potassium level, increased intragastric pressure, bradycardia, and development of postoperative muscle pain, etc. Several attempts have been made to minimize the development of muscle fasciculation following administration of succinylcholine such as pretreatment with small doses of nondepolarizing neuromuscular blocking agent, self-taming of succinylcholine, or the use of hexafluorenium. When small doses of nondepolarizing neuromuscular blocking agent are given before succinylcholine administration, larger doses of succinylcholine should be given to chieve satisfactory relaxation. So, this study was intended to determine the adequate doses of d-tubocurarine chloride(d-Tc) for endotracheal intubation in patients with relative contraindication of using succinylcholine. We Observed the degree of vocal cord relaxation 3 minute after d-Te administration by fiberscopic examination and measured changes in mean blood pressure (MBP) and heart rate, just before, and after intubation, and 5 minutes after intubation. The total number of patients in this study was 100, and the patients were divided into five groups: Group 1, consisting of 10 patients, recieved 0.3㎎/㎏ of d-tubocurarine. Group 2, of 32 patients, recieved 0.4 ㎎/㎏ of d_Tc. Group 3, of 16 patients, recieved 0.45㎎/㎏ of d-Tc. Group 4, of 26 patients, recieved 0.5 ㎎/㎏ of d-Tc. Group 5, of 16 patients, recieved 0.6 ㎎/㎏ of d-Tc. The conclusions are summarized as follows; 1) The adequate doses of d-Tc for endotracheal intubation is 0.5 ㎎/㎏. 2) Maximum reductions in MBP were present 3 minutes following d-Tc administration in each group. 3) Heart rate did not change significantly after d-Tc administration in each group.

흰쥐에서 急性出血性 쇽에 의한 血小板 形態 變化의 電子顯微鏡的 觀察

蔡秉國,張聖鎬,辛正順 고려대학교 의과대학 1988 고려대 의대 잡지 Vol.25 No.1

Experimental studies have suggested that increased and liberated lysosomal enzymes contribute directly to the pathophysiology of hemorrhagic shork by exerting a splanchnic vasoconstrictor effect in the pancreas and in the entire splanchnic region. The major sources of these enzymes are thought to be the intestinal epithelium, liver, pancreas, spleen or kidney. On the other hand, blood platelet also contain large amount of lysosomal enzymes. Response of rat platelet to hemorrhagic shock was examined through using ultrastructural technique. The blood platelet of the rat pretreated with saline responded to hemorrhagic shock with decrease of α-granules and the development of the platelet canalicular system which opens to the extracellular environment and the pseudoped formation . So, these facts suggest that the granules observed to be released from platelet have strongly contributed to the rise in serum lysosomal enzyme. Glucocorticoid has been considered controversial in the treatment of hemorrhagic shock. Glucocorticoid, however, seems to stablized lysosomal membranes, providing cellular protection in hemorrhagic shock. The effect of dexamethasone almost completely inhibited morphological alterations in rat platelet 180 minutes after induction of hemorrhagic shock, and delayed the decrease of α-granules.

실험견에서 흉추경막외마취가 급성미만성 폐포저산소증과 Nw-nitro-L-arginine 으로 유도된 폐고혈압증에 미치는 영향

김종욱,채병국 대한마취과학회 1995 Korean Journal of Anesthesiology Vol.29 No.3

Thoracic epidural anesthesia has been used to manage intraoperative and postoperative pain for thoracic surgical patients with general anesthesia recently, And this combined anesthesia has been associated with less sedation, earlier ambulation, blunting of the stress response and better pain control in the post-operative period. But the effects of thoracic epidural anesthesia on pulmonary shunt, pulmonary vasoactivity and oxygenation are still unknown. The author has investigated the effects of thorarcic epidural anesthesia on pulmonary hypertension induced by acute diffuse alveolar hypoxia and N^W -nitro-L-arginine(L-NNA) in 12 mongrel dogs. Acute diffuse alveolar hypoxia which is similar to the early stage of acute respiratory failure may induce the pulmonary hypertension. And L-NNA, inhibitor of endothelium derived relaxing factor(EDRF), may also induce pulmonary hypertension under hypoxic state. The measurements were made three times, the first was baseline at room air ventilation. Following baseline recordings, saline 4 ml(group A, n=6) or 2% lidocaine 4 ml(group B, n=6) was injected through the epidural catheter and ventilation was started with hypoxic gas mixture(10% O2, 90% N2). The seeond measurements was made 30 min after the hypoxic ventilation and third was 20 min after infusion of L-NNA(50 mg/kg mixed with distill water 50 ml, infusion rate is 50 ml/20min) under the continuous ventilation with hypoxic gas mixture. The results were as follows: 1) There were significant changes in mean pulmonary arterial pressure, pulmonary vascular resistance in group A(p$lt;0.05) and in arterial and mixed venous oxygen tension, arterial and mixed venous oxygen content, intrapulmonary shunt in both groups(p$lt;0.05) 30 minutes after hypoxia but there were not significant differences between groups. 2) There were significant changes in mean pulmonary arterial pressure, in group B (p$lt;0.05) and pulmonary vascular resistance, systemic vascular resistance and mixed venous oxygen tension and content in both groups (p$lt;0.05) 20 miniutes after infusion of L-NNA under the continuous ventilation with hypoxic gas mixture but there were not significant differences between groups. But there were significant changes in central venous pressure in group B(p$lt;0.05) and significant differences between groups(p$lt;0.05) at 20 miniutes after infusion of L-NNA. These results indicate that thoracic epidura1 anesthesia does not influence the pulmonary hypertension directly and does not praduce any unfavorable hemodynamic events during pulmonary hypertension induced by acute diffuse alveolar hypoxia and N^W-nitro-L-arginine. Therefore thoracic epidural anesthesia shoud be valuable assistant to the general anesthesia for pulmonary hypertensive patients. (Korean J Anesthesiol 1995; 29: 317~328)

