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During administration of anesthesia, intraoperative blood pressure control is very important. Sometimes a hypertensive or anti-hypertensive agent is used in order to maintain blood pressure at an adequate level; alpha-agonist and beta-blocker are drugs frequently used. Alpha-agonists are used in various ways including their application together with local anesthetics during an operation for the purpose of vasoconstriction, to control systemic absorption of local anesthetics, to extend the duration of action, or to reduce bleeding from the surgical site. In addition, alpha-agonists are used in cardiopulmonary resuscitation. Beta-blockers are used widely as a therapeutic agent for hypertension, angina, and arrhythmia, and to lower portal pressure in liver cirrhosis. Here, we are reporting the case of acute pulmonary edema that occurred after the administration of phenylephrine, in order to maintain blood pressure in a 52-year-old female patient with liver cirrhosis. The patient was underwent emergent decompressive craniectomy for intracranial hemorrhage without acknowledging her long-term use of a beta-blocker medication.

Cervical plexus blocks (CPBs) have been used in various head and neck surgeries to provide adequate anesthesia and/or analgesia; however, the block is performed in a narrow space in the region of the neck that contains many sensitive structures, multiple fascial layers, and complicated innervation. Since the intermediate CPB was introduced in addition to superficial and deep CPBs in 2004, there has been some confusion regarding the nomenclature and definition of CPBs, particularly the intermediate CPB. Additionally, as the role of ultrasound in the head and neck region has expanded, CPBs can be performed more safely and accurately under ultrasound guidance. In this review, the authors will describe the methods, including ultrasound-guided techniques, and clinical applications of conventional deep and superficial CPBs; in addition, the authors will discuss the controversial issues regarding intermediate CPBs, including nomenclature and associated potential adverse effects that may often be neglected, focusing on the anatomy of the cervical fascial layers and cervical plexus. Finally, the authors will attempt to refine the classification of CPB methods based on the target compartments, which can be easily identified under ultrasound guidance, with consideration of the effects of each method of CPB.

Malfunction of the unidirectional valve in a breathing circuit system may cause hypercapnia from the rebreathing of expired gas, ventilation failure, and barotrauma. Capnography is a useful method for monitoring the integrity of the unidirectional valve. We experienced two cases of malfunction of a unidirectional valve which caused leakage and reverse flow, diagnosed early as a change of the capnographic waveform. One case was caused by expiratory unidirectional valve breakage. The other was caused by an incorrectly-assembled inspiratory unidirectional valve. (Korean J Anesthesiol 2013; 65: 337-340)

Background Monitoring of anesthetic depth is important for successful general anesthesia. It is well known that entropy or BIS monitoring assisted titration of anesthetic drugs decreases their consumption. This study evaluated the effect of remifentanil on consumption of sevoflurane during entropy monitored general anesthesia. Methods Patients were randomly assigned to two groups. The R group was administered 0.1 µg/kg/min of remifentanil and inhaled sevoflurane, while the S group was administered only inhaled sevoflurane. Anesthesia was maintained using sevoflurane with nitrous oxide, and entropy was monitored. In both groups, the concentration of sevoflurane was adjusted to keep the state entropy (SE) value between 40 and 60. End-tidal sevoflurane concentration (ET), entropy value, systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were measured at 5 minute intervals, during a 25 minute period after intubation, skin suture and the end of surgery. Results ET was significantly lower in the R group than the S group. There were no significant differences in entropy value between R and S groups. Conclusions Entropy monitored titration of sevoflurane with remifentanil administration decreased ET with stable hemodynamics.

