Effect of amount of autologous transfusion on serum free hemoglobin concentrations was studied in 36 patients undergoing hip surgery. The patients were divided into two groups: group L (n=15) received autologous transfusion of less than 1, 000ml (200∼800ml, average 680ml), and group H (n=21) received autologous transfusion of more than 1, 000ml (1, 000 ∼1, 800ml, average 1, 174ml). Measurements including serum total hemoglobin concentrations, serum free hemoglobin concentrations, serum total haptoglobin concentrations and serum total bilirubin concentrations were made before transfusion and on the first postoperative day. Total hemoglobin concentrations, free hemoglobin concentrations and total haptoglobin concentrations showed no significant change throughout the time course, whereas total bilirubin concentrations showed a significant increase after transfusion in both groups. Free hemoglobin concentrations increased above the normal range in one patient in group H. The results suggest that autologous transfusion of more than 1, 000ml (1, 000∼1, 800ml) would not affect serum free hemoglobin concentrations.

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During induction of anesthesia by inhalation, the authors determined the fresh gas flow rate that would produce the desired rate of increase in circuit O₂ concentration and anesthetic delivery to the patient while concomitantly conserving total O₂ expenditure. Fresh O₂ flows of 0.5, 1, 2, 4, and 6 l/min were studied. The patients' hemodynamic profiles during anesthetic induction were also evaluated. When fresh O₂ flow was 0.5 or 1 l/min, the time for inspiratory O₂ concentration to reach 90% exceeded 20 min (44±12 and 20±6 min, respectively, mean±SD). With higher flow rates of 2, 4, or 6 l/min, the time to reach 90% inspired concentration of O₂ diminished progressively to 7.4±3.3, 4.3±2.6, 2.1±0.8 min, respectively. The calculated volume of fresh O₂ required to obtain a 96% inspiratory O₂ concentration was significantly smaller with the 2l/min flow than with other flow rate studied. With a flow of 0.5 or 1l/min, the increased O₂ usage was attributed to patient O₂ consumption that occurs during a long O₂ equilibration interval. With a flow of 4 or 6 l/min, the increased O₂ usage probably results from an increased volume of waste gas. When the anesthesia vaporizer was set to deliver 5% isoflurane for 5 min, end-expiratory isoflurane concentrations were greater than 1.76% (MAC intubation) in groups in which fresh O₂ flow was 2, 4, or 6 l/min. Hemodynamic changes were smallest in the group receiving 2 l/min fresh gas flow. These results suggest that a 2 l/min O₂ flow is suitable when a low flow technique is used for inhalational anesthetic induction.

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Before and after surgery in 24 patients scheduled for VATS with genaral anesthesia, the thoracic wall along the proposed line of incision was infiltrated with either 20 ml of saline (G-group, 12 patients) or 20 ml of 1% lidocaine (P-group, 12 patients). Wound pain during mobilization was assessed using the Prince Henry Pain Scale (PHPS) and the Verbal Rating Scale (VRS) and based on the number of times analgesics were administerd. Better analgesia was induced during all stages in the P-group according to PHPS, and it alsoshowed significant improvement (p<0.05) according to VRS. Also, this group showed considerable reduction in postoperative need for opioids compaired to the G-group.Local infiltration with 1% lidocaine in surgical wounds due to VATS improved analgesia postoperatively and is important for attaining good resuls in the use of preemptive analgesia.

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We evaluated the effects of low dose continuous epidural infusion lidocaine (1ml/hr) and morphine (2.7mg/day) on postoperative pain in patients who have undergone cholecys-tectomy (N=60). All cases were epidurally administered 0.25% bupivacaine 6ml with morphine 2 mg post-operatively. These cases were allocated randomly to receive epidural infusion of 1% lidocaine (group L), morphine (group M) or a combination of lidocaine and morphine (group ML) for 72 hours. In group ML, the VAS scores at mobilization and supplementary use of an analgesic for postoperative pain decreased control compared with the other groups. 11 of 20 patients in group ML needed no supplementary analgesic drug and, 15% in group L, 70% in group M and 25% in group ML experienced adverse effects including nausea, dizziness, perspiration and itching. We conclude that epidural co-administration of lidocaine and morphine improves analgesic effect for postoperative pain control without increasing the risk of adverse effects.

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EEG, auditory middle latency evoked response (MLR) and somatosensory evoked poten-tial (SEP) were recorded in 10 patients undergoing hip or knee surgery during general anesthesia with propofol and/or N₂O with epidural block. The analyses were made upen administration of 5mg/kg/hr of propofol+O₂ (P 5mg), 5mg/kg/hr of propofol+N₂O (P 5mg+N₂O), and 10mg/kg/hr of propofol+O₂ (P 10mg) and after extubation. The mean frequency of EEG decreased as infusion rate with propofol increased with no significant difference between administration with P 5mg and P 5mg+N₂O. The amplitude of MLR decreased and the peak latency prolonged as propofol infusion rate increased. The ampli-tude of SEP N₂O significantly decreased during P 5mg+N₂O compared with P 5mg, P 10mg and after extubation. Propofol suppressed EEG and MLR waves, but not SEP N₂O waves. N₂O suppressed the amplitude of SEP N₂O, but not EEG and MLR waves.

