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Background: Only a few studies have evaluated the differences between varying concentrations of a fixed dose of local anesthetics. This study was conducted to compare the effects of two different concentrations of a fixed dose of ropivacaine used in ultrasound-guided interscalene brachial plexus block. Methods: This prospective, randomized, double-blind study included 62 patients who underwent arthroscopic surgery under general anesthesia. The patients were randomly assigned to receive ultrasound-guided interscalene block with 75 mg of ropivacaine at one of two concentrations: 0.75% (10 ml; group C) or 0.375% (20 ml; group V). Time to onset of sensory blockade, degree of blockade, pulmonary function changes, analgesic duration of the interscalene block, postoperative opioid requirement within 24 h, postoperative pain scores, satisfaction, and incidence of complications were recorded. Results: Although the time to onset of sensory blockade was shorter for group C (P = 0.015), successful blockade was achieved at 30 min after the interscalene block in both groups. The analgesic duration of the interscalene block was not significantly different between the groups. The amount of opioid used within 24 h after surgery was significantly reduced for group V compared with group C (P = 0.016). The rest of the parameters did not show any significant differences between the two groups.Conclusion: Compared with 10 ml of 0.75% ropivacaine, interscalene block with 20 ml of 0.375% ropivacaine could be effective for the reduction of postoperative opioid requirement within 24 h after surgery despite it might not prolong the analgesic duration.

BACKGROUND The long-term outcomes of patients discharged from the hospital after successful care in intensive care unit (ICU) are not briskly evaluated in Korea. The aim of this study was to assess long-term mortality of patients treated in the ICU and discharged alive from the hospital and to identify predictive factors of mortality. METHODS In 3,679 adult patients discharged alive from the hospital after ICU care between 2006 and 2011, the 1-year mortality rate (primary outcome measure) was investigated. Various factors were entered into multivariate analysis to identify independent factors of 1-year mortality, including sex, age, severity of illness (APACHE II score), mechanical ventilation, malignancy, readmission, type of admission (emergency, elective surgery, and medical), and diagnostic category (trauma and non-trauma). RESULTS The 1-year mortality rate was 13.4%. Risk factors that were associated with 1-year mortality included age (hazard ratio: 1.03 [95% CI, 1.02-1.04], P < 0.001), APACHE II score (1.03 [1.01-1.04], P < 0.001), mechanical ventilation (1.96 [1.60-2.41], P < 0.001), malignancy (2.31 [1.82-2.94], P < 0.001), readmission (1.65 [1.31-2.07], P < 0.001), emergency surgery (1.66 [1.18-2.34], P = 0.003), ICU admission due to medical causes (4.66 [3.68-5.91], P < 0.001), and non-traumatic diagnostic category (6.04 [1.50-24.38], P = 0.012). CONCLUSIONS The 1-year mortality rate was 13.4%. Old age, high APACHE II score, mechanical ventilation, malignancy, readmission, emergency surgery, ICU admission due to medical causes, and non-traumatic diagnostic category except metabolic/endocrinologic category were associated with 1-year mortality.

Background The supraglottic airway device is an appropriate alternative to tracheal intubation in laparoscopic surgery. We compared the Baska MaskⓇ with i-gelⓇ by measuring the oropharyngeal leak pressure (OLP) and hemodynamic and respiratory parameters during laparoscopic cholecystectomy. Methods A total of 97 patients were randomly allocated to either i-gel group (n = 49) or Baska Mask group (n = 48). Insertion time, number of insertion attempts, fiber-optic view of the glottis, and OLP were recorded. Heart rate, mean arterial pressure, peak airway pressure (PAP), lung compliance, and perioperative complications were assessed before, during, and after pneumoperitoneum. Results There were no significant differences between the two groups regarding demographic data, insertion time, fiber-optic view of the glottis, and the use of airway manipulation. The OLP was higher in the Baska Mask group than in the i-gel group (29.6 ± 6.8 cmH2O and 26.7 ± 4.5 cmH2O, respectively; P = 0.014). Heart rate, mean arterial pressure, PAP, and lung compliance were not significantly different between the groups. The incidence of perioperative complications was small and not statistically significant. Conclusions Both the i-gel and Baska Mask provided a satisfactory airway during laparoscopic cholecystectomy. Compared with the i-gel, the Baska Mask demonstrated a higher OLP.

Background: We compared upper- and lower-body forced-air blankets in terms of their ability to prevent perioperative hypothermia, defined as a reduction in body temperature to < 36.0°C, during the perioperative period in patients undergoing spine surgery in the prone position.Methods: In total, 120 patients scheduled for elective spine surgery under general anesthesia were divided into an upper-warming group (n = 60) and a lower-warming group (n = 60). After inducing anesthesia and preparing the patient for surgery, including prone positioning, the upper and lower bodies of the patients in the upper- and lower-warming groups, respectively, were warmed using a forced-air warmer with specified upper and lower blankets. Body temperature was measured using a tympanic membrane thermometer during the pre- and post-operative periods and using a nasopharyngeal temperature probe during the intraoperative period. Patients were evaluated in terms of shivering, thermal comfort, and satisfaction in the post-anesthesia care unit (PACU).Results: The incidence of intraoperative and postoperative hypothermia was lower in the upper-warming group than in the lower-warming group ([55.2% vs. 75.9%, P = 0.019] and [21.4% vs. 49.1%, P = 0.002]). Perioperative body temperature was higher in the upper-warming group (P < 0.001). However, intraoperative blood loss, postoperative thermal comfort scale and shivering scores, patient satisfaction, and PACU duration were similar in the two groups.Conclusions: The upper-body blanket was more effective than the lower-body blanket for preventing perioperative hypothermia in patients who underwent spine surgery in the prone position.

Cervical epidural anesthesia (CEA) is used for pain control and surgical procedures of the head and neck or upper arm areas. However, the failure rate of CEA is reported to be high, is the failure rate being quite higher than other sites, because of the anatomical differences of the cervical spine. We hypothesized that the loss of resistance (LOR) method combined with the drip infusion method for confirmation of the cervical epidural space can reduce the failure rate. This study investigated the usefulness of the drip infusion method.One hundred chronic renal failure patients undergoing arteriovenous bridge graft for hemodialysis at the upper arm under cervical epidural anesthesia were recruited for this study. In the cervical epidural puncture, we identified the cervical epidural space using a combination of the LOR method with the drip infusion method. After confirmation of the epidural space with LOR method, we decided it was the true epidural space when fluid dripping to the space was present. Otherwise, if fluid dripping was not present, we designated it was pseudo LOR, and we found the true epidural space using the drip infusion method only.In all cases, the combined LOR with drip infusion method, identify the epidural space.Combined LOR with drip infusion method is an efficacious method for the confirmation of the cervical epidural space.

Background Woake's syndrome (WS) is a recurrent nasal polyposis, accompanied by broadening of the nose, frontal sinus aplasia, dyscrinia, and bronchiectasis. There has been no previous report on anesthetic management in patients with WS. Case We describe a case involving a 13-year-old male patient with WS who was scheduled for septorhinoplasty for necrotic ethmoiditis. Anesthesia was induced and maintained with propofol and remifentanil using a target-controlled infusion device. The anesthetic considerations of this rare syndrome and the advantages of an intravenous infusion method over local and volatile anesthesia for these patients are discussed. We report on caveats, such as pulmonary dysfunction during the anesthetic management, and nasal structural problems encountered in WS patients. Conclusions Given that conventional inhaled anesthesia reduces ciliary movement and that local anesthesia with sedative has several disadvantages, perioperative control and precautions against respiratory infections by using antibiotics, and preventing cilio-depressant actions, are important for anesthetic management.

