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Background Congenital central hypoventilation syndrome (CCHS) is a rare disorder characterized by alveolar hypoventilation and autonomic dysregulation. Patients with CCHS have adequate ventilation while awake but exhibit hypoventilation while asleep. More severely affected patients exhibit hypoventilation both when awake and when asleep. Case Here, we report a case of successful spinal anesthesia and postoperative epidural analgesia in a patient with CCHS who underwent orthostatic surgery. Conclusions In patients with CCHS, anesthesia is used with the goal of minimizing respiratory depression to avoid prolonged mechanical ventilation. Regional anesthesia should be considered where appropriate. Continuous oxygen saturation and end-tidal carbon dioxide monitoring must be available.

Background: To investigate and analyze MRI findings in relation to visual analogue scale (VAS), Oswestry Disability In-dex (ODI), psychological-factor, sleep-quality, and Short-Form Health Survey (SF-36) scores among patients with central lumbar spinal stenosis (LSS) for the purpose of elucidating a correlation. Methods: From July 2013 to May 2014, 117 consecutive patients with central LSS were included in this study. All of the MRIs were evaluated by one of the authors, and the evaluated items were the dural sac cross-sectional area (DSCSA), the number of stenotic levels, and the presence and levels of spondylolisthesis. The ODI, VAS, 36-item SF-36, Beck Depres-sion Inventory (BDI), Beck Anxiety Inventory (BAI), and Pittsburgh Sleep Quality Index (PSQI) questionnaires were used to evaluate the participants. Results: There are no correlations between the ODI, VAS, BDI, BAI, PSQI, and SF-36 scores and the minimum DSCSA; however, a significant correlation was found between the ODI scores and multilevel LSS. The BDI, BAI, and PSQI scores are higher for multilevel LSS compared with single-level LSS, but the difference of this mean value is not statistically sig-nificant. Conclusions: A significant correlation was shown between those patients with multilevel LSS and the ODI scores; how-ever, significant correlations were not found between the MRI findings and the psychological factors pertaining to sleep and life qualities.

Background: We postulated that palonosetron, a novel antiemetic agent, might have the effect of alleviating injection pain from propofol and rocuronium. A double-blind, controlled study was undertaken to evaluate the effect of palonosetron on injection pain during total intravenous anesthesia and postoperative nausea and vomiting (PONV) using propofol-remifentanil in breast and thyroid cancer surgery. Methods: Sixty patients were randomly allocated to one of two groups. Before injection of propofol and rocuronium, patients in group S (n = 30) received 4 ml of saline and patients in group P (n = 30) received 75 μg (1.5 ml) of palonosetron mixed with 2.5 ml of saline (n = 30). Patients were evaluated by a blinded anesthesiologist with regard to the scoring of injection pain of propofol, withdrawal response by rocuronium, PONV, shivering, postoperative pain, recall of pain, and overall satisfaction. Results: The differences between groups in the incidence of injection pain due to propofol and rocuronium were insig nificant. However, in group P, the severity of propofol-induced injection pain (3% vs. 33%, P = 0.003) and postoperative pain (P = 0.038) was significantly lower during the first 12 h after surgery. No differences were observed between the groups with respect to PONV, shivering, recall of pain, and overall satisfaction. Conclusions: We concluded that pretreatment of palonosetron was effective to reduce the severity of propofol-induced injection pain and early postoperative pain, although it did not reduce the incidence of injection pain from propofol and rocuronium. (Korean J Anesthesiol 2014; 67: 13-19)

A pulmonary embolism and cerebral infarction are the second and third most common acute cardiovascular diseases after a myocardial infarction. Early diagnosis and appropriate management are important clinical challenges. In this case, a fatal pulmonary embolism and extensive cerebral infarction caused cardiac arrest during spinal anesthesia for total hip replacement surgery. Transesophageal echocardiography indicated a pulmonary embolism and brain CT showed large area of acute infarction at right middle cerebral artery territory. Pulmonary CT angiogram revealed massive pulmonary embolism findings. This paper reviews this case and suggests other preventive modalities.

We experienced a case of sudden onset of hyperkalemia during liver lobectomy and this was followed by ventricular tachycardia and cardiac arrest. The main cause of this fatality is assumed to be the wide range of surgical manipulation that induced reduced hepatic blood flow and ischemic necrosis of the hepatic cells. We report here on this case and we review the relevant medical literature.

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)

