노령 환자에서 대퇴골 전자부 주위 골절에 대한 수술적 치료 시행 후 일상적인 기능적 회복지수

심대무 ( Dae Moo Shim ),김태균 ( Tae Kyun Kim ),김종윤 ( Jong Yun Kim ),최덕화 ( Duk Hwa Choi ),이정숙 ( Joung Suk Lee ),이성인 ( Seong In Lee ) 대한골절학회 2012 대한골절학회지 Vol.25 No.1

목적: 노령의 대퇴골 전자부 주위 골절의 대부분이 수술적 치료를 시행하는바, 이러한 수술적 치료 후 퇴원을 하여도 일상 생활 기능에 큰 영향을 받게 된다. 이에 본 연구에서는 65세 이상의 노령 인구에서 발생한 대퇴골 전자부 주위 골절에서 골절의 형태, 골절 위험 요인과 기능 회복의 정도를 평가하고 회복에 미치는 요인을 파악하고자 하였다. 대상 및 방법: 2006년 1월부터 2007년 12월까지 본원에서 대퇴골 전자부 주위 골절로 수술적 치료를 시행한 환자 중 만 65세 이상의 환자 총 121명에서 1년 이상 추시가 되었던 61명 중 면담 및 전화 설문에 응답한 50명을 대상으로 하였다. 나이, 성별, 수상 방법 및 대퇴골 전자부 주위 골절 종류, 수술을 확인하고 수술 전후 일상 생활 기능 회복 지수 평가표에 따라 100%를 기준으로 하여 점수가 높을수록 기능이 높다고 해석하고 수술 후 일상 생활 기능 회복 정도를 평가하였다. 결과: 평균 연령은 75.8세이었으며, 성별에서 여자가 31명 (62%)으로 남자보다 여자가 많았으며 수상 방법에서 골절의 원인으로 실족이 27명 (54%)으로 가장 많았다. 골절 형태 분석에서 대퇴 전자간부 골절이 34명 (68%)으로 많았으며, 수술 전에 비교하여 기능적 회복 지수는 평균 16.24% 감소하였고, 연령에 높을수록 기능적 회복 지수의 감소도 증가하였고 성별에서는 여성의 기능 회복지수가 높았으며 골절 양상에 따른 경우 대퇴 전자하부 골절에서 17.6% 감소를 가져왔다. 결론: 65세 이상의 고령 환자에서 대퇴골 전자부 주위 골절 수술 후 일상적인 기능 회복 지수는 수술 전에 비하여 평균 16.24% 감소하였으며 가장 많은 감소는 생활 능력 중 기본 생활 능력 회복의 감소였으며 나이는 증가할수록, 성별에서는 여성이, 골절 양상에서는 대퇴 전자하부 골절의 경우 기능적 회복 지수의 감소폭이 큰 것으로 조사되어 이들 요인이 기능 회복에 중요한 영향을 미칠 것으로 생각된다. Purpose: Although most peritrochanteric fractures in old age necessitates surgical treatment, daily life functions are still impaired after discharge. We assessed the types of peritrochanteric fracture, risk factors, and functional recovery in elderly patients who were over 65 years old. We also tried to determine factors for recovery to daily life. Materials and Methods: From January 2006 to December 2007, among 61 patients who were over 65 years old with the possibility of 1 year follow-up, 50 patients were selected through interviews. After verifying age, sex, mode, types of fracture, and method, we analyzed daily living activities with a functional recovery index and estimated recovery of daily life functions after surgery, assuming a score increase if functional recovery was good. Results: The mean age was 75.8 years, and females (31 patients, 62%) exceeded males. Slipping (27 patients, 54%) was the most common cause of fracture, and the intertrochanteric femur fracture was the most common fracture type (34, 68%). The average functional recovery index decreased 16.24% compared with the pre-operation value, having a tendency to decrease more in old age and female patients. Subtrochanteric femur fracture showed a 17.6% decrease in functional recovery index among the fracture types. Conclusion: In elderly patients over 65 years, the functional recovery index after peritrochanteric fracture decreased 16.24% on average compared with the preoperation state. The largest decrease was in basic life ability. The functional recovery index decreased more in old age, females, and subtrochanteric femur fracture, which indicates these factors influence functional recovery.

