법적・제도적 관점에서

학위논문(석사) -- 서울대학교대학원 : 인문대학 협동과정 기록학전공, 2023. 8. 정긍식.우리나라 대통령기록은 일반 공공기록과 동일하게 3단계 체제로 생산 및 관리되고 있다. 즉, 대통령기록생산기관에서 기록을 생산하고(현용기록 단계), 관할 기록관에서 그 기록을 관리 및 보관하며(준현용기록 단계), 대통령기록관에서 이관받은 기록을 보존하고 활용하여 국민들에게 다양한 기록 서비스를 제공한다(비현용기록 단계). 한편, ｢대통령기록물 관리에 관한 법률｣ 제23조에는 대통령기록관의 장이 대통령기록의 관리 및 대통령기록관의 운영과 관련한 제반 사무를 통할(統轄)한다고 규정되어 있다. 그렇다면 대통령기록관의 장이 통할하는 대통령기록관리의 대상에 현용기록, 준현용기록이 포함되는가? 아니면 대통령기록관은 대통령기록생산기관의 관할 기록관에서 넘겨준 기록을 이관받아 보존하고 활용하는, 사후적이고 수동적인 역할만을 하고 있는가? 이 질문에 대한 답을 찾기 위해 대통령기록관의 조직과 업무를 살펴보고, 대통령기록관이 2009년 발간한 ｢대통령기록생산기관 업무매뉴얼｣을 분석하였다. 또, 미국 국가기록관리처(NARA)와의 비교를 통해 우리나라 대통령기록관은 현재 어떠한 역할을 하고 있으며, 그 원인이 무엇인지 고찰하였다. 그 결과, 우리나라 대통령기록관이 비현용기록관리와 관련된 과업만을 주로 수행하는 반면, 현용기록과 준현용기록 단계에 대해서는 관리를 하지 못하고 있기 때문에 사실상 대통령기록 전반에 대한 통할의 역할이 부재한 상황에 있음을 확인하였다. 대통령기록관에서 대통령기록생산기관이나 그 관할 기록관에 대한 선제적인 방향 제시는 이루어지지 않고 있으며, 대통령기록관리가 사후적·수동적으로 이루어지고 있는 것이다. 그 원인을 세 가지로 분석해 보았다. 첫째는 대통령기록관 위상의 문제이다. 대통령기록관은 우리나라 최고의 기록을 다루는 기관임에도 불구하고 행정안전부에 소속되어 있어 그 위상이 낮으며, 독립성과 중립성을 확보하기에 어려움이 있다. 대통령기록관장의 신분보장이나 직무상 독립성을 보장하는 제도는 없으며, 고도의 전문성이 요구되는 대통령기록관 직원에게도 순환보직 체계를 적용함으로써 전문성의 제고가 이루어지지 않고 있다. 둘째는 권력구조의 문제이다. 이는 대통령 및 대통령기록의 특성에서 기인하는 것으로, 대통령기록생산기관, 그중에서도 대통령 보좌기관(대통령비서실)이 대통령의 최측근에 있는 권력기관이기 때문에 그 권한이 막강한 반면, 행정기관인 대통령기록관은 위상이 약하다. 이러한 권력의 불균형으로 대통령기록관이 통할의 역할을 해나가기에 한계가 있는 것이다. 셋째는 후진적 정치문화와 미성숙한 기록문화이다. 각 정당이 정권 창출과 기득권 유지를 주요 목적으로 삼는 정치문화 속에서 기록은 그 중요도가 낮거나 오히려 정쟁의 수단이 되어 왔고, 이후에 책임질 소지를 없애고자 기록을 남기지 않는 행태가 벌어져 왔다. 우리나라 전반적으로도 이를 감시하고 제재할 만큼 기록의 중요성에 대한 인식과 공감대가 형성되어 있지 않다. 이상의 이유에서 대통령기록관은 그 위상이 낮으며, 선제적인 통할의 역할을 하기 어려운 현실에 있다고 할 수 있다. 그러나 이 현실이 개선되지 않으면 대통령기록생산기관에서 기록을 남기지 않고 이관하지 않는 캐비닛 문건 발견 사태, 영포빌딩 논란이 재연될 수 있다. 또한, 현용, 준현용, 비현용기록은 연속선 상에 있는 것이기에, 양질의 대통령기록이 생산 및 보존되기 위해서는 각 대통령기록생산기관과 관할 기록관에 대한 관리가 필수적이다. 이에 대한 개선방안으로 첫째, 대통령기록관의 독립성과 대통령기록관장의 중립성의 확보, 예산 및 전문인력을 확보함으로써 대통령기록관의 위상을 강화해야 한다. 둘째, 대통령기록관과 대통령비서실이 유기적으로 협력함으로써 대통령기록관이 현용, 준현용기록 단계까지 통할하도록 해야 한다. 그 사례가 노무현 정부와 문재인 정부 때 있었다. 이를 위해 특히 대통령기록관의 생산지원과가 강화되어야 하며, 대통령비서실에서도 기록전담기관이 상시 설치되고 그 위상이 확보되어야 한다. 그 외에도 개별 대통령기록관의 건립, 생산단계에서의 시스템에 의한 기록관리, 대통령기록관의 역할 제고를 위한 ｢대통령기록물 관리에 관한 법률｣의 개정 등을 대안으로 생각해 볼 수 있다. 대통령기록관이 해야 할 본질적 역할로서 대통령기록관리 전반을 통할해야 함을 제시한 것과, 대통령기록관과 대통령비서실 간 협력 구축이라는 관계적 측면에서 대안을 제시했다는 것에 본 연구의 의의가 있다.Presidential Records in Korea are produced and managed in the three-level system, similar to the management of general public records. In other words, the Presidential Record Creation Institutions produces records (active records), the competent record repositories manages and stores the records (semi-active records), and the Presidential Archives preserves and utilizes the transferred records to provide various records to the public (non-active records). On the other hand, Article 23 of the Act on the Management of Presidential Records stipulates that the Head of Presidential Archives shall take overall charge of various duties concerning the management of the Presidential records and the operation of the Presidential Archives, and direct and supervise affiliated staff members. If so, are active and semi-active records included in the Management of Presidential Records and is it under the control of the head of the Presidential Archives? Or does the Presidential Archives have an ex-post and passive role in the preservation and utilization of the archives handed from the record repositories of the Presidential Record Creation Institutions? To find an answer to this question, the organization and work of the Presidential Archives were examined, and the Presidential Record Creation Institutions Operation Manual published by the Presidential Records in 2009 was analyzed. In addition, the current role of the Korean Presidential Archives and its reason was considered through comparison with the National Archives and Records Administration (NARA) of the United States. As a result, while the Presidential Archives in Korea mainly performs tasks related to the management of non-active records, it does not manage the active and semi-active records. Therefore, it was confirmed that there is virtually no role to control the overall Presidential records. The Presidential Archives does not proactively suggest directions for the Presidential Record Creation Institutions nor the competent record repositories under its jurisdiction. Management of the Presidential Archives is carried out ex-post and passively. Three causes were analyzed. First is the issue of the status of the