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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.

Cardiovascular comorbidities to the Marfan syndrome may induce hemodynamic instability especially in the parturients during labor or delivery. For anesthesiologists, it is challenging to maintain hemodynamic stability during Cesarean section in those patients with Marfan syndrome. Remifentanil is an ultra-short-acting opioid with rapid onset and offset of action which provides cardiovascular stability during surgery. Together with remifentanil, the use of a laryngeal mask airway can reduce the risk of hypertensive response followed by tracheal intubation. We describe the successful administration of remifentanil and application of laryngeal mask airway for emergent Cesarean section performed under general anesthesia in a patient with Marfan syndrome complicated by ascending aortic aneurysm and heart failure. The use of remifentanil (loading dose of 1 μg/kg for 1 min, 2 min before induction; thereafter continuous infusion dose of 0.1 μg/kg/min) was useful to maintain hemodynamic stability of the parturient throughout the surgery without neonatal respiratory depression. Keywords: Ascending Aortic Aneurysm; Cesarean section; Laryngeal mask airway; Marfan syndrome; Remifentanil

The security of the endotracheal tube (ETT) is important in the anesthesia and intensive care settings. Recently, an ETT holder instead of an adhesive tape is frequently used to provide the fixation of the ETT. There are some studies that focused on the effectiveness of the ETT holder in preventing displacement of ETT compared to an adhesive tape (1, 2). I have experienced the use of an ETT holder (E-holder, KS medical, Bucheon, Korea) in many different anesthesia settings and recognized its usefulness and convenience other than ETT security in the following specific settings. Firstly, the ETT holder is definitely effective for patients undergoing procedures that frequently require the adjustment of ETT (or double lumen tube) location including thoracic surgery. The location of double lumen tube needed for lung separation can be modified for effective ventilation during anesthetic induction or surgery, and after position changes. The tube can be easily relocated to the proper place for lung separation and effective ventilation by unlocking/relocking the button of the ETT holder under flexible bronchoscopic guidance (Fig. 1A), which can facilitate the operative procedure to be performed easily and quickly. Secondly, the ETT holder can be useful in procedures requiring the prone position (3). Especially, it is useful in all circumstances requiring the adjustment of ETT in the prone position. For instance, it is definitely useful for patients with Duchene muscular dystrophy undergoing scoliosis surgery under prone position. Adolescent patients with Duchene muscular dystrophy frequently have tracheobronchial malacia. If so, the airway pressure can be elevated due to the narrowing of the lesion of malacia when changed to the prone position (4). To overcome this problem, a reinforced ETT should be relocated so that it passes the narrowed tracheal lesion under flexible bronchoscopic guidance (Fig. 1B). However, the approach for this management is somewhat challenging with the patient in the prone position, and especially, the release and refixation of ETT with an adhesive tape is very difficult. The ETT can be easily relocated to the proper place to overcome the narrowing part of trachea by unlocking/relocking the button of the ETT holder, which can prevent the risk of respiratory complications associated with ventilatory difficulty and secure the safety of patients. Thirdly, the ETT holder is effective in keeping the ETT in a midline position. This is especially so when a flexible laryngeal mask airway (Flexible LMATM, Wooyoung meditech, Seoul, Korea; FLMA) is used because maintaining a midline position of LMA is very important in securing ventilation without leakage (Fig. 1C, 1D). Although an adhesive tape without a bite block or oral airway may enable an FLMA to be kept in a midline position, there is still a risk of airway obstruction associated with the patient biting an FLMA. Moreover, considering that an FLMA displays a tendency to be pushed out from the pharyngolaryngeal region if it is positioned so that only a low grade sealing is achieved, a tight fixation of the FLMA using the ETT holder is very important. I suggest that the ETT holder can enhance the convenience of anesthesiologists while providing more useful anesthetic management to patients in the above anesthesia settings.

