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If cardiac sympathetic activity increases after myocardial injury, a ventricular electrical storm (VES) may occur. The stellate ganglion block is a minimally invasive technique performed to control VES through temporary sympathetic cessation. This case was treated after 3 stellate ganglion blocks in VES developed after non-ST elevation myocardial infarction. This patient underwent prophylactic stellate ganglion block prior to radical nephrectomy for a renal mass found during hospitalization, and the operation was safely completed. Stellate ganglion block is expected to be a safe treatment option for patients with unstable VES.

Purpose: Adenosine monophosphate-activated protein kinase (AMPK) is thought to inhibit cell proliferation or promote cell death, but the details remain unclear. In this study, we propose that AMPK inhibits the expression of anti-apoptotic B-cell lymphoma 2 (Bcl-2) by relying on the hypoxia-inducible factor 1 alpha (HIF-1α)-induced caveolin-1 (Cav-1) expression pathway in noninvasive human bladder tumor (RT4) cells.Methods: In cells exposed to a hypoxic environment (0.5% oxygen), the levels of expression and phospho-activity of the relevant signaling enzymes were examined via Western blots and reverse transcription-polymerase chain reaction. Cell proliferation was assessed using a Cell Counting Kit-8 assay.Results: The level of expression of Cav-1 was very low or undetectable in RT4 cells. Hypoxia was associated with significantly decreased cell growth, along with marked induction of HIF-1α and Cav-1 expression; additionally, it suppressed the expression of the antiapoptotic marker Bcl-2 while leaving AMPK activity unchanged. Under hypoxic conditions, HIF-1α acts as a transcription factor for Cav-1 mRNA gene expression. The cell growth and Bcl-2 expression suppressed under hypoxia were reversed along with decreases in the induced HIF-1α and Cav-1 levels by AMPK activation with metformin (1mM) or phenformin (0.1mM). In addition, pretreatment with AMPK small interfering RNA not only increased the hypoxia-induced expression of HIF-1α and Cav-1, but also reversed the suppression of Bcl-2 expression. These results suggest that HIF-1α and Cav-1 expression in hypoxic environments is regulated by basal AMPK activity; therefore, the inhibition of Bcl-2 expression cannot be expected when AMPK activity is suppressed, even if Cav-1 expression is elevated.Conclusions: For the first time, we find that AMPK activation can regulate HIF-1α induction as well as HIF-1α-induced Cav1 expression, and the hypoxia-induced inhibitory effect on the antiapoptotic pathway in RT4 cells is due to Cav-1-dependent AMPK activity.

Rationale: Idiopathic ventricular tachycardia (VT) occurs in individuals without structural abnormalities in the heart, accounts for approximately 10% of total VTs. Furthermore, approximately 70% of idiopathic VTs originate from Right ventricular outflow tract (RVOT). However, among perioperative arrhythmias, incidence of VT after surgery is extremely rare and most arrhythmias are atrial origin. Patient concerns: A 69-year-old man with permanent pacemaker underwent colon surgery. Diagnoses: Patient suffered from low blood pressure and dizziness, sweating at post anesthetic care unit (PACU) and heart rate (HR) increased suddenly to 200 beats/min with monomorphic VT after bolus ephedrine administration and continuous dopamine infusion. Interventions: Pacemaker interrogation followed by DC cardioversion was done. Outcomes: Patient's vital signs became normal and symptoms are subsided. Lessons: RVOT VT can be caused by triggering activities, such as ephedrine, dopamine, and inadequate fluid management. These triggering activities are initiated by acceleration of HR from ventricles with infusion of catecholamine which lead monomorphic VT originating from RVOT. RVOT origin PVCs can be precipitated into monomorphic VT by administrating catecholamines such as ephedrine and dopamine even in patient with pacemaker. The mechanism of these VTs includes catecholamine induced acceleration of HR. Since RVOT PVCs can be recognize by 12 EKGs, we should be pay more attentions to the pre-operation EKG and be cautious using catecholamines.

One-third of all hospital-regulated medical waste (RMW) comes from the operating room (OR), and it considerably consists of disposable packaging and wrapping materials for the sterilization of surgical instruments. This study sought to identify the amount and type of waste produced by ORs in order to reduce the RMW so as to achieve environmentally-friendly waste management in the OR. We performed an initial waste segregation of 4 total knee replacement arthroplasties (TKRAs) and 1 total hip replacement arthroplasty, and later of 1 extra TKRA, 1 laparoscopic anterior resection of the colon, and 1 pelviscopy (with radical vaginal hysterectomy), performed at our OR. The total mass of non-regulated medical waste (non-RMW) and blue wrap amounted to 30.5 kg (24.9%), and that of RMW to 92.1 kg (75.1%). In the course of the study, we noted that the non-RMW included recyclables, such as papers, plastics, cardboards, and various wrapping materials. The study showed that a reduction in RMW generation can be achieved through the systematic segregation of OR waste.

Diffuse refractory vascular spasms associated with coronary bypass artery grafting (CABG) are rare but devastating. A 42-year-old male patient with a past history of stent insertion was referred for the surgical treatment of a recurrent left main coronary artery disease. A hemodynamic derangement developed during graft harvesting, necessitating a hurried initiation of cardiopulmonary bypass (CPB). Although CABG was carried out as planned, the patient could not be weaned from the bypass. An emergency coronary angiography demonstrated a diffuse spasm of both native coronary arteries and grafts. CPB was switched to the femorofemoral extracorporeal membrane oxygenator (ECMO). Although he managed to recover from heart failure, his discharge was delayed due to the ischemic injury of the lower limb secondary to cannulation for ECMO. We reviewed the case and literature, placing emphasis on the predisposing factors and appropriate management.

