혈액투석 카테터에 의한 쇄골하정맥 혈전성 폐쇄증의 수술치험 1례

김관민,지현근,안혁,Kim, Kwan-Mien,Chee, Hyun-Keun,Ahn, Hyuk 대한흉부심장혈관외과학회 1995 Journal of Chest Surgery (J Chest Surg) Vol.28 No.1

We are reporting one case of right subclavian vein thrombotic occlusion as a result of previous hemodialysis catheter placement in a patient with a functioning right brachio-cephalic arteriovenous fistula. Its complication was painful right arm swelling, limitation of motion and cellulitis. Diagnosis was confirmed by right subclavian venography and the complication was successfully managed by right subclavian vein-superior vena cava bypass with a GoreTex vascular graft. The arteriovenous fistula had remained to protect patency of the bypass at first, but two months later after the operation, the arteriovenous fistula had to be occluded because of the heart failure resulting from shunt over flow. After ligation of arteriovenous fistula, heart failure improved, and uncomfortable arm swelling did not develop again.

저체온하 순환정지를 이용한 소아 개심술 후의 신경계 이상에 대한 펑가

박계현,전태국,지현근,이정렬,김용진,노준량,서경필,Park, Kay-Hyun,Jun, Tae Gook,Chee, Hyun Keun,Lee, Jeong Ryul,Kim, Yong Jin,Rho, Joon Ryang,Suh, Kyung Phill 대한흉부심장혈관외과학회 1996 Journal of Chest Surgery (J Chest Surg) Vol.29 No.1

Circulatory arrest under deep hypothermia is an important auxiliary means for cardiac surgery, especially useful in pediatric patients. However, its clinical safety, particularly with regard to the neurologic outcome after long duration of circulatory arrest, is still not established. This study is a review of the eight years'clinical experience of hypothermic circulatory arrest at the Seoul national University Children's Hospital. During an eight-year period from January 1986 through December 1993, a total of 589 consecutive cardiac operations were done using circulatory arrest under deep hypothermia. Among them, 434 consecutive patients, in whom the duration of arrest was 20 minutes or more, are the subject of this study. The duration of arrest ranged from 20 minutes to 82 minutes (mean = 38.7 minutes) under rectal temperature in the range from 12.5$^{\circ}C$ to 25.8$^{\circ}C$. Early neurologic abnormalities occurred in 47 patients : seizure attacks in 28 patients, motor paralyses with or w thout seizure in 12, blindness in 2, and no recovery of consciousness in 5 patients. The rate of incidence of early neurologic abnormalities was calculated at 15.7%. 25 patients showed late neuropsychologic sequelae, such as motor paralysis (9 patients), recurrent seizures (6), developmental delay (8), and definitely low intelligence (2). The rate of incidence of late neurologic sequelae was 8.5%, By statistical analysis, the following factors were identified as the risk factors for post-arrest neurologic abnormalities ; 1) long duration of circulatory arrest, 2) lower-than-ideal body weight, 3) preexisting neurological abnormalities, 4) associated non-cardiovascular congenital anouialies, and 5) low blood pressure during the early post-arrest period. It is concluded that circulatory arrest under deep hypothermia is a relatively safe means for pediatric cardiac surgery with acceptable risk. However, to warrant maximal safety, it is desirable to limit the duration of arrest to less th n 40 minutes. In addition, it is our contention that the early post-arrest period is a very critical period during which maintenance of adequate perfusion pressure in important for the neurologic outcome.

저체온순환정지법을 이용한 개심술시 스테로이드의 뇌보호 효과 - 토끼를 이용한 심폐바이패스 실험모델에서 -

김원곤,임청,문현종,전이경,지제근,원태희,이영탁,지현근,김준우,Kim, Won-Gon,Lim, Cheong,Moon, Hyun-Jong,Chun, Eui-Kyung,Chi, Je-Geun,Won, Tae-Hee,Lee, Young-Tak,Chee, Hyun-Keun,Kim, Jun-Woo 대한흉부심장혈관외과학회 1997 Journal of Chest Surgery (J Chest Surg) Vol.30 No.5

