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Background BMS-470539, a recently introduced selective agonist of the melanocortin 1 receptor, is known to have anti-inflammatory properties. In this study, we investigated the effects of BMS-470539 on lipopolysaccharide (LPS)-induced inflammatory responses and delayed apoptosis with its signaling pathways in human neutrophils. Methods Isolated human neutrophils were incubated with various concentrations of BMS-470539 (1, 10, and 100 µM) in the presence or absence of LPS (100 ng/ml), and the expression of pro-inflammatory cytokines, such as tumor necrosis factor alpha, interleukin (IL)-6, and IL-1β, were assessed. The effects of BMS-470539 on the expression of mitogen-activated protein kinases (MAPKs), such as p38, extracellular-signal-regulated kinase 1/2, and c-Jun N-terminal kinase, and the expression of nuclear factor kappa B (NF-κB) in LPS-stimulated human neutrophils, were evaluated by enzyme-linked immunosorbent assay. Neutrophil apoptosis was also measured by fluorescence-activated cell sorting (annexin V/propidium iodide) in LPS-stimulated neutrophils under treatment with BMS-470539. Results BMS-470539 attenuated LPS-induced expression of pro-inflammatory cytokines, and phosphorylation of MAPKs and NF-κB. LPS stimulation reduced neutrophil apoptosis compared to the controls; however, BMS-470539 significantly inhibited the reduction of neutrophil apoptosis. Conclusions BMS-470539 can suppress the inflammatory responses of LPS-stimulated neutrophils by inhibition of MAPK pathways or NF-κB pathway, and it can also inhibit LPS-delayed neutrophil apoptosis.

BACKGROUND: We hypothesized that induction of general anesthesia using sevoflurane improves the accuracy of non-invasive hemoglobin (SpHb) measurement of Masimo Radical-7® Pulse CO-Oximetry by inducing peripheral vasodilation and increasing the perfusion index (PI). The aim of this study is to investigate the change in the SpHb and the PI measured by Rad7 during induction of general anesthesia using sevoflurane. METHODS: The laboratory hemoglobin (Hblab) was measured before surgery by venous blood sampling. The SpHb and the PI was measured twice; before and after the induction of general anesthesia using sevoflurane. The changes of SpHb, Hbbias (Hbbias = SpHb - Hblab), and PI before and after the induction of general anesthesia were analyzed using a paired t-test. Also, a Pearson correlation coefficient analysis was used to analyze the correlation between the Hbbias and the PI. RESULTS: The SpHb and the PI were increased after the induction of general anesthesia using sevoflurane. There was a statistically significant change in the Hbbias from -2.8 to -0.7 after the induction of general anesthesia. However, the limit of agreement (2 SD) of the Hbbias did not change after the induction of general anesthesia. The Pearson correlation coefficient between the Hbbias and the PI was not statistically significant. CONCLUSIONS: During induction of general anesthesia using sevoflurane, the accuracy of SpHb measurement was improved and precision was not changed. The correlation between Hbbias and PI was not significant.

Pediatric hypertensive crisis is a potentially life threatening medical emergency, usually secondary to an underlying disease. Hypertension commonly occurs during general anesthesia, and is usually promptly and appropriately treated by anesthesiologists. However in children with severe, unexplained, or refractory hypertension, it has the potential to cause morbidity and even mortality in susceptible patients. We report an anesthetic management of an unexpected hypertensive crisis that developed during general anesthesia in a three-year-old girl with undiagnosed severe left renal artery stenosis.

Background Green tea modulates neuropathic pain. Reactive oxygen species (ROS) are suggested as a key molecule in the underlying mechanism of neuropathic pain in the spinal cord. We examined the effect of epigallocatechin-3-gallate (EGCG), the major catechin in green tea, in neuropathic pain and clarified the involvement of ROS on the activity of EGCG. Methods Neuropathic pain was induced in male Sprague-Dawley rats by spinal nerve ligation (SNL). A polyethylene tube was intrathecally located. Nociceptive degree was estimated by a von Frey filament and expressed as a paw withdrawal threshold (PWT). To determine the role of ROS on the effect of EGCG, a free radical donor (tert-BuOOH) was pretreated before administration of EGCG. ROS activity was assayed by xanthine oxidase (XO) and malondialdehyde (MDA). Results SNL decreased the PWT compared to sham rats. The decrease remained during the entire observation period. Intrathecal EGCG increased the PWT at the SNL site. Intrathecal tert-BuOOH significantly decreased the effect of EGCG. The levels of both XO and MDA in the spinal cord were increased in SNL rats compared to sham. Intrathecal EGCG decreased the level of XO and MDA. Conclusions EGCG may reduce neuropathic pain by SNL due to the suppression of ROS in the spinal cord.

