(영) RIPC for myocardial protection in patients undergoing aortic …anesthesia.thewithin.kr/register/2015_fall/file/2015_92... · 2015-10-29 · stenosis undergoing aortic valve

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intermittent ventilation during sleep. And Electromyography showed there was no locomotive capacity, except for that in the finger flexors and toe extensors, but his sensory functions were intact. Pulmonary function tests revealed severe restrictive lung disease with a forced expiratory volume at 1 s (FEV1) and a forced vital capacity (FVC) of 0.74 L (20% of the predicted value) and 0.90 L (21% of the predicted value), respectively, and an FEV1/FVC ratio of 82%. We blocked the femoral nerve, lateral femoral cutaneous nerve, and parasacral plexus under ultrasound using 40 mL of 0.375% ropivacaine. The patient underwent a successful operation using peripheral nerve blocks with no complications.

결론(증례 결론): General anesthesia and central neuraxial blockades in patients with severe Duchenne muscular dystrophy are unsafe approaches to anesthesia, because life-threatening complications can develop, including hemodynamic instability and respiratory depression. Peripheral nerve blocks alone are the best way to reduce the risks of critical complications, and are a safe and feasible approach to anesthesia in patients with severe Duchenne muscular dystrophy.

참고문헌1. Gurnaney H, Brown A, Litman RS. Malignant hyper thermia and

muscular dystrophies. Anesth Analg 2009;109:1043-8. 2. de Visme V, Picart F, Le Jouan R, Legrand A, Savry C, Morin V.

Combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia for hip fractures in the elderly. Reg Anesth Pain Med 2000;25:158-62.

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(영) Effect of ramosetron on QTc interval in patients undergoing off-pump coronary artery bypass surgery

Tae Kyong Kim1, Youn Joung Cho1, Che-won Lim1, Jeong Jin Min2, Deok Man Hong1, Yunseok Jeon1*

Department of Anesthesiology, College of Medicine, Seoul National University1, Department of Anesthesiology, Sungkyunkwan University School of Medicine2

Background: Ramosetron is a relatively new 5-hydroxytryptamine 3 receptor antagonist with higher binding affinity and more prolonged duration of action compared to ondansetron. The present study was performed to evaluate the effects of ramosetron on QTc interval and possible cardiovascular adverse effects in patients undergoing cardiac surgery.

Methods: A total of 114 patients who underwent off-pump coronary artery bypass surgery were enrolled in this randomised placebo-controlled trial. Patients were allocated into two groups that received intravenous injection of 0.3 mg ramosetron or normal saline during induction of anaesthesia. QTc intervals

were measured before the operation, intraoperatively (0, 1, 2, 3, 5, 10, 15, 30, 45, 60, 90, 120, and 240 min after injection of ramosetron or normal saline), at the end of the operation, and on postoperative day 1.

Results: There were no differences in mean QTc interval between groups at every time point. However, maximal change in QTc interval during surgery was higher in the ramosetron group than the placebo group (25.1±22.0 vs. 17.5±14.5 ms, 95% CI 0.34-14.78, P=0.040). Also, the number of patients with QTc interval increase > 60 ms was higher in the ramosetron group (5 vs. 0, 95% CI 1.6-18.0, P=0.021). There were no significant differences in cardiovascular complications.

Conclusions: Ramosetron administered during induction of anaesthesia may affect maximal change in QTc interval during off-pump coronary artery bypass surgery. Ramosetron should be used with caution in high risk patients for developing Torsades de Pointes.

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(영) RIPC for myocardial protection in patients undergoing aortic valve replacement for aortic stenosis

Young Song, Jaekwang Shim*, Younglan Kwak

Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine

Background: Despite its solid experimental background, the clinical benefits of remote ischemic preconditioning (RIPC) are inconsistent. We aimed to evaluate the protective effect of RIPC on concentrically hypertrophied myocardium, which is more vulnerable to ischemia-reperfusion injury, in patients with aortic stenosis undergoing aortic valve replacement in a randomized controlled trial.

Methods: So far, 60 patients were randomly allocated to either RIPC or control group. The RIPC group received 3 cycles of 5-min inflation to 300 mmHg and 5-min deflation of an automated upper arm cuff inflator after induction of anesthesia. The control group had a deflated cuff placed on upper arm. The cardiopulmonary bypass (CPB) was commenced within an hour after the completion of interventions. The primary endpoints were 24 h area under curve (AUC) for creatine kinase (CK)-MB and troponin (Tn)-T. The secondary endpoints were the incidence of ventricular fibrillation after reperfusion, and perioperative hemodynamic state.

Results: There were no significant differences in 24 hr AUC of CK-MB (340.6±80.5 ng/mL [RIPC] vs. 375.0±197.8 ng/mL [Control], p=0.434) between the groups. There were trends

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towards lower Tn-T release at 12 hr after reperfusion (0.52±0.17 ng/ml vs. 1.06±0.78 ng/ml, p=0.061) and smaller 24 hr AUC of Tn-T (8.50±1.68 ng/mL vs. 13.57±8.30 ng/mL, p=0.196) in the RIPC group relative to the Control group without statistical significance. The incidence of ventricular fibrillation after reperfusion was also lower in the RIPC group without statistical significance (40% vs. 60%, p=0.196). Perioperative hemodynamic variables and the incidence of major morbidity endpoints were comparable between the groups.

Conclusions: So far, RIPC did not exert definite cardioprotective effects in patients with concentric left ventricular hypertrophy undergoing aortic valve replacement for aortic stenosis, while further enrollment will follow.

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Intraoperative trans-fontanel cerebral ultrasonography in infants during pediatric cardiac surgery

주재우1, 김은희1, 송인경1, 이지현1, 김희수1, 박용희2, 김진태1*

서울대학교 의과대학 마취통증의학교실1, 중앙대학교 의과대학·의학전문대학원 마취통증의학과2

연구배경(서론): This study was performed to evaluate the feasi-bility of intraoperative point-of-care trans-fontanel cerebral ultrasonography (TFCU) to obtain blood flow velocity (BFV) reference values at the internal carotid arteries (ICAs) and peri-callosal part of the anterior cerebral artery (pACA) during pediatric

cardiac surgery under cardiopulmonary bypass (CPB).

대상 및 방법(증례): TFCU was performed at three time points (after induction of anesthesia, during CPB, after CPB) in 35 infants. BFV was measured at both ICAs and pACA through the anterior fontanel with an ultrasound sector probe. We divided patients into Group S (<5 kg, n=16) and Group L (≥5 kg, n=19) for comparisons according to weight. We also compared BFV according to cerebral regional oxygen saturation (rSO2).

결과: All measurements of the BFV at both the ICAs and the pACA were possible. BFVs at the ICAs were lower in Group S than in Group L at all three time points. BFVs at the pACA were similar in both groups except higher value in Group L after CPB. In both groups, rSO2 correlated with BFV at both the ICA and the pACA only during CPB. When the rSO2 was <50, most BFVs (14 of 15 measurements) were lower than the median BFV value during CPB. However, a low rSO2 did not always reflect low BFV before and after CPB.

결론(증례 결론): Point-of-care TFCU can determine BFV at the ICAs and pACA during pediatric cardiac surgery. BFV differs according to the patient’s size. TFCU can be a practical cerebral blood flow monitoring method when rSO2 changes without any specific reason.

참고문헌1. Polito A, Ricci Z, Di Chiara L, Giorni C, Iacoella C, Sanders SP, et

al. Cerebral blood flow during cardiopulmonary bypass in pediatric cardiac surgery: the role of transcranial Doppler--a systematic review of the literature. Cardiovasc Ultrasound 2006;4:47.

2. Lee JH, Min SH, Song IK, Kim HS, Kim CS, Kim JT. Control of Cardiopulmonary Bypass Flow Rate Using Transfontanellar Ultra-sonography and Cerebral Oximetry During Selective Antegrade Cerebral Perfusion. J Cardiothorac Vasc Anesth 2015;5:S1053-0770(15)00132-9.

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Perioperative hypocoagulability is an independent predictor of adverse outcome following OPCAB

소사라, 심재광, 곽영란*

연세대학교 의과대학 세브란스병원 마취통증의학과

연구배경(서론): Hypocoagulability increases morbidity in surgical patients independent of blood loss and transfusion, while evidence is scarce in cardiac surgery. We evaluated the predictive value of perioperative hypocoagulability as assessed by rotational thromboelastometry (ROTEM) for postoperative outcome in patients undergoing off pump coronary bypass (OPCAB).

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대상 및 방법(증례): In 303 patients, ROTEM was performed upon anesthetic induction and 15 min after heparin reversal. For the ROTEM parameters, all readings outside of the reference ranges were classified as abnormal. Patients showing any hypocoagulable value in both ROTEM tests were defined as hypocoagulable (Hypo, n=43) group, while remaining patients were defined as non-hypocoagulable (non-Hypo, n=260) group. Primary end point was to evaluate the predictors for postoperative morbidity end points.

결과: Routine coagulation profiles were comparable between the groups, except that pre- and postoperative platelet counts were significantly lower in the Hypo group. Amount of blood loss, transfusion requirement and incidences of postoperative morbidities were significantly greater in the Hypo group. Only EuroSCORE, diabetes, and hypocoagulability (odds ratio 2.223; 95% confidence interval 1.105-4.474) were found to be independent risk factors for the composite of morbidity end points.

결론(증례 결론): Sustained hypocoagulability in ROTEM test during perioperative period, which could not be depicted by conventional coagulation tests, was associated with an increased morbidity risk independent of blood loss and transfusion after OPCAB.

참고문헌1. Johansson PI, Stensballe J, Vindeløv N, Perner A, Espersen K.

Hypocoagulability, as evaluated by thrombelastography, at admission to the ICU is associated with increased 30-day mortality. Blood Coagul Fibrinolysis 2010;21:168-74.

2. Kunio NR, Differding JA, Watson KM, Stucke RS, Schreiber MA. Thrombelastography-identified coagulopathy is associated with increased morbidity and mortality after traumatic brain injury. Am J Surg 2012;203:584-8.

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Ethyl pyruvate has anti-inflammatory and anti-apoptotic effects in myocardial I/R injury

전지혜1, 소사라2, 신은정1, 곽영란2, 심재광2*

연세대학교 의과대학 마취통증의학과1, 연세대학교 의과대학 세브란스병원 마취통증의학과2

연구배경(서론): High mobility group box 1 (HMGB1) is one of the key inflammatory mediators known to exert its influence via toll-like receptor 4 (TLR4)/NF-κB signaling pathway during myocardial ischemia/reperfusion (I/R) injury. Ethyl pyruvate (EP) is a scavenger of reactive oxygen species exerting cardioprotective effects against I/R injury, which has been also shown to be associated with HMGB1 antagonism. Hyperglycemia during acute myocardial infarction attenuates the efficacies of various experimental protective measures. This study aimed to investigate the protective role of EP against myocardial I/R injury under a clinically relevant moderate hyperglycemic condition.

대상 및 방법(증례): 82 rats were randomly assigned to eight groups: normoglycemia-Sham, normoglycemia-pre-EP treatment (Pre-EP), normoglycemia-I/R-control-saline (IRC), normoglycemia-I/R-post-EP treatment (Post-EP), hyperglycemia-Sham, hy-perglycemia-pre-EP, hyperglycemia-IRC, and hyperglycemia-post-EP. The rats received 1.2 g/kg dextrose or same volume of normal saline depending on the group. I/R was induced by a 30 minutes period of left anterior descending coronary artery ischemia followed by reperfusion for 4 hrs. For one hour before ischemia or after reperfusion, intravenous 50 mg/kg of EP was administered.

Table 1. Predictors of composite of morbidity endpoints

VariablesUnivariate analysis Multivariate analysis

OR (95% CI) p OR (95% CI) p

Euroscore 1.204 (1.108-1.307) <0.001 1.181 (1.084-1.287) <0.001

Diabetes mellitus 1.884 (1.186-2.993) 0.007 1.684 (1.019-2.785) 0.042

Hypertension 2.102 (1.251-3.532) 0.005 1.718 (0.990-2.983) 0.054

Congestive heart failure 2.175 (1.078-4.388) 0.03

Anemia 1.696 (1.066-2.698) 0.026

Low platelet count 2.059 (0.995-4.261) 0.052

Perioperative pRBC transfusion 2.183 (1.359-3.506) 0.001

Hypocoagulable before surgery and after protamine administration

2.346 (1.220-4.510) 0.011 2.223 (1.105-4.474) 0.025

pRBC, packed red blood cells.



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결과: Hyperglycemia-post-EP treatment decreased HMGB1 protein level and the expression of myocardial TLR-2 and TLR-4 in the area of induced ischemia. The decreased NF-κB phosphorylation by post-EP treatment diminished IL-1, IL-6, and TNF-α expression under hyperglycemia. Post-EP treatment also attenuated I/R-related down-regulation of Bcl-2 and up-regulation of Bax in hyperglycemic myocardium. As compared with pre-EP and saline treatment, post-EP treatment significantly reduced myocardial infarct size and myocardial apoptosis after I/R in hyperglycemic myocardium.

결론(증례 결론): Post-EP pretreatment after I/R injury conveyed significant myocardial protection under moderate hyperglycemic condition through anti-inflammatory and anti-apoptotic effects.

참고문헌1. Hu X, Cui B, Zhou X, Xu C, Lu Z, Jiang H. Ethyl pyruvate reduces

myocardial ischemia and reperfusion injury by inhibiting high mobility group box 1 protein in rats. Mol Biol Rep 2012;39:227-31.

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Effect of sodium bicarbonate on postoperative acute kidney injury in infective endocarditis patients

조진선, 심재광, 소사라, 곽영란*


연구배경(서론): Acute kidney injury (AKI) following cardiac surgery is associated with inflammation, oxidative stress, and oxygen free radicals. Patients with infective endocarditis (IE) have a high risk of AKI due to systemic inflammation and infection. Sodium bicarbonate has intrinsic natriuretic effects and ability to alkalize tubular fluid, increasing oxygen delivery and reducing oxidative stress by free radical formation. We investigated whether perioperative sodium bicarbonate infusion could attenuate AKI in IE patients undergoing valvular heart surgery.

대상 및 방법(증례): Fifty-two IE patients undergoing cardiac surgery were randomly assigned to placebo (n=27) or to bicarbonate (n=25) groups. Sodium bicarbonate was administered at a loading dose of 0.5 mmol/kg for 1 h commencing with anesthetic induction, followed by an infusion rate of 0.15 mmol/kg/h for 23 h. The primary endpoint was the incidence of AKI during the first postoperative 48 h. Serum creatinine level and glomerular filtration rate during the postoperative 5 days, and major morbidity endpoints were assessed.

결과: The incidence of AKI based on Acute Kidney Injury Network criteria was 5 (19%) in the control group and 9 (36%) in the bicarbonate group (P=0.156). Serum creatinine level was higher

(P=0.041) and glomerular filtration rate was lower (P=0.038) in the bicarbonate group compared with the control group. The incidences of major morbidity endpoints were not statistically different between the groups.

결론(증례 결론): Perioperative sodium bicarbonate administration was not found to reduce the incidence of AKI in IE patients undergoing cardiac surgery; however, it was associated with the increase of serum creatinine level and the decrease of glomerular filtration rate.

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(영) Use of Sugammadex (Bridion�) in a primagravida with twins undergoing non-obstetric surgery

Yong Sup Shin*, Seong Hyun Song, Ann Youn, Chae Sung Lim, Seok Hwa Yoon, Young Kwon Ko

Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University

Background: The past several of years have been exciting in the anesthetic field as Sugammadex (Bridion�) emerged to quickly, effectively, and safely reverse neuromuscular blockade to ensure self-respiration and avoid maternal hypoxemia and hemodynamic instability. Unfortunately, there is no evidence concerning its safe use in pregnant women. Non-obstetric surgery is increasing and practice of safe anesthesia to avoid consequential maternal hypotension, fetal hypoxia, acidosis, myocardial depression, uterine hyperactivity, and ultimately fetal death is of great importance. Although all anesthetic drugs cross the placenta, it can be considered safe when used in clinical concentrations in patients exhibiting normal maternal physiology. Therefore, maintaining hemodynamic stability and ensuring uterine blood flow to avoid preterm delivery seems to be of higher concern than the teratogenicity of anesthetic drugs.

Methods: A 32-year-old primagravida (65.4 kg, 174 cm) in her second trimester (26 weeks into gestation) with twins of her first pregnancy presented to the emergency room with epigastric pain and projectile vomiting. With a history of open splenectomy, small bowel resection, and appendectomy at age 11, abdominal ultrasonography was unfortunately unable to reveal a clear diagnosis due to previous surgical scars. The patient agreed to an erect abdomen radiography which revealed air fluid levels suspicious of intestinal obstruction. Despite two days of observation for spontaneous resolution of the obstructed bowel on the ward, surgery became inevitable due to pain. Before anesthetic induction, an informed consent from the patient was obtained regarding possible anesthetic complications that may affect both the patient and fetuses. The use of Sugammadex as an option despite lack

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of safety evidence in current literature was also mentioned, in case heavy neuromuscular blockade was needed perioperatively for better intubating conditions, ventilation, or surgical view but might interfere with postoperative ventilation and hemodynamic stability. After preoxygenation, anesthesia was induced with thiopental 5 mg/kg and continuous infusion of remifentanil maintained with 0.5% MAC Desflurane, and fully relaxed with rocuronium 0.5 mg/kg, in which TOF was 0. Fortunately, the patient did not require additional neuromuscular blockade because surgical time for small bowel adhesiolysis took approximately 50 minutes and the surgeon did not feel that the patients muscle was constricting. Also, because the site of obstruction was considered to be the small intestines, the incision site was above the umbilical area and there were minimal to no uterine manipulations. TOF at the end of surgery was 68, and neuromuscular blockade was reversed with 4 mg/kg Sugammadex. With confirmation of full neuromuscular restoration (TOF>95%) such as eye-opening and head lifting, she was extubated with good self-ventilation.

Conclusions: We are not recommending the routine use of Sugammadex in all non-obstetric surgeries because there is currently no clinical evidence supporting the safe use in parturients. We believe surgery should be deferred to the second trimester whenever possible when risks of drug teratogenicity are theoretically low so that these patients are somewhat protected from risks of spontaneous abortion or preterm labor. We hope anesthesiologists continue to report the use of Sugammadex in non-obstetric surgery in pregnant women to advise colleagues on future safe practice.

참고문헌1. Jahr JS, Miller JE, Hiruma J, Emaus K, You M, Meistelman C.

Sugammadex: A Scientific Review Including Safety and Efficacy, Update on Regulatory Issues, and Clinical Use in Europe. Am J Ther 2015;22:288-97.

2. Cheek TG, Baird E. Anesthesia for nonobstetric surgery: maternal and fetal considerations. Clin Obstet Gynecol 2009;52:535-45.

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Succinylcholine 투여 시 발생하는 속상수축 및 근육통을 감소시키는 rocuronium의 precurarizing 최적용량

오유나, 김교상*, 김규남, 이희종

한양대학교 의과대학·의학전문대학원 마취통증의학과

연구배경(서론): Succinylcholine commonly produces frequent adverse effects, including muscle fasciculation and myalgia. The current study identified the optimal dose of rocuronium to prevent succinylcholine-induced fasciculation and myalgia and evaluated the influence of rocuronium on the speed of onset produced by

succinylcholine.

대상 및 방법(증례): This randomized, double-blinded study was conducted in 100 patients randomly allocated into five groups of 20 patients each. Patients were randomized to receive 0.02, 0.03, 0.04, 0.05 and 0.06 mg/kg rocuronium as a precurarizing dose. Neuromuscular monitoring after each precurarizing dose was recorded from the adductor pollicis muscle using acceleromyography with train-of-four stimulation of the ulnar nerve. All patients received succinylcholine 1.5 mg/kg at 2 minutes after the precurarization, and were assessed the incidence and severity of fasciculations, while myalgia was assessed at 24 hours after surgery.

결과: The incidence and severity of visible muscle fasciculation was significantly less with increasing the amount of precurarizing dose of rocuronium (P<0.001). Those of myalgia tend to decrease according to increasing the amount of precurarizing dose of rocuronium, but there was no significance (P=0.072). The onset time of succinylcholine was significantly longer with increasing the amount of precurarizing dose of rocuronium (P<0.001).

결론(증례 결론): Precurarization with 0.04 mg/kg rocuronium was the optimal dose considering the reduction in the incidence and severity of fasciculation and myalgia with acceptable onset time, and the safe and effective precurarization.

참고문헌1. Schreiber JU, Lysakowski C, Fuchs-Buder T, Tramèr MR. Prevention

of succinylcholine-induced fasciculation and myalgia: a meta-analysis of randomized trials. Anesthesiology 2005;103:877-84.



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Effect of dexamethasone on the onset time and recovery profiles of cisatracurium

김상훈*, 소금영, 정기태, 김동우

조선대학교 의과대학·의학전문대학원 마취통증의학과

연구배경(서론): There were reports that single injection of dexamethasone (DEXA) might shorten the onset time as well as the recovery profiles of rocuronium, which is one of the steroidal neuromuscular blocking agents (NMBA). But, with lack of clinical reports on the dexmedetomidine effect of the benzylisoquinolinium series such as cisatracurium. So, in this study, we compared the DEXA effect on the onset time and recovery profiles of cisatracurium according to the different injection time points.

대상 및 방법(증례): After institutional review board approval, a total of 117 ASA I and II patients undergoing general anesthesia were allocated and randomized to 3 groups, in which patients received DEXA 8mg intravenously 2-3 hours before induction of anesthesia (group A, n=39), just before induction of anesthesia (group B, n=39), or the end of surgery (group C, n=39). General anesthesia was induced with propofol and remifentanil, followed 3 minute later by intubation without aid of neuromuscular blocking agents. Neuromuscular function was assessed by acceleromyography of the adductor pollicis during anesthesia maintenance with remifentanil and propofol. And then, all patients received cisatracurium 0.05 mg/kg. We measured and recorded the onset and recovery characteristics.

결과: The onset time of group A (532.7±65.2; P=0.000) and B (559.5±80.6; P=0.011) were significantly shorter than group C (626.6±97 sec). The clinical duration and the recovery index were not significantly differences among them. The recovery to a train-of-four ratio of 0.9 was significantly shorter in Group A (28.9±2.7 min) compared with Group B (31.4±3.6 min; P=0.001).

결론(증례 결론): A single dose of dexamethasone 8 mg hastened the cisatracurium onset time and attenuated cisatracurium-induced block 2 to 3 h before induction of anesthesia. However, the administration of dexamethasone during induction of anesthesia did not influence the recovery profiles of the neuromuscular block except of hastening the onset time.

참고문헌1. Soltész S, Fraisl P, Noé KG, Hinkelbein J, Mellinghoff H, Mencke

T. Dexamethasone decreases the duration of rocuronium-induced neuromuscular block: a randomised controlled study. Eur J Anaes-thesiol 2014;31:417-22.

2. Soltész S, Mencke T, Mey C, Röhrig S, Diefenbach C, Molter GP. Influence of a continuous prednisolone medication on the time course of neuromuscular block of atracurium in patients with chronic inflammatory bowel disease. Br J Anaesth 2008;100:798-802.

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Recurarization after sugammadex in Myasthenia gravis patient

양수안, 한진희*, 강화자, 박성욱

경희대학교 의학전문대학원·의과대학 마취통증의학과

연구배경(서론): We report a case of postoperative residual paralysis in a patient with myasthenia gravis although she was reversed with sugammadex.

대상 및 방법(증례): A 65-year-old woman (weight 60 kg, height 151 cm) was scheduled for elective laparoscopic cholecystectomy. She took pyridostigmine bromide 60 mg daily for myasthenia gravis. Anaesthesia was induced with propofol 120 mg, rocuronium 36 mg and remifentanil 20 mcg. The anesthesia was maintained with desflurane and remifentanil. After 1 hour and 25 minutes, the surgery was finished and TOF count was 3/4. Rocuronium was reversed with sugammadex 120 mg. After 1minute 30 seconds, TOF response was 4/4. The patient was able to open her eyes and raise her hands and legs and breath spontaneously. After extubation she was moved to post anesthetic care unit. After 40 minutes, she could not lift her head and legs and felt heavy. She was not have any problems about respiration. At this time, TOF response was 4/4. An additional bolus of 80 mg sugammadex was given. After 1 min 30 seconds, the movement of her head and legs had recovered.

결론(증례 결론): More studies on the dose of sugammadex in Myasthenia gravis patient are needed.

참고문헌1. Conti-Fine BM, Milani M, Kaminski HJ. Myasthenia gravis: past,

present, and future. J Clin Invest 2006;116:2843-54. 2. O’Neill GN. Acquired disorders of the neuromuscular junction. Int

Anesthesiol Clin 2006;44:107-21.

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Effect of dexamethasone on sugammadex reversal from rocuronium neuromuscular block

인준용1, 최혜란2, 이상석3, 김용범4, 양홍석5*

동국대학교 의과대학·의학전문대학원 일산병원 마취통증의학과1, 인제대학교 의과대학 서울백병원 마취통증의학과2, 인제대학교 의과대학 상계백병원 마취통증의학과3, 가천대학교 의학전문대학원 마취통증의학과4, 울산대학교 의과대학 서울아산병원 마취통증의학과5

연구배경(서론): Sugammadex는 포접과정을 통해 rocuronium이나 vecuronium 같은 스테로이드계 신경근 차단제와 1:1로 결합하여 신경근 차단을 상쇄시키는 modified gamma-cyclodextrin

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이다. 임상에서 흔히 투여되는 스테로이드계 약제는 신경근 차단제와 비슷한 구조이므로 sugammadex에 경쟁적으로 포접되어 sugammadex reversal에 영향을 미칠 가능성이 있다. 특히, 수술 후 구역구토 또는 진통작용을 위해 흔히 투여되는 dexamethasone에 대해서도 같은 우려가 있다.

대상 및 방법(증례): 150-350 g SD rat의 phrenic-nerve hemidia-phragm을 분리하여 Kreb’s solution이 담긴 100 ml 챔버에 넣고 20초 간격으로 supramaximal train-of-four (TOF) 자극을 실시하였다. 10분간 안정화 후, rocuronium 3500 ug을 투여하였고 T1 높이가 5% 미만일 때 최대 차단상태라고 판단하였다. 과거연구의 혈중농도를 참고하여 dexamethasone 0 μg/ml (대조군), 0.5 μg/ml (D0.5군), 5 μg/ml (D5군), 50 μg/ml (D50군)을 무작위 투여하고 10분간 안정화를 거쳤다(군 당 n=10). 먼저, rocuronium에 대한 equimolar sugammadex 용량의 1/2을 투여하였다. 다시 30분의 안정화를 거쳐 나머지 1/2를 투여하였고, 95% T1 높이와 TOF ratio 0.9의 회복시간 및 recovery index를 관찰하였다.

결과: D50군은 대조군, D0.5군, D5군에 비해 TOF ratio 0.9의 회복시간이 유의하게 증가하였다(Fig. 1, P<0.01). D50군은 95% T1 회복시간은 D0.5군, D5군에 비해 유의하게 증가하였으나(P<0.01), 대조군과 뚜렷한 차이를 나타내진 않았다(Fig. 2, P=0.090) Recovery index는 군 간 차이를 보이지 않았다(P=0.055).

결론(증례 결론): 일반적인 임상농도의 Dexamethsone에 대한 급성노출이 sugammadex 작용에 영향을 미친다는 결과는 볼 수 없었다. 그러나, 고농도 dexamethasone이 sugammadex 작용에 영향을 미치는 것을 감안하면 스테로이드계 약제의 영향을 완전히 배제할 수는 없다. 따라서, 다양한 스테로이드계 약제 및 만성 노출에 대한 추가연구가 필요하다.

참고문헌1. Rezonja K, Sostaric M, Vidmar G, Mars T. Dexame thasone produces

dose-dependent inhibition of sugammadex reversal in in vitro innervated primary human muscle cells. Anesth Analg 2014;118:755-63.

2. Czock D, Keller F, Rasche FM, Häussler U. Pharmacokinetics and pharmacodynamics of systemically administered glucocorticoids. Clin Pharmacokinet 2005;44:61-98.

125

(영) Modifiable risk factors of atrial fibrillation in thoracic surgery

Gyu Hong Lee, Soohee Lee, Hyun Joo Ahn*, Jie Ae Kim, Mikyung Yang

Department of Anesthesiology, Sungkyunkwan University School of Medicine

Background: Postoperative atrial fibrillation (POAF) is the most frequent arrhythmia after thoracic surgery and is related to an increased morbidity, mortality and hospital cost. Preoperative identification of patients at risk for POAF is important so that measures may be introduced to prevent its occurrence. This study was aimed to find modifiable risk factors of POAF after thoracic surgery.

Methods: Between April 2009 and February 2015, 4731 patients underwent thoracic surgery larger than lobectomy at a single university hospital. After excluding the patients with previous atrial fibrillation (AF) history, the remaining patients were retrospectively reviewed in this study. Demographic, intraoperative, and postoperative date were compared between non-POAF and POAF groups.

Results: Final analysis included 4,662 patients. Of these, 555 patients developed POAF (11.9%). Risk factors of POAF were age, ASA 3, alcohol abuse [odd ratio (OR)=2.12; 95% confidence interval (CI): 1.61-2.80 for alcohol abuse], open thoracotomy, transfusion (OR=6.42; CI: 5.29-7.78) and use of vasopressor (OR=2.51; CI: 2.09-3.00). Age, alcohol abuse, transfusion, and use of vasopressor were related to POAF in open thoracotomy. In open thoracotomy, the patients to apply thoracic epidural analgesia (TEA) showed lower incidences of POAF (OR=0.75; 95% CI: 0.57-0.98). Age, alcohol abuse, and dopamine/dobutamine were related to POAF in VATS.



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Conclusions: Alcohol should be stopped before operation. TEA is recommended for open thoracotomy. Vasopressor is related to POAF, if it should be used, phenylephrine/norepinephrine is preferred to dopamine/dobutamine. Transfusion should be cautioned in thoracic surgery.

