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Background We previously reported that percutaneous dilatational tracheostomy (PDT) can be safely performed 2 cm below the cricothyroid membrane without the aid of a bronchoscope. Although our simplified method is convenient and does not require sophisticated equipment, the precise location for tracheostomy cannot be confirmed. Because it is recommended that tracheostomy be performed at the second tracheal ring, we assessed whether patient characteristics could predict the distance between the cricothyroid membrane and the second tracheal ring. Methods Data from 490 patients who underwent three-dimensional neck computed tomography from January 2012 to December 2015 were analyzed, and the linear distance from the upper part of the cricoid cartilage (CC) to the lower part of the second tracheal ring (2TR) was measured in the sagittal plane. Results The mean CC-to-2TR distance was 25.26 mm (95% CI 25.02–25.48 mm). Linear regression analysis showed that the predicted CC-to-2TR distance could be calculated as −5.73 + 0.2 × height (cm) + 1.22 × sex (male: 1, female: 0) + 0.01 × age (yr) −0.03 × weight (kg) (adj. R2 = 0.55). Conclusions These results suggest that height and sex should be considered when performing PDT without bronchoscope guidance.

Poland syndrome, which is characterized by an absence of pectoralis muscles and their innervated nerves, is marked by variable chest wall defects due to deficits of 2nd, 3rd, 4th, and 5th ribs and costal cartilage. Additionally, there are other reported combined anomalies of the heart, lung, kidney, ipsilateral hand and foot associated with the syndrome. The lung on the side with the thoracic deformity is more hypoplastic or smaller than the lung on the unaffected side, which can cause herniation of the lung or paradoxical ventilatory movement in severe cases, thereby increasing the risk of respiratory depression and hypoxemia. Patients may have profound lung complications due to depressed respiratory muscle function and exacerbation of the underlying chronic pulmonary disease during the perioperative period. These patients also show increased risk of malignant hyperthermia and therefore require careful attention during general anesthesia. We report here an anesthetic experience during reconstruction surgery of a chest wall defect in a male patient with Poland syndrome.

When first introduced, percutaneous dilatational tracheostomy (PDT) was performed using a bronchoscope. The bronchoscope itself, however, has several disadvantages, including interruption of ventilation. Modifications of the standard PDT technique have suggested that PDT can be safely performed without a bronchoscope. However, the safety of these modifications is unclear and many modifications have yet to be widely adopted. This study retrospectively evaluated the safety of a simplified PDT technique using the Cook® Ciaglia Blue Rhino™ in 186 patients. After confirming the underlying structures by palpation, PDT was performed without a bronchoscope or blunt dissection, 2.0 cm below the cricothyroid membrane. Ultrasonography was used only when palpation was difficult. Except for bleeding in three patients with coagulopathy, none of the patients experienced any early or late complications, and there were no deaths related to PDT. These findings confirm that PDT can be safely performed using a simplified technique, which may be useful in situations with limited equipment and medical personnel.

Background: This study compared intubating conditions and the onset time associated with administration of cisatracurium, a nondepolarizing neuromuscular blocker with a relatively slow onset, according to prior injection of one of two intravenous anesthetic agents: propofol or etomidate. Methods: Forty-six female patients, undergoing general anesthesia and endotracheal intubation for elective surgery, were randomized to two groups; group P were administered propofol (2 mg/kg) prior to cisatracurium (0.2 mg/kg); group E were administered etomidate (0.3 mg/kg) prior to cisatracurium (0.2 mg/kg). We measured intubating conditions and the onset time according to the types of intravenous anesthetic administered. Measurements of heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were taken immediately prior to induction; immediately and 1 min after IV anesthetic administration; and immediately and 1, 2, 3, 4, 5, 7, and 15 min after endotracheal intubation. Results: Intubating conditions were superior in group E compared with group P (P = 0.009). The average onset time of cisatracurium was more rapid in group E (155.74 ± 32.92 s vs. 185.26 ± 38.57 s in group P; P = 0.008). There were no group differences in SBP, DBP, and HR following intravenous anesthetic drug injection and endotracheal intubation. However, SBP and DBP were substantially higher in group E after endotracheal intubation. Conclusions: Etomidate improves intubating conditions and provide a more rapid onset time of cisatracurium during anesthetic induction compared to propofol.

