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Background Congenital central hypoventilation syndrome (CCHS) is a rare disorder characterized by alveolar hypoventilation and autonomic dysregulation. Patients with CCHS have adequate ventilation while awake but exhibit hypoventilation while asleep. More severely affected patients exhibit hypoventilation both when awake and when asleep. Case Here, we report a case of successful spinal anesthesia and postoperative epidural analgesia in a patient with CCHS who underwent orthostatic surgery. Conclusions In patients with CCHS, anesthesia is used with the goal of minimizing respiratory depression to avoid prolonged mechanical ventilation. Regional anesthesia should be considered where appropriate. Continuous oxygen saturation and end-tidal carbon dioxide monitoring must be available.

Background: We postulated that palonosetron, a novel antiemetic agent, might have the effect of alleviating injection pain from propofol and rocuronium. A double-blind, controlled study was undertaken to evaluate the effect of palonosetron on injection pain during total intravenous anesthesia and postoperative nausea and vomiting (PONV) using propofol-remifentanil in breast and thyroid cancer surgery. Methods: Sixty patients were randomly allocated to one of two groups. Before injection of propofol and rocuronium, patients in group S (n = 30) received 4 ml of saline and patients in group P (n = 30) received 75 μg (1.5 ml) of palonosetron mixed with 2.5 ml of saline (n = 30). Patients were evaluated by a blinded anesthesiologist with regard to the scoring of injection pain of propofol, withdrawal response by rocuronium, PONV, shivering, postoperative pain, recall of pain, and overall satisfaction. Results: The differences between groups in the incidence of injection pain due to propofol and rocuronium were insig nificant. However, in group P, the severity of propofol-induced injection pain (3% vs. 33%, P = 0.003) and postoperative pain (P = 0.038) was significantly lower during the first 12 h after surgery. No differences were observed between the groups with respect to PONV, shivering, recall of pain, and overall satisfaction. Conclusions: We concluded that pretreatment of palonosetron was effective to reduce the severity of propofol-induced injection pain and early postoperative pain, although it did not reduce the incidence of injection pain from propofol and rocuronium. (Korean J Anesthesiol 2014; 67: 13-19)

Background: We compared clinical properties and patient satisfaction between spinal anesthesia and popliteal sciatic nerve block (PSNB) for hallux valgus surgery. Methods: Forty patients undergoing hallux valgus surgery were divided into spinal group (spinal anesthesia with 2.5 ml of 0.5% bupivacaine [n = 20]) and PSNB group (PSNB with 30 ml of 0.75% ropivacaine mixed with 10 ml of normal saline solution using a nerve stimulator [n = 20]). The PSNB group used a patient-controlled-analgesia (PCA) pump for postoperative pain control. The quality and side effects were compared between the two groups. A questionnaire was used to evaluate patient satisfaction with the use of anesthetic techniques and postoperative pain control in the PSNB group. This study was assessed 3 days postoperatively by a blinded observer. Results: Procedure time and time from anesthesia until start of sugery were significantly shorter in the spinal group than those in the PSNB group (P < 0.01). Anesthesia-related complications such as hypotension, bradycardia, shivering, nausea/vomitting, post-dural puncture headache (PDPH) and urinary retension were observed in 15%, 10%, 5%, 5%, 10%, and 20% of patients in the spinal group, respectively. PSNB was not associated with these complications. Patient satisfaction was slightly higher for PSNB than for spinal anesthesia. In the PSNB group, patient satisfaction with postoperative pain-control was 95% above ordinary satisfaction. Conclusions: Despite the long duration of the procedure, PSNB is relatively safe, provides an adequate level of anesthesia, effectively controls postoperative pain and reduces side effects. Therefore, PSNB could be a potential anesthetic technique for hallux valgus surgery. (Korean J Anesthesiol 2013; 64: 321-326)

