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Background Intravenous patient-controlled analgesia (IV-PCA) is often used in the postoperative period. However, determining an appropriate opioid dose is difficult. A previous study suggested the usefulness of variable-rate feedback infusion. In this study, we used a dual-channel elastomeric infusion pump to provide changes in PCA infusion rate by pain feedback. Methods Ninety patients undergoing orthopedic surgery of American Society of Anesthesiologists grade I-III and 65 to 79 years of age participated in the study. All patients were given a dual-chamber PCA. Patients were randomly allocated to a treatment group (Group D; PCA drugs divided into both chambers) or control group (Group C; PCA drugs only in the constant flow chamber with normal saline in the adjustable flow chamber). The primary outcome was the amount of fentanyl consumption via PCA bolus. The secondary outcome variables were pain score, total fentanyl consumption, rescue analgesic use, patient satisfaction, recovery scores, and adverse events including postoperative nausea and vomiting (PONV). Results Group D showed decreased fentanyl consumption of the PCA bolus, a decrease in rescue analgesic use, and better patient satisfaction compared with group C. The incidence of PONV was much higher in group C. There was no difference in other adverse events. Conclusions We showed the usefulness of dual chamber IV-PCA to change the flow rate related to pain feedback without any complications. Our results suggest a noble system that might improve existing IV-PCA equipment. Trial registration The study registered at UMIN clinical trial registry (registered date: 05/03/2020, registration number: UMIN000039702).

Acceleromyography at the adductor pollicis located in a distal part of the body may not reflect the degree of neuromuscular blockade (NMB) at the proximally located muscles manipulated during lumbar surgery. We investigated the usefulness and characteristics of acceleromyographic monitoring at the trapezius for providing moderate NMB during lumbar surgery. Fifty patients were randomized to maintain a train-of-four count 1–3 using acceleromyography at the adductor pollicis (group A; n = 25) or the trapezius (group T; n = 25). Total rocuronium dose administered intraoperatively [mean ± SD, 106.4 ± 31.3 vs. 74.1 ± 17.6 mg; P P P = 0.003) and lumbar muscle tone in group T were significantly lower than group A. Time to maximum block with an intubating dose was significantly shorter in group T than group A (44 [37–54] vs. 60 [55–65] sec; P

Background: Experimental research on animals should be performed before applying new treatment modalities in humans. Among experimental animal models, canine model research is a commonly used method. Injecting drugs into the epidural has also been commonly used in the canine animal model. In canine models, epidural catheters are often inserted into the lumbosacral area during epidural drug injection. Unlike the existing canine model, we describe a new and alternative technique of epidural and intrathecal catheterization to investigate methods of epidural drug administration in dogs. Methods: Twelve adult dogs were used in this study. The epidural procedures were performed with dogs in sternal recumbency under deep sedation. Epidural catheterization was perforemed at the T1-T2 intervertebral space with C-arm fluoroscopy guidance. After confirming the loss of resistance, a flexible epidural catheter was passed cranially to the C2-C3 level. The intrathecal procedures were performed with dogs in lateral recumbency under deep sedation. Intrathecal catheterization was performed through the cisterna magna with the neck slightly flexed. An 18-gauge Tuohy needle was inserted into the subarachnoid space through the atlanto-occipital space. After confirming cerebrospinal fluid leakage without bleeding, a flexible intrathecal catheter was passed caudally to the C2-C3 level. Results: All epidural and intrathecal catheterizations were successfully performed under deep sedation without any complications. Conclusion: The new technique of epidural and intrathecal catheterization in canines is an alternative procedure for investigating epidurally administered drugs.