Background: The effect of spinal adrenergic and cholinergic receptors on the anti-nociceptive effect of intrathecal ginsenosides was determined in a rat postoperative pain model. Methods: Catheters were placed into the intrathecal space of male Sprague-Dawley rats. Postoperative pain was evoked by an incision to the plantar surface of a hind paw. Withdrawal thresholds was used as a nociceptive parameter and was measured with a von Frey filament. After observing the effect of intrathecal ginsenosides, an alpha-1 adrenergic receptor antagonist (prazosin), an alpha-2 adrenergic receptor antagonist (yohimbine), a muscarinic acetylcholine receptor antagonist (atropine), and a nicotinic acetylcholine receptor antagonist (mecamylamine) were given 10 min before administration of the ginsenosides to analyze the contribution of spinal adrenergic and cholinergic receptors on the antinociceptive effect of ginsenosides. Results: Paw incision decreased withdrawal threshold in incised site of paw, but no change of withdrawal threshold was not seen in non-incised site. The intrathecal ginsenosides increased withdrawal threshold of the incised paw in a dosedependent manner. Pre-treatment with both prazosin and intrathecal yohimbine antagonized the anti-nociceptive effect of the ginsenosides. However, pre-treatments with atropine or mecamylamine had any effect on the antinociceptive activity of ginsenosides. Conclusions: Intrathecal ginsenosides are effective in attenuation of postoperative pain induced in the rat model. Antinociceptive action of ginsenosides is partially mediated by spinal adrenergic receptors, but does not appear to be related to spinal cholinergic receptors. (Korean J Anesthesiol 2013; 65: 55-60)

Background The authors evaluated the effect of intrathecal mixture of ginsenosides with neostigmine on formalin-induced nociception and made further clear the role of the spinal muscarinic (M) receptors on the activity of ginsenosides. Methods A catheter was located in the intrathecal space of male Sprague-Dawley rats. Pain was evoked by injection of formalin solution (5%, 50 µl) to the hindpaw. Isobolographic analysis was done to characterize drug interaction between ginsenosides and neostigmine. The antagonism of ginsenosides-mediated antinociception was determined with M1 receptor antagonist (pirenzepine), M2 receptor antagonist (methoctramine), M3 receptor antagonist (4-DAMP), M4 receptor antagonist (tropicamide). The expression of muscarinic receptor subtypes was examined with RT-PCR. Results Intrathecal ginsenosides and neostigmine produced an antinociceptive effect during phase 1 and phase 2 in the formalin test. Isobolographic analysis revealed an additive interaction between ginsenosides and neostigmine in both phases. Intrathecal pirenzepine, methoctramine, 4-DAMP, and tropicamide reversed the antinociception of ginsenosides in both phases. M1-M4 receptors mRNA detected in spinal cord of naïve rats and the injection of formalin decreased the expression of M1 receptor mRNA, but it had no effect on the expression of other three muscarinic receptors mRNA. Intrathecal ginsenosides little affected the expression of all of muscarinic receptors mRNA in formalin-injected rats. Conclusions Intrathecal ginsenosides additively interacted with neostigmine in the formalin test. Furthermore, M1-M4 receptors exist in the spinal cord, all of which contribute to the antinocieption of intrathecal ginsenosides.

Transfusion-induced hyperkalemia can lead to cardiac arrest, especially when the patient rapidly receives a large amount of red blood cells (RBCs), previously stored for a long period of time, irradiated or both. We report on a case of application of the Continuous AutoTransfusion System (CATS) to wash RBCs, in order to lower the high potassium (K(+)) level in the packed RBCs unit, during massive transfusion following transfusion-induced hyperkalemic cardiac arrest. After the washing process using CATS, there was no more electrocardiographic abnormality or cardiac arrest due to hyperkalemia. This case emphasizes the potential risk to develop transfusion-related hyperkalemic cardiac arrest, during massive transfusion of irradiated, pre-stored RBCs. CATS can be effectively used to lower the K(+) concentration in the packed RBCs unit, especially when the risk of transfusion-induced hyperkalemia is high.