참고문헌1. Riber LP, Larsen TB, Christensen TD. Postoperative atrial fibrillation

prophylaxis after lung surgery: systemic review and meta analysis. Ann Thorac Surg 2014;98:1989-97.

2. Ivanovic J, Maziak DE, Ramzan S, McGuire AL, Villeneuve PJ, Gilbert S, et al. Incidence, severity and perioperative risk factors for atrial fibrillation following pulmonary resection. Interact Cardiovasc Thorac Surg 2014;18:340-6.

126

식도암 환자에서 식도 절제술 후 발생한 심방세동이 장기생존률에 미치는 영향

진지현1, 문영진1, 조준영1, 김형렬2, 이은호1*, 최인철1

울산대학교 의과대학 서울아산병원 마취통증의학과1, 흉부외과2

연구배경(서론): Newly developed atrial fibrillation (AF) in patients who have undergone an esophagectomy increases the incidence of postoperative complications. However, the clinical implications of AF have not been fully elucidated in those patients. This retrospective observational study investigated the effect of AF on the mortality and predictors for AF in oesophageal cancer patients undergoing esophagectomy.

대상 및 방법(증례): This study evaluated 583 patients undergoing esophagectomy. AF was defined as postoperative newly developed AF requiring treatments. The associations between AF and mortality and the risk factors for AF were evaluated.

결과: AF developed in 63 patients (10.8%). The long-term mortality rates were 46.0% in the AF group and 33.8% in the non-AF group. A Kaplan-Meier curve showed significantly higher long-term mortality in the AF group than in the non-AF group (P=0.045), during a median follow-up of 50.7 months. AF after esophagectomy was an independent risk factor for long-term mortality (hazard ratio 1.6, 95% confidence interval [CI] 1.1-2.4, P=0.017). Advanced age (odds ratio [OR] 1.1, 95% CI 1.1-1.2, P<0.001), preoperative calcium channel blocker (CCBs) (OR 2.5, 95% CI 1.2-5.3, P=0.012), and angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) (OR 0.2, 95% CI 0.1-0.7, P=0.013) were associated with the incidence of AF.

결론(증례 결론): In oesophageal cancer patients, postoperatively developed AF was an independent risk factor for long-term mortality after esophagectomy. In addition, advanced age and

preoperative medications (CCB, ACEI or ARB) were independently associated with the incidence of AF.

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Intraoperative colloid and albumin administration increases postoperative delirium

정대명, 안현주*, 양미경, 김지애, 김덕경, 최지원, 이상민, 박주현

성균관대학교 의과대학 삼성서울병원 마취통증의학과

연구배경(서론): Anesthesia for esophageal cancer surgery re-quires fluid restriction for preventing postoperative pulmonary complications. In this regard colloid and albumin are often used for volume replacement. We investigated the association between the type of fluid and the incidence of postoperative delirium (POD).

대상 및 방법(증례): A retrospective review was completed for all the patients who underwent esophageal cancer surgery from April 2010 and February 2015 (n=965). Patients who developed delirium were sorted out whether they received delirium medications and coded as delirium (+). Multivariate logistic regression analysis was used to evaluate for independent risk factors. The type of fluid was categorized into 2 groups in two ways; colloid vs. non-colloid and albumin vs. non-albumin, respectively.

결과: The overall incidence of POD was 23.2%. The incidence of POD was 1.52 times higher in colloid group than non-colloid group and 1.64 times higher in albumin group than non-albumin group.

결론(증례 결론): The use of colloid and albumin intraoperatively increases POD in patients undergoing esophageal cancer surgery. Avoidance of colloid and albumin administration can decrease POD in patients undergoing esophageal cancer surgery.

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참고문헌1. Böhner H, Hummel TC, Habel U, Miller C, Reinbott S, Yang Q, et al.

Predicting delirium after vascular surgery: a model based on pre- and intraoperative data. Ann Surg 2003;238:149-56.

2. Oztaş B, Akgül S, Arslan FB. Influence of surgical pain stress on the blood-brain barrier permeability in rats. Life Sci 2004;74:1973-9.

128

식도절제술을 시행받는 식도암 환자들에서의 적혈구 수혈과 장기간 사망률

최인철, 이은호*, 진지현, 장명수

울산대학교 의과대학 서울아산병원 마취통증의학과

Backgrounds: Red blood cell (RBC) transfusion has been known to increase a morbidity and mortality in several surgical patients.

Table 1. Baseline Characteristics of the study population*

Characteristics Non-colloid (N=471) colloid (N=565) P Value

Age - yr 63.1 (±9.4) 63.4 (±8.2) 0.60

Sex - no. (%) 0.14

Male 423 (90) 522 (92)

Female 48 (10) 43 (8)

Delirium - no. (%) 92 (20) 148 (26) 0.01

ASA class≥3 - no. (%) 25 (5) 34 (6) 0.08

Educational attainments (equal to and lower than those of high school graduate) - no. (%)

344 (73) 446 (79) 0.03

Alcohol abuse - no. (%) 134 (28) 155 (27) 0.72

Diabetes - no. (%) 72 (15) 88 (16) 0.89

Heart disease - no. (%) 27 (6) 21 (4) 0.12

Cerebral disease - no. (%) 21 (4) 34 (6) 0.27

Liver disease - no. (%) 19 (4) 28 (5) 0.48

Transfusion - no. (%) 88 (19) 120 (21) 0.31

VATS or Robotic surgery - no. (%) 90 (19) 46 (8) <0.01

Hemoglobin - g/dL

Preoperative 13.4±1.8 13.5±1.9 0.72

Postoperative day 1 12.3±1.6 11.8±1.6 <0.01

Albumin - g/dL

Preoperative 4.3±0.4 4.2±0.4 0.12

Postoperative day 1 3.1±0.4 2.8±0.4 <0.01

Other lab values, postoperative day 1

Fasting glucose - mg/dL 194±54 189±52 0.12

Ca - mg/dL 7.6±0.4 7.5±0.4 <0.01

Na - mmol/L 137±2 137±2 <0.01

K - mmol/L 4.4±0.5 4.5±0.5 0.31

Cl - mmol/L 106±3 105±3 <0.01

CRP - mg/dL 5.54±2.86 5.43±2.39 0.53

Surgical duration - min 299 301 0.73

ICU stay after surgery 4±9 4±8 0.78

Hospitalization after surgery 18±21 17±14 0.31

Death during hospitalization - no. (%) 3 (1) 9 (2) 0.24

*Plus-minus values are means±SD. ASA The American Society of Anesthesiologists, VATS Video-assisted thoracoscopic surgery



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The effects of RBC transfusion on outcomes after esophagectomy have rarely been evaluated. We investigated the impacts of RBC transfusion during perioperative period on long-term mortality in a large number of esophageal cancer patients who underwent esophagectomy.

Methods: This study evaluated 589 esophageal cancer patients undergoing esophagectomy. Intraoperative and postoperative RBC transfusions were collected. The associations between RBC transfusion and long-term mortality were evaluated using multivariable analysis with Cox proportional hazards models.

Results: Of the 589 patients, 186 patients (31.6%) received RBC transfusion during perioperative period. Death occurred in 109 (27.0%) patients in who received RBC transfusion and 99 (53.2%) patients in who did not. After adjusting the confounders, there was an incremental association between RBC transfusion and long-term mortality (hazard ratio 1.07, 95% confidence interval 1.06-1.09, P<0.001).

Conclusions: Perioperative RBC transfusion increases long-term mortality in esophageal cancer patients who underwent esophagectomy, although a small number of RBC unit is tansfused.

129

Effect-site concentration of remifentanil for smooth removal of the Double-lumen endotracheal tube

유지영*, 이세련, 김대희

아주대학교 의과대학 마취통증의학과

연구배경(서론): Smooth emergence is important for patient safety and satisfaction. Using double lumen tube (DLT) increase the incidence of hoarseness and airway injury than using single lumen tube for it has large size. Various technique and drugs have been proposed for reducing coughing during extubation including smooth emergence and this is closely correlate with reducing sore throat and hoarseness. One of the proposed technique, the use of short acting opioids especially remifentanil is prefered because it can be maintained during emergence with less respiratory depression. But there is no study about the proper dose of remifentanil for smooth DLT extubation. The purpose of this study was to evaluate the EC50 and EC95 of remifentanil in effect-site TCI for preventing cough during extubation of DLT in total TIVA with propofol and remifentanil.

대상 및 방법(증례): We studied 25 simple lung wedge resection cases with remifentanil-propofol TIVA anesthesia and use Dixon’s up-down method.

결과: 24 Patients were enrolled in this study and no patients were excluded from analysis. Demographic data for the enrolled patients are comparable. The operation time was 29 (range 13-45)min and the intubated time was 62 (range 41-83)min. By Dixon’s method, the EC50 of remifentanil for smooth emergence without cough was 4.1 ng/ml. The awakening effect site concentration of propofol was lower in success group (1.22±0.58 ng/ml) than in failed group (0.98±0.14 ng/ml). The recovery score at PACU admission was comparable in both groups but the duration of stay was longer in success group (47.5±9.2 min) than in failed group (39.29±4.75 min). Haemodynamic values of smooth emergence and failed smooth emergence patients are compared. The MAP and HR were statistically higher in failed smooth emergence patients who had coughed during emergence.

결론(증례 결론): The Ec50 of effect-site concentration of remifen-tanil for smooth emergence was 4.1 ng/ml which is more higher than required enough for smooth removal of single lumen ET-tube.

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Intraoperative changes in pulse transit time during sympathicotomy: a pilot study

유가연, 김성훈, 최대기*


연구배경(서론): Sympathicotomy is a surgical procedure creating a break in the sympathetic signaling pathway to treat palmar hyperhidrosis. We hypothesized that pulse transit time (PTT) measured between the R-wave peak on electrocardiogram and finger pulse would be increased after sympathicotomy.

대상 및 방법(증례): Five patients who underwent sympathicotomy for treatment of palmar hyperhidrosis were included. Electro-cardiogram, left finger pulse oximetric plethysmography, palmar temperature, and noninvasive blood pressure were simultaneously recorded. PTT was measured as the time interval from the R-wave peak on electrocardiogram to the maximal upslope of the photoplethysmogram at 5 min after intubation (T0), 1 min before sympathicotomy (T1), and 5 (T2) and 10 min (T3) after sympathicotomy.

결과: Sympathicotomy was successful in all patients. The value of PTT was significantly increased at 5 min after sympathicotomy (636.7±54.0; P=0.042), compared with presympathicotomy level (T0; 578.6±62.9, T1; 594.2±45.8). However, the value of PTT at 10 min after sympathicotomy (T3; 585.4±44.3) was not significantly different from the presympathicotomy level. Palmar temperature after sympathicotomy was also increased significantly after sympathicotomy but remained the increased level.

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결론(증례 결론): PTT was increased at 5 min after sympathicotomy and then decreased to presympathicotomy level at 10 min after sympathicotomy.

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관상동맥우회술을 받는 환자에서 심폐우회기의 사용 여부와 관상동맥조영술의 시기가 신손상에 미치는 영향에 대한 후향적 연구

김경미, 안상미, 정경운, 김지윤, 이은호*, 최인철


연구배경(서론): 급성 신손상은 관상동맥 우회술(coronary artery bypass graft surgery, CABG)의 흔하고 심각한 합병증으로 알려져 있다. 관상동맥조영술은 관상동맥질환이 의심되는 환자들에게는 병소 여부와 병변의 중등도 및 치료 방법을 결정하기 위해 반드시 시행되어야 하는 검사이지만 심장 수술을 받는 환자에서 관상동맥 조영술과 심폐우회기(cardiopulmonary bypass, CPB)의 사용이 신기능에 영향을 주는 요인이라는 일부 연구 결과들이 있다. CPB의 사용과 관상동맥조영술의 시기가 CABG를 받은 환자의 신기능에 어떤 영향을 미치는지 알아보고 이로 인한 예후를 확인하고자 하였다.

대상 및 방법(증례): 2006년부터 2012년까지 본원에서 정규 수술로 시행된 무인공심폐 관상동맥 우회술(off-pump coronary artery bypass graft surgery, OPCAB) 환자 1670명과 CPB를 사용한 관상동맥 우회술(on-pump coronary artery bypass graft surgery, ONCAB) 환자 701명을 포함한 총 2371명을 대상으로 하였고 응급 수술과 판막이나 대동맥 수술을 동시에 시행한 경우, 수술 전 신기능 손상으로 투석을 시행하던 환자들은 연구에서 제외하였다. 환자들의 전자의무기록 및 혈액 검사 결과를 바탕으로 CPB 사용여부와 관상동맥조영술의 시기를 조사하고 Kidney Disease: Improving Global Outcomes Definition and Staging criteria에 따른 급성 신손상의 발생률을 확인하고 다중로지스틱회귀분석을 통해 위험인자를 확인하였다.

결과: 관상동맥 조영술 후 7일 이내에 CABG를 시행 받은 환자에

Table 1. Demographic Characteristics of the Study Patients Stratified by the Occurrence of Acute Kidney Injury

No AKI (n=1407)

AKI (n=964)

p

Age (year) 62.7±9.3 65.0±8.9 <0.001

Male 1074 (76.3%) 726 (75.3%) 0.568

Body mass index (kg/m2) 24.7±2.8 24.6±3.0 0.709

Hypertension 826 (58.7%) 661 (68.6%) <0.001

Diabetes mellitus 599 (42.6%) 499 (51.8%) <0.001

Congestive heart failure 32 (2.3%) 44 (4.6%) 0.002

Cerebrovascular disease 301 (21.4%) 285 (29.6%) <0.001

Peripheral vascular disease 67 (4.8%) 57 (5.9%) 0.216

eGFR<60 ml/min/1.73 m2 146 (10.4%) 258 (26.8%) <0.001

Preoperative medication

ACEi 549 (39.0%) 458 (47.5%) <0.001

Beta-blocker 871 (61.9%) 603 (62.6%) 0.750

Calcium channel blocker 993 (70.6%) 659 (68.4%) 0.249

Insulin 273 (19.4%) 247 (25.6%) <0.001

Oral hypoglycemic agents 485 (34.5%) 384 (39.8%) 0.008

Statin 1011 (71.9%) 644 (67.0%) 0.012

Aspirin 1042 (74.1%) 733 (76.0%) 0.275

Clopidogrel 787 (55.9%) 535 (55.5%) 0.833

Diuretics 251 (17.8%) 200 (20.7%) 0.076

Logistic EuroSCORE 2.3±3.6 5.1±6.2 <0.001

Ejection fraction (%) 56.6±10.9 54.6±11.4 <0.001

Preoperative laboratory values

Hematocrit (%) 39.4±4.6 37.1±5.0 <0.001

Creatinine (mg/dl) 1.0±0.3 1.1±0.6 <0.001

Total bilirubin (mg/dl) 0.7±0.3 0.7±0.3 0.005

Albumin (g/dl) 3.9±0.4 3.6±0.4 <0.001

Uric acid (mg/dl) 5.4±1.4 5.8±1.6 <0.001

Type of operation <0.001

ONCAB 352 (50.2%) 349 (49.8%)

OPCAB 1055 (63.2%) 615 (36.8%)

Time between CAG and CABG 0.037

≤7 days 686 (57.3%) 512 (42.7%)

>7 days 721 (61.5%) 452 (38.5%)

CPB time (min) 74.4±36.5 90.2±48.5 <0.001

Anesthetic time (min) 306.4±68.0 310.6±73.5 0.152

Crystalloid (ml)* 1542.6±768.6 1355.0±636.4 <0.001

Colloid (ml)* 1071.7±427.0 983.3±422.6 <0.001

Packed red blood cell (unit)* 1.2±1.6 1.8±2.2 <0.001

Fresh frozen plasma (unit)* 0.1±0.6 0.3±0.9 <0.001

Cell saver blood (ml)* 140.6±296.8 109.6±258.1 0.007

Data are expressed as the mean±standard deviation or number (per-centage).AKI=acute kidney injury, ACEi=angiotensin-converting enzyme inhibitor, CAG=coronary angiography, CABG=coronary artery bypass graft surgery, ONCAB=on-pump coronary artery bypass graft surgery, OPCAB=off-pump coronary artery bypass graft surgery, CPB=cardiopulmonary bypass.*Used intraoperatively.



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서 그렇지 않은 환자보다 수술 후 급성 신손상의 발생률이 높았다(42.7% vs. 38.5%, p=0.037). 다중 로지스틱 회귀분석 결과 CABG 환자 전체에서는 연령, 고혈압 병력, 술 전 신기능 감소(eGFR<60 ml/min/1.73 m2), 인슐린의 사용, 낮은 혈장 알부민, 높은 혈중 요산, 관상동맥 조영술 후 7일 이내 수술, CPB의 사용 등이 신손상을 악화시키는 위험요인으로 확인되었다. OPCAB에서는 관상동맥 조영술의 시기와 급성 신손상 발생은 통계적으로 유의하지 않았으나 관상동맥 조영술 후 7일 이내의 ONCAB을 시행하는 것은 급성 신손상의 발생을 1.511배 증가시켰다(p=0.019).

결론(증례 결론): 관상동맥 조영술 후 7일 이내에 ONCAB을 시행하는 것은 수술 후 급성 신손상에 위험인자로 작용하지만 OPCAB에서는 위험 요소가 되지 않았다. 수술 전 신기능이 악화된 상태나 수술을 급하게 시행해야 하는 경우에는 ONCAB 보다는 OPCAB이 신기능 보호 측면에서는 안전한 수술 방법으로 확인되었다.

참고문헌1. Lee EH, Chin JH, Joung KW, Choi DK, Kim WJ, Lee JB, et al. Impact

of the time of coronary angiography on acute kidney injury after elective off-pump coronary artery bypass surgery. Ann Thorac Surg 201396:1635-41.

2. Mehta RH, Honeycutt E, Patel UD, Lopes RD, Williams JB, Shaw LK, et al. Relationship of the time interval between cardiac catheterization and elective coronary artery bypass surgery with postprocedural acute kidney injury. Circulation 2011;124:S149-55.

Table 2. Mortality and Morbidity in the Study Cohort with Reference to Acute Kidney Injury Development

No AKI (n=1407) AKI (n=964) p

Time to extubation (hour) 10.5±11.8 17.9±32.3 <0.001

ICU stay (hour) 52.4±34.7 79.6±147.3 <0.001

Hospital stay (day) 8.8±5.7 12.8±20.0 <0.001

In-hospital death 3 (0.2%) 23 (2.4%) <0.001

1-year mortality 11 (0.8%) 19 (2.0%) 0.011

Data are expressed as the mean±standard deviation or number (percentage).AKI=acute kidney injury, ICU=intensive care unit, KDIGO=Kidney Disease: Improving Global Outcomes Definition and Staging, RRT=renal replacement therapy, 1-year RRT or death=cases of RRT or the number of deaths that occurred during the first postoperative year.

Table 3. Multivariable Logistic Analysis for Acute Kidney Injury in the Study Patients Who Underwent Elective Coronary Artery Bypass Graft after Coronary Angiography

Odds ratio (95% CI)CABG (n=2371)

pOdds ratio (95% CI)

ONCAB (n=701)p

Odds ratio (95% CI)OPCAB (n=1670)

p

Age 1.013 (1.002-1.023) 0.018 1.019 (1.006-1.032) 0.004

Hypertension 1.357 (1.123-1.638) 0.002 1.528 (1.077-2.167) 0.018 1.333 (1.060-1.676) 0.014

eGFR <60 ml/min/1.73 m2 1.714 (1.318-2.229) <0.001 2.084 (1.214-3.578) 0.008 1.679 (1.236-2.279) 0.001

Insulin 1.325 (1.061-1.654) 0.013 1.479 (1.167-1.876) 0.001

Hematocrit 0.955 (0.930-0.981) 0.001

Albumin 0.380 (0.296-0.487) <0.001 0.282 (0.179-0.445) <0.001 0.448 (0.332-0.605) <0.001

Uric acid 1.150 (1.080-1.224) <0.001 1.156 (1.019-1.313) 0.025 1.143 (1.061-1.231) <0.001

CAG interval≤7 days 1.271 (1.062-1.520) 0.009 1.511 (1.070-2.134) 0.019

Use of CPB 1.307 (1.044-1.635) 0.019

CPB time 1.006 (1.002-1.010) 0.007

Crystalloid in the OR 1.000 (0.999-1.000) <0.001

Transfused pRBC in the OR 1.109 (1.042-1.180) 0.001 1.141 (1.031-1.263) 0.011

Transfused FFP in the OR 1.168 (1.024-1.331) 0.021

CABG=coronary artery bypass graft surgery, ONCAB=on-pump coronary artery bypass graft surgery, OPCAB=off-pump coronary artery bypass graft surgery, CAG=coronary angiography, CPB=cardiopulmonary bypass, OR=operating room, pRBC=packed red blood cell, FFP=fresh frozen plasma.

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Remifentanil attenuates systemic inflammatory response in cardiac surgery

이수은1, 이현정1, 리 매2, 송지아1, 곽상현1*

전남대학교 의과대학 마취통증의학교실1, 중국 저장대학교병원 마취통증의학교실2

연구배경(서론): Systemic inflammatory response plays pivotal roles in the pathogenesis of organ dysfunction after cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to investigate whether remifentanil has the effects on the systemic inflammatory response induced by cardiac surgery with CPB.

대상 및 방법(증례): Sixty adult patients undergoing cardiac surgery with CPB were randomly assigned to two groups: a remifentanil (n=30) and a fentanyl group (n=30). The plasma levels of IL-6, IL-8 and malondialdehyde (MDA) were measured at preinduction (T1), just before aortic clamping (T2), just before aortic declamping (T3), 5 (T4), 30 (T5), and 60 (T6) min after aortic declamping. Hemodynamic variables serially recorded at that same times. Myocardial cell damage as assessed by plasma level of creatine kinase-MB (CK-MB) and troponin T were measured before and 24 hr after surgery.

결과: The levels of IL-6, IL-8 and MDA significantly increased from just before aortic declamping in both groups. In the remifentanil group, all of those were significantly lower compared to the fentanyl group from just before aortic declamping (P<0.05). The level of CK-MB and troponin T significantly increased at 24 hr after surgery than preoperative baseline in both groups. In the remifentanil group, both were significantly lower than fentanyl group at 24 hr after surgery.

결론(증례 결론): Remifentanil attenuates systemic inflammatory response more effectively than fentanyl in cardiac surgery with CPB. The mechanism of its effects is likely to be through proinflammatory cytokines (including IL-6, IL-8) and oxidative stress mediator (MDA).

참고문헌1. Mekontso-Dessap A, Houel R, Soustelle C, Kirsch M, Thebert

D, Loisance DY. Risk factors for post-cardiopulmonary bypass vasoplegia in patients with preserved left ventricular function. Ann Thorac Surg 2001;71:1428-32.

2. Franke A, Lante W, Fackeldey V, Becker HP, Thode C, Kuhlmann WD, et al. Proinflammatory and antiinflammatory cytokines after cardiac operation: Different cellular sources at different times. Ann Thorac Surg 2002;74:363-70.

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CABG 술 후 환자에게 지속 정주된 dexmedetomidine의 임상적 효과

김석훈1, 전인정1, 이상석1, 유병훈1*, 김계민1, 정의석2

인제대학교 의과대학 상계백병원 마취통증의학과1, 흉부외과2

연구배경(서론): 술 후 중환자실에서 보조적 기계환기가 필요한 환자들의 진정 및 통증조절은 중요한 사안이다. 그 동안 관상동맥우회술 후 미다졸람 주� (midazolam)제제를 사용하였다. 프리세덱스 주� (dexmedetomidine)은 독특한 진정 및 항 불안 효과를 나타내기에 많이 사용하고 있다. 이에 이 두 약제를 무작위 배정, 술 후 환자의 전반적인 회복과정을 비교하였다.

대상 및 방법(증례): 본 연구는 상계백병원 흉부외과에서 2013년 부터 전신 마취 하에 개심 관상동맥우회술을 받는 환자들을 대상으로 1:1 배정비율로 총 40명을 대상으로 하였다. sternum closure 시기부터 프리세덱스 또는 미다졸람을 사용하여 진정 상태를 유지하였다. 약물 주입 직 후부터 혈압, 맥박, 폐동맥압, cardiac index 측정 하였고 중환자실 입실시기부터는 2시간 간격으로 환자의 진정 및 통증, 혈역학적 변화, 출혈, 섬망, Shivering, Nausea, vomiting, Additional pain control agent 및 Vasopressor 필요여부, 중환자실 입실부터 Ventilator weaning 시기까지의 시간, ICU stay 일수 및 퇴원시기까지 소요된 일수를 비교분석 하였다.

결과: 혈압, 맥박, 폐동맥압, cardiac index, 통증조절상태, 혈역학적 변화, 출혈정도, 섬망, Shivering, Nausea, vomiting, Additional pain control agent 사용 여부 모두 양군 간에 통계학적으로 유의하지 않은 결과를 보였다. 단, 진정의 척도를 나타내는 RASS 의 경우 프리세덱스 군에서 유의하게 낮게 나타났다.

결론(증례 결론): 충분한 통증 조절이 필요한 CABG 술 후 환자들의 진정 및 진통 효과를 위해 미다졸람 또는 프리세덱스와 같은 약제는 모두 효과적임을 알 수 있었다. 단, 충분한 opioid의 사용과 지속적인 모니터링이 동반되어야 할 것이다.

참고문헌1. Ji F, Li Z, Young N, Moore P, Liu H. Perioperative dexmedetomidine

improves mortality in patients undergoing coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2014; 28:267-73.

2. Herr DL, Sum-Ping ST, England M. ICU sedation after coronary artery bypass graft surgery: dexmedetomidine-based versus propofol-based sedation regimens. J Cardiothorac Vasc Anesth 2003;17:576-84.



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(영) Usefulness of IV fluids warming during goal-directed fluid therapy in laparoscopic colon surgery

Gyu-Hong Lee, Duk-Kyung Kim*, Ji-Won Choi, Jung-Bo Park


Background: Intravenous (IV) fluids warming is generally recommended in the enhanced recovery after surgery (ERAS) programs only with evidences proven outside the ERAS programs. We therefore evaluate its clinical usefulness within a goal-directed fluid therapy during laparoscopic colorectal surgery.

Methods: Fifty-two adult patients undergoing laparoscopic colorectal surgery were randomly assigned to receive either IV fluids at room temperature (control group) or warmed IV fluids via a Hotline fluid warmer (warm fluids group). Each patient received a standardized goal-directed fluid regimen using stroke volume variances. Esophageal temperature was measured at 15 min intervals for 2 h after anesthetic induction.

Results: In total, 51 subjects (control, n=26; warm fluids, n=25) were included in the analysis (Table 1). Core temperature drop in the warm fluids group was significantly less than that in the control group, starting from 30 min after induction of anesthesia (P<0.05). As a result, the total temperature drop during the 2 h

study period was significantly less in the warm fluids group than in the control group (0.3±0.3oC vs. 0.5±0.4oC, P=0.013) (Fig. 1). The proportion of patients with intraoperative hypothermia was similar in both groups.

Conclusions: IV fluids warming caused the core temperature to drop less than room temperature IV fluids in laparoscopic colorectal surgery (<2 h) incorporating goal-directed fluid therapy. However, when considering its small difference along with additional costs of IV fluids warmer, routine use of IV fluids warming cannot be justified within the setting of an ERAS program.

Table 1. Demographic, anesthetic, and operative data

Control (n=26) Warm fluids (n=25) P value

Gender (F/M) 13/13 12/13 1.000

Age (years) 50.5±8.7 51.8±10.3 0.631

BMI (kg/m2) 23.8±2.8 23.2±3.1 0.508

ASA physical status (I/II) 21/5 20/5 1.000

Preoperative tympanic temperature (oC) 36.8±0.3 36.8±0.4 0.784

Types of laparoscopic procedures (hemicolectomy, anterior resection, low anterior resection, extended colectomy)

5/8/9/4 11/5/6/3 0.300

Duration of pneumoperitoneum (min) 104.9±35.8 93.8±26.2 0.211

Duration of surgery (min) 140.3±34.7 134.0±31.0 0.497

Duration of anesthesia (min) 185.3±35.4 178.7±35.0 0.502

Colloid administered (ml) 288.5±241.8 320.0±284.3 0.671

Crystalloid administered (ml) 437.1±176.8 486.8±134.2 0.265

EBL (ml) 60.2±46.7 67.0±45.0 0.598

Urine output (ml) 196.2±82.0 153.0±89.7 0.079

Hypothermia (<36.0oC) during the study period (yes/no) 14/12 7/18 0.112

Data are expressed as the mean±standard deviation (SD) or number. BMI body mass index; ASA American Society of Anesthesiologists; EBL estimated blood loss. All fluid input and output data were those in the 2-h study period.

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(영) Effect of goal-directed fluid therapy using stroke volume variation in free flap reconstruction

Eun Jung Kim1, Hyun Joo Kim1, Hyun Jung Lee1, Ji-Young Min1, Won-Sik Kim2, Bon-Nyeo Koo1*

Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine1, Department of Otorhinolaryngology, Severance Hospital, Yonsei University College of Medicine2

Background: Adequate fluid administration improves organ perfusion and tissue oxygen supply by increasing circulating blood volume, while excessive fluid increases perioperative com-plications by fluid accumulation in interstitial space. Ideal fluid management had been emphasized in various surgery. In free flap reconstructive surgery, excessive fluid administration had shown to affect patient morbidity and exacerbate flap outcomes. The aim of this study was to investigate the role of goal-directed fluid therapy using SVV toward patient morbidity and flap outcomes.

Methods: Forty-seven patients scheduled for free flap recon-structive surgery after head and neck cancer resection were randomly assigned into two groups: goal-directed fluid therapy group using SVV (SVV, n=24) and traditional fluid therapy group (control, n=23). Additional fluid was given when either mean blood pressure (MBP)<65 mmHg or CVP<14 mmHg in control group, and when SVV>12% in SVV group. Supplemental dobutamine or norepinephrine were given according to the changes in cardiac index and oxygen delivery in SVV group. The amount of fluid maintenance were the same in both groups.Flap outcomes were assessed and classified as total survival, partial survival, and flap failure. Reoperation, hospital stay, intensive care unit stay, postoperative complications, and postoperative chest X-ray findings were also assessed.