개심술시 전신마취와 병용된 흉추 경막외 마취가 술중 및 술후 Stress Hormone과 심혈관계 지수변화에 미치는 영향

김형미,채병국,신정순 고려대학교 의과대학 1993 고려대 의대 잡지 Vol.30 No.1

Combined anesthesia refers to any combination of regional and general anesthesia, usually a combination of epidural and general anesthesia. Combined anesthesia has been associated with less sedation, earlier ambulation, higher pulmonary flow rates, improved oxygenation, blunting of the stress response and better pain control in the postoperative period. Currently the most commonly employed method of anesthesia for open heart surgery patients is general anesthesia supplemented with opioids and postoperative pain control with IM morphine. This study was undertaken to compare the total doses of fentanyl and vecuronium, duration of endotracheal intubation and ventilatory support, cardiovascular changes, changes in arterial blood gas, changes in cortisol and β-endorphin, and the postoperative pain score in 40 open heart surgery patients given a routine anesthetic regimen or combined anesthesia. Group A (n=20) was given general anesthesia, maintained with a nitrous oxide (2L/min)-oxygen (2L/min)-isoflurane (0.5-2.0 Vol. %) gas mixture and fentanyl (initial dose 10 ㎍/kg with additional doses as required) with routine postoperative care with IM morphine sulfate and Group B (n=20) was given light general anesthesia nitrous oxide (2L/min)-oxygen (2L/min)-isoflurane (0.2-0.5 vol. %) and a continuous epidural infusion of a combination of 0.125% bupivacaine and fentanyl (10 ㎍/ml) through an infusion pump from the start of the operation until the third postoperative day. The results were as follows ; 1. The total amount of fentanyl given to Group B was significantly lower than the amount given to Group A. 2. The duration of endotracheal intubation and ventilatory support was significantly shorter in Group B compared to Group A. 3. The heart rate was slightly higher in Group B compared to Group A, but the only significant difference was seen 30 minutes after skin incision. There was no significant difference in the systolic pressures between the two groups but comparison of the diastolic pressures before cardiopulmonary bypass (CPB) and before skin closure showed significantly higher pressures for Group B. The pulmonary artery pressure (PAP) remained stable in Group A while in Group B, the PAP gradually increased to show a significant increase on POD2. The pulmonary capillary wedge pressure (PCWP) was significantly higher in Group B compared to Group A on POD2 The cardiac output (CO) and cardiac index (CI) was stable in Group B while for Group A, there was a significant decrease from during operation to POD2. The systemic vascular resistance(SVR) showed a significant increase in Group A from during operation to POD1 and POD2 and a significant difference between Group A and Group B on POD1 and on POD2. The pulmonary vascular resistance (PVR) increased significantly from during the operation to POD2 in both Groups A and B. The stroke volume (SV) and stroke volume index(SVI) were significantly greater in Group B compared to Group A on POD2. 4. Analysis of arterial blood showed no significant difference in pH and PCO2 while the PO2 of samples taken before CPB were significantly higher in Group B compared to Group A. The bicarbonate of samples taken before skin closure was significantly lower in Group B compared to Group A. 5. Changes in serum cortisol levels showed significantly lower values before skin closure, POD2, POD3 for Group B compared to Group A. The serum β-endorphin levels were consistently lower in Group B than in Group A although not statistically significant. 6. Postoperative pain relief was evaluated as good, fair, and poor the scores for Group A were 20%, 60%, and 20% and for Group B 75%, 15%, and 10%, showing a higher percentage of good pain relief for Group B. In conclusion, the beneficial effects of combined anesthesia are a reduction in the total dose of all anesthetic agents given, a reduction in duration of endotracheal intubation and postoperative ventilatory care, minimal cardiovascular changes, attenuation of the stress response, and a better quality of postoperative pain control showing that combined anesthesia is an attractive alternative to general anesthesia for open heart surgery patients.