The differential diagnosis of headache is often difficult because the symptom of headache is overlapping. Superficial cervical plexus block is useful in diagnosis and treatment of headache. Headache arising from the neck and radiating to the frontotemporal regions and possibly to the supraorbital region has been defined as cervicogenic headache. A positive response to anesthetic blocks is one of the diagnostic criteria of cervicogenic headache. We experienced a case of headache arising from direct lymph node metastasis of hepatocellular carcinoma adjacent to the superficial cervical plexus during treatment of cervicogenic headache under ultrasonographic guidance. Especially in patients with medical history of cancer, practitioners should consider the possibility of metastasis to cervical lymph nodes and using ultrasonography to evaluate the cervical area prior to the practice.

The anesthetic management of patients with an anterior mediastinal mass is very challenging due to the potential risk of hemodynamic and respiratory compromise. A specialized anesthetic plan should be developed for in patients with an anterior mediastinal mass based on the preoperative clinical symptoms as well as, radiographic, computed tomographic, spirometric, and echocardiographic data [1,2]. A 31-year-old man (height 173.5 cm, weight 70.4 kg) came to our emergency department with right-sided chest discom fort, dry cough, progressive dyspnea, and orthopnea for the previous 4 weeks. The initial chest X-ray evaluation revealed a large amount of right side pleural effusion and a bulky mediastinal mass. Multi directional computed tomography revealed a 12.3 cm homogenous soft tissue mass in the anterior mediastinum compressing the superior vena cava and dis placing the ascending aorta. The trachea and both main bronchi were patent, but a cross-sectional area of the right upper lobe bronchus (7.21 mm) was reduced 44% relative to the left upper lobe bronchus (12.97 mm). Right loculated pleural effusion, totally collapsed right lower lobe and subsegmental atelectasis in the right middle lobe were noted. A therapeutic and diagnostic thoracentesis was done under local anesthesia, and 1,600 ml of pleural fluid was removed. Cytology of pleural fluid revealed many lymphocytes and mesothelial cells, but these were negative for malignancy. However, because dyspnea persisted and pleural effusion was increased after admission, a mediastinoscopic biopsy and pleural decortication were performed under general anesthesia. In the operating room, the CAPIOX emergency bypass system (CAPIOX Ⓡ EBS TM , Terumo Corporation, Tokyo, Japan) was prepared in the event of cardiopulmonary collapse. Before the induction of general anesthesia, a 20-guage catheter was placed in the right radial artery for continuous blood pressure monitoring. The patient was placed in the Semi-Fowler’s position with the head elevated 30 degrees to relieve the discomfort of the supine position. Initial vital signs were blood pressure 105/65 mmHg, heart rate 100 beats/min, respiration 25 breaths/min, and O2 saturation 96%. Preoxygenation with 100% O2 was administered using a face mask, and anesthesia was induced with a continuous infusion of propofol (effect-site concentration 4.0-5.0 μg/ml and remifentanil (effect- site concentration 3.0 5.0 ng/ml using a target-controlled infusion pump (Orchestra Ⓡ Base Primea, Fresenius Vial, Brezins, France) and a bolus dose of rocuronium 50 mg via a preexisting 16-guage IV catheter in the vein on the medial surface of the right leg. Intubation was successfully achieved using the left-sided Robert-Shaw double lumen bronchial tube in the supine position. Breath sounds were heard on both sides of the chest. Mechanical ventilation was maintained with a tidal volume, respiratory rate and partial pressure of end-tidal carbon dioxide of 500 ml, 15 breaths/min, and 28-32 mmHg, respectively. After induction, the arterial blood pressure began to drop to 60/35 mmHg and the heart rate increased to 110 beats/min. Ephedrine 10 mg were administered intravenously, but the vital signs were not improved. A transesophageal echocardiography (TEE) was performed for evaluation of hemodynamic instability. It showed that a large mass compressed the right atrium

