심폐바이패스 없이 시행하는 관상동맥 우회술시 고위험군 환자에서 대동맥내 풍선 펌프의 유용성

조석기,장우익,임청,이철,이재익,김용락,함병문,김기봉,Cho, Suk-Ki,Jang, Woo-Ik,Lim, Cheong,Lee, Cheul,Lee, Jae-Ik,Kim, Yong-Lak,Ham, Byung-Moon,Kim, Ki-Bong 대한흉부심장혈관외과학회 2001 Journal of Chest Surgery (J Chest Surg) Vol.34 No.12

배경 : 심폐바이패스를 하지 않고 심장박동 상태에서 시행하는 관상동맥 우회술(Off-pump Coranary Artery Bypns, OPCAB)은 심장 뒤쪽에 위치한 혈관 문합을 위해서 심첨부를 앞쪽으로 들어 올리는 등 심장의 위치를 변화시켰을 때, 심박출량 감소, 체동맥 혈압 감소, 국소적인 심근 허혈을 심화시켜 심장 기능이 떨어지게 되며 이런 변화는 고위험군 환자에서 심장 뒤쪽에 위치한 혈관문합을 어렵게 한다. 본 연구에서는 고위험군 환자에서 심폐바이패스 없이 시행하는 관상동맥 우회술시 수술 전 대동맥내 풍선펌프 사용의 안전성과 효율성을 밝히고자 하였다. 대상 및 방법 : 1998년 1월부터 2001년 4월까지 서울대학교 의과대학 흉부외과학 교실에서 시행한 OPCAB 300례 중 심장 뒤쪽 혈관의 문합이 필요하였던 189례를 대상으로 하였다. 189명 중 수술 전, 중 대동맥내 풍선펌프 삽입을 시행 받았던 환자 74례(I군, 64례는 수술 전 삽입, 10례는 수술 중 삽입)와 시행 받지 않았던 환자 115 례(II군) 의 임상 결과를 비교하였다. 술 전 대동맥내 풍선펌프 삽입의 적응증으로 심한 좌주 관상동맥 질환( 75% 폐색)이 39례, 지속적인 정맥 내 니트로글리세린과 헤파린의 주입같은 내과적 치료에 반응하지 않는 협심증이 40례, 심박출률이 35% 미만인 좌심실 기능부전이 14례, 최근 4주이내에 급성 심근경색이 있었던 심근 경색후 협심증이7례, 불안정형 협심증이 56례 등이 있었다. 결과 : 평균 원위부 문합수는 I 군이 3.5 0.9, II 군이 3.4 0.9 로 두 군 간에 차이는 없었다. I군에서는 수술 사망은 1명, II 군에서는 2명 있었다. 두 환자군 사이에서 인공호흡기 사용기간, 입원기간 등에 통계적인 차이는 없었으나 중환자실 체류기간은 I 군에서 통계적으로 유의하게 길었다. 두 환자군 사이에서 술 후 부정맥, 수술 중, 후 심근경색, 술 후 급성 신부전 등의 합병증의 발생에는 차이가 없었다. 술 후 대동맥내 풍선펌프를 사용한 시간은 평균 6.7$\pm$9.5 이었으며 대동맥내 풍선펌프와 연관된 합병증은 1명에서 발생하였다. 결론 : 저위험군 환자의 수술 성적과 비교를 통하여 술 전 대동맥내 풍선펌프를 삽입한 고위험군 환자에서 수술결과에 유의한 차이가 없음을 증명하였고 고위험군 환자에서 대동맥내 풍선펌프의 사용은 심장 뒤쪽 혈관 문합을 포함한 OPCAB을 가능케 함을 밝혔다. Background : This study aimed to evaluate the usefulness of preoperative placement of intraaortic balloon pump(IABP) in reducing operative risk and facilitating posterior vessel OPCAB in high risk patients with left main disease( 75% stenosis), intractable resting angina, postinfarction angina, or left ventricular dysfunction(ejection fraction 35%). Material and Method : One hundred eighty- nine consecutive patients who underwent multi-vessel OPCAB including posterior vessel revascularization were studied. The patients were divided into group I(n=74) that received preoperative or intraoperative IABP and group II(n=115) that did not receive IABP. In group I, there were 39 patients with left main disease, 40 patients with intractable resting angina, 14 patients with left ventricular dysfunction and 7 patients with postinfarction angina. Ten patients received intraoperative IABP support due to hemodynamic instability during OPCAB. Result : There was one operative mortality in group I and two mortalities in group II. The average number of distal anastomoses was not different between group I and group II(3.5$\pm$0.9 vs 3.4$\pm$0.9, p=ns). There were no significant differences in the number of posterior vessel anastomosis per patient between the two groups. There were no differences in ventilator support time, length of hospital stay, and morbidity between the two groups. There was one case of IABP-related complication in group I. Conclusion : IABP facilitates posterior vessel OPCAB in high risk patients, with comparable surgical results to low risk patients