Supplemental Digital Content is available in the text, Background: The differences in the incidence and severity of emergence agitation (EA) and emergence times between desflurane and sevoflurane anesthesia have not been as clearly elucidated in children as in adults. Methods: The design of the study is a systematic review with meta-analysis of randomized controlled trials. The study methodology is based on the Cochrane Review Methods. A comprehensive literature search was conducted to identify clinical trials comparing the incidence or severity of EA and emergence times in children anesthetized with desflurane or sevoflurane. Two reviewers independently assessed each study according to predefined inclusion criteria and extracted data from each study using a prespecified data extraction form. The data from each study were combined using a fixed effect or random effect model to calculate the pooled risk ratio (RR) or standardized mean difference (SMD) and 95% confidence interval (CI). Funnel plots were used to assess publication bias. Subgroup and sensitivity analyses were performed. Results: Fourteen studies met the inclusion criteria. Among the 1196 patients in these 14 studies, 588 received desflurane anesthesia and 608 received sevoflurane anesthesia. The incidence of EA was comparable between the 2 groups (pooled RR = 1.21; 95% CI: 0.96–1.53; I2 = 26%), and so was the severity of EA (EA score) between the 2 groups (SMD = 0.12; 95% CI: −0.02 to 0.27; I2 = 0%). Extubation and awakening times were shorter in the desflurane group than in the sevoflurane group; the weighted mean differences were −2.21 (95% CI: −3.62 to −0.81; I2 = 93%) and −2.74 (95% CI: −3.80 to −1.69; I2 = 85%), respectively. No publication bias was found in the funnel plot. The subgroup analysis based on the type of EA scale showed a higher incidence of EA in the desflurane group than in the sevoflurane group in studies using 3-, 4-, or 5-point EA scales; the pooled RR was 1.38 (95% CI: 1.10–1.73; I2 = 37%). Conclusion: The incidence and severity of EA were comparable between desflurane and sevoflurane anesthesia in children; however, emergence times, including extubation and awakening times, were shorter in desflurane anesthesia.

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: Total knee arthroplasty (TKA) generates severe postoperative pain in 60% of patients and moderate pain in 30% of patients. Because inadequate postoperative pain control can hinder early physiotherapy and rehabilitation, it is the most influential factor dictating a good outcome. The purpose of this study was to evaluate the effectiveness of continuous psoas compartment block (PCB) in comparison to intravenous patient-controlled analgesia (IVPCA) in TKA patients. Methods: 40 TKA patients were randomly divided into 2 groups. Group IVPCA (n = 20) received intravenous patient controlled analgesia (IVPCA) for 48 hours. Group PCB (n = 20) received continuous PCB for 48 hours at the fourth intertransverse process of the lumbar using the C-arm. Pain scores, side effects, satisfaction, the length of hospital stay, rescue antiemetics, and analgesics were recorded. Results: Pain scores (VNRS 0-100) were higher in Group IVPCA than in Group PCB. Nausea and sedation occurred more frequently in Group IVPCA than in Group PCB. There were no differences between the groups in the length of the hospital stay, satisfaction scores, and the use of rescue antiemetics and analgesics. Conclusions: Continuous PCB seemed to be an appropriate and reliable technique for TKA patients, because it provided better analgesia and fewer side effects such as nausea and sedation when compared to IVPCA. (Korean J Anesthesiol 2012; 62: 47-51)

Background In many countries, routine clinical anaesthesia does not always involve neuromuscular monitoring. In these clinical settings, the efficacy and safety of sugammadex use has not yet been confirmed. We investigated the efficacy and safety of sugammadex in the absence of neuromuscular monitoring. Methods One hundred and forty patients who underwent laryngeal microsurgery with the use of rocuronium as a neuromuscular blocking agent, without the use of a neuromuscular monitoring device, were retrospectively investigated. The patients were randomly chosen among all the patients who met the inclusion criteria at a tertiary university hospital between July 2013 and February 2015 and were allocated to group S (sugammadex group) or group P (pyridostigmine group) according to the neuromuscular reversal agent administered. Five patients were excluded from analysis and 135 patients completed the study. Primary outcome was extubation time. Secondary outcomes were anaesthesia time, the correlation between anaesthesia time and extubation time, the total amount of rocuronium, and postoperative adverse events in the post-anaesthesia care unit (PACU). Results Extubation time was significantly shorter in group S (6.3 ± 3.9 min) than in group P (9.0 ± 5.4 min). Anaesthesia time was also significantly shorter in group S (30.7 ± 10.3 min) than in group P (35.8 ± 12.6 min). In the patients with an anaesthesia time of 30 min or less, there was a positive correlation between anaesthesia time and extubation time in group P (r = 0.453), but there was no significant relationship in group S. The total amount of rocuronium used was higher in group S (0.62 ± 0.11 mg kg−1) than in group P (0.38 ± 0.14 mg kg−1). Postoperative adverse events in the PACU were comparable between the groups, except for tachycardia events: the incidence of tachycardia was significantly lower in group S (8.0 %) than in group P (17.3 %). Conclusions Sugammadex could shorten anaesthesia and extubation times as well as recovery time in the PACU and reduce postoperative hemodynamic complications in a clinical setting in the absence of neuromuscular monitoring. This may enhance the patients’ recovery in the operating room and PACU while improving the postoperative condition of patients. Trial registration The trial was registered in the UMIN clinical trials registry (www.umin.ac.jp/ctr/index/htm; unique trial number: UMIN000016602; registration number: R000019266; principal investigator’s name: Byung Gun Lim; date of registration: February 22, 2015). Electronic supplementary material The online version of this article (doi:10.1186/s12871-016-0221-2) contains supplementary material, which is available to authorized users.

