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BackgroundIntravenous (IV) dexamethasone prolongs the duration of a peripheral nerve block; however, there is little available information about its optimal effective dose. This study aimed to evaluate the effects of three different doses of IV dexamethasone on the duration of postoperative analgesia to determine the optimal effective dose for a sciatic nerve block.MethodsPatients scheduled for foot and ankle surgery were randomly assigned to receive normal saline or IV dexamethasone (2.5 mg, 5 mg, or 10 mg). An ultrasound-guided popliteal sciatic nerve block was performed using 0.75% ropivacaine (20 ml) before general anesthesia. The duration of postoperative analgesia was the primary outcome, and pain scores, use of rescue analgesia, onset time, adverse effects, and patient satisfaction were assessed as secondary outcomes.ResultsCompared with the control group, the postoperative analgesic duration of the sciatic nerve block was prolonged in groups receiving IV dexamethasone 10 mg (P < 0.001), but not in the groups receiving IV dexamethasone 2.5 mg or 5 mg. The use of rescue analgesics was significantly different among the four groups 24 h postoperatively (P = 0.001) and similar thereafter. However, pain scores were not significantly different among the four groups 24 h postoperatively. There were no statistically significant differences in the other secondary outcomes among the four groups.ConclusionsThis study demonstrated that compared to the controls, only IV dexamethasone 10 mg increased the duration of postoperative analgesia following a sciatic nerve block for foot and ankle surgery without the occurrence of adverse events.

The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.

Inadvertent thermal injury can occur in pediatric patients under general anesthesia during knee arthroscopic surgery. Here, we report the case of a 10-year-old boy who underwent knee arthroscopic surgery under general anesthesia. After the surgery, he complained of pain in the left lower part of his chin and was diagnosed as having a thermal burn. At three-month follow-up, he recovered without any abnormalities except mild hypertrophy of the wound area. Although rare, arthroscopic surgery has the potential to cause thermal injury from the light source. We recommend that the light source should be connected to the arthroscope before switching the power on and disconnected after a considerable time of switching the power off when not in use.

Seborrheic dermatitis is a chronic recurrent inflammatory disorder presumed to be caused by increased sebaceous gland secretion, metabolic changes in the cutaneous microflora, and changes in the host immune function. Stellate ganglion block (SGB) is known to increase the blood flow rate without altering the blood pressure, heart rate, or cardiac output, to stabilize hypertonic conditions of the sympathetic nerves, and to affect the endocrine and immune systems. It is used in the differential diagnosis and treatment of autonomic nervous system disorders of the head, neck, and upper limbs. The authors report the first case of successful treatment of a patient with seborrheic dermatitis through repeated SGB trials.

BACKGROUND Postoperative nausea and vomiting (PONV) is one of the major concerns after anesthesia and surgery, and it may be more frequent in orthopedic patients receiving patient-controlled epidural analgesia (PCEA). The purpose of this study was to compare the effect of palonosetron and dexamethasone on the prevention of PONV in patients undergoing total joint arthroplasty and receiving PCEA. METHODS Patients scheduled for total hip or knee arthroplasty under spinal anesthesia/PCEA were randomly allocated to receive either intravenous palonosetron (0.075 mg, n = 50) or dexamethasone (5 mg, n = 50). Treatments were administered intravenously to the patients 30 min before the beginning of surgery. The total incidence of PONV and incidence in each time period, severity of nausea, need for rescue anti-emetics, pain score, and adverse effects during the first 48 h postoperatively were evaluated. RESULTS The total incidence of PONV was lower in the palonosetron group compared with the dexamethasone group (18.4% vs. 36.7%, P = 0.042), but there were no statistically significant differences in incidence between the groups at all time points. No significant intergroup differences were observed in the severity of nausea, use of rescue anti-emetics, pain score, and adverse effects. CONCLUSIONS Although there were no significant differences in the incidence of PONV between the treatment groups at all time points, intravenous palonosetron reduced the total incidence of PONV in orthopedic patients receiving PCEA compared with dexamethasone.