A 12-years-old boy (165 cm/72 kg) complained of severe posterior neck pain radiating to the right arm. The resting pain score was VAS 80 of 100 and on moving the neck the VAS was 90/100. X-ray and MRI showed C7-T1 intervertebral disc calcification (IDC) with right C8 nerve compression (Fig. 1). Conservative treatment such as, pain medication, physical therapy, and trigger point injection administered at another hospital, failed to relive his pain. Operation was recommended but parental consent was denied. The patient consulted our clinic for pain management. Laboratory finding were normal, and physical examination showed no neurological signs, with non specific electromyography. The severe pain was unresponsive to conservative treatment. We decided to perform cervical root block (CRB) instead of epidural block that was not suitable to the location, and caused fear in the pediatric patient. Fig. 1 Radiological image of the cervical spine and ultrasound image of C8 nerve root block. Lateral X-ray image (A) and sagittal (B), and axial (C) MRI show C7-T1 intervertebral disc calcification (IDC). This IDC caused C8 nerve root compression. Four ventral ... Dual-guided CRB was performed with the patient in the left lateral position, after pre-scanning with ultrasound. We surgically disinfected both cervical areas and protected the ultrasound probe and cable with a sterile ultrasound probe cover (SonoLab™ 18 × 120 cm, Lucky Medical, Seoul, Korea). Right sided 8th CRB was performed with a portable ultrasound instrument, and a 50 mm linear 15-6 MHz probe (SonoSite M-Turbo™, SonoSite Inc., Bothell, WA, USA). The 8th CRB was performed as follows: The 5th, 6th, 7th and 8th cervical roots were identified by scanning from the supraclavicular area to the 6th transverse process. The skin was infiltrated with 1 ml of lidocaine 1%. A nerve stimulating needle with 30o bevel (22-guage, 50 mm, Stimuplex® D, B.Braun, Melsungen, Germany) was inserted under dual-guidance. We used 2 Hz stimulation frequency and an impulse duration of 0.1 ms. The intensity of the stimulating current initially set to deliver 1.5 mA, was decreased to obtain the minimal stimulating current. The needle was repositioned until the minimal stimulating current was ≤ 0.3 mA (Fig. 1). Five ml ropivacaine 0.2% with 10 mg of triamcinolone acetate was injected surrounding the 8th nerve root after careful air bubble removal and an aspiration test. The block was performed 4 times during 2 weeks. VAS was improved by 50% after the first block and the VAS was 20/100 after the 4th procedure. The patient was discharged after 2 weeks since there was no pain. Subsequently, pain relief was with aceclofenac 100 mg for 2 weeks. We did not administer further medication or nerve block. The patient had no pain and neurologic symptoms at the 2 month follow-up visit. Pediatric IDC is a rare disorder without any clear etiologies and mechanisms. Calcification is mostly reported at the level of C6-7, but it may occur at any location [1]. IDC has a higher incidence in males, aged 7 to 8 years [1]. Various clinical symptoms have been reported. Neck pain and stiffness are most common. Low fever, limitation of motion, and muscle spasm are also commonly reported [1]. Neurologic symptoms appear due to compression of the nerve root and spinal cord from herniation, as a result of calcification. Signs of neurologic deficiency, including weakness, sensory loss, and myelopathy are rare [1]. However, 20% of patients exhibit neurologic symptoms due to epidural calcifications. In this case, the patient complained of severe pain, resulting from irritation of the cervical root by the irritants from the calcified cervical disc. The etiology is unclear. Laboratory tests show mostly normal results or moderate inflammatory syndrome [1]. There were non-specific findings in the study case. Radiographs reveal oval or round shaped calcifications that are most often located in the middle of the disk, but sometimes occupy the entire disk. MRI shows regions of reduced signal intensity on both, the T1- and the T2-weighted images, reflecting low proton density of the herniated calcific nucleus pulposus and its relation with myelin and the nerve roots. Rapid confirmation with MRI is very critical when the patient has neurologic symptoms. The symptom disappears within one month, in most cases. Calcification regresses over the course of months to years, but may linger longer without symptoms. IDC is normally a benign condition. Majority of cases are treated conservatively and have good outcomes [2]. Therefore, the treatment of choice is conservative and symptomatic. It includes analgesics, nonsteroidal antiinflammatory medication, muscle relaxants, cervical soft collar, and limited physical activity [1]. The use of corticosteroids therapy has not been discussed in literature to date. IDC is known to be self limited with favorable results on conservative treatment, as described above. Severe pain, uncontrolled by medication, with successful interventional treatment such as CRB, has not been previously reported. Surgery is required in patients who develop progressive neurological deficit [1,3]. A decompression of the spinal cord with an anterior cervical diskectomy and an anterior fusion is usually required. Few cases in literature comment on recurrent neurological symptoms after surgical treatment [1]. Surgical treatment is a good approach for the short term, but it has not been scientifically validated by long term observation of symptoms [3,4]. It is based on the unique anatomic features of the pediatric spine. Curvature forms at age 10, and the adult skeleton completes from then on [5]. Therefore, careful surgical consideration of the effect on the biomechanism in the postadult spine is necessary. The results from a study with long-term observation of 381 young patients with surgery, showed degenerative changes at the adjacent level, and affected curvature [5]. Conservative management is currently the main treatment modality. However, in situations of uncontrolled pain in patients with IDC, CRB with ultrasound guidance is recommended for good results.

