자기공명분석기에 의한 반사성 교감신경성 위축증의 치험

김진수,곽수달,김정순,옥시영,차영덕,박욱,Kim, Jin-Soo,Kwak, Su-Dal,Kim, Jun-Soon,Ok, Sy-Young,Cha, Young-Deog,Park, Wook 대한통증학회 1993 The Korean Journal of Pain Vol.6 No.2

Reflex sympathetic dystrophy is a syndrome characterized by persistent, burning pain, hyperpathia, allodynia & hyperaesthesia in an extremity, with concurrent evidence of autonomic nervous system dysfunction. It generally develops after nerve injury, trauma, surgery, et al. The most successful therapies are directed towards blocking the sympathetic intervention to the affected extremity by regional sympathetic ganglion block or Bier block with sympathetic blocker; other traditional treatments include transcutaneous electrical stimulation, immobilization with cast & splint, physical therapy, psychotherapy, administration of sympathetic blocker, calcitonin, corticosteroid and analgesic agents. The purpose of this report is to evaluate and describe the effects of magnetic resonance following unsatisfactory results with traditional treatments of RSD. A 17 year old female patient, 1 year earlier, had received excision and drainage of pus at the right femoral triangle due to an injury caused by a stone. Afterwards, she experienced burning pain, knee joint stiffness, and muscle dystrophy of the right thigh, especially when standing and walking. Despite a year of number of traditional treatments such as: lumbar sympathetic block, continuous epidural analgesia, transcutaneous electrical stimulation, & administration of predisolone, her pain did not improve. Surprisingly, the patients was able to walk free from pain and difficulty after just one application of magnetic resonance. The patient has been successfully treated with further treatment of two to three times a week for approximately ten weeks. More recently, magnetic resonance has been demonstrated to produce effective results for the relief of pain in a variety of diseases. From our experiences we recognize magnetic resonance as a therapeutic modality which can provide excellent results for the treatment of RSD. It has been suggested that polysynaptic reflex which are disturbed in RSD may be modulated normally on the spinal cord level through the application of magnetic resonance.

자기공명분석기에 의한 반사성 교감시경성 위축증의 치험

김진수(Jin Soo Kim),곽수달(Su Dal Kwak),김정순(Jun 대한통증학회 1993 The Korean Journal of Pain Vol.6 No.2

Reflex sympathetic dystrophy is a syndrome characterized by persistent, burning pain, hyperpathia, allodynia & hyperaesthesia in an extremity, with concurrent evidence of auto- nomic nervous system dysfunction. It generally develops after nerve injury, trauma, surgery, et al. The most successful therapies are directed towards blocking the sympathetic intervention to the affected extremity by regional sympathetic ganglion block or Bier block with sympa- thetic blocker, other traditional treatments include transcutaneous electrical stimulation, immobilization with cast & splint, physical therapy, psychotherapy, administration of sympa- thetic blocker, calcitonin, corticosteroid and analgesic agents. The purpose of this report is to evaluate and describe the effects of magnetic resonance fol- lowing unsatisfactory results with traditional treatments of RSD. A l7 year old female patient, 1 year earlier, had received excision and drainage of pus at the right femoral triangle due to an injury caused by a stone. Afterwards, she experienced burning pain, knee joint stiffness, and muscle dystrophy of the right thigh, especially when standing and walking. Despite a year of number of traditional treatments such as: lumbar sympathetic block, continuous epidural analgesia, transcutaneous electrical stimulation, & administration of predisolone, her pain did not improve. Surprisingly, the patients was able to walk free from pain and difficulty after just one appli- cation of magnetic resonance. The patient has been successfully treated with further treat- ment of two to three times a week for approximately ten weeks. More recently, magnetic resonance has been demonstrated to produce effective results for the relief of pain in a variety of diseases. From our experiences we recognize magnetic resonance as a therapeutic modality which can provide excellent results for the treatment of RSD. It has been suggested that polysynaptic reflex which are disturbed in RSD may be modu- lated normally on the spinl cord level through the application of magnetic resonance.

