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(1) Background: Previous studies reported limited performance of arterial pressure waveform-based cardiac output (CO) estimation (FloTrac/Vigileo system; CO-FloTrac) compared with the intermittent thermodilution technique (COint). However, errors due to bolus maneuver and intermittent measurements of COint could limit its use as a reference. The continuous thermodilution technique (COcont) may relieve such limitations. (2) Methods: The performance of CO-FloTrac was retrospectively assessed using continuous recordings of intraoperative physiological data acquired from patients who underwent off-pump coronary artery bypass graft (OPCAB) surgery with CO monitoring using both CO-FloTrac and COcont. Optimal time adjustments between the two measurements were determined based on R-squared values. (3) Results: A total of 134.2 h of data from 30 patients was included in the final analysis. The mean bias was –0.94 (95% CI, −1.35 to −0.52) L/min and the limits of agreements were −3.64 (95% CI, −4.44 to −3.08) L/min and 1.77 (95% CI, 1.21 to 2.57) L/min. The percentage error was 66.1% (95% CI, 52.4 to 85.8%). Depending on the time scale and the size of the exclusion zone, concordance rates ranged from 61.0% to 75.0%. (4) Conclusion: Despite the time adjustments, CO-FloTrac showed non-negligible overestimation, clinically unacceptable precision, and poor trending ability during OPCAB surgery.

Background Blood pressure measurement is an essential element during intraoperative patient management. However, errors caused by changes in transducer levels can occur during surgery. Methods This single center, prospective, observational study enrolled 25 consecutive patients scheduled for elective cardiac surgery with invasive arterial and central venous pressure (CVP) monitoring. Hydrostatic pressures caused by level differences (leveling pressure) between a reference point (on the center of the left biceps brachii muscle) and the transducers (fixed on the right side of the operating table) for arterial and central lines were continuously measured using a leveling transducer. Adjusted pressures were calculated as measured pressure – leveling pressure. Hypotension (mean arterial pressure 20 mmHg) levels were determined using unadjusted and adjusted pressures. Results Twenty-two patients were included in the analysis. Leveling pressure ≥ 3 mmHg and ≥ 5 mmHg observed at 46.0 and 18.7% of pooled data points, respectively. Determinations of hypotension using unadjusted and adjusted pressures showed disagreements ranging from 3.3 to 9.4% depending on the cutoffs. Disagreements in defined levels of CVP and PAP were observed at 23.0 and 17.2% of the data points, respectively. Conclusions The errors in pressure measurement due to changes in transducer level were not trivial and caused variable disagreements in the determination of MAP, CVP, and PAP levels. To prevent distortions in intraoperative hemodynamic management, strategies should be sought to minimize or adjust for these errors in clinical practice. Trial registration cris.nih.go.kr (KCT0006510).

Intravenous dexamethasone and dexmedetomidine, in conjunction with peripheral nerve blockade, have each been reported to prolong the duration of analgesia. This study tested whether combined use further prolongs analgesia duration after supraclavicular brachial plexus block (BPB) in patients undergoing orthopedic upper extremity surgery. One hundred twenty patients were randomized 1:1:1:1 to Control (saline bolus and midazolam infusion [0.05 mg/kg loading, 20 µg/kg/h thereafter]); DMED (saline bolus and dexmedetomidine infusion [1 μg/kg loading, 0.4 μg/kg/h thereafter]); DEXA (dexamethasone [10 mg] bolus and midazolam infusion); and DMED-DEXA (dexmedetomidine infusion and dexamethasone bolus) groups. The primary outcome was the duration of postoperative analgesia, defined as the time from the end of the BPB to the first dose of analgesia via a patient-controlled device. Median (interquartile range) times to first dose of analgesia in the Control, DMED, DEXA, and DMED-DEXA groups were 8.1 (6.2–11.6), 9.0 (8.1–11.3), 10.7 (8.1–20.5), and 13.2 (11.5–19.1) hours, respectively (p < 0.001). Pairwise comparisons showed significant prolongation of analgesia in the DEXA included groups compared with the non-DEXA included groups (DEXA vs. control, p = 0.045; DEXA vs. DMED, p = 0.045; DMED-DEXA vs. control, p < 0.001; DMED-DEXA vs. DMED, p < 0.001). A mixed effect model showed that dexamethasone was the only significant factor for the prolongation of analgesia (p < 0.001). Intravenous dexamethasone prolonged the analgesia duration of supraclavicular BPB after orthopedic upper extremity surgery. The concurrent use of mild to moderate sedation dose of intravenous dexmedetomidine in addition to intravenous dexamethasone showed no additional benefit to the prolongation of analgesia.

