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Whole lung lavage (WLL) is a therapeutic procedure to remove accumulated material by infusing and draining the lungs with lavage fluid. This procedure has been regarded as the current standard of care to treat pulmonary alveolar proteinosis. However, the WLL protocol has not yet been standardized and the technique has been refined and modified a number of times. A rapid infusion system is a device used to infuse blood or other fluids at precise rates and normothermic conditions. This device is not typically used in WLL, which relies on the passive infusion of fluids using the gravitational force. However, in this study we performed WLL using a rapid infusion system, since we aimed to take advantage of its shorter operation time and greater degree of control over fluid volume and temperature. The patient's symptoms improved without the occurrence of any complications.

Castleman's disease (CD) is a rare lymphoproliferative disorder of undetermined etiology. Unicentric Castleman's disease is confined to a single lymph node; it is usually asymptomatic though sometimes has local manifestations related to mass effects. In contrast, multicentric Castleman's disease (MCD) typically presents with lymphoid hyperplasia at multiple sites; it is associated with systemic symptoms and abnormal laboratory findings, with a less favorable prognosis. In case of anesthesia in CD, an exhaustive preanesthetic evaluation is essential to identify associated clinical manifestations which may influence the management of the anesthesia. Perioperative careful monitoring and proper anesthetic management are both important. We report a case of general anesthesia with anesthetic management in a patient with MCD that has not been documented in the literature.

It has been well documented that there is opioid resistance in neuropathic pain. This indicates that the endogenous opioid system may not be involved effectively in modulating neuropathic pain. The present study sought to determine if activation of the descending pain inhibition system might produce analgesia in the animal neuropathic model we developed. Under ketamine anesthesia, male Sprague-Dawley rats were chronically implanted with stimulating electrodes in the ventral periaqueductal gray matter (PAG) and both the tibial and sural nerves of the sciatic nerve branches were severed. Pain sensitivity was measured with a von Frey filament and acetone applied to the sensitive area for 1 week postoperatively. Rats with neuropathic pain syndrome after transection of the tibial and sural nerves were tested as to the analgesic effects of ventral PAG stimulation for an additional two weeks. Electrical stimulation of the ventral PAG turned out to be highly effective in alleviating neuropathic pain. Mechanical allodynia and cold allodynia were reduced by PAG stimulation. Naloxone reversed the antiallodynic effects of ventral PAG stimulation. These results suggest that activation of the descending pain inhibition system including the ventral PAG reduces neuropathic pain syndrome and that opiates are involved in this system.

We have previously demonstrated that electrical stimulation of the ventral periaqueductal gray matter (PAG) produced analgesia in neuropathic pain in rats. Opioids were also shown to be involved in analgesic effects. This study sought to determine whether opiates microinjected into the ventral PAG produce analgesia. Male Sprague-Dawley rats were chronically implanted with a guide cannula in the PAG under pentobarbital anesthesia and both the tibial and sural nerves were completely cut. Pain sensitivity was postoperatively measured with a von Frey filament and acetone applied to the sensitive area for I week. Opioids such as [D-Ala 2 ,N-MePhe 4 ,Gly(ol) 5 ]-enkephalin (DAMGO) and [D-Pen 2 ,D-Pen 5 ].-enkephalin (DPDPE) were injected into the PAG. DAMGO, a μ-opioid agonist, and DPDPE, a δ-opioid agonist, were highly effective in reducing neuropathic pain. These effects were reversed by naloxone. These results suggest that the neurons in the ventral PAG are activated by opioids to produce analgesia and that specific opioid receptors are involved in the descending pain inhibition system from the PAG.