Purpose: The frequency of thoracic endovascular aortic repair (TEVAR) is increasing due to lower morbidity and mortality than that of open repair. The aim is to evaluate the results of TEVAR in patients with thoracic aortic disease. Methods: Twenty seven patients have undergone TEVAR from October, 2003 to November, 2012. Aortic diagnoses were 7 descending thoracic aortic aneurysms, 6 acute descending aortic dissections, 6 traumatic aortic transactions, 4 aortic arch aneurysms, 2 chronic descending aortic dissections, and 2 penetrating aortic ulcers (PAU). Multi detector computerized tomography (MDCT) aortography was done at one week, one month, six months, and one year interval. Results: Indications for TEVAR were aortic diameter of more than 5.5 cm in 9 patients, traumatic aortic transaction in 6, persistent chest pain in 4, increasing aortic diameter during follow-up period in 3, aneurysm rupture in 3, and PAU more than 2 cm in 2. Hybrid TEVAR was done in 7 patients. Primary technical success, showing complete aneurysmal exclusion, was done except in one patient (96%). There was one operation death (4%). Two patients developed perioperative stroke, but recovered without sequelae. MDCT was done during the mean of 18 months (range, 1 to 98 months) follow-up period. Small type I endoleak was found in two patients (7%), and type III endoleak was found in a patient (4%). Stent graft migration was in one patient. There was no aorta related deaths during the follow-up period. Conclusion: Intermediate term result of TEVAR in patients with thoracic aortic aneurysmal disease was encouraging. It may be used as a treatment option for thoracic aortic disease.

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.

We performed a pharmacogenetic study to analyse the correlation between the clinical responses to ondansetron during a 24-h postoperative period and two single nucleotide polymorphisms (−100_–102 delAAG and ins/delCA) in the serotonin receptor type 3B gene (HTR3B) in 280 Korean patients with tonsillectomy (TS, n=108) or surgery because of gynaecological problems (GY, n=172). The effect of CA/CA homogyzous variant of the ins/delCA allele on lowering the prevention of postoperative vomiting was significant, particularly during the initial 2 h postoperative period (P=0.034) and in the GY group (P=0.013 for complete response and P=0.009 for prevention of vomiting). However, we failed to detect a significant effect of genotypes for the −100_–102delAAG allele during our observation period. Our results suggest that ins/delCA polymorphism in the HTR3B may have clinical relevance to the expected clinical response to prevent postoperative vomiting in patients treated with ondansetron.

Background The sitting position has potential for serious complications such as cerebral ischemia and venous air embolism. This study investigated the effects of intermittent sequential compression device (SCD) on the changes in regional cerebral oxygen saturation (rSO2) during the sitting position. Methods Sixty-six healthy patients undergoing shoulder arthroscopy in sitting position were randomly assigned to either control (N = 33) or SCD (N = 33) groups. Hemodynamic variables and the rSO2 were measured 5 minutes after the induction of anesthesia (Tsupine, baseline values), and 1, 3, and 5 minutes after raising the patient to a 70-degree sitting position (T1, T3, and T5). The incidence of hypotension was recorded. Results The incidence of hypotension was significantly higher in the control group (8/33) than that in the SCD group (1/33) (P = 0.027, odds ratio 0.170, 95% CI 0.042-0.684). The rSO2 was significantly higher in the SCD group compared with those in the control group at T3 and T5. Within the group, rSO2 decreased significantly only in the control group compared with baseline value at T1, T3, and T5. The % change in rSO2 from T0 to T1, T3, and T5 were significantly lower in the SCD group compared to those in the control group. Conclusions The application of SCD to the lower extremities during sitting position under sevoflurane anesthesia was a simple and effective method to attenuate the decrease in cerebral oxygen saturation.

www.ekja.org Background: A prospective, double blind study was performed to compare the clinical effect of vertical infraclavicular and supraclavicular brachial plexus block using a nerve stimulator for upper limb surgery. Methods: One hundred patients receiving upper limb surgery under infraclavicular or supraclavicular brachial plexus block were enrolled in this study. The infraclavicular brachial plexus block was performed using the vertical technique with 30 ml of 0.5% ropivacaine. The supraclavicular brachial plexus block was performed using the plumb bob technique with 30 ml of 0.5% ropivacaine. The block performance-related pain was evaluated. This study observed which nerve type was stimulated, and scored the sensory and motor block. The quality of the block was assessed intra-operatively. The duration of the sensory and motor block as well as the complications were assessed. The patient’s satisfaction with the anesthetic technique was assessed after surgery. Results: There were no significant differences in the block performance-related pain, frequency of the stimulated nerve type, evolution of sensory and motor block quality, or the success of the block. There were no significant differences in the duration of the sensory and motor block. There was a significant difference in the incidence of Horner’s syndrome. Two patients had a pneumothorax in the supraclavicular approach. There were no significant differences in the patient’s satisfaction. Conclusions: Both infraclavicular and supraclavicular brachial plexus block had similar effects. The infraclavicular approach may be preferred to the supraclavicular approach when considering the complications. (Korean J Anesthesiol 2010; 58: 260-266)

