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Background: Shoulder rotation has been shown to increase the acoustic window of ultrasound for thoracic epidural access. However, this effect of shoulder rotation has not yet been confirmed in clinical practice. Objective: This study aimed to evaluate the effects of shoulder rotation on the thoracic epidural blockade in patients with acute or chronic pain in the thoracic region. Study Design: Prospective crossover trial. Setting: Pain clinic of our university in the Republic of Korea. Methods: Forty patients aged 20 – 80 years with acute or chronic pain in the thoracic region who were scheduled to undergo thoracic epidural blockade more than twice. Interventions: The patients underwent repeated fluoroscopy-guided thoracic epidural blockade via the paramedian approach in the lateral decubitus position either with or without shoulder rotation. The primary outcome measure was the attempt time to the confirmed spread of contrast. The number of attempts, total procedure time, vertical interpedicular distance, contrast spreading length, and complications were compared between the 2 positions. Results: The median attempt times in the lateral decubitus and shoulder rotation positions were 138.8 and 132.5 seconds, respectively, and this difference was significant (P = 0.004). Compared with the lateral decubitus position, the shoulder rotation position was also associated with a significantly lower number of attempts (P = 0.03), shorter total procedure time (P < 0.001), and greater vertical interpedicular and contrast spreading distances (P < 0.001 and P = 0.02, respectively). Limitations: The operator in this study was not blinded to the patient groups. Other researchers observed the operator’s procedure and evaluated and recorded the data in an attempt to overcome this bias. However, it was difficult to completely avoid the bias. Second, epidural blockade was performed at various levels (T3–11), and the anatomical features vary among thoracic spine levels. Conclusions: The study findings demonstrate the clinical benefits of the shoulder rotation position versus the lateral decubitus position in terms of successful epidural access during thoracic epidural blockade using the paramedian approach. Key words: contrast spreading length, fluoroscopy, lateral decubitus position, paramedian approach, shoulder rotation, thoracic epidural blockade, vertical interpedicular distance

Background: Lidocaine has been used widely to prevent propofol injection pain. Various methods of administration exist, such as lidocaine premixed with propofol or lidocaine pretreatment using a tourniquet, but it is unclear which method of lidocaine administration is more effective for the prevention of injection pain of propofol LCT/MCT. The purpose of this study was to compare pretreatment of lidocaine with a tourniquet and a premixed injection of lidocaine to prevent injection pain of propofol-LCT/MCT. Methods: Patients were randomly allocated into the pretreatment group (n = 117) or the premixed group (n = 117). The pretreatment group was pretreated with 2 ml of lidocaine 2%, held with a tourniquet, before propofol-LCT/MCT injec tion. The premixed group was injected with a premixed solution of propofol-LCT/MCT and 2 ml of lidocaine 2%. To evaluate the incidence and severity of pain, spontaneous verbal expressions of pain, movement of hand, frowning, and moaning were recorded, and the patients were asked to recall their pain with the visual analogue score (VAS) 30 minutes after awakening from anesthesia. Results: Overall, injection pain occurred in 13.7% of the pretreatment group and 15.4% of the premixed group, without any statistical difference (P = 0.71). There was no difference in spontaneous verbal expressions of pain, movement of hand, frowning, and moaning between the two groups. The pain intensity (VAS) also showed no difference between the two groups (P = 0.49). Conclusions: Pretreatment of lidocaine with a tourniquet showed no more benefit to prevent injection pain of propofol LCT/MCT compared to a premixed injection with lidocaine. (Korean J Anesthesiol 2014; 66: 95-98)

Objective Postoperative pain is one of the major complaints of patients after lumbar fusion surgery. The authors evaluated the effects of intravenous patient controlled analgesia (IV-PCA) using fentanyl or sufentanil on postoperative pain management and pain-related complications. Methods Forty-two patients that had undergone surgery with lumbar instrumentation and fusion at single or double levels constituted the study cohort. Patients were equally and randomly allocated to a sufentanil group (group S) or a fentanyl group (group F) for patient controlled analgesia (PCA). Group S received sufentanil at a dose of 4 μg/kg IV-PCA and group F received fentanyl 24 μg/kg IV-PCA. A numeric rating scale (NRS) of postoperative pain was applied before surgery, and immediately and at 1, 6, and 24 hours (hrs) after surgery. Oswestry disability index (ODI) scores were obtained before surgery and one month after surgery. Opioid-related side effects were also evaluated. Results No significant intergroup difference was observed in NRS or ODI scores at any of the above-mentioned time points. Side effects were more frequent in group F. More specifically, nausea, vomiting rates were significantly higher (p=0.04), but pruritus, hypotension, and headache rates were non-significantly different in the two groups. Conclusion Sufentanil displayed no analgesic advantage over fentanyl postoperatively. However, sufentanil should be considerable for patients at high risk of GI issues, because it had lower postoperative nausea and vomiting rates than fentanyl.

