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Background The conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum cesarean section (CS) often fails, resulting in intraoperative pain. Spinal anesthesia (SA) can provide a denser sensory block than ESA. The purpose of this prospective, non-blinded, parallel-arm, randomized trial was to compare the rate of pain-free surgery between ESA and SA following ELA for intrapartum CS. Methods Both groups received continuous epidural infusions for labor pain at a rate of 10 ml/h. In the ESA group (n = 163), ESA was performed with 17 ml of 2% lidocaine mixed with 100 µg fentanyl, 1 : 200,000 epinephrine, and 2 mEq bicarbonate. In the SA group (n = 160), SA was induced with 10 mg of 0.5% hyperbaric bupivacaine and 15 µg fentanyl. We investigated the failure rate of achieving pain-free surgery and the incidence of complications between the two groups. Results The failure rate of achieving pain-free surgery was higher in the ESA group than the SA group (15.3% vs. 2.5%, P < 0.001). There was no statistical difference between the two groups in the rate of conversion to general anesthesia; however, the rate of analgesic requirement was higher in the ESA group than in the SA group (12.9% vs. 1.3%, P < 0.001). The incidence of high block, nausea, vomiting, hypotension, and shivering and Apgar scores were comparable between the two groups. Conclusions SA after ELA can lower the failure rate of pain-free surgery during intrapartum CS compared to ESA after ELA.

Background Cholesterol plays an important role in the action of opioid analgesics, but its association with postoperative pain has not been clarified. Our study examined the association of pre- and postoperative total serum cholesterol (TSC), and change between the pre- and postoperative TSC levels with postoperative pain outcomes in patients with non-small cell lung cancer (NSCLC) who underwent video-assisted thoracoscopic surgery (VATS) lobectomy. Methods We retrospectively reviewed medical records of patients with NSCLC who underwent VATS lobectomy at the Seoul National University Bundang Hospital in South Korea. We sought to determine the association between preoperative TSC, TSC on postoperative day (POD) 0–1, and pre- and postoperative changes in TSC by comparing numeric rating scale (NRS) scores on POD 0, 1, and 2 and total morphine equivalent consumption on POD 0–2. Multivariate linear regression analyses were used, and P < 0.05 was considered statistically significant. Results A total of 1,720 patients with NSCLC who underwent VATS lobectomy were included in the analysis. The change in TSC, preoperative TSC, and postoperative TSC showed no associations with morphine equivalent consumption on POD 0–2 (P > 0.05). In addition, the changes in TSC, preoperative TSC, and postoperative TSC were not associated with postoperative NRS pain score on POD 0, 1, and 2 (P > 0.05). Conclusions Our results indicated that no significant association was observed between pre- and postoperative TSC level and postoperative pain outcome after VATS lobectomy of the lung.

†† Background: This prospective, randomized, double-blind study was undertaken to compare prophylactic nicardipine infusion with esmolol infusion to determine their effects on the control of hemodynamic response during emergence from total intravenous anesthesia (TIVA) with propofol and remifentanil. Methods: One hundred and thirty two patients undergoing thyroidectomy were divided randomly into 3 groups. About 10 minutes before the end of surgery, propofol was stopped in all the patients and nicardipine group (n = 44) received a continuous infusion of 2 μg/kg/min nicardipine during emergence from TIVA, esmolol group (n = 44) received 250μg/kg/min esmolol, and placebo group received 10−14 ml/hr of isotonic saline until 15 min after transfer to a postanesthesia care unit (PACU). Hemodynamic profiles were measured every minute throughout the study period. Results: MBP was significantly lower in the nicardipine group than in the esmolol group (P ＜ 0.05) from 10 min after PACU transfer until 10 min after study drug infusion stop. On the other hand, HR was significantly lower in the esmolol group than in the nicardipine group from 6 min after drug infusion. Conclusions: Nicardipine infusion attenuated blood pressure increases more effectively than esmolol infusion during emergence from TIVA. (Korean J Anesthesiol 2009; 57: 597∼603)

Magnesium sulfate has been used in preeclampsia patients in order to prevent seizure. It is also used for the treatment of arrhythmia and asthma and as an anesthetic adjunct in patients undergoing surgery for pheochromocytoma. However, its potentiating effects on perioperative analgesia and muscle relaxation have drawn attention recently. These characteristics of magnesium (anesthetic- and analgesic-sparing effect) enable anesthesiologists to reduce the use of anesthetics during surgery and the use of analgesics after surgery. Magnesium sulfate has a high therapeutic index and cost-effectiveness. Considering these diverse characteristics useful for anesthesia, appropriate use of magnesium sulfate would improve surgical outcome and patients' satisfaction.