P-glycoprotein (PGP) is a polymorphic transporter encoded by the ABCB1 gene that contributes to the access of xenobiotics into the brain. There is no report on associations between genetic polymorphisms in ABCB1 and the clinical effects of fentanyl, although fentanyl may be a substrate of PGP. One hundred and twenty-six (126) unrelated Korean patients under spinal anesthesia with intravenous fentanyl (2.5 lg/kg) were recruited. Clinical effects (bispectral index, respiration rate, and need for oxygen supplementation) were monitored and these were compared between genotypes for three single nucleotide polymorphisms in ABCB1 (1236C4T, 2677G4T/A, and 3435C4T). The allele and genotype frequencies were similar to previous data from Asians; the three major haplotypes, TTT (30%), TGC (24%), and CGC (24%) were expected among nine known haplotypes. During the initial 10 min, there were differences in suppression of respiration rate by fentanyl among the three genotypes (P ¼ 0.0933 for 1236C4T; P ¼ 0.0941 for 2677G4A/T; P ¼ 0.0013 for 3435C4T, repeated-measures analysis of variance), but the differences in bispectral index among genotypes were not observed. Furthermore, patients carrying the linked 3435T and 2677T alleles showed a significant difference in the level of respiratory suppression (P ¼ 0.0056); those with genotypes susceptible to fentanyl (1236TT, 2677TT, and 3435TT) showed early (2–3 min) and profound suppression of respiration (65–73% of initial respiration rate) compared with other resistant genotypes (83–85% of initial respiration rate in 1236CC, 2677GG, and 3435CC). Although the need to supply oxygen was not significantly different between genotypes, there was a trend for increased demand by patients carrying both 1236T and 3435T alleles (P ¼ 0.0847). In conclusion, our results confirm ABCB1 genotype data for Koreans and suggest that analysis of ABCB1 polymorphisms may have clinical relevance to prevent respiratory suppression by intravenous fentanyl or to anticipate its clinical effects. P-glycoprotein (PGP), a member of the superfamily of adenosine triphosphate-binding cassette (ABC) transporters, is encoded by the multidrug resistance gene ABCB1 and is an integral membranous protein that actively pumps substrates out of the intracellular compartment. PGP is produced in numerous normal tissues including the gastrointestinal tract, blood–brain barrier, and other barrier tissues involved in the disposition of xenobiotics. 1–5 The abundant expression of PGP in brain capillary endothelial cells might contribute to the limited access of xenobiotics into the central nervous system. Using well-known PGP substrates and/or inhibitors, many investigators presented evidences of which PGP plays an important role in distribution of xenobiotics into the brain. In those experiments using PGP-deficient mdr1

Objective This study was designed to evaluate the serial haemodynamic changes during coronary artery anastomoses using two deep pericardial stay sutures and octopus tissue stabilizer in patients undergoing initial experiences of off-pump coronary artery bypass graft surgery (OPCAB) using continuous cardiac output and mixed venous oxygen saturation (SvO(2)) monitoring. Methods With IRB approval, thirty patients undergoing OPCAB were studied. Pulmonary artery catheter (PAC) for continuous cardiac output and SvO(2) monitoring was inserted before anaesthesia. Haemodynamic measurements were recorded after pericardiotomy for baseline value. During each coronary artery anastomosis, haemodynamic variables were measured at 1,3,5,10, and 15 min after the application of tissue stabilizer and after the removal. Vasopressors were used to maintain mean arterial pressure (MAP) higher than 60 mmHg. Results MAP and heart rate (HR) were maintained without significant change during the anastomoses of all three arteries. Cardiac index (CI), and SvO(2) decreased significantly after stabilizer application in all three arteries. CI was below 2.5 l/min/m(2) and SvO(2) was under 70% during left circumflex artery (LCX) anastomosis. The decrease in CI and SvO(2) were significantly greater during LCX anastomosis. The increase in mean pulmonary artery pressure (MPAP) and pulmonary capillary wedge pressure (PCWP) was significant only in left anterior descending artery (LAD). Central venous pressure (CVP) increased significantly during the anastomosis of all three coronary arteries. The differences in MPAP, PCWP and CVP among the three coronary arteries were not statistically significant. The highest dose of vasoconstrictor was used during LCX anastomosis. Conclusions When the coronary anastomoses were performed with two deep pericardial stay sutures and octopus tissue stabilizer on the beating heart, CI and SvO(2) decreased significantly during all coronary artery anastomoses immediately after the stabilizer application and the degree of reduction in CI and SvO(2) increased with time, though MAP was maintained constantly. CI and SvO(2) during LCX anastomosis were consistently below normal values. Therefore close monitoring and proper managements are needed during graft anastomoses.

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.

Background Carbon dioxide insufflation during laparoscopic surgery results in an acid–base imbalance. The purpose of this study was to investigate the effect of pneumoperitoneum on the acid–base status using Stewart’s approach. Methods Thirty patients undergoing abdominal surgery were allocated to the laparotomy group (n=15) or the laparoscopy group (n=15). The acid–base parameters were measured 10 min after the induction (T1), 40 min after opening the peritoneum or pneumoperitoneum according to the group (T2), at the end of the surgery (T3), and 1 h after the surgery (T4). Results There were no significant differences in the standard base excess (SBE), strong ion gap, or anion gap between the two groups. In both groups, the SBE decreased at T2, T3, and T4 compared with baseline value. At T3 and T4 in the laparotomy group, the apparent strong ion difference (SIDa) and pH were decreased whereas the lactate and chloride were increased compared with their baseline values. At T2 in the laparoscopy group, the pH was decreased whereas Pa co 2 was increased compared with their baseline values. Conclusions The decrease in the pH during the pneumoperitoneum was affected by the increase in Pa co 2, which promptly returned to a normal value after the desufflation. On the other hand, the decrease in the pH after laparotomy was affected by the metabolic factors, which persisted an hour after the surgery.

