Search

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

The pericapsular nerve group (PENG) block targets the nerves innervating the anterior hip surface; however, few studies on this technique are currently available. We investigated the effects of the PENG block on postoperative opioid consumption after a hip surgery. This was a randomized, double-blind, placebo-controlled study conducted at a single institution. Fifty patients undergoing hip surgery were randomly allocated, 25 in each group, to receive a PENG block either using 25 mL of 0.5% ropivacaine (PENG group) or 25 mL of saline (control group). The primary outcome was the total opioid consumption 24 h postoperatively. The secondary outcomes were postoperative pain scores, time to first opioid demand, sensory block efficiency, quadriceps muscle strength, complications, and patient satisfaction. Compared with those in the control group, patients in the PENG group had a significantly lower total opioid consumption 24 h postoperatively (440.72 ± 242.20 μg vs. 611.07 ± 313.89 μg, P = 0.037) and significantly lower pain scores at 30 min postblock and 6 postoperatively ( P < 0.001 and P < 0.001 , respectively). The time to first opioid demand was significantly shorter in the control group than in the PENG group P < 0.001 . Sensory block effectiveness was better in the PENG group 30 min postblock and 6 and 12 h postoperatively than in the control group. Patient satisfaction was also better in the PENG group than in the control group. There were no differences in the other outcomes. The PENG block reduced the total opioid consumption in the first 24 h after hip surgery with no significant effects on quadriceps muscle strength and complication rate. This study was registered at the Korea Clinical Research Information Service (cris.nih.go.kr; Reg. No. KCT0006348) on July 16, 2021.

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

Background The i-gel™ (i-gel) and Laryngeal Mask Airway Supreme™ (LMA Supreme) have been safely used in children. We compared the airway performance of the i-gel and LMA Supreme in infants undergoing general anesthesia. Methods Sixty infants with American Society of Anesthesiologists physical status I or II were randomly assigned to place either the i-gel or the LMA Supreme. The size 1 or 1.5 of each airway was selected by the weight of infants. The primary outcome variable was oropharyngeal leak pressure (OLP). We also assessed insertion success rate, insertion time, fiberoptic view of the larynx, airway quality, airway manipulations, and perioperative complications. Results Demographic data did not differ between the two groups. Insertion success rate was similar in both groups. OLP for the i-gel (26.0 ± 3.8 cmH2O) was higher than for the LMA Supreme (23.7 ± 3.2 cmH2O) (P = 0.016). Insertion time for the i-gel (16.4 ± 2.8 s) was shorter than for the LMA Supreme (18.5 ± 2.7 s) (P = 0.002). There were no differences in fiberoptic view of the larynx, airway quality, airway manipulations, and complications between the two groups. Conclusions This study demonstrated that the i-gel and LMA Supreme provided a similar performance of airway in infants. Compared with the LMA Supreme, the i-gel provided shorter insertion time and higher OLP in infants.

Background Both the i-gel™ (i-gel) and LMA Supreme™ (Supreme) are new single-use second generation supraglottic airway devices available in pediatric sizes. This study was designed to investigate the i-gel in comparison with the Supreme in children undergoing general anesthesia. Methods One hundred children with American Society of Anesthesiologists physical status I or II undergoing general anesthesia were randomly assigned to either the i-gel or the Supreme group (50 children in each group). The device size was chosen according to weight of the children. We assessed the insertion success rate, insertion time, oropharyngeal leak pressure, grade of the fiberoptic glottic view, number of airway manipulations required, and postoperative complications. Results There were no differences in the demographic data between the two groups. The success rate of insertion was same in both groups. The insertion time of the i-gel was longer than that of Supreme (P = 0.004). The oropharyngeal leak pressure in the i-gel group was higher than that in the Supreme group (P = 0.013). On fiberoptic examination, the vocal cords were visible in 90% of the children in the i-gel group and in 96% of the children in the Supreme group. The number of airway manipulations required was higher in the i-gel group (14 cases) than in the Supreme group (1 case) (P < 0.001). There were no differences in complications including blood staining of the device and sore throat between both groups. Conclusions Both the i-gel and Supreme provided a satisfactory airway during general anesthesia in children. Compared to the Supreme, the i-gel demonstrated a higher oropharyngeal leak pressure, longer time for insertion, and a greater number of airway manipulations during anesthesia.

Background Gentamicin reduces acetylcholine release and clindamycin causes end-plate ion channel blockade. Because of these reasons, two drugs show muscular relaxant effect and potentiate the action of nondepolarizing neuromuscular agents. This study was intended to evaluate the effect of gentamicin and clindamycin on rocuronium-induced neuromuscular blockade and the interaction between these drugs. Methods Male Sprague-Dawley rats' phrenic nerves and diaphragms were installed in a bath containing Krebs solution. They were divided into three study groups. The first group was pre-treated with 0.1 (n = 3), 0.2 (n = 4) or 0.5 (n = 3) mM gentamicin and the tension was measured as the concentration of rocuronium was increased. The second group was experimented by increasing gentamicin on 0.25 (n = 5), 0.5 (n = 6) or 1.0 (n = 6) mM clindamycin. The final group was pre-treated with various combinations of gentamicin and clindamycin. The drug concentration was gradually increased until single twitch tension decreased by around 80%. Effective concentration was calculated using a probit model and interaction indices derived the Loewe additivity. Results The administration of gentamicin and the combination of gentamicin and clindamycin enhanced rocuronium-induced neuromuscular blockade. At 0.2 and 0.5 mM gentamicin, synergistic interactions with rocuronium were observed. Likewise, at 0.5 and 1.0 mM clindamycin, synergistic interactions with gentamicin appeared. When all three drugs were combined, in the tetanic fade, all the groups except for those administered with 0.01 mM gentamicin and 0.25 mM clindamycin showed synergistic interactions. Conclusions This study demonstrate that gentamicin and clindamycin potentiated rocuronium induced neuromuscular blockade. Moreover, it was found that these drugs interacted synergistically.