Results: Flap outcomes were not significantly different between the two groups. However, significantly more patients had re-operation due to flap dysfunction in control group compared to the SVV group. Hospital stay, postoperative complications, and postoperative chest X-ray findings were not significantly different although the intensive care unit stay tended to be longer in control group than SVV group.

Conclusions: Goal-directed fluid therapy using stroke volume variation in patients undergoing free flap reconstruction after head and neck cancer resection reduces the reoperation events compared to the traditional fluid therapy.

참고문헌1. Gan TJ, Soppitt A, Maroof M, el-Moalem H, Robertson KM,

Moretti E, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002;97:820-6.

2. Benes J, Chytra I, Altmann P, Hluchy M, Kasal E, Svitak R, et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care 2010;14:R118.

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The laboratory comparison of three different fluid warmers on fluid warming efficacy

김상훈1,2*, 김동준2, 안태훈1,2

조선대학교 의과대학·의학전문대학원 마취통증의학과1, 조선대학교병원 마취통증의학과2

연구배경(서론): The use of warming devices, which operate on various principles, is useful for maintaining perioperative normothermia as well as reducing morbidity and complications. The Mega Acer Kit� (MAK) is designed for warming the fluid via the lumen of a newly designed heated circuit. We conducted to compare the fluid warming capabilities in three different fluid warmers.

대상 및 방법(증례): The intravenous fluid warmers used in this study were the Mega Acer Kit� (Group M, n=10), ThermoSens� (Group T, n=10) and Standard Ranger (Group R, n=10). Fluids, which had been stored in the operating room over the previous 24 h, were delivered at 440 ml/h through preheated warming devices. Recording of Fluid temperature was performed at 2 points during 1 hour: the inlet point and the outlet point (76 cm from the warming device) of fluid warmers.

결과: The fluid temperature at inlet point (Tin) showed no significant differences among the groups. The fluid temperature at outlet point (Tout) was significantly highest in group M at all the time points, and the values in group T were not significantly higher than in group R except of values of several time pointes (P<0.05). The steady state values of “Tout” for three fluid warmers were approached 10 min after starting study, and then maintained the constant temperature until 60 min (35.95±0.39oC vs. 36.01±0.39oC, and 29.37±0.81oC vs. 29.16±0.84oC, 29.97± 0.55oC vs. 29.2±2.38oC, respectively in group M, T and R at 30 min and 60 min, P>0.05).

결론(증례 결론): The MAK heated fluid above 35oC, whereas ThermoSens� and Standard Ranger failed to achieve above 35oC with flows set at 440 ml/h.



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(영) The comparison of the effective dose of cisatracurium between the adult and the elderly

Jeong Ho Kim, Soo Il Lee*, Jong Hwan Lee, Seung Cheol Lee, Kyoung Sub Yoon

Department of Anesthesia and Pain Medicine, College of Medicine, Dong-A University

Background: There are few information about the differences of the effective dose (ED) of cisatracurium between the adult and the elderly. We determined the ED and the onset time of cisatracurium for Koreans adults aged 20 through 64 years and elderly aged ≥65 years.

Methods: We studied two hundred patients with ASA status I or II. Each patient was administered a dose randomly selected from 30, 40, 50, 60 or 70 μg/kg with block randomization. The adult group was allocated 100 patients with 20 patients each group and the elderly group was allocated 100 patients with 20 patients each group. For assessment of muscle relaxation, the magnitude of muscle relaxation (% control) was recorded using an acceleromyography. We recorded the 0.1 Hz single twitch responses of the adductor pollicis and the onset times to maximal blockade. The effect of cisatracurium on single twitch was calculated as% reduction. EDs were estimated by linear regression analysis using a probit model. Results were expressed as means±SD or as 95% confidence intervals. A P value of <0.05 was considered statistically significant.

Results: No significant differences were found in age, weight, height, or BMI within or between groups. The ED50 and ED95 of the adult group was 35.39 μg/kg (95% CI: 31.76-38.29) and 59.58 μg/kg (95% CI: 55.46-65.14). The ED50 and ED95 of the elderly group was 34.89 μg/kg (95% CI: 31.28-37.79) and 55.50 μg/kg (95% CI: 51.90-59.50). The onset time was 375.4±76.9 seconds in the adult group and 369.1±70.0 seconds in the elderly group.

Conclusions: The ED and the onset time were not significantly different between the adult and the elderly.

참고문헌1. Belmont MR, Lien CA, Quessy S, Abou-Donia MM, Abalos A,

Eppich L, et al. The clinical neuromuscular pharma cology of 51W89 in patients receiving nitrous oxide/opioid/barbiturate anesthesia. Anesthesiology 1995;82:1139-45.

2. Lepage JY, Malinovsky JM, Malinge M, Lechevalier T, Dupuch C, Cozian A, et al. Pharmacodynamic dose-response and safety study of cisatracurium (51W89) in adult surgical patients during N2O-O2-opioid anesthesia. Anesth Analg 1996;83:823-9.

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Benefits of deep neuromuscular block in laparoscopic colorectal resection surgery

김명화, 이기영, 유영철*

연세대학교 의과대학 마취통증의학과

연구배경(서론): Laparoscopic surgery can adversely affect the patients’ perioperative physiology and postoperative recovery. Deep muscle relaxation is known to improve the laparoscopic surgical condition. We aimed to compare the effect of between deep neuromuscular block (NMB) and moderate NMB in laparoscopic colorectal surgery.

대상 및 방법(증례): In this prospective double-blind trial, 72 patients undergoing laparoscopic colorectal resection were randomized to the deep or moderate NMB group. Rocuronium was continuously infused for moderate (1-2 TOF) or deep (1-2 PTC) NMB. The adjusted IAP during pneumoperitoneum was recorded at 5-min intervals, and perioperative hemodynamic parameters and postoperative outcomes were assessed.

결과: In the deep NMB group, the average adjusted IAP was lower than that of the moderate NMB group (9.3 vs. 12 mmHg, P<0.0001). Numeric rating scale pain scores at the post-anesthetic and postoperative period and incidence of postoperative shoulder tip pain were lower, while gas passing time and sips of water time were faster in the deep NMB group compared with the moderate NMB group.

결론(증례 결론): In laparoscopic colorectal surgery, deep muscle relaxation showed greater benefits than conventional moderate NMB.

참고문헌1. Martini CH, Boon M, Bevers RF, Aarts LP, Dahan A. Evaluation

of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth 2014;112:498-505.

2. Kopman AF, Naguib M. Laparoscopic surgery and muscle relaxants: is deep block helpful? Anesth Analg. 2015;120:51-8.

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소아에서 rocuronium의 작용발현 시간에 대한 thiopental sodium, ketamine, 그리고 propofol의 효과

심수빈1, 김혜지2, 정기태1, 김동준1, 김상훈1, 정종달1, 유병식1, 임경준1, 소금영1, 안태훈1*

조선대학교 의과대학·의학전문대학원 마취통증의학과1, 광주대중병원2

연구배경(서론): Rapid loss of consciousness and rapid onset of neuromuscular blocking agent is a necessary condition for the rapid sequence intubation. In this study, we compared the effects of thiopental sodium, ketamine, and propofol, which are frequently used for the induction of anesthesia in children, on rocuronium onset time.

대상 및 방법(증례): Patients were allocated into 3 groups according to drugs for the anesthetic induction (total n=89, Group T, thiopental sodium; Groups P, propofol; Group K, ketamine). After loss of consciousness, rocurunium 0.6 mg/kg was administered. Onset time and clinical duration of rocuronium were measured. Intubation conditions were measured by tracheal intubation scoring system. Hemodynamic changes were observed before induction until 5 min after endotracheal intubation.

결과: The onset time was significantly faster in group K (42.7 sec) than group T (61.7 sec) and group P (50.7 sec). There were no significant differences in clinical duration and intubation condition among the groups. Mean blood pressure and heart rate were higher in group K than other groups after intubation.

결론(증례 결론): It seems that ketamine can decrease the onset time of rocuronium than thiopental sodium or propofol.

참고문헌1. Muñoz HR, González AG, Dagnino JA, González JA, Pérez AE. The

effect of ephedrine on the onset time of rocuronium. Anesth Analg 1997;85:437-40.

2. Stoddart PA, Mather SJ. Onset of neuromuscular blockade and intubating conditions one minute after the administration of rocuro-nium in children. Paediatr Anaesth 1998;8:37-40.

Table 1. Onset Time, Clinical Duration, and Intubation Condition

Group T(n = 30)

Group P(n = 30)

Group K(n = 29)

Onset time (sec) 42.7±21.9 50.7±14.0 61.7±19.5*

Clinical duration (min) 30.8±8.8 30.5±7.7 32.3±7.4

ISS 8.9±0.6 8.8±0.5 8.8±0.4



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수술 종료 직전 발생한 하악골 재탈구로 인한 계획되지 않은 재수술

김성완, 유병훈*, 이상석, 김문철, 연준흠, 홍기혁

인제대학교 의과대학 상계백병원 마취통증의학과

연구배경(서론): 하악골 골절에 대한 후향적 연구에 따르면 하악 골절 정복 후 재수술률은 6.31%로 불유합, 부정유합, 부정교합이 가장 큰 원인이었다. 또한 하악골 골절은 비관혈적 정복에 비해 관혈적 정복에서 더 좋은 수술 결과를 제공한다는 연구가 있다.

대상 및 방법(증례): 58세 키 164 cm, 몸무게 63 kg의 과거력이 없는 남자 환자가 외상성 과두하골절로 비관혈적 정복술이 계획되었다. Propofol (120 mg IV)과 rocuronium (40 mg IV)을 이용해 마취를 유도하였다. Sevoflurane과 remifentanyl로 전신마취를 유지하였으며 수술 종료 30분 전 rocuronium (10 mg IV)이 주입되었다. 고무밴드를 이용한 상하악 고정술이 시행되었고 기관 발관 후 수술기법에 따른 구강을 통한 기도관리의 어려움이 예상되어 Sugammadex (200 mg IV)를 사용하여 길항을 하였다. 주입 3분 후 튜브 발관 전 급격한 환자의 움직임과 함께 고정된 고무밴드의 이탈이 확인되었다. 마취 종료후 회복실에서 시행한 엑스레이 검사상 수술 부위 재탈구가 확인되어 즉시 관혈적 정복술을 시행하였고 근이완을 위해 cisatracurium (15 mg)을 사용하였다. 재수술 후 근이완 역전은 pyridostigmine (10 mg IV)과 glycopyrolate (0.2 mg IV)가 사용되었다.

결론(증례 결론): Sugammadex의 사용으로 수술후 잔류 신경근차단제의 작용으로 인한 부적절 자발호흡 회복에 대한 위험은 감소되었다. 그러나 신속한 신경근차단의 역전으로 인해 나타나는 근력회복으로 인한 정복 수술 부위에서의 재골절 위험이 증가할 수 있음을 증례를 통해 확인하였고 향후 수술자의 Sugammadex에 대한 이해와 마취과 의사와 근이완 역전에 대한 긴밀한 협의가 필요로 함을 알 수 있다.

참고문헌1. Gutta R, Tracy K, Johnson C, James LE, Krishnan DG, Marciani RD.

J Oral Maxillofac Surg 2014;2:550-8. 2. Al-Moraissi EA, Ellis E 3rd. Surgical treatment of adult mandibular

condylar fractures provides better outcomes than closed treatment:

a systematic review and meta-analysis. J Oral Maxillofac Surg 2015;73:482-93.

141

Effect of presynaptic M1 M2 receptor modulation on TOF fade and EC95 of rocuronium in rat diaphragm

김용범1, 이상석2, 이경천1, 양홍석3*

가천대학교 의학전문대학원 마취통증의학과1, 인제대학교 의과대학 상계백병원 마취통증의학과2, 울산대학교 의과대학 서울아산병원 마취통증의학과3

연구배경(서론): Acetylcholine (Ach) release at the neuromuscular presynaptic side is modulated by presynaptic muscarinic and adenosine receptors. In low frequency stimulation (less than 5 Hz), M1 receptor augments the Ach release, but M2 receptor inhibits release of Ach when the stimulation is more than 50 Hz. The interaction of muscarinic M1, M2, and purinergic A1 A2A receptor changes the amount of Ach released at various stimulation frequency. We investigated whether pirenzepine, the M1 blocking angent and methoctramine, the M2 blocking agent, contributed to rocuronium-induced TOF fade and EC95 of rocuronium.

대상 및 방법(증례): Phrenic nerve-diaphragm preparations were obtained from adult Sprague-Dawley rats, 250-300 g in weight, and stabilized in 100 mL organ bath filled with Krebs solution, indirectly stimulated with Train-of-Four (TOF) stimulation with 30-second interval. After 15-minute stabilization period, 400 μg of the loading dose and 200 μg of the boost dose of rocuronium are serially added at the organ bath with 3-minute interval until more than 95% blockade of T1 response was obtained. For the experiment group, 1 μM of methoctramine (MET) or 10 nM of pirenzepine (PZP) was made at the organ bath and additional 15-minute reaction time was passed before the loading dose of rocuronium administration. EC95 of rocuronium and TOF ratio (TOFR) of each group was compared.

결과: Eight preparations were enrolled to each group, and total

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of 24 preparation were used for data collection in this study. Comparing with the control group, EC95 of rocuronium in PZP group was significantly lower than control group. Concentration-response curve of rocuronium on T1 depression in PZP group was shifted to left, and EC50 of rocuronium of control and PZP group were 35.1 μΜ and 29.5 μΜ, respectively. But in the MET point of view, there were no statistically significant differences

결론(증례 결론): EC95 and TOFR of rocuronium may modulated by pirenzepine. But blockade of M2 has no effect on the TOF fade and EC95 of rocuronium.

142

(영) Delirium in elderly patients undergoing hip fracture surgery in the sugammadex era

Yun Gu Lee, Chung-Sik Oh, Woon-Seok Kang, Ka Young Rhee, Nam-Sik Woo, Seong-Hyop Kim*

Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine

Background: Residual neuromuscular block (NMB) after emergence from general anesthesia has been an problem for association with pulmonary dysfunction and hypoxia and postoperative pulmonary dysfunction and hypoxia were known to have association with postoperative delirium. Sugammadex have benefit in aspect of early and complete reversal of NMB without cholinergic side effects and reducing frequency of postoperative pulmonary complications and hypoxia. This study evaluated the effect of sugammadex on postoperative delirium in elderly patients undergoing hip fracture surgery.

Methods: Medical records from 174 consecutive patients aged over 60 years undergoing hip fracture surgery with general anaesthesia using a neuromuscular blocking agent from 2012 to 2014 at a university hospital were retrospectively reviewed to compare perioperative incidence of postoperative delirium, pulmonary complications, intensive care unit (ICU) admission, and ICU and hospital stay duration and laboratory findings between patients treated with sugammadex (S group) and conventional cholinesterase inhibitors (C group).

Results: Incidence of postoperative delirium (overall, 35.1% [61/174]) was not significantly different between S and C groups (33.3% [26/78] vs. 36.5% [35/96], respectively, P=0.750), as was the case for postoperative pulmonary complications and laboratory findings; However, time until extubation (6±3 vs. 8±3 minutes in S and C groups, respectively, P<0.001) and postoperative hypoxia occurrence were significantly lower (P=0.010) in S group.

Demographic and clinical characteristics

S group (N=78)

C group (N=96)

P

Gender (M/F) 26/52 41/55 0.215

Age (year) 76±7 75±9 0.240

BMI (kg/m2) 22±4 23±3 0.738

Smoking Hx (pack year) 3±11 3±10 0.903

Underlying Disease

Hypertension 56 59 0.198

DM 24 24 0.495

Dyslipidemia 21 23 0.727

Angina pectoris 9 13 0.820

Current medications

Alpha blocker 0 2 0.502

ARB 23 26 0.738

ACEi 2 2 1.000

Beta blocker 15 13 0.407

CCB 30 30 0.340

Statin 12 23 0.186

LVEF (%) 67.5±9.9 69.0±6.3 0.334

PFT

FEV1 (L) 1.7±0.6 1.7±0.5 0.598

FVC (L) 2.3±0.9 2.5±0.8 0.166

FEF25-75% (L/s) 1.4±0.7 1.3±0.7 0.868

Operation 0.215

CR & IF 34 34

OR & IF 7 14

Bipolar 12 24

THR 25 24

Anaesthesia time (min) 178±46 186±74 0.401

Operation time (min) 126±48 122±68 0.648

pRBC transfusion (unit) 1.4±1.5 1.6±2.4 0.510

Postop bleeding (ml) 230±292 298±329 0.156

Time until extubation (min) 6±3 8±3 0.000

Postop VAS1 39±18 43±14 0.124

Postop VAS2 31±11 32±9 0.567

Data are expressed as numbers of patients or mean±standard deviation.Abbreviations: S group, sugammadex group; C group, con-ventional cholinesterase inhibitor group; M, male; F, female; DM, diabetes mellitus; CVA, cerebrovascular accident; ARB, angiotensin receptor blocker; ACEi, angiotensin converting enzyme inhibitor; CCB, calcium channel blocker; NTG, nitro-glycerin; LVEF, left ventricular ejection fraction before oper-ation; PFT, pulmonary function test before operation; FEV1, forced expiratory volume in 1 second; FVC, forced vital capa-city; FEF25-75%, Forced expiratory flow rate at 25-75%; Op, operation; CR & IF, closed reduction and internal fixation; bipolar, bipolar hemiarthroplasty; THR, total hip replacement; Anaesthesia time, time from arrival at operation room to discharge from operation room; Op time, time from skin incision to dressing; pRBC, packed red blood cell; Postoperative bleeding, postoperative bleeding up to postoperative 24 hours; postop VAS1, postoperative visual analogue scale at discharge from PACU; postop VAS2, postoperative visual analogue scale at postoperative day one.



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Conclusions: In elderly patients undergoing hip fracture surgery with general anaesthesia, sugammadex, relative to conventional cholinesterase inhibitors, did not reduce incidence of postoperative delirium and pulmonary complications despite reducing time until extubation and postoperative hypoxia.

143

VATS lobectomy를 시행 받은 폐암 환자에서 sugammadex가 수술 후 결과에 미치는 효과

조현철, 박상융, 이승철, 최소론*, 정찬종

동아대학교 의과대학 마취통증의학과

연구배경(서론): Lung surgery는 Video-assisted thracoscopic surgery의 사용으로 심혈관계 및 호흡기계 합병증의 발생이 감소하였음에도 불구하고, 여전히 그 빈도가 높게 나타난다. Sugammadex는 rocuronium이나 vecuronium에 직접 결합하여 깊은 수준의 근이완 상태로부터 잔여근 이완 없이 빠르고 안전하게 회복시킨다. 따라서 skeletal muscle의 기능을 빨리 회복시켜 스스로 심호흡을 가능하게 해 줌으로써 불완전한 회복으로 인한 합병증의 감소을 감소시킬 수 있을 것이다. 본 연구는 VATS lobectomy를 시행 받은 환자에서 sugammadex를 사용하였을 경우와 pyridostigmine을 사용한 경우를 비교하여 수술 후 결과에 미치는 영향을 알아보고자 하였다.

대상 및 방법(증례): IRB 승인 하에 2013년 1월 1일부터 2014년 11월 30일까지 ASA I-III에 속하고 VATS lobectomy를 시행 받은 20세 이상의 환자를 전수 조사하여 후향적으로 분석하였다. 1) 입원기록지, 간호기록지를 조사하여 환자의 나이, 성별, 신장, 체중 및 고혈압, 당뇨, 뇌혈관질환, 심혈관질환 등의 동반 질환, lobectomy 부위를 확인하였다. 2) 마취기록지 및 수술기록지를 통해 마취시간 및 수술시간, sugammadex 사용 여부, 술중 Atrial blood gas analysis (ABGA), 마취 종료 후 extubation 여부를 확인하였다. 3) 또한 경과기록지 및 퇴원요약지로 ICU 이송 후 재삽관 여부, ventilator 사용 일수, ICU 재원 일수, 수술 후 총 재원일

수, 흉관 삽입기간, 술후 ABGA 및 술 후 폐렴, 무기폐, 심방세동, 폐색전, 심혈관질환, 신부전, 뇌졸중 발생 등의 합병증 발생 등을 조사하였다.

결과: 수술 중 수술 범위가 확대된 경우 1명과 open으로 전환한 3명을 제외한 총 연구 대상자는 50명이었다. 근이완 역전제로 pyridostigmine을 사용한 군(P군)은 31명, sugammadex (S군)를 사용한 군은 19명이었다. 동반질환으로 당뇨를 가진 환자가 S군에서 유의하게 높게 나타났다. 수술 중 Hypoxia가 47-48% 발생하였으나, 두 군간의 유의한 차이는 보이지 않았다. 전체적으로 합병증은 S군에서 유의하게 감소하였으나, 구체적인 합병증 분류(수술 후 폐렴, 무기폐, 관상동맥 질환 발생 등)에서는 두 군간에 유의한 차이가 나타나지 않았다. 또한 Ventilation을 시행한 기간, ICU에 재원 기간은 차이가 나타나지 않았으나, 흉관 유지 기간과 수술 후 재원기간이 S군에서 유의하게 줄었음을 확인할 수 있었다.

결론(증례 결론): VATS lobectomy를 시행받은 환자에서 sugam-madex를 사용한 경우 수술 후 흉관 삽관 기간이 감소하고, 합병증과 재원일수가 감소하는 결과를 보여주었다.

참고문헌1. Amao R, Zornow MH, Cowan RM, Cheng DC, Morte JB, Allard MW.

Use of sugammadex in patients with a history of pulmonary disease. J Clin Anesth 2012;24:289-97.

2. Abrishami A, Ho J, Wong J, Yin L, Chung F. Sugammadex, a selective reversal medication for preventing postoperative resi-dual neuromuscular blockade. Cochrane Database Syst Rev 2009;4: CD007362.

144

Comparison of prognoses according to pain control methods after lung cancer surgery

류대균, 이은경, 김지애, 양미경, 안현주*


연구배경(서론): We searched whether thoracic epidural analgesia can reduce cancer recurrence and mortality compared to intravenous PCA and painbuster after open thoracotomy for lung cancer.

대상 및 방법(증례): All curative resections by open thoracotomy for primary lung cancer in a single tertiary care university hospital between the year of 2009 and 2013 were analyzed retrospectively. Each patient received thoracic epidural analgesia(TEA, n=619), intravenous PCA (PCA=581), or painbuster (PB, n=537). In-hospital morbidity/mortality, total mortality and cancer recurrence of 3-6 years follow-up were analyzed. Multiple logistic regression was used to adjust confounding factors.

결과: In-hospital mortality was higher in TEA group than PCA

Clinical events during perioperative periods.

S group (N=78)

C group (N=96)

P

Delayed extubation 4 5 1.000

Pulmonary complications 16 19 1.000

Hypoxia 18 41 0.010

Admission to ICU 16 15 0.431

ICU stay duration (days) 0.7±2.0 0.5±2.2 0.481

Hospital stay duration (days) 17 (14-20) 16 (14-21) 0.816

Data are expressed as numbers of patients or mean±standard deviation or median (interquartile range).Abbreviations: S group, sugammadex group; C group, conven-tional cholinesterase inhibitor group; Hypoxia, event of oxygen saturation <95% up to postoperative 24 hours; ICU, intensive care unit.

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and PB group (3.4%, 1.2% and 2.6% respectively P=0.045). Total mortality and cancer recurrence during 3-6 years follow-up were 24.9%, 20.1%, 14.3% (P=0.00) and 34.2%, 32.0%, 30.2% (P=0.138) respectively. In-hospital morbidity including lung complications was lower in PCA group than TEA and PB group (42.5%, 55.6% and 49.2% respectively).

결론(증례 결론): PCA was related to a less morbidity and TEA was related to a higher mortality during postoperative period. Painbuster was relevant to a lower long term mortality. Pain control methods did not influence cancer recurrence. Other variables related to long term mortality were age, sex, BMI, ASA, adjuvant treatment before surgery, duration of operation and transfusion. In-hospital mortality was related to transfusion and use of colloid solutions. Age, sex, duration of operation, transfusion and use of colloid solutions were risk factors of hospital morbidity.

참고문헌1. Cata JP, Gottumukkala V, Thakar D, Keerty D, Gebhardt R, Liu

DD. Effects of postoperative epidural analgesia on recurrence-free and overall survival in patients with nonsmall cell lung cancer. J Clin Anesth 2014;26:3-17.

2. Carli F, Kehlet H, Baldini G, Steel A, McRae K, Slinger P, et al. Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Reg Anesth Pain Med 2011;36:63-72.

145

The effect of iloprost on arterial oxygenation during one-lung ventilation

박찬오, 황원정, 전준표*

가톨릭대학교 의과대학·의학전문대학원 서울성모병원 마취통증의학과

연구배경(서론): During one-lung ventilation in patients undergoing thoracic surgery, the persistent flow in the non-ventilated lung increases intrapulmonary shunt and decreases systemic arterial oxygenation. This study was conducted to evaluate the effects of iloprost on arterial oxygenation during one-lung ventilation in the lateral decubitus position during thoracic surgery.

대상 및 방법(증례): 72 patients undergoing thoracoscopic lobectomy were randomly allocated to three groups: DW (distilled water), IL2.5 (iloprost 2.5mcg), and IL5 (iloprost 5mcg). Study drug was inhaled to ventilated lung for 5 minutes after one-lung ventilation in the lateral decubitus position. Hemodynamic variables, shunt fraction, and arterial oxygenation were obtained at these points: after induction of anesthesia with two-lung ventilation (TLV-i), before treatment with one-lung ventilation in lateral decubitus posisiton (OLV), 10, 20 and 30 min after treatment (OLV+T10, OLV+T20 and OLV+T30), and at the end of surgery with two-lung ventilation in the supine position (TLV-e).

결과: Hemodynamic variables were comparable between three groups. Shunt fraction was significantly lower in IL5 compared with that in DW and IL2.5 during one-lung ventilation. PaO2 was significantly higher in IL5 compared with that in DW and IL2.5 at 10 (198±78 vs. 146±68, 148±70 mmHg, P<0.05), 20 (215±92 vs. 154±70, 156±68 mmHg, P<0.05), and 30min (214±90 vs. 152±64, 154±70 mmHg, P<0.05) after treatment.

결론(증례 결론): Inhaled iloprost at 5 mcg improves arterial oxygenation during one-lung ventilation in the lateral decubitus position during thoracic surgery.

참고문헌1. Rocca GD, Passariello M, Coccia C, Costa MG, Di Marco P, Venuta F,

et al. Inhaled nitric oxide administration during one-lung ventilation in patients undergoing thoracic surgery. J Cardiothorac Vasc Anesth 2001;15:218-23.

2. Silva-Costa-Gomes T, Gallart L, Valles J, Trillo L, Minguella J, Puig MM. Low- vs high-dose almitrine combined with nitric oxide to prevent hypoxia during open-chest one-lung ventilation. Br J Anaesth 2005;95:410-6.

146

폐수술에서 마취통증의학과 의사의 역할 - intraoperative bronchoscopy의 역할과 필요성

이동규, 김희주*, 임상호, 강성욱

고려대학교 의과대학 구로병원 마취통증의학과

연구배경(서론): 최근 video-assisted thoracic surgery (VATs)의 발전으로 비교적 단순한 폐수술 뿐 아니라 pnuemonectomy까지도 VATs를 통한 수술이 이루어 지고 있다. VATs는 one-lung ventilation (OLV)을 시행하더라도 수술 시야가 협소하기 때문에 수술 중 정확한 해부학 구조를 파악하거나 의도하지 않은 손상을 평가하기 위하여 수술 중 bronchoscopy의 도움이 필요하다. 본 증례들에서는 VATs 중 마취과의사에 의한 bronchoscopy 시행으로 외과의의 수술적 판단과 시술에 결정적 역할을 하였던 증례를 보고하려 한다.

대상 및 방법(증례): Case 1. 82세 남자 환자로 rectal cancer 진단으



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로 추적관찰 중 폐의 좌하엽의 상절에 국한된 전이가 발견되어 rectal cancer와 함께 전이된 폐의 절제술을 동시에 시행하였다. 전신마취는 35 Fr Right sided double lumen tube (DLT)를 사용하여 OLV을 시행하였고, 수술 중 좌하엽의 상절의 정확한 경계를 확인하기 위하여 non-ventilated lung에 bronchoscopy (LF-GP, Olympus, Japan, diameter 4.1 mm)를 시행하였다. 좌하엽의 상절 기관지에 bronchoscope을 위치한 뒤 working channel을 통해 high flow의 100% O2를 insufflation하여 해당되는 부분만 inflation을 시킨 뒤 적절한 경계를 따라 surgical stapler로 resection을 시행하였고, 수술 중 시행된 냉동절편검사상 경계면에는 암세포가 발견되지 않았다. Case 2. 71세 남성 환자로 우하엽에 발견된 상피세포성 폐암 절제술을 시행하였다. 수술 전 검사에서 우하엽 기관지 내를 30%가량 막고 있는 기관지내 암종이 발견되었다. 전신 마취 하 35Fr left sided DLT를 사용하여 OLV을 시행하였으며, 마취 후 bronchoscopy로 기관지내 암종의 위치를 확인하였다. 수술 중 우하엽 기관지를 열어 놓은 상태에서 적절한 절제경계를 확보하기 위하여 stapling전에 bronchoscopy를 통하여 남은 기관지의 형태와 기관지내 암종의 완전절제 여부를 확인하였으며, 냉동절편검사에서도 경계부 암세포는 발견되지 않았다. Case 3. 64세 여자환자로 우하엽의 상피세포성 폐암 절제술을 시행하였다. 수술 중 예기지 못한 수술부위의 심각한 유착으로 식도손상이 의심되었다. 정확한 식도의 위치와 손상여부를 확인하기 위하여 bronchoscope을 조심스럽게 식도내 진입하여 moderate flow의 100% O2를 간헐적으로 insufflation하면서 식도내 손상 부위를 검사하였고, 다행히 손상부위는 없었다. 이후 수술을 용이하게 하기 위하여 bronchoscope의 빛을 사용하여 수술시야에서 식도의 위치를 수시로 확인하면서 박리를 시행하였고, 부가적인 손상 없이 수술을 마쳤다. Case 4. 45세 여자환자로 좌하엽에 발생한 소세포성 폐암 절제술이 계획되었다. 수술 중 좌하엽 기관지 분지 부분의 해부학적 구조가 이상함을 발견하여 좌하엽 기관지 절제 후 bronchoscopy를 시행하였다. Bronchoscopy상 lingular segment의 기관지가 심각하게 좁아지는 것을 확인하였으며, 합병증 방지를 위하여 lingular segmentectomy를 결정하여 동시에 시행하였다.