Anesthesiologists commonly use opioids for pain control in the operating room and postanesthesia care unit, and are constantly vigilant in looking for possible adverse outcomes. Therefore, common complications such as nausea, vomiting, and pruritus are well known. However, neurologic complications after opioid administration are relatively rare except for reduced consciousness, for example drowsiness or sedation. We recently experienced a case in which a 73-year-old woman presented predominantly vertical nystagmus as a neurological complication after epidural administration of fentanyl. A few previous reports on opioids as causative agents for nystagmus have all after use of epidural morphine, and there are yet no publications reporting epidural fentanyl as the cause of nystagmus. Physicians should keep in mind that epidural fentanyl could cause the nystagmus as a neurological complication even though it is used within conventional dosage ranges, although this is very rare. Also, when a patient develops nystagmus after epidural fentanyl, it could be a benign side effect caused by epidural fentanyl as we have experienced, but it could also be a sign of serious central nervous system lesions especially in patients with underlying risk factors such as old age, diabetes mellitus, hypertension, and cerebrovascular disease, and thus special attention should be paid to this.

We aimed to investigate the frequency and severity of pain associated with intravenous injection of nefopam and to determine whether a slow rate of administration can effectively reduce such pain.We used a solution containing 30 mg nefopam diluted to 20 ml in saline. In all, 102 adult patients undergoing minor surgery were randomly allocated to one of three administration groups: A (60 ml/h, n = 34); B (120 ml/h, n = 34); or C (180 ml/h, n = 34). All patients scored the maximal pain experienced during the 120-s infusion period, using the visual analogue scale (VAS) and the verbal pain score (VPS). Adverse events including phlebitis were recorded.Eighty-three patients (29 in group A, 27 each in groups B and C) were included in the final analysis. The incidence of injection pain was lower in group A (86.2 %) than in groups B (96.3 %) and C (100 %), but this difference was not statistically significant. The proportion of patients with a tolerable level of pain (VAS 0-3 and VPS 0-1) was significantly higher in group A (79.3 %) versus groups B (7.4 %) and C (3.7 %). The mean VAS scores for groups A, B, and C were 2.2 ± 1.3, 5.1 ± 1.6, and 7.2 ± 1.7, respectively, and these differences were statistically significant.At the slower rate of infusion (60 ml/h) of the 1.5 mg/ml nefopam solution, injection pain intensity was attenuated to a significantly greater degree than at the faster rates.

Background Although the new formulation of lipid-free microemulsion propofol (MP) has some advantages over the lipid emulsion, it reportedly produces more injection pain than lipid-based propofol. Intravenous lidocaine with application of a rubber tourniquet before administration of propofol is considered to be the best method for reducing injection pain; however, this technique is not perfect. Objective The goal of this study was to evaluate the effect of different methods of tourniquet application and lidocaine administration on MP injection pain. Methods This single-center, randomized controlled clinical trial was conducted in 140 patients aged 18 to 65 years. Patients were randomly divided into 4 groups (n = 35 each). Group A received MP (2 mg/kg) after lidocaine (0.6 mg/kg) with a tourniquet with arm down (venous engorgement); group B received MP after lidocaine with a tourniquet with arm up (venous gravity drainage); group C received MP with a tourniquet with arm down; and group D (control group) received MP only (with no tourniquet). In groups A and C, the tourniquet was released after MP; in group B, the tourniquet was released before MP. Injection pain was evaluated by using a verbal pain score (VPS). The bispectral index, the time from the beginning of drug injection to the loss of eyelash reflex, and time to the lowest bispectral index value were recorded. Results Group A showed significantly less incidence of pain than the control group when MP was injected. The mean VPS was significantly lower in groups A, B, and C than in group D (the control group). The VPS of group A was significantly lower than that in group B. Other observed values were not significantly different. Conclusions We concluded that intravenous retention of lidocaine with the application of a rubber tourniquet under venous engorgement of the arm reduces the incidence and intensity of MP injection pain. Clinical trial registry: UMIN000010725.

