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Background: Demand of anesthesia for patients with cerebral palsy is more increasing. But there is still lacking in clinical research regarding how BIS and entropy reflect well on sedative and hypnotic state in patients with cerebral palsy. Methods: Fifteen patients with cerebral palsy (Group CP) and fifteen patients without cerebral palsy (Group NL) scheduled for elective orthopedic surgery were included in the study. Induction of anesthesia was done by having the patient inhale 1 vol% sevoflurane and 100% oxygen using a total fresh gas flow of 8 L/min. Simultaneously BIS, state entropy (SE), response entropy (RE), end-tidal sevoflurane concentration were recorded every 15 seconds till there was no self respiration. When end-tidal sevoflurane concentration had not risen any more for 30 seconds, we increased inhaled sevoflurane concentration in 1 vol% increments. End point of recording was when self respiration was lost or the time sevoflurane concentration reached 8 vol%. Results: No significant differences in RE, SE, BIS at baseline and end point were found between the two groups. No significant difference in the time reach end point was found between the two groups. BIS, SE and RE correlated with end-tidal sevoflurane concentration in the two groups. Conclusions: The authors found no significant difference in the entropy values between patients with CP and normal patients. Also, the entropy values could be interpreted like BIS in patients with CP. And BIS showed a stronger correlation with end tidal sevoflurane concentrations than entropy. (Korean J Anesthesiol 2009;57:422~7)

Left ventricular aneurysm (LVA) and false aneurysm are complications of acute myocardial infarction, trauma, and cardiac surgery. Left ventricular false aneurysm (LVFA) is a particularly catastrophic complication owing to its high propensity for rupture. Surgical resection should be considered for LVFA occurring within three months after myocardial infarction or development of congestive heart failure. In this report, we describe a case of acute heart failure with LVA and LVFA occurring in stage as a complication of myocardial infarction in a 55-year-old man. The patient was also at risk of brain ischemia due to abnormal vessel status and a previous cerebrovascular accident with left-sided weakness. Successful perioperative anesthetic management was achieved by focusing on maintaining marginal upper normal blood pressure to ensure cerebral perfusion and to reduce the risk of false aneurysm rupture.

One-lung ventilation is considered to be mandatory in video-assisted thoracoscopic surgery. However, the authors showed in a previous report that two-lung ventilation with low tidal volume is feasible in thoracoscopic bleb resection (TBR). In this study, they evaluated optimal respiratory rate during TBR under two-lung ventilation with low-tidal volume anesthesia.A prospective, randomized, single-blinded intervention study.An operating room in a teaching hospital.Forty-eight patients who underwent scheduled TBR under general anesthesia.TBR was performed under low-tidal-volume (5 mL/kg), two-lung ventilation. Respiratory rate (RR) varied according to the protocol: 15 (group I), 18 (group II), and 22 cycles/min (group III). Using block randomization method, 16 patients were assigned to each of 3 groups.Minute ventilation of group I was lowered significantly compared with the other groups (p0.001). The results of arterial blood gas analysis were in the physiologic range in all patients. Surgery and anesthetic times and number of endostaples used were not significantly different among the 3 groups.The RR of 15 cycles/min with low-tidal volume (5 mL/kg) and two-lung ventilation did not produce abnormal physiologic changes including arterial pH, partial arterial oxygen pressure, and partial pressure of carbon dioxide and guaranteed an optimal surgical field. Therefore, these setting are considered acceptable for two-lung ventilation during TBR.

Background: Hydrogen sulfide (H2S) produces a protective effect against myocardial ischemia and reperfusion injury. Sevoflurane, which is used for anesthesia in cardiac problem patients, also has a protective effect. This study is designed to reveal the effects of H 2S under sevoflurane using rat hearts. Methods: The hearts were Langendorff-perfused, subjected to 30 minutes ischemia and 60 minutes reperfusion. Group I was a control group. The other groups were pretreated for 15 minutes before ischemia as follows: 1.6% sevoflurane for group S; 18.5 μM H 2S S for group H; and 1.6 % sevoflurane and 18.5 μM H 2S simultaneously for group HS. Hemodynamics and the infarct size were measured. Results: Group HS presented depressed hemodynamics during pretreatment. LV function in group HS achieved better recovery than group I after reperfusion. The infarct size of groups S, H and HS was smaller than group I, while there were no differences between groups S, H and HS. Conclusions: Exogenous H2S did not enhance the preconditioning effects of sevoflurane. Rather, the results suggest that H2S under sevoflurane might depress hemodynamics. (Korean J Anesthesiol 2012; 62: 461-467)

Background: Effective early antiviral treatments reduce both acute zoster pain and the risk of postherpetic neuralgia. The authors hypothesized that the direct neuraxial administration of acyclovir could provide superior drug application to the spinal neural structures with a higher viral burden and have various advantages over the other routes of drug administration in terms of required doses, side effects, and efficacy. Objective To know whether intrathecal acyclovir injection is neurologically and histopathologically safe or not. Study Design: Randomized, experimental trial in rats. Setting: Associated experiment center. Methods: A total of 40 rats weighing between 250-300g were used. The rats were randomly divided into 2 groups of 20 each using a random number table: normal saline group (Group N) and acyclovir group (Group A). Rats in Group N were administered 20 µl of normal saline and Group A were administered the same volume of 700 µg/mL acyclovir into the intrathecal space via an intrathecal catheter. Saline or acyclovir was administered daily for 5 consecutive days. The changes in behavior and sensory-motor function were checked and histopathological findings of the spinal cords were observed by light and electron microscopy. Results: No rats in Group N or Group A showed any behavioral change or sensorymotor dysfunction during the 5-day observation period. Furthermore, no histopathological abnormalities of the spinal cord were observed in the 6th day after the last intrathecal administration of the drug. Limitations: There is a need to perform studies to evaluate long-term safety by observing cumulative neurotoxic effects with continual injection during a long-term period. Conclusions: There was no evidence of neurological and histopathological abnormalities following intrathecal acyclovir injection. Key words: acyclovir, safety, spinal,intrathecal, acute zoster pain, post herpetic neuralgia

Acupuncture has been widely used in alternative medicine for pain relief but may have many complications due to lack of appropriate cares. Pharmacopuncture is a sort of acupuncture that injects a herbal ingredient through a thin tube for the purpose of combining the effects of the herb and acupuncture and it has many pitfalls. The agents used in pharmacopuncture are not refined for a desired effect and not produced by sterile standard processes under strict medical surveillance. We report a case of a 44-yr-old male patient who had multiple abscesses in the psoas region with fever, right low back and hip pain that began after the pharmacopuncture treatment. This case shows that although pharmacopuncture has been practiced widely, it is important that the appropriate aseptic technique should be used to prevent severe infections and other complications.

