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

Background Electromyography and acceleromyography are common neuromuscular monitoring devices. However, questions still remain regarding the use of acceleromyography in children. This study compared the calibration success rates and intubation conditions in children after obtaining the maximal blockade depending on each of the devices. Methods Children, 3 to 6 years old, were randomly allocated to the TOF-Watch SX acceleromyography group or the NMT electromyography group. The induction was performed with propofol, fentanyl, and rocuronium. The bispectral index and 1 Hz single twitch were monitored during observation. The calibration of the each device was begun when the BIS dropped to 60. After successful calibration, rocuronium 0.6 mg/kg was injected. A tracheal intubation was performed when the twitch height suppressed to 0. The rocuronium onset time (time from administration to the maximal depression of twitch height) and intubating conditions were rated in a blinded manner. Results There was no difference in the calibration success rates between the two groups; and the calibration time in the electromyography group (16.7 ± 11.0 seconds) was shorter than the acceleromyography group (28.1 ± 13.4 seconds, P = 0.012). The rocuronium onset time of the electromyography group (73.6 ± 18.9 seconds) was longer than the acceleromyography group (63.9 ± 18.8 seconds, P = 0.042) and the intubation condition of the electromyography group (2.27 ± 0.65) was better than the acceleromyography group (1.86 ± 0.50, P = 0.007). Conclusions Electromyography offers a better compromise than acceleromyography with respect to the duration of calibration process and surrogate for the optimal time of tracheal intubation in children.

Background We investigated the effects of the combined administration of nefopam, a N-methyl-D-aspartate receptor antagonist and low dose remifentanil, on early postoperative pain and analgesic requirement. Methods Fifty patients scheduled to undergo mastoidectomy and tympanoplasty were randomized to be given either nefopam 40 mg mixed with normal saline 100 ml (Group N) or an equal amount of normal saline (Group C) before anesthesia induction. Anesthesia was maintained with 5-6 vol% desflurane and remifentanil 0.05-0.15 µg/kg/min during the surgery. Postoperative pain was controlled by titration of ketorolac in the postanesthesia care unit (PACU) and ward. We evaluated the intraoperative remifentanil dose, recovery profiles, ketorolac demand in the PACU and ward, numeric rating scale (NRS) for pain at time intervals of every 10 min for 1 h in the PACU, 6, 12, 18 and 24 h in a ward, as well as the time to first analgesic requirement in the PACU and ward. Results Ketorolac demand and NRS in the PACU were significantly lower in Group N than Group C (P = 0.002, P = 0.005, respectively). The time to first analgesic requirement in the PACU in Group N were significantly longer than Group C (P = 0.046). There were no significant differences in intraoperative remifentanil dose, ketorolac demand, NRS, and the time to first analgesic requirement in the ward between the groups. Conclusions Nefopam administration combined with low dose remifentanil infusion reduces pain and analgesic consumption during the immediate postoperative period in patients undergoing middle ear surgery under desflurane anesthesia.

The use of neuraxial anesthesia has traditionally been contraindicated in patients with severe aortic stenosis. However, general anesthesia can be riskier than neuraxial anesthesia for severe aortic stenosis patients undergoing spinal surgeries in the prone position as this can cause a major reduction in cardiac output secondary to diminished preload. In addition, general anesthesia, muscle relaxation, and positive-pressure ventilation can decrease venous return and reduce vascular tone, further compromising cardiac output. Combined spinal-epidural anesthesia with closely monitored, careful titration of the local anesthetic dose can be an efficient and safe anesthetic method for managing such patients. We describe the successful management of combined spinal-epidural anesthesia in an asymptomatic severe aortic stenosis patient scheduled for lumbar discectomy.

Patients with cervical spine instability and limited range of motion are challenge to anesthesiologists. It is important to consider alternatetive methods for securing the airway while maintaining neutral position and minimizing neck motion, because these patients are at increased risk for tracheal intubation failure and neurologic injury during airway management or position change. We experienced two cases that patients had cervical spine instability and severe limited range of motion due to the fusion of the entire cervical spine. One patient was a 6-year-old girl weighing 12.7 kg and had Klippel-Feil syndrome with Arnold-Chiari malformation, the other was a 24-year-old female weighing 31 kg and had juvenile rheumatoid arthritis. We successfully performed the intubation by using the fiberoptic intubation though a laryngeal mask airway in these two cases.