BACKGROUND Perioperative opioid administration results in postoperative nausea and vomiting (PONV) and acute opioid tolerance that manifests in increased postoperative pain. Esmolol is an ultra short acting cardioselective β1-adrenergic receptor antagonist, and it has been successfully used for perioperative sympatholysis and it reduces the opioid requirement during total intravenous anesthesia. We tested the hypothesis that perioperative esmolol administration results in decreased PONV and postoperative pain. METHODS Sixty patients undergoing laparoscopic appendectomy were randomly assigned to two groups (Group E and Group C). The Group E patients were administered 5-10 µg/kg/min esmolol with remifentanil that was titrated to the autonomic response. The Group C patients received normal saline that was of the same volume as the esmolol in Group E, and the remifentanil was also titrated to the vital sign. Before intubation and extubation, the Group E patients were administered 1.0 mg/kg esmolol, and the Group C patients were administered normal saline of the same volume. The incidence and severity of PONV, the pain score, the rescue antiemetics and the rescue analgesics were assessed 30 min, 6 h and 24 h after surgery. The mean arterial pressure and heart rate under anesthesia were also recorded. RESULTS PONV and postoperative pain were significantly increased in Group C. These patients needed more antiemetics and analgesics in the first 24 postoperative hours. The mean arterial pressure and heart rate were significantly higher in Group C at the time of intubation and extubation. CONCLUSIONS Perioperative esmolol administration contributes to the significant decrease in PONV and postoperative pain, and so this facilitates earlier discharge.

Despite the reduced use of inflammable anesthetics, there are still a number of reported fire incidents. If an endotracheal tube ignites during anesthesia, it progresses rapidly and the patient experiences a mild to a heavy burn. A severe burn may even cause death [1]. A male patient (171 cm, 51 kg) with a chief complaint of odynophagia was diagnosed with tongue cancer from computed tomography (CT) scan and biopsy. A tracheostomy was scheduled before a radical excision. A brain tumor was discovered by chance from a preoperative magnetic resonance imaging (MRI) scan but it was decided that only observation of the progress would be made because of the very small size of the tumor. Upon arrival in the operating room patient's oxygen saturation was 95%. Anesthesia induction was done and the anesthesiologist intubated the patient. Using direct curved-blade laryngoscopy, a 7.0 internal diameter reinforced polyvinyl chloride endotracheal tube (ETT; Safety-Flex with Murphy Eye; Mallinckrodt, Athlone) was intubated without difficulty. The tube cuff was filled with air. After intubation, the ETT was fixed at a depth of 22 cm from the teeth. A normal breathing sound was made from the auscultation of both lungs. Afterwards, anesthesia maintenance was done with sevoflurane (1-2 vol%, oxygen 2 L/min) and nitrous oxide (2 L/min). An experienced ear-nose-throat (ENT) surgeon who had performed 40 tracheostomies sterilized the surgical site with betadine and alcohol (83% ethanol). After 10 min, electrocautery in the monopolar cutting mode was used for skin incision at the 2-4th tracheal cartilage, at the midpoint between the cricoids cartilage and the sternal notch. Ten minutes into the surgery, the anesthesiologist discovered that the ETCO2 waves were irregular, so he switched respiration to the manual mode. When observing the surgical view, he discovered that the cuff of the ETT had burst. The ENT surgeon tried to stop the bleeding at the tracheal incision site using electrocautery in the bipolar coagulation mode (25 watt). At that moment, grey smoke coming from the tracheostoma was observed. The authors assessed that it was due to an ignition from the ETT. Manual ventilation and the supply of oxygen, nitrous oxide, and sevoflurane from the anesthesia machine were stopped. Smoke came from the tracheostoma for about 3 sec. The ENT surgeon twice poured 10 cc saline at the fire site and extinguished the fire. From the point of ignition to the point of fire extinguishment, the patient was maintained in the state of apnea to reduce the possibility of foreign-body