Objective: Redistribution hypothermia adversely affects hemodynamics and postoperative recovery in patients undergoing cardiac surgery. In off-pump coronary bypass surgery (OPCAB), maintaining the temperature is important because warming by cardiopulmonary bypass is omitted. Prewarming studies reported earlier showing prewarming as an effective means of preventing redistribution hypothermia was time consuming since it required at least 1—2 h to prewarm the patients before the surgery. Because prewarming for such a long time is impractical in clinical practice, this study evaluated the efficacy of active warming during the preanesthetic period for the prevention of redistribution hypothermia in the early operative period of OPCAB. Methods: After gaining the approval of Institutional Review Board and informed consent from the patients, 40 patients undergoing OPCAB were divided into control and prewarming groups. The patients in control group (n = 20) were managed with warm mattresses and cotton blankets, whereas patients in prewarming group (n = 20) were actively warmed with a forced-air warming device before the induction of anesthesia. Hemodynamic variables and temperature were recorded before anesthesia (Tpre) and at 30 min intervals after anesthesia for 90 min (T30, T60, and T90). Results: Active warming duration was 49.7 � 9.9 min. There were no statistically significant differences in skin temperature, core temperature and hemodynamic variables between the two groups at preinduction period except for mean arterial pressure and central venous pressure. The core temperature at T30, T60, and T90 was statistically higher in prewarming group than that in control group. Core temperature of six (30%) and seven patients (35%) in control group was reduced below 35 8C at T60 and T90, respectively, whereas core temperature of only one patient (5%) in prewarming group was reduced below 35 8C at T90 (P = 0.02). Conclusions: Active warming using forced air blanket before the induction of anesthesia reduced the incidence and degree of redistribution hypothermia in patients undergoing OPCAB. It is a simple method with reasonable cost, which does not delay the induction of anesthesia nor the surgery. # 2005 Elsevier B.V. All rights reserved.

Background. Jugular bulb oxygen saturation (Sjvo2) is a surrogate marker for global cerebral oxygenation. The effect of milrinone on Sjvo2 and the cerebrovascular carbon dioxide reactivity (CCO2R) was investigated. Methods. Thirty patients scheduled for coronary artery bypass graft surgery (CABG) were studied prospectively. After sternotomy, normoventilation (at T1; Paco2=4.7–5.0 kPa) and hyperventilation (at T2; Paco2=3.3–3.7 kPa) were induced and the changes in Sjvo2 (Paco2) and P a 2 ( Δ P a 2 ), and Δ S j 2 / Δ P a 2 (CCO2R) were measured. After normoventilation was re-established (at T3), milrinone 50 μg kg−1 was given (at T4), followed by hyperventilation (at T5), and Δ S j 2 , Δ P a 2 and CCO2R were measured. Results. After milrinone administration at normoventilation (T3 and T4), cardiac index and mixed venous oxygen saturation increased, while mean arterial pressure and systemic vascular resistance index decreased, without a significant change in S j 2 . Before milrinone administration (T1 and T2), hyperventilation decreased P a 2 and S j 2 , and Δ S j 2 showed positive linear correlation with Δ P a 2 . After milrinone administration (T4 and T5), hyperventilation decreased P a 2 and S j 2 , and Δ S j 2 showed positive linear correlation with Δ P a 2 . There was no significant difference in CCO2R before and after milrinone administration (13.3 (5.7)% kPa−1 and 12.3 (3.9)% kPa−1, respectively). Conclusions. Although milrinone induced significant haemodynamic changes, S j 2 and CCO2R were unchanged during its administration.

Summary The haemodynamic effects of a continuous infusion of milrinone without an initial bolus dose were evaluated in patients undergoing off-pump coronary artery bypass graft surgery. After internal mammary artery harvest, milrinone 0.5 μg.min−1.kg−1 (29 patients) or a normal saline infusion (33 patients) was started and continued until all graft anastomoses were completed. Haemodynamic variables were recorded before application of the tissue stabiliser, at 1, 3, 5 and 10 min after the application of the stabiliser, and after its removal. The administration of a milrinone infusion was associated with a smaller decrease in cardiac output and mixed venous oxygen saturation during all the coronary artery anastomoses, with no severe complications and a decreased dose of norepinephrine infused to maintain systemic arterial pressure.

Methods and results We report here with a case corresponding to the above disease entity, in which pulmonary veins were drained into a separate posterior chamber, which was connected to the common atrium, thus forming cor triatriatum. A 42-yearold Asian female was consulted for operation of p-ECD and PLSVC, which were detected during the evaluation of complete heart block. She complained of worsening dyspnea and syncope attack for recent one year. The PLSVC had no connection with right sided SVC and was thought to be drained into the left atrial roof directly. The operation was carried out under standard hypothermic cardiopulmonary bypass. A large common atrium without septal remnant was encountered on opening right atrium. The coronary sinus opening was absent and PLSVC was directly drained into atrial roof, to the right of the left atrial appendage. An opening measuring 3x3cm, which at first was confused as atrial septal defect, was seen to the right of PLSVC. An accessory chamber, draining all four pulmonary veins was connected to the common atrium by this opening. After closing mitral valve cleft, a generous intraatrial patch made of bovine pericardium was used to partition the common atrium. The opening connecting pulmonary venous chamber to the atrium was widely extended inferiorly and the upper part of the opening was partly closed to minimize distortion of the patch. The left atrial appendage was also incorporated into the right side of patch to simplify the baffling procedure. The tricuspid annuoplasty was carried out and permanent epicardial pacemaker was implanted n the end. The patient recovered without events.