Background The effectiveness of surgical pleth index (SPI) for managing nociception-antinociception balance during general anesthesia with vasodilators, including nicardipine has not been demonstrated. We aimed to compare the time course during surgery in SPI values in patients receiving nicardipine or remifentanil infusion during thyroidectomy. Methods Forty patients undergoing thyroidectomy were randomly assigned to receive nicardipine (group N; n = 19) or remifentanil (group R; n = 21) along with induction (propofol, fentanyl, and rocuronium) and maintenance (50% desflurane/nitrous oxide in oxygen) anesthesia (goal bispectral index [BIS] ∼50). The infusion of nicardipine or remifentanil was started before the 1st incision and adjusted to keep mean blood pressure (MBP) within ±20% of the preoperative value. SPI, BIS, end-tidal desflurane concentration (EtDes), MBP, and heart rate were recorded at 2.5 minute intervals from the 1st incision to the end of surgery. Extubation and recovery times, pain score/rescue ketorolac consumption, and adverse events in postanesthesia care unit (PACU) were recorded. Results The trend of SPI during surgery was comparable between the 2 groups (P = 0.804), although the heart rates in group N were significantly higher than those in group R (P = 0.040). The patient characteristics, trends of BIS, EtDes, and MBP during surgery, extubation and recovery times, and incidence of nausea/vomiting were comparable between the groups. Group N had significantly lower pain scores and rescue ketorolac consumption at PACU. Conclusion SPI was comparable between patients receiving nicardipine or remifentanil infusion during thyroidectomy under general anesthesia, which suggests that the administration of nicardipine may confound the interpretation of SPI values during general anesthesia. Clinical trial registration This trial was registered in the UMIN clinical trials registry (unique trial number: UMIN000019058; registration number: R000022028; principal investigator's name: Young Ju Won; date of registration: September 17, 2015).

Background This study was designed to determine whether a deep hypnotic state with a bispectral index (BIS) value less than 40 could alleviate withdrawal movement (WM) upon rocuronium injection during anesthesia induction in children. Methods Finally, 135 healthy children (3-12 years) scheduled for minor elective surgery were studied. Without premedication, anesthesia was induced with thiopental sodium 5 mg/kg. Patients were randomized into 2 groups (control vs experimental) and then by virtue of rocuronium injection time, patients in the experimental group were allocated into 2 groups, as follows: in the control group (group C; n = 45), rocuronium 0.6 mg/kg was administered at the loss of eyelash reflex; in the 1st experimental group, rocuronium 0.6 mg/kg was administered when BIS fell to less than 40 (group T; n = 45); however, if BIS did not fall below 40 after thiopental sodium administration, manual ventilation was provided with oxygen 6 L/minute using sevoflurane 8% and then rocuronium was administered when BIS fell below 40 (the 2nd experimental group, group S; n = 45). Rocuronium-induced WM was evaluated using a 4-point scale (no movement; movement/withdrawal involving the arm only; generalized response, with movement/withdrawal of more than 1 extremity, but no requirement for restraint of the body; and generalized response which required restraint of the body and caused coughing or breath-holding). Results No significant differences were found among the groups for patient characteristics including age, sex, height, and location of venous cannula. However, body weight, height, and body mass index in group S were all smaller than those in group T. The incidence of WM caused by rocuronium was 100% in group C, 95.6% in group T, and 80% in group S, and was significantly lower in group S than in group C. The grade of WM was 3.7 ± 0.6 in group C, 3.2 ± 0.9 in group T, and 2.6 ± 1.0 in group S. It was significantly lower in group T than in group C and significantly lower in group S than in groups C and T. Conclusion The confirmation of a deep hypnotic state with BIS values lower than 40 using BIS monitoring can reduce the grade of rocuronium-induced WMs during anesthesia induction using thiopental sodium or sevoflurane in children.

Background:The surgical pleth index (SPI) is proposed for titration of analgesic drugs during general anesthesia. Several reports have investigated the effect of SPI on the consumption of opioids including remifentanil, fentanyl, and sufentanil during anesthesia, but there are no reports abo

Background:Previous studies have shown that sugammadex, a modified γ-cyclodextrin, is a well-tolerated agent for the reversal of neuromuscular blockade (NMB) induced by a steroidal neuromuscular blocking drug in adult patients. However, its use has not been reviewed in pediatric patients. Th