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A 71-year-old male was found to have latent acatalasemia when he rapidly developed methemoglobinemia during total laryngectomy. Methemoglobinemia was induced by a 300ml 1.5% hydrogen peroxide solution used to sterilize the oral cavity. Lack of catalase activity in the oral mucous membrane allowed the hydrogen peroxide to oxidize normal hemoglobin to methemoglobin. Initial clinical signs consisted of reduced oxygen saturation (SpO₂=80%) with high oxygen tension (PaO₂=235mmHg), a darkened blood color near the site of surgery and elevated methemoglobin (11%). His methemoglobinemia was treated with 2, 000mg intravenous ascorbic acid. Following surgery the patient experienced ulceration and edema of the oral mucoua, hemolytic anemia (Hb 7.7g/dl) and liver dysfunction (total bilirubin 5.6mg/dl). Analysis of blood enzymes revealed abnormally low red cell catalase activity. Examination of blood specimens from family members (mother and three children positive) confirmed inherited, asymptomatic acatalasemia.

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A 69-year-old man with diabetes mellitus (DM) was scheduled for vitrectomy. After retrobulbar anesthesia and akinesia, the patient developed bradycardia and hypotension. After performing temporary percutaneous pacing, an intravenous ventricular pacing cathe-ter was introduced. These symptoms were thought to be caused by acute myocardial infarction, since sinus arrest or complete atrial-ventricular-blocking were observed. Coronary angiography was performed and 100% obstruction of the first branch was recognized. PTCA was performed. The patient recieved administration of cathecholamines and IABP for a few days, then recovered completely. This case involved optical surgery under local anesthesia which simplifies preoperative examination and surgical management compared to using general anesthesia. With this method much greater attention should be paid during the perioperative period since patients with DM may develop general vascular complications.

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Coagulation factor X deficiency is a rare homeostatic disorder. Ten cases with factor X deficiency have been reported in Japan and only two of these were operated on. The authors present a case of factor X deficiency successfully treated pen-operatively by freeze-dried human blood-coagulation factor IX (PPSB-HT) administration. The patient was a seventy-one-year-old male with a colon tumor for which transverse colon resection was scheduled. Preoperative examination revealed that the patient had congenital factor X deficiency. To control this homeostatic disorder in the pen-operative period, the authors sought to maintain the blood level of factor X by intravenous administration of PPSB-HT. Prior to the operation, 1, 000 units of PPSB-HT was given intravenously, and the formula estimating the dose necessary to obtain the clinically effective level of factor X was determined. On the day of surgery, the patient received 2, 000 units of PPSB-HT, which was expected to achieve 80∼100% antigen activity. Perioperative hematological study of blood levels of coagulation factor IX, X and PT, APTT values suggested that the patient's hemostatic disorder was adequately controlled by the administration of PPSB-HT at the calculated dose, and intra-operative blood loss was only 75g. The patient experienced no complication and was discharged the hospital.

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The authors present the perioperative management of 3 patients diagnosed as pulmonary thromboembolism with pulmonary perfusion scintigraphy before surgery. Although pulmo-nary perfusion scintigraphy demonstrated defects in some segments, venoscintigraphy and venography for the lower extremities did not reveal residual thrombus, and all patients remained asymptomatic. General anesthesia was performed in two patients for lower abdominal surgeries, and spinal anesthesia was done in one patient for prostate biopsy. Five or three thousand units of heparin was administered subcutaneously two hours before surgery and every 8 or 12 hours following surgery for 3 postoperative days. However heparin was not administered before surgery in the patient with spinal anesthesia. All surgeries were uneventful. None of the patients had abnormal fidings in coagulation tests or increased postoperative bleeding. In patients with pulmonary thromboembolism perioper-ative management should be performed based on precise diagnosis by venoscintigraphy and venography. This report provides a rationale for elective surgery accompanied by perioperative anticoagulation therapy.

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A-34-year old female patient with Marfan syndrome with elevated cold agglutinins was scheduled to recieve Bentall and replacement of the ascending aorta and aortic arch under total cardio-pulmonary bypass with deep hypothermia and retrograde cold cardioplesia. Preoperatively, the patient recieved double filtration-plasmapheresis (DFPP) to reduce plasma cold agglutinin titers. No adverse effects due to cold agglutinin appeared during perioperative course, nevertheless the patient suffered from subdural hemorrhage and mediastinitis postoperatively. Reduction of fibrinogen and immunogloblin by DFPP was suspected as one of the causes of these complications.

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