실험연구 : 모르핀의 항산화 작용에 의한 글루타메이트 세포독성 방어기전

이지현 ( Jienny Lee ),김명선 ( Myung Sunny Kim ),이철 ( Chul Lee ),김향이 ( Hyang Yee Kim ),최덕화 ( Duk Hwa Choi ),김태요 ( Tai Yo Kim ),손용 ( Yong Son ),박래길 ( Rae Kil Park ) 대한마취과학회 2003 Korean Journal of Anesthesiology Vol.45 No.2

감입형 경골 고평부 골절에서 신선 동결 동종 골이식의 사용

김영진 ( Yeung Jin Kim ),채수욱 ( Soo Uk Chae ),양정환 ( Jung Hwan Yang ),이지환 ( Ji Wan Lee ),위대한 ( Dae Han Wi ),최덕화 ( Duk Hwa Choi ) 대한골절학회 2010 대한골절학회지 Vol.23 No.1

목적: 감입형 경골 고평부 골절에서 정복된 관절면의 유지를 위해 사용되는 신선 동결 동종 골이식의 유용성을 알아보고자 하였다. 대상 및 방법: 2004년 5월부터 2008년 5월까지 감입형 경골 고평부 골절로 관혈적 정복 및 내고정술을 시행하여 관절면을 회복한 후 신선 동결 동종 해면골 이식술을 시행한 환자 13명을 대상으로 후향적으로 조사하였다. 평균 나이는 46.6(31∼65)세이었으며, 평균 추시 기간은 36(13∼58)개월이었다. 수술 전·후 및 최종 추시 시 방사선적 결과 판정은 modified Ramussen score를 이용하였고, 기능적 평가는 Lysholm`s knee score로 분석하였다. 결과: 최종 추시 시 체중부하 전·후면 단순 방사선 사진상 전례에서 관절면의 정복이 잘 유지되고 있었고, 함몰이나 골절 정복 소실, 각변형, 부정 유합 등의 합병증은 관찰되지 않았다. 술 후 골유합은 평균 10±0.7주경에 모두 유합을 이루었다. 최종 추시 시 관절 운동은 평균 135(115∼145)도이었고, modified Ramussen score을 이용한 방사선적 결과는 평균 15.3점이었고 10예에서 우수, 3예에서 양호의 결과를 보였다. Lysholm`s knee score는 평균 88.2±4.3점이었다. 결론: 감입형 경골 고평부 골절에서 신선 동결 동종 해면골 이식은 골유합과 기능 회복에 도움이 되며, 정복된 관절면의 유지를 위해 좋은 구조적 보강물이라고 생각된다. Purpose: To assess the behaviour of fresh frozen cancellous allograft used for supporting the reconstructed articular surface in impacted tibial plateau fractures. Materials and Methods: Between May 2004 and May 2008, 13 cases of impacted tibial plateau fracture were evaluated retrospectively. All fractures were treated with open reduction-internal fixation after restoration of the tibial plateau surface and insertion of fresh frozen cancellous allograft chips for subchondral support. Mean age was 46.6 (31∼65) years. Average follow-up period was 36 (13∼58) months. The radiological and clinical result for every patient was assessed according to the modified Rasmussen`s system and Lysholm`s knee score. Results: According to last follow-up weight bearing A-P X-ray, the fresh frozen cancellous allograft incorporated soundly in all cases and no complications such as joint depression, fracture reduction loss, angular deformity, and malunion were found. The mean time to complete bone union was postoperative 10±0.7 weeks. The mean range of motion was 135 (115∼145) degrees. The mean Rasmussen`s radiological score at last follow up was 15.3 (10 cases: excellent, 3 cases: good). The mean Lysholm`s knee score at last follow up was 88.2±4.3. Conclusion: We concluded that fresh frozen cancellous allograft in impacted tibial plateau fractures showed good results in terms of bone union and functional improvement and was considered to be a good structural supporter.

