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Background: Although competency-based education (CBE) is becoming a popular form of medical education, it has not been used to train residents. Recently, the Korean Society of Anesthesiologists completed a pilot implementation and evaluation of a CBE program.This study aims to outline the experience.Methods: The chief training faculty from each hospital took a one-hour online course about CBE. Emails on the seven core competencies and their evaluation were sent ahead of a pilot core competency evaluation (CCE) to residents and faculty. The pilot CCE took place in late 2021, followed by a survey.Results: A total of 68 out of 84 hospitals participated in the pilot CCE. The survey response rate was 55.9% (38/68) for chief training faculty, 10.2% (91/888) for training faculty, and 30.2% (206/683) for residents. More than half of the training faculty thought that CCE was necessary for the education of residents. Residents’ and training faculty’s responses about CCE were generally positive, although their understanding of CCE criteria was low. More than 80% of the hospitals had a defibrillator and cardiopulmonary resuscitation manikin while the rarest piece of equipment was an ultrasound vessel model. Only defibrillators were used in more than half of the hospitals. Thoughts about CCE were related to various factors, such as length of employment, location of hospitals, and the number of residents per grade. Conclusions: This study’s results may be helpful in improving resident education quality to meet the expectations of both teaching faculty and residents while establishing CBE.

Background Postoperative pain control after the minimally invasive repair of pectus excavatum (MIRPE) is essential, but there is a controversy about a better analgesic method between epidural and intravenous (IV) analgesia. This systematic review and meta-analysis aimed to compare the effect of epidural versus IV analgesia following MIRPE. Methods We searched PubMed, MEDLINE, EMBASE, Cochrane Central Register, and ClinicalTrials.gov for randomized control trials (RCTs) dated up to 31st May 2021. The primary outcome was the area under the curve (AUC) of the weighted mean visual analog scale (VAS) after MIRPE. The secondary outcomes were postoperative nausea, operation time, total operating room time, and postoperative length of hospital stay. Results Four RCTs involving 243 patients were finally included in this meta-analysis. The AUC of the weighted mean VAS was 343.62 in the epidural group and 375.24 in IV group. Epidural group showed lower VAS than IV group at 12 hours (mean difference -0.99 [95% CI: -1.52, -0.47], P = 0.001, I2 = 0%), at 24 hours (mean difference -0.65 [95% CI: -1.15, -0.16], P = 0.009, I2 = 0%), and 48 hours (mean difference -0.81 [95% CI: -1.61, -0.01], P = 0.046, I2 = 46%) after the surgery. Conclusion Epidural analgesia after the MIRPE had a better analgesic effect than IV analgesia from 12 hours to 48 hours after surgery, and AUC of VAS was lower in the epidural group. However, IV analgesia may also be a viable option, and physicians should wisely choose analgesic modalities after MIRPE.

Background: Giant lip hemangioma is a rare disease that may cause difficulty in preoxygenation and ventilation when using face masks and intubation during general anesthesia induction.Case: A laparoscopic cholecystectomy was planned for a 77-year-old woman. The patient had a giant lower lip hemangioma that was 12 x 5 x 5 cm, which made preoxygenation and ventilation through a face mask impossible and put her at risk of hemangioma rupture. We preoxygenated her through a high-flow nasal cannula (HFNC). Following propofol and succinylcholine administration, we intubated the patient with a video laryngoscope without desaturation, hemangioma rupture, or CO2 retention. Conclusions: HFNC is a useful tool when difficult intubation is expected in patients who have problems using conventional face masks.