BACKGROUND: To analyze how lidocaine 40 mg mixed prevents injection pain of propofol affects the onset time of rocuronium, tracheal intubating conditions and intubation related hemodynamic changes. METHODS: This study consisted of 70 patients with an American Society of Anesthesiologists (ASA) physical status class 1 or 2 for general anesthesia. All the patients were randomly allocated into two groups: propofol 2 mg/kg plus normal saline 2 ml (Group C) and propofol 2 mg/kg plus 2% lidocaine 40 mg (Group L). Each group was administrated intravenously during induction and the patient was intubated 1 minute after an injection of 0.6 mg/kg of rocuronium. The time at disappearance of the first twitch and intubation scores were recorded. Also, blood pressure and heart rate were measured at the baseline, after intravenous injection of propofol, before intubation, and at 0, 1, 2, 3 and 5 minutes after intubation. RESULTS: There were no significant differences between group C and L (P > 0.05). CONCLUSIONS: 40 mg of lidocaine mixed with propofol to prevent injection pain did not affect the onset time of rocuronium, intubating conditions and intubation related hemodynamic changes.

Non-obstetrical surgery during the first trimester is stressful to both the mother and the fetus. Anesthesiologists are also stressed, not only because of the effects of surgery itself, but also because of the uncertain influences of anesthesia thrown upon on the fetus. The authors present a case of breast surgery successfully performed on a woman 8 weeks pregnant requiring removal of breast abscess by the application of thoracic paravertebral block without any complications. Thoracic paravertebral block may be a safe anesthetic method for non-obstetric surgery during early pregnancy.

There are now several reports of anaphylaxis after rocuronium injection in the Korean population, where only mild to moderate symptoms have been described. This is fortunate, since severe anaphylactic reactions have also been reported after rocuronium injection. Also, among the cases reported in Korea, only one case performed general anesthesia with a neuromuscular blocking agent later on [1]. Hence, we report a case of severe anaphylaxis after injection of rocuronium where the patient showed abrupt severe hypotension and cardiac arrest. After being transferred to the intensive care unit (ICU), ST segment depression was discovered in multiple electrocardiogram (ECG) leads and immediate coronary angiography revealed variant angina. After careful evaluation of the patient's severe anaphylactic reaction, the patient was successfully anesthetized four weeks later. An 82-year-old male (height 169 cm, weight 67 kg) without any past medical history was scheduled for elective laparoscopyassisted distal gastrectomy. Although the preoperative ECG showed several premature ventricular contractions per minute, echocardiography results were normal. During induction, there was a sudden drop in blood pressure (BP) after rocuronium injection. Endotracheal intubation was immediately performed, and although there was no increase in airway resistance, BP continued to be severely hypotensive. The patient did not respond to intravenous ephedrine (10 mg) or phenylephrine (100 µg). Three minutes after the onset of hypotension, skin rash appeared over the entire body in addition to swelling of the eyes. As hemodynamics continued to deteriorate, epinephrine (200 µg) was administered and cardiopulmonary resuscitation (CPR) was initiated. Rapid crystalloid fluid infusion was given after inserting a central venous catheter in the left subclavian vein. CPR was continued for 15 minutes and epinephrine (1 mg) was injected twice over a three-minute period. The patient was also defibrillated due to one episode of ventricular fibrillation during CPR. Hydrocortisone (250 mg) and chlorpheniramine (4 mg) were also injected, while epinephrine and dopamine were continuously infused. The patient was transferred to the ICU after full recovery of consciousness and muscle tone. Twenty-four hours after the event, cardiac enzymes had elevated (Troponin I 5.24 ng/ml, CK-MB 23.5 ng/ml) and ST depression could be seen in the I, aVL, and V2-6 leads of the ECG. Coronary angiography was immediately performed, and the patient was diagnosed with variant angina. Fortunately, the patient recovered without any complications and the operation was delayed by four weeks. Intradermal injection tests were performed twice: at three weeks and at four weeks after the event (Fig. 1). Due to the positive results with rocuronium and vecuronium, cisatracurium was used instead. Intravenous injection of chlorpheniramine (4 mg) was added as premedication. There was no particular event during the second induction period, and the patient was discharged one week later. Fig. 1 Skin prick and intradermal test performed after three weeks and four weeks after the anaphylactic event. (A, B) Skin prick and intradermal test results at three weeks. Only rocuronium shows positive results. (C, D) Skin prick and intradermal test results ... Anaphylactic reaction can affect multiple organs, and although most patients recover spontaneously from mild reactions, respiratory and cardiovascular arrest can occur in a matter of minutes in severe cases. Reitter et al. [2] reported several factors associated with severe symptom: emergency operation, elderly and obese patients, history of hypertension, other cardiovascular disease and/or beta-blocker use. We believe that multiple factors may have caused cardiac arrest during induction with rocuronium in the patient described here. During evaluation after the anaphylactic event, variant angina was detected during cardio-angiography. Secondary acute coronary vasospasm after anaphylaxis was first reported in 1991 and has been termed the 'Kounis syndrome'. The possibility of Kounis syndrome after rocuronium injection was first reported by Fagley et al. [3]. In our present case, there was a significant increase in cardiac enzymes, ST depression was observed in multiple ECG leads and the patient was diagnosed with variant angina through coronary angiography. Although factors such as severe hypotension, ventricular fibrillation and CPR could have contributed to the development of variant angina, we cannot rule out the possibility of Kounis syndrome as the cause of coronary vasospasm. Even though we did not discover changes in the ST segment directly after rocuronium injection, this could have been due to limited ECG monitoring. Only the II lead was monitored during induction, while ST depression was found in the I, aVL and V2-6 leads in the ICU. Other factors such as an unusually prolonged fasting period and a relatively high dose of propofol may also affect the clinical outcome of the patient. The patient had received upper gastrointestinal endoscopy and an enema the previous day. This led to a significantly prolonged fasting time since the patient had to continue fasting for the following operation. Indeed, extremely low central venous pressure (0-2 mmHg) was observed during the event. Since anesthetics, especially propofol, affect the cardiovascular system more significantly in geriatric patients [4], the hypovolemic status combined with the relatively large dose of propofol may have contributed to the severity of the anaphylactic attack. The decision was made to delay the operation by four weeks. Cisatracurium was selected as the neuromuscular blocking agent due to negative results during the skin prick test and intradermal test (Fig. 1). Although some recommend a period of six weeks after the anaphylactic event, tests were performed early due to the patients' strong desire for an early operation [5]. In conclusion, anesthesiologists must always pay special attention during the induction period due to the administration of various drugs over a relatively short period. Although anesthesiologists are skilled in immediate treatment during severe anaphylaxis, they must be aware of factors that could aggravate such physiological conditions. Also, even though extremely rare, anesthesiologists must also be aware of serious complications such as Kounis syndrome.