Presidential Archives. Despite being the best institution in Korea to handle records, the Presidential Archives is affiliated with the Ministry of the Interior and Safety, so its status and position is modest, and therefore difficult to secure autonomy and impartiality. There is no system that guarantees the status or independence of the head of the Presidential Archives, and there is no professional enhancement due to the rotating position system of the Presidential Archives staff, who require a high level of expertise. Second is the issue of power structure. This is attributable to the characteristics of the President and Presidential records. Presidential Record Creation Institutions, especially the institutions assisting the President (Presidential Secretariat), are the most powerful institutions closest to the President, so their authority is powerful, whereas the Presidential Archives, an administrative institution, has weaker status. Due to this power imbalance, there are limits to the role of the Presidential Archives in governance. Third is backward political culture and primitive culture of record keeping. In a political culture where the main purpose of each political party is form the government and maintain vested interests, records have been less important or have become a means of political disputes. In Korea as a whole, there is not enough awareness and consensus on the importance of records to monitor and sanction them. For the above reasons, the Presidential Archives has a low status, and it can be said that it is difficult to play a proactive role of control. Addressing these challenges is essential to avoid reoccurrences of incidents like the Discovery of Cabinet Documents' and the ' Controversy of Yeongpo Building', where records were not kept and transfered by the Presidential Record Creation Institutions. In addition, given the continuous nature of active, semi-active, and non-active records, it is essential to manage the Presidential Record Creation Institution and each competent record repositories in order to produce and preserve high-quality presidential records. As a measure of improvement, first, it is necessary to strengthen the status of the Presidential Archives by securing the independence of the Presidential Archives, the neutrality of the head of the Presidential Archives, and securing sufficient budget and professional manpower. Second, the Presidential Archives and the Office of the President should cooperate organically so that the Presidential Archives has control over the active and semi-active records. Case in point was the Roh Moo-hyun and Moon Jae-in administration. For this purpose, the Record Creation Support Division of the Presidential Archives should be strengthened, and an institution dedicated to record keeping should be established permanently in the Presidential Secretariat with a secured status. Other alternatives include the establishment of individual Presidential Archives, systemic record management at the production stage, and the revision of the Act on the Management of Presidential Records to enhance the role of the Presidential Archives. The significance of this study lies in proposing the essential role that the Presidential Archives should fulfill in overseeing presidential record management as a whole and presenting alternatives from the 'relational perspective' of building cooperation between the Presidential Archives and the Presidential Secretariat.제 1 장 머리말 1 제 1 절 연구의 배경과 목적 1 제 2 절 선행연구 4 제 3 절 연구의 내용과 방법 9 1. 연구의 내용 9 2. 연구의 방법 10 제 2 장 이론적 배경 12 제 1 절 대통령기록의 개념 12 1. 대통령기록의 정의 12 2. 대통령의 특수성 13 3. 대통령기록의 특수성 14 제 2 절 대통령기록 생산현황 분석 16 1. 대통령기록 생산현황 16 2. ｢대통령기록물법｣ 제정 이전 18 제 3 절 ｢대통령기록물법｣의 연혁과 주요 내용 19 1. ｢대통령기록물법｣의 연혁 19 2. ｢대통령기록물법｣의 주요 내용 23 3. 대통령기록관과 3단계 체제 28 제 3 장 대통령기록관의 역할과 문제점 31 제 1 절 대통령기록관의 역할 분석 31 1. 대통령기록관 개요 31 2. 대통령기록관의 역할 31 3. 미국 국가기록관리처 분석 36 4. 종합과 정리 42 제 2 절 원인 분석 45 1. 대통령기록관 위상의 문제 45 2. 권력구조의 문제 49 3. 후진적 정치문화와 미성숙한 기록문화 51 제 4 장 개선방안 57 제 1 절 대통령기록관의 위상 강화 57 1. 대통령기록기관의 독립성 확보 57 2. 대통령기록관장의 중립성 확보 58 3. 예산 및 전문인력의 확보 58 제 2 절 대통령기록관과 대통령비서실의 협력 구축 59 1. 미국 국가기록관리처의 사례 59 2. 노무현 정부와 문재인 정부의 사례 61 3. 대통령기록관 생산지원과의 강화 67 4. 기록관리비서관실의 상시 설치와 위상 확보 68 제 3 절 기타 사항 71 1. 개별 대통령기록관 건립 71 2. 시스템에 의한 기록관리 73 3. ｢대통령기록물법｣의 개정 76 제 5 장 맺음말 80 제 1 절 연구의 요약과 정리 80 제 2 절 연구의 의의와 후속 과제 83 1. 연구의 의의 83 2. 연구의 한계와 과제 84 참고문헌 86 Abstract 91석