Preclinical studies suggest that repeated exposure to anesthetics during a critical period of neurodevelopment induces long-term changes in synaptic transmission, plasticity, and behavior. Such changes are of great concern, as similar changes have also been identified in animal models of neurodevelopmental disorders (NDDs) such as autism. Because of overlapping synaptic changes, it is also possible that anesthetic exposures have a more significant effect in individuals diagnosed with NDDs. Thus, we evaluated the effects of early, multiple anesthetic exposures in BTBR mice, an inbred strain that displays autistic behavior. We discovered that three cycles of sevoflurane anesthesia (2.5%, 1 h) with 2-h intervals between each exposure in late postnatal BTBR mice did not aggravate, but instead improved pathophysiological mechanisms involved with autistic behavior. Sevoflurane exposures restored E/I balance (by increasing inhibitory synaptic transmission), and increased mitochondrial respiration and BDNF signaling in BTBR mice. Most importantly, such changes were associated with reduced autistic behavior in BTBR mice, as sociability was increased in the three-chamber test and repetitive behavior was reduced in the self-grooming test. Our results suggest that anesthetic exposures during neurodevelopment may affect individuals diagnosed with NDDs differently.

Opioid-sparing effects of nefopam during patient-controlled analgesia (PCA) are well demonstrated. We hypothesized that postoperative pain control with an opioid-equivalent dose of nefopam as a single analgesic agent for PCA would not be inferior to fentanyl in laparoscopic gynecologic surgery. In total, 135 patients were randomly assigned to the N (nefopam 200 mg), NF (fentanyl 500 mcg + nefopam 100 mg), and F (fentanyl 1000 mcg) groups (n = 45 patients per group). The primary outcome was the numerical rating scale (NRS) score at rest at 6 h postoperatively, and the non-inferiority limit was set to 1. Secondary outcomes were pain severity and incidence of nausea and vomiting for 48 h postoperatively. Mean differences (MD) in primary outcome between the N and F groups were 0.4 (95% confidence interval (CI) −0.5 to 1.3). The upper limit of 95% CI exceeded the non-inferiority limit. The N group showed higher pain scores than the NF group (MD, 1.1, 95% CI, 0.3–1.9) in pairwise comparisons. No significant intergroup differences were observed in the cumulative dose of PCA usage and incidence of postoperative nausea and vomiting (PONV). In laparoscopic gynecological surgery, nefopam alone showed limited efficacy for postoperative pain control.

Preclinical animal studies have continuously reported the possibility of long-lasting neurotoxic effects after general anesthesia in young animals. Such studies also show that the neurological changes induced by anesthesia in young animals differ by their neurodevelopmental stage. Exposure to anesthetic agents increase dendritic spines and induce sex-dependent changes of excitatory/inhibitory synaptic transmission in late postnatal mice, a critical synaptogenic period. However, the mechanisms underlying these changes remain unclear. Abnormal activation of the mammalian target of rapamycin (mTOR) signaling pathway, an important regulator of neurodevelopment, has also been shown to induce similar changes during neurodevelopment. Interestingly, previous studies show that exposure to general anesthetics during neurodevelopment can activate the mTOR signaling pathway. This study, therefore, evaluated the role of mTOR signaling after exposing postnatal day (PND) 16/17 mice to sevoflurane, a widely used inhalation agent in pediatric patients. We first confirmed that a 2-h exposure of 2.5% sevoflurane could induce widespread mTOR phosphorylation in both male and female mice. Pretreatment with the mTOR inhibitor rapamycin not only prevented anesthesia-induced mTOR phosphorylation, but also the increase in mitochondrial respiration and male-dependent enhancement of excitatory synaptic transmission. However, the changes in inhibitory synaptic transmission that appear after anesthesia in female mice were not affected by rapamycin pretreatment. Our results suggest that mTOR inhibitors may act as potential therapeutic agents for anesthesia-induced changes in the developing brain.