Although paraganglioma (PGL), an extra-adrenal retroperitoneal pheochromocytoma (PHEO), is a rare catecholamine-secreting neuroendocrine tumor, it can cause severe hypertensive crisis during anesthesia or surgery if undiagnosed preoperatively. Extraluminal perigastric masses may be presumed to be gastrointestinal stromal tumors (GISTs) or soft tissue sarcomas even when histologic confirmation is not possible. Therefore, without a histologic diagnosis or symptoms of excessive catecholamine secretion, PGL may be mistaken for GIST. We report a case of preoperatively undiagnosed PGL which caused hypertensive crisis during anesthesia for retroperitoneal mass excision.

Background: A continuous interscalene brachial plexus block is a highly effective postoperative analgesic modality after shoulder surgery. However, there is no consensus regarding the optimal basal infusion rate of ropivacaine for a continuous interscalene brachial plexus block. A prospective, double blind study was performed to compare two different basal rates of 0.2% ropivacaine for a continuous interscalene brachial plexus block after shoulder surgery. Methods: Sixty-two patients receiving shoulder surgery under an interscalene brachial plexus block were included. The continuous interscalene brachial plexus block was performed using a modified lateral technique with 30 ml of 0.5% ropivacaine. Surgery was carried out under an interscalene brachial plexus block or general anesthesia. After surgery, the patients were divided randomly into two groups containing 32 each. During the first 48 h after surgery, groups R8 and R6 received a continuous infusion of 0.2% ropivacaine at 8 ml/h and 6 ml/h, respectively. The pain scores at rest and on movement, supplemental analgesia, motor block, adverse events and patient’s satisfaction were recorded. Results: The pain scores, supplemental analgesia, motor block, adverse events and patient’s satisfaction were similar in the two groups. Conclusions: When providing continuous interscalene brachial plexus block after shoulder surgery, 0.2% ropivacaine at a basal rate of 8 ml/h or 6 ml/h produces similar clinical efficacy. Therefore, decreasing the basal rate of CISB is more appropriate considering the toxicity of local anesthetics. (Korean J Anesthesiol 2010; 59: 27-33)

BACKGROUND: We evaluated the epidural administration of tezampanel, a non-N-methyl-D-aspartate receptor antagonist, in a rat model for postoperative pain. We sought to determine if this drug affects nociception when administered epidurally by testing its effects on responses to heat in normal rats. The effects of epidural tezampanel on pain-related behaviors in rats that underwent plantar incision were also studied. METHODS: Rats were anesthetized and epidural catheters were placed. One day after epidural catheterization, the baseline heat withdrawal latency was measured. Epidural tezampanel or morphine was tested for analgesia by examining their effects against heat withdrawal latency. Motor function was also tested. Comparisons to subcutaneous drug administration were made. Other rats underwent plantar incision after epidural catheterization to assess pain behavior caused by incision. The effects of epidural tezampanel on the cumulative pain scoring, based on guarding, the withdrawal threshold to von Frey filament application, and the withdrawal latency to heat, were measured. The effects of epidural tezampanel on arterial blood pressure and heart rate were also tested. RESULTS: Both epidural morphine and epidural tezampanel increased withdrawal latency to heat. Only subcutaneous morphine affected heat withdrawal latency. After plantar incision, epidural tezampanel decreased the median guarding pain score, increased the heat withdrawal latency and increased the mechanical withdrawal threshold indicating analgesic effects. Arterial blood pressure and heart rate did not change after epidural drug administration. CONCLUSION: These experiments demonstrate that epidural administration of tezampanel produces analgesia to heat, motor side effects in some rats, and reduces pain behaviors caused by incision. No systemic analgesia was apparent using the largest dose.