The effect of milrinone on the intraoperative hemodynamics during off-pump coronary bypass surgery in patients with an elevated echocardiographic index of the ventricular filling pressure

BACKGROUND: Hemodynamic derangement during off-pump coronary artery bypass surgery (OPCAB) is mainly attributed to impaired filling and diastolic dysfunction. An elevated ratio of the mitral velocity to the early-diastolic velocity of the mitral annulus (E/e' > 15) is a relatively new indicator of diastolic function, and this was reported to be associated with impaired hemodynamics during OPCAB. We investigated the efficacy of milrinone on the perioperative hemodynamics and short term outcomes of patients with an E/e' > 15 and who underwent OPCAB. METHODS: The patients were randomly allocated into either group C (control, n = 31) or group M (n = 31) and they were treated with the same amount of either normal saline or milrinone (0.5 µg/kg/min) without bolus loading after completion of internal mammary artery harvest until the end of operation. Hemodynamic measurements were recorded after the induction of anesthesia (T1), 5 min after starting each distal anastomosis of the left anterior descending artery (T2), left circumflex artery (T3) and right coronary artery (T4), and 5 min after sternum closure (T5). RESULTS: The mixed venous oxygen saturation (SvO(2)) was lower through T2-T4 compared to the baseline value in both groups, while the degree of the decrease was significantly less in group M than that in group C. The other hemodynamic variables, the operative data and the postoperative outcomes were similar between the two groups. CONCLUSIONS: Intraoperative infusion of milrinone did not significantly improve the perioperative hemodynamics and the subsequent short term outcomes for the patients with preexisting diastolic dysfunction as represented by an elevated E/e' value, although it reduced the degree of decrease of the SvO(2) during OPCAB.ope