Sugammadex can rapidly reverse neuromuscular blockade and has several advantages over cholinesterase inhibitors. It is unclear, however, whether administration of sugammadex in the absence of intraoperative deep neuromuscular blockade has direct clinical benefits. The present study retrospectively assessed the ability of sugammadex to prevent post-operative respiratory adverse events in patients undergoing laparoscopic colorectal surgery in the absence of routine deep neuromuscular blockade. The medical records of patients who underwent laparoscopic colorectal surgery from 2014 to 2018 in a tertiary care hospital were reviewed. Patients who underwent reversal of neuromuscular blockade with sugammadex or pyridostigmine were subjected to propensity score matching. To assess their relative effects on post-operative adverse respiratory events (defined as a composite of SpO2 < 94% in the post-anesthesia care unit, additional oxygen supplementation during ward transfer or stay, and emergency use of sugammadex in the post-anesthesia care unit), the incidence of these effects was compared in propensity score matched groups of patients treated with sugammadex or pyridostigmine. Of the 602 patients, 210 remained in each group after propensity score matching. The incidence of post-operative respiratory adverse events did not differ significantly in the two groups. These findings suggest that the unrestricted administration of sugammadex not preceded by intra-operative deep neuromuscular blockade does not have clinical benefits, when compared with pyridostigmine, in preventing post-operative respiratory adverse events.

Background Intraoperative hypothermia is common in patients undergoing general anesthesia during arthroscopic hip surgery. In the present study, we assessed the effect of heating and humidifying the airway with a heated wire humidification circuit (HHC) to attenuate the decrease of core temperature and prevent hypothermia in patients undergoing arthroscopic hip surgery under general anesthesia. Methods Fifty-six patients scheduled for arthroscopic hip surgery were randomly assigned to either a control group using a breathing circuit connected with a heat and moisture exchanger (HME) (n = 28) or an HHC group using a heated wire humidification circuit (n = 28). The decrease in core temperature was measured from anesthetic induction and every 15 minutes thereafter using an esophageal stethoscope. Results Decrease in core temperature from anesthetic induction to 120 minutes after induction was lower in the HHC group (-0.60 ± 0.27℃) compared to the control group (-0.86 ± 0.29℃) (P = 0.001). However, there was no statistically significant difference in the incidence of intraoperative hypothermia or the incidence of shivering in the postanesthetic care unit. Conclusions The use of HHC may be considered as a method to attenuate intraoperative decrease in core temperature during arthroscopic hip surgery performed under general anesthesia and exceeding 2 hours in duration.

SummaryBackground The second trimester is a period of neurogenesis and neuronal migration, which can be affected by exposure to anesthetics. Studies also suggest that multiple exposures may have a greater impact on neurodevelopment. Aim We investigated whether in utero single or multiple exposures to anesthetics caused long-term behavior changes. Methods Pregnant mice were randomly divided into four groups on gestational day 14 (GD 14). Mice in the Control × 1 group were exposed to 100% oxygen for 150 min. Mice in the Sevo × 1 group were also exposed to 100% oxygen for 150 min, except that 2.5% sevoflurane was added during the first 120 min. Mice in the Control × 3 and Sevo × 3 group were identically treated as Control × 1 and Sevo × 1 group for three consecutive days, respectively (GD 14–16). Behavioral tests were performed only with the male offspring at the age of 2–4 months. Synaptic plasticity was also compared by inducing long-term potentiation in acute hippocampal slices. Results Single or multiple sevoflurane exposures in pregnant mice during the second trimester did not cause long-lasting behavioral consequences or changes in long-term synaptic plasticity of their offspring. Conclusion Our study suggests that neither single nor multiple exposures of mice to sevoflurane during the fetal developmental period induces long-term behavioral dysfunctions or affects long-term synaptic plasticity. Additional studies focusing on early stages of neurodevelopment are necessary to confirm the effects of sevoflurane exposure during pregnancy.

The Jackson table has minimal effects on cardiac function because it does not elevate abdominal and thoracic pressures. In addition, it decreases venous congestion and increases exposure of the surgical field. However, the hips and knees are flexed with inappropriate padding, and venostasis is promoted and increased. Pulmonary thromboembolism (PTE) is fatal; thus immediate diagnosis and treatment are essential. However, clinical signs of intraoperative PTE are difficult to discern. Thrombolytic therapy can be considered as first-line therapy, but bleeding limits its use. The authors report a case of PTE resulting from patient positional change after spine surgery, and the use of immediate postoperative recombinant tissue-type plasminogen activator.

Regional anesthesia for non-obstetric surgery in parturients is a method to decrease patient and fetal risk during general anesthesia. Thoracic interfascial nerve block can be used as an analgesic technique for surgical procedures of the thorax. The Pecs II block is an interfascial block that targets not only the medial and lateral pectoral nerves, but also the lateral cutaneous branch of the intercostal nerve. Pecto-intercostal fascial block (PIFB) targets the anterior cutaneous branch of the intercostal nerve. The authors successfully performed a modified Pecs II block and PIFB without complications in a parturient who refused general anesthesia for breast surgery.