결론(증례 결론): 여러 복잡한 폐수술 중 시행할 수 있는 broncho-scopy는 수술 중 상황판단을 빠르고 정확하게 하는데 도움이 되어 적절한 수술이 가능하게 한다. 이와 같이 수술 중 bronchoscopy는 OLV과 함께 앙와위, 수술적 조작 등에 의하여 일반적인 해부학적 구조와 다른 모습을 종종 보이므로, 작은 bronchoscope을 능숙하게 다루면서 해부학적 구조를 잘 파악하고 있는 마취통증의학과 의사에 의하여 시행 되는 것이 적절하다.

참고문헌1. Okada M, Mimura T, Ikegaki J, Katoh H, Itoh H, Tsubota N. A

novel video-assisted anatomic segmentectomy technique: selective segmental inflation via bronchofiberoptic jet followed by cautery cutting. J Thorac Cardiovasc Surg 2007;133: 753-8.

2. Kamiyoshihara M, Kakegawa S, Ibe T, Takeyoshi I. Butterfly-needle video-assisted thoracoscopic segmentectomy: a retrospective review and technique in detail. Innovations (Phila) 2009;4:326-30.

147

Effect of different concentrations of iloprost on arterial oxygenation during one-lung ventilation

황원정, 주 진, 전준표*


연구배경(서론): In previous study, we showed that inhaled ilo-prost at 5 mcg improves arterial oxygenation during one-lung ventilation. This study was conducted to evaluate the effect of different concentrations of iloprost on arterial oxygenation during one-lung ventilation.

대상 및 방법(증례): 72 patients undergoing thoracoscopic lobectomy were randomly allocated to three groups: DW (distilled water), IL5 (iloprost 5 mcg), and IL10 (iloprost 10 mcg). Study drug was inhaled to ventilated lung for 5 minutes after one-lung ventilation in the lateral decubitus position. Hemodynamic variables, shunt fraction, and arterial oxygenation were obtained at these points: after induction of anesthesia with two-lung ventilation (TLV-i), before treatment with one-lung ventilation in lateral decubitus posisiton (OLV), 10, 20 and 30 min after treatment (OLV+T10, OLV+T20 and OLV+T30), and at the end of surgery with two-lung ventilation in the supine position (TLV-e).

결과: Hemodynamic variables were comparable between three groups. Shunt fraction in IL10 was sifinificantly lower than that in DW, but was comparable with that in IL5 (P<0.05) during one-lung ventilation. PaO2 in IL5 and IL10 were significantly higher that in DW, but those in two groups were comparable at 10 (146±68 vs. 198±78, 208±80 mmHg, P<0.05), 20 (154±70 vs. 210±92, 215±88 mmHg, P<0.05), and 30min (152±64 vs. 214±90, 223±88 mmHg, P<0.05) after treatment.

결론(증례 결론): Higher concentration of inhaled iloprost dose not provide better oxygenation than lower concentration of inhaed iloprost during one-lung ventilation.

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참고문헌1. Rocca GD, Passariello M, Coccia C, Costa MG, Di Marco P, Venuta F,

et al. Inhaled nitric oxide administration during one-lung ventilation in patients undergoing thoracic surgery. J Cardiothorac Vasc Anesth 2001;15:218-23.

2. Silva-Costa-Gomes T, Gallart L, Valles J, Trillo L, Minguella J, Puig MM. Low- vs high-dose almitrine combined with nitric oxide to prevent hypoxia during open-chest one-lung ventilation. Br J Anaesth 2005;95:410-6.

148

Effect of morphine on lung cancer cell proliperation

채현병, 안현주*, 김지연, 김진경


연구배경(서론): There are inconsistent reports on whether opioids promote or inhibit lung cancer growth. Here, we suggest opioid growth factor receptor (OGFR), a negative regulator of cell proliferation and a receptor of an endogenous opioid, [Met(5)]-enkephalin as a new binding site of morphine and morphine induced cancer suppression.

대상 및 방법(증례): The presence and distribution of OGFR in human lung cancer tissues and lung cancer cell lines were assessed with immunohistochemistry and real-time reverse transcription (RT)-PCR. Human lung cancer cell line, H1975 which expressed high OGFR was used for further analysis to examine the effect of morphine on cancer cell growth and OGFR.

결과: The OGFR was expressed in the lung cancer tissues and all the cancer cell lines tested. Adenocarcinoma showed higher OGFR expression than squamous cell carcinoma (RT PCR RQ value: 15.5±9.1 vs. 4.5±3.2, P<0.05). The OGFR expression showed an inverse correlation with cell proliferation (r=-0.92, P<0.01). Morphine treatment reduced H1975 cell proliferation by 23% (P=0.03). Cancer suppression by morphine disappeared when OGFR was knocked down. Confocal experiment showed morphine binds to the OGFR. Growth suppression by morphine occurred in the S phase in cell cycle.

결론(증례 결론): Lung cancer tissues and lung cancer cell lines express OGFR. Morphine interacts with the OGFR and may suppress lung cancer progression.

149

(영) The effects of heated carrier fluids in decreasing propofol injection pain

Ann Youn, Tzung-Min Hsu, Hee Suk Yoon*


Background: Propofol is a commonly used intravenous anesthetic drug because of its rapid onset and short duration. Its downfall, however, is that 60% of patients experience injection pain, severe enough that they may recall the induction of anesthesia as the most painful part of the perioperative period. Numerous reports on decreasing this injection pain have been reported. The most popular method evaluated through a quantitative systematic review reveals that pretreatment with 0.5 mg/kg lidocaine in combination with a tourniquet for venous occlusion prevented injection pain in 60% of patients. We hypothesized that warming the dorsal vein prepared for injection with intravenous carrier fluids heated to 40 degrees would enhance the effects of lidocaine pretreatment and decrease injection pain than in patients with intravenous carrier fluids of room temperature.

Methods: We established group C as control group who didn’t have any pretreatment. Before anesthetic induction, group R received 20 minutes of room temperature fluids while group H received heated fluids for 20 minutes. A tourniquet was applied proximal to the injection vein before lidocaine pretreatment in group T. At induction, 2ml of lidocaine 2% was administered prior to 25% of propofol 2 mg/kg, a dose known to induce injection pain without losing consciousness. After the initial administration of propofol, injection pain scores were recorded. Pain scores were recorded according to a verbal scale 0= none (negative response to questioning), 1=mild pain (pain reported in response to questioning only, without any behavioral signs), 2=moderate pain (pain reported in response to questioning and accompanied by a behavioral sign, or pain reported simultaneously with a behavioral sign, or pain reported simultaneously with a behavioral sign, but without questioning), 3=severe pain (strong vocal response or response accompanied by facial grimacing, arm withdrawal, or tears). After questioning, the remainder of propofol was administered for anesthetic induction, and rocuronium 0.6 mg/kg wad administered for neuromuscular blockade after loss of eyelash reflex. Anesthesia was maintained with 1%MAC desflurane and 0.5% oxygen. Remifentanil was continuously administered. Changes in vital signs including mean arterial pressure (MBP), heart rate (HR), and pulse oximeter were measured before administering the study fluid, after injection of propofol 2mg/kg, and 5 minutes after intubation.

Results: Heated carrier fluids were as effective as the combination with a tourniquet for venous occlusion with pretreatment with 0.5



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Conclusions: As much as the method utilizing either lidocaine pretreatment or lidocaine premixed with propofol using a tourniquet is effective for decreasing propofol injection pain, it is also considered laborious because it prolongs induction time. However, application of venous heat through warmed fluids is not, and because one single method is ineffective in reducing propofol injection pain, the anesthesiologist should combine several effective methods to increase patient satisfaction.

참고문헌1. Jalota L, Kalira V, George E, Shi YY, Hornuss C, Radke O, et al.

Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ 2011;342:d1110.

2. King SY, Davis FM, Wells JE, Murchison DJ, Pryor PJ. Lidocaine for the prevention of pain due to injection of propofol. Anesth Analg 1992;74:246-9.

150

(영) Effect of intravenous magnesium during endoscopic submucosal dissection for gastric neoplasm

Mingi Ban, Ji Eun Kim, Cheung Soo Shin, So Yeon Kim*

Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine

Background: Endoscopic submucosal dissection (ESD) has been revealed as an effective treatment of early gastric neoplasm and should be performed under sedation with adequate pain control. Magnesium sulfate has analgesic, sedative, and sympatholytic properties. This study examined the effects of intravenous magnesium 50 mg/kg administered before ESD for gastric neoplasm on analgesic and sedative consumptions during ESD and pain after ESD.

Methods: In this randomized, double-blind, and prospective study, patients undergoing ESD randomly received either intravenous magnesium sulfate 50 mg/kg (magnesium group, n=30) or the same volume of normal saline (control group, n=30) over 10 min before the start of sedation. Fentanyl consumption during ESD was the primary end point. Hemodynamics was recorded during the procedure, and abdominal pain was evaluated at 30 min, 6 h, and 24 h after ESD.

Results: During ESD, fentanyl consumption was 24% less in the magnesium group than in the control group (Table 1, p=0.002), although there was no significant difference in propofol consumption (p=0.317). In addition, magnesium attenuated the elevation of mean blood pressure at the time of epinephrine

submucosal injection (p=0.038) and 5 min after submucosal dissection (p=0.004). Less patients of the magnesium group compared to the control group requested for additional analgesics in the recovery room (14% vs. 38%, p=0.043), and the intensity of abdominal pain was lower at 30 min after ESD in the magnesium group (1 [0-5] vs. 3 [0-9], median [range]; p=0.034).

Conclusions: A single-dose intravenous administration of magnesium 50 mg/kg before sedation reduced analgesic requirements both during and after ESD for gastric neoplasm without adverse effects. In addition, magnesium contributed to stable hemodynamics throughout the procedure.

151

전정맥마취 시 remifentanil의 효과처 농도가 propofol의 요구량에 미치는 효과

송경철, 김 진, 한정욱, 양춘우, 김병건, 차영덕, 송장호*

인하대학교 의과대학·의학전문대학원 마취통증의학과

연구배경(서론): 전정맥마취 시 Propofol의 투여량이 증가하는 경우 심장 기능 억제로 활력징후의 불안정성과 마취 종료시 각성지연이 초래될 수 있다. Remifentanil의 병용 투여는 진통작용과 함께 심혈관계 안정성과 빠른 각성을 기대하게 한다. 그러나 Remifentanil은 전신혈관저항 감소에 의한 혈압 저하와 Propofol 투여량 감소에 따르는 마취심도 저하를 초래할 위험이 있다. 본 연구에서는 전정맥마취 중 Remifentanil의 효과처 농도 변화가 Propofol의 요구량, 활력징후, 각성 시간과 술 후 통증발생 등에 미치는 효과를 알아보고자 하였다.

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대상 및 방법(증례): 갑상선 절제술을 시행 받는 20-65세 환자 중 ASA I, II에 속하는 환자 48명이 연구에 참여하였다.목표조절주입장치를 이용하여 Propofol 5 mcg/ml과 Remifentanil 2 ng/ml로 연속정주하여 마취유도를 한 이후 Remifentanil의 효과처 농도를 R2 (2 ng/ml, 24명) 군과 R6 (6 ng/ml, 24명) 군으로 나누어 고정하고 Propofol 농도는 두 군 모두 2 mcg/ml로 시작하여 BIS 값 40-50을 목표로 하여 5분 간격으로 Propofol의 농도를 0.5 mcg/ml 간격으로 조절하였다. 피부절개 25분 후부터 5회의 Propofol 효과처 농도를 평균하여 Propofol의 효과처 농도로 간주하였다. 수술 종료와 동시에Propofol과 Remifentanil의 투여를 중단하였다. Propofol의 효과처 농도와 혈압, 심박수, Ephedrin과 Glycopyrrolate 투여횟수, 약물 투여 중단부터 지시에 반응하여 눈을 뜰 때까지 시간, 회복실에서의 통증점수와 진통제 투여 빈도를 측정하였다.

결과: 두 군에서 유지된 평균 BIS score는 R2군 45.0±3.8, R6군 45.5±3.9이었고, Propofol의 효과처 농도는 R2군이 3.0±0.6 mcg/ml, R6군이 2.4±0.7 mcg/ml로 R6군이 R2군과 비교하여 유의하게 낮았다. 약물의 주입을 중단 후 눈을 뜰 때까지 걸린 시간은 R2군이 11.2±4.3분, R6군이 11.1±3.6분으로 두 군간의 유의한 차이가 없었다. 혈압과 심박수는 R6군이 R2 군에 비하여 유의하게 낮았다. 마취 후 회복실에서의 통증점수와 진통제 투여빈도는 두 군 간에 차이가 없었다.

결론(증례 결론): 갑상선 절제술을 위한 전정정맥마취 시 Remi-fentanil의 효과처 농도 증가(6 ng/ml)는 일정한 BIS를 유지하기 위해 필요한 Propofol의 요구량을 감소시켜 주지만 혈압과 맥박수를 감소시키고 마취종료시 빠른 각성을 유도해 주지 못하였다.

152

마취 유도시 의식소실을 위한 propofol ED95에 remifentanil과 midazolam이 미치는 영향

최수민, 고재철, 윤완섭, 김소연, 한동우*

연세대학교 의과대학 마취통증의학과

연구배경(서론): Propofol은 과량 사용시 저혈압이나 서맥 등의 혈역학적 불안정을 초래할 수 있다. Propofol을 remifentanil 혹은 midazolam과 함께 사용하는 경우 부가 혹은 상승효과를 기대할 수 있으며 propofol의 마취 유도 용량을 줄일 수 있다. 하지만 이러한 약물들을 함께 사용하는 경우 환자 대부분의 의식을 소실 시킬 수 있는 propofol의 최소 용량에 대한 연구는 미미한 실정이다.

대상 및 방법(증례): 전신마취 하에 계획수술 예정인 20세에서 50세 사이의 여성 환자를 대상으로 하였다. 환자를 세 군으로 나누었고, 모든 환자에서 propofol 단회 정주로 마취 유도를 하였다. P군은 병용 약제 없이, PR군은 remifentanil (0.25 mcg/kg/min)을 5분간 지속 정주한 후, PMR군은 midazolam (0.03 mg/kg) 단회 정주와 remifentanil (0.25 mcg/kg/min)을 5분간 지속 정주한 후에 각각 propofol을 정주하였다. Propofol 정주 후 구두자극 및 눈썹반사에 대한 반응을 관찰하여 두 반응 모두가 소실된 경우를 ‘성

공’으로 간주하였고, 두 반응 중 하나라도 소실되지 않는 경우를 ‘실패’로 간주하였다. ‘실패’ 시에는 다음 대상자에게 propofol 0.25 mg/kg를 증량하였다. ‘성공’ 시에는 19분의 1의 확률로 propofol 0.25 mg/kg를 감량하였고, 19분의 18의 확률로 이전 용량을 그대로 사용하였다. 프로빗 분석을 통해 각 군의 propofol ED95를 구하고, 대응표본 및 동일표본 t-test를 이용하여 군간 평균동맥압 및 맥박수를 비교하였다.

결과: 각 군의 95% 환자에서 의식 소실이 발생하는 propofol의 정주 용량(ED95)은 P군에서 1.64 mg/kg, PR군에서 1.26 mg/kg, PMR군에서 0.99 mg/kg이었다. 모든 군에서 propofol을 투여 2분 후에 평균동맥압의 감소를 보였으나(p=0.038, 0.001, 0.019), 군간에 유의한 차이를 보이지는 않았다. PR군에서는 remifentanil 지속 정주 5분 후 맥박수의 유의한 상승을 보였으며(p=0.004), propofol 정주 후 맥박수는 유의하게 감소하였다(p=0.04).

결론(증례 결론): Propofol 단독 정주로 마취 유도를 하는 경우에 비해 remifentanil을 지속 정주한 경우 propofol 정주 용량을 23% 감소시킬 수 있었고, remifentanil 지속 정주와 midazolam을 전처치한 경우 propofol 정주 용량을 40% 감소시킬 수 있었으나, 군 간의 혈역학적인 차이는 없었다.

참고문헌1. Conway DH, Hasan SK, Simpson ME. Target-controlled propofol

requirements at induction of anaesthesia: effect of remifentanil and midazolam. Target-controlled propofol requirements at induction of anaesthesia: effect of remifentanil and midazolam. Eur J Anaesthesiol 2002;19:580-4.

2. Choi SH, Min KT, Lee JR, Choi KW, Han KH, Kim EH, et al. Determination of EC95 of remifentanil for smooth emergence from propofol anesthesia in patients undergoing transsphenoidal surgery. J Neurosurg Anesthesiol 2015;27:160-6.

153

척추마취 시 전투약으로 사용한 diazepam이 dexmedetomidine 정주에 미치는 효과

이용수, 강효석*, 이재우

을지대학교 의과대학 을지병원 마취통증의학과

연구배경(서론): Daizepam and dexmedetomidine are used to reduce anxiety of surgical patients under regional anesthesia. We tried to find out the effect of diazepam as premedication on intravenous dexmedetomidine in spinal anesthesia.

대상 및 방법(증례): 80 patients were randomized into 4 groups receiving 1.0 ug/kg dexmedetomidine loading and 0.5 ug/kg/hr maintainance with or without 7 mg oral diazepam (D-1, N-1), or 0.7 ug/kg dexmedetomidine loading and 0.4 ug/kg/hr maintainance with or without 7 mg oral diazepam (D-0.7, N-0.7) prior to spinal anesthesia. Time to reach BIS 90, 80, 70, 60, Ramsay sedation score, duration motor block, two



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dermatome pinprick sensory regression time and side effets of dexmedetomidine were assessed.

결과: D-1 group showed significantly shorter time to reach BIS 90 and 80 than other groups(p=0.033, p=0.037). There were no significant difference in time for regression of Ramsay sedation score, duration of the motor block, two dermatome sensory regression time and the incidence of side effects among the groups.

결론(증례 결론): Oral diazepam as premedication speeded up the effect of sedation in 1 ug/kg loading and 0.5 ug/kg/hr maintenance of dexmedetomidine without the prolongation of spinal block in spinal anesthesia.

154

The effects of target controlled infusion of propofol and remifentanil undergoing burn dressing

김희영, 이윤경, 곽인숙*

한림대학교 의과대학 마취통증의학과

연구배경(서론): The proper use of analgesia in burn dressing

minimizes its physical and psychological impact. Otherwise, patients can suffer from severe pain. We investigated patient’s satisfaction, change of HR, RR, SpO2, NIBP, Ramsay Sedation Scale(RSS), VAS undergoing burn dressing.

대상 및 방법(증례): Forty one patients aged 19-70 years undergoing burn dressing were enrolled. The patients with less than 10% total burn surface area were excluded. We monitored noninvasive blood pressure (NIBP), heart rate (HR), respiratory rate (RR), pulse oximetry (SpO2). Bispectral index (BIS), Visual analog scale (VAS) and RSS were recorded every 5 minutes. We administrated propofol and remifentanil by target controlled infusion (TCI, Orchestra Base Primea�, Fresenius Kabi, France). Initial concentration of propofol was Ce 2.0 μg/ml, remifentanil was Ce 2.5 ng/ml. If SpO2 was <95% or BIS <80, the concentration were decreased. If patients complained pain, the concentraion were incresed. The total amounts of propofol, remifentanil and duration of anesthesia were recorded. The satisfaction of patients was determined at recovery room.

결과: Patients (n=41) choose a rating scale of Very Good, Good, Fair, Poor, or Very Poor to rate their satisfaction. The ratings are converted to a score between 0 and 5 (Very Good=5, Good=4, Fair=3, Poor=2, and Very Poor=1). 13 male chose good, 10 male very good and 1 female chose fair, 7 female good, 10 female very good. The minimal value of BIS was 79.8±4.4 in male, 86.5±2.1 in female. The maximal value of BIS was 96.3±1.2 in male, 97.5±0.7 in female.

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결론(증례 결론): Burn dressing using propofol and remifentanil reduce patient’s pain and provide high satisfaction without signi-ficant changes of NIBP, HR, RR, SpO2. However, the concentration of propofol and remifentanil shows interpatient’s variability.

155

(영) Aneurysmal SAH is an independent Predictor of AKI in patients following aneurysm clipping surgery

Hye won Jeong, Hyung-Joo Chung, Seung-il Ha, Jun-Gol Song*, Joung-Uk Kim

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine

Background: Acute kidney injury (AKI) is one of the main causes of morbidity and mortality after major surgery. However, little is known about the incidence of AKI after aneurysm clipping surgery. The objective of this study was to assess the incidence of postoperative AKI following aneurysm clipping surgery.

Methods: Between January 2008 and December 2014, 2348 patients who underwent aneurysm clipping surgery were enrolled in our study. The influence of demographic, intraoperative, and postoperative data on the development of postoperative AKI and mortality were assessed by multivariable analyses. Survival analysis according to AKI was performed using the Kaplan─Meier method.

Results: Overall AKI incidence was 2.0% by KDIGO criteria. AKI incidence was higher in aneurysmal subarachnoid hemorrhage (aSAH) group (23 [6.4%] vs, 24 [1.2%], P<0.001) than non-aSAH group. Multivariate logistic regression results indicated that male (OR; 3.0, CI; 1.46-6.20), hemoglobin level (OR; 0.69, CI; 0.56-0.85), serum albumin level (OR; 0.47, CI; 0.23-0.97), mannitol (OR; 1.006, CI; 1.002-1.009), and aSAH (OR; 3.48, CI; 1.82-6.65) were associated with the development of postoperative AKI. Overall mortality was increased in AKI patients according to the Kaplan─Meier method (log─rank test, P<0.001).

Conclusions: Our data demonstrated that aSAH is associated with postoperative AKI, which is a predictor of overall mortality in patients with aneurysm clipping surgery.

156

Ischemic protective effect of hydromorphone in rat glial cells

김연화, 민두재*, 김재환, 이윤숙, 김영성

고려대학교 의과대학 안산병원 마취통증의학과

연구배경(서론): Ischemic insult during operation could cause ischemic-reperfusion injuries in brain and memory impairments. Total intravenous anesthesia (TIVA) is preferred in brain surgery to promote the use of Motor evoked potential (MEP) monitoring and the use of opioids is common in TIVA. However there were few studies about ischemic protective effect of opioids to glial cells

대상 및 방법(증례): We used primary rat mixed glial cell, which were harvested from brain of 1-day-old Rat. i) We divided groups by conditioning period; i) pre-culture, ii) post-culture, or iii) pre + post-culture. All groups were treated 100 nM hydromorphone. We measured reactive oxygen species (ROS) by flow cytometry with dichlorofluorescin diacetate (DCF-DA). Then ROS in glial cells which treated by opioid receptor antagonist were measured after treating 100 nM hydromorphone.

결과: ROS was reduced in hydromorphone treated group, as compared to the control group. There was no difference in pre-conditioned group and post-conditioned group. However, ROS was much more reduced in pre+post-conditioned group compared than pre-conditioned only or post-conditioned only group. Furthermore each selective delta, kappa, and mu OR antagonists partially negated the effect of hydromorphone.

결론(증례 결론): This study provides evidence that hydromorphone has both preconditioning and postconditioning effects on terbutylhydoxide (TBH)-induced oxidative stress. Furthermore we proved each μ, δ, κ opioid receptor relates to protective mechanism of hydromorphone to glial cells.



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157

Effect of dexmedetomidine on the postoperative cerebral hyperperfusion syndrome in moyamoya disease

서형석, 박희평*

서울대학교 의과대학 마취통증의학교실

연구배경(서론): Dexmedetomidine, a selective α2-agonist, can reduce cerebral blood flow and also exert neuroprotection against cerebral ischemia/reperfusion injury. We investigated the effect of dexmedetomidine on the incidence of cerebral hyperperfusion syndrome (CHS) after direct revascularization surgery in patients with moyamoya disease.

대상 및 방법(증례): Electric medical records of 117 patients, who underwent direct revascularization surgery, were reviewed retrospectively. Patients were divided into two groups based upon the use of intraoperative dexmedetomidine; 48 patients received dexmedetomidine loading and continuous administration from the completion of vascular anastomosis until the admission of intensive care unit (Group D). 69 patients received no intraoperative dexmedetomidine (Group ND). The incidence, onset time, and duration of postoperative cerebral hyperperfusion syndrome were noted.

결과: The incidence of cerebral hyperperfusion syndrome was 64.6% and 55.1% in group D and group ND, respectively (P=0.402). In subgroup patients with postoperartive cerebral hyperperfusion syndrome, patients in group D showed faster onset time (0 [0-1.5] vs 1 [0-3], P=0.023) and shorter duration (5 [3-7] vs. 7 [5-9], p=0.037) than those in group ND.

결론(증례 결론): Intraoperative dexmedetomidine administration did not reduce the incidence of postoperative CHS, although intraoperative dexmedetomidine administration reduced the dur-ation of CHS, in patients undergoing direct revascularization surgery for moyamoya disease.

참고문헌1. Hwang JW, Yang HM, Lee H, Lee HK, Jeon YT, Kim JE, et al.

Predictive factors of symptomatic cerebral hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis in adult patients with moyamoya disease. Br J Anaesth 2013;110:773-9.

2. Jeon YT, Hwang JW, Lim YJ, Park SK, Park HP. Postischemic sevoflurane offers no additional neuroprotective benefit to preischemic dexmedetomidine. J Neurosurg Anesthesiol 2013;25:184-90.

158

Optimal mannitol dose for intraoperative brain relaxation in supratentorial brain tumor removal

서형석, 김유진, 박희평*


연구배경(서론): Mannitol is used intraoperatively to induce brain relaxation in patients undergoing supratentorial brain tumor resection. We sought to determine the dose of mannitol that provide adequate brain relaxation with the fewest adverse effects.

대상 및 방법(증례): Patients (n=124) randomly received mannitol at 0.25 g/kg (group A), 0.5 g/kg (group B), 1.0 g/kg (group C), and 1.5 g/kg (group D). The degree of brain relaxation was classified as “bulging”, “firm”, “adequate”, or “perfectly relaxed” by neurosurgeons. “Adequate” or “perfectly relaxed” were considered to indicate satisfactory brain relaxation. The osmolality gap (OG) and serum electrolytes were measured before and after mannitol administration.

결과: The incidence of satisfactory brain relaxation was higher in group C and D than in group A (68% and 65% vs 32%, P<0.05). The incidence of abnormal OG was higher in group C and D than in group A (P<0.05). The incidence of moderate hyponatremia was significantly higher in group D than in other groups (P<0.05). Serum potassium levels were higher in group D than in group A at 30 and 60 min after mannitol administration (P<0.05).

결론(증례 결론): The incidence of satisfactory brain relaxation was higher after the administration of 1.0 g/kg and 1.5 g/kg than 0.25 g/kg dose of mannitol. However, the 1.0 g/kg dose had fewer adverse effects than the 1.5 g/kg dose, suggesting that 1.0 g/kg of mannitol provided satisfactory brain relaxation with the fewest complications in patients undergoing craniotomy for supratentorial brain tumor removal.

참고문헌1. Sorani MD, Morabito D, Rosenthal G, Giacomini KM, Manley GT.

Characterizing the dose-response relationship between mannitol and intracranial pressure in traumatic brain injury patients using a high-frequency physiological data collection system. J Neurotrauma 2008;25:291-8.

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두개성형술 환자에서 negative suction drainage로 유발된 pseudohypoxic brain swelling에 기인한 심정지

정진환, 김선주, 김수련, 이수경, 문현수*

한림대학교 의과대학 마취통증의학과

연구배경(서론): Extradural/subgaleal drainage with a vacuum device is often used in neurosurgery to prevent postoperative hematoma. Several cardiovascular complications including car-diac arrest have been reported to likely be associated with this procedure.

대상 및 방법(증례): We present a stuporous 22-year-old patient who underwent cranioplasty under general anesthesia. The preoperative brain CT showed a marked shrinkage of the left cerebral hemisphere and an increase in ventricular size (Fig. 1). The general anesthesia and operation progressed favorably. However, the time of scalp suture completion, sudden bradycardia and hypotension occurred, followed by cardiac arrest immediately after initiation of subgaleal and epidural suction drainage. Emergent brain CT revealed extensive diffuse brain swelling (Fig.2). Due to the fact that there were no specific causes of brain edema during the procedure, the negative vacuum suction drainage was presumed to be the main cause. The patient was diagnosed with pseudohypoxic brain swelling (PHBS).

결론(증례 결론): Anesthesiologists should consider potential perioperative circulatory collapses or clinical deteriorations related to PHBS following intracranial hypotension in uneventful brain surgery.

참고문헌1. Hernández-Palazón J, Tortosa JA, Sánchez-Bautista S, Martínez-

Lage JF, Pérez-Flores D. Cardiovascular disturbances caused by

extradural negative pressure drainage systems after intracranial surgery. Br J Anaesth 1998;80:599-601.

2. Van Roost D, Thees C, Brenke C, Oppel F, Winkler PA, Schramm J. Pseudohypoxic brain swelling: a newly defined complication after uneventful brain surgery, probably related to suction drainage. Neurosurgery 2003;53:1315-26.