Background Propofol has been widely used for an induction and/or maintenance of general anesthesia, or for sedation for various procedures. Although it has many ideal aspects, there have been several cases of drug abuse and addiction. The authors investigated whether there are abuse liable groups among the general population. Methods We surveyed 169 patients after gastric endoscopic examination, which used propofol as a sedative, with the Addiction Research Center Inventory (ARCI) questionnaire. Other characteristics of the patients, such as past history, smoking habits, depression, anxiety, alcohol abuse liability and sleep disturbance, were recorded by history taking and several questionnaires before the exam. Results Propofol had a high Morphine-Benzedrine Group (MBG) score (representative value for euphoria) of 6.3, which is higher than marijuana, and a Pentobarbital-Chlorpromazine-Alcohol Group (PCAG) score (representative value of sedation) of 8.1, which is lower than most opioids. The MBG score showed no statistically significant correlation between any of the characteristics of the groups. In females, the PCAG score showed a correlation with age, and in males, it showed a correlation with a sleeping problem. Conclusions Propofol had relatively high euphoria and low residual sedative effects. It had a more potent sedative effect in the female group who were young, and in the male group who had a low sleep quality index. There were differences in the abuse liability from a single exposure to propofol in the general population. Further study is needed to evaluate the abuse liability of repeated exposure.

We report a healthy patient with postpartum headache and neck stiffness which were diagnosed as symptoms of pseudoaneurysm of vertebral artery. She had received a Cesarean section under the spinal anesthesia, and complaint of headache and neck stiffness. Epidural blood patches were done twice, but symptoms persisted. Eight days later, she experienced sensory disturbance and emergent laminectomy was done. When persistent postpartum headache occurs after epidural blood patch, more precise differential diagnosis should be made and considering other possible pathologies.

Pediatric intracranial aneurysms are uncommon. Moreover ruptured aneurysms are extremely rare in preterm neonate. In this article we report a case of a 1 month old infant with a ruptured middle cerebral artery (MCA) aneurysm. Aneurysm clipping surgery was scheduled for a 1 month 3 day old female neonate, weighing 2,450 g. She was born at a gestational age of 34 weeks and 2 days weighing 2,300 g. After birth, she was mechanically ventilated due to respiratory distress. On the 11th day after birth, she developed sepsis of unknown origin. She presented with abrupt anemia (hemoglobin dropped from 9.5 g/dl to 6.1 g/dl), and brain computerized tomogram (CT) with contrast enhancement was done identifying a intracranial hemorrhage. External ventricular drainage insertion was done. After the drainage, 3-dimensional CT angiography of the head and neck was done. About a 4.2 × 7.7 mm sized aneurysm, at the left MCA bifurcation site was found. She was transported to operating room for clipping. Before anesthesia, her heart rate was 131 beats/min and blood pressure 68/37 mmHg (arterial catheter at right radial artery) with an infusion of dopamine 10 µg/kg/min and dobutamine 20 µg/kg/min. We connected her endotracheal tube with a ventilator and volume control mechanical ventilation was applied with FIO2 0.5, tidal volume of 20 ml, respiratory rate of 40 breaths/min and positive end-expiratory pressure 4 cmH2O. Peak airway pressure was maintained at about 17-20 cmH2O and peripheral pulse oxygen saturation was maintained at 100% and the endtidal carbon dioxide was maintained at 28-32 mmHg during anesthesia. Anesthesia was maintained with sevoflurane (0.6 vol%) and remifentanil (0.5-1 µg/kg/min). During four hours after the induction, a mean blood pressure of 40-55 mmHg was maintained, but after that time, epinephrine infusion (0-0.6 µg/kg/min) was added because of a reduction in the blood pressure. Total anesthesia time was 7 hours 5 minutes. The patient recovered and was discharged 39 days after the surgery. Intracranial aneurysms occur rarely in preterm neonate so the cause is presumed to be various. In the case of this neonate, a definite causal bacterium was not identified in the culture, but because there was a precedent for sepsis, it is thought to be a septic aneurysm caused by infection. Neonates cannot localize pain due to a premature central nerve system, and it is known that they cannot interpret pain, because there is no memory of a pain experience. However Anand and Carr [1] stated that the pain sensation is conveyed to the brain region such as the sensory motor cortex and thalamus even in neonates. Appropriate anesthesia and analgesic are necessary even in neonates. For anesthesia methods, there is total intravenous anesthesia (TIVA) using propofol and anesthesia with inhalation agents. Propofol reduces the oxygen consumption in the brain, decreases the cerebral blood flow, and contracts