Cerebellar hemorrhage occurs mainly due to hypertension. Postoperative cerebellar hemorrhage is known to be associated frequently with frontotemporal craniotomy, but quite rare with spine operation. A 56-year-old female received spinal fixation due to continuous leg tingling sensation for since two years ago. Twenty-one hours after operation, she was disoriented and unresponsive to voice. Performed computed tomography showed both cerebellar hemorrhage. An emergency decompressive craniotomy was carried out to remove the hematoma. On the basis of this case, we reported this complications and reviewed related literature.

This case report involves tracheal intubation using i-gel® in combination with a lightwand in a patient with a difficult airway, classified as Cormack-Lehane grade 3. I-gel® was used during anesthesia induction to properly maintain ventilation. The authors have previously reported successful tracheal intubation on a patient with a difficult airway through the use of i-gel® and a fiberoptic bronchoscope. However, if the use of a fiberoptic bronchoscope is not immediately available in a patient with a difficult airway, tracheal intubation may be performed by using i-gel® and a lightwand in a patient with difficult airway, allowing the safe induction of anesthesia.

Interscalene brachial plexus block provides effective anesthesia and analgesia for shoulder surgery. One of the disadvantages of this technique is the risk of hemidiaphragmatic paresis, which can occur as a result of phrenic nerve block and can cause a decrease in the pulmonary function, limiting the use of the block in patients with reduced functional residual capacity or a preexisting pulmonary disease. However, it is generally transient and is resolved over the duration of the local anesthetic's action.We present a case of a patient who experienced prolonged hemidiaphragmatic paresis following a continuous interscalene brachial plexus block for the postoperative pain management of shoulder surgery, and suggest a mechanism that may have led to this adverse effect.Nerve injuries associated with peripheral nerve blocks may be caused by several mechanisms. Our findings suggest that perioperative nerve injuries can occur as a result of combined mechanical and chemical injuries.

Central vein catheterization is a common procedure for monitoring the central venous pressure, securing vascular access, administrating vasoactive drugs and removing air embolisms. However, many complications can occur, such as vessel injury, pneumothorax, hydrothorax, nerve injury, arrhythmia and infection at the insertion site. We encountered an unusual complication of a localized right hydrothorax that was initially misinterpreted as an atelectasis after left internal jugular vein catheterization and right lateral positioning for a left lower lobectomy.

The technique of submental intubation in patients with multiple facial fractures and skull base fracture was originally described by Altemir. This technique provides a secure airway and allows intermaxillary fixation while avoiding the complications of nasotracheal intubation or tracheostomy. However, when the endotracheal pilot balloon and endotracheal tube are pulled through the submental incision site using this technique, soft tissues or blood may enter the endotracheal tube and trauma may result in the surrounding tissues. To overcome these problems, we carried out a modification of submental orotracheal intubation using the blue cap on the end of the thoracic catheter in a patient with mandibular fractures and injury to the skull base and found that this modification resulted in a safer and less traumatic intubation.

Various methods of treatment, other than antibiotic therapy, have been proposed for the treatment of female urethral syndrome; however, the results of these treatment methods are disappointing, due perhaps to the use of the wrong treatment approach. The aim of this study was to evaluate the effectiveness of external sphincter relaxant and biofeedback (BFB) with electrical stimulation therapy (EST) in patients who do not respond well to antibiotics. One hundred and five patients with a diagnosis of female urethral syndrome were entered into this study. Antibiotics were given as a first-line therapy for about 3 months. In cases of recurrent or incurable urethral syndrome, antibiotic therapy combined with external sphincter relaxant or BFB with EST were performed. External sphincter relaxant group was composed of 31 patients (29.5%) who showed functional urethral obstruction. Biofeedback group was composed of 41 patients (39.0%) who had severe pain or discomfort with irritative voiding symptoms. Subjective symptom was measured before and after therapy using the Bristol Female Lower Urinary Tract Symptoms questionnaire. Thirty-three patients (31.4%) were treated with antibiotic therapy alone and 7 (21.2%) of these patients recurred. The symptom score of this group changed from 10.51 to 2.85. In the antibiotics plus external sphincter relaxant group (N=31), the symptom score changed from 12.39 to 3.96. Five (16.1%) of these patients recurred and 3 of these 5 underwent urethral dilatation. In the antibiotics plus biofeedback group (N=41), the average urinary frequency changed from 12.2 to 7.7 times a day and nocturia changed from 2.4 to 0.6 times a night. The symptom score improved from 15.22 to 4.69 and the overall satisfaction rate was 87.8% (41.5%: very satisfied, 46.3%: satisfied, 12.2%: no response). Female urethral syndrome is not due to a single factor but is a complex disease due to various combined symptoms and mechanisms. This condition needs to be treated with an appropriate treatment protocol. We believe that satisfactory results could be obtained in female urethral syndrome, which has shown poor prognosis until now, by appropriately combining treatment methods, which include the use of external sphincter relaxants, biofeedback therapy and bladder training, according to indication, and depending on whether symptoms continue after initial antibiotic therapy.