토끼는 심폐바이패스(CPB) 실험동물로서 많은 장점을 가지고 있음에도 불구하고 토끼에서 CPB운용법의 확립은 기술적으로 대단히 어려운 것으로 알려져 있다. 한편 저체온 순환정지법은 심장수술에서 유용하게 사용되고 있으나 뇌 보호상의 문제점이 지적되고 있다. 스테로이드는 일반적으로 뇌부종 치료에 효과가 있는 것으로 알려져 있으나 순환정지시 뇌보호에 미치는 영향에 관해서는 아직 명확하게 규명되지 못하고 있다. 이런 관점에서 본 연구는 첫째 토끼에서 CPB운용법을 확립하고 둘째 이를 바탕으로 순환정지시 스테로이드에 의한 뇌보호 효과를 분석할 목적으로 시행하였다. 흰 토끼 15마리(평균 체중 3,5kg)를 3군의 실험군에 각각 5마리씩 사용하였다. 제 1실험군(대조군)은 순환 정지시 토끼를 수술대와 평행된 자세로 유지하였으며, 제 2실험군에서는 대조군과 다른 실험방법은 동일하나 순환정지시 토끼를 트렌델렌부르그 자세로 유지하였다. 제 3실험군에서는 트렌델렌부르그 자세와 함께 순환정지전 스테로이드(methylprednisolone 30 mg/kg)를 투여하였다. 실험방법은 토끼를 마취시킨후 정중흉골절 개술로 심장을 노출시키고 상행대동맥 및 \ulcorner심방부속지에 각각 3.3mm 동맥캐늘라 및 14 Fr 단일 정맥캐늘라를 삽관하였다. CPB 회로에는 롤러 펌프와 기포형 산화기를 사용하였다. 충전액은 토끼혈액 120-150cc를 포함하여 약 450cc를 사용하였다. 전체 실험시간은 70분으로 심폐바이패스 시작후 10일 동안 관류 및 표면냉각법으로 체온을 20도(직장)까지 감소시킨뒤 40분 동안 순환정지를 시켰다. 순환정지후 관류를 재개하여 20분 동안 재가온으로 체온을 정상화시키면서 심장 박동이 되돌아오는 것을 확인하였다. 관류 유속은 80~ 90mg/min 으로 시작하였고 체온 하강에 따라 유속을 조절하였다. 실험후 토끼를 희생시킨뒤 바로 부검을 시행하여 뇌, 척수, 신장, 십이지장, 폐, 심장, 간장, 비장, 췌장, 위장의 일부를 채취하여 수분함유량을 조사하였다. 각 실험군간의 수분양 비교는 Kruskal-Wallis 비모수 검정법에 의해 분석하였다. CPB 중 관류 유속 변화는 60~l00ml/kg/min 이었다. 동맥압은 대부분 35-55mmhg 사이에서 유지되었다. 재가온후 심장은 전례에서 박동을 재개하였다. 동맥혈가스분석 결과 심한 조직 허혈을 의미하는 정도의 대사 성 산증은 발견되지 않았다. 각 실험군별 조직수분양 측정 결\ulcorner 뇌를 포함한 각 장기들에서 실험군간체 유의 한 차이는 발견되지 않았다. 이러한 실험결과를 통하여 저자들은 (1) 적절한 기법하에서는 토끼에서도 정상 적인 심폐바이패스 운용이 가능하다는 것과, (2) 본 실험 범주에서는 저체온 순환정지시 트렌델렌부르그 자 세에 의한 뇌부종 발현에 대한 스테로이드의 예방효과를 검정할 수없다는 결론을 얻었다. Introduction: The use of rabbits as a cardiopulmonary bypass(CPB) animal model is extremely dif%cult mainly due to technical problems. On the other hand, deep hypothermic circulatory arrest(CA) is used to facilitate surgical repair in a variety of cardiac diseases. Although steroids are generally known to be effective in the treatment of cerebral edema, the protective effects of steroids on the brain during CA are not conclusively established. Objectives of this study are twofold: the establishment of CPB technique in rabbits and the evaluation of preventive effect of steroid on the development of brain edema during CA. Material '||'&'||' Methods: Fifteen New Zealan white rabbits(average body weight 3.5kg) were divided into three experimental groups; control CA group(n=5), CA with Trendelenberg position group(n=5), and CA with Trendelenberg position + steroid(methylprednisolone 30 mglkg) administration group(n=5). After anesthetic induction and tracheostomy, a median sternotomy was performed. An aortic cannula(3.3mm) and a venous ncannula(14 Fr) were inserted, respectively in the ascending aorta and the right atrium. The CPB circuit consisted of a roller pump and a bubble oxygenator. Priming volume of the circuit was approximately 450m1 with 120" 150ml of blood. CPB was initiated at a flow rate of 80~85ml/kg/min, Ten min after the start of CPB, CA was established with duration of 40min at $20^{\circ}C$ of rectal temperature. After CA, CPB was restarted with 20min period of rewarming. Ten min after weaning, the animal was sacrif;cod. One-to-2g portions of the following tissues were rapidly d:ssected and water contents were examined and compared among gr ups: brain, cervical spinal cord, kidney, duodenum, lung, heart, liver, spleen, pancreas. stomach. Statistical significances were analyzed by Kruskal-Wallis nonparametric test. Results: CPB with CA was successfully performed in all cases. Flow rate of 60-100 mlfkgfmin was able to be maintained throughout CPB. During CPB, no significant metabolic acidosis was detected and aortic pressure ranged between 35-55 mmHg. After weaning from CPB, all hearts resumed normal beating spontaneously. There were no statistically significant differences in the water contents of tissues including brain among the three experimental groups. Conclusion: These results indicate (1) CPB can be reliably administered in rabbits if proper technique is used, (2) the effect of steroid on the protection of brain edema related to Trendelenburg position during CA is not established within the scope of this experiment.