One-third of all hospital-regulated medical waste (RMW) comes from the operating room (OR), and it considerably consists of disposable packaging and wrapping materials for the sterilization of surgical instruments. This study sought to identify the amount and type of waste produced by ORs in order to reduce the RMW so as to achieve environmentally-friendly waste management in the OR. We performed an initial waste segregation of 4 total knee replacement arthroplasties (TKRAs) and 1 total hip replacement arthroplasty, and later of 1 extra TKRA, 1 laparoscopic anterior resection of the colon, and 1 pelviscopy (with radical vaginal hysterectomy), performed at our OR. The total mass of non-regulated medical waste (non-RMW) and blue wrap amounted to 30.5 kg (24.9%), and that of RMW to 92.1 kg (75.1%). In the course of the study, we noted that the non-RMW included recyclables, such as papers, plastics, cardboards, and various wrapping materials. The study showed that a reduction in RMW generation can be achieved through the systematic segregation of OR waste.

Background: Demand of anesthesia for patients with cerebral palsy is more increasing. But there is still lacking in clinical research regarding how BIS and entropy reflect well on sedative and hypnotic state in patients with cerebral palsy. Methods: Fifteen patients with cerebral palsy (Group CP) and fifteen patients without cerebral palsy (Group NL) scheduled for elective orthopedic surgery were included in the study. Induction of anesthesia was done by having the patient inhale 1 vol% sevoflurane and 100% oxygen using a total fresh gas flow of 8 L/min. Simultaneously BIS, state entropy (SE), response entropy (RE), end-tidal sevoflurane concentration were recorded every 15 seconds till there was no self respiration. When end-tidal sevoflurane concentration had not risen any more for 30 seconds, we increased inhaled sevoflurane concentration in 1 vol% increments. End point of recording was when self respiration was lost or the time sevoflurane concentration reached 8 vol%. Results: No significant differences in RE, SE, BIS at baseline and end point were found between the two groups. No significant difference in the time reach end point was found between the two groups. BIS, SE and RE correlated with end-tidal sevoflurane concentration in the two groups. Conclusions: The authors found no significant difference in the entropy values between patients with CP and normal patients. Also, the entropy values could be interpreted like BIS in patients with CP. And BIS showed a stronger correlation with end tidal sevoflurane concentrations than entropy. (Korean J Anesthesiol 2009;57:422~7)

Joubert syndrome is a rare autosomal recessive condition in which there is complete or partial agenesis of the cerebellar vermis. The clinical features are hypotonia, ataxia, mental retardation, abnormal ocular movements, typical facial features and episodic tachypnea with alternating apnea. The abnormal respiratory pattern and hypotonia may be exacerbated by anesthetics, and especially, the apneic episodes may be prolonged by administering opioids. Joubert syndrome has been associated with various airway abnormalities such as a high and arched palate, a large or protruding tongue, laryngomalacia, a variable epiglottis and micrognathia. These abnormalities may cause difficulty with tracheal intubation. In this present case, direct laryngoscope-assisted, fiberscopic guided intubation was performed. This case is the first report of anesthetic management in a patient with Joubert syndrome and who underwent palatoplasty in Korea.

Pneumocephalus is common after brain surgeries, but usually is not substantial enough to cause serious complications. We recently encountered a case of post-operative tachypnea after an endoscopic 3rd ventriculostomy. At first, we thought that the hyperventilation was the result of residual paralysis after emergence from anesthesia, but during further evaluation we found a massive pneumocephalus. In such unusual post-operative situations, physicians should consider surgery-related complications as the possible cause as well, along with the anesthetic factors.

Background Electromyography and acceleromyography are common neuromuscular monitoring devices. However, questions still remain regarding the use of acceleromyography in children. This study compared the calibration success rates and intubation conditions in children after obtaining the maximal blockade depending on each of the devices. Methods Children, 3 to 6 years old, were randomly allocated to the TOF-Watch SX acceleromyography group or the NMT electromyography group. The induction was performed with propofol, fentanyl, and rocuronium. The bispectral index and 1 Hz single twitch were monitored during observation. The calibration of the each device was begun when the BIS dropped to 60. After successful calibration, rocuronium 0.6 mg/kg was injected. A tracheal intubation was performed when the twitch height suppressed to 0. The rocuronium onset time (time from administration to the maximal depression of twitch height) and intubating conditions were rated in a blinded manner. Results There was no difference in the calibration success rates between the two groups; and the calibration time in the electromyography group (16.7 ± 11.0 seconds) was shorter than the acceleromyography group (28.1 ± 13.4 seconds, P = 0.012). The rocuronium onset time of the electromyography group (73.6 ± 18.9 seconds) was longer than the acceleromyography group (63.9 ± 18.8 seconds, P = 0.042) and the intubation condition of the electromyography group (2.27 ± 0.65) was better than the acceleromyography group (1.86 ± 0.50, P = 0.007). Conclusions Electromyography offers a better compromise than acceleromyography with respect to the duration of calibration process and surrogate for the optimal time of tracheal intubation in children.