Prognostic value of a tissue Doppler-derived index of left ventricular filling pressure on composite morbidity after off-pump coronary artery bypass surgery

BACKGROUND: The ratio of early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/e') is an indicator of diastolic function that correlates well with left ventricular (LV) filling pressure and is relatively independent of systolic function and rhythm abnormalities. We prospectively evaluated the predictive value of E/e' for postoperative outcome in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB). METHODS: Patients undergoing OPCAB were classified into three groups according to their E/e' ratio: (i) normal E/e' 15. Among those with E/e' between 8 and 15, patients with elevated LV filling pressure were further identified by comprehensive Doppler examination. These patients were classified as having a high LV filling pressure, together with patients who had E/e' ratios >15. Univariate and multivariate regression analyses were used to evaluate the relationship between preoperative variables and composite endpoints for morbidity. RESULTS: In univariate analysis, diabetes mellitus, recent myocardial infarction, chronic obstructive pulmonary disease, serum creatinine (sCr) concentration, E/e' >15, high LV filling pressure, LV ejection fraction, New York Heart Association class III and IV, and use of diuretics were significant risk factors for postoperative morbidity. In multivariate regression analysis of these variables, only sCr (odds ratio 1.4) and E/e' >15 (odds ratio 2.4) or high LV filling pressure (odds ratio 2.8) remained as independent risk factors. CONCLUSIONS: E/e' ratio >15 was a significant predictor of composite endpoints of postoperative morbidity. We suggest that E/e' ratio should be included in the routine preoperative assessment of patients presenting for OPCAB.ope

Efficacy of dexamethasone added to ramosetron for preventing postoperative nausea and vomiting in highly susceptible patients following spine surgery.

BACKGROUND: Opioid-based patient controlled analgesia (PCA) provides adequate pain control following spinal surgeries at the expense of increased risk of postoperative nausea and vomiting (PONV). We evaluated the efficacy of dexamethasone added to ramosetron, which is a newly developed five-hydroxytryptamine receptor 3 antagonist with a higher receptor affinity and longer action duration compared to its congeners, on preventing PONV in highly susceptible patients receiving opioid-based IV PCA after spinal surgery. METHODS: One hundred nonsmoking female patients undergoing spinal surgery were randomly allocated to either a ramosetron group (group R) or a ramosetron plus dexamethasone group (group RD)., Normal saline (1 ml) or 5 mg of dexamethasone was injected before anesthetic induction, while at the end of the surgery, ramosetron (0.3 mg) was administered to all patients and fentanyl-based IV PCA was continued for 48 hrs. The incidence and severity of PONV, pain score and the amount of rescue antiemetics were assessed for 48 hours after surgery. RESULTS: The number of patients with moderate to severe nausea (20 vs. 10, P = 0.029), and overall incidence of vomiting (13 vs. 5, P = 0.037) were significantly lower in the group RD than in the group R, respectively. Rescue antiemetic was used less in the RD group without significance. CONCLUSIONS: Combination of ramosetron and dexamethasone significantly reduced the incidence of moderate to severe nausea and vomiting compared to ramosetron alone in highly susceptible patients receiving opioid-based IV PCA after surgery.ope

Caspase-3 억제와 GATA-4 조절을 통해 bcl-2을 증가시킴으로서 고혈당증에 의해 악화된 심근의 허혈-재관류 손상을 감소시키는 erythropoietin의 효과

Dept. of Medicine/박사Erythropoietin (EPO), an essential hormone for erythropoiesis, can provide protection against myocardial ischemia/reperfusion (I/R) injury. Hyperglycemia during acute myocardial infarction is common and associated with increased organ damage and attenuated efficacy of protective measures. This study aimed to investigate whether EPO could ameliorate the myocardial I/R injury in hyperglycemic rats as well as in normoglycemic rats. Eighty-two Sprague-Dawley rats were randomly assigned to six groups: normoglycemia (NG)-Sham, NG-I/R–control (IRC), NG-I/R-EPO (IRE), hyperglycemia (HG)-Sham, HG-IRC, and HG-IRE. The rats received 1.2 g/kg dextrose or the same volume of normal saline depending on the group. I/R was induced by a 30 min period of ischemia followed by reperfusion for 4 h. For 1 h before I/R injury, intravenous 4000 IU/kg of EPO was administered. EPO pretreatment significantly reduced the infarct size, number of apoptotic cells, and caspase-3 activity compared with untreated I/R rats in hyperglycemic condition. I/R-induced down-regulation of Bcl-2 in myocardium was remarkably attenuated in EPO pretreatment groups under hyperglycemic conditions. EPO administration significantly down-regulated the level of GATA-4 degradation, which was associated with increased stability caused by ERK-regulated GATA-4 post-translational modifications in the myocardium following I/R in hyperglycemic conditions. These results indicate that the protective mechanism of EPO pretreatment before I/R injury involves up-regulation of Bcl-2 via not only down-regulation of caspase-3 activity but also increase of ERK-induced GATA-4 stability in hyperglycemic condition.ope