In patients with cervical spine injuries, respiratory function requires careful attention. Voluntary respiratory control is usually possible with lesions below C4 level although paralysis of the abdominal musculature results in a decreased ability to cough and to clear secretions, which may later lead to respiratory insufficiency. Therefore, injuries above C5 usually necessitate long term mechanical ventilation. Even though weaning criteria are not definitive for the quadriplegic patient, M-mode ultrasonography of the diaphragm may be useful in identifying patients at high risk of difficulty weaning. Diaphragmatic dysfunction (vertical excursion < 10 mm or paradoxical movements) results in frequent early and delayed weaning failures. We present our clinical experience with successful weaning by using M-mode ultrasonography and a cough-assist device for secretion clearance after extubation in a quadriplegic patient undergoing C2-4 spine laminoplasty.

Background: Dexmedetomidine has a sedative analgesic property without respiratory depression. This study evaluated the efficacy of dexmedetomidine as an appropriate sedative drug for monitored anesthesia care (MAC) in outpatients undergoing cataract surgery on both eyes compared with combination of propofol and alfentanil. Methods : Thirty-one eligible patients were randomly divided into two groups on the first operation day. Dexmedetomidine was administered in group D at 0.6 μg/kg/h, and propofol and alfentanil was infused concomitantly in group P at a rate of 2 mg/kg/h and 20 μg/kg/h, respectively. Sedation was titrated at Ramsay sedation score 3. Iowa satisfaction with anesthesia scale (ISAS) of the patients was evaluated postoperatively. Systolic blood pressure (SBP), heart rate (HR), respiration rate (RR), and peripheral oxygen saturation (SpO2) were recorded throughout the surgery. For the second operation, the group assignments were exchanged. Results: Postoperative ISAS was 50.3 (6.2) in group D and 42.7 (8.7) in group P, which was statistically significant (P < 0.001). SBP was significantly lower in group D compared with group P from the beginning of the operation. HR, RR, and SpO2 were comparable between the two groups. There were 8 cases (25.8%) of hypertension in group P, and 1 case (3.2%) in group D (P < 0.05). In contrast, 1 case (3.2%) of hypotension and 1 case (3.2%) of bradycardia occurred in group D. Conclusions: Compared with the combined use of propofol and alfentanil, dexmedetomidine could be used appropriately for MAC in cataract surgery with better satisfaction from the patients and a more stable cardiovascular state. (Korean J Anesthesiol 2011; 61: 453-459)

Background Hydroxyethyl starch (HES) solutions are used as plasma expanders for correcting hypovolemia, but can lead to impaired coagulation. We evaluated the changes in hematological and hemostatic profiles with three types of HES. Methods Patients were randomized to receive volume replacement with 10% pentastarch 260/0.45 in 0.9% saline (Group-PEN, n = 25), 6% tetrastarch 130/0.4 in 0.9% saline (Group-TETS, n = 25), or 6% tetrastarch 130/0.4 in a balanced electrolyte solution (Group-TETB, n = 25). Coagulation was assessed using rotational thromboelastometry (ROTEM®) and other laboratory tests were performed, including measurements of hematological and hemostatic parameters and electrolytes. Results Post-operative ROTEM® parameters changed toward hypocoagulable states in all groups. The post-operative parameters of EXTEM and FIBTEM were more impaired in Group-PEN than in Group-TETB. The percentage change in INTEM clot formation time (P = 0.004) and α-angle (P = 0.003) were smaller in Group-TETS and Group-TETB than in Group-PEN. The percentage change in the FIBTEM maximum clot firmness was greatest in Group-PEN (P = 0.011). The international normalized ratio of prothrombin time (P < 0.001) and the activated partial thromboplastin time (P < 0.001) were significantly prolonged in Group-PEN compared to those of Group-TETB. Conclusions The 6% HES 130/0.4 in a balanced electrolyte solution seemed to have less of an impact on blood coagulation than the 10% HES 260/0.45. No differences in hemostatic profile were observed between the balanced electrolyte and saline-based 6% HES 130/0.4.