Background We investigated the effects of the combined administration of nefopam, a N-methyl-D-aspartate receptor antagonist and low dose remifentanil, on early postoperative pain and analgesic requirement. Methods Fifty patients scheduled to undergo mastoidectomy and tympanoplasty were randomized to be given either nefopam 40 mg mixed with normal saline 100 ml (Group N) or an equal amount of normal saline (Group C) before anesthesia induction. Anesthesia was maintained with 5-6 vol% desflurane and remifentanil 0.05-0.15 µg/kg/min during the surgery. Postoperative pain was controlled by titration of ketorolac in the postanesthesia care unit (PACU) and ward. We evaluated the intraoperative remifentanil dose, recovery profiles, ketorolac demand in the PACU and ward, numeric rating scale (NRS) for pain at time intervals of every 10 min for 1 h in the PACU, 6, 12, 18 and 24 h in a ward, as well as the time to first analgesic requirement in the PACU and ward. Results Ketorolac demand and NRS in the PACU were significantly lower in Group N than Group C (P = 0.002, P = 0.005, respectively). The time to first analgesic requirement in the PACU in Group N were significantly longer than Group C (P = 0.046). There were no significant differences in intraoperative remifentanil dose, ketorolac demand, NRS, and the time to first analgesic requirement in the ward between the groups. Conclusions Nefopam administration combined with low dose remifentanil infusion reduces pain and analgesic consumption during the immediate postoperative period in patients undergoing middle ear surgery under desflurane anesthesia.

The use of neuraxial anesthesia has traditionally been contraindicated in patients with severe aortic stenosis. However, general anesthesia can be riskier than neuraxial anesthesia for severe aortic stenosis patients undergoing spinal surgeries in the prone position as this can cause a major reduction in cardiac output secondary to diminished preload. In addition, general anesthesia, muscle relaxation, and positive-pressure ventilation can decrease venous return and reduce vascular tone, further compromising cardiac output. Combined spinal-epidural anesthesia with closely monitored, careful titration of the local anesthetic dose can be an efficient and safe anesthetic method for managing such patients. We describe the successful management of combined spinal-epidural anesthesia in an asymptomatic severe aortic stenosis patient scheduled for lumbar discectomy.

Background Recent research has shown that reactive oxygen species (ROS) play a significant role in the development and persistence of neuropathic pain through central sensitization via N-methyl-D-aspartate (NMDA) receptor activation. In the present study, we examined whether the intraperitoneal administration of vitamins C and E alone or together could alleviate mechanical allodynia in a chronic post-ischemia pain (CPIP) rat model. Methods Vitamins C and E were administered intraperitoneally to 48 male Sprague Dawley rats once per day for 3 days before hindpaw ischemia-reperfusion (I/R) injury was induced. On the third day, the CPIP rat model was produced by inducing ischemia in the left hindpaw by applying an O-ring for 3 h, followed by reperfusion. Three days after reperfusion, hindpaw mechanical allodynia was assessed by measuring the withdrawal response to von Frey filament stimulation. The rats were sacrificed immediately after behavioral testing to determine the phosphorylated NMDA receptor subunit 1 (pNR1) and extracellular-signal-regulated kinases (pERK) levels in the spinal cord. Results When the antioxidant vitamins C and E were administered intraperitoneally to CPIP rats, I/R injury-induced mechanical allodynia was attenuated, and pNR1 and pERK levels were decreased in the rat spinal cord. Additionally, the co-administration of both vitamins had an increased antiallodynic effect. Conclusions The reduced phosphorylated NR1 and ERK levels indicate that vitamins C and E inhibit the modulation of spinal cord neuropathic pain processing. Co-administration of vitamins C and E had a greater antiallodynic effect.