증례보고 : 체외순환을 사용하지 않는 관상동맥 우회술에서 심장 전위를 위해 사용된 물주머니와 경식도 심장초음파 영상 개선

여진석 ( Jin Seok Yeo ),김태엽 ( Tae Yop Kim ),윤창룡 ( Chang Yong Yoon ),김준석 ( Jun Seok Kim ),지현근 ( Hyun Keun Chee ) 대한마취과학회 2007 Korean Journal of Anesthesiology Vol.52 No.2

During off-pump coronary artery bypass graft surgery (OPCAB), vigorous displacement and compression of the heart producing significant hemodynamic change are essential for optimal exposure of graft anastomoses. Intraoperative transesophageal echocardiography (TEE) is useful in determining hemodynamic compromise and prompting medical and mechanical support. However, in addition to the loss of contact between the heart and diaphragm during the displacement, swabs or snears underneath the heart interrupt the TEE signal transmission, resulting in a compromised transgastric (TG) TEE view. Therefore, TEE monitoring during OPCAB is usually limited to the mid-esophageal view. The authors placed a saline bag (a surgical glove filled with saline) underneath the heart to facilitate this anterior displacement of the heart, as well as avoid the signal interruption of the TG echocardiographic window. As a result, the optimal heart position with the minimal changes in LV regional wall motion, LV function and mitral regurgitation were found using the TG and other TEE views. The series of velocity-time integral of aortic valvular flow (VTI-Ao) in TG long axis view, in addition to SvO2, were then monitored as a surrogate marker of the cardiac output during a graft construction of the left circumflex artery. It was concluded that the use of a saline bag may be useful in avoiding compromise of the TG TEE view and determine the hemodynamic change using VTI-Ao during cardiac displacement for OPCAB. (Korean J Anesthesiol 2007; 52: 231~6)

증례보고 : 개심술 마취에서 동맥압 파형분석을 이용한 심박출량과 중심정맥 산소포화도

김태엽 ( Tae Yop Kim ),권원경 ( Won Kyoung Kwon ),윤창룡 ( Chang Yong Yoon ),김혜경 ( Hae Kyoung Kim ),김준석 ( Jun Seok Kim ),지현근 ( Hyun Keun Chee ) 대한마취과학회 2007 Korean Journal of Anesthesiology Vol.53 No.1

The determination of arterial pressure wave-derived cardiac output (APCO) and central venous O2 saturation (ScvO2) has been introduced as a less invasive procedure for monitoring cardiac function and oxygen delivery. We have used an APCO sensor (FloTrac(TM)) and a monitor for ScvO2 (Vigileo(TM)) in two cases of cardiac valve surgery, where placement of pulmonary artery catheter (PAC) was not applicable due to unfavorable cardiac structure (case 1) and was contraindicated due to an unstable cardiac conduction disorder and arrhythmia (case 2). In case 1, monitoring of APCO was started from the beginning of anesthesia induction and a ScvO2 monitoring central venous catheter was inserted just after anesthesia induction. APCO, ScvO2 and other hemodyanamic information such as arterial BP, CVP, and data obtained from transesophageal echocardiography (TEE) during the pre-cardiopulmonary bypass (CPB) period were measured. APCO and ScvO2 during the post-CPB period showed a reliable correspondence with continuous cardiac output (CCO) and mixed venous O2 saturation (SvO2) as measured by PAC at the end of CPB. In case 2, APCO and ScvO2 were monitored instead of CCO and SvO2. The values of APCO showed a good correlation to intraoperative COs indirectly calculated by the velocity-time integral of the aortic outflow determined in the TEE examination. We experienced that monitoring APCO and ScvO2 is useful for anesthesia management in cardiac valve surgery and can be an alternative to CCO and SvO2 if the placement of PAC and the thermodilution method are not applicable. (Korean J Anesthesiol 2007; 53: 109~14)

제왕절개술에서 경식도 초음파를 이용한 폐혈전색전증의 수술 중 진단

오충식 ( Choong Sik Oh ),곽상원 ( Sang Won Kwak ),김태엽 ( Tae Yop Kim ),우남식 ( Nam Sik Woo ),손인숙 ( In Sook Sohn ),지현근 ( Hyun Keun Chee ) 대한마취과학회 2008 Korean Journal of Anesthesiology Vol.54 No.1

승모판막 성형수술에서 삼차원 경식도 심장초음파의 적용(증례보고)

김성협 ( Seong Hyop Kim ),윤태균 ( Tae Gyoon Yoon ),김태엽 ( Tae Yop Kim ),정화성 ( Hwa Sung Jung ),김준석 ( Jun Seok Kim ),지현근 ( Hyun Keun Chee ),송명근 ( Meong Gun Song ) 대한마취과학회 2008 Korean Journal of Anesthesiology Vol.54 No.6

급성 심근 경색에서 시행한 관상 동맥 우회술의 조기 결과

지현근,이원용,김응중,두영철,한규록,오동진,임종윤 대한순환기학회 1998 Korean Circulation Journal Vol.28 No.8