BACKGROUND General anesthetics induce neuronal apoptosis in the immature brain. Regional anesthesia using local anesthetics can be an alternative to general anesthesia. Therefore, this study investigated the possible effect of lidocaine on neuronal apoptosis. METHODS Fifty-one 7-day-old C57BL6 mice were allocated into control (group C), lidocaine (group L), lidocaine plus midazolam (group LM) and isoflurane (group I) groups. Group C received normal saline administration. Groups L and LM were injected with lidocaine (4 mg/kg, subcutaneously) only and the same dose of lidocaine plus midazolam (9 mg/kg, subcutaneously). Group I was exposed to 0.75 vol% isoflurane for 6 h. After 6 h, apoptotic neurodegeneration was assessed using caspase-3 immunostaining and terminal deoxynucleotidyl transferase dUTP nick-end labelling (TUNEL) staining. RESULTS For the entire brain section, neuronal cells exhibiting caspase-3 activation were observed more frequently in group I than in group C (P < 0.001). In the thalamus, apoptosis of group L was more frequent than that of group C (P < 0.001), but less freqent than that of groups LM and I (P = 0.0075 and P < 0.001, respectively). In the cortex, group I experienced more apoptosis than group L and C (all Ps < 0.001). On TUNEL staining, the difference in apoptosis between the lidocaine and control groups was marginal (P = 0.05). CONCLUSIONS Lidocaine induced minimal apoptosis in the developing brain compared with isoflurane and lidocaine plus midazolam. However, we cannot fully exclude the possible adverse effect of subcutaneously administered lidocaine on the developing brain.

Rubinstein-Taybi syndrome (RTS) is a chromosomal mutation disease, which was first described by Rubinstein and Taybi in 1963. Respiratory infection such as aspiration pneumonia and congenital heart disease are leading causes of death during the one-year post-natal period. The patients with the diseases have difficulties in receiving intubations due to the craniofacial abnormality and anesthesia due to respiratory infection and arrhythmia [1]. A 10-year-old female patient weighing 40 kg (75-90 percentile) with a height of 135 cm (25-50 percentile) had RTS with a microdeletion of chromosome 16, and had no particular medications. She was classified with a grade 1 mental retardation. She usually suffered from sleep apnea syndrome, and visited our hospital for tonsillectomy (grade III) and adenoidectomy. She received surgery to correct the strabismus under general anesthesia at another hospital two years ago, but she was reportedly discharged without any side effects. Microcephaly, down slanting palpebral fissures and beaked nose were observed as RTS traits. Moreover, microstomia, macroglossia, narrow palate, micrognathia, and retrognathia were presented. Any abnormal findings were not present on the chest X-ray, electrocardiogram, and echocardiogram, but difficulties in managing her airways were expected since she was classified as Mallampati class III. She had been deprived of food for eight hours and was intramuscularly injected with 10 mg of famotidine for the risk of aspiration, and then was transferred to the operating room. However, she was extremely anxious; thus, she was administered ketamine (15 mg) and midazolam (1.5 mg) via IV injection under oxygen saturation monitoring, and was transferred to the operating room. She was attached to monitoring equipment such as an electrocardiogram, an oxygen saturation monitor, and a noninvasive blood pressure monitoring machine upon arrival at the operating room. Before induction, her vital signs were 120/74 mmHg (BP), 106 beats/min (HR), 20 times/min (RR), and 94% (SpO2). Oxygen (5 L/min) was provided to the patient via a mask, and the ProSeal LMA was prepared. 