Background: Resiniferatoxin (RTX) is a potent synthetic agonist for transient receptor potential vanilloid subtype 1 (TRPV1), which has a selectivity for antinociception. The analgesic effect of epidural RTX in a rat model of neuropathic pain has not yet been studied. Objectives: The purpose of this study was to evaluate the analgesic effect of epidural RTX on neuropathic pain in a rat model to mechanical and thermal stimulation. The dose-related behavior changes and side effects were also studied. Study design: A randomized, experimental trial. Setting: Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital Methods: A spinal nerve ligation model was prepared using male Sprague-Dawley rats (7 weeks old, weight 230-250 g). An epidural catheter was placed at the L4-L5 level. Each study group (n = 6) received a different dose of RTX: 100 ng, 500 ng, 1 µg, 2 µg, 4 µg and 10 µg. All substances were administered in 20 µL volume doses. The control group (n = 6) received 20 µL of normal saline. We evaluated the response to mechanical and thermal stimuli as well as the sedation score at both short-term (3 hours) and long-term (20 days) after the epidural RTX injection. Results: Prolonged analgesia to thermal stimulation was preceded by a transient dose-dependent hyperalgesia (500 ng, 1 µg) or sedation (≥ 2 µg) during the initial 60 minutes after RTX administration. Marked sedation and hyperventilation were noted at higher doses (≥ 2 µg), while 2 out of 6 rats died with a 10 µg dose. ED50 for epidural RTX was 265 ng (95% confidence interval 216.1–324.9 ng). The increased latency to thermal stimulation continued for 20 days at RTX ≥ 1 µg. But the threshold to mechanical stimulation increased only in the acute period and returned to the baseline after 3-5 days, regardless of the administered dose. Limitations: A histological examination by electron-microscopic staining was not performed. The observation period was not very long (20 days). Conclusion: RTX has potential to be used in an epidural route for neuropathic pain in a rat model with a relatively small amount, which produces transitory improvement of mechanical hypersensitivity and prolonged thermal analgesic response. Key words: Epidural administration, mechanical allodynia, mechanical hypersensitivity, resiniferatoxin, sedation, spinal nerve ligation rat model, thermal hyperalgesia.

Unexpected tracheal narrowing was observed in a patient with Duchenne muscular dystrophy during a corrective operation for thoracolumbar scoliosis. As the operating time progressed, peak airway pressure and end-tidal CO2 increased gradually in the prone position. We found a floppy portion of the trachea using fiberoptic bronchoscopy (FB) in the prone position. We advanced a wire-reinforced tube toward the carina beyond the lesion. This allowed correction of the ventilatory abnormalities. We encountered another patient scheduled for the same operation. We performed FB in advance before the position change and observed a narrowed portion of trachea. We advanced the tracheal tube under FB beyond the pathologic portion and then moved the patient into the prone position. The operation was done successfully without any problems.

To report a complication of airway obstruction during spinal deformity correction surgery in Duchenne muscular dystrophy (DMD) patient, due to lordoscoliosis, airway malacia, and prone surgical positioning, which was rectified by changing the position of the patient and surgery was successfully completed.A 15-year-old boy was diagnosed with DMD and admitted for surgical treatment of thoracolumbar scoliosis. The patient's preoperative Cobb's angle was 79° and the kyphotic angle was -19°. During the initial period of surgery, while in the prone position, peak inspiratory pressure (PIP) suddenly increased from 20-21 to 38-41 cmH2O, wheezing sounds were heard on auscultation of both lungs, and his blood pressure began to fall. Under suspicion of airway problem, intraoperative fiberoptic bronchoscopy was performed which confirmed airway obstruction. Attributing patient's prone position as the cause of airway obstruction, the surgical position of the patient was changed from prone to semi-lateral. After this change, the PIP stabilized to within normal limits (20-23 cmH2O). The surgical correction was successfully completed with a posterior-only pedicle screw by the free-hand technique, with the patient in the semi-lateral position for the rest of surgery.Lordoscoliosis and airway malacia in a patient with DMD can lead to occlusion of the tracheobronchial lumen when the patient is in the prone position. Changing the patient's position from prone to semi-lateral can be of help to reverse this airway obstruction and complete the surgery. Pedicular screw insertion can be safely and effectively carried out in this position using free-hand technique.