Despite the reduced use of inflammable anesthetics, there are still a number of reported fire incidents. If an endotracheal tube ignites during anesthesia, it progresses rapidly and the patient experiences a mild to a heavy burn. A severe burn may even cause death [1]. A male patient (171 cm, 51 kg) with a chief complaint of odynophagia was diagnosed with tongue cancer from computed tomography (CT) scan and biopsy. A tracheostomy was scheduled before a radical excision. A brain tumor was discovered by chance from a preoperative magnetic resonance imaging (MRI) scan but it was decided that only observation of the progress would be made because of the very small size of the tumor. Upon arrival in the operating room patient's oxygen saturation was 95%. Anesthesia induction was done and the anesthesiologist intubated the patient. Using direct curved-blade laryngoscopy, a 7.0 internal diameter reinforced polyvinyl chloride endotracheal tube (ETT; Safety-Flex with Murphy Eye; Mallinckrodt, Athlone) was intubated without difficulty. The tube cuff was filled with air. After intubation, the ETT was fixed at a depth of 22 cm from the teeth. A normal breathing sound was made from the auscultation of both lungs. Afterwards, anesthesia maintenance was done with sevoflurane (1-2 vol%, oxygen 2 L/min) and nitrous oxide (2 L/min). An experienced ear-nose-throat (ENT) surgeon who had performed 40 tracheostomies sterilized the surgical site with betadine and alcohol (83% ethanol). After 10 min, electrocautery in the monopolar cutting mode was used for skin incision at the 2-4th tracheal cartilage, at the midpoint between the cricoids cartilage and the sternal notch. Ten minutes into the surgery, the anesthesiologist discovered that the ETCO2 waves were irregular, so he switched respiration to the manual mode. When observing the surgical view, he discovered that the cuff of the ETT had burst. The ENT surgeon tried to stop the bleeding at the tracheal incision site using electrocautery in the bipolar coagulation mode (25 watt). At that moment, grey smoke coming from the tracheostoma was observed. The authors assessed that it was due to an ignition from the ETT. Manual ventilation and the supply of oxygen, nitrous oxide, and sevoflurane from the anesthesia machine were stopped. Smoke came from the tracheostoma for about 3 sec. The ENT surgeon twice poured 10 cc saline at the fire site and extinguished the fire. From the point of ignition to the point of fire extinguishment, the patient was maintained in the state of apnea to reduce the possibility of foreign-body aspiration. At the time of ignition, the tracheostomy had been almost complete. The incinerated ETT was extubated, and another ETT of the same type was inserted in the complete tracheostomy site (Fig. 1). In the process, the patient maintained a 99% oxygen saturation rate. Total anesthetic time was about 30 min. Fig. 1 Endotracheal tube extubated from the patient. Note the carbides are mostly in the cuff. The patient was sent to the intensive care unit. Oxygen (5 L/min) was supplied through the ETT. The patient maintained spontaneous respiration with no respiratory distress or pain. Upon arrival, the oxygen saturation rate was 95% and PaO2 was 65.8 mmHg. Two hours afterwards, the medical team extubated the ETT and supplied oxygen through the tracheostoma. A bronchoscopy was performed immediately. It showed black carbide covering the area from the trachea to both of the main bronchi. A chest radiograph showed no abnormal findings. Seven weeks afterwards, the patient was moved to the general ward. Oxygen (2 L/min) was supplied through a nasal cannula. Treatment had been planned for the brain tumor. However, the rapid growth and progression of the tumor was fatal before any treatment commenced. The ignition of the electrocautery-caused ETT fire in this case is considered to be due to not fully considering the possibility of ignition of the ETT, not immediately changing the ETT when the cuff burst, not lowering the oxygen ratio, and continuing with the electrocautery procedure. In this case, the ignition source was the ETT. It was observed that the cuff of ETT was the most severely charred. The FiO2 of the supplied oxygen was 0.5. The higher the oxygen rate, the higher is the possibility of fire. If the ratio of oxygen is constant and the ratio of nitrous oxide rises, the risk of a fire rises [2]. The most common fire sources have been reported to be electrocautery (59%), lasers (32%), and optical cables (7%) [3]. Electrocautery can produce temperatures of up to 900-1,500℃ and most likely cause a fire in the ETT [4]. There may be several preventive measures for fire. At first, inflammables must be removed from the surgical view. In situations with the risk of a fire, using electrocautery must be avoided. In a tracheostomy with the risk of ignition, the oxygen ratio should be lowered and air should be used instead of N2O. If the trachea is open and the ETT is exposed, the ETT should be covered with a wet gauze to separate the ETT from the electrocautery. Also filling the cuff of the ETT with saline solution may be considered. This method reduces the risk of ignition, but it requires care that the cuff does not burst from external pressure. If a fire occurs, the surgeon and anesthesiologist must quickly communicate with each other and the anesthesiologist must stop patient respiration, temporarily separate the respiratory circuit from the anesthesia machine and remove the remaining heat and oxygen. Afterwards, respiration and anesthesia should be maintained and the damage site should be observed with direct laryngoscopy and bronchoscopy. If there are carbides, they must be removed, and washing the trachea may be required. Severe lung damage from heat or smoke will require long-term airway maintenance and mechanical ventilation, and a high concentration of steroids as a short-term therapy and antibiotics therapy may help [5]. Use of electrocautery facilitates incision and hemostasis, but it can be a source of ignition. Because an endotracheal tube fire may occur from the use of electrocautery, even with the usually delivered oxygen ratio for general anesthesia, the risk of a fire will always be present if precautions towards fire are not taken. Despite the decline of use of flammable anesthetics in general anesthesia, endotracheal tube fires are possibly occur during a tracheostomy. We report a case of airway fire during a tracheostomy before main surgery. The fire occurred during a surgical tracheostomy under general anesthesia following ignition of the endotracheal tube by diathermy. The endotracheal tube was charred and it's lumen had melted immediately after the accident, bronchofibroscopic examination revealed inhalation injury. We discuss factors that increase the risk of airway fire and management steps that should be undertaken in the event that such a fire occurs.

Background Subarachnoid block is a widely used technique for cesarean section. To improve the quality of analgesia and prolong the duration of analgesia, addition of intrathecal opioids to local anesthetics has been encouraged. We compared the effects of sufentanil 2.5 µg and 5 µg, which were added to intrathecal hyperbaric bupivacaine. Methods We enrolled 105 full term parturients were randomly divided into 3 groups: Group 1 (control), Group 2 (sufentanil 2.5 µg), and Group 3 (sufentanil 5 µg). In every group, 0.5% heavy bupivacaine was added according to the adjusted dose regimen. We determined the maximum level of sensory block and motor block, the quality of intraoperative analgesia, the duration of effective analgesia and side effects. Results There were no significant differences among the 3 groups in the maximum level of the sensory block and motor block. Recovery rate of the sensory block, however, was significantly slower in Group 3 than Group 1. Quality of intraopertive analgesia, muscle relaxation, and duration of effective analgesia were enhanced by increasing the dosage of intrathecal sufentanil. Frequencies of hypotension, maximum sedation level, and pruritus were directly related to the dosage of intrathecal sufentanil, whereas nausea and vomiting occurred only in the groups using sufentanil. Conclusions The addition of sufentanil 2.5 µg for spinal anesthesia provides adequate intraoperative analgesia and good postoperative analgesia with minimal adverse effects on the mother.