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.

Continuous epidural analgesia is commonly used for chronic pain treatment as well as postoperative pain control. Epidural abscess is rare, but it is a serious complication of the continuous epidural analgesia, which leads to neurologic sequelae. Epidural catheter was inserted to a 87-year-old woman who complained of postherpetic neuralgia from T6 dermatome for continuous epidural analgesia. Two weeks later, neuralgia was aggravated along with back pain and tenderness around catheter insertion area. ESR and CRP level was also elevated. Epidural abscess was detected on MRI scan right after removal of catheter. It has been improved with percutaneous drainage via Tuohy needle with antibiotics without need for surgery. We conclude that percutaneous drainage with antibiotics is an effective method for the treatment of early diagnosed epidural abscess without neurologic deficit, especially in the high risk patients for operation. (Korean J Anesthesiol 2008; 54: 123∼6)

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)

Background: Left-to-right shunt through patent ductus arteriosus (PDA) produces significant hemodynamic and respiratory derangements in premature infants. Combined diseases in these patients often preclude attempts to close the PDA medically with indomethacin. Recently, the efficacy of early surgical closure performed in neonatal intensive care unit (NICU) rather than in operating room (OR) has been emphasized to reduce the risks of transferring unstable infants. Therefore, we reviewed the anesthetic management and clinical status of premature infants who underwent early surgical closure of PDA in NICU. Methods: Between 2001 and 2007, we reviewed retrospectively 17 premature infants with extremely low birth weight below 1,500 g and 33 weeks gestational age who underwent early ligation of PDA in NICU with left axillary minithoracotomy. Results: The mean gestational age and weight of infants were 29.4 ± 1.8 (26 +3 − 32) weeks and 849 ± 165 (450 − 1,080) g. Most of the infants had complications related to PDA and prematurity. Diastolic blood pressure and pulse oxymetry saturation changed with ligation of PDA from 27.4 ± 5.3 mmHg and 96.3 ± 2.9% to 38.1 ± 10.0 mmHg and 93.8 ± 2.6%, respectively. The body temperature didn’t show significant alterations. There was no direct procedure-related death although threeinfants died from pneumonia and sepsis at 29, 30 and 34 days postoperatively. Conclusions: Performing early PDA ligation in NICU was demonstrated to be safe and effective, especially in terms of providing continuous care and avoiding the risk of hypothermia. (Korean J Anesthesiol 2008; 54: 53∼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: The effect of a single nucleotide polymorphism (SNP) of the μ-opioid receptor gene at nucleotide position 118 (OPRM1:118A ＞ G) and the MDR1 gene (exon 26: C3435T) have an influence on the interindividual variability of clinical opioid pain therapy. This study aims to evaluate the correlation among pain control and side effects of epidural morphine and these pharmacogenetic modulators. Methods: 194 patients who were undergoing abdominal surgery were included in the study. Patients received a morphine 2 mg bolus and 2 mg/day via epidural route. The VAS score and opioid side effects were checked at postoperative 6, 24 and 48 hr. Patients were genotyped for the known SNPs of the OPRM1 and MDR1. Results: For the SNP of OPRM1, the mutated genotype frequency (homo-wild, heterozygous, and homo-mutants) were 36.8, 47.9 and 15.3%, respectively, and the mutated genotype frequencies for the MDR1 SNP were 46.7, 40.2 and 13.1%, respectively. There were no significant differences in the VAS scores and side effects among the three groups of OPRM1 and MDR1. Yet carriers of the mutated allele 3435 TT, CT of the MDR1 gene showed marginally greater significant sedation effects than did non-carriers (CC) (P = 0.065, the OR was 1.78, 95% CI 0.98-3.24, P = 0.059) and also a lower incidence of analgesic usage (P =0.058). Conclusions: In our data there was a large difference in OPRM1 SNP allele frequency for the Korean population compared to other populations. The SNP of OPRM1 and MDR1 genes did not have significant altered clinical morphine analgesia and side effects via the epidural route. But the SNP of MDR1 gene is more sensitive genetic predictor of the clinical side effects (especially for sedation) and analgesic effects by opioid. (Korean J Anesthesiol 2007; 52: 16~22)

Menkes disease, socalled kinky hair disease or steely hair disease, is a rare Xlinked recessive disorder of intracellular copper transport protein ATP7A defect, due to mutation of ATP7A gene, resulting in copper deficiency. It is characterized by seizure, retarded neurological development, kinky hair, skeletal abnormality, recurrent infection and subnormal body temperature. In addition, gastroesophageal reflux with the risk of aspiration is another important feature. This article is the first report of anesthetic management in a patient with Menkes disease who underwent gastrostomy and bladder diverticulectomy in Korea.