Background: The aims of this study were to compare the stability, correlation with end-tidal sevoflurane, and area below the effect (AUC effect ) vs. time curves of temporal linear mode complexity (TLMC) and approximate entropy (ApEn) during sevoflurane anesthesia. Another study goal was to characterize the time course of the effects of sevoflurane. Methods: Electroencephalogram (EEG) parameter stability was evaluated using the coefficients of variation (CV) of the median baseline (E0), maximal (Emax), and individual median E0 - Emax values. Correlations between sevoflurane concen tration and EEG parameters were tested. AUCeffect vs. time curves of TLMC and ApEn were calculated to quantitate any decrease in central nervous system activities. A sigmoid Emax model was used for pharmacodynamic modeling. Results: TLMC and ApEn demonstrated CVs of 8.36 and 7.35 (for E0) and 19.61 and 13.45 (Emax), respectively. The CVs of the individual median E0 - Emax values were 65.16 for TLMC and 59.97 for ApEn. The Spearman correlation coef ficient was -0.3103 for TLMC and -0.3410 for ApEn (P < 0.001 for both parameters). The median AUC effect value was 338.9 for TLMC and 246.5 for ApEn (P = 0.457). The final pharmacodynamic parameters estimated by sigmoid Emax models were described as follows; E0: 0.614, 0.617, Emax: 0.334, 0.287, Ce50: 5.48, 5.07 vol%, γ: 1.88, 2.01, ke0: 0.306, 0.236 min (TLMC, ApEn). Conclusions: TLMC is comparable to ApEn according to the univariate EEG descriptors of the effects of sevoflurane. A sigmoid Emax model well described the pharmacodynamics of sevoflurane for TLMC and ApEn. (Korean J Anesthesiol 2013; 65: 385-396)

Background: The opioid sparing effect of low dose ketamine is influenced by bolus dose, infusion rate, duration of infusion, and differences in the intensity of postoperative pain. In this study, we investigated the opioid sparing effect of low dose ketamine in patients with intravenous patient-controlled analgesia (PCA) using fentanyl after lumbar spinal fusion surgery, which can cause severe postoperative pain. Methods: Sixty patients scheduled for elective lumbar spinal fusion surgery were randomly assigned to receive one of three study medications (K1 group: ketamine infusion of 1 μg/kg/min following bolus 0.5 mg/kg, K2 group: ketamine infusion of 2 μg/kg/min following bolus 0.5 mg/kg, Control group: saline infusion following bolus of saline). Continuous infusion of ketamine began before skin incision intraoperatively, and continued until 48 h postoperatively. For postoperative pain control, patients were administered fentanyl using IV-PCA (bolus dose 15 μg of fentanyl, lockout interval of 5 min, no basal infusion). For 48 h postoperatively, the total amount of fentanyl consumption, postoperative pain score, adverse effects and patients’ satisfaction were evaluated. Results: The total amount of fentanyl consumption was significantly lower in the K2 group (474 μg) compared to the control group (826 μg) and the K1 group (756 μg) during the 48 h after surgery. Pain scores at rest or with movement, the incidence of adverse events and patient satisfaction were not significantly different among the groups. Conclusions: Low-dose ketamine at 2 μg/kg/min following bolus 0.5 mg/kg significantly reduced the total amount of fentanyl consumption during the 48 h after lumbar spinal fusion surgery without increasing adverse effects. (Korean J Anesthesiol 2013; 64: 524-528)

Background: The hemodynamic responses to endotracheal intubation are associated with sympathoadrenal activity. Polymorphisms in the beta1-adrenergic receptor (β1AR) gene can alter the pathophysiology of specific diseases. The aim of this study is to investigate whether the Ser49Gly and Arg389Gly polymorphism of the β1AR gene have different cardiovascular responses during endotracheal intubation under sevoflurane anesthesia. Methods: Ninety-one healthy patients undergoing general anesthesia were enrolled. Patients underwent slow inhalation induction of anesthesia using sevoflurane in 100% oxygen. Vecuronium 0.15 mg/kg was given for muscle relaxation. Endotracheal intubation was performed by an anesthesiologist. The mean arterial pressure (MAP), heart rate (HR), and the corrected QT (QTc) interval were measured before induction, before laryngoscopy, and immediately after tracheal intubation. Genomic DNA was isolated from the patients’ peripheral blood and then evaluated for the β1AR-49 and β1AR-389 genes using an allele-specific polymerase chain reaction method. Results: No differences were found in the baseline values of MAP, HR, and the QTc interval among β1AR-49 and β1AR-389, respectively. In the case of β1AR-49, the QTc interval change immediately after tracheal intubation was significantly greater in Ser/Ser genotypes than in Ser/Gly genotypes. No differences were observed immediately after tracheal intubation in MAP and HR for β1AR-49 and β1AR-389. Conclusions: We found an association between the Ser49 homozygote gene of β1AR-49 polymorphism and increased QTc prolongation during endotracheal intubation with sevoflurane anesthesia. Thus, β1AR-49 polymorphism may be useful in predicting the risk of arrhythmia during endotracheal intubation in patients with long QT syndrome. (Korean J Anesthesiol 2011; 61: 117-121)

Background: This study was performed to ultrasonographically demonstrate the changes in relationship between the right internal jugular vein (IJV) and an anatomical landmark in two different head positions: neutral and rotated. Methods: This was a randomized clinical trial. One hundred patients scheduled for elective surgery under general anesthesia with endotracheal intubation were enrolled in this study. The patients were placed in the supine position with a neutral head position and without a pillow. The apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and clavicle was marked (AL point : anatomical landmark point). Ultrasonography of the neck anatomy was performed and the skin was marked at the central point of the IJV (US point: ultrasonography point). The other investigator measured the distance from the AL point to the US point (ALUS distance). The patient’s head was then turned 30 o to the left; the same procedure was repeated and the AL-US distance was again measured. The changes in AL-US distance were calculated. Results: The AL-US distance increased significantly after 30 o head rotation compared with that in a head neutral position. The mean ± SD of the AL-US distance was 0.28 ± 0.78 cm in the neutral head position and 0.83 ± 1.03 cm in the head rotated position. Conclusions: The anatomical landmark point becomes more distant from the actual right IJV point and moves more medially after head rotation. We suggest minimizing the angle of head rotation and taking this distance into consideration when using the landmark-guided method. (Korean J Anesthesiol 2011; 61: 107-111)

Tension pneumothorax in newborns is a rare but life-threatening complication. We encountered a case of a full-term neonate with a breech presentation. An elective cesarean section was scheduled. Immediately after delivery, the newborn was found to be breathless with a heart rate

Background During coronary anastomosis in off-pump coronary artery bypass surgery (OPCAB), hemodynamic alternations can be induced by impaired diastolic function of the right ventricle. This study was designed to examine the effect of milrinone on right ventricular function and early outcomes in patients undergoing OPCAB. Methods Forty patients undergoing OPCAB were randomly assigned in a double-blind manner to receive either milrinone (milrinone group, n = 20) or normal saline (control group, n = 20). Hemodynamic variables were measured after pericardiotomy (T1), 5 min after stabilizer application for anastomosis of the left anterior descending coronary artery (LAD, T2), the obtuse marginalis branch (OM, T3), the right coronary artery (RCA, T4), 5 min after sternal closure (T5), and after ICU arrival. The right ventricular ejection fraction (RVEF) and right ventricular volumetric parameters were also measured using the thermodilution technique. For evaluation of early outcomes, the 30-day operative mortality and morbidity risk models were used. Results There was no significant difference in hemodynamic variables, including mean arterial pressure, between the 2 groups, except for the cardiac index and RVEF. The cardiac index and RVEF were significantly greater at T3 in the milrinone group than in the control group. Conclusions Continuous infusion of milrinone demonstrated a beneficial effect on cardiac output and right ventricular function in patients undergoing OPCAB, especially during anastomosis of the graft to the OM artery, and it had no adverse effect on early outcomes.