Background: The aim of this study was to compare the streamlined liner of the pharynx airway (SLIPA) with the classic laryngeal mask airway when used by novice personnel. Methods: There were 114 patients enrolled into this study who underwent general anesthesia were randomly allocated into one of 2 groups; LMA group (n = 57) or SLIPA group (n = 57). After insertion, insertion success rate, insertion time, and hemodynamic responses to insertion were accessed. After surgery, postoperative airway morbidity (sore throat, dysphonia, dysphagia) were evaluated. Results: The SLIPA was successfully inserted in 96% of patients (55/57) and the LMA in 93% (53/57) (P = 0.408). First attempt success rates were 88% (44/57) and 77% (50/57) in the SLIPA and the LMA (P = 0.142). The successful insertion time in SLIPA group (33.4 ± 11.0 sec) was significantly shorter than that of LMA group (38.8 ± 16.6 sec) (P = 0.048) and the insertion time at the first attempt was also shorter in SLIPA group (31.0 ± 6.3 sec) than LMA group (34.7 ± 8.6 sec) (P = 0.013). There was no statistically significant difference between the two groups in hemodynamic responses and postoperative airway morbidity. Conclusions: The SLIPA was similar to the LMA in insertion success rate, hemodynamic response, and postoperative airway morbidity by novice personnel. The insertion time at the first attempt and successful insertion time of the SLIPA were significantly shorter than those of the LMA. Therefore, the SLIPA could be a useful alternative to the LMA as primary SGA for novice personnel. (Korean J Anesthesiol 2012; 63: 136-141)

Background: Percutaneous balloon kyphoplasty is an effective, minimally invasive procedure that is used to relieve pain and stabilize spine fractures caused by severe osteoporosis or osteolysis due to tumor metastasis. However, there remains a risk of bone cement leakage during and after kyphoplasty, especially in cases with severe vertebral wall destruction or neurological deficits. Objective: This article presents a case in which kyphoplasty was used to manage these complications in a woman with vertebral compression fractures caused by tumor metastasis. Design: Case report. Setting: Pain management clinic. Methods: The patient was a 76-year-old woman who had severe low back pain, lower extremity weakness, and cauda equina syndrome because of vertebral compression fracture and spinal metastasis with epidural involvement. The patient had a large bony defect in the vertebra that the bone filler device could pass freely through the anterior body wall. Nevertheless, kyphoplasty was successfully performed by using our new cement injection technique, which is a slow injection of the highly viscous bone cement, followed by a second injection 10 minutes later to allow the previously injected cement to harden. Results: The procedure significantly alleviated all symptoms. The day after the procedure, in the absence of additional pain medication, the pain had dropped dramatically to a numerical rating scale 3-4, and there was an improvement in motor function that allowed the patient to sit and go to the bathroom by herself. In addition, the voiding sensation had returned, which allowed the patient to defecate and urinate normally. Limitations: This report describes a single case report. Conclusion: Our new cement injection technique may allow balloon kyphoplasty to be safely and effectively performed in cancer patients with pathological vertebral compression fractures, even if there are large defects in the anterior vertebral wall and neurological deficits. Key words: Compression fractures, kyphoplasty, metastasis, neurological deficits, osteolysis, polymethylmethacrylate.

A 41-year-old woman, who had no thrombotic risk factors and past history except congenital scoliosis, underwent central venous catheterization (CVC) before correction of the scoliosis. When internal jugular vein (IJV) catheterization using the anatomical landmark technique failed, CVC under ultrasound guidance was tried. As a consequence, thrombosis and hypoplasia of the right IJV were incidentally detected by ultrasonography. Central venous catheters were then successfully placed in other veins under ultrasound guidance. Also, after examinations to rule out the possibility of pulmonary embolism and to clarify the causes of the IJV thrombosis, the patient was found to have protein S deficiency. CVC under ultrasound guidance should be recommended to prevent the failure of cannulation and complications such as thromboembolism in patients who could possibly have anomalies of vessels as a result of anatomical deformities caused by severe scoliosis, even if patients do not have thrombotic risk factors such as a history of central catheter insertion or intravenous drug abuse, cancer, advanced age, cerebral infarction, and left ventricular dysfunction. Also, if venous thrombosis is found in patients without predisposing risk factors, one should ascertain the cause of the hypercoagulable state, for example protein S deficiency, and perform appropriate treatment and prevention of venous thromboembolism.