Background: A correlation between a T-type voltage activated calcium channel (VACC) and pain mechanism has not yet been established. The purpose of this study is to find out the effect of ethosuximide and mibefradil, representative selective T-type VACC blockers on postoperative pain using an incisional pain model of rats. Methods: After performing a plantar incision, rats were stabilized on pl astic mesh for 2 hours. Then, the rats were injected with ethosuximide or mibefradil, intraperitoneally and intrathecally. The level of withdrawal threshold to the von Frey filament near the incision site was determined and the dose response curves were obtained. Results: After an intraperitoneal ethosuximide or mibefradil injection, the dose-response curve showed a dose-dependent increase of the threshold in a withdrawal reaction. After an intrathecal injection of ethosuximide, the threshold of a withdrawal reaction to mechanical stimulation increased and the increase was dose-dependent. After an intrathecal injection of mibefradil, no change occurre d in either the threshold of a withdrawal reaction to mechanical stimulation or a dose-response curve. Conclusions: The T-type VACC blockers in a rat model of postoperative pain showed the antihyperalgesic effect. This effect might be due to blockade of T-type VACC, which was distributed in the peripheral nociceptors or at the supraspinal level. Further studies of the effect of T-type VACC on a pain transmission mechanism at the spinal cord level would be needed. (Korean J Pain 2007; 20: 92�� 99)

Vasopressin, an extremely potent vasoconstrictor, has been widely used for surgical hemostasis in gynecological practices. But, Intramyometrial infiltration of vasopressin is not free of side effects and may cause lethal complications including pulmonary edema, myocardial infarction, and cardiac arrest in spite of infrequency of reported cases. Sudden cardiac arrest was encountered just after intramyometrial injection of vasopressin in our patient undergoing dilation and curettage. We believe that this awful complication was due to baroreflex-mediated regulation of blood pressure, caused by unintentional penetration of vasopressin into the vessels. We herewith discuss the complications of the local injection of vasopressin and the safe dose of vasopressin for intramyometrial injection. (Korean J Anesthesiol 2007; 53: 664～7)

Background: It is generally known that neuraxial anesthesia for adults reduces the demand for hypnotics needed for adequate sedation. Therefore, this study examined the effect of a preoperative caudal block on the general anesthetic requirements for an adequate depth of anesthesia in children. Methods: Twenty children aged 3-5 years, who were set to undergo inguinal herniorraphy, were divided into 2 groups of 10 children each, normal saline and lidocaine groups. Tracheal intubation was performed. After setting up the bispectral index (BIS) monitor, a caudal block was administered to both groups differently, normal saline 0.7 ml/kg was administered to the normal saline group and 1.5% lidocaine 0.7 ml/kg was administered to lidocaine group. The end-tidal concentration of sevoflurane was maintained at 1.5 vol% for 10 minutes in the first patient in both groups, and the BIS value, was measured 6 times every 10 seconds, and averaged. When the BIS was ≥ 50, the end-tidal concentration of sevoflurane was increased by 0.2 vol% in the subsequent patient. When the BIS was less than or equal to 50, the end-tidal concentration of sevoflurane was decreased by 0.2 vol% in the subsequent patient. The MACBIS50 in both groups was calculated using probit analysis. Relative median potency analysis was used to compare the results in both groups. Results: The MACBIS50 of sevoflurane was significantly lower with a 1.5% lidocaine caudal block (1.40 vol% [95% CI, 1.25-1.55 vol%]) compared with the normal saline group (1.77 vol% [95% CI, 1.61-2.00 vol%]). Conclusions: A preoperative caudal block reduces the demand for sevoflurane required for an adequate depth of anesthesia, as measured by the BIS in children. (Korean J Anesthesiol 2007; 52: 29～33)

Postoperative hepatotoxicity may develop from many causes. One of them is direct injury to the liver cell due to anesthetic agents. Each agent has different hepatotoxic risk. Sevoflurane is known to have a very low potential for hepatotoxicity. We report a case of severe hepatic dysfunction after anesthesia with sevoflurane in a pediatric patient who underwent cardiopulmonary bypass surgery.

Combination of propofol and remifentanil is an ideal regimen for total intravenous anesthesia, and the bispectral index (BIS) has been used as an indicator of the sedative state during anesthesia. This study examined the effect of remifentanil on the mean arterial pressure (MAP), heart rate (HR) and BIS to laryngoscopy and tracheal intubation with 4μg/ml of fixed target effect-site concentration infusion of propofol. Methods: In this double-blind study, fifty-one ASA physical status I-II patients, aged 20−60 yr undergoing elective surgery were randomly assigned to one of four groups according to the target effect-site concentration of remifentanil (0, 2, 3, 4 ng/ml). The target-controlled infusion (TCI) of remifentanil was initiated after the effect-site concentration of propofol was maintained with 4μg/ml. After target effect-site concentration of remifentanil was reached, a neuromuscular blockade was produced by rocuronium 1 mg/kg and tracheal intubation was performed after 90 seconds. MAP, HR and BIS were measured at pre-induction, after reaching target effect-site concentration of propofol and remifentanil, before and after tracheal intubation. Results: The changes of MAP, HR and BIS after tracheal intubation were negatively correlated with remifentanil effect-site concentration. Conclusions: Remifentanil attenuated the hemodynamic responses due to tracheal intubation and decreased BIS after tracheal intubation in a comparable dose-dependent fashion.