말판증후군과 동반된 해리성 대동맥류에 대한 대동맥 근부 개형술(改型術): Yacoub-David 수술법

박형주,이승진,박영우,최태명,신원용,곽수달,고정관,이철세,염욱,Park, Hyung-Joo,Lee, Seong-Jin,Park, Young-Woo,Choi, Tai-Myung,Shin, Won-Yong,Kwak, Soo-Dal,Ko, Jeong-Kwan,Lee, Cheol-Sae,Youm, Wook 대한흉부심장혈관외과학회 2001 Journal of Chest Surgery (J Chest Surg) Vol.34 No.7

순턴향대학 턴안병원 흥부외과에서는 Stan$\ulcorner$old type A급성 대동맥 박리증, 대동맥 근부 동맥류 및 대동맥 폐쇄부전을 보인 45세 말판 증후군 환자에게 24m Hemashield 도관을 이용하여 Yacoub-David 수술법에 의한 대동맥 근부 개형술(aortic root remodeling procedure)을 시행하였다 수술은 환자의 대동맥 판막을 보존하면서 대동맥등을 포함한 대동맥 근부의 질병조직을 모두 제거한 후, 글이 발살바동 모양으로 3등분된 인조혈관으로 대동맥등으로부터 상행 대동맥가지 대치하는 방법으로 하였다. 환자는 수술 후 양호한 회복을 보였고 대 동맥 판막의 역류는 완전히 교정되었다. We operated on a Marfan patient who had Stanford type A acute aortic dissection, aortic root aneurysm, and aortic regurgitation. The Yacoub-David aortic root remodeling procedure which preserves native aortic valve and replaces all three aortic sinuses and ascending aorta by a Dacron graft, was applied for this patient. A 24mm Hemashield graft was designed to three tongues at the aortic root end to meet the shape of the Valsalva sinuses. The patient recovered from the procedure uneventfully and there was no aortic regurgitation posto-peratively.

임상연구 : 누두흉 환자에서 Nuss 방법에 의한 수술 전과 후의 폐 역학의 변화

이원섭 ( Won Sup Lee ),권진형 ( Jin Hyung Kwon ),김천숙 ( Chun Suk Kim ),안기량 ( Ki Ryang Ahn ),김지은 ( Ji Eun Kim ),강규식 ( Kyu Sik Kang ),유시현 ( Si Hyun Yoo ),이선학 ( Sun Hak Lee ),곽수달 ( Soo Dal Kwak ) 대한마취과학회 2003 Korean Journal of Anesthesiology Vol.44 No.5

수술 후 통증조절을 위한 지속적 경막외제통 및 정맥내 자가조절법 2,510예에 대한 임상분석

배상철,곽수달,강규식 순천향의학연구소 1998 Journal of Soonchunhyang Medical Science Vol.4 No.2

Background: The efficacy and safety of continuous epidural analgesia(CEA) and intravenous patient-controlled analgesia(IV-PCA) for postoperative analgesia on hospital wards was studied. And then we started postoperateve pain management service using a continuous epidural analgesia and intravenous patient-controlled analgesia. Method: A retrospective study was performed to evaluate the effects of continuous epidural analgesia(CEA): 0.125% bupivacaine 100ml + morphine 5~7mg or clonidine 1800㎍ and intravenous patient-controlled analgesia(IV-PCA): normal saline 20ml + fentanyl 800~1000㎍ or nalbuphine 80~100mg, for postoperative pain relief of 2,510 surgical patients who received general-epidural or epidural-regional anesthesia. Anesthesia records, patients charts, and pain control records were received and classified according to: age, sex, department, operation site, degree of pain relief by CEA and IV-PCA, and side effects(including nausea, vomiting, pururitis, urinary retention and respiratory depression). Results: 1) The study included CEA were 1,022(40.7%) patients and IV-PCA were 1,488(59.3%) patients. 2) From the total of 2,510 patients, there were 2,253(89.8%) female patients; 2,078(82.8%) patients were from Obstetrics and Gyneco]ogy. 3) In the operation site, lower abdomen were 2,053(81.8%), lower extremity were 206(8.2%), upper abdomen 136(5.4%) were order of decreasing frequency. 4) Ninety one percent of the patients experienced mild or no pain in the postoperative course. 5) There were most common complication is the nausea and vomiting. 6) There were eight cases of respiratory depression. The course of treatment consisted of: cesation of infusion, and then administration of oxygen and intravenous naloxone. Conclusions: According to our experiences, we conclude that CEA and IV-PCA is an effective, relatevely safe and highly satisfactory method for postoperative pain management.