Background: This study was performed to evaluate the effectiveness of intravenous low dose ketamine for reducing the incidence and severity of postoperative sore throat (POST). Methods: This was a prospective, randomized, double-blind clinical trial. The study population consisted of 70 patients between 20 and 70 years old who were classified as American Society of Anesthesiologists I-II and were scheduled for elective laparoscopic cholecystectomy. The patients were divided randomly into two groups. Patients in the ketamine group received an intravenous injection of 0.5 mg/kg of ketamine just before induction, followed by 10 μg/kg/min throughout the operation. Patients in the control group received intravenous saline instead of ketamine. The patients were interviewed 1, 6, and 24 h after the operation. The incidence and severity of POST were recorded. Results: No significant differences in the incidence and severity of POST during the 24 h after the operation were found between the two groups (21/31 in the ketamine group vs. 26/34 in the control group, P = 0.398). Conclusions: Intravenous injection of low dose ketamine was not effective for reducing POST. (Korean J Anesthesiol 2010; 59: 22-26)

Thoracic epidural catheterization is used widely for anesthesia and postoperative pain control in thoracic and abdominal surgery. Generally, an epidural catheter is inserted only 4–5 cm into the epidural space, as excessive catheter insertion causes complications like vascular injury and paresthesias [1]. Nevertheless, a catheter can often be inserted quite a distance as a consequence of the catheter becoming dislodged outside the epidural space with changes in the patient’s position. Most studies of the amount of epidural catheter insertion have focused on the lumbar level [2,3]. Therefore, we examined catheter advancement at the thoracic level. This study enrolled 72 mastectomy patients graded as American Society of Anesthesiologists class I or II and treated under general or epidural anesthesia. A thoracic epidural catheter was inserted for post-surgical pain control. Patients with coagulopathy, infection at the needle puncture site, a history of spine surgery, or scoliosis were excluded. The aims of the study were explained to the patients and the study was approved by the Institutional Review Board. In a sitting position, the patient’s neck was flexed as much as possible while the patient held the opposite knee with both hands, and the inferior tips of both scapulas were palpated to find the seventh thoracic spinous process. Then, an epidural puncture was made in the largest interspinous space out of T3–4, T4–5, or T5–6. Using a midline approach, with the bevel of a 17-gauge Tuohy needle facing cephalad, the needle was inserted and the epidural space was confirmed by the loss-ofresistance method using air. Then, a 19-gauge end-hole epidural catheter (Flextip Plus TM Epidural Catheter; Arrow International

Tapia's syndrome is the palsy of the 10th and 12th cranial nerves, resulting in ipsilateral paralysis of the vocal cord and tongue. It is a rare complication which is related to the anesthetic airway management and positioning of the patient's head during the surgery. We describe a patient with a postoperative unilateral Tapia's syndrome, after general anesthesia, with uncomplicated endotracheal intubation. The patient's symptoms improved gradually for three months.

Awake craniotomy is the technique of choice for the patients with lesions on eloquent cortical areas. It is still challenging for anesthesiologists, especially in cases where the patient’s general condition is poor or with a relatively inexperienced surgeon. Occasionally the inability to control airway can lead to complications such as airway obstruction or hypercarbia, which can lead to brain bulging. Different anesthetic combinations have been reported for awake craniotomy. Nevertheless, there is still no consensus about the optimal regimen for awake craniotomy [1]. We experienced six patients with fronto-temporal lesion who needed awake surgery to preserve eloquent areas. Two patients had cardiac problems and one patient had chronic depression (Table 1). All patients received scalp nerve block with 0.75% ropivacaine and 1 : 200,000 epinephrine. Three of the patients under went “asleep-awake” technique using a laryngeal mask airway (LMA). The other patients received moderate to mild sedation. We used propofol and remifentanil infusion for sedation and two patients received dexmedetomidine infusion as an adjuvant. We did not use muscle relaxants in any cases. Mean operation time was 323 minutes and estimated blood loss was 380 ml. One patient with severe snoring refused sedation at first and stayed fully awake until the end of cortical mapping. This patient displayed marked agitation during the awake period. Therefore, we started low dose propofol-remifentanil infusion after cortical mapping and the patient underwent intermittent apnea and hypercarbia (Patient 1). Most of the patients were maintained in a sedated state during the procedures and responded properly during cortical mapping. Two patients with LMA awakened 20-30 min after stopping infusion (Patients 2 and 3), and one (Patient 3) showed moderate hypercarbia. Other patients awakened within 10 min after stopping infusion. Surgeons were satisfied with patient’s brain condition and response. One patient (Patient 5) with moderate sedation experienced extreme fear during the procedure. Others replied that it was endurable. Awake craniotomy is very stressful surgery to patients. Although it is not always consistent, there is a greater possibility of extreme fear in the patients with prior anxiety history (e.g., Patient 5). Patients with medical problems, especially with cardiovascular diseases, may not tolerate the stressful environment and may lead to hemodynamic instability. In such cases, deep sedation is preferred. According to other references, most painful procedures were head pin fixation, manipulating dura, and closure after operation. Patients can easily get stressed during these procedures despite successful scalp nerve block [2]. Therefore, maintaining deep sedation or general anesthetic status during these procedures would be more helpful for patients’ comfort. The most important problem of deep sedation is respiratory depression, and using airway device such as LMA may be a good choice [3]. But, it can also cause delayed awake and some residual effects with dull response or respiratory depression after extubation (e.g., Patients 2 and 3). Hypercarbia brings increased intracranial pressure in spite of normal oxygen saturation, and it can make the surgery harder. Yet, in practice, LMA re-insertion after neurologic test is very dangerous owing to head fixation posture.

We report a rare case of a 72-year-old female who developed extensive subcutaneous emphysema, bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, and pneumoretroperitoneum after a percutaneous dilatational tracheostomy. The patient's T-cannula was accidentally connected to the oxygen line with a non-perforated connector. The patient rapidly developed respiratory insufficiency and subcutaneous emphysema in the neck and both shoulders. The bilateral pneumothoraces were managed using a chest tube. CT scans of the chest, abdomen, and pelvis revealed an extensive distribution of air throughout the chest and abdomen. The patient was treated successfully with supportive care. This case illustrates the rare occurrence of air passing into multiple body compartments, highlighting the potentially serious complications of a tracheostomy and the importance of intensive care during the recovery period.