Peripheral nerve injury frequently leads to neuropathic pain like hyperalgesia, spontaneous pain, mechanical allodynia, thermal allodynia. It is uncertain where the neuropathic pain originates and how it is transmitted to the central nervous system. This study was performed in order to determine which peripheral component may lead to the symptoms of neuropathic pain. Under halothane anesthesia, male Sprague-Dawley rats were subjected to neuropathic surgery by tightly ligating and cutting the tibial and sural nerves and leaving the common peroneal nerve intact. Behavioral tests for mechanical allodynia, thermal allodynia, and spontaneous pain were performed for 2 weeks postoperatively. Subsequently, second operation was performed as follows: in experiment 1, the neuroma was removed; in experiment 2, the dorsal roots of the L4-L6 spinal segments were cut; in experiment 3, the dorsal roots of the L2-L6 spinal segments were cut. Behavioral tests were performed for 4 weeks after the second operation. Following the removal of the neuroma, neuropathic pain remained in experiment 1. After the cutting of the L4-L6 or L2-L6 dorsal roots, neuropathic pain was reduced in experiments 2 and 3. The most remarkable relief was seen after the cutting of the L2-L6 dorsal roots in experiment 3. According to the fact that the sciatic nerve is composed of the L4-L6 spinal nerves and the femoral nerve is composed of the L2-L4 spinal nerves, neuropathic pain is transmitted to the central nervous system via not only the injured nerves but also adjacent intact nerves. These results also suggest that the dorsal root ganglion is very important in the development of neuropathic pain syndrome.

Background: Cerebral hypotension and desaturation can occur during shoulder surgery in the seated position. We evaluated the correlation of cerebral oxygen saturation (rSO2) using near infra-red spectroscopy (NIRS) and mean arterial pressures (MAP) (at the levels of the brain and heart). Methods: Fifty patients, scheduled for the arthroscopic shoulder surgery in the seated position, were enrolled to monitor the rSO2, bispectral Index (BIS), and MAPs at the levels of the brain and heart. The values of each parameter were collected at 5 min after intubation, immediately after placing the patient in the sitting position, 5 min after the patient was seated, immediately after the surgical incision, and every 30 min after incision. Results: A correlation between the cerebral rSO2 and the MAP at the level of brain were statistically significant. Cerebral rSO2 and MAP after a change of posture from supine to sitting position were significantly decreased, compared to the baseline value. Conclusions: Monitoring cerebral rSO2 and MAP at the level of brain can be helpful to detect the possibility of cerebral deoxygenation earlier. (Korean J Anesthesiol 2012; 63: 297-301)

This study was conducted to compare the efficacy of intravenous alfentanil and lidocaine as a pretreatment for the prevention of withdrawal movements following a rocuronium injection and hemodynamic change following tracheal intubation. Methods: This study evaluated 180 patients that were divided into the following 3 pretreatment groups: group C: normal saline, group L: lidocaine 1 mg/kg, group A: alfentanil 10μg/kg. Anesthesia was induced using 5 mg/kg thiopental sodium, after which the test drug was injected. Rocuronium (1 mg/kg) was then administered 1 minute after the test drug was injected over 5 seconds and the response was characterized as one of the following: no movement, movement limited to the wrist, to the elbow or to the shoulder. Intubation was performed 1 minute later. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were then recorded at each of the following points: T1: preinduction, T2: immediately prior to rocuronium injection, T3: immediately after rocuronium injection, T4: immediately prior to intubation, T5: immediately after intubation, T6: 1 minute after intubation, T7: 5 minutes after intubation. Results: The incidence of withdrawal movement was significantly lower in group A than groups C and L (P ＜ 0.05). In addition, SBP, DBP and HR following intubation were significantly lower in group A than group C and group L (P ＜ 0.05). Conclusions: Pretreatment with 10μg/kg of alfentanil effectively reduced the incidence of withdrawal movement in response of rocuronium injection and caused minimal hemodynamic changes following intubation.

Degenerative disc disease of the lumbar spine caused leg pain with associated calf weakness and atrophy. However, an unusual case of leg pain and calf atrophy due to neural compression is reported. We reported a rare case of a Baker's cyst causing common peroneal nerve and tibial nerve entrapment neuropathy. Initially, after arthroscopic menisectomy and cyst decompression, Baker's cyst was recurred and then open excision was done. Until 1 year after surgery, the cyst was not recurred, increased muscle bulk was noted and EMG showed improved findings. But she continued to complain of lower leg weakness and sole paresthesia owing to delayed diagnosis and cyst decompression.