Background: Anesthetic titration using spectral entropy monitoring reduces anesthetic requirements and shortens recovery in adult surgical patients. This study was performed to evaluate the effect of entropy monitoring on end-tidal sevoflurane concentration and recovery characteristics in pediatric patients undergoing sevoflurane anesthesia. Methods: Seventy-eight children (aged 3–12 years) scheduled for a tonsillectomy and/or an adenoidectomy were randomly divided into one of two groups: standard practice (Standard) or entropy-guided (Entropy). In the Standard group, sevoflurane was adjusted to maintain the heart rate and systolic blood pressure (BP) within 20% of the baseline values. In the Entropy group, sevoflurane was adjusted to achieve a state entropy of 40–50. We compared the entropy values, end-tidal sevoflurane concentration and recovery times between groups. Results: During maintenance of anesthesia, the entropy and BP values were higher in the Entropy group (P

The oculocardiac reflex (OCR) occurs frequently during pediatric strabismus surgery. The aim of this study was to assess the effects of various anesthetic regimens on the incidence of OCR during the surgery.Two hundred and eighty children, 1 to 9 years old, undergoing elective strabismus surgery, were randomly assigned to eight groups; ketamine-sevoflurane (KS), ketamine-desflurane (KD), ketamine-propofol (KP), ketamine-remifentanil (KR), midazolam-sevoflurane (MS), midazolam-desflurane (MD), midazolam-propofol (MP), and midazolam-remifentanil (MR). No premedication was given. Anesthesia was induced using ketamine 1 mg kg(-1) or midazolam 0.15 mg kg(-1) with 66% N(2)O in O(2). Laryngeal mask airways (LMAs) were placed with rocuronium 0.5 mg kg(-1). Anesthesia was maintained with sevoflurane 2-3 vol. %, desflurane 5-6 vol. %, propofol 7-8 mg kg(-1) h(-1), or remifentanil 0.75 microg kg(-1) over 1 min, followed by a continuous infusion of remifentanil 0.5 microg kg(-1) min(-1) with 66% N(2)O in O(2). Heart rate (HR) was recorded during extraocular muscle (EOM) manipulation. OCR was defined as a reduction in HR of more than 20% induced by the traction of an EOM.In patients given ketamine, OCR occurred more frequently in the KP (65.7%) and KR (62.9%) groups than in the KD (29.4%) and KS (37.1%) groups (P0.05). In patients given midazolam, OCR occurred more frequently in the MP (54.3%) and MR (60.6%) groups than in the MD (36.4%) and MS (31.4%) groups (P0.05).Propofol or remifentanil anesthesia was associated with a higher incidence of OCR during pediatric strabismus surgery than sevoflurane and desflurane anesthesia, when either ketamine or midazolam was used as an induction agent.

Background: Rapidly acting narcotics enhance the degree of bradycardia due to the oculocardiac reflex (OCR) elicited by extraocular muscle (EOM) tension during strabismus surgery. We evaluated and compared the effects of remifentanil and sevoflurane on OCR during paediatric strabismus surgery. Methods: One hundred and twenty children, 1–9 years old, undergoing elective strabismus surgery, were randomly assigned to receive sevoflurane or remifentanil. No anticholinergic prophylaxis was administered. Anaesthesia was induced using ketamine 1.0 mg/kg or midazolam 0.15 mg/kg with 66% N2O in O2. Laryngeal mask airways were placed with rocuronium 0.5 mg/kg. Anaesthesia was maintained with sevoflurane 2.0–3.0 vol% with 66% N2O in O2 or remifentanil 0.75 μg/kg over 1 min and followed by the continuous infusion of remifentanil 0.5 μg/kg/min with 66% N2O in O2. Heart rate (HR) and blood pressure (BP) were measured and compared. OCR was defined as a reduction in HR of >20% induced by traction of an EOM. Results: During anaesthesia, HR and BP were maintained at a lower level in the remifentanil group than in the sevoflurane group (each, P

We designed this study to evaluate the postoperative analgesic efficacy and safety of intrathecal (i.t.) neostigmine, i.t. morphine, and their combination in patients undergoing cesarean section under spinal anesthesia. Seventy-nine term parturients were randomly divided into four groups to receive isotonic sodium chloride solution 0.2 mL, neostigmine 25 microg, morphine 100 microg, or the combination of i.t. neostigmine 12.5 microg and morphine 50 microg with i.t. 0.5% hyperbaric bupivacaine 12 mg. There were no significant differences among the four groups with regard to spinal anesthesia, maternal blood pressure and heart rate, or fetal status. Postoperative analgesia was provided by i.v. patient-controlled analgesia (PCA) using fentanyl and ketorolac. Compared with the saline group, the time to first PCA use was significantly longer in the neostigmine group (P0.001), with lower 24-h analgesic consumption (P0.001). Nausea and vomiting were the most common side effects of i.t. neostigmine (73.7%). Analgesic effectiveness was similar between the neostigmine and morphine groups. Compared with the neostigmine group, the combination group had significantly prolonged analgesic effect and reduced 24-h PCA consumption (P0.05) with less severity of nausea and vomiting (P = 0.058). Compared with the morphine group, the combination group tended to have prolonged times to first PCA use (P = 0.054) with a lower incidence of pruritus (P0.03).Intrathecal (i.t.) neostigmine 25 microg produced postoperative analgesia for cesarean section similar to that of i.t. morphine 100 microg, but with a high incidence of nausea and vomiting. The combination of i.t. neostigmine 12.5 microg and i.t. morphine 50 microg may produce better postoperative analgesia with fewer side effects than i.t. neostigmine 25 microg or i.t. morphine 100 microg alone.