the cerebral vessels. A target controlled infusion (TCI) model is required to perform TIVA using propofol, and TCI models applicable for infants is the 'Paedfusor' model which can be applied to patients 1 year or older with a weight of 5 kg or more. Our case was a 1 month 3 day old neonate weighing 2,450 g, so currently there are no applicable TCI models. There is controversy regarding the effect of volatile agents on the brain. Jevtoric-Todorovic confirmed that neuroapoptosis occurred in neonate rats when they were exposed to nitrous oxide, isoflurane, and midazolam for 6 hours [2]. Considering the above study, there was the possibility of potential neurotoxicity from the volatile agents; thus in this case, the authors used a minimum amount of 0.6 vol% sevoflurane and added a high dose of opioid. Using a high dose of opioid during anesthesia not only reduces the stress response but can also reduce the amount of anesthetic agent; therefore, it can reduce the neurotoxic effects [3]. Most complications anticipated when using opioids in infants or neonates are respiratory hold or apnea which appears during awakening or the recovery stage after surgery. In our case, the neonate was maintained in an intubation state and received ventilator care after surgery so it was not considered to be a problem. When anesthetizing brain nerves, mild hypothermia (32-34℃) may be maintained to reduce brain oxygen consumption, cerebral blood flow, and intracranial pressure, but the effect is not definite in young patients. Regarding indications for hypothermia, Abraham limited it to neonates with a gestational age of 36 weeks or more who developed hypoxic ischemic encephalopathy within 6 hours of birth, and also restricted it to those who satisfied two more separate criteria [4]. The temperature of the neonate measured in our case was 34.8-37.4℃, and although warm air was turned on intermittently to raise the temperature, there were limitations in stably maintaining body temperature due to loss and replenishment of fluid during surgery, and a relatively large body surface area compared to the weight. The total amount of infused fluid was 169 ml including leukocyte-depleted RBC 10 ml, and the predicted maintenance fluid requirement was calculated to be 100 ml and blood loss of 90 ml. The fluid administered was Lactated Ringer's solution 69 ml, 5% dextrose water 50 ml used to mix the inotropics, and normal saline 40 ml. Electrolyte imbalance was not observed in the blood test performed after surgery. Inotropics were used to maintain blood pressure during surgery, and 24.5 ml of urine was confirmed after surgery so the I/O balance is considered to be appropriate. A surgical case of intracranial aneurysm in a neonate is very rare, but it is believed to be on the rise as more low-birth weight neonates survive because of the development of medical technology. More cases and prospective studies are needed to search for an anesthesia method which is more ideal and has a better outcome for neonatal aneurysm patients.

We report that intraoperative NIM-2 monitoring devices can interfere with bispectral index monitoring. A 45-year-old male with chronic otits media underwent tympanolasty under general anesthesia with NIM-2 monitoring and bispectral index monitoring at our institution. And then, bispectral index monitoring was severely interrupted by facial nerve monitoring.

Epiglottic cysts sometimes compromise a patient's airway, and may make airway management difficult. We report a novel method of intubating a patient with a large epiglottic cyst, using direct laryngoscopy and a light wand. A 53-year-old man with hoarseness was admitted to the hospital. He complained of a mild cough and sore throat for 2 days, without dyspnea. General anesthesia for microscopic laser surgery was planned. Neck computed tomography revealed a nearly non-enhancing cyst, 2.7 × 1.8 × 3.3 cm, located on the right prelingual surface of the epiglottis (Figs. 1A and 1B). Fig. 1 Neck computed tomography (CT) revealed a nearly non-enhancing cyst in the right pre-epiglottic space with concomitant mild airway obstruction ([A] Transverse and [B] Sagittal views). (C) This image shows direct laryngoscope, light wand and laser tube ... In addition to standard monitoring and preparations, we prepared laryngeal mask airways, adult and pediatric fiberoptic bronchoscopes, and an emergency cricothyrotomy kit at the bedside. Two attending anesthesiologists and one resident were present in the operating room. After preoxygenation, propofol 120 mg was given. The patient became unconscious, and we confirmed there was no difficulty with mask ventilation. We then administered rocuronium 25 mg intravenously. After 4 minutes, we attempted intubation with a Macintosh blade no. 3 and 5.0 laser tube (Laser-Flex® Tracheal Tube, Mallinckrodt, St. Louis, MO, USA) without stylet. We carefully placed the tip of the Macintosh blade at the vallecula, avoiding direct pressure on the cyst. After that, an assistant held the handle of the laryngoscope steady. The intubating anesthesiologist then held the hockey stick-shaped light wand in