복강경하 산부인과 수술시 삽관 튜브의 고정위치 변화

최덕화,김향이,하정량 圓光大學校 醫科學硏究所 2002 圓光醫科學 Vol.17 No.2

Background: The purpose of this study was to evaluate changes in the distance between the tip of endotracheal tube(ETT) and the carina by the pneumoperitoneum with Trendelenburg lithotomy position during lapaorscopic gynecologic surgery. Methods: We selected clinical patients who received laparoscopic gynecologic surgery on 20 degree of Trendelenburg lithotomy position under about 12㎝ H_2O of abdominal insufflation pressure. We checked a distance from the tip of ETT to the carina using a fiberoptic bronchoscope. Group 1 (n = 24) was measured the distance after the intubation and the pneumoperitoneum with trendelenburg lithotomy positions 10 minute later, respectively. Group 2 (n = 20) was measured the distance after intubation. And then measurements were taken in the pneumoperitoneum with trendelenburg lithotomy position 10 minute later after the positioning of the ETT fixed with 1 ㎝ shortly. Results: There was a significantly difference in the distance from the ETT to the carina within the Group 1. In group 2, the distance of between the tip of the ETT and carina was not altered significantly. Conclusion: The ETT has been shown to migrate towards the carina during laparoscopic gynecologic surgery. We suggest that the safety position for the ETT during laparoscopic gynecologic surgery should be shorter than fixation length of the ETT in supine position.

C6 glial 세포에서 Glutamate에 의해 유발된 세포사멸에 Morphine이 미치는 보호효과

최덕화,안진영,이철 圓光大學校 醫科學硏究所 2002 圓光醫科學 Vol.17 No.2

This study was designed to investigate the effect of morphine on the glutamate-induced toxicity of rat C6 glial cells. Glutamate increased the death of C6 glial cells in a time and dose-dependent manner, which was revealed as apoptosis characterized by genomic DNA fragmentation. Caspase family cysteine proteases including caspase-3, -8 and -9 proteases were not activated in C6 glial cells by glutamate. However, cleavage of PARP was occurred at 12 hr after treatment of glutamate. Glutamate also activated the transcriptional activators including NF-_KB and AP-1 in C6 glial cells. Glutamate-induced cytotoxicity was prevented by morphine and antioxidants such as NAC and GSH, whereas it was not inhibited by MK-801, an antagonist of glutamate receptor NMDA and opioid agonists including DAMGO, DPDPE, and U69593. A morphine antagonist naloxone did not inhibit the protective effect of morphine on cytotoxicity by glutamate but it prevent the death of C6 glial cells. Glutamate significantly decreased the intracellular contents of GSH and increased the generation of H_2O_2 in C6 glial cells. On the contrary, morphine significantly inhibited the depletion of GSH as well as generation of H_2O_2 in C6 glial cells by glutamate.

전신마취환자에서 기관내 삽관과 후두 마스크의 폐흡인 위험도의 비교

김태요,최덕화,유수진,김혁동,정영표,박수경,조동규,윤재승 대한응급의학회 1998 대한응급의학회지 Vol.9 No.1

Background: There were several studies for the incidence of gastroesophageal reflux associated with the laryngeal mask airway(LMA), but the results of those studies were much different from one another. The aim of this study was to compare the incidence of gastroesophageal reflux and regurgitation of gastric contents between the LMA and the endotracheal tube(ETT). Method: Ninety patients scheduled for elective orthopedic surgery with a standardized general anesthetic technique were randomly allocated to receive either a LMA(n=49) or a ETT(n=41) for airway management. The esophageal manometry was carried out for the exclusion of esophageal motility disorders and the 24-hour ambulatory pH metry was done from one day before the operation. A methylene blue(50mg) capsule was swallowed just before the induction and the simultaneous recordings of pH were maintained during anesthesia. At the end of anesthesia, the episodes of regurgitation of gastric contents above hypopharynx were analyzed by the pharyngeal blue staining and the pH metric data were analyzed for the detection of gastroesophageal reflux episodes during anesthesia. Results: There was no significant difference in the incidence of gastroesophageal reflux(pH? 4) between two groups; only two patients in LMA and three patients in ETT had reflux episodes during the removal or arousal phase. There was no episode of the pharyngeal blue staining in both group. All of the gastroesophageal reflux patients in both group developed a cough or straining during those phases. There was no clinical evidence of aspiration of gastric contents in both group. Conclusion: In comparison with ETT, use of LMA does not appear to increase the incidence of gastroesophageal reflux and regurgitation above hypophryngeal level in positive pressure ventilating patients during long surgical procedures. Therefore, the risk of aspiration in LMA will not be much more than ETT.