체외순환 없는 관상동맥우회술 시행시 심장 고정기의 부착과 거상에 의한 혈역학적 변화

정성미,곽수달,신혜란,곽현주,최미영,곽영란 대한마취과학회 2002 Korean Journal of Anesthesiology Vol.43 No.5

Background: Coronary artery bypass grafting without cardiopulmonary bypass (Off-Pump Coronary Artery Bypass Grafting, OPCAB) causes significant hemodynamic derangement by displacement of the beating heart. The purpose of this study was to analyze the hemodynamic changes caused in relation to grafted arteries by displacing the heart and stabilizing the coronaty arteries in patients undergoing OPCAB. Methods: Nineteen patients underwent OPCSB using two deep pericardial sutures and tissue stabilizers (Octopus Tissue Stabilization Syetem, Medtronic, USA). The hemodynamic variables were obtained after induction of anesthesia, after deep pericardial sutures, before and after anastomosis of each coronary artery during epicardial stabilizing, after sternal closure, and after postoperative 6 hours and 12 hours in the intensive care unit. Results: The hemodynamic variables were maintained with the Trendelenburg position, volume loading and low dose vasopressors after deep pericardial stay sutures. Displacement of the heart and placement of the stabilizer on all coronary territories except the obtuse marginal artery before anastomosis showed no significant difference in hemodynamics compared with baseline. Positioning for the graft to the obtuse marginal artery decreased cardiac index (1.6 ± 0.4 L/min/m^2) and stroke index (27.6 ± 9.9 L/beat/m^2) and increased systemic vascular resistance (2318.9 ± 673.7 dyne·sec·cm^-5), resulting in gemodynamic compromise (P < 0.01). There were no significant hemodynamic and electrocardiographic changes before of after grafting of other coronary arteries but there was a significant increase in cardiac index after postoperative 6 and 12 hours compared with baseline values (P < 0.05). Conclusions: Although the complete revascularization of most coronary arteries is feasible on the beating heart without significant hemodynamic compromise with minimal vasopressor support, the positioning for the graft to the obtuse marginal artery needs special attention because two deep pericardial stay sutures and Octopus tissue stabilizers on the obtuse marginal artery territory induce significant hemodynamic disturbances. (Korean J Anesthesiol 2002; 43: 611~618)

제왕절개술 후 경막외 Clonidine 의 제통효과

김진수,배상철,박욱,김지은,곽수달,강규식 대한마취과학회 2000 Korean Journal of Anesthesiology Vol.39 No.1

Background : The importance of the intrinsic analgesic properties of the alpha 2-agonist is difficult to establish, but many studies have shown the beneficial effect of epidural clonidine in postoperative pain management. The authars examined the analgesic effect of clonidine, a preferential alpha 2-adrener- gic agonist, upon hemodynamics, and side effects during the post-operative period in patients undergoing Cesarean section. Methods : Sixty heaithy parturients undergoing Cesarean section with general anesthesia were divided into two groups as follows: 1) Epidural Morphine group: An initial dose of morphine 3 mg diluted with 10 ml of 0.125% bupivacaine was injected epidurally at time of the peritoneal closure, followed by a ccrntinuous epidural infusion of morphine 7 mg and 100 ml of normal saline for the postoperative 2 days. 2) Epidural Clonidine group: An initial dose of clonidine 150 μg diluted with 10 ml of 0.125% bupivacaine was injected epidurally at time of the peritoneal closure, folowed by a cantinuous epidural infusion of clonidine 1800 μg and 100 ml of normal saline for the postoperative 2 days. Postoperative analgesia was assemed by recording the VAS (Visual Analogue Scale), PHS (Prince Henry Score) at postoperative 1, 2, 3, 6, 12, 24, and 48 hours. Blood pressure, heart rate, sedation, and side effects were also recorderl. Results : There were no statistically significant differences in the VAS and hemodynamic changes between the two groups, but the epidural clonidine reduced the PHS significantly at 1, 2, 3 postoperative hours (P $lt; 0,05). There were less side effects in the cases of epidural clanidine as compared with epidural morphine. Conclusion : In comparison to epidural morphine, epidural clonidine produces a similar degree of analgesia but less side effects. (Korean J Anesthesiol 2000; 39: 77~82)

Mivacurium 과 타근이완제의 작용 발현과 회복의 약동학적 비교연구

이정석,김순임,김성열,곽수달,이진승,홍승택 대한마취과학회 2000 Korean Journal of Anesthesiology Vol.38 No.5