실험연구 : 토끼의 격리폐 모델에서 Pinacidil, Tetraethylammonium과 Glibenclamide가 저산소성 폐혈관 수축반응에 미치는 효과

노영진 ( Young Jin Ro ),윤원희 ( Won Hee Yun ),김종수 ( Chong Soo Kim ),민성원 ( Sung Won Min ),김성덕 ( Seong Deok Kim ),김용락 ( Yong Lak Kim ) 대한마취과학회 2003 Korean Journal of Anesthesiology Vol.45 No.6

수술 전 심장초음파 소견과 심폐우회술 없이 시행하는 관상동맥 우회술 후 예후 판정에 대한 유효성

전윤석 ( Yun Seok Jeon ),이상철 ( Sang Chul Lee ),함병문 ( Byung Moon Ham ),김용락 ( Yong Lak Kim ),김진희 ( Jin Hee Kim ) 대한마취과학회 2003 Korean Journal of Anesthesiology Vol.44 No.4

증례보고 : 폐동맥 혈전내막절제술의 마취 관리

서정훈 ( Jeong Hun Suh ),박지현 ( Ji Hyun Park ),전윤석 ( Yun Seok Jeon ),김진희 ( Jin Hee Kim ),함병문 ( Byung Moon Ham ),김용락 ( Yong Lak Kim ) 대한마취과학회 2003 Korean Journal of Anesthesiology Vol.45 No.6

Lidocaine 정주가 기관내 삽관에 의한 안압 증가에 미치는 영향

김용락,민성원 대한마취과학회 1991 Korean Journal of Anesthesiology Vol.24 No.3

This study was undertaken to determine whether intravenous lidocaine could prevent the acute increase in intraocular pressure associated with laryngoscopy and tracheal intubation. Twenty surgical patients(ASA class 1) who do not have any disease influencing on the intraocular pressure(IOP)(e.g. ophthalmic diseases, diabetes, hypertension, etc.) were studied and divided into two groups, experimental group(n= 10) and control group(n=10). After measurement of preinduction IOP, anesthesia was induced by pentothal 5 mg/kg and vecuronium 0.15 mg/kg, and maintained with 100% oxygen for 3 minutes and baseline IOP was measured. Then, saline and lidocaine(1.5 mg/kg) were injected to controls and experimental group, respectively. One minute and 30 seconds after this, IOP was measured and trachea was intubated. After intubation, anesthesia was maintained with 100% oxygen and 1,5 vo1% halothane and IOP was measured on 1, 3 and 5 minutes after intubation. The results were as follows. 1) One minute and 30 seconds after saline or lidocaine injection(immediately before intubation), IOP was significantly lower in lidocaine group than control group. 2) Peak increases in IOP after intubation were significantly less in lidocaine group than control group. From the above results, the use of 1.5 mg/kg of intravenous lidocaine approximately 1 minute and 30 seconds before tracheal intubation significantly attenuates the increase in IOP. This procedure will be useful in the induction of anesthesia in patients in whom the increase in IOP should be avoided.

Lorazepam 에 의해 억제된 뇌기능 및 순환기능에 대한 Flumazenil 의 역전 효과에 관한 실험적 연구

김용락,오용석,원영천 대한마취과학회 1991 Korean Journal of Anesthesiology Vol.24 No.5

The effects of lorazepam on cerebral function, metabolism, and hemodynamics were studied in eight dogs receiving a general anesthesia with isoflurane(0.5 vo1%)-50% nitrous oxide-oxy-gen. The effects of benzodiazepine antaronist, flumazenil, were also examined. Lorazepam(0.5 mg/kg) administration did decrease mean arterial pressure(MAP) and herat rate(HR). It did significantly decrease cerebral blood flow(CBF)(measured by posterior sagittal sinus outflow method) by 25% of control value(68±l3 vs. 51±12ml/100gm/min, meanSD) and cereberal metabolic rate for oxygen(CMRO ) by 17% (3.96±1.04 vs. 3.30±0.92ml/l00gm/min, mean±SD). Electroencephalogram(EEG) converted to high amplitude, predominantly theta and delta activity. Intracranial pressure(ICP) increased markedly. Following flumazenil(0.06 mg/kg) administration, HR recovered completely to control level but MAP increased only at 5 min. compared to pre-flumazenil value and returned to pre-flumazenil level. CBF recovered to control level for 15 min. and deereaster 30 min. compared to control level but higher than pre-flumazenil level about 9-15%. CMRO recovered completely to control leveL EEG changed to an awake pattern after fluamzenil administration. It is concluded that lorarepam decreased cerebral function and metabolism and depressed hemodynamic fuction. Benzodiazepine antag- onist, flumazenil, was effective in reversing cerebral and hemodynamic effects, may be in dose related manner.