Background: Ketamine can enhance anesthetic and analgesic actions of a local anesthetic via a peripheral mechanism. The authors' goal was to determine whether or not ketamine added to ropivacaine in interscalene brachial plexus blockade prolongs postoperative analgesia. In addition, we wanted to determine the incidence of adverse-effects in patients undergoing hand surgery. Methods: Sixty adults scheduled for forearm or hand surgery under the interscalene brachial plexus block were prospectively randomized to receive one of the solutions of the study. Group P received 0.5% ropivacaine 30 ml, group K received 0.5% ropivacaine 30 ml with 30 mg ketamine, and group C received 0.5% ropivacaine with 30 mg ketamine i.v. Loss of shoulder abduction, elbow flexion, wrist flexion and loss of pinprick in the C4–7 sensory dermatomes were assessed at 1-min intervals. Adverse-effects were assessed every 5 min. The duration of the sensory and motor blocks was assessed after operation. Adverse-effects were also recorded. Results: The onset time of sensory or motor blockade and the duration of sensory or motor blockade were similar in all groups. Adverse-effects occurred in 44% of patients in group K and 94% of group C. Conclusion: This study suggests that 30 mg ketamine added to ropivacaine in the brachial plexus block does not improve the onset or duration of sensory block, but it does cause a relatively high incidence of adverse-effects. These two findings do not encourage the use of ketamine with local anesthetics for brachial plexus blockade.

This report describes two cases of bronchial foreign body removal in small children. The procedure differs from previous reports because a modified port was used for continuous ventilation, making the procedure safer by preventing hypoxemia and airway edema. Additionally, grasping forceps was used with a Fogarty balloon catheter to retrieve the foreign body, reducing damage to the airway mucosa and vocal cords. Finally, the procedure was performed by anesthesiologists, who are airway manipulation experts.

To examine the combined preemptive effects of somatovisceral blockade during laparoscopic cholecystectomy (LC). One hundred fifty-seven patients under general anesthesia receiving local infiltration and/or topical peritoneal local anesthesia were studied. Patients were randomized to receive a total of 150 mg (0.25% 60 mL) bupivacaine via periportal (20 mL) and intraperitoneal (40 mL with 1:200,000 epinephrine) administration of each. Group A received preoperative periportal bupivacaine before incision and intraperitoneal bupivacaine immediately after the pneumoperitoneum. Group B received periportal and intraperitoneal bupivacaine at the end of the operation. Group C (preoperative) and Group D (postoperative) received only periportal bupivacaine and Group E (preoperative) and Group F (postoperative) received only intraperitoneal bupivacaine. The control group received no treatment. Pain and nausea were recorded at one, two, three, six, nine, 12, 24, 36, and 48 hr postoperatively. Throughout the postoperative 48 hr, incisional somatic pain dominated over other pain localizations in the control group (P < 0.05). The incisional pain of groups A, B, C and D was significantly lower than that of the control group in the first and second hours. The incisional pain of groups A and C was significantly lower than that of the control group in the first three hours. Incisional pain dominated during the first two postoperative days after LC. Preoperative somato-visceral or somatic local anesthesia reduced incisional pain during the first three postoperative hours. A combination of somato-visceral local anesthetic treatment did not reduce intraabdominal pain, shoulder pain or nausea more than somatic treatment alone. Preoperative incisional infiltration of local anesthetics is recommended.

Unexpected tracheal narrowing was observed in a patient with Duchenne muscular dystrophy during a corrective operation for thoracolumbar scoliosis. As the operating time progressed, peak airway pressure and end-tidal CO2 increased gradually in the prone position. We found a floppy portion of the trachea using fiberoptic bronchoscopy (FB) in the prone position. We advanced a wire-reinforced tube toward the carina beyond the lesion. This allowed correction of the ventilatory abnormalities. We encountered another patient scheduled for the same operation. We performed FB in advance before the position change and observed a narrowed portion of trachea. We advanced the tracheal tube under FB beyond the pathologic portion and then moved the patient into the prone position. The operation was done successfully without any problems.

Ultrasound guidance has been promoted as a means of reducing the risk of complications during central venous catheterization (CVC), and during internal jugular venous catheterization (IJV), and ultrasound guidance has been reported to reduce the risk of mechanical complications and catheter-placement failures and the time required for insertion [1]. Mild kyphosis or scoliosis does not change cardiopulmonary function, but more aggravated deformities of spine have detrimental effects [2]. Complex interactions during head and neck movement and the fixed insertion depths of preformed endotracheal tubes often cause inadvertent malposition and may result in accidental extubation or inadvertent endobronchial intubation [3]. We report the case of a 53-year-old female patient with kyphosis who was inadvertently endobronchially intubated and rapidly developed tension pneumothorax after ultrasound guided IJV cannulation. A 53-year-old female patient (133 cm tall and 51.5 kg) with a diagnosis of kyphoscoliosis was admitted for posterior correction and fusion. At age 20, she contracted tuberculosis of spine and the kyphoscoliosis subsequently progressed to a kyphosis angle of 90 degrees one year prior to admission. No abnormal chest X-ray, pulmonary function test, laboratory result, or electrocardiogram findings were evident. Lidocaine (40 mg) with 1% propofol (Aquafol®, Daewonpharm, Seoul, Korea) and remifentanil (Ultiva™, GlaxoSmithKline, UK) (Pion TCI®, Bionet, Seoul, Korea) were administered at target concentrations of 4 µg/ml and 3 ng/ml, respectively for induction. After administering 45 mg of rocuronium, the trachea was intubated with a 7.0 mm armored endotracheal tube, and before fixing the tube 20 cm to incisors, lung sounds, chest wall movement in both lung fields, and endotracheal tube depth were confirmed; initial peak inspiratory pressure (PIP) was 15 ± 1 cmH2O. The neck area was prepared and a 7.5-MHz linear-array ultrasound probe, which was connected to a real-time ultrasound unit (SonoSite, Bothell, USA). The probe was covered with ultrasonic gel, wrapped in a sterile plastic sheath and focused at a depth of 4.5 cm. Standard ultrasound two-dimensional (2D) imaging was used to measure the depth and caliber of the IJV, which was found to be patent, compressible, and without thrombi. Catheterization was performed with a 19-gauge, 10-cm needle under continuous dynamic observation and real-time 2D images were obtained by placing the transducer parallel and superior to the clavicle, and over the groove between the sternal and clavicular heads of the sternocleidomastoid muscle. For left side CVC, the patient's head was rotated to the right, but several attempts at left IJV cannulation failed. During an attempt to catheterize the left subclavian vein, vital signs changed to blood pressure 65/47 mmHg, heart rate 70 beats/min, and oxygen saturation 84%. We immediately converted to manual ventilation with 100% O2, but severe resistance was experienced with a PIP 35 ± 4 cmH2O. A chest radiograph revealed unilateral tension pneumothorax in right lung and right endobronchial intubation (Fig. 1). The patient's head was then rotated to the neutral position and the intubation tube was withdrawn to 17 cm from the incisors. Needle aspiration was immediately performed and a chest tube was inserted into the thoracic cavity. Ventilation then improved and PIP was 24 cmH2O, and ABGA showed a pH 7.45, PaCO2 35 mmHg, PaO2 252 mmHg, and SaO2 100%. After the procedure had been completed, the patient was transferred to the intensive care unit with intubation. The chest tube was removed and the patient was discharged without sequelae on the 21th POD. Fig. 1 Chest AP view showing right tension pneumothorax and endobronchial intubation. The use of CVCs may be associated with adverse effects that are hazardous to patients, and these complications are increased by patient anatomy (morbid obesity, cachexia, or local scarring from surgery or radiation treatment), the patient setting (mechanical ventilation), and the operator's skill. In our opinion, the anatomical abnormality and operator inexperience probably contributed in this case. Ultrasound guidance can be performed using either the in-plane (IP) or the out-of-plane (OOP) techniques. The IP technique is performed with the cannula along the long axis of the ultrasound probe, whereas the OOP technique is performed with the cannula along the short axis of the ultrasound probe, and both techniques have advantages and disadvantages. The advantage of the IP technique is that the entire needle (body and tip) is visible and its disadvantage is that reverberation artifacts impair visualization of structures behind the needle. In particular, in cases with a large needle-to-probe distance the needle may be completely obscured. The OOP technique has the advantage that the needle tip is easier to visualize (some block techniques more useful with the OOP technique [4]), and that the needle causes no significant artifacts, and its disadvantage is that the body of the needle is not visualized, which means that if the correct plane of the body of the needle is lost, the body of the needle may be mistaken for the tip. We performed IJV cannulation using the OOP technique in the described case, and we believe that inadvertent misleading introduction of needle was a possible reason of this complication. The diagnosis of pneumothorax may be difficult when manifestations are non-specific, but early diagnosis and treatment are important to prevent tension pneumothorax. Even though the rate of pneumothorax following real-time ultrasound-guided IJV puncture is extremely low, careful consideration of operator, technical, and patient factors may help to reduce the risk of pneumothorax [4]. The kyphosis angle of our patient was 90 degrees, and severe chest wall deformity, a narrow thoracic inlet, and inadequate positioning of the patient secondary to contractures contributed to the difficulty of achieving CVC [5], which demonstrates that ultrasound-guided CVC is not a fail-safe technique in terms of avoiding pneumothorax. Chest wall deformity due to kyphosis also contributed to the risk of endotracheal tube malposition when the head and neck were rotated. We advise that anesthesiologists should be aware of the occurrence of pneumothorax during ultrasound-guided central venous catheterization and of endotracheal tube malposition due to head and neck movement in kyphosis.