160

Tongue bite injury after moter-evoked potential monitoring during spine surgery

조혜령, 김지연, 김준현, 최원주*

인제대학교 의과대학 일산백병원 마취통증의학과

연구배경(서론): Monitoring of motor-evoked potential (MEP) during spine surgery is considered a safe technique but potential hazards. Tongue bite injury is the most common complication during MEP monitoring. Previous case reports have reported bite injuries including minor tongue lacerations, broken teeth, and even bitten endotracheal tube.

대상 및 방법(증례): 53-year-old, 60kg, woman was underwent S2 spinal tumor removal and osteoplastic laminotomy. Surgery proceeded uneventfully with the periodic use of intraoperative high voltage motor evoked potentials (MEP) spinal cord monitoring. Postoperatively, the patient complained of dysarthria and tongue pain. We observed the ventral area half of the patient’s tongue was mucosal erosion and congested.

결론(증례 결론): In our case, the most likely mechanism is a combination of the prone position and electrical stimulation of the masseter and temporalis muscles leading to contraction. Whenever patients undergo spinal surgery with the use of intraoperative MEP monitoring, measures to prevent such injuries need to be considered.



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참고문헌1. Macdonald DB. Intraoperative motor evoked potential monitoring:

overview and update. J Clin Monit Comput 2006;20:347-77. 2. Tamkus A, Rice K. The incidence of bite injuries associated with

transcranial motor-evoked potential monitoring. Anesth Analg 2012;115:663-7.

161

Seizures induced by large amount of prophylactic antibiotics in neurosurgery

강효은, 지대림*

영남대학교 의학전문대학원·의과대학 마취통증의학과

연구배경(서론): Prophylactic antibiotics can be the causes of seizure during perioperative period especially when they excessively used. In this report, five neurosurgical patients injected large amount of prophylactic antibiotics had seizures during postoperative period.

대상 및 방법(증례): First patient was 45 years old, female. She was diagnosed with unruptured aneurysm on Lt. MCA bifurcation. Second patient was 60 years old, female. She was diagnosed with meningioma on anterior clinoid process. She was HCV carrier. Third patient was 49 years old, female and her chief complaint was Lt. facial spasm. Fourth patient was 66 years old, female. She was diagnosed with unruptured aneurysm on Lt. MCA bifurcation. Fifth patient was 72 years old, male and he was diagnosed with unruptured aneurysm on anterior communicating artery. He had been taking beta-blocker for hypertension. Five neurosurgical patients, no any other underlying disease except one who had well controlled hypertension, were injected large amount of prophylactic antibiotics. During surgery all patients had stable vital signs and laboratory findings were non-specific. On the day of surgery, all five patients had seizures several times and they were treated for that. After a few days, four patients were well recovered but one patient expired due to sepsis and dehydration acute renal failure.

결론(증례 결론): Neurosurgical patients who are going to receive general anesthesia are likely already have a number of factors for seizures, so it is difficult to find the real reason for seizure. Therefore anesthesiologists have to closely attend to the possibility of seizures induced by large amount of prophylactic antibiotics.

참고문헌1. Kitaguchi T, Ebi O. Postmarketing survey on the clinical use of

cefotiam. Jpn J Antibiot 1983;36:2029-52. 2. Tadokoro K, Niimi N, Ohtoshi T, Nakajima K, Takafuji S,Onodera

K, et al. Cefotiam-induced IgE-mediated occupational contact anaphylaxis of nurses. Clin Exp Allergy 1994;24:127-33.

162

(영) Evaluation of a new calibrated pulse contour method during living donor liver transplantation

Mi Hye Park, Hyeon Sook Jee, Mi Sook Gwak*, Gaab Soo Kim, Justin Sangwook Ko, Sangbin Han, Soo Joo Choi


Background: Reliable intensive hemodynamic monitoring is essential in patients undergoing liver transplantation, because extensive surgical procedures are complicated with the underlying cirrhotic circulatory alternation. Pulmonary artery catheter (PAC) has been used as clinical gold standard for assessing cardiac output (CO). However, its invasive nature and diagnostic limitations have made questions for using PAC in recipients without pulmonary hypertension. Recently, a new calibrated pulse wave analysis system (VolumeViewTM/EV1000TM; Edwards Lifesciences) has been developed to continuously monitor CO. The transpulmonary thermodilution (TPTD) method performed with this system requires a central venous cannula to inject cold saline, and femoral arterial cannula, and avoids the use of a PAC. The pulse contour analysis is calibrated through the TPTD and is a beat to beat real time ananlysis of the femoral arterial pressure curve. We evaluated whether the VolumeViewTM/EV1000TM is interchangeable with automatic thermodilution using PAC undergoing living donor liver transplantation (LDLT).

Methods: This was a prospective, singlecenter observational study performed in twenty-three recipients undergoing LDLT. The simultaneous CO measurement of PAC (PAC-CO) and VolumeViewTM/EV1000TM (EV-CO) were compared after calibration of VolumeViewTM/EV1000TM over a 10 minutes interval at three phase: dissection (T1-T5), anhepatic (T5-T10), and reperfusion (T11-T15). The statistical Bland-Altman method was used to evaluate the agreement and four-quadrant plot analysis was

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performed to compare the trending abilities.TM

Results: A total of 345 datasets were compared. The overall mean PAC-CO was 7.3±1.8 l/min (range, 3.8 to 13.7), which was slightly higher than the overall mean EV-CO, which was 6.7±1.8 l/min (range, 3.9 to 13.5) (p<0.00). With overall 345 datasets, the mean difference between the two techniques was 0.6 l/min and 95% limits of agreement were -1.3 and 2.4 l/min with a percentage error was 26.2%. The percentage errors in the dissection, anhepatic, and reperfusion phase were 26.7%, 25.6%, and 25.1%. The concordance rate of CO changes between the two techniques was 78.2%.

Conclusions: The calibrated femoral arterial pulse wave analysis method can be considered alternative method of the automatic thermodilution using PAC in patients without pulmonary hypertension undergoing LDLT.

참고문헌1. Rudnick MR, Marchi LD, Plotkin JS. Hemodynamic monitoring

during liver transplantation: A state of the art review. World J Hepatol 2015;7:1302-11.

2. Bendjelid K, Marx G, Kiefer N, Simon TP, Geisen M, Hoeft A, et al. Performance of a new pulse contour method for continuous cardiac output monitoring: validation in critically ill patients. Br J Anaesth 2013;111:573-9.

163

Relationship of intraoperative BNP with early allograft dysfunction in liver transplantation

채민석*, 조민지, 정현식, 박철수


연구배경(서론): Intraoperative BNP has not been studied in associated with posttransplant graft function, so we aimed to clarify its predictive role for early allograft dysfunction (EAD).

대상 및 방법(증례): Perioperative data of 104 LT patients from 2013 to 2015 were retrospectively studied. The relationship of intraop BNP with EAD was analyzed using multivariate logistic regression.

결과: The level of BNP greatly decreased from prehepatic (BNP 182.0±222.1 pg/mL) to anhepatic phase (BNP 122.2±150.6 pg/mL; BNP 121.8±173.2 pg/mL at neohepatic phase). Area under receiver operating characteristic curve (AUC) analysis showed that the mean BNP ≥100 pg/mL showed the highest predicting accuracy for EAD among known EAD predictors (Table 1). After multivariate analysis, the mean BNP ≥100 pg/mL increased the risk of EAD occurrence by approximately three times (OR 2.78;

P=0.045).

결론(증례 결론): Intraoperative mean BNP has a close relationship with EAD, so could be a useful prognostic indicator in LT.

참고문헌1. Arjamaa O. Physiology of natriuretic peptides: The volume overload

hypothesis revisited. World J Cardiol 2014;6:4-7. 2. Lock JF, Schwabauer E, Martus P, Videv N, Pratschke J, Malinowski

M, et al. Early diagnosis of primary nonfunction and indication for reoperation after liver transplantation. Liver Transpl 2010;16:172-80.

164

Bloodless living donor liver transplantation: risk factors, outcome, and diagnostic predictors

안지혜, 윤지욱*

부산대학교 의학전문대학원 마취통증의학과

연구배경(서론): Massive bleeding leading to requirement of blood transfusion is often considered unavoidable during liver transplantation. However, avoiding blood transfusions is desirable due to their well-known risks. This study was designed to compare preoperative clinical and laboratory factors and outcomes between a non-transfusion and a transfusion group of patients undergoing liver transplantation.

대상 및 방법(증례): We conducted a retrospective study among 87 patients who underwent living donor liver transplantation. The group of patients who did not require packed red blood cell transfusion were compared with those who required PRBC transfusion. We compared preoperative risk factors, intraoperative fluid management, and outcomes between the two groups and identified predictive variables for the need for PRBC transfusion.

결과: Compared with the PRBC group, the non-PRBC group had lower average MELD score, and PTT, but higher hemoglobin and hematocrit. The non-PRBC group were more likely to receive colloid, but had shorter ICU and hospital length of stay.



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결론(증례 결론): Patients who did not receive PRBC transfusion had good perioperative conditions. MELD score is a significant predictor of the requirement for PRBC transfusion.

참고문헌1. Cacciarelli TV, Keeffe EB, Moore DH, Burns W, Chuljian P, Busque S,

et al. Primary liver transplantation without transfusion of red blood cells. Surgery 1996;120:698-704.

2. Roullet S, Biais M, Millas E, Revel P, Quinart A, Sztark F. Risk factors for bleeding and transfusion during orthotopic liver transplantation. Ann Fr Anesth Reanim 2011;30:349-52.

Figure. Area under the curve using receiver operating characteristic curves to identify the discriminatory power between the two groups.

Table 1. Preoperative demographics and risk factors

Entire group(n=87)

Non-PRBC group(n=44)

PRBC group(n=43)

P value

Age (yr) 50.7±11.6 53.3±5.4 50.5±11.7 0.077

Gender (Male/Female, %)

66/21 (76/24) 37/7 (84/16) 29/14 (67/33) 0.070

MELD score 13.1±8.0 8.1±1.1* 18.2±8.8 <0.001

Previous abdominal surgery

21 (24) 9 (20) 12 (28) 0.574

Preoperative Hb 12.5±2.2 13.6±1.6* 11.5±2.2 <0.001

Hematocrit (%) 35.9±6.2 39.1±4.4* 32.6±6.0 <0.001

Platelet (×103/μL) 99.3±59.6 106.5±48.7 91.9±68.8 0.257

INR 1.47±0.7 1.16±0.1* 1.80±0.94 <0.001

PTT (sec) 45.5±19.4 37.1±6.3* 54.1±24.0 <0.001

Serum creatinine (mg/dL)

0.87±0.4 0.78±0.2 0.96±0.58 0.066

All measured values are presented as mean±standard deviation or numbers of patients (%).*P<0.05 compared with the PRBC group.Abbreviation: model for end-stage liver disease (MELD) score, hemoglobin (Hb), international normalized ratio of prothrombin time (INR) and partial thromboplastin time (PTT).

Table 2. Intraoperative transfusion of blood components and fluid management

Entire group(n=87)

Non-PRBC group

(n = 44)

PRBC group

(n = 43)P value

PRBC (units) 3.5±5.5 0* 7.1±6.0 <0.001

FFP (units) 3.1±4.7 0* 6.3±4.9 <0.001

Platelet (pheresis, units)

1.4±3.3 0* 2.7±4.2 <0.001

Colloid (mL) 195.4±298.8 272.7±331.6* 116.3±240 0.0138

Albumin (20%, mL) 327.8±224.2 234.1±155.4* 423.7±244 <0.001

All measured values are presented as mean±standard deviation. *P<0.05 compared with the PRBC group.Abbreviation: fresh frozen plasma (FFP).

Table 3. Postoperative outcomes

Entire group(n=87)

Non-PRBC group(n=44)

PRBC group(n=43)

P value

ICU Stay (days) 9.6±6.7 7.3±3.2* 12.0±8.4 <0.001

Hospital Stay (days) 31.6±21.6 27.5±14.7* 35.8±26.4 <0.001

Postoperative mortaility 4 (4.6) 0 (0) 4 (9.3) 0.1305

Postoperative surgical precedures

Re-procedure 6 (6.9) 1 (2.3) 5 (11.6) 0.2149

Bleeding control 9 (10.3) 4 (9.0) 5 (11.6) 1

All measured values are presented as mean±standard deviation. *P<0.05 compared with the PRBC group.

Table 4. Results of receiver operating characteristic curve to identify the discriminatory power between two groups

Cut off value Specificity Sensitivity

MELD score 10.5 100.0 76.7

Hb 11.5 93.2 58.1

Hct 36.6 77.3 74.4

INR 1.31 97.7 79.1

Table 5. Results of logistic regression analysis with forward selection to detect predictors

EstimateStandard

errorOdds ratio P value

MELD score 1.173 0.322 3.232 <<0.001

Platelet 0.014 0.008 1.014 0.072

Sex (Based on a men) -2.050 1.019 0.129 0.044

Creatinine 2.267 2.305 9.554 0.156

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165

Effect of reperfusion on NIRS-derived muscle and cerebral oxygenation during liver transplantation

문영진, 신원정, 전인구, 김욱종, 황규삼*


연구배경(서론): Near-infrared spectroscopy (NIRS) has been used to detect cerebral tissue oxygenation (ScO2) and autoregulation monitoring during liver transplantation (LT) non-invasively. Additionally, a number of studies have highlighted the potential of measuring peripheral muscle tissue oxygenation (SmO2) as a marker of peripheral circulation status. In the present study, we aimed to compare oxygenations of cerebral and muscle tissue simultaneously while acute hemodynamic derangement occurs during reperfusion period of LT.

대상 및 방법(증례): We performed an observational study in 33 liver cirrhosis patients undergoing LT surgery. Both SmO2 and ScO2 were monitored with INVOS 5100 at right flexor digitorum profundus and at the forehead. Serial changes (before, nadir, peak) and their percentage changes were observed during the graft reperfusion period.

결과: After graft reperfusion, severe hypotension suddenly developed (81.5±9.9 mmHg to 42.9±7.4 mmHg). During this period, both SmO2 and ScO2 showed typical pattern of initial nadir and following surge immediately after graft reperfusion. There was no significant difference between nadir values of SmO2 and ScO2. However, peak value of SmO2 and its percentage changes were significantly higher than those of ScO2 (75.2±14.8% vs 60.6±15.4% P<0.001; 37.6±29.4% vs 10.2±7.4%, P<0.001, respectively).

결론(증례 결론): Our results suggest that simultaneous monitoring of NIRS-derived cerebral and muscle tissue oxygen saturation during reperfusion period of LT can identify autoregulatory

potential of cerebral circulation compared to peripheral circulation.

참고문헌1. Jun IG, Shin WJ, Park YS, Song JG, Kim YK, Hwang GS. Factors

affecting intraoperative changes in regional cerebral oxygen saturation in patients undergoing liver transplantation. Transplant Proc 2013;45:245-50.

2. Murkin JM, Arango M. Near-infrared spectroscopy as an index of brain and tissue oxygenation. Br J Anaesth 2009;103(S):i3-13.

166

Use of terlipressin in patient with moderate aortic valve stenosis during liver transplantation

황민호, 임병건*, 원영주, 오혜란, 문숙희

고려대학교 의과대학 구로병원 마취통증의학과

연구배경(서론): Anesthesia for patients with moderate aortic stenosis accompanied by atrial fibrillation during high-risk surgery such as liver transplantation remains a challenge in maintaining control of heart rate and maintenance of cardiac output. The action of terlipressin on V1 receptors leads to splanchnic vasoconstriction and is the key mechanism responsible for increasing systemic vascular resistance and reducing heart rate.

Figure 1. Change of hemodynamic variables during the course of liver transplantation anesthesia and surgery, and the terlipressin infusion period. MAP; mean arterial pressure (mmHg), SVR; systemic vascular resistance (dynes.sec/cm-5), SVV; stroke volume variation (%), CO; cardiac output (L/min), Heart Rate (bpm). The upward arrow indicates the time of reperfusion.



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대상 및 방법(증례): A 79-year-old male patient was scheduled to undergo urgent deceased-donor liver transplantation for ESLD. Transthoracic echocardiography revealed degenerative aortic valve stenosis of moderate grade (aortic valve area by the continuity equation; 1.4 cm2, pressure gradient 41.9/21.8 mmHg) with preserved left ventricular ejection fraction (60-65%). Preoperatively blood pressure was maintained despite tachycardia of 120-160 beats per minute (bpm) suspected as episodic atrial fibrillation with rapid ventricular response. Terlipressin (Glypressin; Ferring, Berlin, Germany) was administered by continuous infusion at a rate of 1-4 μg/kg/h from induction of anesthesia to 30 minuites after reperfusion to maintain a mean arterial pressure >65 mmHg and HR <100 bpm. On the next day, the HR was elevated to 110-160 bpm. There has been no interval change except control of HR in echocardiography.

결론(증례 결론): In conclusion, low-dose intravenous infusion of terlipressin during liver transplantation can be considered in a patient who has AS combined with atrial fibrillation with rapid ventricular response. Such patients should be carefully managed and monitored to prevent adverse effects.

167

Apnea test in ECMO-dependent potential donor

지현숙, 김갑수*


연구배경(서론): 무호흡 검사는 뇌사판정에 필수적인 과정이지만 ECMO에 의존하는 잠재적 뇌사자에서 무호흡 검사에 대한 자료는 없다. 이에 저자들은 본 병원에서 ECMO에 의존하는 잠재적 뇌사자에서 시행한 무호흡 검사 증례를 보고하고자 한다.

대상 및 방법(증례): 54세 여자환자로 급성대동맥박리(Acute aortic dissection, Stanford type A) 진단받고 응급실에서 V-A ECMO (Venoarterial Extracorporeal Membrane Oxygenation) 삽입 후 상행대동맥치환술(Ascending aorta replacement)을 시행했다. ECMO 설정은 RPM 3870, FiO2 0.7 ml/min, O2 flow 4 L/min로 시작했으며, 수술 후 V-A ECMO 유지한 채로 중환자실로 입실했다. 수술 후 7일째 hypoxic brain damage로 뇌사소견 관찰되어 뇌사판정 검사를 시작했다.

결과: 뇌사판정 기준 중 무호흡검사(Apnea test, AT)는 자발호흡이 소실된 이후 자발호흡의 회복가능 여부를 판정하는 임상검사로 100% 산소 또는 95% 산소+ 5% 이산화탄소를 10분간 인공호흡기로 흡입시킨 후 인공호흡기를 제거하고 100% 산소를 기관내관을 통해 6 L/min으로 공급하면서 10분 이내에 관찰하고 동맥혈 이산화탄소 분압(PaCO2) 50 mmHg 이상으로 상승하게 됨을 확인하고, 잠재적 뇌사자의 자발호흡이 없음을 관찰하는 것이다.1) 일반적인 뇌사판정과는 달리, 이 증례는 인공호흡기 이외에 ECMO

또한 이산화탄소 수치에 영향을 줄 수 있기 때문에 인공호흡기를 제거하는 방법만으로는 무호흡 검사를 할 수 없었다. 이에 VA ECMO의 이산화탄소 제거에 영향을 주는 요소 중 하나가 fresh gas flow rate이기 때문에2) sweep gas flow를 처음에는 4.0 l/min으로 시작했다가 이후 3.5 l/min로 유지했고, 무호흡검사 시행 시 3.0 l/min 에서 2.0 l/min으로 감소시켜 검사를 시행했으며, 2번의 무호흡검사 동안 이산화탄소분압이 62.4mmHg, 55.4mmHg로 측정되었다.

결론(증례 결론): ECMO 흡기 가스 속도를 조절함으로써 ECMO에 의존하는 잠재적 뇌사자에서 무호흡 검사를 무사히 시행할 수 있었다.

참고문헌1. 보건복지부 생명윤리정책과. 장기등 이식에 관한 법률. 제 21조 3항. 2. Chung M, Shiloh AL, Carlese A. Monitoring of the adult patient on

venoarterial extracorporeal membrane oxygenation. Scientific World Journal 2014;2014:393258.

168

Effects of allopurinol and apocynin on renal ischemia reperfusion injury

최은경, 정 훈, 박찬윤, 임동건*

경북대학교 의과대학·의학전문대학원 마취통증의학과

연구배경(서론): Reactive oxygen species (ROS), which is a critical mediator of ischemia reperfusion (IR) injury, is generated by numerous sources, including xanthine oxidase (XO), NADPH oxidase (NOX), and the mitochondrial respiration chain. To ameliorate renal injury induced by IR, several therapeutic strategies to inhibit XO and/or NOX have been investigated experimentally. Allopurinol (ALP), a xanthine oxidase inhibitor, and Apocynin (APC), a NADPH oxidase inhibitor, inhibit ROS production via different mechanisms. Thus, combined administration of these inhibitors may be more effective than individual treatment. This study was designed to investigate the renoprotective effect of ALP and APC during renal IR injury individually and in combination.

대상 및 방법(증례): Male Sprague-Dawley rats (275-325 g) were used. Rats (n=30) were divided into: sham operation (Sham); renal IR injury only (Control: 30 min ischemia followed by 24 h reperfusion); ALP was administered 1h before the ischemia (ALP); APC was administered 1h before the ischemia (APC); ALP and APC were coadministered 1h before ischemia (ALP+APC). Blood (for Cr and BUN) and renal tissue (for MDA and SOD with spectrophotometer) were obtained for anlaysis at 24 h after reperfusion. Histopathological analysis using PAS staining was also done.

결과: Renal injury markers (serum Cr, BUN, histologic changes)

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demonstrated that pretreatment with ALP or APC alone, or together ameliorated renal IR injury (P<0.05). Decreased MDA and elevated SOD levels in the pretreatment with ALP or APC alone, or together group demonstrated that the amelioration of renal damage occurred through oxidative stress (P<0.05). However, there was no significant difference between treatment with a single drug and coadministration of ALP and APC.

결론(증례 결론): Administration of ALP and/or APC protects against renal dysfunction caused by IR. NOX and XO may act in series, rather than in parallel.

참고문헌1. Altintas R, Polat A, Vardi N, Oguz F, Beytur A, Sagir M, et al. The

protective effects of apocynin on kidney damage caused by renal ischemia/reperfusion. J Endourol 2013;27:617-24.

2. Liu PG, He SQ, Zhang YH, Wu J. Protective effects of apocynin and allopurinol on ischemia/reperfusion-induced liver injury in mice. World J Gastroenterol 2008;14:2832-7.

169

(영) The effects of etomidate and midazolam on the proliferation of adipose tissue-derived stem cells

Dong Chan Ko1, Ho Park2, Kyoung Ho Ryu1, Won Jun Choi1, Yun Hong Kim1*

Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine1, Department of Clinical Laboratory Science, Wonkwang Health Science University2

Background: Adipose tissue-derived mesenchymal stem cells (ADSC) have the capability of multipotent differentiation. Keeping the applied stem cells at an active proliferation state is an essential part to achieve a desired cell density for tissue regeneration. We investigated the effects of clinically available type-A γ-aminobutyric acid (GABA) receptor agonists on the proliferations of ADSC.

Methods: ADSC cultured in control or adipogenic differentiation medium for 15 days were simultaneously treated with etomidate or midazolam 1 and 50 μM. Cell counting kit 8 assay for the determination of cell viability was conducted in both medium groups at day 0, 3, 6, 9, 12 and 15 in culture.

Results: Under both medium, the overall pattern changes of proliferation activity over time were different between non-medication and medication groups. After day 9 under control medium and after day 6 under differentiation medium, cell proliferation in all the medication groups except etomidate 50 μM group under control medium began to decline significantly

compared to non-medication group. Especially, cell viability under the treatment with etomidate recovered to the level of non-medication group at day 12 of control medium and day 9 of differentiation medium. Moreover, etomidate 50 μM at day 9 under differentiation increased cell proliferation above the level of non-medication group. Then, all the medication groups showed the decline of cell proliferation activity than non-medication group.

Conclusions: Etomidate and midazolam had influences on proliferation of ADSC both under control and differentiation medium.

참고문헌1. Garcia PS, Kolesky SE, Jenkins A. General anesthetic actions on

GABA(A) receptors. Curr Neuropharmacol 2010;8:2-9. 2. Andäng M, Hjerling-Leffler J, Moliner A, Lundgren TK, Castelo-

Branco G, Nanou E, et al. Histone H2AX-dependent GABA(A) receptor regulation of stem cell proliferation. Nature 2008;451:460-4.



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170

EC50 of intravenous oxycodone to blunt hemodynamic responses to endotracheal intubation

정기태1,2, 김상훈1,2*, 소금영1,2, 김동우2

조선대학교 의과대학·의학전문대학원 마취통증의학과1, 조선대학교병원 마취통증의학과2

연구배경(서론): Hemodynamic changes induced by endotracheal intubation can be attenuated by pharmaceutical intervention such as opioid and non-opioid analgesics. We calculated the half maximal effective dose (ED50) of intravenous oxycodone to blunt the hemodynamic responses to laryngoscopy and endotracheal intubation.

대상 및 방법(증례): After institutional review board approval, thirty five male patients, aged between 20 and 65 years, were finally enrolled. First patients were slowly injected with intravenous oxycodone 0.1 mg/kg 20 minutes before anesthesia. The induction of anesthesia and neuromuscular block was started with propofol and rocuronium. And then, 2 minutes later, endotracheal intubation was performed. The dose of intravenous oxycodone for each subsequent patient was determined by the response of the previous patient by the Dixon’s up-and-down method (DUDM) with an interval of 0.01 mg/kg according to the degree of hemodynamics changes with 20% limitation after intubation.

결과: The ED50 of intravenous oxycodone was 0.074±0.008 mg/kg in male patients by DUDM. From probit regression model, the ED50 and ED95 of intravenous oxycodone were 0.069 [95% confidence interval (CI), 0.06-0.077] and 0.091 (CI, 0.077-0.129) mg/kg in male patients, respectively.

결론(증례 결론): The intravenous oxycodone showed the narrow preventive dosage for blunting hemodynamic response to laryngoscopy and endotracheal intubation, and the additional study will be needed to confirm the actual blunting effect of hemodynamic responses to laryngoscopy and endotracheal intubation using the ED50 and ED95 of intravenous oxycodone.

참고문헌1. Dixon WJ. Staircase bioassay: the up-and-down method. Neurosci

Biobehav Rev 1991;15:47-50. 2. Albertin A, Casati A, Deni F, Danelli G, Comotti L, Grifoni F, et al.

Clinical comparison of either small doses of fentanyl or remifentanil for blunting cardiovascular changes induced by tracheal intubation. Minerva Anestesiol 2000;66:691-6.

171

복강경담당절제술 받는 환자에서 성별에 따라 수술 후 통증에 미치는 덱사메타손 효능의 차이

함향도, 이 철*, 손 용, 정용관, 이주환, 김연동, 김지나

원광대학교 의과대학 마취통증의학과

연구배경(서론): Sex-related differences in pain perception and efficacy of pain medication have been increasingly studied. However sex-related differences in the efficacy of dexamethasone pretreatment on pain intensity and opioid consumption have not been demonstrated to date.

대상 및 방법(증례): 1. Three hundred ninety-two ASA 1-2 patients aged 18 to 45 years old were randomly allocated into one of two groups: control group, and dexamethasone group. 2. Each group consisted of 98 males and 98 females;They received intravenous normal saline (control group) or dexamethasone 0.1 mg/kg (dexamethasone group) 1 h before induction of general anesthesia. 3. The primary outcomes: Visual analog scale for pain after surgery, and cumulative PCA consumption containing morphine in females and males of each group. 4. The secondary outcomes : mean morphine consumption base on body weight, time to first analgesic administration, and any episode of PONV.

결과: 1.Visual analog scale for pain (1, 6, and 12 h), cumulative PCA consumption containing morphine, mean morphine consumption based on body weight and any episode of PONV for 24 h after surgery in the dexamethasone group were significantly reduced than the control group, and time of first analgesic administration in the dexamethasone group was significantly longer than the control group (P<0.05). 2. Females in both groups were significantly greater in pain VAS (1 and 6 h), mean morphine consumption and PONV for 24 h after surgery and had shorter times to first analgesic administration than males (P<0.05). 3. In the dexamethasone group, females appeared to be less changed in visual analog scale for pain (1 and 6 h), time to first analgesic administration, and cumulative PCA consumption and showed greater changed in PONV for 24 h after surgery than males (P<0.05).

결론(증례 결론): Females showed greater pain intensity and morphine consumption compared to males. Gonadal hormones may affect the effect of dexamethasone on pain intensity and morphine consumption.

참고문헌1. Bartley EJ, Fillingim RB. Sex differences in pain: a brief review of

clinical and experimental findings. Br J Anaesth 2013;111:52-8. 2. Bisgaard T, Klarskov B, Kehlet H, Rosenberg J. Preoperative

dexamethasone improves surgical outcome after laparoscopic cholecystectomy: a randomized double-blind placebo-controlled trial. Ann Surg 2003;238:651-60.

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172

Betahistine reduces postoperative nausea and vomiting after laparoscopic gynecological surgery

변정익, 조진선, 김은정, 이재훈, 김소연, 김정민, 구본녀*


연구배경(서론): Patients undergoing laparoscopic gynecological surgery are at high risk of postoperative nausea and vomiting (PONV). We compared the antiemetic efficacy of ondansetron plus betahistine with that of ondansetron alone in this patient population.

대상 및 방법(증례): In this randomized, double-blinded study, 168 patients were randomly allocated to receive placebo (O group) or betahistine 18 mg (OB group) orally 3 h before surgery and 24 h thereafter. In both groups, ondansetron 4 mg was administered at the end of surgery and 8 mg was added to an intravenous patient-controlled analgesia (IV-PCA) fentanyl solution. The primary outcome was complete response (no PONV and no rescue antiemetics) during the first 48 h after surgery. The severity of nausea, pain score, and adverse events were assessed.

결과: The incidence of complete response was significantly higher in OB group than in O group (69% vs. 46%, P=0.004). The severity of nausea was lower in OB group than in O group during 30 min to 6 h and 6 to 24 h after surgery (P=0.001 and <0.001). Pain score was similar between the groups. The incidence of dizziness was lower in OB group than in O group (13% vs. 40%, P<0.001). Six patients (7%) in OB group and 15 patients (18%) in O group

required early IV-PCA discontinuation, primarily because of PONV and/or dizziness (P=0.038).