Background Intravenous anesthesia has been reported to have a favorable effect on the prognosis of cancer patients. This study was performed to analyze data regarding the relation between anesthetics and the prognosis of cancer patients in our hospital. Methods The medical records of patients who underwent surgical resection for gastric, lung, liver, colon, and breast cancer between January 2006 and December 2009 were reviewed. Depending on the type of anesthetic, it was divided into total intravenous anesthesia (TIVA) or volatile inhaled anesthesia (VIA) group. The 5-year overall survival outcomes were analyzed by log-rank test. Cox proportional hazards modeling was used for sensitivity. Results The number of patients finally included in the comparison after propensity matching came to 729 in each group. The number of surviving patients at 5 years came to 660 (90.5%) in the TIVA and 673 (92.3%) in the VIA. The type of anesthetic did not affect the 5-year survival rate according to the log-rank test (P = 0.21). Variables associated with a significant increase in the hazard of death after multivariable analysis were male sex and metastasis at surgery. Conclusions There were no differences in 5-year overall survival between two groups in the cancer surgery. Trial registration Trial registration: CRIS KCT0004101. Retrospectively registered 28 June 2019.

ObjectiveAlthough opioids may induce nausea and vomiting, they possess sedative effects and can reduce intraoperative nausea and vomiting (IONV). This study assessed the effect of adding fentanyl to midazolam on sedation levels and IONV during cesarean section under spinal anesthesia.MethodsEighty parturients scheduled for elective cesarean section were enrolled in the study. Following fetal delivery, patients were administered 0.05 mg/kg of midazolam plus 0.03 mL/kg of normal saline (M group) or 0.05 mg/kg of midazolam plus 1.5 μg/kg of fentanyl (MF group). The primary outcome was the incidence of IONV. The secondary outcomes were incidence of postoperative nausea and vomiting (PONV), intraoperative sedation level, and five-point patient satisfaction score (PSS).ResultsThe IONV incidence was significantly lower in the MF group compared with the M group (5% [2/40] vs. 25% [10/40]). The PONV incidence did not differ significantly between the groups. The intraoperative sedation level tended to be deeper in the MF group. The 5-point PSS was significantly higher in the MF group. There was a strong correlation between the sedation level and IONV incidence.ConclusionsAdding fentanyl to midazolam is effective for sedation and to prevent IONV in women who are undergoing cesarean section under spinal anesthesia.

Currently, sevoflurane and remifentanil are utilized frequently for the inhalation induction of anesthesia. However, there is currently an insufficient amount of clinical data regarding the inhalation induction of sevoflurane after the administration of remifentanil.80 patients undergoing elective surgery were allocated randomly to four groups. Group A inhaled only sevoflurane at 8 vol%. Other groups were administered 3 ng/ml of remifentanil and inhaled sevoflurane at 8 vol% (group B) or 6 vol% (group C) or 4 vol% (group D). All groups also received 0.6 mg/kg of rocuronium. The blood pressure and heart rate were measured at pre-induction, and before and after tracheal intubation. After operation, the patients??levels of satisfaction with the inhalation induction were evaluated.The time to loss of consciousness was substantially longer in group D than in the other groups, but no significant differences were noted among the groups in terms of satisfaction scores. The HR in groups B, C and D increased significantly after pre-intubation as compared to baseline in group A. The HR decreased significantly during induction as compared to group A. The MAP in groups B, C and D decreased significantly at 1 and 2 minutes after tracheal intubation as compared to group A. In group D only, we noted no significant differences in the MAP as compared to baseline at 1, 2 minutes after tracheal intubation.4 vol% sevoflurane was a more appropriate concentration for the inhalation induction of anesthesia when coupled with 3 ng/ml of remifentanil.

BACKGROUND: There has been little data reporting the usefulness of intensivist-performed bedside drainage of pleural effusion via ultrasound (US)-guided pigtail catheter. The objective of this study is to clarify the usefulness and safety of these methods in comparison with radiologist-performed procedures. METHODS: Data of patients with pleural effusion treated with US-guided pigtail catheter drainage were analyzed. All procedures were performed from September 2012 to September. 2013 by a well-trained intensivist or radiologist. RESULTS: Pleural effusion was drained in 25 patients in 33 sessions. A radiologist performed 21 sessions, and an intensivist performed 12 sessions. Procedures during mechanical ventilation were performed in 15 (71.4%) patients by a radiologist and in 10 (83.3%) by an intensivist (p = 0.678). The success rate was not significantly different in radiologist- and intensivist-performed procedures, 95.2% (20/21) and 83.3% (10/12), respectively (p = 0.538). The average duration for procedures (including in-hospital transfer) was longer in radiologist-performed cases (p = 0.001). Although the results are limited because of the small population size, aggravation of oxygenation, CO2 retention, and decrease of mean arterial blood pressure were not statistically different in the groups. Pigtail-associated complications including hemothorax, pneumothorax, hepatic perforation, empyema, kink in the catheter, and subcutaneous hematoma were not found. CONCLUSIONS: Intensivist-performed bedside drainage of pleural effusion via ultrasound (US)-guided pigtail catheter is useful and safe and may be recommended in some patients in an intensive care unit.

