Acute and Critical Care

Volume 2 (1); March 1987

An Experimental Study for Inhalation of Halothane during High Frequency Jet Ventilation in a Lung Model: Won Oak Kim, Jin Ho Kim, Yang Sik Shin, Chung Hyun Cho; Korean J Crit Care Med. 1987;2(1):1-5.

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Abstract PDF: High frequency ventilation techniques re accepted for upper airway and intrathoracic surgery under general anesthesia, Good oxygenation and ventilation are achieved with good airway control and operative conditions. However, the jet ventilating system is of an open character with mandatory use of intravenous anesthesia. The present study was done to administer inhalation anesthetics (halothane) during high frequency ventilation. The high frequency injector was adapted to an angiocatheter with a swivel connector, while the entrainment orifice of the side port was connected to the anesthesia circuit to facilitate the administration of inhalation anesthetics. Variables thought to be important in determing the inspiratory peak halothane concentration and diluting inspiratory oxygen concentration for estimation of gaseous influx from the anesthesia circuit were evaluated in an experimental lung model. Changing the halothane concentration of the vaporizer(1,3,5%), ispiratory: expiratory (I:E) ratio(0.2: 0.2, 0.2: 0.4, 0.2: 0.6, 0.2: 0.8, 0.2: 1.0 sec.). driving gas pressure(DGP) (10,30,50 psi), the inspiratory peak halothane and oxygen concentration were measured, The results were analyzed to predict the association and relationship of the inspiratory peak halothane and oxygen concentration with each variable. Partial coefficient of halothane concentration of the vaporizer, I:E ratio, DGP were 0.7224,0.3724,0.3386 and R squares were 0.5219,0.6605, 0.7752 to the inspiratory peak halo- thane concentration. Partial coefficient of I:E ratio, DGP were- 0. 9386, 0.1138 and R squares were 0.8809,0.8939 to the inspiratory oxygen concentration, Halothane concentration of the vaporizer was the most associated factor to the inspiratory peak halothane concentration and I:E ratio to the inspiratory oxygen concentration. Clinically, if DGP and I:E ratio are determined, the halothane concentration of the vaporizer will be the predictor of the inspiratory halothane concentration. But in a. certain condition, the inspiratory peak halothane concentration could at be achieved to a proper level for maintaining anesthesia by this experimental model, In conclusion, most of the high frequency jet systems used clinically are of the open character allowing entrainment of additional gases and difficult to apply if volitile agents are to be used. Special predictable vaporiiers have to be developed to apply volitile agents in any situation of I:E ratio and DGF by this method of administering inhalation agents during high frequency jet ventilation.

The Effect of Tourniquets Applied on Four Extremities During Closed-chest Cardiac Massage: Jong Ho Lee, Joo Young Choi; Korean J Crit Care Med. 1987;2(1):6-15.

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Abstract PDF: Closed-chest cardiac massage(CCCM) has been thought to prccuce blood flow by compression of the heart between sternum and spine, but contradictory views have been expressed by several investigators, We studied the arterio-venous pressure differences in 15 rabbits to clarify the effect of tourniquets applied on four extremities to mimic the effect of cross clamping of abdominal abdominal aorta in experimenta1 cardiac resuscitation. The experimental animals were divided. into two groups, tourniquet applied group and (●ccntrol) group. This was done to observe the changes of peripheral vascular tone during CCCM with tourniquets applied on four extremities as compared to the control group, The arterio-venous pressure difference generated by CCCM was recorded throughout the experiment with tracing speed of 0. 25cm/sec. The recorded area of arterio-verous pressure difference was measured using planimeter at regular time intervals. The measured areas of both groups were expressed by 10mmHg×4 seconds as 1cm2 for the basic unit. The rapid tracing of the recorded pressure waves was analyzed in both groups. The results obtained were as follows; 1. The area, 1 minute after CCCM was 17. 16±7. 37cm2 in tourniquet group and 8.69±3. 0lcm2 in ccntrol group. This value of tourniquet group was significantly increased as much as 97. 47%(p<0.05). 2. Arterio-venous pressure differences were gradually decreased as time passed by in both groups. Through this experiment, it is inferred that; 1. The application of tourniquets during CCCM helps the central venous pressure to decrease and the arterial pressure increase, thus improving the tissue perfusion. 2. The decrease of jugular venous pressure by tourniquet application may be caused by compIete closure of aortic valve during diastolic phase of CCCM. 3. The decrease of arteria#1 pressure generated by CCCM as time passes by may be due to decreasing the peripheral vascular tone.