결론(증례 결론): Compared to ondansetron alone, ondansetron plus betahistine was more effective to prevent PONV and dizziness in high-risk patients undergoing laparoscopic gynecological surgery.

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당뇨 쥐 모델에서 지질 유제가 백서의 심혈관계에 미치는 영향

박지영, 박경언, 옥성호, 손주태, 이헌근, 정영균, 신일우*

경상대학교 의학전문대학원 마취통증의학과

연구배경(서론): 지질 유제가 최근 국소마취제, 칼슘길항제 등 다양한 약제의 독성에 효과가 있는 것으로 보고되고 있다. 지질 유제의 이런 효과는 지질 함몰 이론, 심근수축력 증가, 혈관 내피 기능 변화 같은 가설들로 설명하고 있다[1]. 저자들은 지질 유제의 심근수축력 증가가 혈관내피의 기능과 관계가 있다고 보고하였다[2]. 2형 당뇨는 고혈당과 유리 지방산 증가로 인한 혈관 내피 기능부전으로 심혈관, 신장, 신경, 눈 등의 기능적 손상까지 일으키는 질병이다. 이에 본 저자들은 백서의 당뇨 모델에서는 지질 유제가 어떤 작용을 일으키는지 연구해 보았다.

대상 및 방법(증례): 250-300 g의 8주령 백서에서 당뇨군(n=7)은 streptozocin 80 mg/kg을 복강내로 주사하여 9주간 더 사육하여 당뇨 쥐 모델을 만들었다. 백서가 17주령이 되었을 때 모두 실험을 실시하였다(비당뇨군 n=7). 모든 군에서 Lipofundin� 20%를 3 ml/kg 일회 정주한 후 5분간 수축기 혈압, 이완기 혈압, 맥박수를 측정하고 심장 수축력 지표인 RPP도 계산하였다.

결과: 당뇨군에서는 모두 고혈당을 나타내었고 몸무게 또한 감소하여 당뇨 쥐 모델이 잘 만들어졌음을 확인하였다. 지질 유제 주입 후 당뇨군에서는 수축기 혈압이 평균 138%로 증가하였고 비 당뇨군에서는 평균 177%로 증가하여 비 당뇨군의 혈압이 더 크게 증가한 것을 볼 수 있었다(p<0.01). 이완기 혈압과 맥박수는 차이가 없었고 RPP 또한 당뇨군에서는 평균 123%, 비 당뇨군에서는 평균 160%로 비 당뇨군이 더 크게 증가하였다(p<0.01).

결론(증례 결론): 이 연구를 통해 본 저자들은 지질 유제가 당뇨 모델에서는 혈압 상승 효과가 제한된다는 것을 확인 할 수 있었다. 이것은 당뇨 모델 백서에서는 지질 유제가 유입 되기 전, 당뇨로 인해 이미 산화 질소(NO)가 감소 되어 있어 지질 유제의 혈관 수축 작용에 제한이 있었다고 생각해 볼 수 있을 것이다. 또한 당뇨 군에서 혈관내피뿐만 아니라 평활근 손상으로 인해 혈관 수축 제한, 혈압 상승 제한이 일어난 것도 고려해 볼 수 있을 것이다.

참고문헌1. Fettiplace MR, Weinberg G. Past, Present, and Future of Lipid Resus-

citation Therapy. JPEN J Parenter Enteral Nutr 2015;39:72S-83S. 2. Shin IW, Hah YS, Kim C, Park J, Shin H, Park KE, et al. Systemic

Figure. The occurrence of PONV, PONV combined with dizziness and dizziness during the first 48 h postoperatively. Betahistine reduces significantly the incidence of PONV combined with dizziness and dizziness. The numbers are percent of patients. A: Ondansetron group (total n=84), B: Ondansetron-betahistine group (total n=83). Left crescent (moderate gray) represents the presence of only PONV, the central area (dark gray) represents the presence of both PONV and dizziness, and the right crescent (light gray) represents the presence of only dizziness. *P<0.05 compared to Ondansetron group.



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blockage of nitric oxide synthase by L-NAME increases left ventricular systolic pressure, which is not augmented further by Intralipid�. Int J Biol Sci 2014;10:367-76.

174

Inhibitory effect of mepivacaine on the vasodilation induced by ATP-sensitive potassium channel

옥성호1, 백지석2, 손주태1*

경상대학교 의학전문대학원 마취통증의학과1, 부산대학교 의학전문대학원 마취통증의학과2

연구배경(서론): Mepivacaine is an aminoamide local anesthetic that causes vasoconstriction and decreased blood flow. Mepivacaine-induced vasoconstriction involves activation of protein kinase C (PKC), and various vasoconstrictors inhibit adenosine triphosphate (ATP)-sensitive potassium channel via PKC activation. The goal of this in vitro study was to investigate the effect of mepivacaine on the vasodilation induced by the ATP-sensitive potassium channel activator levcromakalim in isolated rat aorta.

대상 및 방법(증례): Endothelium-denuded rat aortas were sus-pended for isometric tension recording. Levcromakalim dose (10-8 to 10-5 M)-response curves were generated in the presence or absence of mepivacaine (3×10-5 and 10-4 M), the ATP-sensitive potassium channel inhibitor glibenclamide, and combined treat-ment with mepivacaine plus glibenclamide. Levcromakalim dose-response curves were also generated for aortas pretreated with the PKC inhibitor GF 109203X, mepivacaine, and GF 109203X plus mepivacaine. Levcromakalim dose-response curves were generated in aortas precontracted with phenylephrine or the PKC activator phorbol 12,13-dibutyrate (PDBu). Diltiazem dose-response curves were generated in the presence or absence of mepivacaine.

결과: Mepivacaine attenuated levcromakalim-induced vasodilation. Mepivacaine had no effect on levcromakalim-induced vasodilation in aortas pretreated with glibenclamide. Pretreatment with GF

109203X attenuated the observed mepivacaine-induced inhi-bition of levcromakalim-induced vasodilation. The magnitude of levcromakalim-induced vasodilation was lower in PDBu-induced precontracted aortas than in phenylephrine-induced precontracted aortas. Mepivacaine had no effect on diltiazem-induced vasodilation.

결론(증례 결론): Taken together, these results suggest that mepivacaine attenuates the vasodilation induced by the ATP-sensitive potassium channel activator levcromakalim through the activation of PKC in isolated rat aortas.

참고문헌1. Ok SH, Kwon SC, Yeol Han J, Yu J, Shin IW, Lee HK, et al.

Mepivacaine-induced contraction involves increased calcium sensitization mediated via Rho kinase and protein kinase C in endothelium-denuded rat aorta. Eur J Pharmacol 2014;723:185-93.

2. Ko EA, Han J, Jung ID, Park WS. Physiological roles of K+ channels in vascular smooth muscle cells. J Smooth Muscle Res 2008;44:65-81.

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Comparison of two needle technique during subclavian venous catheterization

김유진1, 김병건2, 임영진1, 전영태3, 황정원3, 김현창4, 최윤형1, 박희평1*

서울대학교 의과대학 마취통증의학교실1, 인하대학교 의과대학·의학전문대학원 마취통증의학과2, 서울대학교 의과대학 분당서울대학교병원 마취통증의학과3, 계명대학교 의과대학 마취통증의학과4

연구배경(서론): In clinical practice, both the thin-wall introducer needle (TWIN) technique and the catheter-over-needle (CON) technique can be used for central venous catheterization. We compared the incidence of catheterization-related complications and the success rate of catheterization between these two techniques in patients requiring central venous catheterization.

대상 및 방법(증례): 414 patients underwent infraclavicular subclavian venous catheterization using either the TWIN technique (Group T, n=208) or the CON technique (Group C, n=206).

결과: The catheterization-related complication rate was higher in Group C than in Group T (15.5% vs. 5.8%, P=0.001). The success rate of catheterization at the first attempt without any complication or technical disturbance was significantly lower in Group C than in Group T (35.4% vs. 62.0%, P<0.001). The overall success rate of catheterization was lower in Group C than in Group T (92.7% vs. 97.1%, P=0.046).

결론(증례 결론): For infraclavicular subclavian venous catheteriz-ation, the CON technique showed a higher catheterization-related

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Table 1. Catheterization-related complications between two catheterization techniques.

Overall (n=414) Landmark method (n=312)Ultrasound-guided method

(n=102)

Group C(n=206)

Group T(n=208)

P-valueGroup C(n=156)

Group T(n=156)

P-valueGroup C(n = 50)

Group T(n = 52)

P-value

Total complications* 32 (15.5%) 12 (5.8%) 0.001 27 (17.3%) 11 (7.1%) 0.009 5 (10.0%) 1 (1.9%) 0.109

Arterial puncture 6 (2.9 %) 2 (1.0 %) 0.174 6 (3.8%) 2 (1.3%) 0.283 0 (0.0%) 0 (0.0%) -

Pneumothorax 2 (1.0%) 0 (0.0%) 0.247 2 (1.3%) 0 (0.0%) 0.498 0 (0.0%) 0 (0.0%) -

Hemothorax 0 (0.0%) 0 (0.0%) - 0 (0.0%) 0 (0.0%) - 0 (0.0%) 0 (0.0%) -

Misplacement of the catheter tip 8 (3.9%) 4 (1.9%) 0.258 7 (4.5%) 4 (2.6%) 0.541 1 (2.0%) 0 (0.0%) 0.490

Contralateral subclavian vein 4 1 4 1 0 0

Ipsilateral internal jugular vein 4 3 3 3 1 0

Hematoma 21 (10.2%) 8 (3.8%) 0.012 16 (10.3%) 7 (4.5%) 0.081 5 (10.0%) 1 (1.9%) 0.109

Hematoma only 16 6 12 5 4 1

Hematoma+arterial puncture 2 2 2 2 0 0

Hematoma+Misplacement of the catheter tip

3 0 2 0 1 0

Data are presented as number of patients (%). *: patients with two complications are counted as one patient. The thin-wall introducer needle technique and the catheter-over-needle technique for subclavian venous catheterization are used in group T and group C respectively.

Table 2. Procedural characteristics of subclavian venous catheterization between two catheterization techniques.according to the equipment

Overall (n=414) Landmark method (n=312)Ultrasound-guided method

(n=102)

Group C(n=206)

Group T(n=208)


Group T(n=156)


Group T(n=52)

P-value

Success rate of catheterization

First attempt* 73 (35.4%) 129 (62.0%) <0.001 54 (34.6%) 96 (61.5%) <0.001 19 (38.0%) 33 (63.5%) 0.017

Overall 191 (92.7%) 202 (97.1%) 0.046 141 (90.4%) 150 (96.2%) 0.068 50 (100.0%) 52 (100.0%) -

Total insertion time, s 122.9±75.6 101.9±58.3 0.002 106.9±67.7 86.0±42.7 0.002 169.4±78.8 147.6±72.1 0.149

Successful venous puncture at the first needling attempt

146 (70.9%) 155 (74.5%) 0.405 111 (71.2%) 116 (74.4%) 0.611 34 (68.0%) 39(75.0%) 0.512

Number of needling attempts for venous puncture

1.5±1.0 1.4±1.0 0.649 1.5±1.0 1.5±1.1 0.914 1.4±0.6 1.3 ±0.6 0.250

Number of manipulation attempts for

Guiding sheath insertion 1.3±0.7 - - 1.4±0.8 - - 1.3±0.5 - -

Guidewire insertion 1.2±0.6 1.2±0.6 0.725 1.2±0.7 1.2±0.7 0.516 1.2±0.4 1.1±0.3 0.339

Dilator insertion 1.5±0.8 1.2±0.5 <0.001 1.5±0.9 1.2±0.5 <0.001 1.5±0.6 1.3±0.6 0.014

Catheter insertion 1.1±0.4 1.1±0.3 0.237 1.1±0.4 1.1±0.3 0.150 1.1 ±0.3 1.1±0.3 0.776

Venous puncture† 0.008 0.001 0.739

During the needle advancement

189 (95.0%) 178 (87.3%) 144 (96.6%) 130 (85.5%) 45 (90.0%) 48 (92.3%)

During the needle withdrawal

10 (5.0%) 26 (12.7%) 5 (3.4%) 22 (14.5%) 5 (10.0%) 4 (7.7%)

Incidence of rescue mechanical ventilation

25 (12.1%) 19 (9.1%) 0.343 11 (7.1%) 9 (5.8%) 0.818 14 (28.0%) 10 (19.2%) 0.354

Data are presented as mean±SD or number of patients (%). *: the success rate of catheterization at the first attempt without any complication or technical disturbance such as failed venous puncture and difficulties in insertion of the guidewire, dilator, or catheter, †: 11 cases (8: arterial puncture, 3: failed venous puncture even after 6 attempts) with failed venous puncture are not considered. The thin-wall introducer needle technique and the catheter-over-needle technique for subclavian venous catheterization are used in group T and group C respectively.



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complication rate, longer insertion time, and lower success rate of catheterization than the TWIN technique.

참고문헌1. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM.

Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331:1735-8.

2. Lee YH, Kim TK, Jung YS, Cho YJ, Yoon S, Seo JH, et al. Comparison of Needle Insertion and Guidewire Placement Techniques During Internal Jugular Vein Catheterization: The Thin-Wall Introducer Needle Technique Versus the Cannula-Over-Needle Technique. Crit Care Med. 2015; 43: 2112-6.

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The efficacy of aprepitant plus palonosetron vs aprepitant plus ramosetron for prevention of PONV

최은경, 전영훈*, 김시오, 박성식, 김동경


연구배경(서론): Postoperative nausea and vomiting (PONV) is a common and unpleasant postsurgical complication. Among diverse neurotransmitter related to PONV, neurokinin-1 (NK1) and 5-HT3 receptor is known to be involved. Aprepitant is a highly selective and potent NK1 receptor antagonist. The new 5-HT3-receptor antagonist palonosetron with a half-life around 40 hours and a 30 to 100 times higher receptor binding affinity has shown significant antiemetic activity. The purpose of this study was to compare the efficacy of PONV prevention with aprepitant plus palonosetron (group P) versus aprepitant plus ramosetron (group R) in high risk patients undergoing for laparoscopic cholecy-stectomy.

대상 및 방법(증례): Eighty eight patients were enrolled into one of two groups. All patients received aprepitant 80 mg P.O. at 2 h before surgery. The group P was given palonosetron 0.075 mg IV after induction of anesthesia and group R was given ramosetron 0.3 mg IV at the end of surgery. The incidence and severity of PONV and use of rescue drug were assessed at 2 and 24 h after surgery and were analysed for the time intervals 0-2 h, 2-24 h, and 0-24 h.

결과: The incidence of nausea is lower in the group P than in the group R at 2 h, and 24 h after surgery. But there was no significant difference in the incidence of vomiting between two groups. The nausea severity was significantly less in the group p than in the group R during 0-2 h and 2-24 h after surgery. In addition, use of rescue antiemetics was less in the group R than in the group P after surgery.

결론(증례 결론): Aprepitant plus palonosetron significantly reduce

the incidence and severity of PONV compared to aprepitant plus ramosetron in high risk patients undergoing for laparoscopic cholecystectomy.

참고문헌1. Rojas C, Raje M, Tsukamoto T, Slusher BS. Molecular mechanisms of

5-HT(3) and NK(1) receptor antagonists in prevention of emesis. Eur J Pharmacol 2014;722:26-37.

2. Stathis M, Pietra C, Rojas C, Slusher BS. Inhibition of substance P-mediated responses in NG108-15 cells by netupitant and palono-setron exhibit synergistic effects. Eur J Pharmacol 2014;698:25-30.

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전산소화의 산소 농도에 따른 하품(yawning)의 발생 빈도

김보영, 문은진, 이재우, 강종만*, 이봉재, 김동옥

경희대학교 의학전문대학원·의과대학 강동경희대학교병원 마취통증의학과

연구배경(서론): 하품(yawning)은 일상생활에서 흔히 발생하는 무의식적인 호흡운동이다. 하품이 발생하는 이유에 대해서는 정확히 알려진 바가 없지만 스트레스를 받을 때 인간의 뇌를 각성시키기 위한 수단이라는 것이 통설이다. 하품은 마취 유도시에도 흔히 관찰된다. 마취 유도는 의식을 소실하는 과정이므로 마취 유도시의 하품은 의식 소실에 대한 저항 즉 각성의 수단으로 발생한다고 추측해 볼 수 있다. 이와 반대로 우리가 잠자리에 들기 전 하품을 하는 것처럼 수면의 시작점 혹은 대뇌가 수면을 요구하는 신호로서 생각해 볼 수도 있다. 본 연구는 마취 유도시 발생하는 하품의 발생 조건으로서 산소 역할을 알아보고자 하였다. 전산소화 과정에서 산소의 농도를 다르게 하여 환자에게 투여한 후 하품 발생 여부를 관찰하였다.

대상 및 방법(증례): 본 연구는 정규수술로 의뢰된 ASA 1 및 2에 해당하는 20-65세 남녀 성인 환자 22명을 대상으로 하였다. 대상환자 중 뇌 질환, 허혈성 심질환, 임산부 및 수면무호흡증이 있거나 BMI 30 이상의 환자는 제외하였다. 모든 환자는 전투약을 하지 않은 상태로 수술실에 입실하였으며, 무작위로 100% 산소 6L (FiO2 1)를 투여하여 전산소화를 하는 군(n=11)과 100% 산소 2 L 와 Air 4 L (FiO2 0.473)를 투여하여 전산소화 하는 군(n=11)으로 나뉘었다. 전산소화는 마스크를 환자에게 밀착시켜 편안한 상태에서 3분간 숨쉬는 것으로 시행되었다. 마취 유도는 propofol (약 2 mg/kg)로 하였으며 normal saline으로 flush하여 즉시 투여되도록 하였다. Propofol 이외에 투여되는 약은 없었다. 환자의 활력징후는 면밀히 관찰되었으며 20% 이상의 변화를 보이는 경우 연구는 즉각 중단되며 적절한 치료가 시행될 예정이였으나 이에 해당하는 경우는 발생하지 않았다. 하품은 입을 벌리며 발생하는 깊은 흡기 후에 호기하는 것으로 정의되었다. Propofol이 투여 후 1분 30초동안 관찰하였으며 그 이전이라도 산소포화도가 95% 미만으로 떨어지거나 환자의 활력징후가 불안정하게 변화하면 연구는 즉시 중단될 예정이였으나 이에 해당하는 경우는 없었다. 양압환기는 실시되지 않았다.

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결과: 실험에 참여한 두 군간에 나이 및 남녀의 성비, 체중 및 투여된 propofol 의 양은 유의한 차이가 없었다. 하품은 FiO2 1 군과 FiO2 0.473 군에서 각각 8, 5명에서 나타났으며 발생률은 각각 72.7%, 45.5%이다. 두 군간 통계적으로 유의한 차이는 나타나지 않았다(P value=0.387). 두 군에서 하품을 한 경우 하품의 횟수가 다회 관찰되는 경우가 있었다. FiO2 1 군에서는 2회 하품을 한 경우가 2명, 3회 1명, 4회 1명 관찰되었다. FiO2 0.473 군에서는 2회 1명 3회 1명 관찰되었다. Propofol 투여 후 환자가 중얼거리는 모습이 관찰되는 경우가 1회 있었으며 이 경우 하품은 하지 않았다.

결론(증례 결론): 본 연구를 통해서 산소 농도에 따라 마취 유도시 발생하는 하품의 정도에는 차이가 없음을 알 수 있었다. 본 연구는 정확한 혈중 산소분율을 측정하지 못한 제한점을 가지고 있으나 산소 농도와 하품 발생의 상관관계에 대한 보다 정교한 연구 결과를 제시했다는 데 의미가 있다.

참고문헌1. Kim DW, Joo JD, Kil HY. Can Yawning be used as an indicator of

induction of anesthesia? Korean J Anesthesiol 2000;39:S1-6. 2. Provine RR, Tate BC, Geldmacher LL. Yawning: no effect of 3-5%

CO2, 100% O2, and exercise. Behav Neural Bio. 1987;48:382-93.

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2009년부터 2013년까지 국내 패혈증의 역학, 결과 그리고 의료자원 소비

정혜선1, 류호걸1*, 오승영2, 이한나1, 조송희4, 장은진3

서울대학교 의과대학 마취통증의학교실1, 외과학교실2, 안동국립대학교 정보통계학교실3, 한국 보건의료원구원4

연구배경(서론): The aim of this study is to estimate the incidence, clinical outcomes, and healthcare costs of sepsis in Korea.

대상 및 방법(증례): Using data from the Health Insurance Review & Assessment Service, patients who were admitted to the hospital with the diagnosis of sepsis from 2009 to 2013 were analyzed. Patients who claimed as ICD-10 codes for sepsis were stratified by their age and sex. To define the incidence, mid-year population census was used as denominators. The incidence and in-hospital mortality of sepsis were analyzed according to diagnosed year, age, and sex in order to evaluate trends over 5 years. We compared differences in patient demographics, comorbidities, and

requirement of ICU care.

결과: Incidence of sepsis decreased from 97/100,000 population in 2009 to 82/100,000 population in 2013 and in-hospital mortality decreased from 39.0% in 2009 to 37.8% in 2013 (P<0.001). Mean hospital cost for each case was 7,887 USD and national hospital cost for sepsis was 26 million USD which accounted for 0.26% of the Korean total medical expenditure in 2013. Length of stay decreased from 25.3 days to 21.1 days (P<0.001) and ICU admission rate decreased from 29.7% to 27.5% (P<0.001) between 2009 and 2013.

결론(증례 결론): In Korea, the incidence and in-hospital mortality of sepsis decreased with increasing trend with age and male sex between 2009 and 2013. The proportion of national hospital cost for sepsis accounted for 0.26% of the Korean total medical expenditure in 2013.

참고문헌1. Castellanos-Ortega A, Suberviola B, García-Astudillo LA, Holanda

MS, Ortiz F, Llorca J, et al. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three-year follow-up quasi-experimental study. Crit Care Med 2010;38:1036-43.

2. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013;39:165-228.

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The use of esophageal stethoscope in a difficult levin tube insertion during general anesthesia

신준익, 정대희, 최정현*, 박성욱, 강화자

경희대학교 의학전문대학원·의과대학 마취통증의학과

연구배경(서론): Nasogastric tube (NGT) insertion using video laryngoscope in anesthetized and intubated patients has been shown to facilitate NGT insertion and reduce the duration of the procedure. We attempted this method after failing NGT insertion with the conventional method; however, this second attempt also failed. We finally inserted the NGT while introducing an esophageal stethoscope (ESS) in addition to a McGrath MAC video laryngoscope.

대상 및 방법(증례): A 68-year-old male was admitted to the operating room for laparoscopic exploration for large bowel perforation. Routine monitors were used, and anesthesia was induced with propofol (1.5 mg/kg) and remifentanil (1 μg/kg). After injection of rocuronium (0.8 mg/kg), the patient was intubated with a 7.5-mm endotracheal tube under McGrath MAC



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video laryngoscope because of an expected difficult airway due to previous cervical spine surgery and restricted neck motion. To decompress gastric air and contents, blind NGT insertion was attempted but failed several times. We attempted McGrath MAC-assisted insertion shortly afterward, but it also failed due to kinking of the NGT in the hypopharynx. Magill forceps and a smaller-diameter NGT were also unhelpful. Due to these failed attempts, we decided to use an ESS to guide the NGT through the oral cavity. While the NGT was inserted with Magill forceps assisted by a McGrath MAC, another practitioner inserted the ESS. This technique allowed successful insertion of the NGT.

결론(증례 결론): In cases of difficult insertion of NGT during general anesthesia in spite of using a video laryngoscope, simultaneous ESS can be used.

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Hypoalbuminemia on POD 2 is an independent risk factor of pleural effusion after donor hepatectomy

김정원, 신원정, 문영진, 송준걸*, 황규삼


연구배경(서론): It has been shown that pleural effusion is one of the most complication after hepatectomy. Hypoalbuminemia has been known as a risk factor of pleural effusion after heptectomy for primary liver cancer. However, there is limited information about the relationship between postoperative serum albumin level and pleural effusion incidence in living donor liver transplantation. The aim of our study was to evaluate the relationship between serum albumin level and pleural effusion after donor hepatectomy in living donor liver transplantation.

대상 및 방법(증례): Between January 2004 and January 2014, 2294 consecutive donors (mean age, 28.9±8.4, male 68.6%) underwent donor hepatectomy were evaluated retrospectively to identify factors related to postoperative pleural effusion. Multivariate logistic regression analyses were performed to determine whether the postoperative day (POD) 2 serum albumin level was an independent risk factor. Additionally, propensity score (PS) analysis was performed to reduce the influence of possible confounding variables.

결과: Among the 2294 donors, the overall rate of pleural effusion was 45.6% (n=1046). Fifty-five percent (n=1259) of the donors had an albumin level lower than 3.0 g/dL on POD 2. Multivariate analysis revealed that body mass index (p=0.018), right hepatectomy (p=0.016), administration of intraoperative ephedrine (p=0.040), and low albumin (<3.0 g/dL) on POD 2 (p<0.001) were independent risk factors for postoperative pleural

effusion. In addition, both IPTW and PS matching results showed that POD 2 serum albumin level <3.0 g/dL was associated with the development of postoperative pleural effusion (Odds ratio 1.8 and 2.1; 95% CI, 1.54-2.17 and 1.66-2.63; p<0.001 and p<0.001, respectively).

결론(증례 결론): Our results suggested that POD2 serum albumin level <3.0 g/dL can predict postoperative pleural effusion in donor hepatectmy for living liver transplantation.

181

Ventriculo-arterial coupling in cirrhotic patients undergoing liver transplantation

김정원, 신원정, 문영진, 장동민, 정성문, 황규삼*


연구배경(서론): Ventriculo-arterial coupling (VAC) has been believed to assess the interaction between ventricular performance and effective arterial load. However, the VAC of cirrhotic cardiomyopathy characterized by low-resistance hyperdynamic circulation is unknown. The aims of our study are to investigate the alteration in VAC in cirrhotic patients compared with healthy controls, and ability of the VAC to predict mortality after liver transplantation.

대상 및 방법(증례): In this retrospective study, we analyzed prospectively collected data of 914 consecutive liver transplant recipients without overt cardiovascular disease. Using systolic blood pressure and preoperative echocardiographic measurements, we calculated parameters of pressure-volume relationship, including end-systolic and end-diastolic left ventricular elastance (Ees and Eed), arterial elastance (Ea), and VAC (Ea/Ees).

결과: Compared to matched healthy controls, patients had significantly lower Ees, Ea and VAC. Disease severity based on Model for End-stage Liver Disease (MELD) was reversely related with the VAC (P=0.006). During a mean follow-up time of 30 months, there were 96 deaths (10.5%). After adjustment for clinical factors including age, serum creatinine, and MELD, the VAC remained as an independent predictor of mortality (hazard ratio, 4.06; 95% confidence interval, 1.49-11.04; P=0.005). The Kaplan-Meier curves stratified by MELD score >25 showed that patients with VAC >0.63 had a significantly worse survival rate than those with VAC ≤0.63 (adjusted log-rank P=0.005).

결론(증례 결론): In cirrhotic patients, VAC is lower than healthy controls, and tends to decrease as liver cirrhosis and hyperdynamic circulation progress. However, our results suggest that in patients with high MELD score, decoupling of ventriculo-arterial relationship is associated with mortality after liver transplantation.

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생체 공여 간이식 수혜 환자에서 혈 중 싸이토카인과 수술 인자와의 연관성

이창희, 채민석, 박철수, 이재민, 최종호, 정현식*


연구배경(서론): 간이식 수술은 수술 중 혈동학적 불안정 및 면역학적으로 큰 변화를 동반하는 수술이다. 현재까지 간이식 마취는 혈동학적 안정성을 유지하는 데 촛점을 두었다. 수술 중 혈동학적 안전성을 유지하는 것도 중요하지만 그에 못지 않게 면역학적으로도 안정화를 유도한다면 술 후 예후에도 긍정적인 영향을 미칠 것은 당연하다. 이에 간이식을 수혜 받는 환자에서 면역학적 상태를 반영하는 혈 중 싸이토카인 수치와 수술과 연관된 인자와의 관련성을 알아보고자 한다.

대상 및 방법(증례): 성인 생체 공여 간이식을 받는 166명을 대상으로 하였다. 술 전 인자로써 MELD 점수를 계산하였고, 수술 전 염증 정도를 반영하는 C-reactive protein을 측정하였다. 수술 중 혈동학적으로 가장 불안정한 시기인 신간의 재관류 시기에 재관류 증후군의 지속시간과 그 당시의 혈동학적 안정성을 유지하기 위해 투여된 약물을 기록하였다. 술 후 인자로써 환자의 술 후 감염력과 중환자실 재원 기간 및 총 재원 일 수를 기록하였다. 혈 중 싸이토카인은 IFN γ, IL 10, IL 2, IL 6, TNF α에 대해 수술 직 전 및 후 각각 측정하였다.

결과: 술 전 인자로써 MELD 점수 및 CRP는 술 전 IL 6, 10과 연관성이 있었으며 술 후 까지 유지되었다. 술 중 인자로써는 재관류 증후군의 지속시간과 술 후 IL 6와는 역의 상관관계가 있었으며, 술 전 IL 6, 10이 높은 환자에서 재관류 증후군을 극복하기 위해 투여된 약물 농도가 더 높은 것으로 나타났다. 술 후 IL 6가 높으

면 술 후 인자들이 나쁜 것으로 나타났으며, 간 공여자 인자와는 IL 2와의 연관성이 높았다.

결론(증례 결론): 본 연구의 결과를 임상 분야에 적용하는 것에는 아직은 주의를 기우려야 한다. 하지만, 이러한 면역학 연구를 바탕으로 수술 전 후 싸이토카인 수치로 술 후 합병증을 예측할 수 있는 자료로써 활용이 가능하며, 향 후 심화 연구를 통해서 수술 전 및 중 면역학적 조절을 함으로써 술 후 예후에 긍정적인 영향을 줄 수 있는 방법을 모색할 수 있으리라 사료된다.