Electroconvulsive therapy (ECT) had been used for psychiatric diseases such as depression. Recently, modified ECT is preferred, where the patient is in a state of muscle relaxation induced by muscle relaxant before the influx of electrical current. Although muscle relaxant is used, forceful jaw clenching is inevitable during ECT, since masticatory muscles, particularly the temporalis and the masseter, are directly stimulated by the electrical current. Although biting pressure in a conscious individual is usually controlled by a feedback mechanism to avoid excessive strain, this feedback mechanism does not come into action in an anesthetized patient [1]. Therefore, the teeth or other intraoral structures can be injured from biting or invagination during modified ECT. Psychiatric patients are especially vulnerable to intraoral injuries during modified ECT, because they are more likely to have drug-related dry mouth, smoking, and/or alcohol addiction. In xerostomia patients, the change in the pH and the immune function secondary to reduced salivary flow may also lead to an increased risk of intraoral infection [2]. In order to prevent intraoral injury during modified ECT, mouthguards rather than oral airways are used. Various types of gags and mouthguards have been used such as rubber bite blocks, braided guaze gags, gauze wrapped tongue blades and mouthguards. McClure devised a gag made of dental plastic, and also described about molded mouthguards [1]. But individually molded mouthguards like hard rubber bite blocks are so firm that care should be given to prevent soft tissue injuries such as tongue bites which can occur between the teeth and the mouthguard. We would like to describe a tongue laceration case which occurred during modified ECT despite using a mouthguard. A 71-year-old female patient was admitted for modified ECT under the diagnosis of depression. The mouthguard was made of silicone, immersed in hot water before use and transformed to fit the denture of the patient (Fig. 1A). After modified ECT was given, tongue laceration was found, which seemed to have occurred from biting between the mouthguard and the teeth. Tongue laceration was 1.5 cm long and 0.5 cm deep. Neither active bleeding nor hematoma was observed. After physical examination by an otolaryngologist, it was sutured simply with Vicryl 4-0 under local anesthesia (Fig. 1B). The wound recovered well without complication. Fig. 1 The mouthguard in proper position (A). Tongue laceration repaired with a simple continuous suture. The tongue has an irregular and dry fissured surface, which is a typical characteristic of dry mouth (B). Intraoral soft tissue injuries, especially tongue injuries generally recover well after simple treatment because of the abundant blood supply. Most tongue lacerations do not require sutures. Lacerations that should be repaired with suture include bisecting wounds, lateral border wounds, wounds with active hemorrhage, wounds larger than 2 cm, gaping wounds and amputation injuries [3,4]. If the patient cooperates well, tongue laceration can be sutured under local anesthesia using absorbable material such as Vicryl 4-0 [3]. Some lacerations may cause airway complications including intraoral structure swelling and difficult breathing. In the case of hematoma, blood fills the submandibular space, the floor of the mouth becomes full, and then the tongue is forced upwards and backwards, causing an elevation of the tongue and airway obstruction. If swelling and difficult breathing became severe, early nasotracheal intubation or tracheostomy should be considered for airway protection. Extubation should be performed after the swelling subsides. While active arterial bleeding requires intervention, subsequent treatments are usually conservative, such as steroids, antibiotics and reversal of any coagulopathy [5]. Before all else, one should examine the patient's dental and oral condition carefully and check whether the mouthguard fits well to the patient before performing ECT. If necessary, the patient should get dental treatment in advance to ensure his or her safety during ECT.