A 22-years-old female patient at 171 cm and 67 kg visited the Department of Breast Surgery of the hospital with a mass accompanied with pain on the left side breast as chief complaints. Since physical examination revealed a suspected huge mass, breast surgeon decided to perform surgical excision and requested anesthesia to our department. Surgery of breast tumor is often under local anesthesia. However, in case of big size tumor, surgery is usually performed under general anesthesia. The patient feared general anesthesia. Unlike abdominal surgery, there is no need to control visceral pain for breast and anterior thoracic wall surgery. Therefore, we decided to perform resection under regional anesthesia. Herein, we report a successful anesthetic and pain management of the patient undergoing excision of a huge breast fibroadenoma under regional anesthesia using Pecs II and internal intercostal plane block.

A 31-year old male patient who was 173 cm tall and weighed 67 kg visited our ENT clinic with dyspnea and laryngeal papilloma as his main complaints. According to laryngoscopic findings, a diffuse large papilloma was observed at the posterior wall of the left subglottis (Fig. 1A). The patient was scheduled for the removal of the papilloma under general anesthesia. Fig. 1 (A) pre-operative laryngoscopic image shows a diffuse large papilloma on the posterior wall of the left subglottis. (B) Intra-operative laryngoscopic image after excision of the papilloma. Laryngoscopic image shows the clear posterior wall of the subglottis ... Since the patient was adamantly opposed to invasive procedures such as a tracheostomy, awake intubation was considered for safety reasons, but finally a fiberoptic bronchoscopy (FOB) and cricothyroidotomy set were prepared in case of trachea obstruction, considering that the size of the tumor was not large enough to obstruct the trachea. Anesthesia was induced with propofol, remifentanil, and rocuronium. Fortunately, ventilation was satisfactory, and tracheal intubation was performed. A tracheal tube 6.0 mm in inner diameter (ID) was inserted. Upon completion of preparations for surgery, an attempt was made to replace the tracheal tube with a tube that was 5.0 mm in ID using a Cook airway exchange catheter® (CAEC: Cook Critical Care, Bloomington, USA) with a 14.0 of French size, 83 cm of length and 3.0 mm of ID, but only the CAEC was left in due to difficulty in surgery, and the tracheal tube was removed to surgery (Fig. 1B). The CAEC was fixed at the teeth after fitting at 22 cm because the length between the teeth and the superior aspect of the carina through FOB using a tracheal tube was 22 cm. In order to immediately reintubate and monitor end-tidal CO2 (EtCO2) in case of problems in ventilation or oxygenation, an adapter and the tracheal tube were left on the CAEC (Fig. 1C). Additionally, an injector for high-frequency jet ventilation (HFJV) was also prepared (Fig. 1D). For preventing aspiration, the patient's position was changed to the Trendelenburg position (Fig. 1C). In an attempt to avoid risks of developing ignition caused by the electrocautery, continuous ventilation was replaced by the on-and-off procedure; when the pulse oximeter oxygen saturation (SpO2) of the patient fell to 90% or below, the procedure was stopped, and the reservoir bag was filled with an O2 flush; and after bagging at 100-120 times/minute, and the peak inspiratory pressure did not exceed 30 cmH2O resulting in an SpO2 of at 95% or greater, the procedure was resumed. At the end of the operation (Fig. 1C), a tracheal tube that had a 6.0 mm ID was intubated. Since microlaryngeal surgeries are performed under general anesthesia, small-diameter endotracheal tubes or jet ventilation are