Background: The aim of this study was to compare the streamlined liner of the pharynx airway (SLIPA) with the classic laryngeal mask airway when used by novice personnel. Methods: There were 114 patients enrolled into this study who underwent general anesthesia were randomly allocated into one of 2 groups; LMA group (n = 57) or SLIPA group (n = 57). After insertion, insertion success rate, insertion time, and hemodynamic responses to insertion were accessed. After surgery, postoperative airway morbidity (sore throat, dysphonia, dysphagia) were evaluated. Results: The SLIPA was successfully inserted in 96% of patients (55/57) and the LMA in 93% (53/57) (P = 0.408). First attempt success rates were 88% (44/57) and 77% (50/57) in the SLIPA and the LMA (P = 0.142). The successful insertion time in SLIPA group (33.4 ± 11.0 sec) was significantly shorter than that of LMA group (38.8 ± 16.6 sec) (P = 0.048) and the insertion time at the first attempt was also shorter in SLIPA group (31.0 ± 6.3 sec) than LMA group (34.7 ± 8.6 sec) (P = 0.013). There was no statistically significant difference between the two groups in hemodynamic responses and postoperative airway morbidity. Conclusions: The SLIPA was similar to the LMA in insertion success rate, hemodynamic response, and postoperative airway morbidity by novice personnel. The insertion time at the first attempt and successful insertion time of the SLIPA were significantly shorter than those of the LMA. Therefore, the SLIPA could be a useful alternative to the LMA as primary SGA for novice personnel. (Korean J Anesthesiol 2012; 63: 136-141)

A 41-year-old woman, who had no thrombotic risk factors and past history except congenital scoliosis, underwent central venous catheterization (CVC) before correction of the scoliosis. When internal jugular vein (IJV) catheterization using the anatomical landmark technique failed, CVC under ultrasound guidance was tried. As a consequence, thrombosis and hypoplasia of the right IJV were incidentally detected by ultrasonography. Central venous catheters were then successfully placed in other veins under ultrasound guidance. Also, after examinations to rule out the possibility of pulmonary embolism and to clarify the causes of the IJV thrombosis, the patient was found to have protein S deficiency. CVC under ultrasound guidance should be recommended to prevent the failure of cannulation and complications such as thromboembolism in patients who could possibly have anomalies of vessels as a result of anatomical deformities caused by severe scoliosis, even if patients do not have thrombotic risk factors such as a history of central catheter insertion or intravenous drug abuse, cancer, advanced age, cerebral infarction, and left ventricular dysfunction. Also, if venous thrombosis is found in patients without predisposing risk factors, one should ascertain the cause of the hypercoagulable state, for example protein S deficiency, and perform appropriate treatment and prevention of venous thromboembolism.

To the Editor, The SLIPA, a cuffless, hollow, boot-shaped, soft plastic supraglottic airway device (SLIPA; SLIPA Medical Ltd., London, UK), has advantages over other laryngeal mask airway devices (LMADs) because it provides better protection from regurgitation and has a better perilaryngeal seal. However, SLIPA has not been tested in difficult airways. We report successful management of a difficult airway with SLIPA after laryngeal mask airway failure. We obtained the patient’s written consent to publish this report. A 50-yr-old man (169 cm, 90 kg) with gastroesophageal reflux disease (GERD) was scheduled for reconstruction of finger tendons under general anesthesia. Difficult intubation was anticipated because of the patient’s large tongue, short neck, thyromental distance, and a Mallampati score of 4. Because he refused awake fibreoptic intubation, we decided to insert a LMAD. After administering fentanyl 100 lg, thiopental sodium 450 mg, and succinylcholine 90 mg, a LMAD (Solus; Intersurgical Ltd. Wokingham, UK) size 5 was inserted. Immediately after insertion, no leak was heard, the end-tidal carbon dioxide concentration (ETCO2) was 28-30 mmHg, and the peak inspiratory airway pressure (PIP) was 22-25 cm H2O. At one minute after insertion, however, the PIP suddenly increased to 35 cmH2O, and a leak was detected. The LMAD was removed, and another insertion attempt was made after administering succinylcholine 50 mg. This time, the PIP was 40-45 cm H2O, and leaks were audible immediately. A fibreoptic bronchoscope (FOB) was inserted through the airway port of the LMAD, and the anterior portion of the epiglottis was found to be blocking the view. The fibrescope was passed under the epiglottis to examine the glottis, and a glottic narrowing was found. After removing the LMAD, a size 55 SLIPA was inserted. The PIP decreased to 20-23 cm H2O, and the ETCO2 was 32-33 mmHg. No leak was detected. The FOB was inserted, through which the vocal cords were well visualized, and the periglottic seal was seen to be improved. Afterward, ventilation was maintained well, and there were no complications, including airway obstruction or aspiration. Examination of the glottis via the FOB provided possible explanations for the different performances of the two devices. First, the position of the epiglottis was different, which might be due to the designs of the respective bowls. The laryngeal aperture of SLIPA consists of a wide portion and a narrow portion, preventing airway obstruction (Figure), whereas the absence of epiglottic bars on the Solus could cause epiglottis downfolding and subsequent airway obstruction. However, previous reports suggested that because disposable LMADs, including the Solus, have a deeper bowl, ventilation is well maintained despite the absence of epiglottic bars. In this case, the FOB passed under the epiglottis with ease, which makes obstruction by the epiglottis improbable. Second, the presence of a cuff and the shape and location of the bowl should be considered. The space between the tongue and posterior pharyngeal wall was probably narrow in this patient, becoming narrower because of laryngopharyngeal edema caused by GERD. In a narrow space, inflating the LMAD cuff could increase pressure in the laryngopharynx and cause distortion of laryngeal B. G. Lim, MD K. J. Kim, MD M. H. Kong, MD, PhD N. S. Kim, MD, PhD S. H. Lim, MD, PhD M. K. Lee, MD, PhD I. O. Lee, MD, PhD (&) Guro Hospital, College of Medicine, Korea University, Seoul, South Korea e-mail: iloklee@korea.ac.kr