70 mg of propofol was administered via IV injection, and 25 mg of rocuronium was intravenously injected after confirming mask ventilation. One hundred seconds later, we performed an intubation with a cuffed tube (reinforced 5.5 mm). The laryngoscopic view was defined as Cormark & Lehane grade II. However, the tube did not advance further around the subglottic area; therefore, intubation was performed with the cuffed tube (reinforced 5.0 mm). At that time, vital signs were stable. We began operating by maintaining oxygen (1 L/min), air (2 L/min), and sevoflurane (1.5-2.5 vol%). Premature ventricular contraction was detected on the EKG three times in a row immediately after the surgery. Premature ventricular contraction continued for five minutes based on the 10 to 15 out of 110 beats/min. Therefore, we discontinued the surgery and waited, but it recovered to a normal rhythm without any other medication. After that, we resumed the operation. The vital signs during the surgery were 100-120/60-80 mmHg (BP), 90-120 beats/min (HR), 14-16 times/min (RR), and 99% (SpO2). We confirmed that self-respiration fully recovered by the time the surgery was completed, and then, glycopyrrolate (0.2 mg) and pyridostigmine (5 mg) were administered. As a result, we transferred the patient to the recovery room. The patient was extubated as she began opening her eyes and attempted extubation by herself. 2 L/min of oxygen was injected through the nasal cannula after confirming her self-respiration (99% SpO2). No complications were found after transferring her to the ward; thus, she was discharged two days after the operation. There are characteristics associated with RTS such as microcephaly, beaked nose, and low-set ears, down slanting palpebral fissures, broad nasal bridge, strabismus, high arched eyebrows, high arched and narrow palate, hypoplastic maxilla, micrognathia, microstomia, and so on. In addition, the signs of RTS include broad thumbs and hallux, polydactyly and syndactyly, short height (male-153 cm, female-147 cm), mental retardation (IQ 25-79, mean 36-51), congenital heart disease such as ventricular septal defect, patent ductus arteriosus, atrial septal defect, coarctation of the aorta, pulmonic stenosis, bicuspid aortic valve, hypertrichosis, cryptorchism, glaucoma, malignant tumor, etc [2]. Congenital tracheal stenosis, abnormal pulmonary lobulation, excess mucous secretion, and gastroesophageal reflux all could increase the risk of aspiration. Some have choanal atresia or nasal septal deviation, so nasal intubation should be evaluated prior to performing the operation. If a brief surgery or ophthalmic surgery is scheduled, LMA could be utilized. It is possible with ProSeal LMA to achieve intermittent positive ventilation. Thus, it reduces the risk of aspiration of the stomach contents and sealing the larynx 50% more than that of classic LMA [1]. Succinylcholine is a priority option for patients having difficulty in manipulating the airway; however, a 14-year-old patient experienced arrhythmia 15 seconds after an injection of succinylcholine, which was provided by Stirt. After that, multifocal premature ventricular contraction followed by superventricular tachycardia occurred, and then occasional premature atrial contraction was observed. Moreover, the same patient reportedly experienced arrhythmia after receiving neostigmine and atropine two years ago. As a result, we stress the fact that we need to pay attention to the effect of neuromuscular blocking agents on the heart [3]. Injections of neostigmine and atropine, which alter the sympathetic and parasympathetic systems, cause premature atrial or ventricular contractions on average in 42% of adults. However, it frequently causes arrhythmia more in RTS patients than in people without the disease. Therefore, sedatives and opioids lead to increasing apnea. Consequently, they must be used carefully. We are able to induce caudal block combined with general anesthesia for infants with RTS who are scheduled for surgery with an incarcerated inguinal hernia. By doing so, opioids and muscle relaxants can be avoided, reportedly resulting in decreased risk of post-operative hypopnea and apnea [4]. RTS patients are expected to experience difficult airway management due to abnormal anatomical structures, and pretreatments will be inevitable after identifying the response to the anesthetics, which is in all likelihood an arrhythmia. In addition, effort to prevent respiratory complications should be made. In this regard, we report this case with a literature review.