Natural orifice transluminal endoscopic surgery (NOTES) is an evolving field of minimally invasive surgery. NOTES reaches the target organ by inserting the endoscope through a natural orifice (e.g. mouth, anus, urethra, vagina) and offers advantages of less postoperative pain and lower complication rate. Since its first description in 2004, NOTES has progressed from use on animal models to humans. We experienced anesthetic care of two patients who underwent transoral NOTES under general anesthesia.

Background Minimal-flow anesthesia can meet the demands of a modern society that is more sensitive to environmental protection and economic burdens. This study compared the safety and efficacy of minimal-flow desflurane anesthesia with conventional high-flow desflurane anesthesia for prolonged laparoscopic surgery. Methods Forty-six male patients (ASA physical status II or III) undergoing laparoscopic urologic surgery for more than 6 hours were randomly divided into two groups: the high-flow (HF) group and the minimal-flow (MF) group. The HF group was continuously administered a fresh gas flow of 4 L/min. In the MF group, a fresh gas flow of 4 L/min was administered for the first 20 minutes and was thereafter lowered to 0.5 L/min. Inspiratory and expiratory desflurane concentrations, respiratory variables, and hemodynamic variables were continuously monitored during administration of anesthesia. Measurements of carboxyhemoglobin (COHb) concentration and arterial blood gas analysis were performed every 2 hours during anesthesia. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), blood urea nitrogen (BUN) and creatinine were measured on the first and second day after the surgery. Results Demographic data and duration of anesthesia were not different between the two groups. Significant differences were not observed between the two groups in terms of hemodynamic variables, respiratory variables, and inspiratory and expiratory desflurane concentrations. Inspiratory O2 concentration was maintained lower in the MF group than in the HF group (43-53% vs. 53-59%; P < 0.05). Compared with the HF group, COHb concentrations was higher (P < 0.05), but not increased from the baseline value in the MF group. Serum AST, ALT, BUN, and creatinine were not significantly different between the two groups. Conclusions In prolonged laparoscopic surgery, no significant differences were found in safety and efficacy between minimal-flow and high-flow desflurane anesthesia.

Background Sore throat and hoarseness are common complications after general anesthesia with tracheal intubation. The position for patients can affect the incidence of postoperative sore throat (POST) by causing displacement of the endotracheal tube. This study investigated the prophylactic effect of dexamethasone in prone position surgeries. Methods One hundred-fifty patients undergoing lumbar spine surgery (18-75 yr) were randomly allocated into the normal saline group (group P, n = 50), dexamethasone 0.1 mg/kg group (group D1, n = 50) or dexamethasone 0.2 mg/kg group (group D2, n = 50). The incidence and severity of POST, hoarseness, and cough were measured using direct interview at 1, 6, and 24 h after tracheal extubation. The severity of POST, hoarseness, and cough were graded using a 4-point scale. Results At 1, 6, and 24 h after extubation, the incidence of sore throat was significantly lower in group D1 (1 h; P = 0.015, 6 h; P < 0.001, 24 h; P = 0.038) and group D2 (1 h; P < 0.001, 6 h; P < 0.001, 24 h; P = 0.017) compared to group P. There were less number of patients in the groups D1 and D2 than group P suffering from moderate grade of POST at 1, 24 h after extubation. The incidence of hoarseness at 1, 6, and 24 h after extubation was significantly lower in groups D2 than group P (P < 0.001). There were no significant differences in the incidence of cough among the three groups. Conclusions The prophylactic use of dexamethasone 0.1 mg/kg and 0.2 mg/kg in prone surgery reduces the incidence of postoperative sore throat and dexamethasone 0.2 mg/kg decreases the incidence of hoarseness.

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

Background In laparoscopic surgical procedures, many clinicians recommend supraglottic airway devices as good alternatives to intubation. We compared the i-gel® (i-gel) and LMA Supreme® (Supreme Laryngeal Mask Airway, SLMA) airway devices during laparoscopic cholecystectomy regarding sealing pressure and respiratory parameters before, during, and after pneumoperitoneum. Methods Following Institutional Review Board approval and written informed consent, 93 patients were randomly allocated into the i-gel (n = 47) or SLMA group (n = 46). Insertion time, number of insertion attempts, and fiberoptic view of glottis were recorded. Oropharyngeal leak pressure (OLP), the use of airway manipulation, peak inspiratory pressure, lung compliance, and hemodynamic parameters were measured before, during, and after pneumoperitoneum. Results There were no significant differences between the two groups regarding demographic data, insertion time, fiberoptic view of glottis, and the use of airway manipulation. The gastric tube insertion time was longer in the i-gel group (20.4 ± 3.9 s) than in the SLMA group (16.7 ± 1.6 s) (P < 0.001). All devices were inserted on the first attempt, excluding one case in each group. Peak inspiratory pressure, lung compliance, and OLP changed following carbon dioxide pneumoperitoneum in each group, but there were no significant differences between the groups. Conclusions Both the i-gel and SLMA airway devices can be comparably used in patients who undergo laparoscopic cholecystectomy, and they offer similar performance including OLP.

Pheochromocytoma is a catecholamine-secreting tumor. Reduction of the high risk of intraoperative hypertension during tumor manipulation requires adequate preoperative preparation. Even though adequate pretreatment is performed, uncontrolled hemodynamic responses during the surgery may result in postoperative complications. In particular, undiagnosed pheochromocytoma without any pretreatment can lead to highly severe life-threatening hypertensive crisis [1]. Therefore, it has always posed a great challenge for anesthesiologists [2]. In the case of our patient, induction of spinal anesthesia helped in the prevention of severe hypertension and, consequently, the development of severe complications.