the left hand and used it both for leverage and as a light source. Gently elevating both the epiglottis and cyst with the light wand in the upper left direction revealed the lower third of the glottis with sufficient light. We then intubated the patient. After intubation, we began mechanical ventilation with air. Tidal volume was set to 500 ml, respiration rate was 12 per minute, and peak airway pressure was 26 cmH2O. Anesthesia was maintained with sevoflurane 1.5-2.0 vol% and remifentanil continuous infusion of 0.1-2.0 mcg/kg/min. Oxygen saturation was maintained at a minimum of 95% throughout the surgery and in the recovery room. The patient recovered and was discharged after 1 day without any adverse events. Most epiglottic cysts are located on the lingual surface or vallecula, which makes intubation difficult, when a cyst is large. For the treatment of epiglottic cysts, simple aspiration of the cyst results in frequent recurrence, so complete removal is recommended [1]. For this removal, laser surgery seems to be superior to cold instrument surgery, in many respects. During laser surgery, the use of laser resistant endotracheal tubes is recommended to avoid catastrophic airway fires. There are several choices for laser resistant endotracheal tubes, including wrapping metal foil around conventional tubes, Xomed Laser-Shield (Laser-Shield®II Endotracheal Tube, Medtronic Xomed, Jacksonville, FL, USA), and Mallinckrodt Laser-Flex. Inevitably, methods or tubes such as these are accompanied by an increase in the wall thickness of the tubes. With the Laser-Flex, for example, the outer diameter (OD) of the tubes is at least 2.5 mm greater than the internal diameter (ID). This number is considerable in comparison to the thickness of conventional tubes, which is 1.3 mm at minimum. In our case, when intubation was attempted, the epiglottic cyst blocked the light from the laryngoscope, so structures behind the cyst were not visible (Fig. 1C). To circumvent this problem, there are several possible options. First, we could use a Miller blade or a Magill blade. Holding the epiglottis from the lower surface, together with the cyst, may allow direct visualization of the vocal cords without blockage of the light. However, considering the size of the cyst, this maneuver might fail. In addition pressure of the blade may rupture the cyst and cause pulmonary aspiration of its contents. Second, we could aspirate the contents of the cyst and then try the conventional intubation method. If the mass was not entirely cystic, or lobulated, the chances of success would be slim. Furthermore, attempting aspiration without first securing the airway may significantly increase the risk of pulmonary aspiration of cyst contents. Lastly, we could choose larger diameter tubes to use a light wand, intubating stylet, or fiberoptic bronchoscope. For airway surgery, though, it is rational to choose the smallest tubes possible to facilitate the surgery. We chose an ID 5.0 Laser tube, the OD of which is equivalent to the OD of an ID 5.5 conventional tube. The OD of an adult fiberoptic bronchoscope used for awake intubation is 5.0 mm, the same as the ID of the Laser tube. The OD of a light wand is 5.55 mm, still larger than the ID of the tube. The OD of the intubating stylet was 4.65 mm, but due to small differences between the ID of the tube and the OD of the stylet, using it was impossible. In patients with more difficult airways, it may be rational to choose a Laser-Flex tube with a bigger ID and use a stylet in it, but this also may be difficult because of the dimmed light caused by the cyst. A light wand may still be difficult to use because of the large OD of a light wand for an ID 6.0 Laser tube. The difference in diameter between the two is only 0.45 mm. Laser tubes are rigid and difficult to use with a fiberoptic bronchoscope. In addition, to use an adult bronchoscope, one must use a tube with an ID larger than 6.0 mm. A McCoy blade can be helpful in some situations. In our case it might be effective, but considering the size and the location of the cyst, even elevating the epiglottis might not make it possible to move the cyst away from the light source. In actuality, levering of the epiglottis in the ventral and cranial direction would move the cyst closer to the light source and might make the view dimmer. Using a fiberoptic bronchoscope or light wand in the presence of a large epiglottic cyst is also a difficulty, because of the mass blocking the passage. Recently, Choi et al. [2] reported a case of intubation of a patient with a large glottic mass. In their report, introducing a flexible bronchoscope was difficult and ultimately not possible, in spite of attempts at guidance and visualization with the GlideScope® (Verathon Inc., Bothell, WA, USA) video laryngoscope. The authors did not report the size of the mass in their case, but the picture included in their report shows similarity to our case. Epiglottic cysts poses great challenges for anesthesiologists in some cases. Our method can be a relatively easy, less invasive, simple method dealing with some large epiglottic cysts.