Background: The increasing shortage of liver donors has resulted in exponential growth of living donor liver transplantation (LDLT). There are obvious concerns about the increased risk to the donors. There has been study on the impact of donation as a function of the degree of resection. However, the effect of inhaled anesthetics combined with the degree of parenchymal loss on the liver function has not been quantified. We analyzed the prothrombin time (PT), as hepatic synthetic function, after donor hepatectomy (DH) with the recipient undergoing general anesthesia with different types of inhaled anesthetics. Methods: One-hundred thirty-four patients who underwent DH were enrolled. The patients were randomly divided into four groups: enflurane (group E), isoflurane (group I), sevoflurane (group S), and desflurane (group D). Anesthesia was performed according to institutional standards. The PT was measured for 7 days before and daily after DH (POD). Total liver volume and resected liver volume were measured and fraction of the graft volume was calculated. Results: The PT peaked on POD 1 in all groups. A significantly lower PT was observed in group D compared to the other groups until POD 3. The fraction of the graft volume showed significant correlation with the PT change. PT abnormalities were affected by the preoperative PT, the graft fraction and inhaled anesthetics. Conclusions: Desflurane induced lesser elevation of the PT than did the other inhaled anesthetics until POD 3. The preoperative PT, the graft fraction and the inhaled anesthetics may be key factors for inducing postoperative PT abnormalities.

Background: This study was designed to demonstrate the peripheral effect of ketamine on the synovia of the knee joint and evaluate the analgesic effect of an intraarticular ketamine injection following knee arthroscopy. Methods: In a double blind randomized study, 80 ASA class 1 or 2 patients were selected for elective arthroscopic knee surgery. The patients received either 20 ml of normal saline (Group C, n = 19), 20 ml of 0.5% ropivacaine (Group R, n = 21), 1 mg/kg of ketamine mixed with 20 ml of normal saline (Group K, n = 20) or 1 mg/kg of ketamine mixed with 20 ml of 0.5% ropivacaine (Group RK, n = 20), intraarticularly, just prior to wound closure. Postoperative pain was evaluated using a visual analogue scale (VAS 0 to 100) score at 1, 2, 6, 12, 24 and 48 hours after the intraarticular injection, with the side effects found in the four groups also evaluated. The patients’ requests for rescue analgesic were recorded, total doses of tarasyn calculated and the overall patient satisfaction also evaluated. Results: The difference in the VAS scores for all time periods was not significant. The number of patients receiving rescue analgesics and the total doses received in Group C were greater than those for the other groups, but this was not significant. No side effects were observed in any of the patients. Conclusions: Ketamine and local anesthetics have been reported to have peripheral analgesic effects, with variable duration in the measurements of pain and hyperalgesia. However, we failed to demonstrate a peripheral analgesic effect on postoperative arthroscopic pain.

Adenotonsillectomy is one of the most common operations being performed in children. Fortunately, pulmonary edema is an infrequent perioperative complication, but pulmonary edema complicting adenotonsillectomy has been reported to occur mainly during the induction of anesthesia or immediately after extubation of endotracheal tube. The etiology of pulmonary edema in these cases is presumed to be the sudden relief of chronic airway obstruction or acute upper airway obstruction (UAO), such as post-extubation laryngospasm and laryngeal edema. The purpose of this paper is to report the occurrence of pulmonary edema during the adenotonsillectomy, which is both rare and unpredictable, especially at 40 to 50 minutes after endotracheal intubation. In addition, we describe its clinical course.