Neuraxial analgesia has become a popular technique for management of labor pain [1,2]. However, an increase in the incidence of fetal heart rate (FHR) changes after intrathecal analgesia has been reported [1,2]. Although it is known that fetal bradycardia caused by labor analgesia induction does not usually increase the risk of emergent operative deliveries [3], we experienced a case of persistent fetal bradycardia after uneventful spinal analgesia, which led to an emergency cesarean section. A 39-year-old woman (weight 60.9 kg, height 157.4 cm) at 37+1week of gestational age was admitted for induction of labor. She was diagnosed with preeclampsia and intrauterine growth retardation. On the first day, dinoprostone slow release pessary (Propess®, Bukwang Pharma, Seoul, Korea) was inserted into the vagina for seven hours. After removal of the pessary, intravenous infusion of oxytocin was started. After forty-five minutes, the cervix was fully dilated and the patient complained of severe pain (numerical rating scale, NRS; 8). We decided to perform spinal analgesia without epidural catheter insertion due to shortage of time until delivery. The parturient was laid on her left side with her body bent forwards. Spinal analgesia was performed at the L3-4 level with a 25 G Whitacre needle. A mixture of ropivacaine 3.6 mg and fentanyl 20 µg was administered intrathecally. No adverse event occurred during the procedure. One minute after the procedure, the analgesia level reached T12, and NRS score for labor pain decreased from 8 to 3. However, at about two minutes after spinal analgesia, fetal heart rate decreased to 50-70 beats per minute (bpm) (Fig. 1). Maternal blood pressure was 135/70 mmHg when fetal bradycardia developed. Oxytocin infusion was stopped. The parturient was laid in the left lateral decubitus position, and intravenous (IV) hydration was provided; however, fetal bradycardia persisted. Tocolytic agents were not used. Fourteen minutes after spinal analgesia, emergency cesarean section was performed by the attending obstetrician. Fig. 1 Fetal heart rate, and the tocogram at the time of fetal bradycardia. General anesthesia was induced by IV infusion of thiopental sodium (5 mg/kg), and succinylcholine (1 mg/kg). Anesthesia was maintained with O2, N2O and 1-1.5 vol% sevoflurane. A male baby with a body weight of 2.03 kg was delivered. He showed whole body cyanosis and could not establish self respiration at birth with a heart rate below 100 bpm. The Apgarscore was 1/2/2 at 1/5/10 minutes after birth, respectively. After endotracheal intubation, the baby was transferred to the neonatal intensive care unit. Brain computed tomography revealed hemorrhagic infarction in the right middle cerebral artery territory along with hematoma in the right occipital lobe. The baby was discharged from the hospital one month later and regular follow-up of rehabilitation was continued. FHR changes after neuraxial analgesia are not uncommon [1-3]. One possible pathophysiological mechanism is that rapid pain relief causes a short-term imbalance between maternal epinephrine and norepinephrine levels, leading to uterine hyperstimulation [1-3]. But the exact mechanisms are still unknown. The type of neuraxial block could affect the incidence of FHR abnormalities. Abrao et al. [4] reported that combined spinalepidural analgesia (CSE) is associated with a significantly higher incidence of FHR abnormalities than epidural analgesia. They suggested that faster pain relief results in a higher probability of uterine hyperactivity [4]. However, this mechanism has not been clearly demonstrated in a study. Van de Velde et al. [2] demonstrated that spinal analgesia using intrathecal bupivacaine (2.5 mg), sufentanil (1.5 µg) and epinephrine (2.5 µg) provided a equally fast pain relief as that by spinal analgesia using high-dose intrathecal sufentanil (7.5 µg) only. However, FHR changes were more frequent in those who were administered a higher dose of intrathecal sufentanil. Based on this result, it seems that high-dose intrathecal opioid plays a role in causing FHR changes, and the onset of rapid analgesia is not the most important causative factor. In our case, we used 0.2% ropivacaine (3.6 mg) and fentanyl (20 µg) intrathecally without epidural analgesia. Our dose of the intrathecal opioid was not as high as that of intrathecal sufentanil (7.5 µg), which was used by Van de Velde et al. in their study. Recently, a case-control study reported that the difference between pre- and post-analgesia pain scores and a higher sensory block height were the risk factors for fetal bradycardia following CSE analgesia for labor pain [1]. These results do not explain the development of fetal bradycardia in our case, because the sensory analgesia level after spinal analgesia had only reached T12. Fortunately, however, it has been reported that neuraxial analgesia-related FHR changes neither increase the rate of operative deliveries nor affect the maternal and neonatal outcomes [3]. In most cases, FHR changes are temporary and can be managed well with conservative methods such as oxygen supply, use of vasopressors, position change and use of tocolytic agents [3]. But, these conservative methods were ineffective in our case and a cesarean section was inevitable. As fetal distress and cesarean section are relatively common in the delivery room, other causes of FHR abnormalities should be assessed. Holdcroft and Dob [5] suggested that some iatrogenic events during regional analgesia such as an incorrect infusion dose of oxytocin can precipitate fetal distress. The other possible iatrogenic factors should also be excluded because spinal analgesia could be an innocent bystander in such cases. Cheng et al. [1] reported that the mean time between CSE and fetal bradycardia is 24.1 minutes (SD 16.93). In our case, fetal bradycardia developed after spinal analgesia within a shorter time period (2 minutes). This could just be a coincidence. But, there was no evidence of oxytocin overdose and there were no risk factors for fetal bradycardia. It is not clear which factor caused FHR abnormalities in our case. As mentioned above, there is an increased incidence of fetal bradycardia during labor analgesia due to various reasons. The anesthesiologists should remember that there is a possibility of development of fetal heart rate abnormalities after labor analgesia. Hence, careful fetal heart rate monitoring is necessary after labor analgesia.

Colonoscopy is a common procedure for the diagnosis and treatment of colorectal disease. Traditionally, sedation and monitoring during colonoscopy have been performed by gastroenterologists. However, due to the recent increase in the aging population as well as in the number of complex procedures being performed, anesthesiologists become involved in anesthesia care to ensure patient safety and comfort. Although colonoscopy is considered as a relatively safe procedure, it can cause serious complications such as bowel perforation at a frequency of 0.07 to 0.10% [1]. We report a rare case of colonoscopic perforation resulting in extensive subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum and pneumoperitoneum. A 71-year-old woman (63 kg, 163 cm) underwent a colonoscopy for abdominal discomfort. She had a history of hysterectomy 20 years ago, and no current medical problems. Her laboratory test values and chest radiography were normal. Colonoscopy was performed under intravenous sedation with midazolam 4 mg, and SpO2 was maintained at 98-99%. During the procedure, sedation and monitoring were performed by the gastroenterologist and nurse. When the colonoscope was advanced to the colosigmoid junction, perforation occurred and the procedure was terminated immediately. Air was used as an insufflation agent with a low setting for the air - flow regulation. Subsequently, the patient showed massive swelling of the face and neck. She complained of mild abdominal pain, and physical examination revealed a slightly distended abdomen with diffuse tenderness. Vital signs were within normal limits, and no signs of respiratory distress were observed. Chest, and abdominal X-ray, and CT scans showed severe pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum, and subcutaneous air in the anterior chest wall, posterior back muscles, and neck (Fig. 1). Fig. 1 (A) Chest radiograph shows marked subcutaneous emphysema (white arrow), pneumomediastinum (arrow head) and subdiaphragmatic free air (black arrow). (B) Abdominal radiograph shows pneumoperitoneum (white arrow) and retroperitoneal free air outlining the ... An emergency operation was performed 3 hours after the perforation. There was extensive subcutaneous emphysema with crepitus in the neck and face, although, the patient did not complain of dyspnea. Baseline vital signs showed blood pressure of 162/66 mmHg, heart rate of 90 beats/min, and SpO2 of 100% on 6 L/min of oxygen by facial mask. General anesthesia was induced with thiopental 5 mg/kg and rocuronium 0.8 mg/kg. Although laryngoscopy revealed grossly emphysematous pharyngeal tissues around the vocal cords and a Cormack-Lehane grade of 2 with cricoid pressure, we were able to advance an I.D. 7.0 mm endotracheal tube with a stylet. Anesthesia was maintained with sevoflurane in oxygen at 2 L/min. Mechanical ventilation was applied with a tidal volume of 500 ml, peak inspiratory pressure of 24 cmH2O, and end-tidal CO2 of 30-32 mmHg. A baseline arterial blood gas analysis showed the following results: pH, 7.37, PaCO2, 36.0 mmHg, PaO2, 323.0 mmHg, and SaO2, 100%. A 15 mm perforation in the posterior colosigmoid junction was detected, and segmental resection and anastomosis were performed. During the operation, the patient's vital signs, airway pressure, and end-tidal CO2 remained stable. The patient was transferred to the intensive care unit, and a follow-up radiograph showed no significant changes. She was successfully weaned from mechanical ventilation and extubated on postoperative day 1. Her subcutaneous emphysema markedly resolved on the second postoperative day and she was transferred to the general ward. Subcutaneous emphysema with pneumomediastinum is a recognized but uncommon complication of colonoscopy. In this case, our patient experienced a posterior colonic perforation and developed the whole spectrum of extraluminal air. Regarding the mechanism of extraluminal air diffusion, the spaces between the retroperitoneum, mediastinum, and subcutaneous tissue are anatomically continuous [2]. When perforation occurs, intraluminal compressed air may escape into either the peritoneum or retroperitoneum. The air in the retroperitoneum travels along fascial planes, mesentery, and large vessels and through the diaphragmatic hiatus, and it further spreads to the mediastinum and subcutaneous tissues [2,3]. Pneumothorax can develop when the mediastinal parietal pleura ruptures or the pneumoperitoneum extends to the intrapleural space through diaphragmatic fenestrations [4]. If gas insufflation continues to the perforated colon, it can cause life-threatening tension pneumothorax and acute respiratory failure requiring intubation and thoracentesis [2-4]. Symptoms can occur immediately or several hours after perforation, therefore, continuous observation by appropriately trained staff is required. In our case, the patient did not develop a pneumothorax immediately after the perforation, however, follow-up chest X-rays were performed to assess for any changes. The presentation symptoms may include periorbital swelling, pneumoscrotum, and pneumopericardium [3]. Therefore, perforation should be suspected in patients who developed sudden subcutaneous emphysema or unremitting abdominal pain following colonoscopy. In the present case, we postponed the extubation to avoid potential airway obstruction from the associated pharyngeal swelling. Emphysematous pharyngeal tissue can hinder direct visualization of the vocal cords and causes upper respiratory tract obstruction [5]. Therefore, we should be prepared for the possibility of difficult airway management and avoid the use of nitrous oxide in patients with multiple pathologically air-filled spaces. As the demand for anesthesia care for colonoscopy increases, awareness and management of its potential complications become essential. An understanding of the pathophysiological consequences of intestinal perforation following colonoscopy, and awareness of the associated clinical signs and symptoms are important to provide early diagnosis and proper management.