The number of patients with spinal cord injury (SCI) has increased recently due to the development of medical management and rehabilitation. As the survival rates of females with SCI are increasing, the number of parturient females with SCI is also rising [1]. Autonomic dysreflexia (ADR) is the most serious complication in parturient females with SCI above the T10 level, because uterine contractions and labor pain cannot be detected by the patients themselves. Early fetal and uterine monitoring with adequate labor analgesia is essential to prevent ADR [2]. Parturient females with SCI should be assessed by a multidisciplinary team that includes an obstetric anesthesiologist, obstetrician, and neurologist, and an intrapartum care plan should be established early to avoid labor-induced ADR [3]. We herein present a case of a parturient female with SCI at the level of T6 who was admitted for early labor analgesia but in whom normal delivery failed; an emergency cesarean section was successfully performed under epidural anesthesia. A 36-year-old, 148 cm, 49 kg, primigravida and primipara parturient female was admitted at 34 + 2 weeks' gestation for delivery. She had been paraplegic with muscular atrophy due to T6 damage after suffering from poliomyelitis when she was 5 years old. Partial sensation remained below T10. She reported no previous experience of ADR. Uterine contraction and labor pain are known to potentially induce ADR; in addition, her uterine contractions were thought to be insufficient for vaginal delivery. Thus, she was admitted for careful observation of her uterine contractions and for induction of labor. No blood test abnormalities were noted at the time of admission, but cardiomegaly was evident on a chest X-ray. Pulmonary function testing showed a moderate restrictive pattern (FVC, 55%; FEV1, 63%; FEV1/FVC, 90%), but the results of her arterial blood gas analysis were within the normal range. A sinus rhythm was present on the electrocardiogram (ECG), and mild mitral/atrial regurgitation with normal systolic function (ejection fraction, 68%) and a graft valve was observed on echocardiography. The cardiologist stated that according to her cardiac function, she might be at low risk for delivery, and if a hypertensive event occurred due to ADR, it could be controlled with nitroglycerine, nicardipine, and nitroprusside. At the time of admission, her vital signs were stable (blood pressure, 90-106/50-65 mmHg; heart rate, 77-88 /min; respiratory rate, 20 /min; body temperature, 35.8℃). Upon admission, her cervical dilatation was 3 to 4 cm and effacement was 50%. A continuous fetal heart rate and labor monitoring were maintained, but there was no progression for 6 days after admission. On the seventh day after admission, the amniotic membrane ruptured and the uterus contracted for 5 to 6 min cycles. Epidural labor analgesia was planned, and an epidural catheter was inserted through the L4-5 interspace upon feeling a loss of resistance. An injection of 0.75% ropivacaine (10 ml, 75 mg), fentanyl (200 µg), and normal saline (87 ml) (total amount, 100 ml) was administered as a bolus dose after a test dose, and a patient-controlled analgesia pump for continuous infusion was connected with the remainder (90 ml) of the mixture at a flow rate of 10 ml/h. A radial arterial catheter was placed, and continuous monitoring of her blood pressure, ECG, and pulse oximetry was performed. About 2 h later, an oxytocin infusion was started to induce labor. Her cervix was fully effaced 4 h after the oxytocin infusion was begun, and her blood pressure and heart rate became elevated slightly to 154/104 mmHg and 82 /min, respectively. ADR was suspected, and a continuous infusion of nitroglycerine was started from 0.4 µg/kg/min and tapered for 2 h. About 3 h after full cervical effacement, failure of descent was diagnosed and an emergent cesarean section was planned. The patient was transferred to the operating room without premedication, and standard monitoring was begun, including ECG, pulse oximetry, and continuous invasive blood pressure measurement. A facial mask with a reserve bag was fitted to the patient with a fresh gas flow of 6 L/min of 100% oxygen. Seven milliliters of 0.75% (52.5 mg) ropivacaine was injected via an epidural catheter, and her level of sensory block was determined at T6 using an alcohol swab and pinprick test. During the emergency cesarean section, the vital signs of the patient were stable (blood pressure, 127/84 mmHg; heart rate, 100 /min; oxygen saturation, 100%). After placental extraction, 30 IU of oxytocin was administered and titrated according to her blood pressure and uterine contractions. Her level of sensory block was determined to be at T6 using an alcohol swab after the surgery, and there were no hemodynamic abnormalities during the cesarean section. Hemodynamic monitoring was continued in the recovery room, and the epidural catheter was removed 1 h after the surgery. Postoperative pain control was achieved using an intravenous NSAID. ADR is initiated by noxious stimuli below the lesion. Such noxious stimuli may include bowel or bladder distension, pelvic examination, uterine contraction, or pain [2]. The impulse is then transmitted to the spinothalamic tract and posterior columns. Sympathetic spinal reflexes are propagated, and the inhibitory outflow from the hypothalamus increases. However, the inhibitory outflow cannot be transmitted in patients with SCI, and this unregulated sympathetic activity leads to severe hypertension [3]. It is important to avoid trigger factors, especially during pregnancy. For example, urinary catheterization or pelvic examination using a speculum should be performed under topical anesthesia, and a proper bowel regimen should be applied if the patient complains of constipation or bowel distension [1]. Hypertension is also a sign of pre-eclampsia; therefore, distinguishing ADR from preeclampsia is important for appropriate treatment. In cases of ADR, hypertension and other symptoms are synchronous with uterine contraction, but the symptoms in patients with pre-eclampsia are independent of uterine contractions. In addition, an elevated LFT may be seen in patients with pre-eclampsia, in contrast to the normal LFT of patients with ADR [1]. Epidural catheterization should be established early in labor and maintained during the postoperative period for adequate pain control. Achievement of a T10 sensory level or higher should be attempted [2]. Despite the lack of sensation, epidural catheterization for continuous analgesia is considered to be the most effective method of preventing ADR during labor [4]. In the present patient, the epidural catheter was removed in the recovery room to prevent catheter infection because decubitus ulcers were present near the insertion site of the epidural catheter, and methicillin-resistant Staphylococcus aureus was cultured from the sore.

