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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

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)

Here, we report a previously unrecorded species, Sin-an-sae-u-nan-cho (Calanthe aristulifera Rchb. f.). It was discovered on Heuksan Island in Jeollanam-do. Its natural habitat was a subtropical forest. The species can easily be characterized by the simple trichomes on the back of its leaves and spur. This species is important because new horticultural races of Calanthe can be developed by cross-breeding with other species of Calanthe.

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.

The authors investigated the changes of cortical sensorimotor activity in functional MRI (fMRI) and functional recovery in spinal cord injury (SCI) patients who had been treated by bone marrow cell transplantation.Nineteen patients with SCI were included in this study; ten patients with clinical improvement and nine without. The cortical sensorimotor activations were studied using the proprioceptive stimulation during the fMRI.Diagnostic accuracy of fMRI with neurological improvement was 70.0% and 44.4% for sensitivity and specificity, respectively. Signal activation in the ipsilateral motor cortex in fMRI was commonly observed in the clinically neurological improved group (p-value=0.002). Signal activation in the contralateral temporal lobe and basal ganglia was more commonly found in the neurological unimproved group (p-value0.001). Signal activation in other locations was not statistically different.In patients with SCI, activation patterns of fMRI between patients with neurologic recovery and those without varied. Such plasticity should be considered in evaluating SCI interventions based on behavioral and neurological measurements.

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.

OBJECTIVE In this study, the authors assessed the ability of rat bone marrow derived mesenchymal stem cells (BMDMSCs), in the presence of a growth factor, fibroblast growth factor-4 (FGF-4) and hydroxyapatite, to act as a scaffold for posterolateral spinal fusion in a rat model. METHODS Using a rat posterolateral spine fusion model, the experimental study comprised 3 groups. Group 1 was composed of 6 animals that were implanted with 0.08 gram hydroxyapatite only. Group 2 was composed of 6 animals that were implanted with 0.08 gram hydroxyapatite containing 1 x 10(6)/ 60 microL rat of BMDMSCs. Group 3 was composed of 6 animals that were implanted with 0.08 gram hydroxyapatite containing 1 x 10(6)/ 60 microL of rat BMDMSCs and FGF-4 1 microG to induce the bony differentiation of the BMDMSCs. Rats were assessed using radiographs obtained at 4, 6, and 8 weeks postoperatively. After sacrifice, spines were explanted and assessed by manual palpation, high-resolution microcomputerized tomography, and histological analysis. RESULTS Radiographic, high-resolution microcomputerized tomographic, and manual palpation revealed spinal fusion in five rats (83%) in Group 2 at 8 weeks. However, in Group 1, three (60%) rats developed fusion at L4-L5 by radiography and two (40%) by manual palpation in radiographic examination. In addition, in Group 3, bone fusion was observed in only 50% of rats by manual palpation and radiographic examination at this time. CONCLUSION The present study demonstrates that 0.08 gram of hydroxyapatite with 1 x 10(6)/ 60 microL rat of BMDMSCs induced bone fusion. FGF-4, added to differentiate primitive 1 x 10(6)/ 60 microL rat of BMDMSCs did not induce fusion. Based on histologic data, FGF-4 appears to induce fibrotic change rather than differentiation to bone by 1 x 10(6)/ 60 microL rat of BMDMSCs.

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.

Lung resection surgery in patients with a previous internal mammary artery (IMA) graft to coronary arteries is challenging, because the arterial graft may be injured during dissection of adhesions between the graft and the lung [1-3]. A 68-year-old male patient, diagnosed with a squamous cell carcinoma in the left lower lobe of the lung, required a left lower lobectomy. The patient (height, 160.4 cm; weight, 73.5 kg) was on the following medications: Aspirin, clopidogrel, losartan, amlodipine, and atorvastatin. Three years previously the patient had a coronary artery bypass graft surgery including a left IMA graft to the left anterior descending (LAD) artery. An electrocardiogram (ECG) showed normal sinus rhythm, occasional premature ventricular contractions (PVCs), and left ventricular hypertrophy. A preoperative transthoracic echocardio gram showed mild inferior wall hypokinesia. Preoperative coronary angiography revealed a patent left IMA to LAD artery flow. After the patient arrived in the operating room, catheteri zation was performed on the patient's right radial artery. The patient was induced with 1-3.5 vol% sevoflurane after receiving 100 mg of propofol and 60 mg of lidocaine by intravenous injection. Tracheal intubation using a double lumen endotracheal tube (37 Fr) was performed for one-lung ventilation 3 minutes after the patient received 50 mg of rocuronium by intravenous injection. A central venous catheter was inserted into the right internal jugular vein due to the fear of graft pedicle injury and because we prefer the right internal jugular vein due to its straight course. At the start of the surgery, the patient’s blood pressure was stable (mean systolic pressure, 100-120 mmHg; diastolic pressure, 40-60 mmHg). After the thoracotomy, a severe adhesion between the upper lobe and the surrounding parietal pleura was noticed. The operator compressed the pericardium to control the bleeding using a sponge stick without considering the left internal mammary artery (LIMA) pedicle. During this period, ST-segment depression occurred, a series of PVCs appeared in about 5-6 seconds, and blood pressure decreased on the direct arterial pressure monitor (systolic pressure, 60 mmHg; diastolic pressure, 30 mmHg). Phenylephrine (20 μg/cc from a micro solution set) was dripped to increase blood pressure. The operator was notified immediately, the sponge stick compression was stopped, and the ECG and the blood pressure recovered to the previous state. Subsequent

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)

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.

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: 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.