Aortic dissection during pregnancy is a devastating event for both the pregnant woman and the baby. We report a case of acute aortic dissection (Stanford type A) in a pregnant woman with Marfan syndrome at the 29(th) week of gestation. She underwent a cesarean section followed by an ascending aorta and total arch replacement with cardiopulmonary bypass, without a prior sternotomy. The hemodynamic parameters were kept stable during the cesarean section by using inotropes and vasopressors under transesophageal echocardiography monitoring. The newborn survived after endotracheal intubation and management in a neonatal intensive care unit.

Background There are few information about the differences of the effective dose (ED) of cisatracurium between the adult and the elderly. We investigated the ED and the onset time of cisatracurium in the adults and the elderly. Methods We studied two hundred patients of the adults aged 20 through 64 years and the elderly aged ≥ 65 years, with American Society of Anesthesiologists physical status I or II. Each 100 patients with 20 patients of each dose group, randomly selected from 30, 40, 50, 60 or 70 µg/kg of cisatracurium, were randomly allocated to the adults and the elderly groups. We recorded the 0.1 Hz single twitch responses of the adductor pollicis and the onset times to maximal blockade. The magnitude of muscle relaxation was recorded by using an acceleromyography. The effect of cisatracurium on single twitch was calculated as percent reduction. After converting each drug dose into logarithm and percent reduction of the muscle reduction into probit, the EDs representing the muscle relaxation effects of 5%, 25%, 50%, 75% and 95% were estimated using the linear regression analysis. Results No significant differences were found in age, weight, height, or body mass index within or between the groups. The ED50 and ED95 of the adult group were 35.39 and 59.58 µg/kg. The ED50 and ED95 of the elderly group were 34.89 and 55.50 µg/kg, respectively. The onset times were 375.4 ± 76.9 seconds in the adult group and 369.1 ± 70.0 seconds in the elderly group. Conclusions The ED and the onset time were not significantly different between the adult and the elderly.

We report a case of an erroneously elevated bispectral index (BIS) during robot assisted thyroidectomy using an electromyographic endotracheal tube (EMG tube), which is safe and useful for laryngeal electromyographic monitoring. Ten minutes after start of the operation, a sudden increase of BIS value up to 98 was noticed. The BIS values were not decreased to < 65 with supplemental anesthetics. The anesthetic method was changed from total intravenous anesthesia to balanced anesthesia. The BIS sensor and monitor were changed and other models were used. These interventions did not alter BIS values. BIS levels remained between 60 and 70 throughout the main procedure and intermittently increased to the mid-90s without any trace of poor signal quality. At the end of the surgery, the BIS values returned to normal range. The patient did not complain of intraoperative recall. Knowledge of potential interference from the use of an EMG tube must be considered when interpreting BIS.

Since the early 1980s, the implantable intrathecal drug pump (ITDP) has been used increasingly to manage chronic pain. Prior to making a decision to implant an ITDP, trial administration of the intrathecal (IT) drug should be performed to estimate the effective dose for a starting set of implantable ITDPs. There is no standard method of trial IT drug administration, though. Therefore, this paper reports 20 cases of IT morphine trial with single and repetitive injections until the appropriate dose was attained with respect to analgesia and its side effects. The trial procedure was performed with daily sequential IT injections using morphine and 0.3% mepivacaine. Twelve out of the total of 20 patients had positive responses. Thus, it is inferred that daily sequential IT morphine injections combined with a placebo injection as a trial ITDP would be useful in evaluating the effectiveness and adverse effects of IT morphine infusion with clinically insignificant side effects. (Korean J Anesthesiol 2011; 60: 138-141)

BACKGROUND Aquafol, a microemulsion propofol, causes more severe and frequent pain on injection than propofol. The purpose of this study was to compare a combination of lidocaine and ketamine on aquafol-induced pain with lidocaine or ketamine alone during the induction of anesthesia. METHODS In this prospective, randomized, double-blinded study, 130 healthy patients who were undergoing elective surgery under general anesthesia were enrolled. The patients received IV lidocaine 40 mg plus ketamine 25 mg (Group LK, n = 43), lidocaine 40 mg (Group L, n = 42), or ketamine 25 mg (Group K, n = 45) with a rubber tourniquet on the forearm 1 min before the injection of microemulsion propofol. The pain score was assessed by a 4-point verbal rating scale (VRS) at 10 seconds after injection of microemulsion propofol 30 mg and during the injection of the remaining total dose. RESULTS The incidence and severity of pain was significantly lower in Group LK than Group L or Group K at 10 seconds after the injection of microemulsion propofol 30 mg (P < 0.05). And the incidence and severity of pain was significantly lower in Group LK and Group K than Group L during the injection of the remaining total dose (P < 0.05). CONCLUSIONS Pretreatment with IV lidocaine 40 mg plus ketamine 25 mg with a rubber tourniquet on the forearm 1 min before the injection of microemulsion propofol is more effective than lidocaine 40 mg or ketamine 25 mg alone in preventing pain from the injection of microemulsion propofol.