Background Anesthesia during the synaptogenic period induces dendritic spine formation, which may affect neurodevelopment. The authors, therefore, evaluated whether changes in synaptic transmission after dendritic spine formation induced by sevoflurane were associated with long-term behavioral changes. The effects of sevoflurane on mitochondrial function were also assessed to further understand the mechanism behind spinogenesis. Methods Postnatal day 16 to 17 mice were exposed to sevoflurane (2.5% for 2 h), and synaptic transmission was measured in the medial prefrontal cortex 6 h or 5 days later. The expression of postsynaptic proteins and mitochondrial function were measured after anesthesia. Long-term behavioral changes were assessed in adult mice. Results Sevoflurane increased the expression of excitatory postsynaptic proteins in male and female mice (n = 3 to 5 per group). Sevoflurane exposure in male mice transiently increased miniature excitatory postsynaptic current frequency (control: 8.53 ± 2.87; sevoflurane: 11.09 ± 2.58) but decreased miniature inhibitory postsynaptic current frequency (control: 10.18 ± 4.66; sevoflurane: 6.88 ± 2.15). Unexpectedly, sevoflurane increased miniature inhibitory postsynaptic current frequency (control: 1.81 ± 1.11; sevoflurane: 3.56 ± 1.74) in female mice (neurons, n = 10 to 21 per group). Sevoflurane also increased mitochondrial respiration in male mice (n = 5 to 8 per group). However, such changes from anesthesia during the critical period did not induce long-term behavioral consequences. Values are presented as mean ± SD. Conclusions Sevoflurane exposure during the critical period induces mitochondrial hyperactivity and transient imbalance of excitatory/inhibitory synaptic transmission, without long-lasting behavioral consequences. Further studies are needed to confirm sexual differences and to define the role of mitochondrial activity during anesthesia-induced spine formation.

In addition to classical synaptic transmission, information is transmitted between cells via the activation of extrasynaptic receptors that generate persistent tonic current in the brain. While growing evidence supports the presence of tonic NMDA current (INMDA) generated by extrasynaptic NMDA receptors (eNMDARs), the functional significance of tonic INMDA in various brain regions remains poorly understood. Here, we demonstrate that activation of eNMDARs that generate INMDA facilitates the α-amino-3-hydroxy-5-methylisoxazole-4-proprionate receptor (AMPAR)-mediated steady-state current in supraoptic nucleus (SON) magnocellular neurosecretory cells (MNCs). In low-Mg(2+) artificial cerebrospinal fluid (aCSF), glutamate induced an inward shift in Iho lding (IGLU) at a holding potential (Vholding) of -70 mV which was partly blocked by an AMPAR antagonist, NBQX. NBQX-sensitive IGLU was observed even in normal aCSF at Vholding of -40 mV or -20 mV. IGLU was completely abolished by pretreatment with an NMDAR blocker, AP5, under all tested conditions. AMPA induced a reproducible inward shift in Iholding (IAMPA) in SON MNCs. Pretreatment with AP5 attenuated IAMPA amplitudes to ~60% of the control levels in low-Mg(2+) aCSF, but not in normal aCSF at Vholding of -70 mV. IAMPA attenuation by AP5 was also prominent in normal aCSF at depolarized holding potentials. Memantine, an eNMDAR blocker, mimicked the AP5-induced IAMPA attenuation in SON MNCs. Finally, chronic dehydration did not affect IAMPA attenuation by AP5 in the neurons. These results suggest that tonic INMDA, mediated by eNMDAR, facilitates AMPAR function, changing the postsynaptic response to its agonists in normal and osmotically challenged SON MNCs.