Background Postoperative nausea and vomiting (PONV) is the major complication related to general anesthesia, occurring in 60-80% of patients after thyroidectomy. The objective of this study was to compare the effects of an intraoperative dexmedetomidine infusion with remifentanil, as anesthetic adjuvants of balanced anesthesia, on PONV in patients undergoing thyroidectomy. Methods Eighty patients scheduled for thyroidectomy were randomized into the following two groups: 1) The dexmedetomidine group (Group D), who received an initial loading dose of dexmedetomidine (1 µg/kg over 10 min) during the induction of anesthesia, followed by a continuous infusion at a rate of 0.3-0.5 µg/kg/h; 2) the remifentanil group (group R), who received remifentanil at an initial target effect site concentration of 4 ng/ml during the induction of anesthesia, followed by a target effect site concentration of 2-3 ng/ml. PONV was assessed during the first 24 hours in 2 time periods (0-2 h and 2-24 h). The pain intensity, sedation score, extubation time, and hemodynamics were also assessed. Results During the 2 time periods, the incidence and severity of PONV in group D were significantly lower than in group R. In addition, the need for rescue antiemetics was significantly lower in group D than in group R. The effect of dexmedetomidine on postoperative pain relief (2-24 h) was superior to that of remifentanil. The hemodynamics were similar in both groups, whereas eye opening and extubation time were delayed in group D. Conclusions Adjuvant use of intraoperative dexmedetomidine infusion may be effective for the prevention of PONV.

Patients with cervical spine instability and limited range of motion are challenge to anesthesiologists. It is important to consider alternatetive methods for securing the airway while maintaining neutral position and minimizing neck motion, because these patients are at increased risk for tracheal intubation failure and neurologic injury during airway management or position change. We experienced two cases that patients had cervical spine instability and severe limited range of motion due to the fusion of the entire cervical spine. One patient was a 6-year-old girl weighing 12.7 kg and had Klippel-Feil syndrome with Arnold-Chiari malformation, the other was a 24-year-old female weighing 31 kg and had juvenile rheumatoid arthritis. We successfully performed the intubation by using the fiberoptic intubation though a laryngeal mask airway in these two cases.

Background: Total knee arthroplasty (TKA) generates severe postoperative pain in 60% of patients and moderate pain in 30% of patients. Because inadequate postoperative pain control can hinder early physiotherapy and rehabilitation, it is the most influential factor dictating a good outcome. The purpose of this study was to evaluate the effectiveness of continuous psoas compartment block (PCB) in comparison to intravenous patient-controlled analgesia (IVPCA) in TKA patients. Methods: 40 TKA patients were randomly divided into 2 groups. Group IVPCA (n = 20) received intravenous patient controlled analgesia (IVPCA) for 48 hours. Group PCB (n = 20) received continuous PCB for 48 hours at the fourth intertransverse process of the lumbar using the C-arm. Pain scores, side effects, satisfaction, the length of hospital stay, rescue antiemetics, and analgesics were recorded. Results: Pain scores (VNRS 0-100) were higher in Group IVPCA than in Group PCB. Nausea and sedation occurred more frequently in Group IVPCA than in Group PCB. There were no differences between the groups in the length of the hospital stay, satisfaction scores, and the use of rescue antiemetics and analgesics. Conclusions: Continuous PCB seemed to be an appropriate and reliable technique for TKA patients, because it provided better analgesia and fewer side effects such as nausea and sedation when compared to IVPCA. (Korean J Anesthesiol 2012; 62: 47-51)

Background Since 2009, database construction of anesthesia-related adverse events has been initiated through the legislation committee of the Korean Society of Anesthesiologists (KSA), based on expert consultation referrals provided by police departments, civil courts, and criminal courts. Methods This study was a retrospective descriptive analysis of expert consultation referrals on surgical anesthesia-related cases between December 2008 and July 2010. Results During the given period, 46 surgical anesthesia-related cases were referred to the KSA legislation committee for expert consultation. Because six cases were excluded due to insufficient data, 40 cases were included in the final analysis. Of 40 cases, 29 (72.5%) resulted in death. Respiratory events were most common in both surviving/disabled and dead patients (36.4 vs. 51.7%, respectively; P > 0.05). Overall, respiratory depression due to the drugs used for monitored anesthesia care (MAC) was the most common specific mechanism (25%), in which all but one case (profound brain damage) resulted in death. In all of these cases, surgeons or physicians provided MAC without the help of anesthesiologists. Conclusions Overall, the most common damaging mechanism was related to respiratory depression due to sedatives or anesthetics used for MAC. Almost all MAC injury cases are believed to be preventable with the use of additional or better monitoring and an effective response to initial physiological derangement. Thus, it is essential to establish practical MAC guidelines and adhere to these guidelines strictly to reduce the occurrence of severe anesthesia-related adverse outcomes.