We experienced difficulty in ventilating the lungs of a patient after tracheal intubation. After intubation, an insufficient amount of tidal volume (V(T)) was delivered to the patient and the fiberoptic bronchoscopic examination identified partial abutment of the endotracheal tube (ETT) orifice against the tracheal wall. After various attempts to correctly place the ETT, a double-lumen endotracheal tube was placed to achieve a sufficient V(T). It is important to notice that even an appropriately placed ETT may get obstructed due to the left sided bevel at its tip.

Central venous catheterization is performed in the operating room, intensive care unit and emergency room for various reasons. Internal jugular vein is preferred in the operating room due to little chance of pneumothorax and straight route for catheterization to the right atrium. We experienced a case of central venous catheter malposition to cephalad in the right internal jugular vein. A 60-year-old man, 176 cm in height and 82 kg in weight, was presented for Whipple's operation due to the bile duct cancer. After completion of anesthesia induction and intubation, patient's head was turned left in Trendelenburg position. After skin disinfection, 18 guage, 2 inch thin-walled needle was inserted at the point of sternocleidomastoid (SCM) muscle apex along with medial border of lateral head of SCM muscle about angle of 45 degree to skin without using the finder needle. At the same time, anesthesiologist's left 2nd, 3rd, and 4th fingers palpated the patient's right carotid artery for avoiding arterial puncture. However, blood was not aspirated, needle was reinserted more medial direction about angle of 70 degree to skin. After aspiration of venous blood from needle, the J shape guide wire was introduced via the guiding needle using Seldinger technique. Introduction of 20 cm of J-shaped wire was done without any problem, except some resistance at 5 cm depth of the internal jugural vein. Seven Fr double lumen catheter (Prime-S®, Sungwon medical, Cheongju, Korea) was advanced to the following J-shaped wire. Blood aspiration was done to remove the air in catheter without any resistance. Catheter was sutured at the proper site and surgery was done as planned. After the operation, the patient was transferred to an intensive care unit. Head and neck antero-posterior view X-ray was checked because the central venous catheter was not seen on chest X-ray. Antero-posterior view of the head and neck showed that central venous catheter was bent sharply to the cephalad in the right internal jugular vein (Fig. 1). We removed malpositioned catheter and reinserted central venous catheter via the same side subclavian vein. The proper position of subcalvian catheter was confirmed by a chest X-ray and the patient discharged at postoperative day 13. Fig. 1 Neck anteroposterior view shows that central venous catheter is bent sharply to the cephalad in right internal jugular vein. As one of the various complications, catheter malposition via Internal jugular vein (IJV) can be associated with central venous catheterization via IJV (5.3%) [1]. There are many case reports of malpositioning central venous catheter that were positioned in the jugular venous arch via the right subclavian vein [2], in the internal thoracic vein via the internal jugular vein [3] etc. However, this is the first case of malposition of the catheter, which was bent upward. Bending the catheter is very rare because the right internal jugular vein is the straight route for catheterization to the right atrium. Although there was some resistance during introduction of the J-shaped wire, blood aspiration via catheter was normal, dripping of the fluid seemed normal and central venous pressure curve showed no other abnormal findings. We postulate that the J-shaped wire was bent in the cephalad direction at the moment of resistance. The other postulated cause is an acute angle of the introducing needle when it punctured the internal jugular vein. We cannot rule out the anatomical variation of the external jugular vein and internal jugular vein. Deslaugiers et al. [4] reported that 60% of the external jugular vein is drained to junction of the internal jugular vein and subclavian vein, drained to the subclavian vein in 36%, and drained to the internal jugular vein in 4%. However, we did not confirm the anatomical variation with venous angiogram. It seems that we should be careful when we introduce the wire with some resistance. Malpositioning of the catheter results in monitoring inaccurate central venous pressure, damage to vascular wall, and forming the thrombus. However, the chance of thrombus formation is very low since the blood flow velocity is very fast in the internal jugular vein. In addition, it is impossible that the infused drug inflows to the brain. Although, the most precise method to confirm the complications is examination of the X-ray after the catheterization, ultrasono-guided central venous catheter placement is increasing the success rate, shortening the procedure time, decreasing the complication and the easiest method for acknowledging the direction of catheter, needle and guide wire during the entire catheterization process [5]. In summary, if there is any problem during the central venous catheterization, ultrasonography can be used for optimal catheter placement, and prevention of complications. Additionally, X-ray must be examined to confirm the position of the catheter and incidental complication.