aspiration. At the time of ignition, the tracheostomy had been almost complete. The incinerated ETT was extubated, and another ETT of the same type was inserted in the complete tracheostomy site (Fig. 1). In the process, the patient maintained a 99% oxygen saturation rate. Total anesthetic time was about 30 min. Fig. 1 Endotracheal tube extubated from the patient. Note the carbides are mostly in the cuff. The patient was sent to the intensive care unit. Oxygen (5 L/min) was supplied through the ETT. The patient maintained spontaneous respiration with no respiratory distress or pain. Upon arrival, the oxygen saturation rate was 95% and PaO2 was 65.8 mmHg. Two hours afterwards, the medical team extubated the ETT and supplied oxygen through the tracheostoma. A bronchoscopy was performed immediately. It showed black carbide covering the area from the trachea to both of the main bronchi. A chest radiograph showed no abnormal findings. Seven weeks afterwards, the patient was moved to the general ward. Oxygen (2 L/min) was supplied through a nasal cannula. Treatment had been planned for the brain tumor. However, the rapid growth and progression of the tumor was fatal before any treatment commenced. The ignition of the electrocautery-caused ETT fire in this case is considered to be due to not fully considering the possibility of ignition of the ETT, not immediately changing the ETT when the cuff burst, not lowering the oxygen ratio, and continuing with the electrocautery procedure. In this case, the ignition source was the ETT. It was observed that the cuff of ETT was the most severely charred. The FiO2 of the supplied oxygen was 0.5. The higher the oxygen rate, the higher is the possibility of fire. If the ratio of oxygen is constant and the ratio of nitrous oxide rises, the risk of a fire rises [2]. The most common fire sources have been reported to be electrocautery (59%), lasers (32%), and optical cables (7%) [3]. Electrocautery can produce temperatures of up to 900-1,500℃ and most likely cause a fire in the ETT [4]. There may be several preventive measures for fire. At first, inflammables must be removed from the surgical view. In situations with the risk of a fire, using electrocautery must be avoided. In a tracheostomy with the risk of ignition, the oxygen ratio should be lowered and air should be used instead of N2O. If the trachea is open and the ETT is exposed, the ETT should be covered with a wet gauze to separate the ETT from the electrocautery. Also filling the cuff of the ETT with saline solution may be considered. This method reduces the risk of ignition, but it requires care that the cuff does not burst from external pressure. If a fire occurs, the surgeon and anesthesiologist must quickly communicate with each other and the anesthesiologist must stop patient respiration, temporarily separate the respiratory circuit from the anesthesia machine and remove the remaining heat and oxygen. Afterwards, respiration and anesthesia should be maintained and the damage site should be observed with direct laryngoscopy and bronchoscopy. If there are carbides, they must be removed, and washing the trachea may be required. Severe lung damage from heat or smoke will require long-term airway maintenance and mechanical ventilation, and a high concentration of steroids as a short-term therapy and antibiotics therapy may help [5]. Use of electrocautery facilitates incision and hemostasis, but it can be a source of ignition. Because an endotracheal tube fire may occur from the use of electrocautery, even with the usually delivered oxygen ratio for general anesthesia, the risk of a fire will always be present if precautions towards fire are not taken. Despite the decline of use of flammable anesthetics in general anesthesia, endotracheal tube fires are possibly occur during a tracheostomy. We report a case of airway fire during a tracheostomy before main surgery. The fire occurred during a surgical tracheostomy under general anesthesia following ignition of the endotracheal tube by diathermy. The endotracheal tube was charred and it's lumen had melted immediately after the accident, bronchofibroscopic examination revealed inhalation injury. We discuss factors that increase the risk of airway fire and management steps that should be undertaken in the event that such a fire occurs.