generally used for tracheal airway management according to the size and location of tumors. As one of the most useful methods of airway management in laryngeal surgery, jet ventilation, has been widely used because the view of the larynx is not blocked [1]. Supraglottic jet ventilation is a method of jet oxygenating via the vocal cords, which is ideal for surgical exposure, but anesthesiologists experience difficulty when using this method of airway management. Moreover, supraglottic jet ventilation may cause gastric distension because of high pressure and malalignment, inefficient or ineffective ventilation caused by barotraumas and malposition, and many potential complications including aspiration of blood and debris in the hypercarbia and bronchi [2,3]. Subglottic jet ventilation is a method using a small tube via the glottis below the vocal cord, which requires a tube and an injector. Subglottic jet ventilation provides anesthesiologists with convenience in ventilation, and does not cause aspiration of blood and debris. When a small tube is used, surgical exposure and access are not blocked. Recent animal and human studies proved the superiority of subglottic jet ventilation in microlaryngeal surgery [4]. Despite this, the method is not free from the risk of developing complications including barotraumas. In this case, oxygenation was well maintained to prevent barotraumas by filling the reservoir bag with an O2 flush, and adjusting the water so as not to exceed 30 cmH2O of maximum inhaling pressure through bagging at 100-120 times/min. If oxygenation was not well maintained, a CAEC could be used as a tube, and the airway could be maintained by HFJV using an injector already prepared. If that method was not enough, the tracheal tube could be re-intubated, enabling a controlled mode of ventilation. Accordingly, airway management using a CAEC is considered to be very safe for airway management of patients. If clinics are not well equipped with injectors, a CAEC can be used as a tube, and subglottic jet ventilation may be performed using an O2 flush with the anesthesia machine as an injector. In this case, the anesthesia machine, an S/5 Aespire™ (GE Healthcare, USA), was used. In this machine, the O2 flush is activated by setting the O2 flush button to 241 ± 7 kPa (35 ± 1.0 psi) of pressure, which can be used as an injector in case of an emergency to help airway management. A CAEC is a hollow and semirigid catheter enabling oxygen insufflations, and has a blunt catheter tip, lowering the risk of tracheobronchial trauma or lung laceration, and consequently, it has been used for tube replacements or extubation trials [5]. Unlike the tubes for general jet ventilation, since a CAEC can be used for intubating a tracheal tube by virtue of the catheter functioning as a guide wire, can be connected with a typical circuit or EtCO2 adapter through a RAPI-FIT® adapter (Fig. 1C), and can be connected with the injector for HFJV (Fig. 1D), anesthesiologists may be able to perform airway management much more easily and safely. CAECs with various types and sizes are produced, and anesthesiologists may choose CAECs appropriate to cases for effective airway management during anesthetic procedures. In conclusion, when a CAEC is used in operations using laryngoscopy, the merits are summarized as follows: First, no additional tube is necessary for jet ventilation. Second, a CAEC can be connected to a typical anesthesia machine and a capnograph monitor via a RAPI-FIT® adapter. Third, a tracheal tube can be intubated at any time in an emergency such as unexpected oxygenation and development of ventilation problems or aspiration. Last, the intubated tracheal tube may be usefully used for confirming through FOB.