고령환자의 대퇴전자부 골절의 술전 중 후 관리

김용락 대한골절학회 1994 대한골절학회지 Vol.7 No.2

전신마취하 환자에서 단일형 호흡회로의 사용시 혈역학반응 및 동맥혈가스분석

김용락,최윤정,염광원,박학수,전용석 대한마취과학회 1997 Korean Journal of Anesthesiology Vol.32 No.3

Background : Most of nonrebreathing circuits were used for pediatrics, not for adults and the high flow of fresh gas and specially designed valve or lever should be needed. The current study was designed to compare between one corrugated tube(universal FTMcircuit) and two corrugated tube in patients with oral and maxillofacial surgery under general anesthesia. Methods : Twenty adults undergoing oral and maxillofacial surgery were anesthetized with enflurane- N2O-fentanyl after radial arterial cannulation. Under the condition with stable vital signs, ventilator was setted with tidal volume 10ml/kg, respiratory rate 11 breaths/min using two separate limbs(expiratory and inspiratory limbs) and one corrugated tube of anesthesia machine. Mean arterial pressure, heart rate, saturated pulse oxygen, end tidal carbon dioxide, peak inspiratory oxygen, arterial blood gas analysis were measured at 15, 30min during the use of each circuit. Results; There were no differences of mean arterial pressure, heart rate, end tidal carbon dioxide, saturated pulse oxygen. peak inspiratory presssure and arterial blood gas analysis between 2 circuits during mechanical ventilation. Conclusions: Universal FTMcircuit of single limb could substituted for the two corrugated tube, especially in patients with oral and maxiolofacial surgery. (Korean J Anesthesiol 1997; 32: 366∼369)

피부에서 흉부 경막외강까지의 깊이에 관한 연구

김용락,도상환 대한마취과학회 1995 Korean Journal of Anesthesiology Vol.29 No.2

The depth from the skin to the thoracic epidural space was measured in 121 patients (41 male and 80 female patients) receiving epidural analgesia. The patients age, sex, height, weight were obtained before measuring the distance. The needle angle to the vertical axis to the skin was obtained during inserting Touhy needle. The mean depth was 6.0± 1.3 cm, which correlated with other anatomic measurements except height. The depth was correlated with the needle angle. The group with needle angle greater than 30 was greater in depth than the other groups. The mean depth was 6.0±1.4 cm in males and 6.0±1.3 cm in females and there was no difference in depth between male and female. The mean depth was 5.7±1.3 cm at the T5-6 interspace and 6.2±1.3 cm at the T6-7 interspace and there was no difference in depth between the two groups. (Korean J Anesthesiol 1995; 29: 244~248)

척추수술시 Esmolol 을 이용한 유도저혈압

김종수,이진호,김지애,고홍,김용락,도상환,오용석 대한마취과학회 1998 Korean Journal of Anesthesiology Vol.35 No.5

Background: Esmolol as a drug for induced hypotension can, not only avoid many drawbacks of nitroprusside, but reduce the amount of intraoperative bleeding and make better operative field. This study was performed to evalute cardiovascular changes during esmolol-induced controlled hypotension. Methods: Induced hypotension using esmolol was applied to 18 adult patients receiving spinal surgery under the diagnosis of spinal stenosis or scoliosis. After prehydraion of 2,000 ml of crystalloid solution, 0.5 mg/kg esmolol was used as loading dose once, twice or three times until mean blood pressure (MBP) fell below 70 mmHg, followed by continuous infusion (50∼300 g/kg/min) of esmolol. MBP and heart rate (HR) were measured before, 5, 10, 15, 30, 60 and 90 min after esmolol administration, and 5, 10 and 15 minutes after discontinuation of esmolol. In 8 patients, cardiac output (CO) and mixed venous oxygen tension and saturation were measured before, during and after esmolol use. Results: MBP was decreased from 91 12 mmHg to 67 7 mmHg after 15 min (P<0.05). HR(BPM) was decreased from 76 17 to about 60 after 15 min (P<0.05). CO was decreased about 30% during induced hypotension but recoverd to initial level 15 min after esmolol discontinuation. While oxygen transport was reduced significantly during induced hypotension (P<0.05), oxygen consumption was maintained all the time. Conclusion: With the use of esmolol, stable hypotension could be achieved. Although oxygen transport decreased possibly due to reduction of CO, but oxygen consumption was maintained. (Korean J Anesthesiol 1998; 35: 921∼925)