Central venous catheterization (CVC) can be difficult, especially with pediatric patients in critical care. Accessing the subclavian vein (SCV) can cause serious complications, including pneumothorax, arterial puncture, and hemothorax. Recently, the ultrasonographic (USG) technique has gained popularity, but its efficiency is not yet confirmed. Subclavian venous catheterization (SCVC) through the supraclavicular approach (SCA) with USG or accessing the brachiocephalic vein through the infraclavicular approach (ICA) has been reported in the past. A useful technique is reported that involves the use of a 40 mm probe rather than the usual 25 mm probe in order to confirm the location of the needle while successfully performing subclavian venous catheterization in pediatric patients weighing 1.1 kg to 15.0 kg.

Central venous catheterization (CVC) is vital for anesthetic management in pediatric patients undergoing major surgery [1]. The internal jugular vein (IJV), subclavian vein (SCV), and femoral vein are the most commonly used sites for CVC. Unfortunately, the failure rate and incidence of complications are much higher in pediatric patients due to the relatively small size of the vessels [2]. Experience is essential in order to successfully perform CVC in pediatric patients without causing complications. Other significant factors include the selection of an appropriate vein and a catheter of a suitable size. The IJV is relatively larger and easier to access than the SCV, and has been preferred for CVC in pediatric patients by many physicians. Yet, the IJV is easily collapsed by the ultrasound (US) probe or by needle pressure, making CVC challenging even though the vein may be well observed via US. In contrast, the SCV is not easily collapsed due to the presence of the clavicle and can be more appropriate when long-term catheter placement is required [3]. Although there are several studies regarding the size of the IJV in pediatric patients [1,2], few studies have been performed related to the size of the SCV. We attempted to find the most suitable variable, such as age, weight, or height, that could predict the size of the SCV in pediatric patients by measuring the size of the SCV in a group of these patients using ultrasound. Thirty-eight pediatric patients from 1 month to 10 years of age, who underwent an elective surgery were included in this study. Patients included in the study were scheduled for minor operations: inguinal hernia repair, hydrocelectomy, circumcision, and upper and lower extremity surgeries. Patients with congenital or cardiovascular diseases, and patients scheduled for cardiac, intracranial, or major vascular operations were excluded from the study. After induction of general anesthesia, patients were placed in a supine position with their arms positioned next to the trunk. The SCV was located with a linear probe using a method implemented previously [4]. Briefly, the longitudinalsection image of the SCV was obtained with an 18 MHz linear probe (LA435: 6–18 MHz, Esaote, Genova, Italy). Images were obtained by a single physican after acquiring a view in which the SCV seemed to have the largest diameter and the clavicle was positioned in the center of the image. Images were obtained three times on both sides at the end-expiratory phase of ventilation and were measured by two different study participants using image analysis software (MyLab TM Desk, Esaote, Genova, Italy). The internal diameter of the SCV was measured directly laterally and medially to the clavicle shadow, and defined as the average of these two values. The average of the values measured by the two different study participants was used as the SCV diameter in each pediatric patient. For statistical analysis, variables of regression modeling were selected using the stepwise selection method. R 3.1.0 (R Core Team, Vienna, Austria) was used as the statistical software, and variables were selected using the faraway and leaps packages. The leaps package automatically selects variables, and the Bayesian information criterion was used as the selection criterion. Sex, height, weight, and age were selected as independent variables