Background: The Glidescope Videolaryngoscope (GVL) is a newly developed video laryngoscope. It offers a significantly improved laryngeal view and facilitates endotracheal intubation in difficult airways, but it is controversial in that it offers an improved laryngeal view in normal airways as well. And the price of GVL is expensive. We hypothesized that intubation carried out by fully experienced anesthesiologists using the GVL with appropriate pre-anesthetic preparations offers an improved laryngeal view and shortened intubation time in normal airways. Therefore, the aim of this study was to compare the GVL with the Macintosh laryngoscope in normal airways and to determine whether GVL can substitute the Macintosh laryngoscope. Methods: This study included 60 patients with an ASA physical status of class 1 or 2 requiring tracheal intubation for elective surgery. All patients were randomly allocated into two groups, GVL (group G) or Macintosh (group M). ADS (airway difficulty score) was recorded before induction of anesthesia. The anesthesiologist scored vocal cord visualization using the percentage of glottic opening (POGO) visible and the subjective ease of intubation on a visual analogue scale (VAS). The time required to intubate was recorded by an assistant. Results: There was a significant increase in POGO when using the GVL (P < 0.05). However, there was no difference in the time required for a successful tracheal intubation using the GVL compared with the Macintosh laryngoscope. The VAS score on the ease of intubation was significantly lower for the GVL than for the Macintosh laryngoscope (P < 0.05). Conclusions: GVL could be a first-line tool in normal airways. (Korean J Anesthesiol 2011; 60: 339-343)

Non-obstetrical surgery during the first trimester is stressful to both the mother and the fetus. Anesthesiologists are also stressed, not only because of the effects of surgery itself, but also because of the uncertain influences of anesthesia thrown upon on the fetus. The authors present a case of breast surgery successfully performed on a woman 8 weeks pregnant requiring removal of breast abscess by the application of thoracic paravertebral block without any complications. Thoracic paravertebral block may be a safe anesthetic method for non-obstetric surgery during early pregnancy.

Background Anesthesia methods and drugs affect postoperative nausea and vomiting. Propofol is known to have antiemetic effects. We compared the incidence of postoperative vomiting (POV) in children undergoing an adenotonsillectomy; anesthesia in one group was induced with propofol and maintained with sevoflurane and nitrous oxide, and the other group received total intravenous anesthesia (TIVA) with propofol-remifentanil. Methods Ninety children, ASA physical status I, were assigned randomly to one of two groups. In the PSN group, anesthesia was maintained with 2-3 vol% sevoflurane and 50% nitrous oxide. In the PR group, anesthesia was maintained with 10 mg/kg/h propofol and 0.25 µg/kg/min remifentanil. In both groups, anesthesia was induced with 0.5 µg/kg remifentanil and 2 mg/kg propofol. The incidence of POV and the need for rescue antiemetics were assessed in the postanesthesia care unit at 6, 12, and 24 hours postoperatively. Results The total incidence of POV was not significantly different between the groups; POV occurred in eight (17.7%) and three (6.7%) children in the PSN and PR groups, respectively. Postoperative frequency of retching in the recovery room was significantly higher in the PSN group, with four children (8.9%) in the PSN group compared to none (0%) in the PR group (P = 0.041). The frequency of POV 24 hrs after exiting the recovery room tended to be higher in the PSN group than the PR group, but no statistically significant difference was observed. Conclusions If the development of POV in the early anesthetic recovery phase of children undergoing adenotonsillectomy is adequately prevented, propofol-induced anesthesia maintained with sevoflurane-nitrous oxide is as safe as TIVA with propofol-remifentanil.

This study is to investigate strengths and weaknesses of On-line Language Program(OLP) compared to face-to-face language learning and suggest some ideas to revitalize OLP in Korea. A survey, which was composed of all 191 college students, was conducted to know about their awareness and use of OLP. The results are the followings. First, although OLP has some advantages over face-to-face language learning in sparing time and school expenses, OLP is not necessarily economical because of its low cost of equipment. Second, OLP needs to make institutional devices to prevent students from learning language with disinclination and inattention. Third, language experts need to prepare the appraisal criteria of OLP so that students can select the language program to their language level and the government has to provide administrative and financial support for revitalizing OLP. Finally, this quality OLP can supplement or even replace face-to-face language learning and can also reduce the expenses to take a language course abroad.

Encountering a patient with unanticipated laryngotracheal stenosis (LTS) during anesthetic induction is challenging for an anesthesiologist. Because routine history taking and pre-anesthetic evaluation cannot rule out the possibility of LTS, other measures should be taken. Perioperative airway maintenance is considered crucial for avoiding complications such as airway edema, bleeding, obstruction, collapse, and ultimately respiratory failure and arrest. We report an unanticipated tracheal stenosis discovered during anesthetic induction that hindered endotracheal intubation. Because airway maintenance was difficult, we postponed surgery until determining the cause of the difficult entry, considered possible therapeutic approaches (both anesthetic and surgical), and provided successful surgery with a continuous epidural block.