Hemothorax is a possible immediate complication of central venous catheterization. We experienced a patient who suffered from massive hemothorax 72 hours after right subclavian venous catheterization. A 29-year-old female patient with Marfan's syndrome underwent the Bentall's operation and aortic arch replacement with an artificial graft, which was performed uneventfully. She recovered favorably in the intensive care unit and was transferred to the general ward on postoperative day 3. Immediately after the removal of the catheter in the general ward, massive hemothorax developed and emergent thoracotomy should have been performed to control bleeding. We report this case to re-emphasize the careful monitoring even after removal of central venous catheter and the need for ultrasound guidance during insertion of central venous catheters.

Gastric bypass surgery is recognized as the most effective treatment for severely obese patients who cannot effectively control their weight through diet and exercise. During gastric bypass surgery, proper anesthetic management requires special attention from preoperative assessment to postoperative recovery, especially for airway management. We reviewed the electronic medical records of 66 patients who received laparoscopic gastric bypass surgery for being overweight or diagnosed as obesity from January 2011 to May 2013 and analyzed the collected data in relation to the body mass index (BMI) as follows: Group 1 - BMI of 25 to less than 30 (n = 5); Group 2 - BMI of 30 to less than 35 (n = 12); Group 3 - BMI of 35 to less than 40 (n = 2); Group 4 - BMI of 40 to less than 50 (n = 16); and Group 5 - BMI of 50 or greater (n = 5). Among the subject patients, 78.8% had metabolic syndrome, 48.5% had diabetes, 43.9% had hypertension, 33.3% had both diabetes and hypertension. The prevalence rates of metabolic syndrome, type 2 diabetes mellitus, and hypertension were not significantly dif ferent among the groups. Polysomnography (PSG) performed on 60 of the 66 subject patients revealed that 41 patients (68.3%) had moderate to severe obstructive sleep apnea (OSA, Apneahypopnea index; AHI of 15 or greater). Laryngoscopic view during intubation showed 97% of the patients with grade 1 or 2, 3% with grade 3 and 0% with grade 4 (Grade 1: no difficulty in la ryngoscopic view, Grade 2: only posterior extremity of the glottis is visible, Grade 3: only the epiglottis is seen, and Grade 4: no recognizable structures). There were no significant inter-group differences in the number of patients with difficult intubations corresponding to grade 3 or 4. During the induction of patients undergoing gastric bypass surgery, difficult airways or intubation should be anticipated. Therefore, it is very important to prepare airway management devices, including a surgical airway. Brodsky et al. reported that in morbid obese patients, the Mallampati score and neck circumference were more precise predictable factors in determining difficult intubation rather than weight and body mass index [1]. Using the ramped position, in which the external acoustic meatus and sternal notch heights are matched, provides a higher success rate in the intubation of severe obese patients compared to the standard sniffing position. All subject patients in our analysis received intubation in the ramped position. During surgery, the number of positive end expiratory pressure (PEEP) applied patients for the 5 groups were 0 (0%), 3 (25.0%), 17 (60.7%), 13 (81.3%) and 4 (80.0%), respectively. The number of patients admitted to the intensive care unit immediately after surgery for each of the 5 groups were 1 (20.0%), 1 (8.3%), 1 (3.6%), 1 (6.3%) and 2 (40.0%), respectively, and there were no significant differences among the groups. Obese patients who undergo gastric bypass surgery have a relatively high incidence of obstructive OSA. OSA is the occurrence of apnea or hypopnea due to repetitive partial or complete blockade of the upper airway. Patients with OSA have a higher risk of airway obstruction after general anesthesia and they are more susceptible to myocardial ischemia, congestive heart failure, cerebrovascular ischemia, and hypoxemia [2]. This risk is not only due to the residual effects of the anesthetic agents including muscle relaxants and opioids but also due to a decrease in the upper airway muscle tone. While proper diagnosis and management of OSA prior to gastric bypass surgery will be

A 38-year-old woman underwent a 4-hour operation in the prone position for a laminectomy at C4-7 and posterior cervical decompressive fusion at C7-T1 under general anesthesia. After undraping at the end of surgery, considerable swelling with many blisters of the left forearm and hand was observed. The chest roll at the left side had moved cephalad into the axilla and compressed the axillary structures. An emergency fasciotomy to decompress the compartments of the forearm and dorsal surface of the hand was performed. In the post anesthesia care unit, the radial pulse of the left hand was palpable and the level of oxygen saturation was normal. Forearm and hand edema subsided gradually over several days and the patient was discharged with full function of her left arm. This compartment syndrome suggests careful attention should be paid to the position of the chest roll when the prone position is established for a long duration.