The Prader-Willi syndrome (PWS) is a rare disorder characterized by infantile hypotonia, subsequent obesity with hyperphagia. Hypogonadism, cryptorchidism, delayed psychomotor development, short status, strabismus, myopia, scoliosis, kyphosis and temperature regulation abnormality are other features. The cause of this syndrome is unknown, but a disturbance in the hypothalamus has been postulated because of the various manifestation of the syndrome. The major genetic mechanism giving rise to PWS is a paternal deletion of about the same size in the 15q11-q13 region, that occurs in 70% of the cases. The principal problems related to anesthesia are those that are secondary to the patient's hypoglycemia, skeletal muscle hypotonia and obesity. An 20-month-old boy with PWS was scheduled for surgical correction of bilateral undescended testes. The trachea was intubated with the aid of succinylcholine 7.5 mg intravenous injection. Muscle relaxation was facilitated with intermittent intravenous administration of atracurium (total dose 8 mg). No prolonged effect of muscle relaxants was observed during anaesthesia. High grade fever (38-) was present during anaesthesia.

Background: Arterial pressure measured in a peripheral artery sometimes underestimates central arterial pressure after discontinuation of cardiopulmonary bypass (CPB) for reasons that are still unclear. Therefore, the sideport of the aortic cannula is often used for measurement of central pressure because it is accessible and is near the ascending aorta. This study was designed to assess whether blood pressure measured at the sideport of the aortic cannula mirrors blood pressure measured within the ascending aorta. Methods: Blood pressure was compared in 21 patients 5 minute after discontinuation of CPB at two sites: at the tip of the 23-gauge needle that points distally at a 25 to 30 angle to the blood flow within the ascending aorta and at the sideport of the aortic cannula. The effects on the sideport-to-aorta pressure differences and wave contour were tested by placing a clamp at the proximal and distal end of the arterial line (aortic cannula sideport-oxygenator tube) of the CPB circuit. Results: There were no statistical differences between systolic, diastolic and mean blood pressure measured at the sideport and ascending aorta when the clamp was applied to the proximal end. The average sideport-to-aorta systolic pressure differences (0.3 3.1 mmHg ranged from -5 to 6 mmHg), diastolic pressure differences (-0.9 2.1 mmHg ranged from -4 to 4 mmHg) and mean pressure differences (-0.5 1.0 mmHg ranged from -2 to 2 mmHg) were not significantly different. No statistical differences were noted between pressures measured at the two sites when the clamp was applied to the distal end of the arterial line. Conclusions: It is concluded that the pressure measured at the sideport of the aortic cannula reflects the pressure in the ascending aorta after discontinuation of CPB.

Background: Propofol often causes pain when injected into small peripheral veins, but the pain can be minimized by using a larger vein. This study was designed to determine whether local warming of the injection site and forearm before propofol injection is effective in reducing pain. Methods: Sixty adult patients undergoing general anesthesia for an elective surgery were randomly allocated to one of two groups. All were unpremedicated and had an 18-gauge cannula inserted into a cephalic vein on the wrist. Patients in group 1 (n = 30) received 1% propofol at room temperature. Patients in group 2 (n = 30) received 1% propofol after local warming (36-37oC) of the injection site and forearm using a forced-air warming system (Bair Hugger). For each patient, the pain during injection of the propofol solution was graded as none, mild, moderate, or severe. Results: Overall the incidence of pain was significantly reduced in group 2 (36.7%) compared with group 1 (66.7%). No patients complained of pain at the injection site and forearm in group 2. However, there was no significant difference in the incidence or severity of pain on the elbow and axilla between the two groups. Conclusions: We found that local warming applied to the injection site (wrist) and forearm before propofol injection is significantly effective in reducing pain at the injection site and forearm, but there was no improvement of pain on the elbow and axilla when injecting.