Massive air leakage through a lacerated lung produces inadequate ventilation and hypoxemia. Tube exchange from a single to double lumen endotracheal tube (DLT), and lung separation to maintain oxygenation, are challenging for seriously injured patients. In this case report, we aim to describe how a bronchial blocker (BB) makes it easier to perform a lung separation in this situation; it also increases the overall safety of the procedure. A 35-year-old female (163 cm, 47 kg) suffered from blunt chest trauma due to a traffic accident; the accident caused right-sided lung laceration with massive air leakage. Paradoxically, positive ventilation worsened SaO2 and leakage increased through a chest tube. We introduced BB while the patient was still awake: Left-side one-lung ventilation (OLV) was established and anesthesia was induced. After PaO2 was maximized with OLV, we changed the endotracheal tube to DLT without a hypoxic event. By BB placement, we maintained PaO2 at a secure level, conducted mechanical ventilation and exchanged the tube without deterioration. (Korean J Anesthesiol 2014; 67: 354-357)

Background Sevoflurane anesthesia commonly causes emergence agitation (EA) in children. One previous study has reported that the use of nitrous oxide (N2O) during the washout of sevoflurane may reduce EA by decreasing the residual sevoflurane concentration, while many animal studies suggest that N2O poses a potential risk to children. The present study was designed to compare EA in children assigned to receive sevoflurane with N2O (group N) or sevoflurane alone (group S). Methods We enrolled 80 children aged 3-10 years. Anesthesia was induced with 5 mg/kg thiopental sodium, 0.6 mg/kg rocuronium and 0.5 mg/kg ketorolac, and was maintained with 50% N2O and sevoflurane in group N or with sevoflurane alone in group S. The sevoflurane concentration was adjusted with a bispectral index (BIS) of 40-60. After completion of the surgery, N2O and sevoflurane were simultaneously discontinued and replaced with oxygen (O2) at 6 L/min. End-tidal sevoflurane concentration (Et Sevo) (%), BIS at the end of surgery, Et Sevo at recovery of self-respiration and emergence profiles were recorded. EA occurrence, pain score and rescue fentanyl consumption were assessed in the postanesthesia care unit. Results Et Sevo was significantly lower in group N (1.9%) than in group S (2.3%) at the end of surgery. However, there were no differences in Et Sevo at recovery of self-respiration, emergence times, the incidence of EA, pain score or dose of rescue fentanyl between the groups. Conclusions In children undergoing adenotonsillectomy with preemptive ketorolac, anesthetic maintenance using sevoflurane alone does not affect the incidence of EA or emergence profiles compared to anesthetic maintenance using sevoflurane with N2O.

Tracheal bronchus (TB) is an aberrant, accessary or ectopic bronchus arising almost exclusively from the right side of the tracheal wall above the carina. In our center, 673 bronchoscopic examinations were performed from 2009 to 2011 in patients undergoing one lung ventilation (OLV) and 3 TB were found. The incidence of a TB at bronchoscopy was 0.45% in our research, which is consistent with the reported incidence range from 0.1-5%. The clinician should consider the possibility of anomalous right upper lobe bronchus and perform bronchoscopy prior to the right bronchial blocker insertion, when left-sided OLV using bronchial blocker is planned. Also, for the patient with TB, a double lumen tube insertion is recommended than a blocker insertion to achieve OLV completely.

Background Lipid-emulsion propofol (LP) has cardioprotective effects against ischemia-reperfusion injury, but it has lipid-related side effects. Microemulsion propofol (MP) is a lipid-free propofol emulsified with 10% purified poloxamer 188 (PP188). PP188 is a nonionic surfactant and has cardioprotective effects. However, some reports have suggested that reduced cardioprotective effects were observed when the cardioprotective agents were used in combination even though each cardioprotective agent has cardioprotective effects. The aims of this study were to examine and compare the cardioprotective effects of MP and LP. Methods 50 isolated rat hearts were perfused with modified Kreb's solution. They were divided into 4 groups and underwent 30 minutes of ischemia and 60 minutes of reperfusion. Control group: ischemia-reperfusion was performed without treatment. LP, MP and PP groups: LP, MP and PP188 were infused during the pre-ischemic and reperfusion period, respectively. Hemodynamic parameters and coronary effluent flow rate (CEFR) were measured. Infarct size was determined using triphenyl-tetrazolium staining. Results In the MP group, systolic pressure was maintained near baseline, the systolic pressure was higher than that in the other groups and HR was lower than that in the other groups during reperfusion. Diastolic pressure was transiently increased in the PP group after treatment and at 5 minutes after reperfusion compared with that in the control group and in the the LP group. There were no differences in dP/dtmax and CEFR between groups. Infarct size in the LP, MP and PP groups was smaller than that in the control group, but there were no significant differences between these three groups. Conclusions MP has cardioprotective effects similar to those of LP. MP can be used for cardiac anesthesia in cases with ischemia-reperfusion injury to avoid the lipid-related side effects of LP.

Elbow tuberculosis is a rare disease which accounts for 1-3% of all cases of osteoarticular tuberculosis. The diagnosis of tuberculous arthritis is very difficult in most clinical situations because of the insidious onset, indolent process, and mild and non-specific local or systemic symptoms. Thus, the confirmatory diagnosis and effective treatment for tuberculous arthritis are delayed until the disease progresses to an advanced stage in many clinical settings. Herein we report a case of septic arthritis of the elbow due to Mycobacterium tuberculosis as a result of misdiagnosis and delayed treatments.

Nitrous oxide (N2O) may increase middle ear pressure during anesthesia, resulting in the displacement of tympanic membrane graft for tympanoplasty.This study was performed to assess the feasibility of remifentanil instead of N2O by comparing hemodynamics, recovery profiles, postoperative analgesia and complications during isoflurane-based anesthesia for tympanoplasty. Methods:Forty patientsundergoing tympanoplasty were randomly allocated to N2O-isoflurane anesthesia (group N) and remifentanil-isoflurane anesthesia (group R).In group N, N2O was used from induction to 15−30 minutes prior to grafting tympanic membrane and then N2O was changed to air.In group R, remifentanil was infused to the end of surgery.Isoflurane was used in both groups.We compared mean arterial pressure (MAP), heart rate (HR) and recovery times between groups during perioperative period.Postoperative pain, analgesic demand and nausea/vomiting during postoperative period were also compared. Results:MAP and HR were significantly higher in group N than group R at 1 minute, 5 minutes after intubation, skin incision and closure.Hypertensive and tachycardiac events were also more frequent in group N during operation.Time to spontaneous respiration was significantly shorter in group N, but times to eye opening, extubation and recovery of orientation were significantly shorter in group R.There were no significant differences in pain scores, analgesic demand and nausea/vomiting during postoperative period. Conclusions:Remifentanil can provide more stable hemodynamic status and faster emergence than N2O without significant increase of pain level, analgesic demand and adverse effects in isoflurane-based anesthesia for tympanoplasty.