Background: The purpose of this study was to evaluate mivacurium in the pharmacokinetics of onset and offset. Methods: In 127 adult patients of ASA physical status I or II without any factors involving the neuromuscular function under general anesthesia, onset time (lag and manifest time) and clinical duration were measured after bolus or divided doses of EDgs X 2 of succinylcholine (SCC), rocuronium (ROC), atracurium (ATR), mivacurium (MIV), pancuronium (PAN) or vecuronium (VEC). Recovery time was defined as the recovery index and total duration measured after subsequent EDgs of MIV at 25% recovery of control twitch height from neuromuscular block induced by EDgs X 2 of ATR, MIV, PAN or VEC. Plasma cholinesterase (PChE) levels were measured following PAN or ATR. Results: Onset t.ime was faster with SCC and ROC, the low potency drugs, than with ATR, MIV, PAN or VEC, the high potent drugs. Manifest time was shorter in low potency drugs but longer in high potency drugs than lag time after bolus or divided doses of muscle relaxants given. Divided doses of various drugs induced a shortened onset time, but the patterns of relationship between lag and manifest time associated with drug potency did not alter. The recovery times with administered MIV were slowest after PAN pretreatrnent, and fastest after MIV pretreatment. PChE levels decreased significantly from 3 min to over 180 min after PAN administeration but not ATR. Conclusions: The onset time of MIV was not improved dne to high drug potency as other nondepo- larizing neuromuscular blockers. However, in spite of high potency, the recovery time of MIV was faster than other drugs. This results may be depend upon PChE activity rather than drug potency. Additionally, the prolonged recovery of MIV was not only under the influence of low PChE activity but also other some factors such as: the first relaxants administered before MIV dominated the neuromuscular block so that the duration of MIV given subsequently changed to resemble that of the first. The longer elimination half-life of the underlying relaxant prolonged the effects of subsequent shorter acting MIV. Structural similarities or dis-similarities between the interacting MIV and other drugs may have effects more potent in dis-similarity than in similarity. ( Korean J Anesthesiol 2000; 38 : 773-782 )

분만시 지속적 또는 간헐적 투여에 의한 경막외 제통의 비교

박욱,이은찬,배상철,강규식,곽수달 순천향의학연구소 1997 Journal of Soonchunhyang Medical Science Vol.3 No.2

Background : Continuous epidural infusion of the mixed solution of local anesthetic (bupivacaine) and lipid-soluble opioid (fentanyl) has known as a more useful method than intermittent epidural injection for relief of pain during labor. The purpose of this study was to compare a clinical usefulness between continuous infusion and intermittent injection with epidural analgesia during labor. Methods: One hundred healthy parturients were divided into two groups as follows: Continuous epidural group (C-group); 50 parturients received epidural analgesia continuously with 0.167% bupivacaine and 0.000167% fentanyl in the speed of 10 ml h-1 at cervical dilatation (3-5 cm) and then injected 0.25% bupivacaine 5 ml additionally at complaints of severe labor pain. Intermittent epidural group (I-group); 50 parturients received inermittently 0.167% bupivacaine and 0.00083% fentanyl in the initial dose of 12 ml at cervical dilatation (3-5 cm) and then additionally used the same dose at severe labor pain. Result: There were no statistically significant differences in the clinical states of maternoneonate, pain free score, degree of motor block, mode of delivery, cause of Cesarean section, neonatal Apgar score and incidence of side effects between groups(Table 1.2.3.7.8). The total dose of bupivacaine and fentanyl, the duration of lst and 2nd delivery stages and the frequency of top up injection for incomplete relief of pain during labor appeared significant differences in statistics between groups (Table 4.5.6). Conclusion: It was similar to the effectiveness of maternal epidural analgesia during labor between groups by means of continuous or intermittent injection.

분만시 지속적 경막외 제통에 따른 제왕절개의 빈도

이동기,배상철,박욱,곽수달,강규식,황경호 대한마취과학회 1998 Korean Journal of Anesthesiology Vol.34 No.4

Background : This retrospective study was subjected to evaluate a causal relation in the incidences of Cesarean section with or without epidural analgesia during labor Methods : All of the subjects was divided into two groups which consisted of 394 cases wanted epidural analgesia as Epidural group and 2938 cases unwanted it as Non-epidural group. Continuous lumbar epidural analgesia was performed at L3-4 interspace with catheter advancing 3 cm cephalad when cervix was dilated to at least 3∼5 cm and then patient was placed lateral decubitus or sitting posture. 0.125% bupivacaine 10 ml was injected initially via the epidural catheter and then followed by a mixture (10 ml) of bupivacaine 16.7 mg and fentanyl 16.7 μg hourly to be infused continuously. The data were analysed using Pearson's χ2 test with p<0.05 taken as a significant difference. Results: The incidence of normal spontaneous vaginal delivery and Cesarean section, the cause of alteration to Cesarean section, and gestational frequency followed bsarean section rate showed no significant difference between two groups. The occurrence of neonate below 7 points of Apgar score at one and five minute after Cesarean section was rather more in Non-epidural group (p$lt;0.05) than that in Epidural group. Conclusion : It is concluded that the continuous lumbar epidural analgesia with the dose of bupivacaine and fentanyl as mentioned above does not affect to Cesarean section rate during labor, which provides safe and effective for labor pain control. (Korean J Anesthesiol 1998; 34: 809∼813)