Background The aim of this study was to evaluate the sedative effect of dexmedetomidine (DEX) added to ropivacaine for supraclavicular brachial plexus block (BPB) using the bispectral index (BIS). Methods Sixty patients (American Society of Anesthesiologists physical status 1 or 2, aged 20-65 years) undergoing wrist and hand surgery under supraclavicular BPB were randomly allocated to two groups. Ultrasound-guided supraclavicular BPB was performed with 40 ml of ropivacaine 0.5% and 1 µg/kg of DEX (Group RD) or 0.01 ml/kg of normal saline (Group R). The primary endpoint was the BIS change during 60 min after block. The secondary endpoint was the change in the mean arterial blood pressure (MAP), heart rate (HR), and SpO2 and the onset time and duration of the sensory and motor block. Results In Group RD, the BIS decreased significantly until 30 min after the block (69.2 ± 13.7), but remained relatively constant to 60 min (63.8 ± 15.3). The MAP, HR and BIS were significantly decreased compared with Group R. The onset time of the sensory and motor block were significantly faster in Group RD than in Group R. The duration of the sensory and motor block were significantly increased in Group RD. Conclusions DEX added to ropivacaine for brachial plexus block induced sedation that corresponds to a BIS value of 60 from which patients are easily awakened in a lucid state. In addition, perineural DEX shortened the onset time and prolonged the duration of the sensory and motor blocks.

Central venous catheterization (CVC) has been essential in the management of critically ill premature infants for total parenteral nutrition (TPN), hemodynamic monitoring, administration of fluids, drugs or blood products, the route for blood sampling, and etc. [1]. Due to technical difficulties and various complications, a reliable CVC has become an important field of long-term care for low birth weight infants. Complications during and after CVC are divided into three groups: mechanical, thrombotic and infectious complications that make long-term patency impossible in critically ill infants [2]. The puncture techniques, insertion sites, and managements of indwelling central venous catheters are also key factors of long-term patency of CVC. We report a case of three times successful CVC, using the same left subclavian vein in an extremely premature infants with necrotizing enterocolitis and giant hydrocephalus for about three months period, without any remarkable complications. A premature female infant, weighing 1.28 kg was transferred from the local clinic, where the infant was delivered by a cesarean section at pregnant 29 weeks gestation. When transferred, she was intubated with self respiration for the management of acute respiratory distress syndrome. Two days after admission, the ventriculargaleal shunt was performed for accompanying giant hydrocephalus, under general anesthesia. After induction of anesthesia, the supraclavicular subclavian venous catheterization (SCSVC) was done at the request of the department of pediatrics. For the CVC of the infant, only the left subclavian vein was available, because the umbilical vein and the both femoral veins were obstructed or unavailable due to previous uses. Furthermore, the right central veins were to be secured by the surgeon for the protection of surgical field. The first left SCSVC (Fig. 1A) was done with 4 F double lumen entral venous catheter (Arrow Guard®, Arrow international Inc., USA) under Seldinger technique, using anatomical landmarks, and was removed after 4 weeks maintenance at neonatal intensive care unit (NICU) for the prevention of catheter-related infections. The bacterial culture of removed catheter tip was negative. Eight weeks after the first operation, when the body weight of the infant was 2.1 kg, the second same left SCSVC (Fig. 1B) was performed under general anesthesia for the ventriculoperitoneal shunt (VPS) to relieve hydrocephalus. The second catheter was removed after 3 weeks maintenance at NICU and the third left SCSVC (Fig. 1C) was carried out on the same day (when the body weight was 2.31 kg) under sedation. The third catheter was patent till the revision of VPS, which was done 4 weeks after the third CVC and the body weight of infant increased to 3.2 kg. Fig. 1 Chest radiographs after (A) 1st, (B) 2nd, and (C) 3rd supraclvicular subclavian vein catheterization. Those show catheter tips located in the right atrium. All CVCs were done by the same anesthesiologist, with the use of maximal barriers of infection (operation gown, sterile glove, cap, mask, and large sterile sheet drape). Instead of ultrasound (US)-guided central venous catheterization, we used the classic anatomical landmark technique for the puncture of the left subclavian vein [3]. The infant was positioned supine and 15 degree of Trendelenburg position with the arms beside the body and the head turned to the right side. Landmarks for skin puncture were the clavicosternomastoid angles, formed by the lateral head of the left sternocleidomastoid muscle and the upper border of the left clavicle. Then, the needles were introduced at this point and directed inferio-medial-posteriorly at 30-45 degree to the sagittal plane. During three times for left SCSVC, we succeeded subclavian punctures with one or two skin punctures. During and after CVC procedures, there were no remarkable changes in the vital signs, pulse oximeters and electrocardiograms. The central venous catheters were advanced about 6-7 cm from the skin and confirmed the intraatrial positioning by the follow up chest radiography. To secure the long-term patency of the catheter, we applied intermittent low dose heparin (1 unit/ml) irrigations of catheters and uses of alternative line of double lumen catheter for the infusion of TPN. Because only the left central veins were feasible for CVC and long-term patency without any vascular complications were needed for this low birth weight premature infant, successful cannulations of the left subclavian vein were very important. US-guided central venous catheterization was introduced as the gold standard for the central vein catheterization, and has been claimed to decrease complications related to the procedure [4]. However, we did not adopt US-guided central vein catheterization, because there were not adequate anatomical spaces of sono-transducer for the left internal jugular vein due to the short neck and the large hydrocephalic head, and the left subclavian vein was not clearly visible due to the left clavicle. As such, we chose the classical Yoffa technique [3] for SCSVCs. The advantages of the supraclavicular approach over the infraclavicular access are shorter distance from the skin to vein, well defined landmarks, and fewer complications, such as pneumothorax or the great artery punctures; therefore, we applied the supraclavicular approach for three times CVC. In terms of safety, it has been known that the tip of central venous catheter should not be in the right atrium, to avoid complications. However, we advanced the catheter tips into the right atrium for long-term patency to overcome a short distance from the skin to the superior vena cava, and fortunately, intraatrial positioning did not provoke any serious complications during the three months of CVC. The late complications related to CVC are listed as infectious, thrombotic, and embolic complications, which disturb longterm patency of catheter. To upgrade the long-term patency of catheter, low dose heparin mixed with TPN solution, and continuous infusion of low dose heparin or warfarin were known to be the effective methods [5]. For this case, we used the intermittent 1-2 ml heparin (1 unit/ml) irrigation every 4 hours to prevent thrombosis and to keep long-term patency. In conclusion, we performed the same left SCSVC three times for a premature infant and maintained the patency without any serious complications for about three months period. The certain knowledge of anatomical landmarks and technical skills of anesthesiologist are needed for simple, safe, and time-saving SCSVC in prematurity.

Background Transverse abdominis plane (TAP) block can be recommended as a multimodal method to reduce postoperative pain in laparoscopic abdominal surgery. However, it is unclear whether TAP block following local anesthetic infiltration is effective. We planned this study to evaluate the effectiveness of the latter technique in laparoscopic totally extraperitoneal hernia repair (TEP). Methods We randomly divided patients into two groups: the control group (n = 37) and TAP group (n = 37). Following the induction of general anesthesia, as a preemptive method, all of the patients were subjected to local anesthetic infiltration at the trocar sites, and the TAP group was subjected to ultrasound-guided bilateral TAP block with 30 ml of 0.375% ropivacaine in addition before TEP. Pain was assessed in the recovery room and post-surgery at 4, 8, and 24 h. Additionally, during the postoperative 24 h, the total injected dose of analgesics and incidence of nausea were recorded. Results On arrival in the recovery room, the pain score of the TAP group (4.33 ± 1.83) was found to be significantly lower than that of the control group (5.73 ± 2.04). However, the pain score was not significantly different between the TAP group and control group at 4, 8, and 24 h post-surgery. The total amounts of analgesics used in the TAP group were significantly less than in the control group. No significant difference was found in the incidence of nausea between the two groups. Conclusions TAP block following local infiltration had a clinical advantage only in the recovery room.