Breast surgery is a common procedure performed in women. Many women who undergo breast surgery suffer from ill-defined pain syndromes. A nerve block is used in the treatment of the acute and chronic pain, but the effectiveness of the treatment has been limited because of its short duration. Recently, the advent of pulsed radiofrequency lesioning (PRF) has proved a successful treatment for chronic refractory pain involving the peripheral nerves. We experienced a case of a 52-year-old female patient complaining of chronic breast neuropathic pain after breast reduction, which was relieved after PRF lesioning of the 4th thoracic spinal nerve and its root.

Long QT syndrome (LQTS) is an arrhythmogenic cardiovascular disorder resulting from mutations in cardiac ion channels. LQTS is characterized by prolonged ventricular repolarization and frequently manifests itself as QT interval prolongation on the electrocardiogram (ECG). A variety of commonly prescribed anesthetic drugs possess the adverse property of prolonging cardiac repolarization and may provoke serious ventricular tachyarrhythmia called 'torsades de pointes', ventricular fibrillation, and sudden death. We experienced a case of ventricular tachycardia and ventricular fibrillation after anesthetic induction and it came out into the open that anesthetic induction provoked long QT syndrome.

In the literature, 7% of all cases of herpes zoster present as herpes zoster ophthalmicus (HZO). Of these cases, 20 to 79% have orbital involvement [1]. Nearly all orbital tissues, including extra-ocular muscles, can be affected by the varicella zoster virus. Orbital involvement may present as keratitis, uveitis, scleritis, optic neuritis, ocular motor palsy, or postherpetic neuralgia (PHN) [2]. HZO is often suspected when ophthalmic symptoms and signs follow characteristic skin rashes and edema. Here, we report an unusual case where orbital myositis preceded vesicular skin eruptions. A 66 year-old man, who had diabetes for 15 years and hypertension for 10 years, was hospitalized due to a 4-day history of left orbital shooting pain. Cranial nerve examination was nearly normal except for mild ptosis and hyperemic conjunctiva on the left side. Ophthalmic examination revealed normal intraocular pressure and normal eyeground. There were no specific findings in other physical examinations. Orbital CT revealed left orbital myositis involving superior, inferior, medial, and lateral rectus muscles compared with the right orbit (Fig. 1A). We treated him with intra-venous mannitol, 60 mg/day per-oral prednisolone (nisolone®, Kukje, Seongnam, Korea), levofloxin eye-drops (Cravit®, Santen, Shiga, Japan), dorzolamide HCl 2% with timolol 0.5% (Cosopt®, MSD, Seoul, Korea), and latamoprost (Xalost®, Taejoon, Seoul, Korea). Fig. 1 (A) Orbital computed tomography (CT) image with contrast, coronal view. CT shows relatively moderately enhanced and enlarged left superior, inferior, medial, and lateral rectus muscles compared with right orbit. (B) 2 weeks later, a follow-up orbital ... After 3-days, he developed vesicular skin rashes at the distribution of the ophthalmic branch of the left trigeminal nerve and along the nasal ridge (Hutchinson's sign) (Fig. 1C). He complained of severe pain in his left forehead and nose. The pattern of the pain included lancinating, shooting, and itching sensations. The pain measured by the visual analogue scale (VAS) was approximately 90/100 mm. Laboratory data, including routine biochemical and hematological examinations, were normal except for glucose (423 mg/dl) and hemoglobin A1c (10.6%). The erythrocyte sedimentation rate (ESR) was 30 mm/hr and C-reactive protein (CRP) was 0.74 mg/dl. Immunologic studies, including IgA, IgM, C3, C4, antimitochondrial antibody (AMIA), anti-nuclear antibody (ANA), and anti-double stranded DNA, were all within normal limits. Thyroid function test was normal and the VDRL/TPHA test was negative. Immediately, we treated him with 7-day intra-venous (IV) acyclovir, IV dexamethasone, and per-oral (PO) gabapentin. At the same time, we performed supraorbital and supratrochlear nerve blocks. After the nerve block, the headache and allodynia were improved. The eyelid swelling and orbital pain gradually lessened by the time he was discharged. The patient returned to our clinic with persistent left orbital pain and paroxysmal