UNLABELLED We evaluated the clinical efficacy and safety of spinal anesthesia with 0.5% hyperbaric ropivacaine compared with 0.5% hyperbaric bupivacaine for elective cesarean delivery. Sixty healthy, full-term parturients were randomly assigned to receive either 12 mg of 0.5% hyperbaric bupivacaine or 18 mg of 0.5% hyperbaric ropivacaine intrathecally. There were no significant differences in demographic or surgical variables or neonatal outcomes between groups. Onset time of sensory block to T10 or to peak level was later in the Ropivacaine group (P < 0.05). The median (range) peak level of analgesia was T3 (T1-5) in the Bupivacaine group and T3 (T1-4) in the Ropivacaine group. Time for sensory block to recede to T10 did not differ between groups. Duration of sensory block was shorter in the Ropivacaine group (188.5 +/- 28.2 min vs 162.5 +/- 20.2 min; P < 0.05). Complete motor block of the lower extremities was obtained in all patients. Ropivacaine also produced a shorter duration of motor blockade than bupivacaine (113.7 +/- 18.6 min vs 158.7 +/- 31.2 min; P < 0.000). The intraoperative quality of anesthesia was excellent and similar in both groups. Side effects did not differ between groups. Eighteen milligrams of 0.5% hyperbaric ropivacaine provided effective spinal anesthesia with shorter duration of sensory and motor block, compared with 12 mg of 0.5% hyperbaric bupivacaine when administered for cesarean delivery IMPLICATIONS Eighteen milligrams of 0.5% hyperbaric ropivacaine provided effective spinal anesthesia with shorter duration of sensory and motor block, compared with 12mg of 0.5% hyperbaric bupivacaine when administered for cesarean delivery.

Background: Etomidate has a stable hemodynamic profile after induction, but hypertension and tachycardia are frequent after intubation as well as myoclonus. We compared the effects of fentanyl and remifentanil on the hemodynamic response to intubation and myoclonus during etomidate induction in elderly patients. Methods: Ninety ASA I or II patients aged over 65 were randomly assigned to 3 groups. Group C received normal saline 10 ml (n = 30), group F and R were pretreated with fentanyl 1.0 μg/kg (n = 30) or remifentanil 1.0 μg/kg with continuous infusion of 0.1 μg/kg/min (n = 30) 1 min before induction with etomidate 0.2 mg/kg. Endotracheal intubation was performed after administration of rocuronium 0.8 mg/kg. Systolic blood pressure (SBP), mean arterial pressure, diastolic blood pressure (DBP), heart rate (HR), and the incidence and intensity of myoclonus were recorded. Results: After intubation, group R showed significant decreases compared with groups C and F for all of the hemodynamic variables measured. The incidences of increases in SBP and HR of more than 30% of the baseline levels, SBP of > 200 mmHg, and HR of > 120 beats/min were significantly lower in group R (0%, 10%, 0%, and 0%, respectively) compared with groups C (83%, 83%, 30%, and 13%, respectively) and F (63%, 77%, 13%, and 7%, respectively). The frequency and intensity of myoclonus were significantly decreased in both groups F and R compared with group C. Conclusions: Pretreatment with remifentanil suppressed cardiovascular reactions to endotracheal intubation more effectively than that of fentanyl during etomidate induction. Both opioids reduced the incidence of myoclonus. (Korean J Anesthesiol 2013; 64: 12-18)

Background: Neostigmine augments clindamycin-induced neuromuscular block and antagonizes rocuroniuminduced neuromuscular block; however, it remains unclear whether neostigmine enhances the neuromuscular blocking (NMB) that is caused by combinations of rocuronium and clindamycin. The intent of this study was to determine whether neostigmine potentiates the muscle relaxation that is induced by combinations of rocuronium and clindamycin and to estimate whether both clindamycin and rocuronium have synergistic actions on NMB. Methods: Forty-one left phrenic nerve-hemidiaphragms (from male Sprague-Dawley rats, 150-250 g) were mounted in Krebs solution. Three consecutive single twitches (ST, 0.1 Hz) and one tetanic tension (50 Hz for 1.9 s) were obtained for each increase in concentration of rocuronium or clindamycin. The concentrations of rocuronium were cumulatively increased until an 80% to 90% reduction in ST was attained in the Krebs solutions pre-treated with 0 (n = 5), 0.1 (n = 1), 0.25 (n = 1), 0.5 (n = 4), or 1.0 (n = 1) mM clindamycin or with 0 (n = 4), 0.1 (n = 1), 0.5 (n = 5), 1.0 (n = 5), or 2.0 (n = 4) mM clindamycin in combination with 250 nM neostigmine, and so were the concentrations of clindamycin in the Krebs solutions pre-treated with 0 (n = 6) or 250 nM (n = 6) neostigmine. Results: Clindamycin increased the potency of rocuronium for ST and tetanic fade, irrespective of the presence of neostigmine. Neostigmine shifted the concentration-response curve of rocuronium to the right in the presence or absence of clindamycin. The interaction between rocuronium and clindamycin was synergistic when clindamycin concentrations were in excess of 0.5 mM, irrespective of the presence of neostigmine. Conclusions: Neostigmine may partially antagonize the neuromuscular block that is induced by a combination of clindamycin and rocuronium. Clinicians are advised to be aware that clindamycin synergistically increases the degree of rocuronium-induced neuromuscular block, even when neostigmine is present. (Korean J Anesthesiol 2011; 61: 320-326)