Background: We hypothesized that, even in patients taking aspirin, the variance of preoperative platelet response to collagen might be associated with myocardial injury during coronary artery bypass graft (CABG) surgery. Therefore, we evaluated the relationship between preoperative whole-blood aggregometry (WBA) by collagen and the post operative myocardial injuries. Methods: For 44 patients who were scheduled for elective off -pump CABG and taking aspirin, WBA was measured by the impedance method in the presence of collagen (2 mg/ml or 5 mg/ml) as stimulatory agents. After CABG, myocardial injury was evaluated by analysis of the creatine kinase (CK), creatine kinase-MB (CK-MB), and lactate dehydrogenase (LD), and by electrocardiography. Results: High response group (n = 13) on preoperative WBA with collagen (2 and 5 mg/ml) showed significantly higher postoperative cardiac enzyme levels (CK, CK-MB and LD) than those of low response group (n = 31). Conclusions: In patients who take aspirin and undergoing off -pump CABG, the preoperative platelet response to collagen is correlated with postoperative myocardial injury.

Electrocardiography (ECG) is an essential monitoring method that provides important information related to cardiac physiology. However, the sinus rhythm can be interpreted as a serious arrhythmia, such as ventricular tachycardia (VT), due to artifacts [1]. We present a case in which a VT-like artifact appeared on an ECG during a total thyroidectomy. A 33-year-old female was admitted for a thyroidectomy due to hyperthyroidism. There were no significant findings on a pre-operational examination, including thyroid function test. The ECG showed a normal sinus rhythm. The thyroid was significantly enlarged overall; the sizes of the right lobe, isthmus, and left lobe were 7 × 3 × 3 cm, 5 × 1.5 × 1 cm, and 6.5 × 3.5 × 2 cm, respectively. Initial vital signs were blood pressure (BP) of 120/70 mmHg, pulse rate (PR) of 70 /min, body temperature of 36.5℃, and SaO2 of 98%. ECG leads were attached to both infraspinatus muscle area and lateral side of left 4th rib. Anesthesia was induced with propofol, rocuronium and remifentanil. After the endotracheal intubation, anesthesia maintained with sevoflurane, remifentanil. An electrocautery grounding pad was attached to the left peroneal posterior surface, and electrical noise was not observed. The surgery proceeded, but 170 minutes into the operation, when the operator retracted the upper pole for dissection, the PR increased to above 190 /min with a VT-like ECG rhythm. At that time, BP was 110/70 mmHg. We asked for an immediate suspension of surgery and identified it as an arrhythmia related to thyroid disease. Esmolol 30 mg was administered, and then amiodarone and direct current cardioversion were prepared to address the VT. Immediately after the administration, the PR fell to within the normal range of 70-80 /min and normal QRS rhythm was restored. However, a similar manifestation on the ECG and tachycardia were seen 15 minutes later on the same surgical procedure. At that time, the patient presented a BP of 103/63 mmHg, PR of 74 /min, and normal pulse oximeter wave was observed. On analyzing the ECG rhythm strip printed from the monitor, the hidden QRS wave was found within the waveform suspected as artifacts (Fig. 1). The surgery was continued without further treatment, and completed without any problem. The patient presented a stable hemodynamic status and clear consciousness, and discharged on day 7 post-operation. Fig. 1 Rhythm strips on both events. It relevantly showing notch sign (arrow) and spike sign (bold arrow). ECG artifacts can be classified into two main groups: physiological and nonphysiological artifacts. Some causes of physiological artifacts include muscular activity and the movement of patients [2]. Narrow, rapid, and spiky electromyographic signals may present on the ECG due to muscular activity, but these signals are mostly filtered by recent ECG monitors. Artifacts due to movement result from the ECG electrode being attached to the patient's skin; as it actively generates the potential difference between the interior and exterior of the skin. Stretching the skin changes the degree of skin potential, which can cause various artifacts on the ECG [3]. Epidermal