Background: Dexmedetomidine extends the duration of nerve block when administered perineurally together with local anesthetics by central and/or peripheral action. In this study, we compared the duration of nerve block between dexmedetomidine and epinephrine as an adjuvant to 1% mepivacaine in infraclavicular brachial plexus block. Methods: Thirty patients, scheduled for upper limb surgery were assigned randomly to 3 groups of 10 patients each. We performed brachial plexus block using a nerve stimulator. In the control group (group C), patients received 40 ml of 1% mepivacaine. In group E, patients received 40 ml of 1% mepivacaine containing 200 μg of epinephrine as an adjuvant. In group D, patients received 40 ml of 1% mepivacaine containing 1 μg/kg of dexmedetomidine as an adjuvant. Sensory block duration, motor block duration, time to sense pain, and onset time were assessed. We also monitored blood pressure, heart rate, oxygen saturation and bispectral index. Results: In group D and group E, sensory block duration, motor block duration and time to sense first pain were pro longed significantly compared to group C. However, there was no significant difference between group D and group E. Conclusions: Perineural 1 μg/kg of dexmedetomidine similarly prolonged nerve block duration compared to 200 μg of epinephrine, but slowed heart rate. Thus, dexmedetomidine is expected to be a good alternative as an adjuvant to local anesthesia in patients who are cautioned against epinephrine. (Korean J Anesthesiol 2014; 66: 283-289)

The spine surgery performed in the prone position could cause severe complications such as visual acuity impairment, spinal infarct and rhabdomyolysis. When treating rhabdomyolysis, it is important to prevent acute renal failure from accompanying rhabdomyolysis due to the poor prognosis. We have experienced two cases of rhabdomyolysis after spine surgery where dark urine was present during spine surgery under general anesthesia. Anesthesiologists should pay attention for early diagnosis and treatment of the rhabdomyolysis developing during the spine surgery.

Background: There is no assessment of internet sites that carry information on chronic pain disease. So we assessed the quality of information about postherpetic neuralgia available on Korean internet sites. Methods: The keywords 'postherpetic neuralgia', 'herpes zoster, neuropathic pain', 'herpes zoster, pain', 'herpes zoster' were searched in Korean on four search engines in Korea between the 1st to the 15th of May, 2009. We evaluated the outcome on two factors; the aspect of the contents which is subdivided into two categories, the content and authorship, and the technical aspect including web design, and efficiency. Results: A total of 26 internet sites were found. Among these sites, 6 (23%) informed by anesthesiologist. The average score of the 26 internet sites was only 37.4 20.1 out of a total of 100. A mean score of the contents was 13.3 8.3 out of 40 points, the authorship was 10.0 6.7 out of 20 points, the design was 9.2 5.3 out of 20 points, the efficiency was 6.8 4.3 out of 20 points. When comparing the score between anesthesiologist and non-anesthesiologist, the contents was 18.7 7.4 vs. 11.7 7.9, the authorship was 13.4 4.7 vs. 9.0 6.8, the design was 12.5 4.2 vs. 8.3 5.2 and the efficiency was 6.8 4.5 vs. 4.3 4.0 (P ＜ 0.05). Conclusions: There is a need for more accurate information about postherpetic neuralgia on the Korean internet by anesthesiologists.