Background The beach chair position (BCP) can cause significant hypotension. Epinephrine is used to prolong the duration of local anesthetics; it is also absorbed into blood and can exert systemic effects. This study determined the effects of epinephrine mixed with ropivacaine for an interscalene block (ISB) on hemodynamic changes related to BCP. Methods Patient data collected from March 2013 to August 2014 were used retrospectively. We divided the patients into three groups: 1) ISB only, 2) I+G (general anesthesia after ISB without epinephrine), and 3) I+E+G (general anesthesia after ISB with epinephrine). Mean blood pressure (MBP) and heart rate (HR) were measured for 30 minutes at 5-minute intervals. Results The study analyzed data from 431 patients. MBP tended to decrease gradually in the groups I+G and I+E+G. There were significant differences in MBP between the groups I+G and I, and between the groups I+G and I+E+G. Group I+E+G showed a significant increase in HR compared with the other two groups. Conclusions ISB with an epinephrine mixture did not prevent hypotension caused by the BCP after general anesthesia. HR increased only in response to the epinephrine mixture. A well-planned prospective study is required to compare hemodynamic changes in that context.

There are now several reports of anaphylaxis after rocuronium injection in the Korean population, where only mild to moderate symptoms have been described. This is fortunate, since severe anaphylactic reactions have also been reported after rocuronium injection. Also, among the cases reported in Korea, only one case performed general anesthesia with a neuromuscular blocking agent later on [1]. Hence, we report a case of severe anaphylaxis after injection of rocuronium where the patient showed abrupt severe hypotension and cardiac arrest. After being transferred to the intensive care unit (ICU), ST segment depression was discovered in multiple electrocardiogram (ECG) leads and immediate coronary angiography revealed variant angina. After careful evaluation of the patient's severe anaphylactic reaction, the patient was successfully anesthetized four weeks later. An 82-year-old male (height 169 cm, weight 67 kg) without any past medical history was scheduled for elective laparoscopyassisted distal gastrectomy. Although the preoperative ECG showed several premature ventricular contractions per minute, echocardiography results were normal. During induction, there was a sudden drop in blood pressure (BP) after rocuronium injection. Endotracheal intubation was immediately performed, and although there was no increase in airway resistance, BP continued to be severely hypotensive. The patient did not respond to intravenous ephedrine (10 mg) or phenylephrine (100 µg). Three minutes after the onset of hypotension, skin rash appeared over the entire body in addition to swelling of the eyes. As hemodynamics continued to deteriorate, epinephrine (200 µg) was administered and cardiopulmonary resuscitation (CPR) was initiated. Rapid crystalloid fluid infusion was given after inserting a central venous catheter in the left subclavian vein. CPR was continued for 15 minutes and epinephrine (1 mg) was injected twice over a three-minute period. The patient was also defibrillated due to one episode of ventricular fibrillation during CPR. Hydrocortisone (250 mg) and chlorpheniramine (4 mg) were also injected, while epinephrine and dopamine were continuously infused. The patient was transferred to the ICU after full recovery of consciousness and muscle tone. Twenty-four hours after the event, cardiac enzymes had elevated (Troponin I 5.24 ng/ml, CK-MB 23.5 ng/ml) and ST depression could be seen in the I, aVL, and V2-6 leads of the ECG. Coronary angiography was immediately performed, and the patient was diagnosed with variant angina. Fortunately, the patient recovered without any complications and the operation was delayed by four weeks. Intradermal injection tests were performed twice: at three weeks and at four weeks after the event (Fig. 1). Due to the positive results with rocuronium and vecuronium, cisatracurium was used instead. Intravenous injection of chlorpheniramine (4 mg) was added as premedication. There was no particular event during the second induction period, and the patient was discharged one week later. Fig. 1 Skin prick and intradermal test performed after three weeks and four weeks after the anaphylactic event. (A, B) Skin prick and intradermal test results at three weeks. Only rocuronium shows positive results. (C, D) Skin prick and intradermal test results ... Anaphylactic reaction can affect multiple organs, and although most patients recover spontaneously from mild reactions, respiratory and cardiovascular arrest can occur in a matter of minutes in severe cases. Reitter et al. [2] reported several factors associated with severe symptom: emergency operation, elderly and obese patients, history of hypertension, other cardiovascular disease and/or beta-blocker use. We believe that multiple factors may have caused cardiac arrest during induction with rocuronium in the patient described here. During evaluation after the anaphylactic event, variant angina was detected during cardio-angiography. Secondary acute coronary vasospasm after anaphylaxis was first reported in 1991 and has been termed the 'Kounis syndrome'. The possibility of Kounis syndrome after rocuronium injection was first reported by Fagley et al. [3]. In our present case, there was a significant increase in cardiac enzymes, ST depression was observed in multiple ECG leads and the patient was diagnosed with variant angina through coronary angiography. Although factors such as severe hypotension, ventricular fibrillation and CPR could have contributed to the development of variant angina, we cannot rule out the possibility of Kounis syndrome as the cause of coronary vasospasm. Even though we did not discover changes in the ST segment directly after rocuronium injection, this could have been due to limited ECG monitoring. Only the II lead was monitored during induction, while ST depression was found in the I, aVL and V2-6 leads in the ICU. Other factors such as an unusually prolonged fasting period and a relatively high dose of propofol may also affect the clinical outcome of the patient. The patient had received upper gastrointestinal endoscopy and an enema the previous day. This led to a significantly prolonged fasting time since the patient had to continue fasting for the following operation. Indeed, extremely low central venous pressure (0-2 mmHg) was observed during the event. Since anesthetics, especially propofol, affect the cardiovascular system more significantly in geriatric patients [4], the hypovolemic status combined with the relatively large dose of propofol may have contributed to the severity of the anaphylactic attack. The decision was made to delay the operation by four weeks. Cisatracurium was selected as the neuromuscular blocking agent due to negative results during the skin prick test and intradermal test (Fig. 1). Although some recommend a period of six weeks after the anaphylactic event, tests were performed early due to the patients' strong desire for an early operation [5]. In conclusion, anesthesiologists must always pay special attention during the induction period due to the administration of various drugs over a relatively short period. Although anesthesiologists are skilled in immediate treatment during severe anaphylaxis, they must be aware of factors that could aggravate such physiological conditions. Also, even though extremely rare, anesthesiologists must also be aware of serious complications such as Kounis syndrome.