Background: Minimal-flow and low-flow anesthesia provide many advantages, including reduced costs and pollution, and conservation of body heat and airway humidity. However, low-flow sevoflurane anesthesia is associated with an increase in the circuit concentration of compound A, which causes nephrotoxicity in rats. Therefore, this study was conducted to assess the effects of prolonged minimal-flow sevoflurane anesthesia on hepatic and renal function. Methods: Forty female patients who underwent free flap surgery lasting more than 8 hours randomly received either high-flow (5 L/min) or minimal-flow (0.5 L/min) sevoflurane anesthesia. Hepatic functions were then assessed by measuring the serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and total bilirubin levels. In addition, renal functions were assessed by measuring the blood urea nitrogen (BUN) and serum creatinine levels and by spot urinalysis. Venous blood and spot urine samples were obtained prior to administration of the anesthesia, and then on the first, third and fifth days following administration of the anesthesia. Results: The anesthetic time (9.9 ± 1.7 vs. 9.6 ± 2.0 h) and sevoflurane exposure (8.2 ± 1.7 vs. 7.4 ± 1.9 MAC-h) were not different between the high-flow and minimal-flow anesthesia group. The serum AST, ALT, ALP and total bilirubin levels were within the normal range throughout the study period in both groups. Additionally, the BUN and serum creatinine levels were within the normal range throughout the study period in both groups. Furthermore, there were no significant differences in any hepatic or renal biomarkers between the two groups. Conclusions: No significant differences in postoperative hepatic and renal function were observed between the minimal-flow and high-flow sevoflurane anesthesia groups. (Korean J Anesthesiol 2008; 54: 501～6)

Background: The Cobra Perilaryngeal Airway (CobraPLA) and the Laryngeal Mas k Airway (LMA) Classic are supraglottic airway devices. We compared the performance of the CobraPLA and the LMA Classic devices during volume-controlled ventilation in children. Methods: Eighty children, ASA physical status I-II, aged 1−10 years were randomly assigned with either the CobraPLA or the LMA Classic for airway management. Anesthesia was induced with 1 mg/kg ketamine and 2.0 mg/kg propofol, and muscle relaxation was obtained with the use of 0.5 mg/kg rocuronium. All patients were mechanically ventilated with a tidal volume of 10 m/kg in 1−3% sevoflurane, oxygen and air. The number of insertions, oropharyngeal leak pressure, and fiberoptic airway position were measured. Measurements of blood pressure, heart rate, oxygen saturation, end-tidal carbon dioxide, and peak inspiratory pressure were recorded every 5 minutes. Postoperative adverse events were assessed. Results: There was no significant difference between the use of the two devices with respect to the number of insertions, time of insertion, and fiberoptic score. The oropharyngeal leak pressure was significantly higher for the CobraPLA than the LMA Classic (25.4 ± 4.9 cmH2O versus 20.3 ± 5.4 cmH2O; P ＜ 0.001). Hemodynamic and respiratory variables were similar with the use of both devices. The incidence of adverse events was not different with the use of both devices. Conclusions: Both airway devices provided an adequate airway and effective ventilation during volume-controlled ventilation in children. The CobraPLA had a higher sealing pressure than the LMA Classic. (Korean J Anesthesiol 2008; 55: 145～9)

Background: Etomidate is frequently used as an induction agent in the elderly patients. This study was done to determine whether etomidate-based induction can provide hemodynamic stability and fentanyl decreases the incidence of myoclonus. Methods: Eighty ASA II or III patients older than 65 years were randomly allocated to four groups. Group 1 (n = 20) received etomidate 0.2 mg/kg after normal saline 3 ml, Group 2 (n = 20) received etomidate 0.25 mg/kg after normal saline 3 ml, Group 3 (n = 20) received fentanyl 2 ug/kg before the administration of etomidate 0.2 mg/kg, Group 4 (n = 20) received fentanyl 2 ug/kg before the administration of etomidate 0.25 mg/kg. The time interval from etomidate infusion to loss of eyelash reflex, to decrease bispectral index (BIS) 50, to intubation were recorded. We measured hemodynamic change, the BIS index, the incidence, duration and grade of myoclonus. Results: There were no significant differences in time interval, mean arterial pressure (MAP), BIS index between groups. MAP and HR were increased after intubation in all groups. The incidence of myoclonus were 25%, 30%, 0%, 15% respectively. There were no significant differences in incidence and duration of myoclonus between 4 groups, but group 3 had reduced incidence compared with group 1. Conclusions: Loss of consciousness and hemodynamic changes during induction with 0.2 mg/kg and 0.25 mg/kg of etomidate were appropriate. Pretreatment with fentanyl and small dose of etomidate decrease the incidence of myoclonus.

Methods: In a prospective double-blind trial, 30 patients undergoing cardiac valve replacement surgery were randomly assigned to receive intravenous protamine (n = 15) or intraaortic protamine (n = 15). Arterial pressure (AP), pulmonary arterial pressure (PAP), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and pulmonary vascular resistance index (PVRI) were measured. Results: The changes of HR, AP, PAP, CI, SVRI, PVRI were not significantly different between both groups. Both groups maintained hemodynamic stability afer protamine administration. Conclusions: There were no significant difference in the hemodynamic changes following intraaortic and intravenous administration of protamine after cardiopulmonary bypass. And there were no hemodynamic benefits of intraaortic versus intravenous administration of protamine. (Korean J Anesthesiol 2007; 53: 338～43)