It is difficult to determine respiratory criteria of fitness for surgery and anesthesia in patients with intractable chronic obstructive pulmonary disease (COPD), who have high mortality and morbidity in the perioperative period. Also, it is commonly assumed that general anesthesia carries a greater risk of perioperative pulmonary complications than regional anesthesia in patients with COPD. A 79-yr-old COPD female patient complaining of right hip pain due to fracture of right femur neck and dyspnea on rest was admitted for surgery. Even after aggressive medical management for COPD during the preoperative period, dyspnea on rest and expiratory wheezing were not improved. The results of the pulmonary function test and the immediate preoperative arterial blood gas analysis were as follows: FVC 0.97 L, FEV1 0.38 L, FEF25-75% 0.11 L/sec, PaO2 47.6 mmHg, and PaCO2 68 mmHg. We report the anesthetic considerations for the epidural block for the severe COPD patient associated with hypoxemia and hypercarbia. (Korean J Anesthesiol 1999; 36: 540∼546)

Background : The hemodynamic responses to laryngoscopy and endotracheal intubation, tachycardia and arterial hypertension, are well known and should be minimized. The purpose of this study is comparison of effects of low-dose sufentanil and fentanyl on the changes of blood pressure and heart rate due to laryngoscopy and endotracheal intubation. Methods : The cardiovascular responses were measured and compared in 60 patients, between 20∼65 years old, ASA class I or II, undergoing elective operation pretreated with normal saline (n=20, control group), fentanyl 3 g/kg (n=20, fentanyl group), and sufentanil 0.6 g/kg (n=20, sufentanil group), respectively. Anesthesia was induced intravenously with pentothal sodium 4∼5 mg/kg and endotracheal intubation was conducted after injection of succinylcholine 1 mg/kg. The changes of systolic arterial pressure, mean arterial pressure, diastolic arterial pressure, heart rate, and SpO2 (saturation of arterial oxygen) were measured at postsedation with pentothal sodium, 30 seconds, 1 minute, and 3 minutes following intubation. The variables of each group were compared with preinduction baseline values and fentanyl and sufentanil groups were compared with control group. Data were analyzed for statistical significance using repeated measures of ANOVA (analysis of variance). P＜0.05 was considered statistically significant. Results : The systolic and mean arterial pressures at 30 seconds and 1 minute and diastolic arterial pressure at 30 seconds after laryngoscopy and intubation in sufentanil group were significantly lower than values of control group (p＜0.01). The heart rates at 30 seconds and 1 minute were significantly attenuated compared with control group (p＜0.05). The blood pressures and heart rates of fentanyl group at 30 seconds after intubation were significantly attenuated compared with control group (p＜0.05). Conclusions : The results suggest that pretreatment of fentanyl 3 g/kg and sufentanil 0.6 g/kg is effective to prevent the elevation of blood pressures and heart rates, and sufentanil 0.6 g/kg is more effective than fentanyl 3 g/kg to attenuate the hemodynamic changes due to laryngoscopy and intubation. (Korean J Anesthesiol 1998; 35: 662∼668)

Background : The clinicians frequently use crystalloid solutions to manage inpatients and outpatients. Recently Normosol becomes available but there is little understanding of Normosol. So we surveyed residents to assess the level of knowledge about three crystalloid solutions. Methods : The respondents were 46 residents of internal medicine, general surgery, pediatrics, and anesthesiology. The questionnaire asked for the following information: To list the constituents and their concentrations in each 1 litre of normal saline, Hartmann's solution, and Normosol; to match correct pH and osmolality to each solutions; to describe the metabolism and role of lactate in Hartmann's solution. Results : All 46 (100%) knew that both sodium and chloride ions were present in normal saline. Twenty six (57%) of them knew correct concentration of sodium and chloride. The presence of sodium ion in Hartmann's solution was known by 44 (96%) and its concentration was recognized by 20 (43%). Chloride ion and potassium ion in Hartmann's solution were recognized by 43 (93%) and 42 (91%), respectively. Fifteen (33%) knew correct constituents of Hartmann's solution. Only three (7%) knew correct constituents and their concentration of Hartmann's solution. Thirty six (76%) knew that bicarbonate is formed by metabolism of lactate. No one accurately recorded the correct constituents of Normosol. Conclusions : The constituents and their concentrations of normal saline are well known to residents but those of Hartmann's solution and Normosol are not. Our survey reveals that there was little understanding of the reasons for including lactate in Hartmann's solution and even less of presence of acetate in Normosol. (Korean J Anesthesiol 1998; 34: 403∼408)