n-3-Polyunsaturated fatty acids (PUFAs) protect against myocardial infarction, arteriosclerosis and high blood pressure by stimulating endothelial nitric oxide synthase (eNOS) to increase nitric oxide (NO) production. However, the mechanism remains to be elucidated. This study investigated the role of SIRT1 in the protective effects of docosahexaenoic acid (DHA) in vascular endothelial cells. Exposure of human umbilical vein endothelial cells (HUVECs) to 0.3–30 μM DHA did not affect cell viability, and DHA treatment dose-dependently increased SIRT1 expression. The DHA-mediated increase in SIRT1 expression induced eNOS deacetylation, increasing endothelial NO. However, inhibition of SIRT1 inhibited DHA-mediated increases in NO production. This effect was mediated via deacetylation of lysines 496 and 506 in the eNOS calmodulin-binding domain. The effects of DHA were also demonstrated in rat aortic rings, in which DHA treatment increased SIRT1 expression and bioavailable NO. Our results demonstrate that SIRT1 plays an important role in DHA-mediated increases in bioavailable NO via decreased eNOS acetylation.

Background: Respiratory dynamics may be monitored and evaluated indirectly by measuring the peak inspiratory pressure and plateau pressure. In this study, the respiratory dynamics of patients undergoing spinal surgery using a Jackson surgical table were observed with a device after converting their position from supine to prone. The effects of the dynamic compliance and airway resistance were observed from the changes in peak inspiratory pressure and plateau. Methods: Twenty five patients were selected as subjects scheduled to undergo lumbar spine surgery. After intubation, the patients were ventilated mechanically with a tidal volume of 10 ml/kg and a respiration rate of 10/min. Anesthesia was maintained with sevoflurane 1.5%, nitrous oxide 2 L/min and oxygen 2 L/min. The peak inspiratory pressure, plateau pressure, resistance, compliance, arterial oxygen tension, carbon dioxide tension, heart rate and arterial blood pressure were measured at 10 minutes after the induction of anesthesia. These parameters were measured again 10 minutes after placing the patient in the prone position. Results: The prone position did not significantly affect the arterial oxygen tension, carbon dioxide tension, blood pressure and heart rate, but significantly increased the peak inspiratory pressure and resistance and decreased the dynamic compliance. Conclusions: The peak inspiratory pressure was increased using a Jackson surgical table to minimize the abdominal pressure when converting from the supine to prone position. This might be due to a decrease in lung and chest compliance as well as an increase in airway resistance. (Korean J Anesthesiol 2010; 59: 323-328)