Spinal cord stimulation (SCS) is an effective therapy for chronic and intractable neuropathic pain. We present a case report of successful pain control using SCS implantation in a patient with chronic, intractable stump pain for 36 years. The patient lost his two legs under the knees during the Vietnam War and ha d an amputation. After that he suffered stump pain for 36 years due to recurrent neuroma even after neuroma excision was performed over 30 times. We inserted the dual percutaneous leads at the level of left T9 and right T10 in this patient and could get complete pain relief without any complications. (Korean J Anesthesiol 2008; 55: 648～51)

Pulmonary edema is usually bilateral, but can be uncommonly unilateral. Although unilateral pulmonary edema (UPE) can occur owing to various etiologies, it usually occurs at a patient who has an underlying defect or abnormality in the cardiopulmonary system except a case of negative-pressure pulmonary edema. Especially UPE following general anesthesia is a rare complication in a healthy patient. Re-expansion pulmonary edema (REPE) as a cause of UPE mostly occurs when a chronically collapsed lung is rapidly re-expanded after pneumothorax. There are some reports associated with REPE following one-lung ventilation used to facilitate surgery, in which there is no chronically collapsed lung. There are, however, little reported cases of a more acute form of this complication following re-expansion after atelectasis due to only several minutes of an inadvertent main stem bronchial intubation during operation. A report of the occurrence of UPE in a healthy, young male undergoing two-jaw surgery is described.

Iatrogenic aortic dissection (IAD) is a life-threatening complication that can occur during open heart surgery, therefore IAD requires early diagnosis and prompt management. We describe here a case of IAD that occurred during mitral valve replacement. The transesophageal echocardiography (TEE) evaluation revealed features indicative of acute aortic dissection and the tear was successfully repaired by interposition of a graft.

We report a case in which epidural anesthesia was successfully administered during a cesarean section of a 35 years old parturient patient with severe congestive heart failure and respiratory in sufficiency at 33 weeks of gestation. The patient had a past history of mitral regurgitation and mitral valve prolapse treated by mitral valve replacement ten years prior. When limited motion of the prosthetic mitral valve developed, congestive heart failure recurred and was aggravated by the pregnancy. In addition, the patient presented with symptoms of respiratory insufficiency including NYHA III dyspnea, orthopnea, severe pulmonary hypertension (systolic pulmonary arterial pressure: 112 mmHg) due to severe aortic regurgitation, pleural effusion and pulmonary edema on admission. Four-days after admission, with premature labor pain and fetal distress, the patient underwent an emergency cesarean section. Due to the orthopnea, the patient could not breathe in the supine position, and we chose to give epidural anesthesia at a sitting position for preserving self-respiration and to prevent a ventilation-perfusion mismatch that would possibly develop during general anesthesia. Moreover, we could control postoperative pain and maintain a minimal, gradual hemodynamic change throughout the epidural anesthesia. During surgery, the hemodynamic instabilities were controlled by the use of dopamine, dobutamine, ephedrine and milrinone. We safely finished the cesarean section under epidural anesthesia and the patient was sent to the intensive care unit postoperatively to manage congestive heart failure and respiratory insufficiency. (Korean J Anesthesiol 2007; 53: 656～9)

Background: Ischemic preconditioning (IPC) has protective effects on myocardial ischemia. These effects may be caused by ATP (adenosine triphosphate) sensitive potassium () channel activation. Amiodarone also has pharmacologic preconditioning effects, especially suppression of reperfusion arrhythmia. The mechanisms of amiodarone effects are different from that of IPC. The aim of this study using the isolated rat working heart was 1) to confirm whether IPC and amiodarone protected against reperfusion injury; and, if so, 2) to example whether combination of IPC and amiodarone demonstrated additive effect or not. Methods: Isolated rat hearts were stabilized for 30 minutes and were subdivided into four groups. Control group was subjected low-flow ischemia of 5% dextrose water for 30 minutes. IPC group was pretreated with IPC. In Amiodarone group, whole process was same as control group except amiodarone administration during low-flow ischemia. Amiodarone-IPC group, IPC was applied and also administrated amiodarone. Isovolumetric left ventricular end systolic pressure (LVESP), left ventricular end diastolic pressure (LVEDP), dP/ and heart rate were measured. Results: Group II showed more recovered LVESP, less developed ventricular stiffness, more preserved coronary effluent flow, earlier termination of arrhythmia and smaller infarct size than Group I. Group III showed preserved LVESP and dP/, less developed ventricular stiffness, shortest arrhythmia sustaining time, smallest infarct size among all groups. These myocardial protective effects were abolished in Group IV. Conclusions: We observed that IPC and amiodarone administration, each has myocardial protective effects against myocardial ischemia, but when they are dealt at the same time, their beneficial effects diminished.

Complex regional pain syndrome (CRPS) is a condition characterized by regional pain, sensory alterations, motor dysfunction, and abnormality in body temperature, sudomotor activation, skin color changes and regional edema which often appears in the extremities after the onset of a noxious event. CRPS is a disabling disorder with an unknown mechanism. We present a CRPS case which is extremely resistant to conventional pharmaceutical and other therapeutic treatments in the left upper limb, which was treated successfully with continuous interscalene brachial plexus block (BPB).

Background: Sevoflurane is an inhalational anesthetic that produces rapid induction, emergence and little cardiovascular depression. Elevated sympathetic activity during surgery produces undesirable effects on the cardiovascular system, such as hypertension, tachycardia or arrhythmias. So combined general and epidural anesthesia have been used recently for the operation, especially the abdominal surgery. This study was performed to evaluate the cardiovascular effects of thoracic epidural anesthesia during sevoflurane general anesthesia. Methods: Forty patients of ASA class 1-2 undergoing elective subtotal gastrectomy were divided into 5 groups. Thoracic epidural bolus injection was administered via an epidural catheter during sevoflurane general anesthesia in a double-blind random manner: Group 1; normal saline (N/S) 10 ml (placebo), Group 2; morphine 0.1 mg/kg mixed with N/S in 10 ml, Group 3; fentanyl 1 mcg/kg mixed with N/S in 10 ml, Group 4; 1% lidocaine 10 ml, and Group 5; 1% lidocaine 10 ml mixed with morphine 0.1 mg/kg and fentanyl 1 mcg/kg. Systolic and diastolic blood pressures, pulse rates, peripheral oxygen saturation levels (Sp) and end-tidal carbon dioxide partial pressures (ETC) were measured every 5 minutes. Results: Systolic and diastolic blood pressures were significantly reduced from 10 minutes after epidural bolus injection in groups 4 and 5, but these decreases in blood pressure were not severe enough to require treatment in either group. Pulse rates were significantly decreased from 10 minutes after injection in groups 3, 4, and 5, but these decreases in pulse rate were not so severe enough to require treatment in 3 groups. Sp and ETC were stable, and arrhythmia was not observed. Conclusions: The thoracic epidural injection of 1% lidocaine mixed with morphine 0.1 mg/kg and fentanyl 1 mcg/kg can be safely used during sevoflurane anesthesia without severe cardiovascular complications during upper abdominal surgery in ASA 1-2 patients.