Unexpected tracheal narrowing was observed in a patient with Duchenne muscular dystrophy during a corrective operation for thoracolumbar scoliosis. As the operating time progressed, peak airway pressure and end-tidal CO2 increased gradually in the prone position. We found a floppy portion of the trachea using fiberoptic bronchoscopy (FB) in the prone position. We advanced a wire-reinforced tube toward the carina beyond the lesion. This allowed correction of the ventilatory abnormalities. We encountered another patient scheduled for the same operation. We performed FB in advance before the position change and observed a narrowed portion of trachea. We advanced the tracheal tube under FB beyond the pathologic portion and then moved the patient into the prone position. The operation was done successfully without any problems.

Neuroendovascular interventions using coil embolization, stent insertion, or balloon-expander techniques are currently employed to treat intracranial aneurysms, arteriovenous malformations (AVMs), and cerebrovascular stenosis or occlusion. Several complications may occur during neurointervention, including rupture of vessels, vasospasm, thromboembolism, or catheter malposition. Techniques used to monitor complications associated with neurointervention include neurologic examination, electroencephalography (EEG), motor- and somatosensory-evoked potentials, assessment of transjugular oxygen saturation, transcranial Doppler ultrasound monitoring, and measurement of cerebral oxygen saturation. Although the application and utility of near-infrared cerebral oxymetry during neuroendovascular intervention have been evaluated [1-3], statistical analysis was lacking and relatively small numbers of patients were studied. The bispectral index (BIS) is a complex parameter calculated from several EEG-derived sub-parameters, including the relative beta ratio, high-order bispectrum, and the burst suppression ratio. BIS has been widely used to evaluate sedative-hypnotic status during surgery under general anesthesia. However, to the best of our knowledge, no previous study has examined changes in BIS values during neurointerventions. Thus, the aim of the present study was to assess changes in BIS and regional cerebral oxygen saturation (rSO2) using near-infrared spectroscopy (NIRS) in anesthetized patients undergoing neuroendovascular interventions. This study was approved by our Institutional Review Board prior to study commencement. After written informed consent had been obtained from each patient or parents of adolescent patient, 28 patients (male 12, female 16), aged 14-81 years (mean 50.9 ± 14.3), undergoing elective neuroendovascular procedures conducted by neurointerventionists were enrolled in the study. Patients were diagnosed with cerebral aneurysms (n = 17), cerebral vascular stenosis (n = 2), AVMs (n = 8), or carotid tumor (n = 1). A BIS sensor and two cerebral oxymeter sensors were placed on the forehead of each patient to provide continuous and simultaneous monitoring of BIS and rSO2. General anesthesia was induced with target-controlled infusion (TCI) of propofol 3.0 µg/ml, remifentanil 5.0 ng/ml, and a bolus injection of 50 mg atracurium. Anesthesia was maintained with air (1.5 L/min) and oxygen (1 L/min), intermittent bolus injections of atracurium, and continuous infusion of propofol (2.0-3.0 µg/ml) and remifentanil (3.0-5.0 ng/ml). Hemodynamic, BIS, and rSO2 values were obtained immediately before and after, and 5 min after, neuroendovascular intervention (either embolization or stent insertion). The TCI rates of propofol and remifentanil did not change over this interval. All data are presented as means ± standard deviations. Statistical analysis was performed using SPSS version 12 (SPSS Inc., Chicago, IL, USA). All continuous parameters studied were evaluated using repeated measures analysis of variance. For all comparisons, a P value less than 0.05 was considered to be statistically significant. There were no significant hemodynamic differences immediately before, immediately after, or 5 min after commencement of intervention except for mean arterial blood pressure 5 min after intervention (Table 1). The BIS value was increased significantly 5 min after intervention compared to preintervention values (P < 0.05). The hemisphere ipsilateral to the lesion in patients under general anesthesia showed a significant increase in rSO2 both immediately and 5 min after intervention (P < 0.05). Interestingly, the rSO2 value in the side contralateral to the lesion in patients under general anesthesia was also increased significantly 5 min after intervention (P < 0.05). Table 1 Hemodynamic Parameters, BIS and Regional Cerebral Oxygen Saturation (%) During Neuroendovascular Intervention (n = 28) The primary positive finding of this study was that, in patients under general anesthesia, the BIS value was increased 5 min after neurointervention without any concomitant significant hemodynamic change. Thus, changes in cerebral blood flow caused by an intervention may affect cerebral electrical activity. Our results suggest that cerebral electrical activity may increase, or at least, may not disturb after neuroendovascular embolization or stent insertion. In the present study, total intravascular anesthesia with TCI of propofol and remifentanil was used during neuroendovascular procedures. EEG signal output and BIS can both be affected by propofol and remifentanil, in a dose-dependent manner [4]. Therefore, the TCI rates of propofol and remifentanil were not varied from immediately before neurointervention to at least 5 min after neurointervention, to exclude any effect of anesthetic drugs on the parameters measured. Both propofol and remifentanil concentrations did not affect the changes of hemodynamics, BIS and rSO2 values significantly. Kuroda et al. [5] found that NIRS was useful to evaluate the state of cerebral oxygenation continuously during carotid surgery and could be a more sensitive measure to detect ischemic crisis than other indirect methods for measuring regional cerebral blood flow. Also, it has been reported that acute and persistent decreases in oxygen saturation were associated with vascular complications arising in the course of neuroendovascular procedures, and were detectable before development of clinical symptoms [2,3]. In the present study, the rSO2 values in patients under general anesthesia were not altered significantly after neuroendovascular intervention. Interestingly, the mean rSO2 value of the side contralateral to the lesion in patients under general anesthesia increased 5 min after intervention. This may be attributed to restoration of cerebral blood flow influenced the well-developed collateral circulation. One of limitations of NIRS and BIS is that the BIS as well as rSO2 values only indicate the alterations of frontal area of the brain. Therefore, our results may not be adequate to reflect on the exact changes of whole cerebral perfusion before and after neurointervention. In addition, it is well known that cerebral perfusion was altered by arterial partial CO2 pressure (PaCO2). Although we did not evaluate the exact levels of PaCO2, patients were maintained end-tidal CO2 values in the range of 30-35 mmHg during the procedure in the present study. Another limitation is the relatively lack of consistency for patient selection. Although we could not rule out that the disease-specific intervention may affect the cerebral electrical activity and/or cerebral blood flow, all patients included in this study were conducted the embolization or stent insertion which aimed at the adequate restoration of cerebral perfusion. In conclusion, both BIS and the rSO2 values were increased, or at least were not altered after neuroendovascular intervention without significant hemodynamic change in anesthetized patients. These results indicate that both cerebral electrical activity and cerebral blood flow increase immediately after neuroendovascular intervention in anesthetized patients.