stretch-induced voltage changes are the primary cause of motion artifacts, and such artifacts are not filtered [2]. In our case, a VT-like abnormal rhythm appeared on the ECG when the operator was conducting traction and dissection at the upper pole of the thyroid. Therefore, an epidermal stretch-induced voltage change due to the traction of the skin during traction of the huge thyroid can not be ruled out as causing the artifact. Common causes for nonphysiological artifacts include insufficient electrode gel or contamination of the electrode by betadine [2]. However, there is a low possibility of the abnormal signal being caused by insufficient gel or contamination, because the abnormal ECG was presented in the middle of surgery and a protective film was applied to prevent electrode contamination. While using monopolar electrocauterization, a faulty ground or electrical noise input may be another cause of nonphysiological artifacts. In this case, the electrocauterizer grounding pad was attached to the left peroneal surface, and there was no abnormal manifestation on the ECG at cauterization prior to the occurrence of the abnormal rhythm; hence, there is a low possibility of artifact due to these factors. Also, thyrotoxic crisis could be a possibility. However, although there was an increase in the heartbeat on ECG, at that time BP was normal; this situation differs from thyrotoxic crisis, where systolic hypertension under a high-output state with a widening of pulse pressure is observed. Furthermore, as most of the thyroid gland was dissected, there is a low possibility that an abrupt input of thyroid hormone into the blood vessel could have caused VT. Huang et al. [4] suggested a diagnostic algorithm for pseudo-VT caused by a tremor-induced artifact. For a suspected manifestation of VT on ECG, pseudo-VT can be diagnosed when one of the following signs is observed: "sinus sign", where the sinus rhythm and normal P, QRS, and T wave are observed in a single limb lead (leads I, II, III); "spike sign", where a regular or irregular tiny spike is observed on the QRS complex; and "notch sign", where a notch is observed on the QRS-like complex with sinus rhythm cycle. In this case, the spike sign and notch sign were observed, and pseudo-VT caused by an artifact was diagnosed accordingly. Arrhythmia during anesthesia is a frequently experienced manifestation. Especially, VT may cause a serious hemodynamic abnormality, immediate diagnosis and treatment are important. However, a normal rhythm can be construed as a serious arrhythmia due to the artifact. Therefore, it is crucial to consider the possibility of unnecessary and potentially fatal treatment at all times. Srikureja et al. [5] reported that artifacts as a causative factor always should be taken into account when a hemodynamically stable, asymptomatic patient presents with an abnormality on the ECG and confirmation of each lead on 12-lead ECG at the time of the episode, and checking the basic pulse. In conclusion, when suspecting arrhythmia during anesthesia, it is essential to confirm the uniform occurrence of arrhythmia on other confirmable leads, and the diagnostic approach should include collecting clinical evidences such as the wave form on the pulse oximeter, PR and BP at the time of the event.

Mounier-Kuhn-syndrome patients have markedly dilated trachea and main bronchi due to an atrophy or absence of elastic fibers and thinning of smooth muscle layers in the tracheobronchial tree. Although this syndrome is rare, airway management is challenging and general anesthesia may produce fatal results. However, only a few cases have been reported and this condition is not widely known among anesthesiologists. We present the case of a tracheobronchomegaly patient undergoing an emergency off-pump coronary artery bypass. Although the trachea was markedly dilated with numerous tracheal diverticuli, there was an undilated 2 cm portion below the vocal cords found on the preoperative CT. Under a preparation of extracorporeal membrane oxygenation, we intubated and placed the balloon of an endotracheal tube (I.D. 9 mm) at this portion, and maintained ventilation during the operation. This case showed that a precise preoperative evaluation and anesthetic plan is essential for successful anesthetic management.