Brugada syndrome (BS) is an idiopathic ventricular fibrillation characterized by a right bundle branch block, and ST segment elevation in the right precordial leads (V1 to V3) without evidence of underlying structural heart disease and susceptibility to ventricular arrhythmias that may culminate in syncope or sudden death [1]. Although diagnosis of BS before the operation and anesthesia is very critical, it is well recognized that the classical electrocardiography (ECG) pattern can be intermittent and is often concealed, and there are no family history, no history of unexplainable syncope, tachycardia, no typical ECG findings in 50% patients, making the diagnosis not always apparent [2]. We describe a case of total intravenous anesthesia (TIVA) with propofol and remifentanil in a female patient with BS. A 56-year-old woman was presented for perforated appendicitis with periappendicial abscess. She had no known underlying disease and no past history. Preoperative ECG revealed right bundle branch block and ST segment elevation in the precordial lead (V1-3) (type I ECG abnormality), which suggested BS (Fig. 1B). She had no past history of syncope, tachycardia or chest pain, except family history of nocturnal sudden death of her brother ten years ago. A previous ECG from 5 years ago showed incomplete right bundle branch block (I-RBBB) (Fig. 1A). Fig. 1 (A) ECG findings from 5 years ago shows incomplete right bundle branch block, (B) preoperative ECG shows Brugada syndrome displaying coved-type ST-segment elevation ≥ 2 mm in more than one right precordial lead (V1-V3), followed by negative T ... Having been informed of the associated risks, the patient was taken to the operating room and routine monitors were applied. A radial arterial pressure was monitored. Prior to the induction of anesthesia, automatic defibrillator pads (Physio-Control Quick-Combo Electrodes, Medtronic, USA) for cardioversion were attached to her anterior chest. ECG monitoring from external defibrillator was done simultaneously. The patient's blood pressure (BP), heart rate (HR), oxygen saturation was 132/78 mmHg, 92 beats/min and 99%, respectively. Anesthesia was induced with intravenous target controlled infusion (TCI) of propofol with the effect site concentration (Cet) of 3.5 µg/ml and remifentanil with Cet of 3 ng/ml, using TCI pump. Verbal response was lost when the propofol reached the Cet of 0.8 µg/ml and remifentanil at 2 ng/ml. The bispectral index at this moment was 60 and 0.6 mg/kg of rocuronium was administered. Intubation was performed when the Cet of propofol reached 3.5 µg/ and remifentanil 2.5 ng/ml. The patient's BP and HR recorded 121/68 mmHg, and 82 beats/min after intubation. Laparoscopic appendectomy lasted 40 minutes. We did not administer anticholinesterase to antagonize the rocuronium. The patient recovered spontaneously and was extubated when propofol reached Cet of 0.5 µg/ml and remifentanil 1.0 ng/ml. The BP and HR was 140/68 mmHg, and 85 beats/min when the patient was extubated. The patient was transferred to the intensive care unit with the automatic defibrillator pads. Twelve leads ECG on the arrival of intensive care unit showed normal, except I-RBBB (Fig. 1C). The vital signs were stable and postoperative pain was also controlled with intravenous patient controlled analgesics. The cardiac rhythm was uneventful during surgery and at intensive care unit. The patient was transferred to the general ward 24 hours after the operation, and there was no episode of tachyarrhythmia throughout her hospital stay. A history of unexplained syncope or rapid palpitations with presyncope is concerning. Fifty percent of diagnosis of BS is made with family history and typical ECG findings [2]. In this case, despite having family history, the patient did not know about her disease. In a review of 163 cases, males (n = 150) far outnumbered females (n = 13) and 58% of patients were of Asian ancestry. The number of male patients with BS is 11 times more than that of female [3]. This is the first female case report in Korea, which is related to anesthesia. Because ECG can be normalized transiently in up to 50% of cases, the intermittent nature of these findings can make diagnosis of the BS difficult. In this case, ECG findings from 5 years ago, in intensive care unit, and 24 hours Holter test showed only I-RBBB pattern. I-RBBB is a common ECG finding on preoperative screening, and is not considered seriously in most cases. It is not possible to undergo pharmacological drug challenge and electro-physiologic stimulation for all the patients who have I-RBBB findings, but we have to make an effort to take careful history of patients and their family to find out BS. More recently, it has been recommended that all patients with isolated type I ECG abnormality should be considered at a risk of sudden death. It would seem sensible to treat these patients undergoing anesthesia as having the condition [2]. In general, implantable cardioverter-defibrillator implantation is recommended for all patients who have already had symptoms and for asymptomatic patients in whom the electro-physiologic stimulation induces ventricular arrhythmias or those with family history, especially if they present a spontaneous type I ECG pattern [2]. The risk of ventricular arrhythmias in the perioperative period is of concern as the pharmacological and physiological changes that occur during anesthesia are implicated in precipitating such events. An understanding of modulating agents and conditions is essential for planning of appropriate techniques and prevention of crisis. Depth of anesthesia should be balanced to minimize these effects, as bradycardia or increased vagal tone as a result of surgical stimulation have also been implicated in the development of Brugada ECG changes [4]. We used propofol-remifentanil for induction and maintenance of anesthesia because major advantages of TIVA are hemodynamic stability and reduced hemodynamic response during the emergence when compared with balanced anesthesia. Although, the most common opioid used in BS is fentanyl [4], Ahn and Kim [5] reported successful case of using remifentail. In our case, we successfully managed intubation, maintenance, and fully awake extubation without hemodynamic instabilities or tarchyarrhythmic events using TIVA. The range of blood pressure and heart rate changes were within 9 and 11%, respectively, of the preoperative value. In conclusion, this case shows that I-RBBB can be the only sign of BS, and we have to take a careful history of patients with I-RBBB, both male and female. TIVA is considered as one of the available anesthetic methods for BS patients.