Background: This study compared the correlation of bispectral index (BIS) or entropy with different sevoflurane concentrations between children with and without cerebral palsy (CP) during induction. Methods: For eighty-two children (40 CP and 42 non-CP children), anesthesia was induced with sevoflurane. BIS and entropy (response entropy and state entropy (RE and SE)) were recorded before and after the induction of anesthesia at end-tidal sevoflurane concentrations of 1&ndash, 3 vol%. The sedation status was assessed using an Observer&rsquo, s Assessment of Alertness/Sedation scale. The ability to predict awareness was estimated using the area under the receiver-operator characteristic curve (AUC) analysis. Results: RE, SE and BIS values decreased continuously over the observed concentration range of sevoflurane in both groups. The SE values while awake and the RE, SE, BIS values at 3 vol% sevoflurane were lower in children with CP than in those without CP. The AUC of the BIS was significantly better than RE or SE in children without CP. The AUC of the BIS was not significantly higher than that of the RE or SE in children with CP. Conclusion: BIS seems better correlated than entropy with the clinical state of loss of response in children without CP, but not in those with CP.

New developments in spinal cord stimulation (SCS) have improved the treatment of patients with chronic pain. Although the overall safety of modern SCS has been established, there are no published reports regarding safety considerations when implanting a burst-mode spinal cord stimulator in patients with permanent cardiac pacemakers (PCPs). An 80-year-old man with a complete atrioventricular block implanted with a PCP was considered as a candidate for burst-mode SCS due to well-established postherpetic neuralgia (>180 days after rash). Cardiac monitoring during the burst-mode spinal cord stimulator trial and insertion did not indicate any interference. After the insertion of the burst-mode spinal cord stimulator, the patient showed functional improvement and significant pain relief. The safety of traditional tonic-mode SCS in patients with PCP has been previously reported. This is the first case report describing the safe and effective use of burst-mode SCS in a patient with PCP.

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

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

Background:To compare surgical pleth index (SPI)-guided analgesia with conventional analgesia by evaluating intraoperative analgesic requirements, postoperative pain, and emergence agitation in children.Methods:This study was designed as a parallel, two-arm, double-blind, randomized controlled trial. Forty-five children undergoing elective adenotonsillectomy were randomly allocated to SPI-guided group (SPI-guided analgesia group, n = 21) or control group (conventional analgesia group, n = 24). Anesthesia was maintained with sevoflurane 2 to 3 vol% in 50% nitrous oxide and oxygen to achieve state entropy between 40 and 60. Intraoperative fentanyl 0.5 μg/kg was administered for the first event persisting 3 min and subsequent events persisting 5 min. An event was defined as an SPI over 50 (SPI-guided group) or a blood pressure or heart rate 20% above the baseline (control group). The primary outcome was intraoperative fentanyl requirement. Secondary outcomes included intraoperative sevoflurane consumption, postoperative emergence agitation and pain score, and postoperative rescue analgesic requirements.Results:Intraoperative fentanyl requirement was lower in SPI-guided group than in control group (0.43 ± 0.53 vs. 1.73 ± 0.59 μg/kg; P < 0.001). Intraoperative sevoflurane consumption was similar. The proportion of patients with high emergence agitation scores (4 to 5) was greater in SPI-guided group (61.9 vs. 25.0%; P = 0.01). The postoperative pain score and rescue fentanyl consumption were higher in SPI-guided group (7 [4.5; 9] vs. 3 [2; 6.75]; P = 0.002; 0.50 ± 0.34 vs. 0.29 ± 0.30 μg/kg; P = 0.04).Conclusions:As currently constructed, SPI does not appear to be valid in children. This may be due to both differences in blood vessel distensibility and baseline increased heart rates in children versus adults.