2,3 - DPG Concentration in Neonatal Blood at Birth: Hyun Seog Moon, Byung Kwon Choi; Korean J Crit Care Med. 1987;2(1):16-20.

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Abstract PDF: Hematocrit and 2,3-DPG(2,3-diphosphoglycerate) in whole blood and packed cell were measured about 19 normal neonates at birth & 34 normal adults, The results were as followed, 1) Hematocrit value was higher in neonates than in adults. 2) 2,3-DPG concentration in whole blood is similar between neonates and adults. 3) 2,3-DPG concentration in packed cell is also similat between neonates and adults. Oxygen disaociation curve of normal fetal blood is deviated to left from normal adults curve. lt seems to survive fetal life which is very low oxygen tension. From this study, 2,3-DPG concentration is not functionated to deviated oxygen dissociation curve, but fetal hemoglobin itself, high carbon dioxide tension and/or low pH can be enfluenced to oxygen dissociation curve,

Evaluation of the Emergency Room Patients: Young Taek Kim, Jong Ho Lee, Jong Ho Lee, Se Ung Chon; Korean J Crit Care Med. 1987;2(1):21-25.

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Abstract PDF: The extended medical insurance system has resulted in increasing numbers of patients who go directly to specialists in the general hospitals via consultation of general practice physicians in local clinics as well as on the patient's own decision. In order to classify and evaluate the. patients, who come to the emergency room of the general hospital, whether the patients disease status. truely needed emergency treatment or whether the patients were treated adequately or not at the emergency room, we reviewed retrospectively 3.775 patients who came to the emergency room of Kang Nam St, Mary's Hospital between January and July 1984. We classified them according to their age, sex, department. the status of disease(emergency or not) and evaluated the adequacy of emergency treatment and the prognosis. We conclued as follows; 1) Every emergency room should be prepared with adequate equipment and operated by sufficient numbers of well trained medical personnel. 2) It is necessary that the medical personnel who work at the emergency room should be continuously educated and trained for adequate care of the patients with centraI nervous system, respiratory system, gastrointestinal system and cardiovascular system problems. 3) Our review revealed that it seems necessary that the specialists in emergency care, including cardiopulmonary resuscitation, should be stationed at emergency room. 4) For the more efficient operation of the emergency room, the establishment of a medical delivery system is necessary.

Statistical Study on the Emergency Patients: Hak San Kim, Young Cheol Kim, Soo Woong Yoo, Yul Ja Kim, Hak Choong Lee; Korean J Crit Care Med. 1987;2(1):26-35.

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Abstract PDF: Five thousand forty three patients with avallable data out of total 6.992 patients who visited the Emergency room of the National Medical Coater from 1st Jan. to 3lst Dec., 1980, were analyzed in several aspects. The results were are follows; 1. During the contemporary periods, the Emergency patients were 6,992. 3.1% of total 225,604 patients who visited Out-Patient department or Emergency room of National Me- dical Center, and 46% of the Emergency patients were admitted. 2. Socially active persons, ranged from 21 to 50 years in age, occupied more than half of the total Emergency patients and 15. 4% were under 10 of the age. 3. Sixty six percent of the Emergency patients visited within first day after the onset of symptoms and 8. 5% of whom did over 7 days. 4.Most of the patients arrived to Emergency room during the every time of the day except mid-night (p-4 O'clock) and early morning, and 70% of whom during P.M. time. 5. Deaths after arrival to Emergency room were 14 cases, 0, 3% of the total Emergency patients. 6. On arrival to Emergency room, 11. 9 of patients showed abnormal mental status and 0. 9% were in the #shock state. 7. The urgent management performed at Emergency room were as follows: Oxygen administration(12.9%), gastric irrigation(5.5%) transfusion(3.4%), anti-hypertensive drug administration(3.1%), endotracheal intubation (2. 3%), vasopressor administration(l.0%) and cardio-pulmonary resuscitation(0.7%). 8. Accoring to the Korean Standard Classification of Disease , the most common disease(1 digit system classification) were Injury and Po inoning(32.0%). Diseases of the Digestive system(17.1%), Complications of Pregnancy Childbirth and the Puerperium(10.6%), Infe- ctious and Parasitic Diseases, Diseases of the Respiratory system, Diseases of the Circulatory system and Neoplasm in order. The patients with accident visited more rapidly than those suffering from chronic diseases.