Background: The aims of this national survey were to determine the views of Korean people regarding the specialty of anesthesiology and the role of anesthesiologists and to consider the ways in which individual anesthesiologists and the Korean Society of Anesthesiologists inform the public. Methods: This off-line national survey was conducted by a professional research organization to obtain exact and reliable data. The questionnaire included structured questions to identify perceptions of the specialty of anesthesiology and the role of anesthesiologists inside and outside the operating room, people’s desire for explanation of anesthesia by anesthesiologists, and their opinion about the best way to raise awareness about anesthesia and anesthesiologists. Results: Of the respondents, 25.2% did not know that anesthesiologists are in charge of anesthesia during surgery. Furthermore, even respondents who knew that had very little knowledge of anesthesiologists’ actual roles inside and outside the operating room. Respondents wanted their anesthesiologist to inform them about their anesthesia. Conclusions: The public’s awareness regarding the role of anesthesiologists seems to be inadequate. To improve this awareness, in hospitals, each anesthesiologist should provide patients with more exact and detailed information. Simultaneously, the National Society of Anesthesiology should provide systematic information reflecting the public’s thoughts. (Korean J Anesthesiol 2014; 66: 12-17)

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

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

We report a case of pulmonary edema developed in a 33-year-old female who underwent two-stage bilateral carotid body tumor excision. About 1 month ago, she had undergone a left carotid body tumor excision. After the operation, her tongue was deviated to left side. Bilateral hypoglossal nerve injury was suspected. These injuries should be carefully monitored in patients who will undergo a similar procedure on both sides because a bilateral deficit of the hypoglossal nerve is poorly tolerated, resulting potentially serious pulmonary edema. In recovery room, she became pale and SpO 2 was fall down. We reintubated her immediately and the pulmonary edema was treated using a supportive management. She was discharged without any signs of dyspnea or airway obstruction, but hypoglossal nerve injury remained. We discuss the possible etiology of the upper airway obstruction after the neck surgery and review the literatures associated with the pulmonary edema following upper airway obstruction. (Korean J Anesthesiol 2007; 53: 274～6)

Background: Several survey reported that use of dietary supplements including herbal medicine was common in the preoperative period. The use of such remedies has implications for the anesthesiologists because of the potential for drug interactions and side effects. Little information is available on the frequency of use in the surgical population in Korea. This study was purposed to find out the frequency and predictors of the use of dietary supplements in presurgical patients. Methods: A questionnaire was distributed to all patients at the preoperative visit from May 2006 to August 2006. The questionnaire inquired as to basic demographics, use of dietary supplements, the name and number of dietary supplements used, reasons to take the dietary supplements, and whether the patient had informed anesthesiologist of the use. Results: A total 1,072 completed surveys showed that overall 37% of presurgical patients reported the use of dietary supplements. Less than half of the patients told their anesthesiologists that they were using dietary supplements. The most commonly used dietary supplements were ginseng, soy, glucosamine, garlic, prunus mume, mushroom, siberian ginseng, fish oils, aloe, ginger, and gingko in order of incidence. Young age was predictor associated with lower use of dietary supplements. Conclusions: Use of dietary supplements is common in the preoperative peri od in Korea. Documentation of the use of these products in the perioperative period is important to consider the potential interaction of dietary supplements with medical medicine or anesthetics.

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

Background: The interaction between ischemic preconditioning (IPC) and propofol-induced cardioprotective effects during prolonged cold ischemia has not been studied yet. The purpose of this study is to investigate the effects of ischemic preconditioning and propofol on cardiac function and the development of endothelial injury after 4 hours of cold cardioplegia and reperfusion. Methods: After suspension of the isolated heart on the Langendorff perfusion system, we took a stabilizing period for 15 minutes, perfusion period for 15 minutes, global cold (4) ischemic period for 4 hours, and then reperfusion period for 60 minutes. There were 4 groups: (1) CONTROL group, no intervention; (2) IPC group, two 2-minute total coronary clusions interspaced with 5 minutes of normal reperfusion; (3) PROPOFOL group, propofol (2M) was infused during reperfusion period; (4) BOTH group, ischemic preconditioning and postischemic propofol treatment group. The measurements of cardiac performances, such as left ventricular developed pressure (LVDP), rate of ventricular pressure generation (dp/dt), and heart rate (HR) was obtained at pre- and postischemic periods. For the evaluation of endothelial injury during reperfusion period, coronary flow responses to bradykinin were tested. Infarct size was measured using the triphenyl tetrazolium stain. Results: IPC, PROPOFOL, and BOTH groups showed better outcome of LVDP, dp/dt, HR, and flow responses to bradykinin than CONTROL group did. But there is no statistically significant difference in variables among the three groups. Conclusions: Ischemic preconditioning and postischemic propofol have cardioprotective effect respectively but no additive effect after 4 hours cold cardioplegia and reperfusion.

Three cases of the abdominal pain, which are derived from the rectus abdominis, were presented. The abdominal pains of unknown origin are frequently misdiagnosed as arisen from visceral sources. That brings inappropriate diagnostic tests and unsatisfactory treatments. If patients have no intraabdominal cause, we must pay attention to the possibility that patients with abdominal pain may suffer from this presumed nerve entrapment syndrome or myofacial pain syndrome. Rectus abdominis syndrome is causes by entrapment of an anterior cutaneous branch of one or more thoracic intercostal nerves. Myofacial pain syndrome is defined as the sensory, motor and autonomic symptoms caused by the myofacial trigger points. The authors report three cases of abdominal pain caused by trigger point in the rectus abdominis muscle. On physical examination, trigger points in the rectus abdominis muscle were found, and abdominal pain was successfully treated by trigger point injections. (Korean J Anesthesiol 2006; 51: 243~5)