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

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

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

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: Effective early antiviral treatments reduce both acute zoster pain and the risk of postherpetic neuralgia. The authors hypothesized that the direct neuraxial administration of acyclovir could provide superior drug application to the spinal neural structures with a higher viral burden and have various advantages over the other routes of drug administration in terms of required doses, side effects, and efficacy. Objective To know whether intrathecal acyclovir injection is neurologically and histopathologically safe or not. Study Design: Randomized, experimental trial in rats. Setting: Associated experiment center. Methods: A total of 40 rats weighing between 250-300g were used. The rats were randomly divided into 2 groups of 20 each using a random number table: normal saline group (Group N) and acyclovir group (Group A). Rats in Group N were administered 20 µl of normal saline and Group A were administered the same volume of 700 µg/mL acyclovir into the intrathecal space via an intrathecal catheter. Saline or acyclovir was administered daily for 5 consecutive days. The changes in behavior and sensory-motor function were checked and histopathological findings of the spinal cords were observed by light and electron microscopy. Results: No rats in Group N or Group A showed any behavioral change or sensorymotor dysfunction during the 5-day observation period. Furthermore, no histopathological abnormalities of the spinal cord were observed in the 6th day after the last intrathecal administration of the drug. Limitations: There is a need to perform studies to evaluate long-term safety by observing cumulative neurotoxic effects with continual injection during a long-term period. Conclusions: There was no evidence of neurological and histopathological abnormalities following intrathecal acyclovir injection. Key words: acyclovir, safety, spinal,intrathecal, acute zoster pain, post herpetic neuralgia

The purpose of this study was to determine the effectiveness of antihistamine therapy for withdrawal movements caused by rocuronium injection. One hundred seventy one ASA I-II adults undergoing elective surgery were randomly assigned to one of two groups. Patients in the control group (Group C) were premedicated with 2 mL normal saline, and those in the antihistamine group (Group A) were pre-medicated with 2 mL (45.5 mg) pheniramine maleate. After the administration of thiopental sodium 5 mg/kg, rocuronium 0.6 mg/kg was injected. Withdrawal movements were assessed using a four-grade scale. The administration of antihistamine reveals lower grade of withdrawal movement after rocuronium injection.

Spinal cord stimulation (SCS) is highly successful for treating neuropathic pain but its effect is limited for central origin pain caused by cord injury. The authors describe a case in which pain was successfully controlled by SCS implantation in a patient with intractable chronic neuropathic pain after T5 meningioma removal. The authors tried lead insertion over the T5 level passing through postoperative adhesions to produce adequate stimulation to the patient's painful areas fully enough without any complications. This case showed good response to SCS even though it was a central type of neuropathic pain by spinal cord injury.

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

Background 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

DNA damage, lipid peroxidation and protein oxidation were evaluated in rats exposed to a 1% isoflurane atmosphere with or without alcohol administration (administrated by gastric intubation at 4 g/kg body weight as a 50% solution). Single cell gel electrophoresis assays were performed in order to evaluate DNA damage occurring in the lymphocytes, spleen, bone marrow, brain, livers and lung of rats exposed to 1% isoflurane for 30 or 60 min with/without ethanol. Levels of malondialdehydes (MDA), a metabolite of lipid peroxidation, were determined in plasma and tissues. Carbonyl contents were also analyzed to determine levels of protein oxidation in plasma and tissues. Levels of DNA damage in lymphocytes, bone marrow, and the organ tissues of rats exposed to isoflurane were found to increase time dependently, and alcohol increased DNA damage. Lipid peroxidation and protein oxidation results showed patterns that differed from those of DNA damage. Levels of MDA in plasma, bone marrow, spleen, and the livers of rats exposed to isoflurane with/without ethanol were found to be time dependently increased, but this was not observed in the brain or lung. However, protein oxidation levels were significantly increased in the plasma, brains, and lungs of rats exposed to isoflurane, and exposure to isoflurane and alcohol, significantly increased these levels in plasma and brain. The present study demonstrates that isoflurane exposure results in significant DNA damage in rat lymphocytes, bone marrow, spleen, brain, livers, and lung. Moreover, alcohol was found to be as a strong inducer of DNA damage, lipid peroxidation and protein oxidation. However, no evidence in association between DNA damage, lipid peroxidation and protein oxidation was found. Regarding the effects of isoflurane and alcohol on oxidative damages, single strand DNA damages may be a useful biomarkers and blood cells and plasma appear to be more sensitive targets to oxidative damage than other tissues.

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

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

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

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

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

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

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

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

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

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

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