Background: The use of monitored anesthesia care (MAC) as the technique of choice for a variety of invasive or noninvasive procedures is increasing. The purpose of this study to compare the outcomes of two different methods, spinal anesthesia and ilioinguinal-hypogastric nerve block (IHNB) with target concentrated infusion of remifentanil for inguinal herniorrhaphy. Methods: Fifty patients were assigned to spinal anesthesia (Group S) or IHNB with MAC group (Group M). In Group M, IHNB was performed and the effect site concentration of remifentanil, starting from 2 ng/ml, was titrated according to the respiratory rate or discomfort, either by increasing or decreasing the dose by 0.3 ng/ml. The groups were compared to assess hemodynamic values, oxygen saturation, bispectral index (BIS), observer assessment alertness/sedation scale (OAA/S), visual analogue scale (VAS) for pain score and patients’ and surgeon’s satisfaction. Results: BIS and OAA/S were not significantly different between the two groups. Hemodynamic variables were stable in Group M. Thirteen patients in the same group showed decreased respiratory rate without desaturation, and recovered immediately by encouraging taking deep breaths without the use of assist ventilation. Although VAS in the ward was not significantly different between the two groups, interestingly, patients’ and surgeon’s satisfaction scores (P = 0.0004, P = 0.004) were higher in Group M. The number of the patients who suffered from urinary retention was higher in Group S (P = 0.0021). Conclusions: IHNB under MAC with remifentanil is a useful method for inguinal herniorrhaphy reflecting hemodynamic stability, fewer side effects and higher satisfaction. This approach can be applied for outpatient surgeries and patients who are unfit for spinal anesthesia or general anesthesia. (Korean J Anesthesiol 2013; 64: 414-419)

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)

Stress-induced cardiomyopathy (SICM) presenting as an acute myocardial dysfunction is characterized by transient left ventricular wall motion abnormality, which has been known to be associated with excessive catecholamine production caused due to various types of stress. Sympathetic hyperactivity is common during the perioperative period, and reports of SICM occurring during this period have actually increased. We present a case of SICM following negative pressure pulmonary edema due to upper airway obstruction during emergence from anesthesia. Excessive catecholamine release in response to respiratory difficulty could have been the underlying inciting factor.

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)

Endoscopic thyroidectomy is gaining popularity, but it can increase the risk of certain complications. Carbon dioxide insufflation in the neck may cause adverse effects on hemodynamic and ventilatory aspects. We report the anesthetic course and complications that were encountered during endoscopic thyroidectomy. Although the surgery was successful, the patient developed signs of hypercarbia, subcutaneous emphysema and pneumothorax.

Toxic epidermal necrolysis (TEN) is rare but serious cutaneous reaction with significant mortality and long-term morbidity. Various etiologies, particularly numerous medications and infectious agents have been implicated. It is characterized as inflammatory bullous lesions of the skin and mucous membrane and can develop serious complications such as pneumonia, pneumothorax, sepsis and renal failure. In general, patients with TEN are managed as severe second-degree burn patients with preventing excessive fluid deficit and infections. In this case, we aimed to present anesthetic management of a 26-year-old pregnant woman with TEN who received general anesthesia during emergent cesarean section.

Background: Gabapentin decreases acute nociceptive pain in animal and human studies when given before surgical incision. Various doses of gabapentin have been used (300−1,200 mg) to measure this preemptive effect. Here, we evaluated the optimal dose of gabapentin for reducing fentanyl consumption and the adverse effects of gabapentin following gynecologic surgery. Methods: We recruited 100 patients who underwent laparotomy for gynecologic surgery. Patients were randomly divided into 4 groups and received a placebo (control), gabapentin 300 mg (G 300), gabapentin 600 mg (G 600), or gabapentin 1,200 mg (G 1200) 2 h before surgery. Postoperatively, patients received fentanyl via an intravenous patient controlled analgesia device. The cumulative fentanyl doses were recorded 2, 6, 12, 24 h, and 48 h postoperatively, and the sedation scale was recorded in the post anesthetic care unit (PACU). Results: The postoperative fentanyl requirement was lower with gabapentin treatment, but there was no significant differences for the different doses. PACU sedation scores were not different in any group. Conclusions: Gabapentin has a preemptive effect in gynecologic surgery, but there were no additional fentanyl-sparing benefits at doses above 300 mg. Thus, 300 mg is an optimal dose for decreasing fentanyl consumption following gynecologic surgery.

Background: Sevoflurane is one of the most popular anesthetics, used in pediatric anesthesia, but emergence agitation is more common with using sevoflurane as compared to that with using the other inhalation anesthetics. Sevoflurane exerts its effect on γ-aminobutyric acid (GABA) ergic transmission. This study aimed to investigate if genetic variations at the GABRγ2 (single nucleotide polymorphism [SNP] 211037 C/T, nucleotide position 3145 in intron A/G) on the 5q33 chromosome were associated with the development of emergence agitation when sevoflurane is used. Methods: One hundred fourteen, pre-school aged patients who were to undergo tonsillectomy and adenoidectomy were included in this study. Anesthesia was induced with 5 mg/kg of thiopental sodium, 0.02 mg/kg of atropine and 0.1 mg/kg of vecuronium, and this was maintained with 3% sevoflurane and 50% N2O in oxygen. The incidence of emergence agitation and the emergence agitation scores were assessed at 0 min, 10 min, 20 min and 30 min after arriving at the post anesthetic care unit (PACU). Genomic DNA from peripheral leukocytes was isolated using the QIAamp Blood Minikits and the GABRγ2 genetic polymorphisms were analyzed by performing polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Results: There were no significant differences of the emergence agitation scores among the genotypes in the GABRγ2SNP211037 C/T and GABRγ2-nucleotide position 3145 in intron A/G. There was a trend in which the AA group in the GABRγ2nucleotide position 3145 in intron A/G has a lower incidence of emergence agitation compared with the non-AA group, but this was without statistical significance (P = 0.07). Conclusions: There is a possibility that the GABR2 genetic polymorphism may affect the development of emergence agitation when sevoflurane is used in pediatric anesthesia. (Korean J Anesthesiol 2008; 55: 139∼44)

Hereditary haemorrhagic telangiectasia (HHT), or Osler-Weber-Rendu syndrome is an autosomal dominant disorder characterized by recurrent epistaxis, mucocutaneous telangiectasias, and visceral involvement including arteriovenous malformations that may develop in any organ, especially in the lung, brain, liver and GI tract. Early screening and regular follow up of patients with HHT are important to minimize the risk of development of serious sequelae. We report a case of 46-year-old female patient who had “suspected HHT” and review the literature on this rare disease.