양측 하악 매복지치 동시 발치를 위한 의식하 진정의 비교 연구: Propofol, Fentanyl과 Diazepam, Morphine

김영균,채병국,최현규,Kim, Young-Kyun,Chae, Byung-Kook,Choi, Hyun-Kyu 대한치과마취과학회 2003 Journal of Dental Anesthesia and Pain Medicine Vol.3 No.2

Background: The purpose of this study was to compare the availability of propofol and fentanyl (P + F) with diazepam and morphine (D + M) for intravenous conscious sedation during third molar surgery. Methods: Forty patients without systemic disease were operated under IV conscious sedation administered by either of the two techniques. Monitoring consisted of continuous observation of pulse rate, blood pressure, oxygen saturation, and the respiratory rate and were recorded every 15 minutes. Cooperation score was measured 5 and 15 minutes after induction of IV sedation. Following the operation, the surgeon and patients completed questionnaires including pain visual analog scale, amnesia, and side effects. Results: The P + F group was significantly more cooperative than the D + M group. The side effects of D + M group included pain on injection, nausea/vomiting and abdominal pain. The side effects of P + F group included talkativeness, nausea/vomiting, temporary apnea, pain on injection and vertigo. Conclusions: In this study, there were following benefits in the P + F group; more cooperative status and less pain perception. But respiratory depression developed in some patients.

전신마취후 전율시 Doxapram 용량에 따른 전율 억제 효과

이일옥,채병국 대한마취과학회 1995 Korean Journal of Anesthesiology Vol.29 No.1

Among the pharmacological methods treating postoperative shivering, there were no studies which compare the doses of doxapram. In this study, we have compared the effectiveness of doxapram in a placebo-controlled, double blind method. Sixty patients who shivered after operation under general anesthesia were examined. They were allocated randomly to receive normal saline(n=15), doxapram l mg/Kg(n=15), 1.5 mg/Kg(n=15) or 2 mg/Kg(n=15) from identical syringes intravenously. The investigator who gave the intravenous injection was unaware of the treatment received by the patient, and assessed the shivering. Both doxapram 1.5 mg/Kg and 2 mg/Kg were effective on shivering within 1~2 minutes after intravenous injection. In the saline group, all patients were still shivering 10 minutes after injection. In the doxapram 1 mg/Kg group, only two patients had stopped shivering by 6, 7 minutes after injection. In the doxapram 1.5 mg/Kg group, only three patients were shivering after injection. In the doxapram 2 mg/Kg group, only one patient was shivering after injection. We conclude that doxapram 1.5 mg/kg and 2 mg/kg were effective on postoperative shivering. And the results suggested that doxapram 2 mg/kg may be marginally superior to doxapram 1.5 mg/kg in this respect. (Korean J Anesthesiol 1995; 29: 70~75)

개흉수술후 Fentanyl 과 Bupivacaine 혼합약제의 경막외 지속적주입이 술후 진통효과 및 폐기능에 미치는 효과

김병기,장성호,채병국 대한마취과학회 1992 Korean Journal of Anesthesiology Vol.25 No.2

Patients undergoing thoracotomy experience severe postoperative pain and marked respiratory impairment. Analgesics(narcotics or loeal anesthetics) administered via epidural catheter in epidural space have been shown to provide postoperative analgesia and improve respiratory mechanics after thoracotomy. Several different methods have been utilized in an attempt to reduce pain and pulmonary mechanics after thoracotomy. These include epidural blocks using local anesthetics, epidural narcotics, ketamine, steroid, and clonidine. These methods have been shown to provide pain relief with relative preservation of lung volumes in the postoperative period, but have disadvantages. Especially epidural local anesthetics may cause hypotension and motor blockade of lower extremities, and epidural narcotics may cause pruritus, nausea and vomiting, urinary retension and respiratory depression. In an attempt to provide excellent analgesia and improve pulmonary mechanics after thoracotomy and to decrease the side effects associated with the intermittent bolus administration of epidural narcotics or local anesthetics, we performed a study of continuously administered epidural infusion of small concentration of fentanyl combined with low concentration of bupivacaine. Twenty eight patients undergoing thoracotomy were randomized into groups based upon a postoperative pain regimen as indicated: Group I: intermittent intramuscualr injection of nalbuphine 0.2 mg/kg(n=13), Group II: continuous epidural injection of mixtures of 0.2/ bupivacaine and fentanyl 3 ug/ml(n= 15). Two, 8, 24 and 48 hours postoperative, the following indices were measured: visual analogue pain scale, vital capacity, tidal volume, arterial blood gas analysis(pH, PaCO₂, PaO₂), side effects, and 24 hour urine 17-ketosteroids. The results were as follows: 1) Pain score was evaluated by visual analogue pain scale postoperatively and the pain scores significantly decresed in group II as compaired with those in group I. 2) Vital capacity and tidal volume in group II were more improved than group I. 3) There was no difference in arterial blood gas analysis except for decreased PaO₂ at 2 hour and 24 hour compared with preoperative value in group I. 4) Major complications in group II were two cases of nausea and vomiting, one case of urinary retension, whereas only I patient in group I complained of nausea and vomiting. 5) No significant difference occurred in 24 hour urine l7-ketosteroid at 24 hour and 48 hour postoperatively in group I and group II, which were within normal limits.