Background: Epidural opioids are used for the treatment of postoperative pain, but the incidence of side effects like nausea, vomiting, and pruritus is high. The aim of this study was to determine the optimal method for administering epidural droperidol to reduce the side effects of epidural opioids. Methods: A randomly sampled group of 145 patients that had undergone abdominal or lower leg surgery under general anesthesia were divided into the four groups. All patients received morphine 4 mg, fentanyl 500g and 0.2% ropivacaine 100 ml using a 2-day epidural infusion pump, and morphine 1 mg, fentanyl 50 g and 0.2% ropivacine 10 ml by epidural bolus. Group 1 patients (control group, n=40) did not receive epidural droperidol. Group 2 patients (n =35) received 2.5 mg of droperidol as an epidural bolus. Group 3 patients (n=35) received 2.5mg of droperidol as a continuous infusion. Group 4 patients (n=35) received 1.23mg of droperidol as an epidural bolus and 1.25 mg of droperidol as a continuous infusion simultaneously, Nausea, vomiting, and pruritus were assessed and recorded by a blind observer 1, 6, 24, and 48 hours after the bolus epidural administration of droperidol. Results: There was no significant difference between the four groups in terms of the intensity of sedation, nausea, vomiting, and pruritus. The incidence of nausea and vomiting in groups 2,3, and 4 at 1 hour, in groups 2 and 4 at 6 hours, and in groups 3 at 48 hours was significantly lower than in control group. The incidences of pruritus in groups 2,3, and 4 at 6 hours, and in groups 3 and 4 at 24 and 48 hours were significantly less than that of control group. Conclusions: Epidural bolus droperidol is effective at reducing nausea, and vomiting during the early postoperative stage. Contimuous epidural droperidol is also effective at reducing the pruritys during the late postoperative stage.

Propofol (2,6-diisopropylphenol) inhibited bronchoconstriction 1,2) and caused a decrease in arterial blood pressure that is partly due to a vasodilation. Although several mechanisms of these effects have been proposed, a decrease in intracellular calcium ([Ca]i) has been suggested to be a possible mechanism. In fact, propofol reduced [Ca]i and inositol 1,4,5-triphosphate (IP3) in various cells including smooth muscle cells, 6-9) myocytes, and cultured glial cells. However, despite of numerous studies, the mechanisms underlying the reduction of [Ca]i induced by propofol are still unclear. In addition, several studies have reported that propofol protects cells in rat hepatocytes and endothelial cells against oxidative stress, and have tried to investigate the effect of propofol on reactive oxygen species (ROS) production by chemiluminescence in neutrophills and endothelial cells. It was also reported that the phosphatidic acid-induced elevation of [Ca ]i is mediated by H2O2 in Rat-2 fibroblasts. 17)

Background: Sevoflurane, a newly developed halogenated inhalation anesthetic agent shows myocardial protective effects against global ischemia like other inhalation agents. We investigated differences between pharmacologic preconditioning effects at various concentrations of sevoflurane. Methods: Forty male Sprague-Dawley rats were subdivided into 4 groups (each n = 10). All groups underwent the same procedure (Langendorff preparation, 30 minutes ischemia and 60 minutes reperfusion) except for the concentrations of sevoflurane. The control group received no sevoflurane treatment. The sevo 1.6% group was given 1.6% sevoflurane before ischemia, the sevo 2.05% group was given 2.05% sevoflurane before ischemia, and the sevo 2.5% group was given 2.5% sevoflurane before ischemia. Hemodynamic parameters of all groups were recorded through a thin, saline-filled latex balloon and a transducer. Coronary flows were also measured. All hearts were stained by triphenyl tetrazolium to measure infarct size. Results: The sevoflurane administered groups showed higher left ventricular end systolic pressures and lower left ventricular end diastolic pressures than the control group after ischemia and reperfusion. The dP/ of the sevoflurane administration groups showed a more rapid recovery pattern after ischemia than the control. But no differences were found between the sevoflurane administered groups. Infarct sizes in the sevoflurane administered groups were smaller than those in the control group, and there were no significant differences between the sevoflurane administered groups. Conclusions: Sevoflurane (even below one MAC) administration before myocardial ischemia has a superb cardioprotective effects, i.e., rapid recovery of left ventricular fuctions, less stiffness development, and a reduced infarct size. There were no significant differences between the sevoflurane administered groups.

Background: In addition to its general anesthetic effect, ketamine has a local anesthetic-like action by a peripheral mechanism. We evaluated the effects of injecting ketamine 45 mg in a supraclavicular brachial plexus blockade (SBPB) with 0.5% ropivacaine 150 mg. In addition, we evaluated the incidence of side effects. Methods: Thirty four adult patients scheduled for upper extremity surgery were randomly allocated to one of three groups;group 1 (placebo group, n = 10) received 0.5% ropivacaine 30 ml for SBPB and intravenous saline 0.9 ml, group 2 (ketamine group, n = 13) received 0.5% ropivacaine 30 ml with ketamine 0.9 ml (45 mg) for SBPB, and group 3 (control group, n = 8) received 0.5% ropivacaine 30 ml for SBPB and intravenous ketamine 0.9 ml (45 mg). At 1-minute intervals after SBPB, patients were assessed for loss of shoulder abduction, elbow flexion, and wrist flexion, and for loss of pinprick sensation in the deltoid, radial, median, and ulnar dermatomes. Side effects and sedation scores were recorded at 5-minute intervals after SBPB. Before discharge, patients were asked when full sensation or motor function recovered. Results: The speeds of onset for both the motor and sensory blocks were similar in all three groups. The duration of postoperative analgesia and paralysis were similar in the three groups. Side effects were experienced by 62% of patients in group 2 and by 100% of patients in group 3. Conclusions: We found that the addition of ketamine (45 mg) to brachial plexus blockade does not offer either a quicker onset or a longer duration of anesthesia when using 0.5% ropivacaine SBPB, and it caused a relatively high incidence of side effects.

Background: Desflurane and sevoflurane have been shown to induce pharmacologic preconditioning in experimental studies. The present study was aimed at comparing the myocardial protective effects of these two halogenated anesthetics in terms preconditioning induction. Methods: Three groups of Sprague-Dawley rat hearts (n = 10 each) were perfused with oxygenated modified Kreb's solution using a Langendorff perfusion device. All groups underwent 30 minutes of global ischemia and 60 minutes of reperfusion after a stabilization period of 30 minutes. Before ischemia, hearts underwent a preconditioning period consisting of either no inhalation for 20 minutes (control group), or 15 minutes of either MAC desflurane or sevoflurane followed by 5 minutes of washout. Left ventricular end systolic pressure (LVESP), left ventricular end diastolic pressure (LVEDP), heart rate (HR) and maximal rate of change of ventricular pressure (dP/dt) were measured at after inhalation, before ischemia, and 5 minutes, 30 minutes and 60 minutes after reperfusion. Coronary sinus effluent also was measured. Infarct size was measured by triphenyl tetrazolium staining. Results: LVESP and dP/dt were decreased in the control group, but remained unchanged in the desflurane and sevoflurane groups during the reperfusion period. LVEDP was increased in all groups, but the magnitude of the increase was smaller in the desflurane and sevoflurane groups than in the control group during the reperfusion period. HR was increased in the control group, but remained unchanged in the desflurane and sevoflurane groups during the reperfusion period. Coronary blood flow was decreased in all groups. Infarct size for the two anesthetics were smaller than in the control group. Differences in hemodynamics was observed between the desflurane and sevoflurane group at any time. Conclusions: Desflurane and sevoflurane had similar myocardial preconditioning effects in isolated rat heart.