Background: The purpose of this study was to investigate the effectiveness of ondansetron and midazolam in the prevention of PONV after thyroidectomy. Methods: One hundred nineteen women undergoing thyroidectomy under general anesthesia were randomized to receive midazolam 0.075 mg/kg (Group M, n = 41), ondansetron 4 mg (Group O, n = 39), or normal saline 10 ml (Group C, n = 39) intravenously. The incidence and severity of nausea, vomiting, and pain were assessed as 6 and 24 h after the end of surgery. Results: The incidence of PONV was 34% in Group M, 46% in Group O, and 64% in Group C, which showed a significant difference between Group C and Group M, but not Group O. However, there were no significant differences between groups in pain scores and the incidence of sedation. Conclusions: We recommend the use of midazolam as an effective antiemetic after thyroidectomy. (Korean J Anesthesiol 2007; 53: 344～9)

1Department of Anesthesiology and Pain Medicine and 2Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea Various causes of endotracheal tube obstruction during general anesthesia exist. Herein, the case of a 77-year old male patient, with tracheal deviation, who was intubated with an endotracheal tube in the emergency room, without a Murphy eye, is reported. He was transferred to the operating room for the removal of a subdural hematoma. The endotracheal tube suddenly became obstructed during flexion of neck for the craniotomy procedure. The distal bevel of the endotracheal tube, without Murphy eye, was discovered to have come into contact with the tracheal wall, with the airway being obstructed during the fiberoptic bronchoscopy. Shortly after extubation of the obstructed tube, an armored tube, with a Murphy eye, was reintubated, after which the respiration pattern immediately returned to normal

Background: Succinylcholine (Sch) has been considered to be the neuromuscular blockade (NMB) of choice in clinical anesthesia due to its rapid onset and short duration of action. Despite these clinical advantages, the use of Sch has decreased recently on account of its potentially fatal adverse effects such as cardiac arrest and malignant hyperthermia. The aim of this report was to analyze the frequency and the indications of Sch as well as to discover an alternative to decreasing the frequency of Sch use. Methods: The medical records of a total of 33,972 cases under general anesthesia were collected retrospectively, and the frequency of Sch use and the reason for choosing Sch was analyzed. The side effects and other complications of Sch were also analyzed. Results: A muscle relaxant was administered in 32,724 cases (96.3%) out of 33,972 cases, and Sch was used in 647 of these cases (1.9%). The reasons for choosing Sch were the rapid sequence induction (291 cases), short operation time (220 cases), recent food intake (51 cases), habitual use (78 cases) and reintubation (7 cases). There were 211 cases of the single administration of Sch and 13 cases in whom Sch was injected repeatedly. A non-depolarizing muscle relaxant (NDMR) was used after Sch administration in 423 cases. Precurarization was carried out in 434 cases (67%) and no severe complications were observed. Conclusions: The frequency of using Sch use can be decreased by reducing the habitual use and choosing the intubating dose of the intermediate acting NDMR as an alternative. (Korean J Anesthesiol 2007; 52: 392~5)

Two cases showed intermittent myoclonic movements in the lower extremities after receiving combined spinal-epidural anesthesia (CSE). Case 1: A 73-year-old female patient, underwent CSE, for a total knee replacement of right leg. Anesthesia was performed at L3/4 interspace with 2.0 ml of 0.5% tetracaine, mixed with normal saline and patient's own cerebrospinal fluid and epinephrine 1：200,000. Epidural catheter was inserted 3 cm-cephalad. Patient-controlled analgesia regimen was made with sufentanil 100 ug, 0.75% ropivacaine 30 ml, and naloxone 0.55 mg, with normal saline. The infusion regimen began at the end of the surgery, finished uneventfully after one and half hours. After 3 hours, the patient developed symmetric hip adductions of large amplitude and extensions of both legs for 2 to 3 seconds. Until valproate 800 mg was given, the movements repeated at 1 to 2 minute intervals for 3 hours. Case 2: The anesthesia and analgesia for 74-year-old female patient was done in similar fashion. Three hours after the end of operation, the patient showed myoclonic movements on right leg for about 30 seconds. The movements occurred at 2-3 minute intervals for the subsequent 2 hours and resolved spontaneously.

A 54-year-old male patient with squamous cell carcinoma of lung was scheduled for right lower lobectomy. He had suffered from diabetes mellitus during 8 years, but his preoperative electrocardiogram was normal sinus rhythm. During right thoracotomy, 2 times of unstable paroxysmal supraventricular tachycardia (PSVT) appeared but returned to normal sinus rhythm by carotid sinus massage. But, third unstable PSVT was not controlled by adenosine and anterior - lateral paddle positioned biphasic cardioversion. We changed anterior-lateral paddle position to anterior-posterior paddle position. And PSVT terminated abruptly and changed to sinus rhythm. So we present a case of unstable PSVT during right thoracotomy and treated with anterior-posterior paddle positioned biphasic cardioversion.