Background: Postoperative nausea and vomiting (PONV) are common problems in patients undergoing general anesthesia. Ondansetron is widely used for this problems. But, some patients treated with ondansetron do not respond to therapy. We hypothesized that patients with genetic variation in receptor and CYP2D6 gene might respond differently to ondansetron treatment. Methods: 135 patients undergoing gynecologic surgery were given 4 mg ondansetron 15 min before extubation. The assessment of PONV was performed during AAG deletion mutation, the incidence of nausea and vomiting

Background: Combination of propofol and remifentanil is an ideal regimen for total intravenous anesthesia. The purpose of this study is to determine the effect-site concentration of remifentanil for prevention of hemodynamic responses to tracheal intubation during fixed propofol infusion (4g/ml) and to find any sexual differences. Methods: Thirty ASA physical status I-II patients undergoing general anesthesia were assigned to male (n = 15), and female (n = 15) group. All patients received a target controlled infusion (TCI) of propofol with a fixed effect-site concentration of 4g/ml. After target effect-site concentration of propofol and remifentanil was reached, tracheal intubation was performed. The hemodynamic changes (systolic/diastolic blood pressure, mean arterial pressure, and heart rate) were measured at 1 and 2 min before tracheal intubation (baseline), immediately after, 1, 2, 3, 4 and 5 min following tracheal intubation. In both groups, effect-site concentration of remifentanil was initiated with 3 ng/ml. Subsequent concentration of remifentanil was determined by hemodynamic responses of the previous patient to tracheal intubation based on up and down sequential allocation. Results: The mean EC50 of remifentanil for prevention of hemodynamic responses to tracheal intubation were 1.37 ng/ml (95% CI, 0.95-1.81 ng/ml) in male group and 1.05 ng/ml (95% CI, 0.68-1.40 ng/ml) in female group, respectively. In addition, there were no statistical significant differences between two groups. Conclusions: Relatively small dosages of remifentanil (0.68-1.81 ng/ml) for attenuation of hemodynamic responses to tracheal intubation was needed in Korean population in propofol TCI and there were no sexual differences.

In patients undergoing cardiac surgery, unintentional systemic hypothermia causes peripheral vasoconstriction and thus increases myocardial afterload, and coagulopathy and postoperative bleeding can also occur. In the field of cardiac surgery, the performance of off-pump coronary artery bypass graft surgery (OPCAB) has become more frequent, and active temperature control management has become one of the important parts of anesthetic management for OPCAB. However, elevating room temperature, warming intravenous fluids, and heating ventilator gases have limited effect. There have been numerous reports that active warming before anesthesia reduces the core-to-peripheral tissue temperature gradient and the propensity for heat redistribution after the induction of anesthesia and as a result prevents intraoperative hypothermia. Previous studies have shown that at least 1-2 hours of prewarming prevented intraoperative hypothermia but was considered as impractical. Recently, it has been reported that a brief period of prewarming, for example 15 minutes, would be easy to accommodate and could be combined with intraoperative warming, which is undoubtedly effective after the redistribution period. This study was designed to evaluate the efficacy of active preoperative warming with forced air on the development of intraoperative hypothermia in patients undergoing cardiac surgery. Active Warming during Preanesthetic Period Reduces Hypothermia without Delay of Anesthesia in Cardiac Surgery

Background: Aspirin has been shown to effectively increase survival and reduce morbidity in patients with ischemic heart disease. Continued aspirin use during the preoperative period could increase the postoperative blood loss in patients who have on-pump coronary artery bypass grafting. This study aimed to determine the effect of continued aspirin use before off-pump CABG on intraoperative and postoperative bleeding and coagulation profile in thromboelastography. Methods: In 43 patients undergoing OPCAB, they were assigned aspirin user (n = 22), who received aspirin until the day of operation or nonaspirin user (n = 21), who discontinued aspirin before 7 days before the surgery. Intraoperative and postoperative bleeding and transfusion requirement were measured. TEG was performed and R, K, angle, maximum amplitude and TEG index was measured at preinduction and at 24 hours after surgery. Results: There were no differences in patient characteristics between aspirin users and nonaspirin users. We found no significant difference between postoperative bleeding and blood product requirements for the two groups. Similarly, we found no significant difference in the coagulation profiles. Conclusions: The use of aspirin continued preoperatively does not increase intraoperative and postoperative blood loss, and blood product requirement and influence on coagulation profile.

Background: During general anesthesia, the most commonly used way of keeping airway patency is endotracheal intubation. However, for relatively short and simple surgery, less invasive method using laryngeal tube (LT) or laryngeal mask airway (LMA) is generally accepted and the comparative study between the two apparatus is now being actively done. In this study, we evaluated the usefulness of two apparatus from pediatric patients. Methods: We select 58 children from one to ten years old who are to be given short operation and then anesthetize 30 children by using LT and 28 children by LMA. The size of LT and LMA is chosen by body weight according to the manufacturer´s recommendation. We evaluated the seal pressure of LT and LMA, ventilatory efficiency, attempt number, facility of insertion, proper positioning confirmed by fiberoptic bronchoscopy, and complications. Results: There was no statistically significant difference in the attempt number and facility of insertion between the two groups. LT and LMA were both properly positioned and the ventilation efficiency was not different from the two groups. The LT group shows higher seal pressure than the LMA group and there is no correlation between sealing pressure and ventilation efficiency. There is close correlation between bronchoscopic grade and ventilatory efficiency. complications are not different between two groups. Conclusions: Both LT and LMA are useful for simple surgery of children and LT has higher sealing pressure.