인공호흡기의 습도조절기에서의 세균배양 검사

장성호,임혜자,채병국,김종욱,공명훈 대한마취과학회 1994 Korean Journal of Anesthesiology Vol.27 No.3

Nosocomial infection represent a significant cause of patient morbidity and mortality, especially in the ICU and nosocomial pneumonia that cause high mortality may arise from contaminated respiratory equipments. This study was done to investigate the relationship of micro-organisms in upper respiratory tract and ventilatory equipment, especially humidifier. The total number of cases in this study was 20 and the specimen for bacteriologic culture were taken from the pharynx, the distilled water and the inner wall of humidifier and toilet of trachea at the 0, 4, 8, 12, 24, 48 hours after initiation of mechanical ventilation. The results obtained from the bacteriologic culture were as follows. 1) The most frequently found organism at the pharynx was Pseudomonas aeruginosa and next was Coagulase Negative Staphylococcus, followed by Streptococcus viridans, Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus group D, Enterobacter agglomerans, Acinetobacter spp. 2) The most frequently found organism at the trachea was Pseudomonas aeruginosa and next was Klebsiella pneumoniae followed by Coagulase Negative Staphylococcus, Streptocoecus viridans, Pseudomonas picketti, Staphylococcus aureus and no growth in 5 cases. 3) The most frequently found organism in the fluid of humidifier was Pseudomonas aeruginosa and next was Pseudomonas picketti, Klebsiella pneumoniae, Streptococcus group D and no growth in 2 cases. 4) The most frequently found organism at the pharynx was Pseudomonas aeruginosa and next was Pseudomonas picketti, Klebsiella pneumoniae, Streptococcus group D, Serratia liquefacines, Acinetobacter spp and no growth in 3 cases. 5) The number of isolated organisms in the fluid of humidifier was 3 at 0 hour and 18 after 48 hours and at the wall 2 at 0 hour and 15 after 48 hours. 6) The number of same organism that was isolated between the pharynx and trachea was 13 among 15 cases and between the wall and fluid of humidifier was 15 among 16 cases and between trachea and fluid of humidifier was 10 among 14 cases.

단시간 후두 현미경 수술 마취를 위한 Propofol 과 Succinylcholine 의 지속 주입

이혜원,장성호,채병국,최종욱 대한마취과학회 1996 Korean Journal of Anesthesiology Vol.31 No.5

Background: Anesthetic technique for laryngeal microscopic surgery should be focused on rapid recovery of deep anesthesia and full muscle relaxation. This study was taken to evaluate the effect of continuous infusion of propofol and succinylcholine for this kind of anesthetic goal. Methods: Forty patients scheduled for laryngeal microscopic surgery of short duration(15 min) were randomly allocated into two groups. Anesthesia was induced and maintained with either propofol(2.5 mg/kg followed by a continuous infusion of 0.1 mg/kg/min) in group P or with thiopental (5.0 mg/kg) and inhalation of 1∼2 vol % enflurane for maintenance of anesthesia in group T/E. Succinylcholine(1 mg/kg followed by continuous infusion of 0.1 mg/kg/min) was administered to facilitate tracheal intubation and maintain neuromuscular blockade. Results: No significant difference of duration of anesthesia appeared between two groups. Additional doses of succinylcholine were needed in 10% of group P and 30% of group T/E (p$lt;0.05). In group P, time to response to suction catheter(136±54 vs 232±116 sec), time to eye open spontaneously or to verbal commands (368±142 vs 549±165 sec) and time to extubation (454±117 vs 647±181 sec) were significantly shorter comparing to group T/E. The quality of awakening was more favorable in group P(p$lt;0.05). Laryngeal suspension induced bradycardia in 15% of group P and in 5% of group T/E. Both group P and group T/E (10% vs 30%) needed esmolol infusion to control the blood pressure during surgical procedure. Conclusion: Rapid recovery of anesthesia and muscle relaxation can be expected after continuous infusion of propofol(2.5 mg/kg followed by O.1mg/kg/min) and succinylcholine(1 mg/kg followed by 0.1 mg/kg/min) supplemented with 50% N₂O in 50% O₂, for short duration of laryngeal microscopic surgery.