The occurrences of pneumothorax and pneumomediastinum are rare, but considered to be potentially life-threatening conditions in patients undergoing functional endoscopic sinus surgery under general anesthesia. Tracheobronchial rupture may results in serious complications, such as pneumothorax and pneumomediastinum. It may occur accidentally by endotracheal tube when the patient's neck is flexed or extended. We report the case of a 48-year-old female patient who developed massive subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum seven hours after functional endoscopic sinus surgery under general anesthesia.

Endoscopic thyroidectomy is gaining popularity, but it can increase the risk of certain complications. Carbon dioxide insufflation in the neck may cause adverse effects on hemodynamic and ventilatory aspects. We report the anesthetic course and complications that were encountered during endoscopic thyroidectomy. Although the surgery was successful, the patient developed signs of hypercarbia, subcutaneous emphysema and pneumothorax.

The color of urine in patients who receive anesthetic gives much medical information to a medical team. So, we must check the urine color and know the cause of discoloration of the urine from anesthetic patients. Green urine is rare indeed and it is a benign potential side effect of propofol; this phenomenon is related to the metabolism of propofol. We experienced green urine from a long-term anesthetized patient who received a continuous infusion of propofol. We report here on this unusual case and we review the relevant literature.

Hereditary haemorrhagic telangiectasia (HHT), or Osler-Weber-Rendu syndrome is an autosomal dominant disorder characterized by recurrent epistaxis, mucocutaneous telangiectasias, and visceral involvement including arteriovenous malformations that may develop in any organ, especially in the lung, brain, liver and GI tract. Early screening and regular follow up of patients with HHT are important to minimize the risk of development of serious sequelae. We report a case of 46-year-old female patient who had “suspected HHT” and review the literature on this rare disease.

Background: Remifentanil and sevoflurane are characterized by rapid emergence from anesthesia. Therefore, propofol-remifentanil anesthesia (PR) and sevoflurane-nitrous oxide anesthesia (SN) were compared with regard to the recovery characteristics in children. Methods: Sixty children scheduled for tonsillectomy were randomly assigned to receive PR (n = 30) or SN (n = 30). The PR group was induced by remifentanil, propofol and vecuronium, maintained with infusion of remifentanil and propofol. The SN group was induced by sevoflurane, nitrous oxide, vecuronium maintained with sevoflurane in 50% nitrous oxide. At the end of operation, all anesthetics were discontinued and 100% oxygen was inspirated in both groups. The times to spontaneous breathing, extubation, eye opening, PACU discharge were assessed and postoperative nausea/vomiting, agitation were noted. Results: Spontaneous breathing occurred after 9.29 1.02 minutes (PR) versus 6.85 0.60 minutes (SN) (P ＜ 0.05), extubation after 9.19 0.91 minutes versus 8.87 0.67 minutes, eye opening after 9.47 1.01 minutes versus 14.85 0.80 minutes (P ＜ 0.05) and PACU discharge after 21.32 2.01 minutes versus 27.55 1.72 minutes (P ＜ 0.05). The occurrence of postoperative nausea/vomiting was 7% (PR) versus 13% (SN), and the incidence of agitation was 60% (PR) versus 83% (SN). Conclusions: It was observed that the recovery of propofol-remifentanil anesthesia was faster than that of sevoflurane-nitrous oxide anesthesia, except spontaneous breathing. The incidences of postoperative nausea/vomiting were low in both groups, and the incidences of agitation were higher in SN group than in PR group.

A 54-year-old male patient with squamous cell carcinoma of lung was scheduled for right lower lobectomy. He had suffered from diabetes mellitus during 8 years, but his preoperative electrocardiogram was normal sinus rhythm. During right thoracotomy, 2 times of unstable paroxysmal supraventricular tachycardia (PSVT) appeared but returned to normal sinus rhythm by carotid sinus massage. But, third unstable PSVT was not controlled by adenosine and anterior - lateral paddle positioned biphasic cardioversion. We changed anterior-lateral paddle position to anterior-posterior paddle position. And PSVT terminated abruptly and changed to sinus rhythm. So we present a case of unstable PSVT during right thoracotomy and treated with anterior-posterior paddle positioned biphasic cardioversion.

Background: The purpose of this study was to evaluate the effect of low dose i.v. ketamine in combination with epidural morphine on postoperative pain after gastrectomy. Methods: 40 patients scheduled for elective gastrectomy were investigated in a randomized study. All patients received epidural morphine (0.05 mg/kg) and bupivacaine (0.25%) as a bolus dose of 10 ml 40 min prior to skin incision. In addition, patient- controlled epidural analgesia (PCEA) with epidural bupivacaine (0.125%) and morphine (0.1 mg/ml) (bolus dose 1 ml, continuous infusion 1 ml/h, lock out interval 15 min) was offered from the time after 10 ml bolus dose. In the ketamine group, ketamine 0.5 mg/kg was administered 10 min prior to skin incision and then maintained continuously until skin closure at a dosage of 10/kg/min. In the second group anesthesia was induced with thiopental sodium 4 mg/kg, midazolam 0.5 mg/kg, vecuronium 0.1 mg/kg and maintained with 66% -O2, 1-3 vol% enflurane. The intensities of spontaneous pain and of coughing associated pain were measured using a visual analogue scale. Cumulative morphine consumption was measured at 2, 6, 12, 24, 48 h after surgery. Side effects were evaluated at 48 h after surgery. Results: VAS and cumulative morphine consumption at 2, 6, 12, 24, 48 h postoperatively showed no statistical differences between the two groups, and no statistical differences in side effects were observed at 48h after surgery. Conclusions: We were unable to demonstrate any additional analgesic effect of low dose i.v. ketamine in combination with epidural morphine and bupivacaine.