경막외 신경차단 시술중 발생한 전척수 마취

손용,윤재승,최덕화 대한마취과학회 1998 Korean Journal of Anesthesiology Vol.35 No.1

Epidural nerve block is the most widely practiced procedure in the pain clinic. Accidental dural puncture during epidural nerve block also has been associated with postdural puncture headache and total spinal anesthesia. Especially, total spinal anesthesia is the most serious complication of epidural nerve block and can lead to a life threatening conditions. We have experienced two cases in whom total spinal anesthesia occurred during epidural nerve block for neck and lower back pain control. Immediately after epidural nerve block, the patients became unresponsive and apneic with loss of muscle tone in all extremity. We performed resuscitations and about 3 hours later the patients recovered completely without any complication. (Korean J Anesthesiol 1998; 35: 177∼180)

후두 마스크 제거 시기가 위-식도 역류에 미치는 영향

박수경,김태요,정영표,안선연,최덕화 대한마취과학회 1998 Korean Journal of Anesthesiology Vol.34 No.5

Background : There were several studies for the incidence of gastroesophageal reflux associated with the laryngeal mask airway(LMA), but the results of those studies were much different from one another. This conflicting results may be due to the time of the removal of LMA, which has been usually after the arousal(when the patient can open the mouth on command). So, the authors investigated the incidence of the gastroesophageal reflux and the regurgitation of gastric contents above the upper esophageal sphincter associated with the difference of the time of the removal of LMA. Methods : Sixty three patients scheduled for elective orthopedic surgery with a standardized general anesthetic technique were allocated randomly to Group A(n=34, LMA was removed when the rejection signs such as struggle, restlessness, swallowing and cough came out.) or Group B(n=29, LMA was removed after arousal). For the detection of reflux and regurgitation episodes during anesthesia, a pH monitoring probe was positioned in the lower esophagus and a methylene blue(50 mg) gelatine capsule was swallowed just before induction. At the end of anesthesia, the episodes of reflux and regurgitation of gastric contents were analyzed according to the pharyngeal blue staining or pH≤4. Results : The incidence of reflux(pH≤4) from the time of the rejection signs to the removal of LMA and the total incidence of reflux in Group B were significantly higher than that of Group A. No patient in both group showed pharyngeal staining of methylene blue. There was no clinical evidence of aspiration of gastric contents in either group. Conclusion : Maintenance of LMA until the patient can open the mouth on command seems to increase the incidence of the gastroesophageal reflux. (Korean J Anesthesiol 1998; 34: 956∼960)

척추 신경근 차단술 이후에 발생된 급성 복통 : 1예 보고

김태균,심대무,김영진,김형준,최덕화,양환덕 圓光大學校 醫科學硏究所 2003 圓光醫科學 Vol.18 No.2

마취유도제 차이는 기관내 삽관시 Verapamil과 Esmolol의 혈압과 심박수 변화에 영향을 미치는가?

손용,윤재승,정영표,하정량,최덕화 대한마취과학회 1999 Korean Journal of Anesthesiology Vol.37 No.2

Background: Antihypertensive agents such as verapamil and esmolol are well known for their effects of hemodynamic stabilization on tracheal intubation. But hemodynamic discrepancies in these agents may result from different techniques of anesthetic induction. The aim of the present study was to compare and evaluate their efficacy in controlling hemodynamic responses to tracheal intubation under the different anesthetic induction agents. Methods: Seventy-two patients, ASA physical status Ⅰ or Ⅱ, were randomly assigned to one of six groups (n = 12 each): a Thiopental-Saline (T-S) group and a Propofol-Saline (P-S) group in saline 10ml; a Thiopental-Verapamil (T-V) group and a Propofol-Verapamil (P-V) group in verapamil 0.1 mg/kg; a Thiopental-Esmolol (T-E) group and a Propofol-Exmolol (P-E) group in esmolol 1 mg/kg according to the induction agents, thiopental or propofol. Anesthesia was induced with thiopental 5 mg/kg or propofol 2 mg/kg intravenous, respectively. Next, saline, verapamil and esmolol were administered as a bolus, and were immediately followed by succinylcholine 1.5 mg/kg. Tracheal intubation was carried out 60 s and 90 s after the intravenous injections of verapamil and esmolol, respectively. Systolic and diastolic blood pressure and heart rate were measured before induction and every minute for 5 minutes after tracheal intubation. Results: There was a significant attenuation in systolic and diastolic arterial pressure after tracheal intubation in the verapamil groups compared to the esmolol groups. Heart rates were significantly lower in the esmolol groups than in the verapamil groups after tracheal intubation. Conclusions: Verapamil 0.1 mg/kg and esmolol 1 mg/kg attenuated increases in blood pressure and heart rate after tracheal intubation. The different anesthetic induction agents did not influence the hemodynamic effects of verapamil and esmolol on tracheal intubation. (Korean J Anesthesiol 1999; 37: 221~226)