체외순환 없는 관상동맥우회술시 혈역학적 불안정을 예측할 수 있는 수술 전 요인

Dept. of Medicine/석사[한글] 서론심장수술에 있어서 수술 기법, 마취 유지 방법, 고정장치의 발전에 따라 체외순환 없는 관상동맥우회술(off-pump coronary artery bypass graft surgery, OPCAB)이 각광 받고 있으며 체외순환을 사용하는 관상동맥우회술과 비교하여 유사한 안전성과 우회로의 개통성를 보인다[1,2]. 하지만 체외순환을 하지 않을 경우 우회로 조성과 수술부위 확보를 위한 심장의 변위는 심방압 증가, 심박출지수 감소, 혼합정맥혈 산소포화도(SvO2) 감소를 초래하며 심방의 충만압 증가와 크기 증가는 이완기 장애로 이어진다. 체외순환 없는 관상동맥 우회술시 응급으로 체외순환으로 전환하는 경우 환자의 이환율과 사망률이 현저히 증가한다. 본 연구에서는 OPCAB을 시행 받았던 환자들을 OPCAB중 혈역학적 변화가 가장 심한 둔각 변연지 문합시 SvO2가 60% 이하와 이상으로 유지되었던 군으로 나누어 수술 전 심실의 이완기 기능을 나타내는 지표들을 포함한 여러 인자들을 비교하고 SvO2의 저하와의 연관성을 조사하였다.대상 및 방법본원에서 OPCAB을 시행받은 204명의 환자들을 대상으로 둔각 변연지 문합중 1. SvO2 < 60% 인 군과 2. SvO2 ≥ 60% 인 군으로 나눈 후 이미 알려진 체외순환으로의 전환을 고려해야 하는 지표들과 수술전 심초음파에서 이완기 장애를 나타내는 지표 및 좌심실 비대 정도 등을 두 군간 비교하여 혈역학적 불안정을 예측할 수 있는 요인들을 비교하고 SvO2의 저하와의 연관성을 분석하였다.결과문합시 혈역학적 불안정과 연관이 있는 인자들은 연령, 수술전 좌심실 박출분율 그리고 좌심실 이완기 충만압을 나타내는 지표 (E/E’)로 나타났으며 문합중 혼합정맥혈 산소포화도가 60%이하로 감소되었던 환자들이 입원일수가 유의하게 많은 것으로 관찰되었다.고찰 및 결론관상동맥 문합 중 발생하는 SvO2의 저하와 이로 인한 혈역학적 불안정의 가능성이 높은 고령, 수술전 좌심실 박출분률과 좌심실 이완기 충만압이 증가된 환자에 있어서는 수술중 심장수축 촉진제의 사용등 적절한 치료가 중요하며 수술전 선택적 체외순환 관상동맥우회술의 가능성 또한 고려해 보아야 한다. [영문]IntroductionDue to the advances in stabilization devices, surgical technique and anesthetic management strategies, multivessel off-pump coronary artery bypass surgery (OPCAB) has gained increased popularity with comparable safety and early graft patency to conventional on-pump coronary artery bypass grafting (CABG) [1,2]. For complete revascularization during OPCAB, the heart must be lifted and tilted in order to expose the posterior and lateral wall of the heart. This displacement of the heart causes increase in atrial pressures, decrease in cardiac index (CI) leading to a reduced mixed venous saturation (SvO2). The positional change of the apex increases the filling pressure and the size of the atria which impairs diastolic filling and causes diastolic dysfunction[5]. These changes may cause significant hemodynamic derangement leading to emergent conversion to on-pump CABG. The patients who required conversion to on-pump have significantly higher operative mortality and morbidity than either completed OPCAB or on-pump CABG patients [6, 7]. Therefore we evaluated the relationship between preoperative patients’ characteristics including indices of diastolic function with drop in SvO2 during grafting as a marker of hemodynamic deterioration during mechanical displacement of the heart and their effects on patients’ outcome following multivessel OPCABPatients and MethodsA total of 204 consecutive patients scheduled for elective, isolated, multivessel OPCAB at Severance Hospital between March 2006 and September 2007 were studied prospectively. During the period of heart displacement, mean systemic arterial pressure was maintained above 70 mmHg with norepinephrine infusion. SvO2 was calibrated using venous blood gas analyses, 15 min after the induction and during Y-graft construction and continuously monitored. Patients were allocated into two groups according to SvO2 values during grafting; 1) patients with SvO2 ≥ 60%, Group 1, 2) patients with SvO2 < 60%, Group 2. Patients’ characteristics and preoperative transthoracic echocardiographic variables including indices of diastolic function were LVEF, degree of MR, LVEDD, LVESD, IVSd, IVSs, LA volume index, and E/E’ were assessed. Intraoperative characteristics including operation time, number of grafts performed, total duration of distal anastomoses, and total amount of infused fluid and urine output and postoperative data including 24h postoperative CK-MB level, length of stay in the ICU and total length of postoperative hospitalization were evaluated. To characterize the patients developing decrease in SvO2 and its effect on postoperative outcome, data between the groups were compared using Chi-square test, Fisher's exact test or independent t-test as appropriate.ResultsNone of the patients required conversion to emergency on-pump CABG. The increased preoperative echocardiographic index of diastolic function (E/E’), advanced age and increased LVEF were independent risk factors of more pronounced hemodynamic deterioration during grafting. The patients who had decreased SvO2 to below 60% during grafting required significantly longer length of postoperative hospitalization.ConclusionThe appropriate therapeutic measures, such as use of inotropic support and elective on-pump CABG should be considered in patients with increased preoperative echocardiographic index of diastolic function (E/E’), advanced age and increased LVEF.ope