Background: Rocuronium bromide is a new steroidal nondepolarizing neuromusular blocking drug characterized by a rapid onset and intermediate duration of action. I.V. rocuronium produces intense discomfort at the site of injection, so many trials have been conducted on prevention of pain induced by I.V. rocuronium. This study evaluate venous retension induced forearm was squeezed with a tourniquet, affect lidocaine efficacy. Methods: Test was performed alert patients and unconscious patients. One group received lidocaine (0.5 mg/kg) and the other forearm was squeezed with tourniquet keeping the lidocaine (0.5 mg/kg) within the vein. After 30, 60 seconds rocuronium (0.6 mg/kg) was injected. propofol (2 mg/kg) induce patients unconsiousness. Results: There was statistical difference in reduction pain and withdrawal among groups. Squeezing group showed less pain and withdrawal than no squeezing group. Conclusions: Venous retension induced forearm was squeezed with a tourniquet, lidocaine reduce pain and withdrawal movement more effectively.

Background: For anesthesia in cesarean section N0 and low concentrations of inhalation anesthetics are regarded as the anesthetic agent of choice. But a low level of anesthesia frequently leads to increased maternal hemodynamic responses and awareness. The effects of a 3g/kg fentanyl bolus injection after umbilical cord clamping was evaluated in 20 full-term parturients, scheduled for elective cesarean section, versus to 20 parturients without fentanyl. Methods: The forty parturients (ASA physical status 1, 2) scheduled for cesarean section were randomized to either a N20-enflurane (E group) or a N0-enflurane-fentanyl (F group). Thiopental sodium (4 mg/kg) and succinylcholine (1.5 mg/kg) were administered intravenously for the induction and endotracheal intubation. Anesthesia was maintained with 50% N0 and 1 % enflurane in oxygen until delivery. After delivery, the intravenous injection of 0.5 mg/kg of atracurium was administered, controlled ventilation was applied to maintain PC0 at 30 to 35 mmHg with N0 (3 L/min) and O (1.5 L/min). Immediately after clamping the umbilical cord, 3g/kg of fentanyl (F group only) was administered. Heart rate, blood pressure, awareness, recovery time, postoperative complication and recall were evaluated. Results: Heart rate values at 10 and 20 min after umbilical cord clamping and 5 min after extubation, and mean arterial pressure at 5, 10 and 20 min after umbilical cord clamping in group F were found to be significantly lower than in group E. Conclusions: We conclude that N0-enflurane-fentanyl at 3g/kg is clinically satisfactory in anesthesia for cesarean section, having no adverse effects on the mother.

We had a case of respiratory difficulty following total thyroidectomy due to bilateral vocal cord palsy. The patient was a 49-year-old female undergoing total thyroidectomy for papillary carcinoma of the thyroid. Anesthesia was performed uneventfully. Spontaneous respiration resumed after reversal of the neuromuscular blockade. However, after arriving at the postanesthesia care unit, she developed hypertension, anxiety, tachypnea, and inspiratory stridor during deep inspiration. Because the patient maintained adequate oxygen saturation, we confirmed bilateral vocal cord palsy by fiberoptic laryngoscopy. During the operation, the surgeon experienced difficulty dissecting the bilateral recurrent laryngeal nerves from the surrounded tumor. So we consider that direct nerve injury was responsible for the bilateral vocal cord palsy. Movement of the right vocal cord recovered a week later.

Age-related vertebral fractures occur frequently in the elderly recently. An epidural block has been introduced as an effective management for the treatment of pain with vertebral compression fractures. While an epidural block is considered to be reasonably safe, serious complications may occur even when this invasive procedure is related to pain. Vasovagally mediated episodes of hypotension and bradycardia are thought to be a common cause of recurrent unexplained syncope. Precipitating factors include pain, trauma, fatigue, blood loss, or prolonged motionless standing. We report one case of vasovagal syncope associated with severe bradycardia and hypotension in a 78 year-old male patient with vertebral fractures. Syncopal attacks occurred during a caudal epidural block. The patient was resuscitated successfully and recovered without any adverse effects. (Korean J Anesthesiol 2001; 41: 383-387)