Background: The purpose of this study was to evaluate the effect of low dose i.v. ketamine in combination with epidural morphine on postoperative pain after gastrectomy. Methods: 40 patients scheduled for elective gastrectomy were investigated in a randomized study. All patients received epidural morphine (0.05 mg/kg) and bupivacaine (0.25%) as a bolus dose of 10 ml 40 min prior to skin incision. In addition, patient- controlled epidural analgesia (PCEA) with epidural bupivacaine (0.125%) and morphine (0.1 mg/ml) (bolus dose 1 ml, continuous infusion 1 ml/h, lock out interval 15 min) was offered from the time after 10 ml bolus dose. In the ketamine group, ketamine 0.5 mg/kg was administered 10 min prior to skin incision and then maintained continuously until skin closure at a dosage of 10/kg/min. In the second group anesthesia was induced with thiopental sodium 4 mg/kg, midazolam 0.5 mg/kg, vecuronium 0.1 mg/kg and maintained with 66% -O2, 1-3 vol% enflurane. The intensities of spontaneous pain and of coughing associated pain were measured using a visual analogue scale. Cumulative morphine consumption was measured at 2, 6, 12, 24, 48 h after surgery. Side effects were evaluated at 48 h after surgery. Results: VAS and cumulative morphine consumption at 2, 6, 12, 24, 48 h postoperatively showed no statistical differences between the two groups, and no statistical differences in side effects were observed at 48h after surgery. Conclusions: We were unable to demonstrate any additional analgesic effect of low dose i.v. ketamine in combination with epidural morphine and bupivacaine.

Background: Total spinal anesthesia (TSA) after injections of local anesthetics into the intrathecal space during epidural anesthesia is not rare. TSA anesthetizes cranial nerves and peripheral nerves, causes specific circulatory disturbances related to autonomic imbalance. Spectral analysis of heart rate variability (HRV) and blood pressure variability (BPV) provide a dynamic assessment of sympathetic and parasympathetic tone. Cross-spectral analysis has been used to emphasize this dynamic baroreflex control of HR as a frequency-dependent phenomenon and allows an assessment of baroreflex function. To examine the effects of TSA on the autonomic nervous system, we used spectral and cross-spectral analytic methods. Methods: We investigated 14 rats before and after TSA. Power spectral densities of blood pressure (BP) and heart rate (HR) were estimated by fast Fourier transform. To evaluate the effect of TSA on baroreflex function, the cross spectral gain, phase, and coherence between beat-to-beat BP and HR signals were calculated by using transfer function analysis. Results: With the onset of TSA, BP and HR significantly decreased. TSA significantly decreased the low frequency (LF) and high frequency (HF) components of HRV and BPV. Baroreflex sensitivity (BRS) obtained from transfer function gain between these variables was significantly decreased. Conclusions: TSA reduces the LF and HF components of HRV and BPV. These suggest that TSA in rats decreases both parasympathetic and sympathetic drive. Moreover, the decrease in BRS suggests impairment of cardiac baroreflex buffering function during TSA.

Background: It is well known that the loud noise exposure can lead to noise-induced hearing loss (NIHL). Drilling during mastoid surgery may result in NIHL. The noise level produced by drilling of the mastoid bone can exceed 125 dB HL (hearing level); therefore, mastoid surgery itself is associated with a lower incidence of NIHL than expected. The aim of this study was to analyze the effects of isoflurane on NIHL and hair cell morphological changes. Methods: BALB/c mice were divided into 2 groups; a control group (n = 20) and an isoflurane group (n = 20). The mice of both groups were exposed to 120 dB SPL (sound pressure level) broadband white noise for 3 hours per day, for 3 consecutive days. The mice in the isoflurane group were anesthetized with isoflurane while exposed to the noise. The auditory brainstem response (ABR) thresholds were determined 1 day before and after the noise-exposure and then again after 7 days. Both cochlea were removed and stained using fluorescent isothiocyanate (FITC) phalloidin. Results: 1 day prior to noise-exposure, the ABR thresholds were those of a normal hearing level in both the control and isoflurane groups. In the control group, the mean hearing threshold was 78.0 2.6 dB HL after 1 day of noise-exposure and 81.5 3.4 dB HL after 1 week; in the isoflurane group, the mean hearing threshold was 49 11.7 dB HL after 1 day and 30.5 9.3 dB HL after 1 week. The hearing thresholds after noise exposure in the control were significantly higher than those in the isoflurane group (P ＜ 0.05). Conclusions: The occurrence of NIHL decreased and the hair cell damage suppressed in the mice exposed to intense noise while anesthetized by isoflurane.

Background: Relatively little is known about the effects of general anesthesia on blood pressure variability (BPV). This study was designed to evaluate the changes of high frequency (HF) and low frequency (LF) of BPV before and during general anesthesia with sevoflurane. Methods: Beat-to-beat blood pressure was recorded at conscious baseline and during general anesthesia at 2% end-tidal sevoflurane in 17 healthy living-liver transplantation donors. BPV estimated by power spectra of systolic (SBP) and mean blood pressure (MBP) was calculated. Results: Both LF power of SBP and MBP were diminished to 96.2% and 97.1% during sevoflurane anesthesia (5.52.8 to 0.20.2 mm, 6.63.7 to 0.2+/-0.2 mm, P

Central venous cannulation via an internal jugular vein has become a common procedure in the management and monitoring of severely ill patients. Although complications such as carotid artery puncture or pneumothorax have been reported, hemothorax is relatively uncommon. We describe a case of hydrohemothorax and subclavian artery laceration which occurred during right internal jugular vein cannulation. A 44-year-old female patient was admitted for laparoscopic adrenalectomy under general anesthesia. For central venous pressure monitoring, central venous cannulation performed. However, dilator overinsertion injured the right subclavian artery. This led to a massive ipsilateral hydrohemothorax requiring thoracotomy for subclavian artery repair. This case suggests that central venous cannulation should be done carefully and improves awareness of the potential for dilator induced injury.