Background 5-HT3 receptor antagonist, dexamethasone and droperidol were used for the prevention of postoperative nausea and vomiting (PONV). Recently, neurokinin-1 (NK1) antagonist has been used for PONV. We evaluated the effect of oral aprepitant premedication in addition to ondansetron. Methods A total 90 patients scheduled for elective rhinolaryngological surgery were allocated to three groups (Control, Ap80, Ap125), each of 30 at random. Ondansetron 4 mg was injected intravenously to all patients just before the end of surgery. On the morning of surgery, 80 mg and 125 mg aprepitant were additionally administered into the Ap80 group and Ap125 group, respectively. The rhodes index of nausea, vomiting and retching (RINVR) was checked at 6 hr and 24 hr after surgery. Results Twelve patients who used steroids unexpectedly were excluded. Finally 78 patients (control : Ap80 : Ap125 = 24 : 28 : 26) were enrolled. Overall PONV occurrence rate of Ap125 group (1/26, 3.9%) was lower (P = 0.015) than the control group (7/24, 29.2%) at 6 hr after surgery. The nausea distress score of Ap125 group (0.04 ± 0.20) was lower (P = 0.032) than the control group (0.67 ± 1.24) at 6 hr after surgery. No evident side effect of aprepitant was observed. Conclusions Oral aprepitant 125 mg can be used as combination therapy for the prevention of PONV.

Background: Tracheal intubation causes a reflex tracheal constriction that leads to increased airway resistance. Inhalation anesthetics can prevent or minimize this response. Therefore, this study was conducted to evaluate the effect of 1 MAC sevoflurane or desflurane on respiratory mechanics in children after anesthetic induction using propofol and tracheal intubation. Methods: Sixty children undergoing elective surgery with tracheal intubation were assigned into two groups at random, a 1 MAC concentration of sevoflurane (n = 30) and a desflurane (n = 30) group. Anesthesia was induced using propofol (1.5 mg/kg) and tracheal intubation was facilitated using rocuronium (0.6 mg/kg). A respiratory profile monitor was used to measure the respiratory resistance, dynamic compliance and peak inspiratory airway pressure. The measurements were made at three time points, after three inspirations from the beginning of mechanical ventilation (baseline) and at 5 and 10 min after the administration of inhalation anesthetics. Results: Sevoflurane and desflurane led to a significant decrease in respiratory resistance and increased dynamic compliance at 5 and 10 min when compared to baseline. There were no significant differences in respiratory resistance and dynamic compliance between the two groups. Conclusions: A 1 MAC concentration of sevoflurane and desflurane has a similar bronchodilatory effect after tracheal intubation in children. (Korean J Anesthesiol 2009; 57: 714∼8)

Background: Despite new anesthetic drugs and antiemetics, the incidence of postoperative nausea and vomiting remains between 20% and 70%. The authors tested the hypothesis that seasonal diet and temperature change and preoperative gastric emptying time affects the incidence of postoperative nausea and vomiting. Methods: We conducted a retrospective cohort study of 626 women had undergone laparoscopic hysterectomy. Patients were anesthetized with nitrous oxides and inhalation anesthetics or propofol and injected butorphanol or nalbuphine or patient-controlled analgesia for postoperative pain control. Data were collected from records of recovery room and ward nurse's record and analysed with student t-test or chi-square test and logistic regression. Results are presented as meanSD; P

Spontaneous intracranial hypotension is a syndrome characterized by postural headache without trauma, spinal anesthesia or other medical history. The headache is usually resolved in a few days or weeks if the patient remains in bed with good hydration. Relief can usually be obtained by the application of a blood patch, by injecting 10-20 ml of the patient's own blood into the epidural space close to the leakage site. In the overwhelming majority of patients, the leak is at the level of the spine, particularly the thoracic spine and cervicothoracic junction. Spontaneous intracranial hypotension presenting with mental change has rarely been reported. We report a 39 years old male patient who was diagnosed with spontaneous intracranial hypotension. The patient experienced continuous headache followed by slight mental change. The patient was successfully managed by 3 episodes of epidural blood patch.

Propofol has become a popular intravenous agent for the induction and maintenance of total intravenous anesthesia (TIVA). However, the pro- or anticonvulsant properties of propofol remain controversial and abnormal muscle movement and convulsive activity are possible side-effects. We report a case in which a healthy 42-year-old man developed myoclonic and tonic-clonic seizures related to the use of propofol for sedation during a brachial plexus block.