Background: Neck and shoulder pain is fairly common among adolescents in Korea and results in significant health problem. The aims of this prospective study was to identify the effects of education, in terms of recognition of this issue and posture correction, on prevalence and severity of neck and shoulder pain in Korean adolescents. Methods: A prospective, observational cohort design was used. The 912 students from two academic high schools in the city of Seoul were eligible for the current study and 887 completed this study. After a baseline cross-sectional survey, students listened to a lecture about cervical health, focusing on good posture, habits, and stretching exercises to protect the spine, and were encouraged by their teachers to keep the appropriate position. And follow-ups were conducted 3 months later, to evaluate the effect of education. Results: The prevalence of neck and shoulder pain was decreased 19.5% (from 82.5 to 66.4%). The baseline mean usual and worst numeric rating scale were 19.9/100 (95% CI, 18.1-21.7) and 31.2/100 (95% CI, 28.7-33.2), respectively. On the follow-up survey, the mean usual and worst numeric rating scale were decreased significantly by 24.1 and 21.7%, respectively, compared with baseline (P < 0.01). Of the 570 students reporting neck and shoulder pain, 16.4% responded that they had experienced improvement during the 3 months. Conclusions: Education; recognition of this issue and posture correction, for cervical health appeared to be effective in decreasing the prevalence and severity of neck and shoulder pain at a 3 month follow-up. (Korean J Anesthesiol 2014; 67: 198-204)

Although fentanyl-induced cough is generally transient and benign, it can give rise to serious problems in patients to whom increasing intracranial, intraocular or intraabdominal pressures may create dangerous situations. This case demonstrates aspiration pneumonia as a complication, exhibiting severe cough induced by intravenous injection of fentanyl.

Light chain systemic amyloidosis is rare but may accompany laryngeal or pulmonary involvement, which may increase the risk in airway management. We present a case of a patient planned for resection of cervical epidural mass. The patient had face and neck ecchymoses and purpuras with an unknown cause. Mask ventilation and intubation were successful, but the operation was cancelled to evaluate bleeding from facial skin lesions. A diagnosis of light chain systemic amyloidosis prompted evaluation of involvement of other organs and treatment. This case shows the importance of preoperative evaluation and careful airway management in patients with systemic amyloidosis.

Background: The ultrasound-guided transverse abdominis plane block (TAPB) reduces postoperative pain after laparoscopic abdominal surgery. But, its effect post laparoscopic totally extraperitoneal hernia repair (TEP) is not clear. In this study, we evaluated the analgesic effect of ultrasound-guided TAPB in TEP. Methods: In this prospective, randomized study, forty adult patients (ASA I-II) scheduled for a TEP under general anesthesia were studied. In the TAPB group (n = 20), an ultrasound-guided bilateral TAPB was performed with 0.375% ropivacaine 15 ml on each side after the induction of general anesthesia. The control group (n = 20) did not have TAPB performed. Fentanyl 50 μg was repeatedly injected as per the patient’s request in the recovery room. Pain scores at rest and on coughing were assessed postoperatively in the recovery room (20 min, at discharge) and at 4, 8, and 24 hours after surgery. Results: In the recovery room, pain scores (numeric rating scale, 0-10) at postoperative 20 min were lower in the TAPB group (3.9 ± 1.6, 4.9 ± 1.8) than the control group (6.9 ± 1.6, 8.0 ± 1.6) at rest and on coughing. Also, pain scores upon discharge from the recovery room were lower in the TAPB group (3.2 ± 1.2, 4.2 ± 1.5) than the control group (5.3 ± 1.6, 6.5 ± 1.8) at rest and on coughing. Conclusions: The ultrasound-guided TAPB in patients that had undergone TEP reduced postoperative pain scores and the fentanyl requirement in the recovery room. Also, pain scores on coughing were reduced until postoperative 8 hours. (Korean J Anesthesiol 2012; 63: 227-232)

This paper reports the case of a 65-year-old woman with a history of mild arterial hypertension who presented with acute pulmonary edema immediately after a total thyroidectomy. The edema was found to have been caused by an acute upper airway obstruction secondary to bilateral vocal cord paralysis. Her pulmonary edema resolved with treatment including reintubation, mechanical ventilation with positive end-expiratory pressure, diuretics, morphine, and fluid restriction. This report discusses the possible pathogenesis of this rare clinical situation. This case highlights the possibility of an acute upper airway obstruction caused by bilateral vocal cord paralysis after a total thyroidectomy and the need for prompt treatment to prevent the development of pulmonary edema.

Background: The purpose of this study was to evaluate the effect of an aprepitant, neurokinin-1(NK1) receptor antagonist, for reducing postoperative nausea and vomiting (PONV) for up to 24 hours in patients regarded as high risk undergoing gynecological surgery with intravenous patient-controlled analgesia (IV PCA) using fentanyl. Methods: In this randomized, open label, case-control study 84 gynecological surgical patients receiving a standardized general anesthesia were investigated. Patients were randomly allocated to receive aprepitant 80 mg P.O. approximately 2-3 hours before operation (aprepitant group) or none (control group). All patients received ramosetron 0.3 mg IV after induction of anesthesia. The incidence of PONV, severity of nausea, and use of rescue antiemetics were evaluated for up to 24 hours postoperatively. Results: The incidence of nausea was significantly lower in the aprepitant group (50.0%) compared to the control group (80.9%) during the first 24 hours following surgery. The incidence of vomiting was significantly lower in the aprepitant group (4.7%) compared to the control group (42.8%) during the first 24 hours following surgery. In addition, the severity of nausea was less among those in the aprepitant group compared with the control group over a period of 24 hours post-surgery (P < 0.05). Use of rescue antiemetics was lower in the aprepitant group than in the control group during 24 hours postoperatively (P < 0.05). Conclusions: In patients regarded as high risk undergoing gynecological surgery with IV PCA using fentanyl, the aprepitant plus ramosetron ware more effective than ramosetron alone to decrease the incidence of PONV, use of rescue antiemetics and nausea severity for up to 24 hours postoperatively. (Korean J Anesthesiol 2012; 63: 221-226)

Background Experimental and clinical studies have suggested that remifentanil probably causes acute tolerance or postinfusion hyperalgesia. This study was designed to confirm whether remifentanil given during propofol anesthesia induced postoperative pain sensitization, and we wanted to investigate whether pregabalin could prevent this pronociceptive effect. Methods Sixty patients who were scheduled for total abdominal hysterectomy were randomly allocated to receive (1) a placebo as premedication and an intraoperative saline infusion (control group), (2) a placebo as premedication and an intraoperative infusion of remifentanil at a rate of 3-4 ng/ml (remifentanil group), or (3) pregabalin 150 mg as premedication and an intraoperative infusion of remifentanil at a rate of 3-4 ng/ml (pregabalin-remifentanil group). Postoperative pain was controlled by titration of fentanyl in the postanesthetic care unit (PACU), followed by patient-controlled analgesia (PCA) with fentanyl. The patients were evaluated using the visual analogue scale (VAS) for pain scores at rest and after cough, consumption of fentanyl, sedation score and any side effects that were noted over the 48 h postoperative period. Results The fentanyl titration dose given in the PACU was significantly larger in the remifentanil group as compared with those of the other two groups. At rest, the VAS pain score in the remifentanil group at 2 h after arrival in the PACU was significantly higher than those in the other two groups. Conclusions The results of this study show that remifentanil added to propofol anesthesia causes pain sensitization in the immediate postoperative period. Pretreatment with pregabalin prevents this pronociceptive effect and so this may be useful for the management of acute postoperative pain when remifentanil and propofol are used as anesthetics.