Background: Peripheral venous pressure (PVP) was known to have significant correlation with central venous pressure (CVP) in patients with normal and abnormal cardiac function. The purpose of this study is to evaluate the possibility of PVP as a substitute of CVP for volume status monitoring. Methods: 41 hypovolemic patients with pulmonary capillary wedge pressure (PCWP) below 10 mmHg, scheduled for elective coronary artery bypass graft were included. CVP and PVP were measured from proximal port of pulmonary artery (PA) catheter and antecubital vein, respectively. Each was connected to the same monitoring system by rigid tubes of same length. Measurements were performed as follows: after PA catheter insertion; after increasing PCWP above 10 mmHg by I.V. fluid infusion; and after anesthesia induction. Hemodynamic variables were recorded at end-expiration after stabilizing for 5-10 minutes. For statistical analysis, Bland and Altman plot was created. Results: The overall mean bias between CVP and PVP was -0.7 mmHg (95% confidence interval, -1--0.5). Limits of agreement of mean bias was 2.1--3.6 mmHg. 118 out of 121 PVP measurements were within the ranges of CVP 3 mmHg (98%). The direction of CVP change was predicted by PVP in 68%. However, larger changes of PVP (2 mmHg) predicted the changes of CVP with increased accuracy (90%). There were only 5 cases that CVP and PVP had changed in opposite direction. Conclusions: In conclusion, PVP has a potential to be a substitutional hemodynamic parameter of CVP.

Background: Laryngoscopy and tracheal intubation often provoke an undesirable increase in blood pressure and heart rate. This study was done to determine median effective dose (ED50) of nicardipine for prevention of hemodynamic response to tracheal intubation during induction of anesthesia with thiopental, propofol, or etomidate. Methods: Fourty-five ASA physical status 1 adult patients were allocated into three group; thiopental group (n = 15), propofol group (n = 15), and etomidate group (n = 15). The first patient of each groups received 10/kg of nicardipine 1 minute before induction. Subsequent dose was determined by the hemodynamic response of the previous patient to tracheal intubation based on Dixon's up and down sequential allocation. The test dosing interval was set at 3/kg. If mean arterial pressure increased more than 20% after tracheal intubation, dose of the subsequent patient was increased by 3/kg. If not, it was decreased by 3/kg. Blood pressure was measured after arrival at the operating room, before tracheal intubation, and 1, 2, 3, 4, and 5 minutes following intubation by non invasive method. Results: ED50 of nicardipine for attenuation of hypertensive response after tracheal intubation were 18.0/kg (95% Confidence Limit [CL], 14.8-22.0/kg), 6.2/kg (CL, 2.6-9.5/kg), and 16.7/kg (CL, 13.6-20.7/kg) in thiopental group, propofol group and etomidate group, respectively. Conclusions: We concluded that less nicardipine dose in propofol group was needed to prevent hypertensive response after tracheal intubation (P

Background: Preoperative -adrenergic receptor (-AR) antagonist administration is known to improve ventricular function by decreasing the myocardial oxygen demand in coronary artery obstructive disease (CAOD). This study evaluated the effect of preoperative propranolol on response to -AR agonist, dobutamine in patients undergoing off-pump coronary artery bypass graft surgery (CABG) Methods: Twenty six patients undergoing off-pump CABG, and treated with propranolol preoperatively, were enrolled in this study. After anesthesia, the infusion of dobutamine was started at 2/kg/min (D2) for 5 min and then increased to 4/kg/min (D4) and 8/kg/min (D8) in succession. The same protocol was performed twice before and after coronary artery anastomosis (pre-graft and post-graft). Hemodynamic variables were measured just before the infusion of dobutamine (D0, baseline) and after each dobutamine infusion at D2, D4 and D8. Results: No significant change was observed in the cardiac index (CI) during the pre-graft period, but CI increased significantly at D4 and D8 compared with D0 during the post-graft period. Mean arterial pressure (MAP), mean pulmonary artery pressure (MPAP) and systemic vascular resistance index (SVRI) increased at D2, D4 and D8 and heart rate (HR) decreased at D2 and D4 during the pre-graft period. MAP and SVRI did not change and HR and CI increased at D4 and D8 during the post-graft period. The % change of CI from D0 significantly increased at D4 and D8 during the post-graft period than during the pre-graft period but not at D2. MAP, SVRI and MPAP after dobutamine infusion significantly increased during the pre-graft period than during the post-graft period. HR showed a reversed trend. Conclusions: Dobutamine infusion did not exert any known positive inotropic effect, besides increased MAP, MPAP and SVRI, in patients treated with propranolol preoperatively undergoing off-pump CABG during the pre-graft period. Meanwhile, dobutamine exerted slight inotropic effects during the post-graft period. Cautious use of dobutamine during the pre-graft period is needed in patients treated with propranolol preoperatively.

Background: Coronary artery bypass grafting without cardiopulmonary bypass (Off-Pump Coronary Artery Bypass Grafting, OPCAB) causes significant hemodynamic derangement by displacement of the beating heart. The purpose of this study was to analyze the hemodynamic changes caused in relation to grafted arteries by displacing the heart and stabilizing the coronary arteries in patients undergoing OPCAB. Methods: Nineteen patients underwent OPCAB using two deep pericardial sutures and tissue stabilizers (Octopus Tissue Stabilization Syetem, Medtronic, USA). The hemodynamic variables were obtained after induction of anesthesia, after deep pericardial sutures, before and after anastomosis of each coronary artery during epicardial stabilizing, after sternal closure, and after postoperative 6 hours and 12 hours in the intensive care unit. Results: The hemodynamic variables were maintained with the Trendelenburg position, volume loading and low dose vasopressors after deep pericardial stay sutures. Displacement of the heart and placement of the stabilizer on all coronary territories except the obtuse marginal artery before anastomosis showed no significant difference in hemodynamics compared with baseline. Positioning for the graft to the obtuse marginal artery decreased cardiac index (1.6 0.4 L/min/) and stroke index (27.6 9.9 L/beat/) and increased systemic vascular resistance (2318.9 673.7 dyne . sec . ), resulting in hemodynamic compromise (P