and lancinating pain along the nose ridge and forehead. We performed supraorbital and supratrochlear nerve blocks then and again in two weeks, for a total of three times. The pain was reduced to VAS 10-20/100 mm. A follow-up orbital CT revealed resolved myositis in the rectus muscles (Fig. 1B). The patient was undergoing oral administration of gabapentin (600 mg/day). He revisited the hospital 5 months later without particular exacerbation of the pain or any other inconvenience in his daily tasks. Ophthalmic complications following HZO result directly from inflammatory changes or nerve damage, or indirectly from tissue scarring. These complications vary from mild, which may pass unnoticed, to severe, which may threaten life or sight. Except for diplopia, our patient developed characteristic symptoms of orbital myositis, such as orbital pain worsening with eye movements, proptosis, swollen eyelid, and hyperemic conjunctiva. He had Hutchinson's sign, which is typical for HZO [1]. Normal immunologic and serologic surveys excluded other etiologies of orbital myositis, for example, thyroid disease, syphilis, and auto-immune diseases. His ocular symptoms improved after antiviral therapy and the follow-up orbital MRI four months later revealed total recovery of orbital myositis. Typically, ophthalmic complications of HZO occur between 5 days and 14 days following cutaneous lesions. Our case is unusual in that the orbital myositis preceded vesicular rashes. Two similar patients have been reported previously [3,4]. Both patients came to the hospital for retrobulbar pain with diplopia. Volpe et al. demonstrated orbital myositis on computed tomographic (CT) scans in their patient one day before the development of skin vesicles [3]. As reported by Kawasaki et al., MRI demonstrated orbital myositis three days prior to appearance of typical skin eruptions in their patient [4]. In these two patients and ours, their extraocular myositis had excellent recovery. However, our patient suffered from PHN, which did not occur in the previously reported patients. Although Marsh and Cooper had proposed extraocular myositis as a possible cause of ophthalmoplegia in HZO [2], it was not well documented until these case reports. To date, there is no histopathologic study of orbital myositis in HZO [4]. Orbital myositis preceding vesicular skin eruptions is a diagnostic challenge in HZO. Since zoster rashes may develop one week or more after dermatomal pain [1], serological and immunological tests may be helpful for early diagnosis in extraocular myositis preceding zoster rashes. In 1958, Lewis reported a syndrome of "ophthalmic zoster sine herpete" [5], in which orbital pain, extraocular palsy, and periorbital skin swelling occurred without skin rashes. "Ophthalmic zoster sine herpete" further confounds the diagnosis of HZO. We emphasize that, even without vesicular skin rashes, a diagnosis of extraocular myositis case as idiopathic should not be given before the availability of negative serological and immunological results for herpes zoster. In conclusion, orbital myositis can be the presenting sign of HZO. In these patients, recovery of extraocular myositis is excellent and serological and immunological studies may be helpful for early diagnosis. HZO should be listed as a cause of acute orbital myositis even without skin eruptions. Therefore, early diagnosis of acute orbital myositis and anti-viral therapy will prevent PHN. And, if zoster skin rashes are found, we should control pain aggressively by nerve blocks to prevent the development to PHN.

Airway management is important during general anesthesia. Difficulties with a direct laryngoscopy can be managed successfully in a routine manner using a laryngeal mask airway. A 65-year-old woman was scheduled to undergo gynecologic surgery. After injecting the intravenous induction agents and muscle relaxants, intubation was attempted with a direct laryngoscope. However, the vocal cords could not be observed with only the epiglottis being slightly visible. Although intubation was re-attempted by another anesthesiologist, it failed. Intubation was successfully performed via an intubating laryngeal mask airway (ILMA) after additional 100% oxygen mask ventilation. We report a case of vocal cord palsy subsequent to tracheal extubation after endotracheal intubation via ILMA.