Background: This study was designed to compare the effects of anesthetic methods used recently on emergence delirium in pediatric strabismus surgery. Methods: Two hundred and thirty two children, aged 2-10 years, undergoing strabismus surgery, were randomly assigned to one of eight groups; ketamine-desflurane (n = 30), ketamine-sevoflurane (n = 30), ketamine-propofol (n = 30), ketamine-remifentanil (n = 27), midazolam-desflurane (n = 28), midazolam-sevoflurane (n = 30), midazolam-propofol (n = 27), and midazolam-remifentanil (n = 30). Anesthesia was induced with ketamine 1.0 mg/kg or midazolam 0.15 mg/kg. Laryngeal mask airway (LMA) was placed with rocuronium 0.5 mg/kg. Anesthesia was maintained with desflurane 5-6 vol%, sevoflurane 2-3 vol%, propofol 7-8 mg/kg/hr, and remifentanil 0.5μg/kg/min under N2O 66% in O2. Ventilation was controlled to maintain normocapnia. The status of emergence delirium (ED) was evaluated by a blinded observer until discharge from postanesthetic care unit. Results: There was no differences in age, sex, weight, height, anesthetic time, and recovery time among the eight groups. ED occurred in 54 children (23.3%), but severe ED needed treatment was not occurred. Compared with ketamine group, midazolam group showed less incidence of ED. Propofol and remifentanil groups showed less incidence of ED compared with desflurane and sevoflurane groups. ED group was more younger and more temperamental compared with nonED group. Conclusions: Propofol or remifentanil anesthesia provided less incidence of ED compared with desflurane and sevoflurane in pediatric strabismus surgery. (Korean J Anesthesiol 2007; 52: 138～42)

Background: The postoperative period is associated with the increased production of cytokines, which augments the sensitivity to pain. Epidural analgesia might reduce the postoperative stress response and influence the immune function. This study evaluated the effect of patient-controlled epidural analgesia (PCEA) on the cytokine response, compared with patient-controlled intravenous analgesia (PCIA) in patients undergoing a gastrectomy. Methods: Twenty-nine patients undergoing a gastrectomy were randomly assigned to one of two postoperative pain management techniques: PCIA (fentanyl 15/ml) or PCEA (fentanyl 3/ml in 0.1% ropivacaine). The level of postoperative pain was assessed at rest and during coughing using the visual analog scale (VAS). Blood samples were collected before administering anesthesia and 6, 24, and 48 h after surgery. The plasma concentrations of the tumor necrosis factor (TNF)-, interleukin (IL)-1, IL-6, IL-8, IL-1ra, IL-10, and IL-2 were assessed. Results: The patients in the PCEA group showed lower VAS pain scores during the 72 h after surgery, compared with the patients in the PCIA group. There was no change in the levels of TNF- and IL-2 between the two groups at all times examined. In both groups, the levels of IL-1, IL-6, IL-8, IL-1ra, and IL-10 increased after surgery (each group, P ＜ 0.05) but there was no significant differences between the two groups. Conclusions: These results suggest that PCEA has no added influences on the cytokine responses after a gastrectomy.

Background: This study evaluated the hemodynamic response and recovery profile of remifentanil- anesthesia, compared with sevoflurane- anesthesia in pediatric strabismus surgery. Methods: Fifty-seven healthy children aged 1-9 years undergoing strabismus surgery were randomly assigned to two groups, group R or group S. None of the children was premedicated with an anticholinergic agent. Anesthesia was induced with intravenous ketamine 1.0 mg/kg. A laryngeal mask airway (LMA) was placed with rocuronium 0.4 mg/kg. Anesthesia was maintained with sevoflurane 2.0-3.0 vol% and N2O 66% in group S, and with remifentanil 0.75g/kg over 1 min followed by remifentanil 0.5 g/kg/min and 66% in group R. At the end of surgery, the anesthetic agents were discontinued, and the early emergence, recovery, and side effects were assessed. Results: During anesthesia, the heart rate and blood pressure were lower in group R (P ＜ 0.05). The incidence of an oculocardiac reflex was similar in both groups. The times to spontaneous ventilation and the removal of LMA were similar in the two groups. The times from eye opening to command, orientation and full recovery were faster in group R (P ＜ 0.05). The incidence of postoperative nausea and vomiting was similar in both groups. The incidence of coughing was lower in group R (P ＜ 0.05). Mild pruritus developed in 17.2% of patients in group R. Conclusions: In pediatric strabismus surgery, remifentanil provided similar hemodynamic stability, and an earlier and smoother recovery, compared with sevoflurane anesthesia.

Background: The change of expression of the -adrenergic receptor (-AR) subtypes in the thalamus and hypothalamus were investigated in a neuropathic pain rat model. Methods: The left sciatic nerve was clamped for creating a neuropathic pain model in five rats. A sham operation was done in three rats as control group. Behavioral tests for pain were conducted by using mechanical stimuli applied to the hind paws. After 7 days, the expression of -AR subtype mRNA in the rat thalamus and hypothalamus was measured using real time polymerase chain reaction. Results: Mechanical allodynia were developed on postoperative 1, 3, and 7 days in the neuropathic pain model. The expression of -AR, -AR, and -AR was significantly higher in the thalamus and hypothalamus in the neuropathic pain model (P ＞ 0.05). Conclusions: These results would suggest that the subtypes of -AR in thalamus and hypothalamus may contribute to produce neuropathic pain.

Background: Patient satisfaction with anesthesia is an important outcome of hospital care. The aim of this study was to assess the overall level of satisfaction with anesthetic care and to identify predictive factors associated with dissatisfaction. Methods: Our subjects were adult in-patients with ASA 1-3 who had undergone an elective operation during the previous 12 months. The major measure of subjective outcome was the overall level of satisfaction with anesthetic care on the first day after operation. Patients were asked to rate if they were 'very satisfied', 'somewhat satisfied', 'neutral', 'somewhat dissatisfied' or 'very dissatisfied'. We also measured other predetermined outcomes, such as nausea, vomiting, pain and other complications. Results: At the time of analysis, our database contained information on 3376 patients. 283 (8.4%) patients were 'very satisfied', 1826 (54.1%) were 'somewhat satisfied', 1119 (33.1%) were 'neutral', 133 (3.9%) were ´somewhat dissatisfied´ and 15 (0.4%) were 'very dissatisfied' with their anaesthetic care. The number of postanesthetic factors (81.7%) were greater than the number of preanesthetic factors (8.8%) and intranesthetic factors (9.5%) for dissatisfaction with anesthetic care. The causes of dissatisfaction were postoperative pain (43 patients, 29.1%), postoperative nausea and vomiting (17, 11.5%), sore throat (17, 11.5%), waiting a long time before surgery (9, 6.1%), myalgia (6, 4.1%), back pain (6, 4.1%) and other complications. Strong relations were found between patient dissatisfaction and an anesthetic duration of more than 2 hours, moderate or severe postoperative pain, moderate to severe postoperative nausea and vomiting, and other anesthesia-related adverse events. Conclusions: This study found that patient satisfaction with anesthetic care is high and identified several factors associated with dissatisfaction that may be preventable or better managed.