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

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

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

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

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

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

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

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

Background : Sometimes hypoxemia occurs in the postoperative recovery room because of post- operative residual curarization (PORC). Some reports show that postoperative residual curarization is common. FORC occurs after the use of the long-acting muscle relaxants. It has been recommended to use intermediate-acting muscle relaxants and a TOF monitor to decrease PORC. The purpose of this study was to examine whether the use of the TOF monitor during propofol anesthesia affects the incidence of postoperative residual curarization. Methods : 38 ASA I or II patients were divided randomly into two groups of 19 each. They received propofol-fentanyl-nitrous oxide for anesthesia. Pancuronium (80 ― 100 μg/kg) was used to facilitate tracheal intubation and additional doses were used to maintain surgical relaxation. The requirement for incremental doses of pancuronium and adequacy of recovery following reversal were assessed, either with (control group: n = 19) or without (experimental group: n = 19) TOF monitoring. Fifteen minutes after the arrival at the recovery room, neuromuscular function was assessed clinically and by using TOF. Results : There were no statistical differences in body weight, age, or duration of operation between the two groups. There was no statistical difference in the total dose of pancuronium and total dose of pancuronium relative to body weight and duration of operation. There were statistical differences in TOF ratio in the recovery room (0.73 vs. 0.86). The incidence of PORC was 47% in the control group and 5% in the experimental group. Conclusions : Though the monitoring of TOF did not effect the dose of muscle relaxant, it may have reduced the incidence of PORC. However, the PORC had no clinical significance because the mean TOF ratio in the two groups was over 0.7 and there were no clinical signs of residual muscle weakness. (Korean J Anesthesiol 2000; 38: 783-788)

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

Background : Urinary retention after anorectal surgeiy is thought to be a mild· complication but has a high incidence. Since anal pain and distention can contribute to the urethral spasm reflex which may cause urinary retention, we investigated the effect of absorbable gelatin sponge (Gelfoam) used for anal packing postoperatively on urinary retention after hemorrhoidectomy under spinal anesthesia. Methods : One hundred and nineteen ASA Physical Status I patients scheduled for hemorrhoidectomy were selected. Patients were randomly divided into Group A, postoperative anal packing free group and Group B, postoperative anal pacfking group and studied prospectively. Spinal anesthesia was performed with the level of 25 gauge Quincke needle parallel to dura fibers at lumber 3-4 inteHertebral space and the injection of hyperbaric 0.5% tetracaine 6 mg (1.2 ml) to patients in sitting position. After hemorrhoidectomy, all patients were permitted to ambulate as soon as possible and urinate spontaneously. If urinary retention occurred, urinary catheterization was done temporarily. The number of patients who received urinary catheterization were recorded. Surgical technique and the total amount of intravenous fluid during the operation were controlled. Results : The incidence of urinary retention in Group A (11/57, 19.3%) was similar to that in Group B (10/62, 16.1%) (P=- 0.651, X(2)= 0.205, degree of freedom=1). Conclusions : Our study did not indicate the clue that the absence of anal packing helped to reduce the incidence of urinary retention after hemorrhoidectomy under spinal anesthesia. (Korean J Anesthesicl 2000; 38: 30∼34)

Trendelenburg position has been used for the low abdominal and pelvic surgery or for the management of the hypotensive patients. But, various adverse effects can also occur in steep Trendelenburg position, of which brachial plexus injury has been known as the most common nerve injury during this position under the general anesthesia especiaUy when the shoulder braces are used. We experienced a case of brachial plexus palsy in a 53 year old woman who had a laparas-copy assisted vaginal hysterectomy(LAVH) under the general anesthesia for myoma uteri for four and a half hours. During the operation she was in a 30°-tilting Trendelenburg and combined lithotomy position with her arms tucked at her side with drawsheet and shoulder braces were placed over the acromioclavicular joints bilaterally. In the morning of the postoperative 1st day, she complained the right shouder pain and the right arm tingling sensation and weakness. After needle electromyography and nerve conduction study, it was decided that she got an intraoperative brachial plexus injury mainly involving the lateral cord of the brachial plexus, resulting from the nerve compression caused by shoulder braces in Trendelenburg position. The symptoms were improved after the physical therapy and she was recommended to take more physical therapy after discharge.

Nesidioblastosis is a rare disease characterized clinically by persistent hypoglycemia with inappropriately elevated circulating insulin concentration. Adequate early diagnosis should be established and subtotal pancreatectomy performed before itreversible cerebral damage caused by glucose deficit. The authors got a chance to anesthetize 56-day-old male patient for subtotal pancreatectomy because of nesidioblastosis, Following an induction of anesthesia with intravenous thiapental sodium 5 mg/kg and succinylchohne 1 mg/kg, endotracheal intubation was performed and anesthesia was maintained with pancuronium bromide and O2-N2O-enflurane. Intravenous fluid was maintained with 1-2-3 solution 30 ml and 15% D/W 40 ml mixed with 20 ml of 20 mEq/L NaCI.