Venous air embolism (VAE) during intestinal endoscopy is a rare complication. We report a case of cardiovascular collapse due to VAE confirmed by transesophageal echocardiography (TEE) during intraoperative intestinal endoscopy. TEE detected air bubbles in the left ventricle up to 1 hour after the event. When a patient deteriorates during endoscopic procedures, VAE and possible paradoxical air embolism (PAE) should be suspected. This case demonstrates that TEE can play an important role in diagnosing and managing an air embolism in anesthetized patients. In addition, this case demonstrates that PAEs may occur longer than expected after recovery from VAE-induced cardiovascular collapse.

Central venous catheterization is associated with a large number of complications, such as pneumothorax, hydrothorax, hemothorax, phlebothrombosis, pericardial tamponade, air embolism, aberrant placement and line sepsis. There are many case reports of the extravasation of various central venous catheter fluids, including the intravenous fluids, total parenteral nutrition and chemotherapeutic agents into the pleural cavity and mediastinum. These have led to hydrothorax, hydromediastinum and pericardial effusions. We report a case of the extravasation of intravenous contrast into the pleural cavity after dynamic CT through a left subclavian catheter.

There are several causes for low back and leg pain. Peripheral artery occlusive disease (PAOD) is also one cause of leg pain and is a disease that causes occlusion in the lower limb artery. PAOD can require even amputation if diagnosis is delayed, so proactive diagnosis and treatment is needed. Many ways of diagnosis have been developed by several researchers. One of these methods is the ankle-brachial index (ABI), a noninvasive, very simple and useful method that is widely used through blood pressure measurement of the lower and upper extremities [1,2]. The authors diagnosed a patient who visited the outpatient office of the pain clinic in our hospital due to low back and leg pain as peripheral vascular disease using the ABI. The patient was a 78-years old male with low back pain and both leg pain for seven years. The patient was 170 cm, 63 kg, with no sign of obesity, had been taking 2 mg of warfarin once daily because of hypertension and arterial fibrillation. He was diagnosed with coronary artery occlusive disease (CAOD) 3 vessel disease 2 years ago and had received a stent insertion for two times. The patient was a farmer with a history of falling from a cultivator twice several years ago, and since those incidences, had continuous pain in his lower back and bilateral legs. He had received a selective transforaminal epidural block at a private clinic 3 years ago but it was not effective. The patient had complained of severe pain rated as 70/100 mm by the visual analogue scale for pain at the time of visit to the pain clinic and also informed that when rested, he had less pain, but after walking about 50 to 100 m, the leg would swell and be painful. He did not show any other specific signs or symptoms other than direct tenderness of L4 and L5 from the physical examination, and motor nerve as well as sensory nerve was intact. He had never had a spine MRI, but from a simple radiograph taken a year ago, the finding of L1 and L2 compression fracture as well as L4/5, L5/S1 spinal stenosis had been observed. He was under concomitant medication of torasemide 5 mg, warfarin 2 mg, telmisartan 40 mg and clopidogrel 100 mg currently. After considering the symptoms reported and observed and the findings from physical examination as well as x-ray, the patient was suspected as having the spinal nerve compression-induced radiculopathy. Therefore, we considered performing a diagnostic nerve block but since the patient was taking warfarin and clopidogrel we been decided to perform the nerve block after discontinuing the medication. And taking into account that he was older, had hypertension and CAOD, and had been smoked one pack of cigarette daily for 50 years, we could not rule out vascular origin pain, so we decided to implement the comparatively simple and noninvasive ABI. First, we measured the blood pressure (BP) of the patient's brachial artery as well as posterior tibial artery by cuffing a non-invasive sphygmomanometer on both upper arm and ankle. The BP of upper limbs was measured as 118/64 mmHg on the right side, and 123/60 mmHg on the left side, whereas the BP of lower limbs was measured very low as 57/49 mmHg on the right side for the first time and as 84/59 mmHg at the second time. From the left side lower limb, his BP was measured as 120/52 mmHg. When we calculated the ABI of the right side leg, the first result was 0.48, and the second was 0.71. Therefore, immediate interdisciplinary medical care to the Cardiology Department was requested since the patient was suspected to have PAOD. A CT-lower extremity angiography with contrast was implemented in the patient. Narrowing of vascular inner diameter over the image of CT angiography was observed over right anterior tibial artery and external iliac artery (Fig. 1). Patient was then admitted to the hospital via the Cardiology Department and underwent a percutaneous angioplasty. Fig. 1 CT-lower extremity angiography (contrast) showing Right external iliac artery 80% luminal stenosis (arrow). PAOD is very common disease with a provenance of up 12 to 14% in the general population and its prevalence is age-dependent, showing 10%, in those ≥ 60 years old [3], and 20% for those ≥ 75 years old [4]. The most common cause is atherosclerosis in which the blood flow to tissues is reduced by single or multiple stenosis, resulting in expression of pain and cramp in leg with intermittent claudication as main symptom, which becomes more severe during exercise and improves during resting time. However, most patients are asymptomatic and undiagnostic, so only 12-18% demonstrate typical symptoms [1]. There has been a report that 40% of patients with CAOD and cerebrovascular disease had concurrent PAOD in connection to atherosclerotic syndrome as the risk factor, and out of those with PAOD, 60% had CAOD and cerebrovascular disease concurrently [5]. There are other risk factors such as smoking, old age, diabetes, obesity, hypertension as well as family history of hypertension, hypercholesterolemia. In this patient's case, he had many risk factors including being a current smoker, old age, hypertension, arterial fibrillation and CAOD 3-vessel, thereby, not only the lumbar radiculopathy but also the PAOD-induced vascular pain were suspected as the causes of pain. Similar to the patient in aforementioned case report, if a patient has a spine lesion concurrently being identified from images of MRI or X-ray, cardiovascular risk factors including old age, current smoking, cardiovascular disease, diabetes and hypertension, and for those suspected with PAOD, a differential diagnosis should be made by checking ABI, while always keeping the possibility of pain from PAOD-induced pain in mind.