The vasovagal response is characterized by an inappropriate combination of bradycardia and paradoxical vasodilation. During a general or neuraxial anesthesia-induced sympathectomy, a sudden vagal activation and/or an acute reduction in sympathetic tone can cause serious vasovagal responses. Neuraxial anesthesia for Cesarean section may trigger vasovagal response, due to multiple risk factors; high neuraxial block, sudden hemorrhage, aortocarval compression, peritoneal manipulation, and emotional stress. A 39-year-old pregnant woman, at 38 weeks of gestation with episodes of non-sustained ventricular arrhythmia and newly developed vasovagal syncope during pregnancy, was scheduled to undergo a spinal anesthesia for an elective Cesarean section. Immediately after the placental expulsion, a sudden severe bradycardia, followed by a cardiac arrest occurred. The patient fully recovered after prompt cardiopulmonary resuscitation with chest compression, manual ventilation with oxygen, rapid injection of epinephrine and hydration. This case illustrates a serious potential risk of vasovagal response superimposed on neuraxial anesthesia, during a Cesarean section, especially during placental expulsion.

Background We investigated the effects of a magnesium sulfate pretreatment on intubating conditions and cardiovascular responses during rapid sequence tracheal intubation (RSI) in this double-blind randomized study. Methods Adult patients (n = 154) were randomly allocated to a rocuronium-0.6, rocuronium-0.9, or magnesium group. The magnesium group was pretreated with 50 mg/kg MgSO4, and the other two groups received the same volume of isotonic saline. Anesthesia was induced with alfentanil, propofol, and either 0.6 mg/kg (rocuronium-0.6 and magnesium groups) or 0.9 mg/kg (rocuronium-0.9 group) rocuronium. An anesthesiologist, blinded to the group assignments, performed RSI and assessed the intubating conditions. Systolic arterial pressure (SAP) and heart rate (HR) were recorded before the magnesium sulfate or normal saline was administered, before anesthesia induction, before intubation, and every minute after intubation for 5 min. Results Airway features were similar among the three groups. The intubating conditions were improved significantly in the magnesium group (P < 0.001) compared with the other two groups. Significant increases in SAP at 1 min after intubation were observed in the rocuronium-0.6 and -0.9 groups when compared with the magnesium group (P < 0.05). HR was comparable among the three groups (P > 0.05). No hypertensive episode occurred during the immediate post-intubation period in the magnesium group (P = 0.001), and tachycardia occurred most frequently in the rocuronium-0.6 group (P < 0.05). Conclusions MgSO4 administered prior to RSI using alfentanil, propofol, and rocuronium may improve intubating conditions and prevent post-intubation hypertension.