BACKGROUND: Propofol and remifentanil are usually co-administered and have shown synergistic effect for anesthesia. However, the synergistic effect of the two drugs on hypnosis measured by bispectral index (BIS) was controversial in previous studies. The aim of this study was to identify the interaction of propofol and remifentanil on BIS and the optimal dose combinations for hypnosis under 66% N(2)O during surgery. METHODS: Patients (age 55-75 and American Society of Anesthesiologists [ASA] 1-2) undergoing gastrectomy were enrolled in this study. Propofol and remifentanil were co-administered incrementally at 1 : 1 potent ratio (the P1R1 group), at 1 : 2 potent ratio (the P1R2 group), or at 2 : 1 potent ratio (the P2R1 group) using effect site target-controlled infusion and BIS was measured. 66% N(2)O was concomitantly administered to all groups. The dose-effect curves, the 90% effective dose (EC(90)) for adequate hypnosis (BIS 40), isobolograms and combination index were obtained by Calcusyn program (Biosoft) to reveal the interaction of propofol and remifentanil. RESULTS: The P2R1 group showed synergistic action on BIS. However, the other groups needed larger amount of each drug than the doses of additive action. The EC(90) of the P2R1 group was propofol, 3.34 µg/ml and remifentanil, 2.41 ng/ml under 66% of N(2)O. CONCLUSIONS: Propofol dominant co-administration is needed for dose reduction in BIS guided hypnosis.

Background: Breast reconstruction following mastectomy has become increasingly popular in recent years. The purpose of this study was to compare the efficacy of cervical epidural patient-controlled analgesia (CEA) and intravenous patient-controlled analgesia (IV-PCA) for controlling the postoperative pain and the side effects after mastectomy with immediate Latissimus dorsi (LD) flap breast reconstruction. Methods: Sixty patients who were to undergo mastectomy with immediate LD flap breast reconstruction were randomly assigned to receive CEA (Group CEA, (n = 30), 0.15% ropivacaine + fentanyl 4 μg/ml) or IV-PCA (Group IV-PCA (n = 30) fentanyl 20 μg/kg + ketorolac 3 mg/kg) for postoperative pain control via a PCA pump (basal rate: 2 ml/h, bolus: 2 ml, lock out interval: 15 min) after their operation. Before general anesthesia, an epidural catheter was inserted at the cervical (C)7-thoracic (T)1 level in the patients of the CEA group. The resting visual analogue scale (VAS) for pain, the systolic blood pressure, the heart rate and the side effects were recorded for 48 hours after operation. Results: The VAS at rest was significantly lower in the CEA group than that in the IV-PCA group at 16 hours after surgery. The CEA group required less additional analgesics as compared with the group IV- PCA. There were no significant differences in the systolic blood pressure, the heart rate and the incidence of side effects between the two groups. Conclusions: We conclude that cervical epidural analgesia, as compared with intravenous patient-controlled analgesia, provides effective pain control and it shows a similar incidence of side effects after mastectomy with immediate LD flap breast reconstruction. (Korean J Anesthesiol 2009; 56: 669~74)

The incidence of post-dural puncture meningitis is very low. A 44-year-old patient developed a fever (38℃, headache, neck stiffness, nausea, and vomiting after combined spinal epidural (CSE) anesthesia and surgery for closed reduction and internal fixation (CRIF) with intramedullary (IM) nailing, tibia, Rt. With a preliminary diagnosis of bacterial meningitis, empiric broad spectrum antimicrobial treatment was immediately started after cerebrospinal fluid (CSF) sampling. The CSF was clear and revealed a white blood cell count, protein, glucose, and pressure of 146/μl, 225 mg/dl, 48 mg/dl (serum 151 mg/dl), and 26 cmH2O, respectively. The CSF stain and culture were negative. Considering the injection of preventive antibiotics before CSE anesthesia, partially treated bacterial meningitis was suspected. Four weeks later, clinical symptoms had improved before the patient was discharged. (Korean J Anesthesiol 2009; 56: 337~40)

Eisenmenger's syndrome describes the elevation of pulmonary arterial (PA) pressure to the systemic level caused by an increased pulmonary vascular resistance with reversed or bi-directional shunt through an intracardiac or aortopulmonary communication. We report a case of an emergent craniotomy for cerebellar abscess in a 21-year-old male patient with Eisenmenger syndrome secondary to Large VSD. A PA catheter was inserted via right femoral vein, but could not be advanced pass the pulmonic valve. After futile attempts to place the catheter tip in the right ventricle. Anesthesia was induced with etomidate, rocuronium, midazolam and fentanyl and maintained with only high dose fentanyl. Milinone and norepinephrine were infused continuously to decrease right to left shunt. He was transferred to the intensive care unit under intubated state and treated with antibiotics for a few days due to intermittent high fever. The operation ended without major complications and the patient was discharged 42 days later.

Hypercapnia augments cardiac output and can initiate a sympathetically mediated release of catecholamines to increase cardiac output. Many studies of hemodynamic changes by hypercapnia under general anesthesia with inhalation anesthetics besides sevoflurane. This study examined the hemodynamic changes by increasing end-tidal carbon dioxide (EtCO2) under sevoflurane-N2O anesthesia.Twenty patients were enrolled in the study. We studied stable, mechanically ventilated patients under general anesthesia maintained with O2 2 L/min - N2O 2 L/min - sevoflurane (1.5-2.5 vol%). Hypercapnia were obtained by reducing tidal volume and respiratory rate. EtCO2 was adjusted to 30, 40, 50 mmHg with each concentration maintained for 15 min. Global hemodynamic variables were monitored with a pulmonary artery catheter.There were no changes in mean arterial pressure or heart rate by hypercapnia. Acute moderate hypercapnia increased cardiac output (4.9 +/- 1.7, 5.5 +/- 1.7, 6.2 +/- 2.1 L/min; P0.05), cardiac index (3.0 +/- 0.9, 3.4 +/- 0.9, 3.8 +/- 1.1 L/min/m2; P0.05), pulmonary artery pressure (16.9 +/- 3.7, 19.6 +/- 4.2, 23.0 +/- 4.7 mmHg), but did not decrease systemic vascular resistance (1,558.3 +/- 500.4, 1,423.5 +/- 678.6, 1,156.8 +/- 374.0 dynes.sec/cm5; P0.05).When we changed patient EtCO2 to 30, 40, and 50 mmHg, there were no changes in mean arterial blood pressure and heart rate, but systemic vascular resistance decreased, and cardiac output, cardiac index and mean pulmonary arterial pressure increased significantly.

Background: Inhalation induction with desflurane can cause airway irritability and sympathetic stimulation. The aim of this study was to investigate whether lidocaine and fentanyl could reduce these unwanted reactions. Methods: Seventy-five patients who had premedication with midazolam were randomly allocated to one of three groups to receive intravenous saline (S group), lidocaine 1.5 mg/kg (L group), fentanyl 1 μg/kg (F group), respectively, before tidal volume induction with desflurane in oxygen and nitrous oxide. We recorded airway irritability such as cough, apnea, laryngospasm and excitatory movement and hemodynamic changes. Results: Airway irritability was not significantly different between the groups. In F group, mean blood pressure at LOC ver and LOC BIS and heart rate at LOC ver, LOC BIS and just before intubation were lower than those of S group (P ＜ 0.05). Other results were not significantly different. Conclusions: The results of the study showed that intravenous fentanyl and lidocaine had no beneficial effects to reduce airway irritability, but intravenous fentanyl could significantly reduce hemodynamic stimulation during inhalation induction with desflurane in the patients who were premedicated with midazolam. (Korean J Anesthesiol 2009; 57: 693∼7)