Clinical Analysis of Cases Dead within 48 Hours after Admission: In Ho Kim, Mi Ja Kim, Hong Soon Lee, Hak Choong Lee; Korean J Crit Care Med. 1987;2(1):36-42.

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Abstract PDF: The authors performed a review on the records of 64 cases who lied within 48 hours after admission to the medical ward, department of interal medicine, National Medical Center, from February 1979 to September 1983. We tried in this analysis to seek the preadmission health status of the patients, the contributing factors to the early death and the problems related with the future critical care. Thirty one patients had limitingor advanced un-derlying diseases with organ failure such as liver cirrhosis, congestive heart failure and malignancy. Considerable portion of the subject presented mental impairment and dyspnea as their chief complaints on admission. Azotemia was found in 19 of 23 patients with available data. Fourteen of 17 patients with available data showed high anion gap metabolic aido-sis. Mechananical ventilation had to be performed in 23 patients and dopamine had to be infused in 20 patients. Major immediate causes of death were sepsis, respiratory failure, arrhythmia, and hepatic failure. The predominent pathophysiologid factor of their early death was considered as the interaction among underlying diseases, delayed admission, acute aggra-vating factors, severe infection and multiple organ failure.

A Clinical Study on Dyspneic Patients Admitted through Emergency Room: Won Tae Chung, Gye Ik Sohn, Jang Geun Park, Soon Kew Park, Young Kee Shin; Korean J Crit Care Med. 1987;2(1):43-49.

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Abstract PDF: Authors obtained the following results through the clinical study on 129 cases of dyspneic patients, admitted through the Emergency Room of Pusan National University Hospital from January 1984 to June 1985. 1) The study group was 129 patients with dyspnea, male 81 caaes(62.8%) and female 48 cases(37.2%). Male to female ratio was 1.7:l. 2) Underlying diseases were pulmonary diseases in 61 cases(47,3%), cardiovascular diseases in 56 cases(43.4%). 3) The most frequently associated symptoms with dyspnea were coughing in pulmonary diseases and chest pain in cardiovascular diseases. 4) Respiratory rate was much more markedly increased in cardiovascular diseases than in pulmonary diseases. 5) Abnormal breathing sound was noted in 85 eases(65.9%), and arrythmia and cardiac murmur were noted in 8 cases(6.2%) at auscultation. 6) Mental status was alert in most of the cases(80.6%). 7) Pulmonary function test revealed the more marked impairment in pulmonary diseases, and there were more significant differences in FEV and FEF25 ~75%.

Clinical Survey of Paitents on Ventilar Support in the Intensive Care Unit: Shin Ok Koh, Hung Kun Oh; Korean J Crit Care Med. 1987;2(1):50-59.

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Abstract PDF: The Intensive Care Unit(ICU) of Severance Hospital was opened on October 18, 1968 with 7 beds and expanded to 19 beds on February 2, 1981. Statistical analysis of ICU patients was already been reported twice: 1. from 1970 to 1977 with 3,072 cases and 2. from 1975 to 1981 with 4.348 cases The following is a report of clinical analysis of 1,458 ventilator eases which comprised 33. 5% of ICU patients from march 1975 to February 1982. Until 1979 pressure and volume cycled ventilators were used in even ratio; however, since 1980, volume-cycled ventilators such as the Bennett MAI and the Bourns LS 104-150 were mainly used. The ratio of ventilator eases from the Department of Internal Medicine and Cardiac Surgery remained almost constant at 30: 30 from 1975 to 1977 However since 1978, the Cardiac Surgery ventilator cases increased to over 50% of the total. The number of ventilator cases be low the ten year age group was 396 cases, about 27 of the total. They have increased year by year. Among 537 ventilator cases in 1981, the Bennett MAI and II were used in 225, 203 cases respectively. In the under 1 year old age group, 36 cases(43.9%) and 30 cases(36.6%) were put on with the Bourns LS 104-150 and Drager babylog I respectively. 487(90.7%) of cases were supported with controlled mechanical ventilation(CMV) mode and 135(25%) with the positive end expiratory pressure (PEEP). Of 537 cases, 441(85%) were disconnected from the ventilator within 3 days. Death according to duration of ventilator support were 47(18.8%), 38(23.8%) and 14(36.9%,) in 1., 2 and 10 days respecitively. But, for the period of 10~19 days, the number of deaths was 4(36.4%) and for 20 or more days 1 cases(25%) 3. Incidence of causative disease for ventilator support was postcardiac operation cases(301 case, 56%) followed by CNS(central nervous system), 1RDS(idiopathic respiratory distress syndrome), and laparotomy cases in that order. All ventilator cases with neuromuscular disease survived, but none with DIC(Disseminated Intravascular Coagulopathy) did. From above results it can be conciuded that ventilator support cases are increasing and the attendant mortality rate is decreasing year by year.