A 69-year-old female of American Society of Anesthesiologists physical status II was admitted for a left total knee replacement. She had injured her left knee with a crump when she had picked up something to her right side 2 months prior. She complained of a limping gait due to a disturbance in walking, with a score of 20 on the visual analog scale (VAS) ranging from 0 to 100 (0, no pain; 100, worst pain imaginable). She had had a history of hypertension for over 10 years. The laboratory data showed within-normal ranges, except for the following: VDRL 1: 1 reactive and TPHA 1: 160++ reactive. She had been treated for syphilis 30 years prior, and her symptoms and signs were clear. The electrocardiography (ECG) and chest X-ray showed nonspecific findings.

To identify change in recognition of day surgery, a survey in the form of a questionnaire was conducted based on a similar survey carried out in 1997 [3]. Data was collected from May to August in 2012 and 205 people (adult patients and parents of pediatric patients) answered this survey. When including local anesthetics, the utility rate of day surgery (day surgery cases out of all the hospital surgery patients) was 30.39%, 23.80%, 22.21%, 22.17%, and 18.26% in the five groups. The rate of day surgery cases in which an anesthesiolo gist was involved was only 11.63%, 12.92%, 11.7%, 10.83% and 8.89% (Fig. 1). Although most of the day surgery cases were

Background: Patients showed a different response following intravenous midazolam injection. Some children showed irritability or were not sedated by midazolam. We hypothesized that there may be genetic variations of the MDR1 gene, based on the response to midazolam. Methods: One hundred and ninety-three pediatric patients were recruited in this study. Midazolam (0.1 mg/kg) was injected intravenously before surgery. Anxiety score (activity, vocalizations, emotional expressivity, state of apparent arousal) was checked before and 5 minutes after midazolam injection. In addition, other manifestations after midazolam injection were recorded. After anesthesia, 2 ml of blood was sampled. Children were genotyped MDR1. Haplotype was analyzed using the software package PHASE, version 2.0. Results: The observed frequencies of MDR1 haplotype of TTT, TGC, CAC, CGC were 0.334, 0.205, 0.182 and 0.225, respectively. There was no significant correlation between the response of midazolam and the MDR1 haplotype of TTT, TGC, CAC or CGC (P = 0. 98). Conclusions: Genotyping of MDR1 may not be related to the response of midazolam in children. (Korean J Anesthesiol 2012; 62: 332-336)

Background We wanted to determine the postoperative analgesic efficacy of preincisional caudal epidural block versus instillation (splash block) following inguinal herniorrhaphy in children. Methods Thirty children (age range: 1-7 years) who were scheduled to undergo inguinal herniorrhaphy were divided into 2 groups: the caudal block group and the splash block group with 15 children in each group. Tracheal intubation was performed. Fifteen children received caudal block with 1.0 ml/kg of 0.25% ropivacaine (Group 1). Caudal block was performed using the loss of resistance method via the sacral hiatus. Fifteen children in Group 2 received local instillation (splash block) in the surgical site with up to 0.4 ml/kg of 0.25% ropivacaine. The patients were observed for 90 minutes in the postanesthesia care unit and then they were transferred to the ward. The pain scores were taken 4 times. We assessed pain using the Faces pain scores. Results There were no significant differences between the groups regarding the pain scores at 10, 30 and 60 minutes upon entering the postanesthesia care unit. The pain scores of Group 1 were slightly lower at the last evaluation point when compared to that of Group 2. One patient in Group 1 required supplemental postoperative intravenous (IV) tramadol, while all the other patients in both groups did not require supplemental IV tramadol. The intraoperative requirement for sevoflurane was decreased in Group 1 as compared to that of Group 2. There were no major complications related to either type of block. Conclusions We conclude that a splash block can have a similar analgesic effect as that of a caudal block for the postoperative herniorrhaphy pain of children.

Background Unlike its use during stable conditions, central venous pressure (CVP) monitoring from a peripherally inserted central venous catheter (PICC) has not often been used in surgeries with significant hemodynamic alterations. The aim of this study was to evaluate the feasibility of measuring PICC pressure (PICCP) as an alternative to measuring centrally inserted central catheter pressure (CICCP) in adult liver transplantation (LT) patients. Methods We measured PICCP and CICCP simultaneously during each main surgical period in adult LT. Statistical analysis was performed using simple linear regression analysis to observe whether changes in PICCP paralleled by simultaneous changes in CICCP. Correlation analysis and Bland-Altman analysis were used to determine the degree of agreement between the two devices. Differences were considered statistically significant when P values were less than 0.05. Results A total of 1342 data pairs were collected from 35 patients. The PICCPs and CICCPs were highly correlated overall (r = 0.970, P < 0.001) as well as at each period measured. The differences among each period were not clinically significant (0.33 mmHg for pre-anhepatic, 0.32 mmHg for anhepatic, -0.15 mmHg for reperfusion, and -0.10 mmHg for neohepatic periods). The overall mean difference was 0.14 mmHg (95% confidence interval: 0.09-0.19) and PICCP tended to give a higher reading by between 0.09 and 0.19 mmHg overall. The limit of agreement was -1.74 to 2.02 overall. Conclusions These findings suggest that PICCP can be a reasonable alternative to CICCP in situations of dynamic systemic compliance and preload, as well as under stable hemodynamic conditions.