참고문헌1. Tsai YF, Liu FC, Sung WC, Lin CC, Chung PC, Lee WC, et al. Ischemic

reperfusion injury-induced oxidative stress and pro-inflammatory mediators in liver transplantation recipients. Transplant Proc 2014; 46:1082-6.

2. Platz KP, Mueller AR, Rossaint R, Steinmüller T, Lemmens HP, Lobeck H, et al. Cytokine pattern during rejection and infection after liver transplantation--improvements in postoperative monitoring? Transplantation 1996;62:1441-50.

183

Photoplethysmographic amplitude to pulse pressure ratio during liver graft reperfusion

이주현, 문영진, 신원정, 황규삼*


연구배경(서론): Photoplethysmographic (PPG) waveforms provid-ed by pulse oximetry can offer beat-to-beat changes in intravascular blood volume, it has been suggested that the ratio of

Pre-Operative Post-Operative

IFN γ IL 10 IL 2 IL 6 TNF α IFN γ IL 10 IL 2 IL 6 TNF α

Pre-Operative

MELD Coefficient 0.026 0.245* 0.032 0.291* 0.163* 0.043 0.100* -0.017 0.141* 0.190*

CRP Coefficient -0.017 0.262* 0.022 0.352* 0.152* -0.041 0.114* -0.046 0.113* 0.136*

Intra-Operative

RPS(s) Coefficient 0.072 -0.023 -0.027 -0.062 -0.035 0.009 0.051 -0.023 -0.118* -0.034

Inotropics (mcg) Coefficient -0.012 0.110* -0.039 0.148* 0.064 0.050 0.038 -0.082 0.011 0.058

Post-Operative

Hospital stay (d) Coefficient 0.037 0.074 0.040 0.083 0.088 0.240* 0.194* 0.102 0.261* 0.183

ICU stay (h) Coefficient -0.110 -0.010 0.076 -0.047 0.074 -0.012 0.105 -0.008 0.133* 0.135

Infection Coefficient 0.114 0.204 0.038 0.173* 0.087 0.240* 0.113 0.166* 0.226* 0.058

Donor

GRWR Coefficient 0.144 0.015 0.145* 0.027 -0.054 0.127 -0.047 0.155* 0.051 -0.142*

Fatty Change (%) Coefficient 0.007 -0.060 0.132 -0.029 -0.108 0.101 -0.054 0.160* 0.097 -0.048

Cold IT (m) Coefficient 0.100 0.020 0.016 0.276 0.048 -0.124 0.027 -0.003 0.024 0.017

Warm IT Coefficient 0.326 0.114 0.129 0.097 -0.073 0.252* 0.070 0.282* -0.166 -0.186



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volume change to arterial pressure change may reflect response of vascular resistance and compliance to vasoconstrictors.

대상 및 방법(증례): In 10 recipients, radial arterial pressure and plethysmographic waveforms were recorded immediately after reperfusion. We calculated the ratio of amplitude of plethysmography to arterial pulse pressure (PPGamp/PP). We compared beat-to-beat PPGamp/PP to total peripheral resistance (TPR) and arterial windkessel compliance (Cwk) obtained from the analysis of corresponding arterial pressure waveform.

결과: Immediately after reperfusion, PP decreased (-47±6%) and PPGamp increased (40±13%), thus PPGamp/PP markedly increased (70±33%) Beat-to-beat PPGamp/PP was negatively correlated with TPR and was positively correlated with Cwk. Beat-to-beat PPGamp/PP was negatively correlated with TPR (mean r=-0.799 [95% CI -0.851-0.748] on linear regression and r2=0.830 [95% CI 0.761-0.899] on curvilinear regression), and was positively correlated with Cwk (mean r=0.745 [95% CI 0.663-0.826] on linear regression and r2=0.863 [95% CI 0.769-0.956] on curvilinear regression)

결론(증례 결론): Our results suggest that relative compliance obtained from the relationship between plethysmographic and arterial pressure waveforms can track the abrupt change of vascular characteristics associated with hypotension during liver graft reperfusion.

참고문헌1. Shelley KH, Murray WB, Chang D. Arterial-pulse oximetry loops: a

new method of monitoring vascular tone. J Clin Monit 1997;13:223-8.

184

간이식 마취유도후 비위관 삽입으로 발생한 심한 비출혈

김동준, 김연희*, 이윤숙, 김운영, 김재환, 박영철


연구배경(서론): Cirrhosis has many possible manifestations. Impaired platelet function and prolonged clotting times may increase the risk of epistaxis arising from minimal trauma. And that cause sometimes seriously and occasionally with fatal results.

대상 및 방법(증례): A 60-year-old man (height 152 cm, body weight 75 kg) with ESLD due to hepatitis B virus-related hepatocellular carcinoma was scheduled for a living donor LT. Before surgery, he had liver cirrhosis (Child-Pugh score, 10; Model for End-stage Liver Disease [MELD] score, 14) accompanied by underlying diseases such as asthma. He had recurrent ascites, mild esophageal and gastric varices. Initial blood gas and chemistry measurements were within the normal range. The platelet count was 59,000× 109/L, international normalized ratio was 1.27, and partial thromboplastin time was 35 s. After anesthesia induction, the nasogastric tube was introduced before the surgery. We tried to insert both nasal cavities due to insertion failure. There was immediate bleeding from the mouth and nose. Repeated suction of the oral cavity was necessary, prompting examination of the nasopharynx, which showed a venous bleeding point in the both nasal cavity. We tried to cauterize bleeding sites under endoscopic guidance, but cauterization was failed due to bleeding tendency. The nasal cavity bleeding was more and more severe. Both nasal gauze packs with epinephrine HCl (Bosmin�) were inserted to achieve haemostasis. We used a fivefold dilution (0.02%, a total of 50 ml) of 0.1% bosmin divided to 5 times. The nasal bleeding was gradually controlled and the hemodynamic status stabilized as surgery progressed. 16 hours later, the surgery was ended and complete hemostasis was confirmed.

결론(증례 결론): Mortality rates of severe epistaxis approaching 5% have been reported for all patients with posterior epistaxis. A complete understanding of these complications which might occur during liver transplantaion is therefore important for appropriate management of the anesthesia.

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Inhibition of ROS downregulates MAPK pathway in spinal cord after limb ischemia reperfusion injury

최은경, 나호인, 임동건, 곽경화*


연구배경(서론): Ischemia reperfusion (IR) can cause life-threaten-ing remote organ injury as well as local injury. Mitogen-activated protein kinase (MAPK) plays an important role in intracellular signal transduction, and reactive oxygen species (ROS) can promote phosphorylation of MAPK signaling pathways including extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinase (JNK), and p38. We examined the activity of MAPK family members in rat spinal cord after hind limb IR and analyzed the role of ROS as mediators of MAPK signaling under these conditions.

대상 및 방법(증례): In experiment 1, hind limb IR rats were treated intraperitoneally with one of following agents at 30 min before reperfusion: allopurinol (4, 40 mg/kg), superoxide dismutase (SOD, 4000 U/kg), N-nitro-L-arginine methyl ester (L-NAME, 10 mg/kg), or SOD (4000 U/kg) + L-NAME (10 mg/kg). In experiment 2, 5, 10, 15, 20-tetrakis (N-methyl-4'-pyridyl) porphyrinato iron (III) (FeTMPyP) was administered intraperitoneally (1, 3, or 10 mg/kg) 30 min before reperfusion. After 3 d reperfusion period, the spinal cord (L4-6) was harvested to investigate MAPK signaling activity.

결과: In experiment 1, p-ERK and p-JNK levels were significantly higher in the IR group than sham group. Administration of allopurinol, SOD, L-NAME, or SOD + L-NAME significantly reduced the IR-induced increase in p-ERK and p-JNK levels. There were no significant differences in p-p38 levels. In experiment 2, FeTMPyP significantly reduced the IR-induced increase in p-ERK and p-JNK levels in a dose-dependent manner.

결론(증례 결론): Activation of ERK and JNK in the spinal cord was induced by hind limb IR and was not accompanied by p38 activation at 3 d after reperfusion. IR-induced MAPK phosphorylation was reduced by inhibition of superoxide, nitric oxide, and peroxynitrite, indicating that ROS produced by hind limb IR mediate the activation of these signaling pathways in the spinal cord, potentially affecting distant organs.

참고문헌1. Son Y, Cheong YK, Kim NH, Chung HT, Kang DG, Pae HO. Mitogen-

Activated Protein Kinases and Reactive Oxygen Species: How Can ROS Activate MAPK Pathways? J Signal Transduct 2011;2011:792639.

2. Torres M, Forman HJ. Redox signaling and the MAP kinase pathways. Biofactors 2003;17:287-96.

186

알코올성 간경화 환자에서의 간이식 수술 중 발생한 예상치 못한 대량 항문출혈

이창형, 김연희*, 이윤숙, 김운영, 김재환, 박영절


연구배경(서론): Cirrhosis has many possible manifestations. These signs and symptoms may be either as a direct result of the failure of liver cells or secondary to the resultant portal hypertension. Portal hypertension leads to the development of new veins that called collateral vessels. Collateral vessels develop at specific places, such as esophagus, stomach, abdominal wall and rectum. Especially, collateral vessels located in other site than the gastroesophageal region are defined as ectopic varics. And these varices are fragile and can rupture easily, resulting in a large amount of blood loss. And that cause sometimes seriously and occasionally with fatal results.

대상 및 방법(증례): We experienced a case of massive anorectal bleeding during living donor liver transplantation in a 52-year-old woman with known alcoholic cirrhosis, portal hypertension, ascites, and esophageal varices. During liver transplantation, emergent control of bleeding was obtained with gauze packing during liver transplantation. In the instance, blood products and fluids were rapidly infused with a rapid infusion system for the hemodynamic stability. After transplantation, bleeding was stop spontaneously. The patients were managed successfully and recovered uneventfully.

결론(증례 결론): Few cases have reported, especially as intra-operative complications, anorectal hemorrhage related to liver transplantation. However, keep in mind that massive anorectal hemorrhage could occur during liver transplantation in end stage liver disease patients under surgical drapes.

참고문헌1. Khaliq A, Dutta U, Kochhar R, Chalapathi A, Singh K. Massive

lower gastrointestinal bleed due to rectal varix. Intern Emerg Med 2012;7:S57-9.

187

Lipid emulsion inhibits the cytotoxicity induced by verapamil in H9c2 rat cardiomyoblasts

옥성호, 신일우, 이헌근, 정영균, 손주태*

경상대학교 의학전문대학원 마취통증의학과

연구배경(서론): Lipid emulsion is widely used to treat systemic



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toxicity induced by several drugs, including local anesthetics and calcium channel blockers, without specific antidotes. The goal of this in vitro study was to investigate the effect of lipid emulsion on the cytotoxicity induced by toxic-dose calcium channel blockers in the H9c2 rat cardiomyoblast.

대상 및 방법(증례): The MTT assay was used to investigate the effect of Intralipid (0.05 and 0.1%) on the decreased cell viability induced by a toxic dose of verapamil (2×10-4 M) or diltiazem (3.5×10-4 M) in H9c2 rat cardiomyoblasts with or without naloxone, LY-294002 and MK-2206. Western blotting was used to investigate the effect of Intralipid on the expression of cleaved caspase-3, Bax and caspase-8 induced by verapamil in h9c2 cells pretreated with naloxone or LY-294002. The TUNEL assay was performed to detect apoptosis in H9c2 cells pretreated with verapamil alone or Intralipid plus verapamil.

결과: Intralipid-mediated inhibition of the decrease in cell viability was higher in H9c2 cells post-treated with verapamil than in H9c2 cells post-treated with diltiazem. Intralipid attenuated the increase in cleaved caspase-3 expression and caspase-8 induced by the toxic dose of verapamil. Pretreatment with naloxone, MK-2206 or LY-294002 inhibited Intralipid-mediated attenuation of decreased cell viability and increased cleaved caspase-3 expression induced by toxic dose of verapamil. Intralipid inhibited the increase in TUNEL-positive cells induced by verapamil.

결론(증례 결론): Taken together, these results suggest that Intralipid attenuates the decreased cell viability induced by a toxic dose of verapamil via the extrinsic apoptotic pathway associated with opioid receptor and phosphoinositide-3 kinase. The protective effect of Intralipid may be partially associated with the lipid solubility of the calcium channel blocker (oil/Ringer partition coefficient: 16.7 [verapamil] versus 0.02 [diltiazem]).

참고문헌1. Ok SH, Sohn JT, Baik JS, Kim JG, Park SS, Sung HJ, et al. Lipid

emulsion reverses Levobupivacaine-induced responses in isolated rat aortic vessels. Anesthesiology 2011;114:293-301.

2. Pang DC, Sperelakis N. Uptake of calcium antagonistic drugs into muscles as related to their lipid solubilities. Biochem Pharmacol 1984;33:821-6.

188

Sugammadex에 의한 anaphylactic shock 과 피내 검사

주유미, 성춘호, 홍성진, 이지영, 문호식, 김동규, 신상호, 전진영*

가톨릭대학교 의과대학·의학전문대학원 여의도성모병원 마취통증의학과

연구배경(서론): 마취제에 의한 과민반응의 가장 주된 원인은 근

이완제에 의한 IgE 의존 반응이다. Sugammadex는 gamma-cyclodextrin의 구조로 aminosteroidal 신경근 차단제를 감싸 신장에서 배설 하여 신경근 차단을 회복시키는 약물이다.

대상 및 방법(증례): 60세 남자가 손의 연부 조직 감염으로 절개 및 배액 응급수술을 전신 마취로 시행 받았다. 환자는 알러지 반응 기왕력이 없었으며 이전 3번의 전신마취 시 합병증은 없었다. 마취 유도는 remifentanil, propofol, succinylcholine을 사용하였으며 마취 유지를 위해 rocuronium 0.6 mg/kg, desflurane, remifentanil을 사용하였다. 수술 시간은 15분이었고 수술 종료 후 sugammadex를 3 mg/kg 정맥 투여 하였다. 회복실로 이송 중 두드러기, 가려움 호소가 있었고 지속적인 혈압 저하로 anaphylactic shock 의심하여 항히스타민제, adrenaline, 수액 보충, 스테로이드 투여를 하였다. 30분 후 안정된 활력징후, 규칙적인 호흡 양상을 보였다. 중환자실에서 24시간 집중 관찰 시행 하였으며 특이 합병증 없이 퇴원하였다. 1달 후 정규수술이 계획되어 전신 마취 시행 중 피내검사를 시행하였으며 sugammadex 1:100과 1:1000 희석액, sugammadex와 rocuronium 동량의 결합액에서 양성반응을 보였다.

결론(증례 결론): 기도관리가 어려운 경우 sugammadex의 사용이 유용하나 이 약제의 사용으로 인한 기도 과민 반응이 발생시 기도관리가 더욱 힘들어 질 수 있다. sugammadex 사용시 수분내의 과민반응을 발생 여부 관찰이 필요하겠다.

참고문헌1. Tsur A, Kalansky A. Hypersensitivity associated with sugammadex

administration: a systematic review. Anaesthesia 2014;69:1251-7. 2. Brockow K, Przybilla B, Aberer W, Bircher AJ, Brehler R, Dickel H,

et al. Guideline for the diagnosis of drug hypersensitivity reactions: S2K-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI) and the German Dermatological Society (DDG) in collaboration with the Association of German Allergologists (AeDA), the German Society for Pediatric Allergology and Environmental Medicine (GPA), the German Contact Dermatitis Research Group (DKG), the Swiss Society for Allergy and Immunology (SGAI), the Austrian Society for Allergology and Immunology (ÖGAI), the German Academy of Allergology and Environmental Medicine (DAAU), the German Center for Documentation of Severe Skin Reactions and the German Federal Institute for Drugs and Medical Products (BfArM). Allergo J Int 2015;24:94-105.

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Dexmedetomidine-induced contraction involves calcium sensitization mediated by PKC and Rho-kinase

손주태1*, 옥성호1, 권성춘2, 신일우1, 정영균1, 이헌근1, 백지석3, 홍정민3

경상대학교 의학전문대학원 마취통증의학과1, 가톨릭관동대학교 의과대학 생리학교실 2, 부산대학교 의학전문대학원 마취통증의학과3

연구배경(서론): High dose of DMT produces alpha-2 adrenoceptor-mediated vasoconstriction, leading to hypertension. Calcium sensitization is induced by inhibition of myosin light chain phosphatase mediated by phosphorylation of either myosin phosphatase target subunit 1 (MYPT1) or phosphorylation-dependent inhibitory protein of myosin phosphatase (CPI-17), leading to increased phosphorylation of regulatory light chain of myosin (MLC20). The goal of this in vitro study was to investigate the associated signal pathway responsible for increased calcium sensitization that contributes to dexmedetomidine-induced contraction in isolated rat aorta.

대상 및 방법(증례): DMT (10-6 M)-induced contraction was measured continuously in the presence or absence of following inhibitors for 60 min: rauwolscine, Y-27532, chelerythrine and ML-7 hydrochloride. The effect of chelerythrine and Y-27632 on the intracellular calcium concentration ([Ca2+]i) and ten-sion induced by cumulative addition of DMT was measured simultaneously with the acetoxymethyl ester of a fure-2 loaded aortic strip. The effect of rauwolscine, chelerythrine, Y-27632, and ML-7 hydrochloride on the CPI-17, MYPT1 and MLC20 phosphorylation induced by DMT in rat aortic vascular smooth muscle cells was examined using Western blotting.

결과: Chelerythrine, Y-27632, ML-7 and rauwolscine attenuated DMT-induced contraction. The pretreatment with chelerythrine or Y-27632 shifted the DMT-induced [Ca2+]i-tension curves to the lower right side. Rauwolscine and chelerythrine attenuated DMT-induced CPI-17 phosphorylation. Y-27632 attenuated DMT-induced MYPT1 phosphorylation. Rauwolscine, Y-27632 and ML-7 hydrochloride attenuated DMT-induced MLC20 phosphorylation.

결론(증례 결론): Taken together, these results suggest that DMT-induced contraction involves increased calcium sensitization induced by PKC- and Rho-mediated pathways involving CPI-17, MYPT1 and MLC20 phosphorylation in isolated rat aorta.

참고문헌1. Ok SH, Byon HJ, Jin H, Kim HJ, Kim W, Nam IK, et al.

Dexmedetomidine-induced contraction involves c-Jun NH2 -terminal kinase phosphorylation through activation of the 5-lipoxygenase

pathway in the isolated endothelium-denuded rat aorta. Clin Exp Pharmacol Physiol 2014;41:1014-22.

2. Akata T. Cellular and molecular mechanisms regulating vascular tone. Part 2: regulatory mechanisms modulating Ca2+ mobilization and/or myofilament Ca2+ sensitivity in vascular smooth muscle cells. J Anesth 2007;21:232-42.

190

(영) Multiple exposures of sevoflurane in a patient with hepatic damage by curshing injuries

Kyoung Lin Chae, Dong Young Kim, Sang Yoong Park, Ji Hyeon Lee, Chan Jong Chung*

Department of Anesthesia and Pain Medicine, College of Medicine, Dong-A University

Background: Although there are a few of reports about hepatic toxicity after sevoflurane anesthesia, hepatotoxicity of sevoflurane due to its metabolism and biotransformation has been considered to be very low.[1] We report a case that a patient with high levels of AST/ALT by crushing injuries had relatively low hepatotoxicity after more than 20 sevoflurane anesthesia in 3 months.

Methods: A male patient (21 years old, 79 kg/178 cm), who had no past history about health, had crushing injuries with pelvic fracture, fracture of lower limb and hemoperitoneum by a traffic accident. AST/ALT 137/65 IU/L, total/direct bilirubin 5.0/2.8 mg/dl, PT/aPTT 15.6/36.8 sec were checked. Anesthesia was induced with propofol 140 mg IV and rocuronium 70 mg IV, and maintained with sevoflurane 1-2% and remifentanil 0.05-0.15 mcg/kg/min for CR and EF of femur fracture, and sigmoid loop colostomy. On the 5th day after the surgery, he received 2nd surgery for removing pelvic abscess under general anesthesia with sevoflurane 1-2% and remifentanil 0.05-0.15 mcg/kg/min. Thereafter, a few of aseptic dressings for open wound at lower extremity were tried under local blocks and then monitored anesthetic care with propofol-katamine-fentanyl. However, because of deep and extensive wounds, and inadequate analgesia, the dressings were not effectively accomplished. Therefore, the mask anesthesia with sevoflurane 2-4% and fentanyl was performed, once a day, a total of 26 times. Two months after the injuries, he complained severe pain on RUQ of abdomen with AST/ALT 269/139 IU/L. He was diagnosed as gallstones and cholecystitis on US. Anesthesia was maintained with sevoflurane 2-3% for laparoscopic cholecysytectomy. After a few of days, the levels of AST/ALT and other laboratoy findings were recovered within normal range. He was discharged from hospital 6 months after the injuries.

Conclusions: When do repeated general anesthesia or anesthesia



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to patient with hepatic dysfunction, it is supposed to be helpful to use sevoflurane.

참고문헌1. Tanikawa M, Mitsuhata H, Shimizu R, Akazawa S, Fukuda H, Saitoh

K, et al. Effects of repeated sevoflurane anesthesia on hepatic and renal function in a pediatric patient. Masui 1994;43:1593-5.

191

Cytotoxicity of halogenated volatile anesthetics on human bone marrow stromal cells and chondrocytes

백재원1, 권 구1, 고원욱1, 김하정1, 안태수2, 장재석2, 노영진1, 양홍석1*

울산대학교 의과대학 서울아산병원 마취통증의학과1, 정형외과2

연구배경(서론): Previous in vitro experiments and in vivo animal studies have demonstrated that exposure to halogenated volatile anesthetics may cause cell damage and apoptosis to immune cells and brain cells. The effect of volatile anesthetics on human bone marrow stromal cells (BMSC) and chondrocytes are currently unknown.

대상 및 방법(증례): Human BMSC and chondrocytes were harvested from six individuals. The cells were cultured and exposed to desflurane, sevoflurane and isoflurane in different concentrations (0.1 mM, 1 mM, 10 mM, 100 mM) each for 2, 8 and 24 hours. Lactate dehydrogenase (LDH) release was measured and the viability of cells was observed through inverted microscope.

결과: Exposure to 0.1 mM, 1 mM, and 10 mM of volatile anesthetics did not increase the release of LDH in human BMSC and chondrocytes regardless of desflurane, sevoflurane or isoflurane at 2 and 8 hours. A trend of increased LDH release was observed after 24 hour exposure to each volatile anesthetic, but did not demonstrate statistical significance. However, at 100 mM concentration, exposure to sevoflurane and isoflurane demonstrated significant increase in LDH release at every time points in both BMSC and chondrocytes (p<0.01). Exposure to 100 mM of desflurane did not increase the release of LDH at any time points.

결론(증례 결론): Desflurane, sevoflurane and isoflurane at clinically relevant concentrations do not seem to cause cell injury to human BMSC and chondrocytes. Prolonged exposure to halogenated volatile anesthetics may have potential cytotoxicity.

참고문헌1. Breu A, Scheidhammer I, Kujat R, Graf B, Angele P. Local anesthetic

cytotoxicity on human mesenchymal stem cells during chondrogenic

differentiation. Knee Surg Sports Traumatol Arthrosc. 2015;23:937-45.

192

Effects of remifentanil on induction and recovery profiles during sevoflurane anesthesia in children

최재규, 박선경, 윤수지, 백혜선, 정유선, 박재현, 서정화*


연구배경(서론): Although sevoflurane is widely used in pediatric anesthetic practice, its sole use may be insufficient to prevent noxious stimuli induced by tracheal intubation or cause emergence agitation during recovery. Therefore, this meta-analysis was performed to determine whether administration of remifentanil may improve induction and recovery profiles during sevoflurane anesthesia in children.

대상 및 방법(증례): A comprehensive literature search was conducted to identify randomized controlled trials involving children <18 years of age who received sevoflurane anesthesia combined with or without intravenous remifentanil. Two authors independently assessed study quality and extracted data from included studies. Random effects models were applied to calculate pooled relative risks (RR) for dichotomous data; mean differences (MD) for continuous data, and corresponding 95% confidence intervals (CIs). Quality of the evidence was assessed for each outcome using GRADE guidelines. The primary outcomes were hemodynamic response to tracheal intubation and the incidence of emergence agitation during recovery.

결과: Out of 1030 studies screened, 14 studies involving 1028 children were included in the analysis. The use of remifentanil reduced changes of blood pressure and heart rate during tracheal intubation (MD -15.9 mmHg, 95% CI -21.7 to -10.1 mmHg for blood pressure and MD -20.4 min-1, 95% CI -23.0 to -17.9 min-1 for heart rate; 654 participants in 8 studies, high quality

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of evidence). Moreover, the incidence of emergence agitation decreased when remifentanil was administered combined with sevoflurane during intraoperative period (RR 0.51, 95% CI 0.31 to 0.85, 284 participants in 5 studies, moderate quality of evidence).

결론(증례 결론): This meta-analysis showed that the use of remifentanil attenuated hemodynamic fluctuation during tracheal intubation and decreased emergence agitation under sevoflurane anesthesia in children.

193

Ramosetron versus palonosetron for preventing PONV: association with ABCB1 polymorphisms

이현정, 소사라, 송종욱, 심재광, 곽영란*


연구배경(서론): Ramosetron and palonosetron are used for the prevention of postoperative nausea and vomiting (PONV), yet their relative efficacy is still controversial. ABCB1 polymorphism may influence the efficacy of 5-hydroxytryptamine 3 antagonists by altering their efflux-transporter at the blood-brain barrier. We compared the efficacy of ramosetron with palonosetron on preventing PONV and its association with ABCB1 polymorphisms in patients using fentanyl-based intravenous patient-controlled analgesia after spine surgery.

대상 및 방법(증례): After randomization, 296 patients were allocated to receive two boluses (20 min before the end of surgery and 24 h after surgery) of either ramosetron 0.3 mg (n=150) or palonosetron 0.075 mg (n=146). The incidence and severity of PONV, amount of consumed fentanyl, and pain intensity were serially assessed for postoperative 48 h. ABCB1 polymorphisms 3435C>T and 2677G>T/A were also assessed.

결과: Overall incidence of PONV during postoperative 48 h was similar between the groups (57% [ramosetron] vs. 56% [palonosetron], P=0.748). The incidence of vomiting was lower in the ramosetron group compared with the palonosetron group (3% vs. 9%, P=0.021). Among patients exhibiting PONV, mild PONV was more frequent in the ramosetron group compared with the palonosetron group (64% vs. 44%, P=0.041). Of these patients, mild PONV was more frequent in the ramosetron group in patients with ABCB1 3435CT (64% vs. 32%, P=0.044) and TT (91% vs. 33%, P=0.017) genotypes. In patients with other ABCB1 genotypes, there were no differences in the incidence and severity of PONV between the two groups.

결론(증례 결론): Ramosetron was more effective in reducing the severity of nausea and the incidence of vomiting in patients

receiving opioid-based pain regimen following spine surgery. Yet, these beneficial influences were only evident in patients with ABCB1 CT or TT genotypes, which constituted 50% of the studied patients.

참고문헌1. Roh GU, Yang SY, Shim JK, Kwak YL. Efficacy of palonosetron versus

ramosetron on preventing opioid-based analgesia-related nausea and vomiting after lumbar spinal surgery: a prospective, randomized, and double-blind trial. Spine (Phila Pa 1976) 2014;39:E543-9.

2. Babaoglu MO, Bayar B, Aynacioglu AS, Kerb R, Abali H, Celik I, et al. Association of the ABCB1 3435C>T polymorphism with antiemetic efficacy of 5-hydroxytryptamine type 3 antagonists. Clin Pharmacol Ther 2005;78:619-26.

194

수술의 당일 취소 및 연기의 원인파악을 통한 개선책 숙사

주범준, 배고은, 최성욱, 신혜원, 이혜원, 임혜자, 임춘학*

고려대학교 의과대학 안암병원 마취통증의학과

연구배경(서론): There are many causes of cancellation or delay of surgery including insufficient preparation for anesthesia, improper condition. Whatever reason is, surgery cancellation or delay could lead to patient’s dissatisfaction or late return to community. The aim of this study is to find various causes leading to cancellation and delay of surgery. According to these results, we expect to find solutions for reducing the incidence of surgery cancellation and delay.

대상 및 방법(증례): We have done the survey prospectively and participants are patients who underwent surgery with anesthesia for 63 days from May 26 2015 at Korea university Anam hospital. Survey subjects are the number of surgery, emergency, delay and cancel. Moreover, we go over age, ASA classification, department, diagnosis including the case of delay and cancellation. The cause of cancellation is divided into five categories which include sub-categories; (Patient problems: improper condition (P3). Inadequate preparation for anesthesia and surgery: inadequate evaluation for underlyng disease (A1). absence of surgeon (S1), Problem of schedule: lack of operating room (J2), scheduling date error (J4), Change of treatment: change of way of surgery (T1).

결과: From 3365 cases, there are 133 of delay and 38 of cancellation during the surgery. The most common cause of delay is P3(19.5%), J4 (19.5%), A1. T1 (47.4%) and P1 are the most common factor for cancellation. Furthermore, over 70% case happens from 50s to 80s. ASA Class 3 recorded the highest delay late as 8.9% and have the common cause for P3 and A1. The cancellation rate for Male has more than twice of Female. The case of emergency has recorded 1.5 times of elective case. We could find the biggest risk



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factor from the detailed survey.

결론(증례 결론): Improper condition, scheduling date error, inadequate evaluation for underlyng disease were the common causes of delay in our institution. Therefore, it could be improved through introducing preoperative evaluation clinic and schedule management system.

참고문헌1. Conway JB, Goldberg J, Chung F. Preadmission anaesthesia

consultation clinic. Can J Anaesth 1992;39:1051-7. 2. Yoon SZ, Lee SI, Lee HW, Lim HJ, Yoon SM, Chang SH. The effect of

increasing operating room capacity on day-of-surgery cancellation. Anaesth Intensive Care 2009;37:261-6.