Pulmonary Insufficiency after Massive Blood Transfusion: Hae Keum Kil, Shin Ok Koh, Kyung Sook Chung, Kang Won Park; Korean J Crit Care Med. 1987;2(1):60-65.

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Abstract PDF: Massive blood transfusion may be defined as the acute administration of blood more than one and a half times the patient's estimated blood volume. When stored whole blood is infused, complications such as coagulation defect, volume overload, acid-base disturbance and pulmonary complications. will deve1op. Massive transfusion has been associated with the development of adult respiratory distress syndrome(ARDS) in man, and both humoral factor and microemboli have been proposed as the injurious agent in the transfused blood. We experienced the patient who bad suffered from acute respiratory failure after the transfusion of massive amount of whole blood and managed him effectively with ventilatory support with positive end expiratory pressure under the monitoring of cardiopulmonary function via the Swan-Ganz Catheter at 1CU.

Anesthesia for Cesarian Section of two High - Risk Teoxemia of Pregnancy: Chong Hyun Lee; Korean J Crit Care Med. 1987;2(1):66-69.

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Abstract PDF: Pre-eclampsia or eclampsia is a cause of maternal morbidity and mortality. It is characterized by the triad of maternal hypertension, proteinuria and generalized edema. The etiology of pre-eclampsia or eclampsia is thought to be a decreased placental perfusion which results in an increased production of renin, angiotensin, aldosteron, thrombolplastin and a decreased production of prostaglandin. Anesthesiologists have to perform anesthesia technic for high-risk toxemia of pregnancy, and make proper choices of anesthesia method and drugs. Advantages of generaI anesthesia for Cesarian-section in cases of eclampsia include rapid induction, less hypotension, control of venti1ation and fetal oxygenation. Disadvantages include myocardial depression from the anesthetic drugs, hypertension during light anesthesia, the interaction between magnesium sulfate and muscle relaxants which might lead to prolonged respiratory paralysis and neonatal depression associated with the general anesthesia. The author used general anesthesia for the Cesarian-section in two severe toxemic patients who had pulmonary edema and bloody sputum because of congestive heartfailure. One patient had cardiac arrest upon arrival at the emergency room and after cardiopulmonary resuscitation the Cesarian-section was performed. The mother had complete recovery, but the baby expired in twenty-ninehours, The Motber and twin babies in the other case had complete recovery.

Congenital Posterolateral Diaphragmatic Hernia ( Bochdalek Hernia ): Jung Ho Kang; Korean J Crit Care Med. 1987;2(1):70-74.

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Abstract PDF: This hernia, most often referred to as formen of Bochdalek hernia, usually present posteriorly- teriorly through a persistent pleuroperitoneal canal, The majority are found on the left side. Usually there is no sac. The hernia may contain 1iver, colon, and smali intestine on the right. On the left, it may contain stomach, spleen, colon, smallintestine, omentum and even liver. The diaphragmatic defect on the left usually will involve a malrotation of the intestine and duodenal band, We have experienced with one case of Bochdalek hernia for 3 month old male patient, whitch was corrected by interrupted direct suture of diaphragm, and reduction of stomch, colon and spleen. The postoperative course was unevenful, and dicharged Postoperative 7 days later. Now we report one case of Bochdalek hernia with literature review.

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