A 39-year-old female was suffering from cold-induced Raynaud's attacks in both hands and feet, with symptoms being most severe in her left foot. The patient did not respond to medical treatments and was referred to our department of pain medicine. We performed sequential bipolar radiofrequency lumbar sympathectomy to the patient, which offered a long duration of symptom relief. Sequential bipolar radiofrequency lesions could create continuous strip lesion, and thus, could achieve better results, while the potential risk of liquid neurolytic agents could be avoided.

Myocardial bridge is a congenital anomaly characterized by narrowing of some of the epicardial coronary arterial segments running in the myocardium during systole. Occasionally, the compression of a coronary artery by a myocardial bridge can be associated with the clinical manifestations of myocardial ischemia, and might even trigger a myocardial infarction or malignant ventricular arrhythmias. We report a case of ventricular fibrillation due to coronary spasm at the site of myocardial bridge. A 56-year-old man who had suffered from bronchial asthma was given remifentanil combined with sevoflurane in general anesthesia for endoscopic sinus surgery. During the surgery, ventricular fibrillation occurred following coronary spasm with bradycardia, hypotension, bronchospasm. we found myocardial bridge that coincided with an area of coronary spasm after coronary angiography.

Very late stent thrombosis after implantation of drug eluting stent is rare, but its consequences are potentially fatal. Stent thrombosis may be occurred in perioperative period because of interruption of anticoagulation therapy and intraoperative hypercoagulability. We report a case of very late stent thrombosis in a 49-year-old male patient during total gastrectomy. ST-segment elevation in lead II occurred during the surgery and followed by cardiac arrest. After external cardiac massage and electrocardioversion, normal sinus rhythm was restored. Postoperative 12 lead ECG showed ST-segment elevation in leads II, III, aVF and serum cardiac enzymes such as CPK, CK-MB, and Troponin T were markedly elevated. Postoperative coronary angiography showed complete occlusion of the right coronary artery stent. Emergency percutaneous transluminal coronary angioplasty was performed and the patient recovered uneventfully.

Hiccups are common benign and usually transient phenomenon that occur in nearly everyone. However, persistent or intractable hiccups can cause multiple problems including malnutrition, weight loss, fatigue, dehydration, insomnia, and wound dehiscence. We have experienced a case of postoperative persistent hiccup. The patient was formerly diagnosed tongue cancer and developed persistent hiccup after partial glossectomy with modified radical neck dissection and a radial forearm free-flap operation. He was unsuccessfully managed using pharmacologic methods, and then we tried phrenic nerve block guided by ultrasonography and a nerve stimulator because the surface anatomy of neck was deformed by the previous operation. Thirty minutes after the block, the hiccups disappeared.

Low back pain is common during pregnancy and has been reported in as many as 56% of pregnant women.However, the incidence of symptomatic lumbar disc displacement in pregnancy is exceedingly rare, and anesthetic management is particularly important in such cases because the attending anesthesiologist and surgeon must consider the effects of the anesthesia, the patient's position, and surgery on the fetus.We administered an epidural anesthesia for percutaneous endoscopic lumbar discectomy at 35 weeks of gestation with the patient in the prone position.The patient maintained an uneventful pregnancy and delivered a healthy baby at 38 weeks of gestation

We report a case of tibial nerve palsy after pneumatic tourniquet application for 40 minutes with a tourniquet pressure of 300 mmHg. A 45 years old woman with morbid obesity and diabetes mellitus was underwent partial lateral meniscectomy of left knee. Even 3 months after the event, nerve palsy was not completely recovered. The case underscores the necessity of being aware of the potential for complications associated with tourniquets, despite following recommended guidelines of tourniquet time and pressure. Especially, in the patients with metabolic diseases such as diabetes mellites or obesity, safe duration of tourniquet application may be shortened.