Background: The aim of this study was to compare the streamlined liner of the pharynx airway (SLIPA) with the classic laryngeal mask airway when used by novice personnel. Methods: There were 114 patients enrolled into this study who underwent general anesthesia were randomly allocated into one of 2 groups; LMA group (n = 57) or SLIPA group (n = 57). After insertion, insertion success rate, insertion time, and hemodynamic responses to insertion were accessed. After surgery, postoperative airway morbidity (sore throat, dysphonia, dysphagia) were evaluated. Results: The SLIPA was successfully inserted in 96% of patients (55/57) and the LMA in 93% (53/57) (P = 0.408). First attempt success rates were 88% (44/57) and 77% (50/57) in the SLIPA and the LMA (P = 0.142). The successful insertion time in SLIPA group (33.4 ± 11.0 sec) was significantly shorter than that of LMA group (38.8 ± 16.6 sec) (P = 0.048) and the insertion time at the first attempt was also shorter in SLIPA group (31.0 ± 6.3 sec) than LMA group (34.7 ± 8.6 sec) (P = 0.013). There was no statistically significant difference between the two groups in hemodynamic responses and postoperative airway morbidity. Conclusions: The SLIPA was similar to the LMA in insertion success rate, hemodynamic response, and postoperative airway morbidity by novice personnel. The insertion time at the first attempt and successful insertion time of the SLIPA were significantly shorter than those of the LMA. Therefore, the SLIPA could be a useful alternative to the LMA as primary SGA for novice personnel. (Korean J Anesthesiol 2012; 63: 136-141)