Guillain-Barré syndrome is an acute inflammatory demyelinating polyradiculopathy characterized by progressive motor weakness, areflexia, and ascending paralysis. Guillain-Barré syndrome is extremely rare in pregnant patients, and there are no established guidelines for delivery or safest anesthetic methods. We report a Cesarean delivery in the case of a 32-year old woman who was diagnosed with Guillain-Barré syndrome 18 weeks into gestation. Tracheostomy was performed due to progressive respiratory muscle weakness and respiratory failure, and ventilator support was required in the intensive care unit. The respiratory difficulty was exacerbated by the growth of the fetus, necessitating emergency Cesarean delivery. The delivery was successfully performed under general anesthesia, and the patient recovered without neurological sequelae.

Anaphylaxis is an acute and fatal systemic allergic reaction to an allergen, and it can be an unpredictable and life-threatening cause during anesthesia. Latex is the second most common cause of anaphylaxis following the use of neuromuscular blocking agents during general anesthesia or surgery. We report on a 67-year-old male who had undergone surgery under general anesthesia without any problem but who presented with severe intraoperative anaphylaxis to latex surgical gloves. This case emphasizes the need for anesthesiologists to quickly diagnose and properly manage an allergic reaction in patients under general anesthesia.

Hysteroscopy is frequently used to assist the diagnosis and treatment of a series uterine diseases. However, complications associated with the procedure including fluid overload, hyponatremia, hypo-osmolality, hemorrhage, uterine perforation, and air embolism have been reported. The incidence of fluid overload with hyponatremia during hysteroscopic procedures has been reported to be up to 6% and it can probe fatal. Thus, early recognition of this condition and prompt intervention thereof is important to prevent adverse sequelae. Here, we report a case of hyponatremia with incidental fluid overload during hysteroscopy. We detected the signs of complication early on and were thus able to manage it promptly without any resulting adverse sequelae.

Kennedy’s disease is a rare lower motor neuron disease affecting the limbs and bulbar musculature. Regional anesthesia is generally the recommended anesthetic technique in patients with Kennedy’s disease because of bulbar involvement and airway clearing disturbance. We administered general anesthesia in a patient with Kennedy’s disease who was undergoing a laparoscopic cholecystectomy. We closely monitored the degree of neuromuscular blockade throughout the operation and injected atracurium on demand. There was no exacerbation of neurologic signs or symptoms postoperatively. Therefore, we report the successful administration of general anesthesia for laparoscopic cholecystectomy in a patient with Kennedy’s disease.

Background: Etomidate frequently causes myoclonus. Since the myoclonus is caused by a transient disequilibrium due to etomidate exposure in the CNS, we hypothesized that a slow rate of injection of the drug may decrease the incidence of myoclonus. We conducted a prospective randomized study to compare the effect of two different types of the etomidate injection rate on the incidence and severity of myoclonus. Methods: Fifty patients were randomly assigned to the fast-injection group (group F) or slow-injection group (group S): Group F patients received etomidate (0.3 mg/kg) over ten seconds. The same dose was administered over two minutes for group S patients. The response to the injection of etomidate was grade d on a four-point scale in a blinded manner. The time to loss of consciousness (LOC) was also recorded. Results: The incidence of myoclonus was significantly lower (P ＜ 0.001) in group S patients; 84% and 28% in group F and group S patients, respectively. The myoclonus was also significantly less severe in group S patients (P ＜ 0.001). The time to LOC was significantly longer in group S patients (106 ± 22 sec) than that of group F patients (49 ± 18 sec, P ＜ 0.001). Conclusions: With same dose, a slower rate of injection resulted in a lower incidence of myoclonus and can effectively reduce myoclonus without the use of a pretreatment agent. (Korean J Anesthesiol 2008; 55: 305～7)