Background: In experimental models, several volatile anesthetics have been found to beneficially mimic ischemic preconditioning (IPC) during ischemia and reperfusion. These effects of IPC and volatile anesthetics are mediated by KATP channels, the authors examined following hypothesis: Desflurane administration before myocardial ischemia, has pharmacologic preconditioning effects on the myocardium (better functional recovory, and reduced infarct size), and these effects are mediated by KATP channel activation. Methods: Isolated Sprague-Dawley rat hearts (n = 40) were perfused at a constant pressure with oxygenated modified Kreb's solution. After a stabilization period, they were subdivided into four groups; group 1 to 4. Group 1 underwent 30 minutes of global ischemia and 60 minutes of reperfusion. Group 2 received an ischemic preconditioning period before global ischemia and reperfusion as group 1. In group 3, 6.8 vol% desflurane was added to the perfusion medium for 15 minutes and a 5 minutes wash-out period was introduced before global ischemia and reperfusion. In group 4, during the 6.8 vol% desflurane administration, glibenclamide was injected at a constant rate, before global ischemia and reperfusion. In each group, isovolumetric left ventricular pressure (LVP), heart rate and the maximun rate of change of the ventricular pressure () were measured using a thin, saline-filled latex balloon and a transducer. Coronary flow and the LDH level of effluent were measured at 5, 30, 60 minutes after reperfusion. All hearts were stained with triphenyl tetrazolium to determine infarct size. Results: Desflurane administration before global ischemia showed protective effects, like IPC, on functional recovery and infarct reduction. LVP was less depressed in group 3 and group 2. in group 2 recovered after global ischemia to some degree, but remained slightly depressed in group 3. Decreased heart rate and coronary flow were observed in groups 2, 3 and 4. LDH showed a decreasing pattern in group 2 and 3. Infarct size was smaller in groups 2 and 3 than in groups 1 and 4. These benefical effects of desflurane were blocked by glibenclamide administration. Conclusions: Desflurane was found to have beneficial effects, and mimicked IPC by preservaing LVP, reducing infarct size, and the degree of cardiac enzyme release. These beneficial effects were abolished by administering the KATP channel blocker, glibenclamide. The protecitve effects of desflurane administration against myocardial ischemia were mediated by KATP channels.

Fiberoptic bronchoscope guided tracheal intubation is more popular in patient with expected difficult intubation by conventional laryngoscopy. We report a case of smooth fiberoptic bronchoscope guided tracheal intubation under local anesthesia. A 10% lidocaine spray 2-3 puffs of pharyngolaryngeal topical anesthesia and 2% lidocaine injection through a 19 gauge epidural catheter (ARROW) placed over the fiberoptic bronchoscope suction channel for laryngeal and tracheal anesthesia were sufficient to prevent pain, coughing and nausea.

Background: Desflurane depresses the contractile function of the myocardium. It also causes direct coronary vasodilation. Milrinone, a phosphodiesterase III inhibitor, usually increases myocardial contractility and also has vasodilatory activity. Some inhalation anesthetic agents, such as isoflurane, are safely combined with phosphodiesterase III inhibitors clinically, but milrinone sometimes causes significant hypotension by reducing systemic vascular resistance. The purpose of this study was to evaluate the effect of the combined use of desflurane and milrinone on the function of the isolated rat heart. Method: Thirty isolated rat hearts were divided into two groups. [Group 1 (n = 15): desflurane, Group 2 (n = 15): desflurane and milrinone] They were perfused continuously with modified Krebs' solution in a Langendorff retrograde perfusion apparatus. After measuring the control values of the hemodynamic and oxygenation parameters in each group, we administered 6.6 vol% of desflurane to both groups and added sequential perfusion of modified Krebs' solution containing 0.5, 1.0, and 1.5/ml of milrinone in Group 2 and then measured the parameters and analyzed them statistically. Results: Baseline measurements in both groups were not statistically different. In Group 1, desflurane significantly decreased LVP (55 5 mmHg), dp/dt (557 65 mmHg/sec) and MV (71.2 16.3 ml/g/min) after 15 minutes. CF (13.9 3.1 ml/g/min) and D (176.7 43.4 ml/g/min) were increased after 15 minutes. There was no further change after this. In Group 2, desflurane decreased LVP (53 18 mmHg), dp/dt (558 90 mmHg/sec) and MV (72.0 11.0 ml/g/min) and increased CF (14.2 1.9 ml/g/min) and D (175.3 29.1 ml/g/min). But, there was no significant difference in the effects of desflurane between the two groups. Milrinone restored LVP, dp/dt and MV to the baseline level, but not with dose-dependency. Desflurane-induced elevated CF and D did not show further changes. Conclusions: These findings suggest that milrinone increased myocardial contractility and restored the desflurane-induced myocardial depression of the isolated rat heart without further increase of oxygen consumption from the baseline control value. In addition, no additive effects was observed on coronary blood flow when these two agents were used in combination.

Background: Renal dysfunction is a serious complication that sometimes occurs after on-pump coronary artery bypass grafting. Recently, the off-pump coronary artery bypass (OPCAB) is used. We investigated whether this practice can reduce renal compromise. Methods: Eighty patients underwent CABG surgery between March 2001 and March 2002. Among these, 50 patients received CABG with cardiopulmonary bypass (CPB) and 30 patients received OPCAB. The data collected included age, gender, history of diabetes, history of hypertension, history of congestive heart failuere, preoperative serum creatinine (PreCr) level, peak postoperative serum creatinine (Peak PostCr) level, preoperative and postoperative left ventriclular ejection fraction, preoperative ACE inhibitor use, perioperative angiography with contrast dye. Perioperative changes in creatinine clearance (DCrCl) were calculated using changes in the pre and postoperative serum creatinine values. Moderate postoperative renal dysfuntion was defined as a peak postoperative creatinine value of greater than 1.5 times and below 2.0 times the preoperative creatinine value. Severe postoperative renal dysfunction was defined as a peak postoperative creatinine of more than twice the preoperative creatinine value. Results: Moderate renal dysfunction was observed in 10% of patients in the on-pump group and in 17.6% of the patients in the off-pump group. Severe renal dysfunction was observed in 6.7% of patients in the on-pump group and in 5.9% of the patients in the 0ff-pump group. Multivariate liner regression analysis showed that the preoperative and immediate postoperative creatinine clearance are associated with postoperative renal dysfuntion in both groups. Conclusions: In this retrospective study, we could not confirm that OPCAB reduces perioperative renal dysfunction more so than CABG with CPB. Diabetes was found to be significantly associated with postoperative renal dysfunction in CABG with CPB.