Right internal jugular vein catheterization is performed frequently as central venous catheterization by the landmark method. This procedure, however, might prove difficulty due to anatomic variations or thrombosis of internal jugular vein. We failed to catheterize right internal jugular vein by the landmark method in 70-year-old female patient. And then, we detected right internal jugular vein thrombosis by ultrasound scan. Left internal jugular vein catheterization was performed by the ultrasound guided technique. Central venous catheterization has possibility to fail despite several attempts by the landmark method. Then, ultrasound guided approach is a good choice to aid central venous catheterization when difficulties or complications have been encountered.

Anaphylaxis is one of major causes of morbidity and mortality during anesthesia. Muscle relaxants are the most common cause of anaphylaxis during anesthesia. A 54-year-old woman was scheduled for thyroidectomy. She had no history of allergy and had never previously undergone general anesthesia, Lidocaine, propofol and vecuronium were injected sequentially to induce general anesthesia. Two minutes after the vecuronium injection, severe hypotension, tachycardia and bronchospasm developed, and delayed skin rashes appeared. The patient recovered without any significant complications after immedi ate proper intensive care. The operation was delayed and a skin test was performed on the 7 th day after discharge. She revealed a positive skin test for vecuronium. The anesthesia was re-induced without muscle relaxant and maintained with propofol and remifentanil infusion. Surgery was completed uneventfully, and the patient recovered without any adverse reaction. (Korean J Anesthesiol 2008; 55: 613～7)

Iatrogenic vertebro-vertebral arteriovenous fistula (AVF) is an uncommon complication resulting from various procedures such as central venous catheter insertion. The incidence may be underestimated since the diagnosis is not easy because of its rarity. A central venous catheterization via the internal jugular vein was attempted in a 43-year-old female who presented for intracranial aneurysmal clipping under general anesthesia. Inadvertent arterial puncture was recognized as pulsatile arterial blood flow through the needle. The needle was removed and local compression was applied to the puncture site. The catheter was inserted via the right femoral vein. After surgery, the patient recovered from anesthesia without any complications. On postoperative day 5, thrill and bruit on the right side of the neck were noted on physical examination. Angiography confirmed vertebro-vertebral AVF, which was successfully obliterated with a stent 3 months later.

Background: It is well known that the level of lactate increases in wounds, which is not necessarily caused by a limitation of oxygen delivery, so may not primarily indicate ischemia. In this study, we measured the time course of the changes in the concentrations of lactate produced by incisions at 3 different sites (hind paw, gastrocnemius muscle and paraspinal area) in order to find factors that may activate and sensitize the nociceptors at the incision sites. Methods: Incisions were made in either one side of plantar aspect of hind paw, paraspinal area or gastrocnemius muscle. The other side of each rat received a sham incision. Microdialysis fibers were inserted into the incisional area and sham incisional side of each rat on postoperative days 0, 1, 2, 4, 7 (8), 10 and 14. The concentrations of tissue lactates were then measured and compared. Results: In the hind paw, the concentration of tissue lactate increased on the day of incision and on postoperative days 1 through 7, but was no different to that of the control paw on days 10 and 14. In the gastrocnemius muscle, the lactate concentration increased on postoperative days 1 through 4, and the paraspinal lactate also increased on the day of incision and on postoperative days 1 through 8, but had normalized by postoperative day 14. Conclusions: These data suggest that tissue lactate level increases after incisions, and is in part, parallel to the pH and pain behaviors caused by the incisions. Together, high lactate and low pH may contribute to incisional pain.

We report a case of myxoid sarcoma in the left atrium, which was diagnosed as benign myxoma on preoperative echocardiography. At operation, semisolid mobile masses were found that attached with broad stalk to the posterior left atrial wall and that invaded into the left pulmonary vein and the anterior mitral leaflet. The patient underwent excision of left atrial tumor masses, mitral valve replacement, and left pneumonectomy. The histological diagnosis was undifferentiated cardiac myxoid sarcoma. Although echocardiography lead to the choice of diagnostic test of intra-atrial tumor, magnetic resonance imaging, computed tomography, and intraoperative transesophageal echocardiography may be needed for differential diagnosis, with indeterminate malignant findings on preoperative transthoracic echocardiography. Anesthesiologists are often confronted with cases that are unusual, therefore preoperative understanding of the cases are important for safe anesthetic management.