Background: Determining the precise magnitude, duration, and mechanism of hypotension caused by intravenous amiodarone could potentially increase the safety of drug administration to critically ill patients. The objective of this study was to characterize the immediate cardiovascular actions of an intravenous loading dose of amiodarone administered using echocardiographic and hemodynamic measurements. Methods: In a prospective double-blind trial, 20 patients undergoing off-pump coronary artery bypass graft surgery were randomly assigned to receive intravenous amiodarone (n = 10) or placebo (n = 10). Heart rate (HR), arterial blood pressure (systolic, diastolic, mean; SAP, DAP, MAP), pulmonary artery pressure (systolic, diastolic, mean; PSAP, PDAP, PMAP), cardiac output (CO), central venous pressure (CVP), left ventricular ejection fraction (LVEF) were measured. Results: HR, SAP, DAP, MAP, PSAP, PDAP, PMAP, CO by thermodilution method, CVP, LVEF by echocardiographic measurements was not significantly different in both group. Hypotension requiring intervention occurred in 2 of 10 patients after amiodarone administration and in none of 10 patients after placebo. Conclusions: Hypotension requiring intervention occurred 20% after amiodarone administration, the cause of these hypotension were thought to be arterial dilatation but was not associated with decreased cardiac output or left ventricular ejection fraction and corrected successfully by intravenous administration of phenylephrine.

Background: Intrathecal or epidural neostigmine has a postoperative analgesic effect. In this study we evaluated the effects of epidural neostigmine on postoperative analgesia and stress responses after gastrectomy. Methods: Eighty, ASA physical status 1 or 2, patients scheduled for gastrectomy were randomly assigned to one (n = 20) of four groups. Patients received of 0.25% bupivacaine with either saline (N0 group), neostigmine /kg (N5 group), neostigmine /kg (N10 group), neostigmine /kg (N15 group) epidurally 30 minutes before operation. All patients received identical general anesthesia. Patient-controlled epidural analgesia (PCEA) was provided by bupivacaine (0.05%) and fentanyl (/ml for postoperative analgesia. Results: The N10 and N15 groups showed reduced 24-h PCEA consumptions compared with the N0 and N5 groups (P /kg in bupivacaine produced a postoperative analgesic effect, but did not suppress stress responses after gastrectomy.

Background: Epidural butorphanol produces effective analgesia with fewer side effects than morphine in obstetric patients. The analgesic efficacy and side effects of epidural butorphanol were compared with epidural fentanyl for patient-controlled epidural analgesia (PCEA) after gastrectomy. Methods: After obtaining patient consent, 75 patients undergoing elective gastrectomy were randomly allocated to epidural butorphanol and epidural fentanyl groups. An epidural catheter was introduced at the T7-8 or T9-10 intervertebral spaces before operation. General anesthesia was maintained with N2O / O2, enflurane and vecuronium. Postop-erative analgesia was provided using a PCEA with either fentanyl 5μg/ml or butorphanol 50μg/ml in a 0.05% bupivacaine solution. When patients first required analgesics after complete recovery of conscious-ness from general anesthesia, a bolus of 5 ml of PCEA solution was initially administered in both groups. The PCEA was set to deliver a bolus of 2 ml, with a lockout interval of 10 min, and no basal infusion. PCEA consumption, pain intensity using a visual analog score (VAS), patient's satisfaction to PCEA, and side effects were evaluated. Results: No significant difference in PCEA consumption, VAS pain score, or patient's satisfaction to PCEA was found between the two groups. The incidence of pruritus in the butorphanol g roup was less than that in the fentanyl group (P ＜ 0.05). Conclusions: PCEA with butorphanol provided similar postoperative analgesia with less pruritus than fentanyl in gastrectomized

Hemostasis and a clear field are obtained by the local infiltration of a local anesthetic mixed with epinephrine. However, epinephrine may in itself, due to its cardiovascular effect, cause arryhthmia, heart failure, pulmonary edema, and even cardiac arrest. We describe a 10-year-old patient who developed ventricular premature contraction and acute pulmonary edema due to epinephrine infiltration during tonsillectomy. The patient recovered without any sequelae after intensive treatment involving fluid restriction, diuretics, dobutamine infusion, and oxygen by mask at 5 L/min.

We report a case of accidental intrathecal administration of Nucomyt (acetylcysteine), a mucolytic agent used for intratracheal instillation. A 21-year-old healthy female with a complete syndactyly at the 4th and 5th toes was scheduled for a web release under spinal anesthesia. Immediately after accidental intrathecal administration of Nucomyt 2.4 ml instead of bupivacaine for spinal anesthesia, tonic extension developed at first in the lower extremities and then the upper extremities, too. Thiopental sodium 200 mg was injected intravenously twice. Endotracheal general anesthesia with -enflurane-vecuronium was maintained for the operation for about two hours. For about 1 hour after emergence of general anesthesia, tonic extension intermittently developed in the lower extremities and was controlled with midazolam. Mild elevated blood pressure, tachycardia, tachypnea, high fever (up to 38.5) and respiratory acidosis occurred. Thirty minutes later, she became mentally clear with a normal neurologic examination. No delayed sequelae were detectable at a follow-up visit 1 month and 1 year after surgery.