Optimal dose of propofol for intubation after sevoflurane inhalation without neuromuscular blocking agent in children

BACKGROUND: This study was designed to determine the optimal dose of propofol for excellent intubating conditions in children without neuromuscular blockade at various alveolar concentrations of sevoflurane. METHODS: Sixty-three children, aged 0.5-5 years, were randomized to three groups of end-tidal sevoflurane concentration (ETsevo) 3%, 3.5%, and 4%. Inhalation anesthesia was started with sevoflurane 7% in 100% oxygen. When the patients became unconscious, inspired concentration was adjusted to obtain the target ETsevo for each group. When ETsevo reached the target concentration, a predetermined dose of propofol was given and tracheal intubation was performed. The proper dose of propofol was determined using the 'up-and-down' method. RESULTS: The median dose (95% confidence intervals) of propofol for excellent tracheal intubating conditions in 50% of children were 1.25 mg/kg (0.84-1.75) at ETsevo of 3%, 0.76 mg/kg (0.35-1.21) at 3.5%, and 0.47 mg/kg (0.26-1.09) at 4%. The frequency of adverse effects was not different between groups during induction and recovery. CONCLUSION: Propofol 1.5-2 mg/kg provides excellent intubating conditions at 3-4% ETsevo in children without using any neuromuscular blocking agent.ope

Optimal effect-site concentration of remifentanil for preventing cough during emergence from sevoflurane-remifentanil anaesthesia.

This randomised, double-blinded, controlled trial was designed to identify the optimal dose of remifentanil for cough suppression without adverse effects during emergence from sevoflurane-remifentanil anaesthesia for thyroidectomy. One hundred and four patients were randomly assigned to maintain target effect-site concentrations of remifentanil at 0 (control group), 1.0 (remifentail 1 group), or 1.5 ng.ml(-1) (remifentanil 1.5 group) during emergence. The incidence of coughing was lower in the remifentanil 1.5 group (31%) than in the control group (74%) or remifentanil 1 group (63%) (p = 0.0004). In addition, the severity of coughing during extubation was lower in the remifentanil 1.5 group (median (IQR [range]) 0 (0-1 [0-1]) than in the control group (1 (0-2 [0-3])) and remifentanil 1 group (1 (0-2 [0-3])) (p = 0.004). Haemodynamic changes were reduced, but emergence time and stay in the post-anaesthesia care unit was prolonged in the remifentanil 1.5 group. Maintaining the remifentanil effect-site concentration at 1.5 ng.ml(-1) during emergence from sevoflurane-remifentanil anaesthesia reduces the incidence and severity of coughing without serious adverse events and may provide haemodynamic stability in patients undergoing thyroidectomy. However, awakening may be delayed.ope