To the Editor, The SLIPA, a cuffless, hollow, boot-shaped, soft plastic supraglottic airway device (SLIPA; SLIPA Medical Ltd., London, UK), has advantages over other laryngeal mask airway devices (LMADs) because it provides better protection from regurgitation and has a better perilaryngeal seal. However, SLIPA has not been tested in difficult airways. We report successful management of a difficult airway with SLIPA after laryngeal mask airway failure. We obtained the patient’s written consent to publish this report. A 50-yr-old man (169 cm, 90 kg) with gastroesophageal reflux disease (GERD) was scheduled for reconstruction of finger tendons under general anesthesia. Difficult intubation was anticipated because of the patient’s large tongue, short neck, thyromental distance, and a Mallampati score of 4. Because he refused awake fibreoptic intubation, we decided to insert a LMAD. After administering fentanyl 100 lg, thiopental sodium 450 mg, and succinylcholine 90 mg, a LMAD (Solus; Intersurgical Ltd. Wokingham, UK) size 5 was inserted. Immediately after insertion, no leak was heard, the end-tidal carbon dioxide concentration (ETCO2) was 28-30 mmHg, and the peak inspiratory airway pressure (PIP) was 22-25 cm H2O. At one minute after insertion, however, the PIP suddenly increased to 35 cmH2O, and a leak was detected. The LMAD was removed, and another insertion attempt was made after administering succinylcholine 50 mg. This time, the PIP was 40-45 cm H2O, and leaks were audible immediately. A fibreoptic bronchoscope (FOB) was inserted through the airway port of the LMAD, and the anterior portion of the epiglottis was found to be blocking the view. The fibrescope was passed under the epiglottis to examine the glottis, and a glottic narrowing was found. After removing the LMAD, a size 55 SLIPA was inserted. The PIP decreased to 20-23 cm H2O, and the ETCO2 was 32-33 mmHg. No leak was detected. The FOB was inserted, through which the vocal cords were well visualized, and the periglottic seal was seen to be improved. Afterward, ventilation was maintained well, and there were no complications, including airway obstruction or aspiration. Examination of the glottis via the FOB provided possible explanations for the different performances of the two devices. First, the position of the epiglottis was different, which might be due to the designs of the respective bowls. The laryngeal aperture of SLIPA consists of a wide portion and a narrow portion, preventing airway obstruction (Figure), whereas the absence of epiglottic bars on the Solus could cause epiglottis downfolding and subsequent airway obstruction. However, previous reports suggested that because disposable LMADs, including the Solus, have a deeper bowl, ventilation is well maintained despite the absence of epiglottic bars. In this case, the FOB passed under the epiglottis with ease, which makes obstruction by the epiglottis improbable. Second, the presence of a cuff and the shape and location of the bowl should be considered. The space between the tongue and posterior pharyngeal wall was probably narrow in this patient, becoming narrower because of laryngopharyngeal edema caused by GERD. In a narrow space, inflating the LMAD cuff could increase pressure in the laryngopharynx and cause distortion of laryngeal B. G. Lim, MD K. J. Kim, MD M. H. Kong, MD, PhD N. S. Kim, MD, PhD S. H. Lim, MD, PhD M. K. Lee, MD, PhD I. O. Lee, MD, PhD (&) Guro Hospital, College of Medicine, Korea University, Seoul, South Korea e-mail: iloklee@korea.ac.kr

Hyperexcitatory behaviors occurring after sevoflurane anesthesia are of serious clinical concern, but the underlying mechanism is unknown. These behaviors may result from the potentiation by sevoflurane of GABAergic depolarization/excitation in neocortical neurons, cells implicated in the genesis of consciousness and arousal. The current study sought to provide evidence for this hypothesis with rats, the neocortical neurons of which are known to respond to GABA (γ-aminobutyric acid) with depolarization/excitation at early stages of development (i.e., until the second postnatal week) and with hyperpolarization/inhibition during adulthood. Employing behavioral tests and electrophysiological recordings in neocortical slice preparations, we found: (1) sevoflurane produced PAHBs (post-anesthetic hyperexcitatory behaviors) in postnatal day (P)1–15 rats, whereas it failed to elicit PAHBs in P16 or older rats; (2) GABAergic PSPs (postsynaptic potentials) were depolarizing/excitatory in the neocortical neurons of P5 and P10 rats, whereas mostly hyperpolarizing/inhibitory in the cells of adult rats; (3) at P14–15, −importer NKCC (Na+-K+−2Cl−cotransporter)] treatment at P5 suppressed PAHBs and depolarizing GABAergic responses; and (5) sevoflurane at 1 % (i.e., concentration

Background: Serotonin-also known as 5-hydroxytryptamine or 5-HT-can induce nausea and vomiting (NV) by peripheral mechanisms via the activation of 5-HT3 receptors. In this study, we observed perioperative NV, including intraoperative NV, and changes in serum 5-HT concentrations. We evaluated the relationship between perioperative NV and serum 5-HT levels in patients undergoing cesarean section under epidural anesthesia, and carried out a pilot study to determine if further studies on a larger scale were justified. Methods: Twenty-eight patients who were scheduled for cesarean section under epidural anesthesia were included in the study. Patients were assigned to 2 groups according to the occurrence of NV after induction, i.e., an NV-positive or an NV-negative group. Serum 5-HT concentrations were measured before induction, at the time that NV occurred (in the case of the NV-positive group) or 5 min after the umbilical cord clamping (in the case of the NV-negative group) during surgery, and at 2 h postoperatively. Results: NV occurred in 10 of the 28 patients. No significant differences in serum 5-HT concentrations were found within or between the two groups. Conclusions: This study suggests that there is no correlation between serum 5-HT concentration and the occurrence of perioperative NV in patients undergoing cesarean section under epidural anesthesia, and the findings do not seem to support further investigations regarding a possible relationship between serum 5-HT concentration and perioperative NV. (Korean J Anesthesiol 2014; 67: 384-390)