Background: The arterial baroreflex is a key mechanism for maintaining blood pressure homeostasis. Low-dose atropine (LDA) causes bradycardia, either by acting on the sinoatrial node or due to its effect on central muscarinic receptors, which increases vagal activity. We evaluated the effect of LDA on baroreflex sensitivity (BRS) in healthy awake subjects. Methods: We assessed changes in RR interval (RRI) and systolic blood pressure (SBP), power spectral densities of heart rate variability (HRV) and systolic blood pressure variability (SBPV), and spontaneous BRS by using transfer function analysis before and after LDA (2/kg) in 17 healthy volunteers. Results: LDA induced not only bradycardia but also increased of the high-frequency (HF) component of HRV, RMSSD (root mean squared successive difference interval), and pNN50 (percentage of sinus cycles differing from the preceding cycle by > 50 ms). The HF and LF components of SBPV remained unchanged. Spontaneous BRS determined by transfer function analysis increased significantly (P

We had a case of respiratory difficulty following total thyroidectomy due to bilateral vocal cord palsy. The patient was a 49-year-old female undergoing total thyroidectomy for papillary carcinoma of the thyroid. Anesthesia was performed uneventfully. Spontaneous respiration resumed after reversal of the neuromuscular blockade. However, after arriving at the postanesthesia care unit, she developed hypertension, anxiety, tachypnea, and inspiratory stridor during deep inspiration. Because the patient maintained adequate oxygen saturation, we confirmed bilateral vocal cord palsy by fiberoptic laryngoscopy. During the operation, the surgeon experienced difficulty dissecting the bilateral recurrent laryngeal nerves from the surrounded tumor. So we consider that direct nerve injury was responsible for the bilateral vocal cord palsy. Movement of the right vocal cord recovered a week later.

Background: Patients with end-stage liver disease have a hyperdynamic circulatory state complicated by a high right ventricular end-diastolic volume index (RVEDVI) and a low ventricular performance. These changes often make if difficult to evaluate volume status and preload. In this study, we analyzed hemodynamic profiles after a rapid fluid challenge in the recipients of a liver transplant. Methods: Hemodynamic responses were evaluated before and after 200 ml of a 5% albumin challenge in forty patients, recipients of a liver transplant with a Swan-Ganz right-heart ejection fraction oximetry thermodilution cathether. Patients were divided into two groups, group A (responders, n = 12, 10% increase in stroke volume index (SVI) after fluid challenge) and group B (non-responders, n = 28, decrease or 5.9% vs 42.8 5.7%), a higher RVEDVI (120.8 19.4 ml/ vs 143.6 26.3 ml/), and a higher right ventricular end-systolic volume index (RVESVI) (60.8 14.0 ml/ vs 82.8 20.5 ml/) than group A. In group B, the cardic index (CI) and right ventricular stroke work index (RVSWI) were not increased after the fluid challenge. There was a mild decrease in the mean arterial pressure (MAP) in group B after the fluid challenge. There was a moderate negative correlation between the fluid-induced change in SVI and the baseline RVEDVI in all patients (r = -0.40, P

We experienced a case of a cesarean section of a 32-year-old female with an thoracic aortic dissection under general anesthesia. An aortic dissection in pregnancy is rare but a potentially catastrophic occurrence. There is a poor prognosis if an aortic dissection occurs in pregnancy in the third trimester. The importance in anesthetic management of these patients should prevent any hypertension in response to intubation and surgery with appropriate preoperative care and monitoring.

Background: The combination of local anesthetics and opioids in the spinal anesthesia has a synergic analgesic effect. Therefore, we compared intraoperative conditions and clinical effects of low dose (5mg) bupivacaine added with fentanyl versus a conventional dose(10 mg) of bupivacaine in spinal anesthesia for a transurethral resection of the prostate (TURP). Methods: Forty five ASA class 1 and 2 patients scheduled for a TURP were randomly divided into three groups. Group B (n = 15) received bupivacaine 10 mg, group BF (n = 15) received bupivacaine 5 mg added with fentanyl 20g, and group BFE received bupivacaine 5 mg added with fentanyl 20 and 0.2 mg epinephrine. Blood pressure and heart rate were recorded every 5 minutes before and after spinal anesthesia. Sensory blockade was measured by a pin-prick test and motor blockade was evaluated by the Bromage motor scale. Side effects including pruritus, nausea, vomiting, respiratory depression, and intraoperative pain were observed. Results: The duration of sensory and motor blockade in group BF was significantly shorter than in group B and group BFE (P to low dose bupivacaine 5 mg resulted in short lasting motor and sensory block, compared with conventional dose bupivacaine 10 mg. Therefore, we concluded that the clinical application of this method could provide adequate analgesia with early discharge and no serious side effects for TURP patients.

Background: It is controversial that an electrocardiography (EEG) is valuable in evaluation of patients with headache. The purpose of this study was to determine whether EEG brain mapping can be a useful indicator for evaluating the analgesic efficacy of treatment on the patient with an occipital headache. Methods: We did an EEG on 20 patients with occipital headaches at the peri-laser application period. The laser was radiated for 3 minutes a third of the total distance from the external occipital protuberance to the mastoid process on the superior nuchal line. An EEG was taken before laser radiation as control use, and at 10, 30 and 60 minutes after laser radiation by 32 channel electrodes (international 10-20 system). The EEG mapping was red for the high electric potential and blue for the low electric potential. Results: Compared with control group, the alpha wave increased significantly in parieto-occipital and occipital region at 60 minutes after laser radiation (P