Trigeminal neuralgia is sudden, usually unilateral, severe brief stabbing recurrent pain in the distribution of one or more branches of the 5th cranial nerve. Treatments of trigeminal neuralgia include systemic trials of medications and surgical procedures such as microvascular decompression, stereotactic radiosurgery, percutaneous glycerol or alcohol rhizolysis, percutaneous radiofrequency rhizotomy, and percutaneous balloon compression (PBC). PBC of the trigeminal ganglion using a balloon catheter was introduced by Mullan and Lichtor in 1983. Since then, many papers have been published describing results of this technique. Typically, this procedure is performed under general anesthesia. However, little is known about the use of PBC for the treatment of trigeminal neuralgia in Korea. We report here our anesthetic management of percutaneous balloon compression of trigeminal ganglion for the treatment of the trigeminal neuralgia by total intravenous anesthesia.

Although Guglielmi Detachable Coil (GDC) endovascular treatment of intracranial aneurysms has become an alternative to surgery, the main complication continues to be thromboembolic events. In our patient, we found thrombus at the third branch of the right middle cerebral artery after coil embolization. We added intravenous heparin and gave abciximab, an antiplatelet agent through the catheter. We then elevated the blood pressure and administered intravenous colloid solution to maintain adequate collateral circulation. One day later, the patient presented with acute focal infartion in the right frontal lobe and we treated her with low molecular weight heparin. After seven days, the patient’s symptoms disappeared, and there was no residual neurological deficit. Therefore, we believe potential clinical complications can be avoided through early recognition of thrombus and appropriate medical therapy. Furthermore, it is necessary to prevent hypotension and to maintain proper hematocrit levels during operations in patients having risk factors for thrombosis.

Background: Laryngoscopy and endotracheal intubation cause hemodynamic changes such as hypertension and tachycardia. Adjuvant fentanyl administration have been used to reduce the hemodynamic changes. Remifentanil, a newly developed ultra short acting opioid, has recently been used to reduce the hemodynamic changes. This study investigated the effects of fentanyl and remifentanil on hemodynamic responses to laryngoscopy and endotracheal intubation. Methods: Sixth ASA class I or II patients who scheduled for elective surgery were divided randomly into 3 groups. Each patient received normal saline, fentanyl 1.5g/kg or remifentanil 1.5g/kg, respectively. Predetermined drugs for each group were administered over 30 seconds after induction of anesthesia with TCI of propofol effect site target concentration 4.0g/ml and rocuronium 1.0 mg/kg. Laryngoscopy and endotracheal intubation was carried out and systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and heart rate (HR) were measured baseline (initial), before intubation (BI) and during 5 minutes after intubation (I1 to I5). Results: In the fentanyl group, I1 HR value was significantly higher than baseline. In the remifentanil group, SBP and MAP were significantly lower than baseline during post-intubation period. Fentanyl and remifentanil groups show lesser hemodynamic changes than those in the control group. There were no significant differences of hemodynamic changes between fentanyl and remifentanil group. Conclusions: Fentanyl and remifentanil can attenuate hemodynamic responses after laryngoscopy and endotracheal intubation.

Metastatic spinal tumor may cause pain by direct tumor involvement of bone with activation of local nociceptors or compression of adjacent structures. As an adjunct to pharmacologic therapy, many patients benefit from the use of additional nerve blocks to treat cancer pain. However, they require repeated injections as nerve block under local anesthetic sometimes only give the patient temporary relief of pain. Recently, the advent of pulsed radiofrequency application has proved a successful treatment for refractory pain disorders. A 43 year-old man was presented with a constant, dull, aching pain in the posterior neck with radicular pain referred to right shoulder due to metastatic cervical spinal tumor. Right C5 and C6 medial branch nerve blocks, with local anesthetic-steroid injections were effective, but short pain relief for a couple of days. However, the pain relief lasted longer and was effective with pulsed radiofrequency application over 3 months.