195

수술 중, 후 가온시트(Ready heat�)를 이용한 체온상승 효과

유병훈*, 이상석, 김계민, 홍기혁, 홍성수, 김용덕

인제대학교 의과대학 상계백병원 마취통증의학과

연구배경(서론): 주술기 환자의 체온을 정상범위 내로 유지하는 것은 중요하다. 그러나 많은 환자들이 여러 가지 합병증의 원인이 되는 저체온증을 보이는데, 이는 대부분 부적절한 체온조절과 차가운 수술실 환경이 원인이다. 저체온증 교정을 위하여 회복실에서 면반시트 또는 강제공기가열시스템을 이용하고 있으나 정상체온을 유지하기 어렵다. 이에 새로운 장비인 가온시트 (Ready heat�, Techtrade, USA)을 통한 체온상승 효과를 알아보고자 한다.

대상 및 방법(증례): 본 연구는 본원에서 정규수술로 전신마취하에 경요도적방광종양절제술을 받는 환자 총 50명을 대상으로 하였다. 면반시트(110×200cm)군과 가온시트(Ready heat�) 군을 수술 당일 무작위 배정하여 진행하였으며 마취유도 직전, 수술 직후, 수술 중(10분 간격)으로 나누어 식도체온, 고막체온, 피부체온을 측정하였다. 회복실 입실 이후에는 30분동안 10분 간격으로 고막체온, 피부체온, 온도 만족도를 측정하고 혈역학적 변화, 산소포화도, 떨림 등 전반적인 회복상태를 비교평가 하였다. 고막체온계(Braun ThermoScan�)를 이용하여 양쪽 고막체온을 측정하였으며 피부체온은 기계(MV1000�)를 통해서 측정하였다.

결과: 회복실 고막체온은 양 군 간에 통계학적으로 유의한 차이를 보이지 않았으나 수술 중 식도체온은 양군 간에 통계학적으로 유의한 차이를 보였다.

결론(증례 결론): 주술기 환자의 저체온증 예방을 위해 가온시트(Ready heat�, Techtrade, USA)를 사용하는 것이 면반시트(110×200 cm)를 사용하는 것보다 체온상승 효과가 큼을 알 수 있었다.

참고문헌1. Torossian A, Bräuer A, Höcker J, Bein B, Wulf H, Horn EP.

Preventing inadvertent perioperative hypothermia. Dtsch Arztebl Int 2015;112:166-72.

2. Shin KM, Ahn JH, Kim IS, Lee JY, Kang SS, Hong SJ, et al. The efficacy of pre-warming on reducing intraprocedural hypothermia in endovascular coiling of cerebral aneurysms. BMC Anesthesiol 2015;15:8.

196

Propofol/remifentanil과 sevoflurane/remifentanil 마취에서의 수술후 회복 - 메타분석

이정우1, 이상귀1, 김동찬1, 신인수2, 한영진1*

전북대학교 의학전문대학원 마취통증의학과1, 전주대학교2

연구배경(서론): 전정맥마취와 수술중 레미펜타닐을 주입하는 Sevoflurane 마취에서의 수술후 마취 회복을 메타분석으로 살펴보고자 한다. 마취중단후 각성시간과 기관내관의 발관 시간, 회복실에서의 수술후 구역 및 구토 및 떨림(shivering)의 빈도에 대하여 두 마취 방법에 따른 차이가 있는지 여부를 알아보고자하였다.

대상 및 방법(증례): 두 명의 저자가 독립적으로 검색을 수행하여 Pubmed, EMBASE, Cochrane Library에서 RCT 연구의 문헌을 검색하였다. 검색된 문헌을 연구에 포함할지 여부는 공동연구자 두 명(Lee, Kim)이 합의하여 결정하였고, 만일 합의가 이루어지지 않을 때에는 세번째 연구자의(Shin) 결정에 따라 정하였다. 주요 결과는 마취 방법에 따른 회복실에서의 수술후 구역 및 구토의 빈도가 차이나는지 알아보는 것이며, 그 외 마취중단후 각성시간과 기관내관의 발관 시간, 떨림(shivering)에 대하여 차이 있는지 알고자하였다.

결과: 수술후 구역 및 구토의 빈도는 Sevoflurane/remifentanil 마취가 propofol/remifentanil 마취보다 높게 나왔으며, 그외 마취 중단후 각성시간과 기관내관의 발관시간은 두 방법에서 차이가 없었다. 떨림은 propofol/remifentanil 마취 방법에서 Sevoflurane/remifentanil 마취 보다 높은 빈도를 나타냈다.

결론(증례 결론): Propofol/remifentanil 또는 Sevoflurane/remifen-tanil 마취에서의 수술후 회복은 마취 방법에 따라서 회복 지수에서 차이가 있다. 하지만 회복하는데 더 나은 마취방법을 결정하기 위해서는 추가 연구가 필요하다고 생각한다.

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197

The effect of dopamine administrating route of the vessels by comparing the effective time

손지선*, 김동찬, 이준례, 이준호, 권영준

전북대학교 의학전문대학원 마취통증의학과

연구배경(서론): During general anesthesia, hypotension occurs commonly due to inhibition of central nervous system activation or surgical bleeding. Vasopressors required for hemodynamic stability. If expression of the effect of vasopressors is delayed, the risk of cardiovascular collapse is very high. This study was to evaluate the time difference from the administration of dopamine to expression of hemodynamic effect by the dopamine administrating route of veins (External Jugular Vein (EJV), Cephalic vein (CV) and Great saphenous vein (GSV)).

대상 및 방법(증례): Patients, who required general anesthesia, aged 20-60 and ASA 1-2, were allocated in 3 groups by the route of dopamine infusion. Group 1 was infused in CV, group 2 was in GSV and group 3 was in EJV. The monitoring devices for vital signs were applied and NICCOMO was applied additionally. Six

minutes after intubation, hemodynamic parameters were recorded, and dopamine was continuously infused with a rate of 10 mcg/kg/min. Hemodynamic change was recorded form the infusion of dopamine for 15 minutes at 1 minute interval. Dopamine infusion began when systolic blood pressure (BP) was less than 90 mmHg or diastolic BP was less than 60 mmHg, or BP was decreased more than 20 mmHg in systolic or 10 mmHg in diastolic from the baseline. Dopamine infusion was held when systolic BP was more than 180 mmHg or diastolic BP was more than 120 mmHg, HR was more than 120/min, and ischemia in ECG was found.

결과: Systolic BP 12 minutes after beginning of infusion in EJV group presented increase compare to baseline value but heart rate 6 minutes after beginning of infusion in EJV group presented decrease. There is no difference among groups for hemodynamic parameters.

결론(증례 결론): There was no clinical difference in the expression of dopamine effect by the route of infusion after dopamine infusion with the rate of 10 mcg/kg/min. Although there was no clinical significantly difference among the groups, increase of systolic blood pressure was expressed most quickly in the EJV group.

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A simple epidural simulator is useful for training novice anesthesiologist

최재문*, 유환희, 김성훈, 김지현, 이수경, 정성문


연구배경(서론): The administration of epidural anesthesia relies entirely on the feel and experience, which is difficult to teach to a trainee. We designed a simple epidural simulator to enable trainees to experience various degrees of pressure resistance at each lumbar structure and feel loss of resistance (LOR).

대상 및 방법(증례): A Perifix� LOR syringe and 1-, 5-, 10-, and 50-mL volume syringes were assembled using three-way stopcocks. For pressure resistance, participants applied force onto the plunger of the LOR syringe and indicated the layer (muscle, subcutaneous fat, or interspinous ligament; ligamentum flavum; or epidural space) that the needle tip was believed to be traversing. A numerical rating score (NRS) was used to assess LOR to air and saline, and applicability for training purposes.

결과: A total of 89 experienced anesthesiologists completed this study. Overall 89% of anesthesiologists regarded air pressure resistance to the 50-mL syringe as epidural space (odds ratio, 602.3 compared to 5-mL syringe and 144.4 compared to 10-mL syringe). Resistance to the 10-mL syringe was most frequently classified as muscle, subcutaneous fat, or interspinous ligament,



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while resistance to 1-mL syringe was seen as ligamentum flavum (odds ratio, 2.3 for 5-mL syringe and 18.6 for 10-mL syringe). The NRS for the LOR to air and saline were a median of 8 and 7, respectively. The NRS regarding the applicability for training purposes were a median of 9.

결론(증례 결론): Our epidural simulator is a simple device that can be easily constructed using syringes. We expect this simulator may provide valid haptic feedback and appears to be a promising tool for training novice anesthesiologists.

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발표대회1

Off-pump coronary artery bypass 수술을 받는 환자에서 20% 알부민의 예방적 투여가 술후 급성신손상에 미치는 영향

조준영, 김욱종, 진지현, 최대기, 이은호*, 심지연, 최인철


연구배경(서론): 저알부민혈증은 급성신손상의 위험성을 증가시킬수 있다. 따라서 우리는 무인공심폐 관상동맥 우회술을 받는 환자에서 수술 직전에 투여된 20% 알부민 용액이 술후 급성신손상의 발생률에 영향을 미치는지에 대해서 알아보고자 하였다.

대상 및 방법(증례): 무작위 배정을 통한 이중맹검 연구로, 수술전 혈청 알부민 농도가 4.0 g/dl 미만인 220명의 환자를 대상으로 하였다. 술 전 혈청 알부민 농도에 따라(3.5-3.9 g/dl, 3.0-3.4 g/dl, 또는 <3.0 g/dl, retrospectively) 각각 100 ml, 200 ml, 또는 300 ml의 20% 알부민 용액을 수술 전에 투여받거나, 또는 같은 용량의 saline을 수술 전에 투여받았다. Primary outcome은 수술 후의 급성신손상의 발생률이었고, 술후 급성신손상은 Acute Kidney Injury Network (AKIN) 진단기준에 따라 정의되었다.

결과: 환자의 characteristics와 perioperative data는 수술 동안의 소변량을 제외하고는 두 그룹간 비슷하였다. 수술 중의 소변량은 대조군에 비해 알부민군에서 유의하게 높았다(P=0.006). 수술 후 급성신손상의 발생률은 알부민군에서 대조군에 비해 유의하게 낮았다(14 [13.7%] vs. 26 [25.7%], P=0.048; odds ratio, 0.42; 95% confidence interval, 0.21-0.89, P=0.024). 심각한 급성신손상, 신대체요법의 사용, 30일 사망률, 그리고 다른 임상적 outcome들은 두 그룹간 차이가 없었으며, 의미있는 부작용은 없었다.

결론(증례 결론): 수술 전 혈청 알부민 농도가 4.0 g/dl 미만인 무인공심폐 관상동맥 우회술을 받는 환자에서 술 전 20% 알부민의 투여는 수술동안 소변량을 유의하게 증가시켰으며, 술 후 급성신손상의 위험을 줄였다.

참고문헌 1. Lee EH, Baek SH, Chin JH, Choi DK, Son HJ, et al. Preoperative

hypoalbuminemia is a major risk factor for acute kidney injury following off-pump coronary artery bypass surgery. Intensive Care Med. 2012;38:1478-86.

2. Wiedermann CJ, Wiedermann W, Joannidis M. Hypoalbumine mia and acute kidney injury: A meta-analysis of observational clinical studies. Intensive Care Med 2010;36:1657-65.

발표대회2

Ultrasound assessment of gastric volume after drinking carbohydrate-containing fluids in children

송인경, 정성애, 이지현, 김은희, 김진태, 김희수*


연구배경(서론): Gastric ultrasound (US) is a valid and reliable tool to assess the nature and volume of gastric content at the bedside noninvasively both in adults and in children. Recent perioperative fasting guidelines recommend that it is safe to drink carbohydrate-rich fluids up to 2 hours before elective surgery. The purpose of this study was to assess the gastric volume using the US before and after drinking the carbohydrate-fluids preoperatively in fasted children.

대상 및 방법(증례): Pediatric patients aged younger than 18 years, scheduled for elective surgery under general anesthesia and fasted for 8 hours were enrolled prospectively. On the day of surgery, initial US assessment of gastric volume was performed 8 hours after fasting. Two hours before the surgery, the carbohydrate-drink was given according to patients’ age; 15 ml for patients less than 3 years old and 10 ml for those over 3 years old. Just before the induction of general anesthesia, secondary US assessment of gastric volume was performed.

결과: Among 86 of the enrolled patients, 79 completed the study: 3 patients declined to ingest the requested amount of the carbohydrate-drink and the surgery was delayed more than 2 hours in 4 patients. In all examinations, the gastric antrum was located successfully in the epigastric area. Mean±SD of initial and secondary US measurements were 2.09±0.97 cm2 and 1.85 ±0.94 cm2, respectively (P=0.011; mean difference 0.24, 95% CI 0.06-0.43). There were 1 cases of perioperative nausea (1.3%) and 2 cases of perioperative vomiting (2.5%).

결론(증례 결론): The carbohydrate-drink administered 2 hours prior to surgery did not distend the gastric volume nor cause serious complications in pediatric patients. Children should be encouraged to drink clear fluids including carbohydrates up to 2 hours before elective surgery if necessary.



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발표대회3

신경병증성 통증 발생에 있어서 nefopam이 autophagy와 JNK 발현에 미치는 효과

정기태 1*, 오선희3, 임경준1, 유병식1, 소금영1, 안태훈1, 정종달1, 김상훈1, 이현영1, 윤명하2

조선대학교 의과대학·의학전문대학원 마취통증의학과1, 전남대학교 의과대학 마취통증의학교실2, 조선대학교 기초의과학부3

연구배경(서론): Recent study has introduced the block in completion of basal autophagy as a consequences of spinal nerve ligation (SNL). Nefopam is considered to be a drug for the treatment of neuropathic pain. We investigated the effect of nefopam on the development of neuropathic pain after SNL and involvement autophagy.

대상 및 방법(증례): Neuropathic pain was induced by SNL in male SD rats. Rats were divided into three groups: group S (sham operated), group C received N/S intraperitonealy for three days (control), and group E received nefopam (30 mg/kg) intraperitonealy for three days immediately following SNL. The paw withdrawal threshold (PWT) was examined with a von Frey filament three days following SNL. On the 3rd, 5th, 7th, and 14th following SNL, the PWT was examined. The expression the microtubule-associated protein 1 light chain 3 (LC3-I) and P-JNK were evaluated on the 7th and 14th following SNL.

결과: The PWT was significantly increased in the rats from group E compared with the rats from groups C (P<0.05). Levels of LC3-I has increased and the p-JNK has decreased on the 14th day.

결론(증례 결론): Nefopam increased withdrawal threshold after SNL and the mode of action seems to be downregulation of p- JNK-mediated autophagy.

참고문헌1. Berliocchi L, Russo R, Maiaru M, Levato A, Bagetta G,Corasaniti MT.

Autophagy impairment in a mouse model of neuropathic pain. Mol Pain 2011;7:83.

2. Nam JS, Cheong YS, Karm MH, Ahn HS, Sim JH, Kim JS, et al. Effects of nefopam on streptozotocin-induced diabetic neuropathic pain in rats. Korean J Pain 2014;27:326-33.

발표대회4

(영) Augmented pulse pressure variation to predict of fluid responsiveness in open-chest condition

Seungwon Choi, Jeong Jin Min, Jong Hwan Lee*, Sangmin M. Lee, Hyun Sung Cho


Background: Pulse pressure variation (PPV) is a well-known dynamic preload indicator to predict fluid responsiveness. However, its usefulness in open-chest conditions has been controversial. We evaluated whether PPV measured during Valsalva maneuver can predict fluid responsiveness after sternotomy.

Methods: We assessed thirty three patients who underwent off-pump coronary arterial bypass grafting. PPV were calculated before and after sternotomy, during Valsalva maneuver, and after volume expansion. Valsalva maneuver was performed after sternotomy with the constant airway pressure of 30 cmH2O for 2 breaths duration. After volume expansion with 6 ml/kg of balanced crystalloid, patients were defined as responders by a ≥12% increase in the cardiac index.

Results: Median (IQR) PPV during Valsalva maneuver was signi-ficantly higher in responders (n=14) than in non-responders (n=19) (66.68 (61.62-87.20) vs. 50.66 (44.69-54.42), P<0.001). The receiver-operating characteristic curve revealed that pulse pressure variation measured during Valsalva maneuver could predict fluid responsiveness (area under the curve 0.915, P<0.0001) with a cut-off value of 55.45%.

Conclusions: Pulse pressure variation measured during Valsalva maneuver can be used to guide fluid management under open-chest condition in the patients undergoing off-pump coronary

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arterial bypassing.

참고문헌1. de Waal EE, Rex S, Kruitwagen CL, Kalkman CJ, Buhre WF. Dynamic

preload indicators fail to predict fluid responsiveness in open-chest conditions. Crit Care Med 2009;37:510-5.

2. Wyffels PA, Sergeant P, Wouters PF. The value of pulse pressure and stroke volume variation as predictors of fluid responsiveness during open chest surgery. Anaesthesia 2010;65:704-9.

발표대회5

SAPS3에 기초한 기계환기 이탈 양상의 분석

윤소희, 박종국*, 김강우

제주대학교 의과전문대학원 마취통증의학과

연구배경(서론): The aim of this study was the SAPS 3 score to describe the weaning pattern characteristics of patients receiving mechanical ventilation.

대상 및 방법(증례): The electronic medical records of patients admitted to the ICU of a single 630-bed university hospital between September 2014 and February 2015 were retrospectively reviewed. General SAPS 3 model was evaluated for all patients, and for subgroups of patients: those receiving mechanical ventilation (MV) and those not receiving mechanical ventilation (non-MV). Patients receiving MV were further subdivided into two groups, based on the type of ventilator weaning (simple weaning [MV-Simple weaning] and others [MV-Others]); patient characteristics and mortality rate were compared based on SAPS 3 scores.

결과: SAPS 3 scores, observed mortality, and predicted mortality were significantly higher in the MV-Others subgroup than in the MV-Simple weaning subgroup. Hospital mortality rate was considerably higher in patients with higher SAPS 3 scores.

결론(증례 결론): We believe this method will be useful in predicting weaning difficulty and mortality in patients requiring mechanical ventilation.

참고문헌1. Moreno RP, Metnitz PG, Almeida E, Jordan B, Bauer P, Campos RA,

et al. SAPS 3--From evaluation of the patient to evaluation of the intensive care unit. Part 2: Development of a prognostic model for hospital mortality at ICU admission. Intensive Care Med 2005;31(10): 1345-55.

발표대회6

Analysis of equipment-associated error of patient-controlled analgesia

손효정, 김성훈, 류정옥, 강미라, 김명희, 황재현*


연구배경(서론): Patient-controlled Analgesia (PCA) is one of the most popular and effective management of postoperative pain control.[1] Various types of infusion pump are used for safe and accurate administration of analgesic drug. We evaluated causes of equipment-associated PCA error, by each type of infusion pump.

대상 및 방법(증례): Clinical records were collected by Acute Pain Service team nurses at a 2715-bed tertiary clinical center, dated from January 1, 2011 to December 31, 2014. All types of PCA, such as intravenous PCA, epidural PCA, and nerve block PCA, are included for analysis. Four kinds of infusion pump were used during the study period; elastometric balloon infuser, carbon-dioxide driven infuser, semi-electronic disposable pump, and electronic programmable pump. We analyzed cause of equipment-associated PCA error.

결과: Among 82698 surgical patients using PCA, 155 cases (0.19%) of equipment-associated error have been noticed during 4 years. Most common type of error was underflow as 47 cases (30.3%). Electronic programmable pump shows high incidence of PCA error among the 4 type of devices, as 70 per 15052 patients (0.5%). Overflow was the major component of electronic programmable



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pump associated error, as 16 per 70 cases (22.9%). Otherwise, underflow was most common error of semi-electronic disposable pump, as 27 per 56 cases (48.2%).

결론(증례 결론): Equipment-associated PCA error is most com-monly caused by PCA underflow. Understanding equipment-associated PCA error helps better application of infusion pump device, eventually improving patient safety.

참고문헌1. Schein JR, Hicks RW, Nelson WW, Sikirica V, Doyle DJ. Patient-

controlled analgesia-related medication errors in the postoperative period: causes and prevention. Drug Saf 2009;32:549-59.

발표대회7

Effects of total intravenous and desflurane anesthesia on natural killer cell activity

강수정, 조진선, 김소연, 구본녀*


연구배경(서론): Although anesthetic agents and opioids have been shown to induce immune suppression, it remains unclear whether there are differences between the effects of anesthetic techniques on natural killer (NK) cell activity, one of the body’s main defenses against spread of cancer. The aim of this study was to compare the effects of total intravenous anesthesia (TIVA) and desflurane anesthesia on NK cell activities in patients undergoing surgery for breast cancer.

대상 및 방법(증례): Forty-eight patients undergoing breast cancer resection were randomized into one of two groups (24 patients

each): Group 1 received desflurane and analgesia with opioid and Group 2 received TIVA and analgesia with non-opioid. The primary endpoint was the cytotoxic activity of NK cell, measured preoperatively and at 24 h postoperatively. Interleurkin-2 levels were also assessed.

결과: NK cell activities (%) decreased in the Group 1 from 18.9 [9.5, 23.4] preoperatively to 10.9 [6.8, 17.5] postoperatively, whereas they increased in the Group 2 from 15.6 [7.2, 20.9] to 16.8 [7.8, 27.0]. Significant differences in NK cell activities were found between the groups using the linear mixed model analysis (P=0.048). Interleukin-2 levels did not show any statistical differences between the groups.

결론(증례 결론): TIVA and non-opioid use was associated with the increase of NK cell activity, whereas desflurane anesthesia and opioid use was associated with the decrease of NK cell activity. TIVA and non-opioid use preserved NK cell activity after surgery, in contrast to desflurane anesthesia and opioid use.

Table 1. Types of equipment-associated PCA errors by continuous infusion pump type

Equipment typeElastometric

balloon infuser(n=14625)

Carbon-dioxide driven infuser

(n=18709)

Semi-electronic disposable pump

(n=34312)

Electronic programmable

pump (n=15052)

Equipment-associated error 9 (0.06%) 20 (0.11%) 56 (0.16%) 70 (0.47%)

Types of equipment-associated error

Overflow 4 (44.4%) 1 (5%) 7 (12.5%) 16 (22.9%)

Underflow 2 (22.2%) 12 (60%) 27 (48.2%) 6 (8.6%)

Display error 0 0 7 (12.5%) 15 (21.4%)

Button malfuction 2 (22.2%) 0 5 (8.9%) 13 (18.6%)

Leakage 1 (11.1%) 5 (25%) 1 (1.8%) 2 (2.9%)

Inadequate pressure production 0 2 (10%) 0 0

Pump turn-off 0 0 3 (5.4%) 11 (15.7%)

Locking error 0 0 5 (8.9%) 4 (5.7%)

Defective pump 0 0 1 (1.8%) 3 (4.3%)

Data are number(%)

Figure. Natural killer cell activity of effector cells before and after anesthesia and surgery. E:T=1.25:1.; E, effector cells (peripheral blood mononuclear cells from patients); T, target cells (K562 cells).

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발표대회8

A method for quantifying the depth of anesthesia of rats based on physiological signal model

박정준, 허 협, 최성욱, 윤승주*, 임춘학, 신혜원, 이혜원, 임혜자

고려대학교 의과대학 안암병원 마취통증의학과

연구배경(서론): Detection of intraoperative awareness during anesthesia has historically been a major focus of research and technology development in anesthesiology.1 In recent years, a number of electroencephalography (EEG) based anesthetic depth monitors have been developed.2 However still many researchers are concentrating on developing anesthetic depth monitor. We compared a signal model that gives a quantitative description of the changes in EEG with respect to the change of the percent of pyramidal cells in active state with bispectral index (BIS) in measuring EEG signals from anesthetized rats.

대상 및 방법(증례): Eight Sprague Dawley rats (4 male and 4 female) weighing 150-200g, aged 6-8 weeks were used in this study. The measurements of EEG were started after placing the electrodes to the rats after initial anesthesia, and the rats were kept in a chamber during the measurement. After transferring the raw EEG signal obtained from BIS VISTA monitor to a computer, the data is processed using MATLAB. The quantitative description is obtained by dividing the number of points above the threshold value by the total number of points in the EEG segment. Spectral entropy was calculated for comparing with the quantitative description.

결과: The bland and atman of the quantitative description and spectral entropy results in a relatively consistent -50 quantitative description bias.

결론(증례 결론): The proposed method has simple and intuitive algorithm based on a physiological signal model which suggests the intrinsic relationship between the depth of anesthesia and the waveform of EEG.

참고문헌1. Kurata J, Hemmings HC Jr. Memory and awareness in anaesthesia.

Br J Anaesth 2015;115(s):i1-i3.2. Ellerkmann RK, Liermann VM, Alves TM, Wenningmann I, Kreuer S,

Wilhelm W, et al. Spectral entropy and bispectral index as measures of the electroencephalographic effects of sevoflurane. Anesthesiology 2004;101:1275-82.

발표대회9

Preoperative beta-blocker is independently associated with postoperative AKI following LT

김선기*, 전인구, 송준걸, 황규삼


연구배경(서론): Nonselective β-blockers (NSBB) therapy has been shown to reduce portal pressure and risk of variceal bleeding in patients with cirrhosis. However, conflict results have been revealed the beneficial effect of NSBB in patients with end-stage cirrhosis. The aim of this study was to evaluate whether the use of NSBB was a risk factor for development of acute kidney injury (AKI) and mortality after liver transplantation surgery.

대상 및 방법(증례): We performed a single-center retrospective analysis of 1908 patients who underwent liver transplantation from 2008 through 2014. Patients were divided into two groups on the basis of preoperative NSBB use. The AKI was defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria. The incidence of postoperative AKI and overall mortality was assessed between two groups using propensity score analysis.

결과: The median follow-up for the whole patients was 3.4 years. The incidence of AKI was 68.9% (n=286) in NSBB group and 63.5% (n=948) in no NSBB group (P=0.041). After propensity score matching, there was no difference in the incidence of AKI between two groups [68.4% in NSBB group and 65.4% in no NSBB group (P=0.368), respectively]. Moreover, NSBB use was not associated with overall mortality after propensity score matching (hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.52-1.45; P=0.595). However, in multivariate logistic regression analysis, after patients were divided by subgroups based on model for end-stage liver disease (MELD) score, NSBB use was an independent risk factor for AKI in patients with MELD score >15 (OR, 1.77; 95% CI, 1.13-2.77; P=0.013).



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결론(증례 결론): Our results demonstrated that preoperative NSBB use is independently associated with AKI in patients with MELD >15. However, NSBB use was not associated with overall mortality in patients with advanced stage liver cirrhosis who undergo liver transplantation surgery.

발표대회10

Optimal chest compression site during cardiopulmonary resuscitation in the prone position

오혜원1, 권민지2, 김은희1, 송인경1, 이지현1, 김희수1, 김종성1, 김진태1*

서울대학교 의과대학 마취통증의학교실1, 서울대학교 의과대학2

연구배경(서론): The optimal chest compression site during cardiopulmonary resuscitation (CPR) in the prone position has not been investigated extensively. The purpose of this study was to determine the optimal chest compression site for CPR in the prone position.

대상 및 방법(증례): We reviewed the chest computed tomography images of 100 patients taken in the prone position. The vertebral body levels crossing the medial angle of the scapula, the inferior angle of the scapula, and the spinous process of the vertebral body connected to the most inferior rib were identified, and we selected the image level at which the left ventricle (LV) cross-sectional area was the largest. This level was defined as the optimal compression site level and was evaluated using anatomical landmarks. We calculated the ratio of the distance from the C7 spinous process to the level of the largest LV cross-sectional area to the length from the C7 spinous process to the spinous process of the vertebral body connected with the most inferior rib.

결과: The level of the largest LV cross-sectional area in the prone position was the T8-T9 level (range T7-T10), which corresponds to one vertebral level below the inferior angle of the scapula. This level is 67±7% of the length from the C7 spinous process to the spinous process of the vertebra attached to the most inferior rib.

결론(증례 결론): The optimal chest compression level in the prone position is one vertebral level below the inferior angle of the scapula, which corresponds to the lower third of the length from the C7 to T12 spinous process.

참고문헌1. Beltran SL, Mashour GA. Unsuccessful cardiopul monary resuscitation

during neurosurgery: is the supine position always optimal? Anes-thesiology 2008;108:163-4.

2. Wei J. Card iopulmonary resuscitation in prone position: a simplified method for outpatients. Resuscitation 2004;62:120-1.

001

(영) Failed intubation of an unanticipated postintubation tracheal stenosis

Ann Youn, Soo Yong Park, Seok Hwa Yoon*


Background: Encountering a patient with unanticipated laryngo-tracheal stenosis (LTS) during anesthetic induction is challenging. Because routine history taking and preanesthetic evaluation cannot rule out the possibility of LTS, other methods should be sought out and perioperative airway maintenance considered crucial to avoid complications such as airway edema, bleeding, obstruction, collapse, and ultimately respiratory failure and arrest.

Methods: A 69 year old female patient was scheduled for total knee replacement (TKR). Past medical history revealed prior TKR of the other knee three years ago at another hospital. The patient complained of occasional mild dyspnea during exercise, but chest radiographic readings by radiology were non-specific. Spirometry was within normal results as well as analysis of arterial blood gas. Both lung sounds were clear and no chest abnormalities were observed. She was anesthetically induced with propofol 60mg and rocuronium 30mg. Initial intubation was attempted with a 7.0mm internal diameter endotracheal tube (ET) which failed to pass the larynx. After a second attempt failed with a 6.5mm internal diameter ET due to continuous resistance. We used a GlideScope� to visualize and identify the source of resistance where the subglottic area was divided into two sections with a septum. A laryngeal mask airway (LMA) (I-gel�, 4.0) was inserted for temporary ventilation, but peak airway pressures high as 30 mmHg did not improve even after injection of additional neuromuscular blockade. Inadequate ventilation lead the attending anesthesiologist to awake the patient and postpone surgery until further evaluation. The patient regained consciousness without any respiratory symptoms. Neck CT and fiberoptic endoscopy revealed fibrous tissue at the glottis level dividing the anterior and

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