In the treatment of unruptured intracranial aneurysms, Guglielmi detachable coil (GDC) embolization is a good alternative to surgical clipping which requires invasive surgery [1]. The authors experienced a delayed emergence from anesthesia in a post anesthesia care unit (PACU) after GDC embolization of an unruptured intracranial aneurysm under general anesthesia. We report a case of a thromboembolism at the Lt. posterior cerebral artery detected on an angiogram that was immediately performed after a neurologic deficit was detected in the patient. A 70-year-old male (169 cm, 74 kg) was admitted for the treatment of a 6 mm unruptured basilar top aneurysm that had been incidentally found during a work up for lung cancer. He was on hypertension and diabetes mellitus medications and had taken aspirin with clopidogrel for 5 days prior to the procedure. Routine laboratory tests were unremarkable and he did not have any neurologic deficit on admission. Bispectral index monitoring was added to the routine monitoring and general anesthesia was induced with intravenous propofol 120 mg, alfentanil 400 μg and rocuronium 50 mg. After tracheal intubation, deep anesthesia was maintained with 6% desflurane in 50% oxygen with nitrous oxide to secure immobil ity during the procedure. Phenylephrine was continuously infused to compensate for the hypotension. There was no remark able event during the procedure. Glycopyrrolate 0.4 mg and neostigmine 1.5 mg were administered after the completion of the procedure. The patient was extubated after confirmation that the bispectral index had reached 80 and self respiration had sufficiently recovered. The patient opened his eyes when his name was called. The proce dure took 45 minutes and the total anesthesia time was 70 minutes. The total dosage of rocuronium was 60 mg. In the PACU, oxygen supplementation of 5 L/min with a facial mask was sufficient to maintain the SpO 2 at 100%, but the patient could not obey commands and looked uncomfortable while breathing. The blood pressure and heart rate were stable and the tympanic membrane temperature was 35.8 o C. To rule out the possibility of incomplete recovery from the neuromuscular blocking agent, additional glycopyrrolate 0.2 mg and neostigmine 1.0 mg were injected intravenously. Muscle relaxation was monitored with an electrical stimulator by applying the

Recurrent herpes zoster occurs at a low frequency among immunocompetent individuals. Particularly in young people, recurrent herpes zoster is known to be rare [1]. As the authors found a case of a young woman with no particular past medical history in whom herpes zoster recurred and IgG subclass deficiency was diagnosed on additional testings, we herein report the case.

Background: This study was designed to determine the optimal anesthetic depth for the maintenance and recovery in interventional neuroradiology. Methods: Eighty-eight patients undergoing interventional neuroradiology were randomly allocated to light anesthesia (n = 44) or deep anesthesia (n = 44) groups based on the value of the bispectral index (BIS). Anesthesia was induced with propofol, alfentanil, and rocuronium and maintained with 1−3% sevoflurane. The concentration of sevoflurane was titrated to maintain BIS at 40−49 (deep anesthesia group) or 50−59 (light anesthesia group). Phenylephrine was used to maintain the mean arterial pressure within 20% of preinduction values. Recovery times were recorded. Results: The light anesthesia group had a more rapid recovery to spontaneous ventilation, eye opening, extubation, and orientation (4.1 ± 2.3 vs. 5.3 ± 1.8 min, 6.9 ± 3.2 min vs. 9.1 ± 3.2 min, 8.2 ± 3.1 min vs. 10.7 ± 3.3 min, 10.0 ± 3.9 min vs. 12.9 ± 5.5 min, all P < 0.01) compared to the deep anesthesia group. The use of phenylephrine was significantly increased in the deep anesthesia group (768 ± 184 vs. 320 ± 82 μg, P < 0.01). More patients moved during the procedure in the light anesthesia group (6/44 [14%] vs. 0/44 [0%], P = 0.026). Conclusions: BIS values between 50 and 59 for interventional neuroradiology were associated with a more rapid recovery and favorable hemodynamic response, but also with more patient movement. We suggest that maintaining BIS values between 40 and 49 is preferable for the prevention of patient movement during anesthesia for interventional neuroradiology.