Background The standard bifrontal application of the bispectral index (BIS) sensor interferes with the operative field in neurosurgery and plastic surgery. The aim of this study was to compare the standard frontal BIS sensor position with an alternative position across the mandible. Methods Two BIS™ Quatro sensors (Aspect Medical Systems, Newton, MA, USA) mounted on the frontal and mandibular regions were connected to BIS Vista™ monitors on each patient during general anesthesia. Data from each position were collected at awake, loss of consciousness, intubation, incision, every 30 minutes during the intraoperative period and emergence. These data were compared using Bland-Altman and scatter plot analyses. Results Scatter plot analysis revealed a significant correlation between BIS values of frontal and mandibular positions (R = 0.869, P = 0.000), except during emergence (R = 0.253, P = 0.077). Bland-Altman analysis revealed a negative bias of 3.2 with a limit of agreement of 16.5/-22.9, in which 3.7% of the values were outside of the limit of agreement. Additional values included -2.9 (14.1/-8.3) while patients were awake, -21.7 (14.9/-58.3) at loss of consciousness, -1.8 (9.0/-12.5) during maintenance, and -1.9 (14.9/-18.8) during emergence. Conclusions Overall, BIS values do not agree between the standard frontal position and an alternative mandibular position. However, during the anesthesia maintenance period, the mandibular position can be availably used as an alternative position if the operative field renders the standard frontal position unavailable.

Microtia reconstructive surgery is usually a multi-stage repair procedure that involves the use of cartilage and skin grafts. Complications can arise at both ear reconstruction sites and cartilage donor sites. In particular, pneumothorax, atelectasis, chest scars, and chest deformities are known to be associated with the harvesting of costal cartilage. However, delayed pleural effusion can also develop. Our patient complained of a cough and chest pain at 5 days postoperatively, and pleural effusion was detected by chest radiography. However, thoracentesis was not performed and the effusion resolved spontaneously and completely.

Ossification of the yellow ligament (OYL) is a pathologic condition that causes spinal stenosis, which is a form of ectopic ossification. OYL causes compressive myelopathy and radiculopathy. Although the pathogenesis of OYL is still unclear, diffuse mechanical stresses and degenerative changes caused by extreme ranges of motion may be related to the development of OYL in young sportsmen. Here we report an interesting case of thoracic radiculopathy due to OYL in a 35-year-old male amateur judo player who was successfully treated with continuous thoracic patient controlled epidural analgesia and epidural adhesiolysis.

Nitrous oxide (N2O) may increase middle ear pressure during anesthesia, resulting in the displacement of tympanic membrane graft for tympanoplasty.This study was performed to assess the feasibility of remifentanil instead of N2O by comparing hemodynamics, recovery profiles, postoperative analgesia and complications during isoflurane-based anesthesia for tympanoplasty. Methods:Forty patientsundergoing tympanoplasty were randomly allocated to N2O-isoflurane anesthesia (group N) and remifentanil-isoflurane anesthesia (group R).In group N, N2O was used from induction to 15−30 minutes prior to grafting tympanic membrane and then N2O was changed to air.In group R, remifentanil was infused to the end of surgery.Isoflurane was used in both groups.We compared mean arterial pressure (MAP), heart rate (HR) and recovery times between groups during perioperative period.Postoperative pain, analgesic demand and nausea/vomiting during postoperative period were also compared. Results:MAP and HR were significantly higher in group N than group R at 1 minute, 5 minutes after intubation, skin incision and closure.Hypertensive and tachycardiac events were also more frequent in group N during operation.Time to spontaneous respiration was significantly shorter in group N, but times to eye opening, extubation and recovery of orientation were significantly shorter in group R.There were no significant differences in pain scores, analgesic demand and nausea/vomiting during postoperative period. Conclusions:Remifentanil can provide more stable hemodynamic status and faster emergence than N2O without significant increase of pain level, analgesic demand and adverse effects in isoflurane-based anesthesia for tympanoplasty.

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.