Background: Acute normovolemic hemodilution (ANH) is recognized as the easiest, the most economical and valuable autologous blood saved method among the types of autotransfusion. We studied whether this method could reduce the transfusion requirement of allogenic blood in total knee arthroplasty to investigate the efficacy of ANH. Methods: The thirty patients were randomized and divided into two groups. In the ANH group (n = 15), 2 units of autologous blood were procured from a CVP catheter immediately before or after anesthetic induction, while Ringer's lactate and colloid solution were infused to maintain normovolemia via a different venous catheter. Perioperative changes of hemoglobin, hematocrit, platelets, prothrombin time (PT), transfusion requirements and the amount of postoperative drainage were compared. Results: There were no significant difference between the two groups in terms of perioperative changes of hemoglobin, hematocrit or platelets. And, there was significantly reduced demand for packed RBC transfusion in the ANH group (362.7 236.4 ml) compared with the control group (668.0 259.3 ml) (P ＜ 0.05). However, no significant difference was observed between the two groups in terms of postoperative drainage amount. Conclusions: ANH can reduce transfusion requirements in total knee arthroplasty surgery if this is accompanied by appropriate patient selection and monitoring.

Background: W e evaluated the efficacy and safety of positive pressure ventilation (PPV with a ProSeal laryngeal mask airway (PLMA as compared with an endotracheal tube (ETT and with a classic laryngeal mask airway (LMA during laparoscopic cholecystectomy. Methods: One hundred ASA 1 2 adults scheduled for elective laparoscopic cholecystectomy were randomly assigned to ETT LMA or PLMA. Anesthesia was induced with fentanyl 2μg/kg lidocaine 0.5 mg/kg and propofol 2 mg/kg and maintained with a continous infusion of propofol 6-12 mg/kg/h in 67% N 2O atracurium and fentanyl. ETT LMA or PLMA was placed with atracurium 0.5 mg/kg. Respiratory and hemodynamic parameters were measured before and after intraabdominal CO2 insufflation. The surgeon assessed the degree of gastric distension change using a laparoscope. R esults: Oxygen saturation end tidal CO2 inspiratory pressure expiratory tidal volume and compliance of the respiratory system were similar in the three groups. Blood pressure and heart rate were lower in the PLMA and LMA groups than in the ETT group 5 min after induction (P ＜ 0.05. Audible gas leakage occurred more so in the LMA group (48.5% than in the PLMA group (8.8%. Because of inadequate ventilation endotracheal intubation was changed in one case in the LMA group. The degrees of gastric distension change were similar in the three groups. The PLMA and LMA resulted in less coughing after removal than ETT (P ＜ 0.05. A postoperative sore throat and dysphagia were similar in the three groups but dysphonia was more frequent in the ETT group. C onclusion: During laparoscopic cholecystectomy PPV with PLMA provide more effective pulmonary ventilation than LMA and fewer side effects than ETT. (Korean J Anesthesiol 2003; 44: 739～746

Background: We compared the antiemetic efficacy of droperidol, granisetron, and propofol in postoperative nausea and vomiting (PONV) in the patients who received epidural anesthesia with bupivacaine and morphine. Methods: Among one hundred and sixty one ASA physical status I or II patients who received an abdominal hysterectomy under epidural anesthesia, sixty patients who showed PONV and thereby received antiemetics were randomly assigned into 3 groups: droperidol 0.75 mg (droperidol group: n = 20), granisetron 1.0 mg (granisetron group: n = 20) or propofol 20 mg (propofol group: n = 20) by an intravenous injection. Antiemetics were injected according to the patient request up to 3 times of initial dose. Nausea, vomiting, sedation, anxiety, and discomfort were assessed and the time interval between each antiemetic administration was recorded by a blind observer for 30 min after the injection of antiemetics. Results: Success rates in PONV control for 30 min after the 1st antiemetic administration were 90%, 95%, and 85% in the droperidol, granisetron, and propofol group, respectively. The propofol group experienced a higher relapse incidence (90%) than other groups (droperidol: 35%, granisetron: 25%)(P 501 min: P

Background : Hypoxia often occurs during anesthesia of patients with tetralogy of Fallot (TOF). The factors that determine pulmonary circulation and oxygenation in patient with TOF are the degree of obstruction of right ventricular outflow tract (RVOT), right ventricular filling pressure, systemic vascular resistance, loss of negative pleural cavity pressure by thoracotomy, change of pulmonary vascular resistance due to positive pressure ventilation and degree of arteriopulmonary collateral connection. Hence pulse oximetry is a noninvasive technique for measuring arterial O2 saturation continuously, this study examined the correlation between the change of percutaneous arterial oxygen saturation (△SpO2) and the change of mean arterial pressure (△MAP) using pulse oximetry in these patients. Methods : Twenty pediatric patients undergoing modified Blalock-Taussig shunt or total corrective operation were prospectively investigated. Immediately after induction, baseline values of MAP and SpO2 were determined and if there were some changes in SpO2 from baseline during operation, MAP on that value of SpO2 were collected. If SpO2 reduced, patients were treated with infusion of fresh frozen plasma or pentastach (2∼10 ml/kg), injection of phenylephrine (10 g/kg) or esmolol (0.5 mg/kg). Results : Intravascular volume loading only was executed in 4 patients, intravascular volume loading and phenylephrine administration was executed in 11 patients, and intravascular volume loading, phenylephrine and β-blocker administration was executed in 5 patients. There were no significant correlation between △MAP and △SpO2 from linear correlation and regression analysis (r=0.23, p＜0.05). Conclusions : Because △SpO2 were not closely related with △MAP and above mentioned factors could act closely among each others, meticulous anesthetic management is necessary during palliative or total corrective operation in patients with TOF. (Korean J Anesthesiol 1999; 36: 397∼401)