Background: It is known that pain after a laparoscopic cholecystectomy is less compared with an open cholecystectomy. There are various methods of pain relief used but a controversy exists over the effectiveness and value of intraperitoneal local anesthetics. The aim of this study was to investigate which components of pain were more predominant for pain after a laparoscopic cholecystectomy, somatic pain or visceral pain. Methods: Twenty-four patients who received an elective laparoscopic cholecystectomy were selected. General anesthesia was induced with thiopental sodium and succinylcholine, and maintained with vecuronium and isoflurane. After surgery, the degree of postoperative somatic pain (superficial, sharp and definite in the abdominal wall) and visceral pain (dull, vague and/or colicky in the peritoneal cavity) was assessed at postoperative 1, 3, 6, 9, 24 and 36-hour by a 10 cm-visual analogue scale (VAS) scores and other complaints were recorded. Results: VAS scores of somatic pain were significantly higher than those of visceral pain at all the recorded times. Conclusions: Somatic pain was predominant after a laparoscopic cholecystectomy compared with visceral pain and it should be helpful to treat pain after a laparoscopic cholecystectomy. (Korean J Anesthesiol 2001; 41: 66-70)

Background: Ketamine enhances local anesthetic and analgesic effects of bupivacaine by peripheral mechanisms. We evaluated the additive effects of ketamine (30 mg) on 0.5%, and 0.75% ropivacaine (total 30 ml) for an interscalene brachial plexus blockade (IBPB). Methods: Thirty five adult patients scheduled for major forearm or hand surgery were prospectively randomized to receive one of the following solutions. Group 1 received 0.75% ropivacaine 28 ml with normal saline 2 ml, group 2 received 0.75% ropivacaine 28 ml with 5% ketamine 0.6 ml and normal saline 1.4 ml, group 3 received 0.75% ropivacaine 20 ml with normal saline 10 ml, and group 4 received 0.75% ropivacaine 20 ml with 5% ketamine 0.6 ml and normal saline 9.4 ml. At 1 minute intervals after IBPB, patients were assessed to determine loss of shoulder abduction, elbow flexion, wrist flexion and loss of pinprick in the deltoid, radial, median, and ulnar dermatomes. At 5 minute intervals after IBPB, pulse rate, blood pressure, sedation score and level of discomfort were assessed. Before discharge, patients were asked to document when incisional discomfort began and when full sensation and motor control returned to the arm. Results: The onset time of loss of pinprick and motor blockade were similar. Duration of sensory and motor blockade were similar in all groups. Hemodynamic changes and sedation scores were not significantly different in all groups. Conclusions: We demonstrated that 30 mg of ketamine didn't enhance the onset and duration of sensory or motor blockade of ropivacaine during the 0.75% or 0.5% ropivacaine IBPB. (Korean J Anesthesiol 2001; 40: 721∼727) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

Background: Local anesthetics are often used for a regional block in patients who are being treated with calcium channel blockers (CCB). Bupivacaine is a local anesthetic with potential for serious cardiovascular toxicity. Ropivacaine is a relatively new local anesthetic. It is clinically equipotent and chemically similar to bupivacaine. Diltiazem (CCB) is a potent coronary and systemic vasodilator with antiarrhythmic properties. Local anesthetics such as bupivacaine and ropivacaine have been suggested to show drug interactions with diltiazem. Therefore, we tried to observe the drug interactions between bupivacaine, ropivacaine and diltiazem using an animal model. Methods: This study was performed using an isolated rat heart (N = 40) by the Langendorff method. After a stabilization period, all hearts were subjected to the application of local anesthetics of a 1μg/ml or 3μg/ml concentration, respectively. Thereafter, they were subdivided into four groups; the bupivacaine (B) group, bupivacaine with diltiazem (BD) group, ropivacaine (R) group, and ropivacaine with diltiazem (RD) group. Parameters such as, LVP, dp/dt, heart rate (HR), coronary flow (CF), DO2, and MVO2 were measured. Results: All parameters decreased in all groups, respectively (P < 0.05). The BD group and R group showed a lower LVP and dp/dt than those of the B group (P < 0.05). The BD group and B group showed lower HR than that of the R group (P < 0.05). The RD group showed a higher CF than other groups (P < 0.05). Conclusions: The negative inotropic potency of bupivacaine was enhanced in the presence of diltiazem. We suggest that diltiazem has a protective effect against reduction of CF by ropivacaine. Therefore, we should consider this when selecting local anesthetics for cardiovascular patients under the treatment of diltiazem. (Korean J Anesthesiol 2001; 40: 365∼375) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

Background : The addition of various opioids to 0.5% hyperbaric bupivacaine intrathecally seems to potentiate analgesic effects of bupivacaine and to prolong the duration of analgesia. We compared the effect of intrathecal meperidine 0.25 mg/kg and 0.5 mg/kg, fentanyl 0.15 ug/kg, and placebo when administered together with 0.5% hyperbaric bupivacaine 9 mg for cesarean section. Methods : Forty-four healthy term parturients were randomly allocated (n=11 per group) to receive the test solution (1 ml) containing preservative-free normal saline (control group), fentanyl 0.15 ug/kg, meperidine 0.25 mg/kg, or meperidine 0.5 mg/kg intrathecally, immediately followed by the injection of 0.5% hyperbaric bupivacaine 9 mg. We observed the effective postoperative analgesic duration (time to VAS ≥4), quality of anesthesia and side effects. Results: The effective postoperative analgesic duration significantly increased in the groups receiving opioid compared with the control group (P < 0.05); control group 101.4 ± 28.6 min; fentanyl group 192.3 ± 27,2 min; meperidine 0.25 mg/kg group 208.8 ± 21.7 min; meperidine 0.5 mg/kg group 289.8 ± 53.6 min (data expressed as mean ± SD), The quality of anesthesia was excellent in 100% of the moperidine gorup but ill 82% of the fentanyl group and 91% of the control group. The incidence of nausea and vomiting were higher in the meperidine 0.5 mg/kg group (73%) than in the remaining groups (P< 0.05). Conolusions : The addition of fentanyl 0.15 ug/kg or meperidine 0.25 mg/kg to 0.5% hyperbaric bupivacaine 9 mg for spinal anesthesia improves intraoperative analgesia and provides analgesia into the immediate postoperative period with no adverse effects on mother or neonate. (Korean J Anesthesiol 2000; 38: 49∼57)

Background : Although visual analogue scale (VAS) is a good self-assessment method for postoperative pain, faces pain scale (FPS) may be also used as objective assessment method in patients with unavailable of VAS. We investigated the usefulness of facial rating scale (FRS), the variants of VAS and FPS, compared with VAS in postoperative adult patients. Methods : One hundred and six, ASA 1 or 2, patients undergoing elective surgery under general anesthesia were educated VAS (10 cm) and FRS. One hour after operation, patients self-reported VAS and FRS were measured in the recovery room. The scores were analyzed by Spearman's correlation and Intraclass correlation. Results : Correlations indicated a highly significant relationship between VAS and FRS (Spearman's correlation coefficient = 0.84, Intraclass correlation coefficient = 0.92, both of P < 0.01). Conclusions: FRS may be useful for self-reported pain assessment instead of VAS in postoperative adult patients. (Korean J Anesthesiol 2000; 39: 696-699)