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Euglycemic diabetic ketoacidosis (EDKA) can be difficult to recognize during surgery, particularly when the anion gap (AG) is within the normal range. A 73-year-old female patient with type 2 diabetes mellitus underwent surgical adhesiolysis and enterostomy for intestinal obstruction. The patient showed a normal serum glucose level and hyperchloremic acidosis but had an accumulation of unmeasured anions (UA) detected by partitioning of the standard base excess (SBE). This prompted testing for serum ketones, which confirmed the presence of EDKA during surgery. The calculation of the hyperchloremic base deficit as a percentage of the total acidifying base deficit revealed a significant contribution of hyperchloremic acidosis to the severity of mixed metabolic acidosis. The AG approach can misdiagnose high AG metabolic acidosis (HAGMA) with hyperchloremic acidosis as hyperchloremic acidosis only. Partitioning of the SBE can be useful for detecting UA when both HAGMA and hyperchloremic acidosis are present, and it may help determine the necessity of treating hyperchloremia during EDKA.

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PURPOSE: This randomized, controlled, double-blind study was designed to determine the optimal dose of remifentanil for preventing complications associated with the removal of a laryngeal mask airway (LMA) without delaying emergence. MATERIALS AND METHODS: This study randomly assigned 128 patients to remifentanil effect-site concentrations (Ce) of 0 ng/mL (group R0), 0.5 ng/mL (group R0.5), 1.0 ng/mL (group R1.0), and 1.5 ng/mL (group R1.5) during emergence. The emergence and recovery profiles were recorded. Adverse events such as coughing, airway obstruction, breath-holding, agitation, desaturation, nausea, and vomiting were also evaluated. RESULTS: The number of patients with respiratory complications such as coughing and breath-holding was significantly lower in the R1.0 and R1.5 groups than in the R0 group (p<0.05). Emergence agitation also decreased in the R1.0 and R1.5 groups (p<0.0083). The time to LMA removal was significantly longer in the R1.5 group than in the other groups (p<0.05). CONCLUSION: Maintaining a remifentanil Ce of 1.0 ng/mL during emergence may suppress adverse events such as coughing, breath-holding, and agitation following the removal of LMA without delayed awakening.

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PURPOSE: This randomized, controlled, double-blind study was designed to determine the optimal dose of remifentanil for preventing complications associated with the removal of a laryngeal mask airway (LMA) without delaying emergence. MATERIALS AND METHODS: This study randomly assigned 128 patients to remifentanil effect-site concentrations (Ce) of 0 ng/mL (group R0), 0.5 ng/mL (group R0.5), 1.0 ng/mL (group R1.0), and 1.5 ng/mL (group R1.5) during emergence. The emergence and recovery profiles were recorded. Adverse events such as coughing, airway obstruction, breath-holding, agitation, desaturation, nausea, and vomiting were also evaluated. RESULTS: The number of patients with respiratory complications such as coughing and breath-holding was significantly lower in the R1.0 and R1.5 groups than in the R0 group (p<0.05). Emergence agitation also decreased in the R1.0 and R1.5 groups (p<0.0083). The time to LMA removal was significantly longer in the R1.5 group than in the other groups (p<0.05). CONCLUSION: Maintaining a remifentanil Ce of 1.0 ng/mL during emergence may suppress adverse events such as coughing, breath-holding, and agitation following the removal of LMA without delayed awakening.

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We experienced conversion of supraventricular arrhythmia to normal sinus rhythm in three patients during general anesthesia using propofol and remifentanil. This may be related to direct inhibition of the cardiac conduction system or activation of the parasympathetic system. The literature review suggests that propofol and remifentanil have antiarrhythmic potential, reverting supraventricular arrhythmia during anesthesia.

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BACKGROUND: Oropharyngeal manipulation is problematic when patients have a gag reflex. Sedation can suppress gag reflex, but can cause serious airway problems. We compared remifentanil (Group R) and propofol (Group P) in terms of cooperation and loss of gag reflex, while drugs were administered incrementally using target controlled infusion (TCI). METHODS: Fifty seven patients who required awake fiberoptic intubation were randomized to Group R or Group P. After measurement of baseline gag trigger point index (GTPI), TCI was set to effect-site concentration (Ce) of 1 ng/ml (Group R) or 1 microg/ml (Group P), then titrated by 0.5 increment until GTPI score reached 0. The incidence of drop-out and decreased cooperation, Ramsay sedation scale (RSS) and Ce at loss of GR, and complications were assessed. RESULTS: Seven patients were dropped out in Group P due to deep sedation and disobedient behavior, but none in Group R (P = 0.015). Gag reflex suppressed as RSS increased in both groups (P < 0.001), however, the incidence of elimination of gag reflex clustered at RSS 2 in Group R (P < 0.001), whereas it was evenly distributed in Group P (P = 0.20). The incidence of patients who were spontaneously roused (gag reflex elimination at RSS 1 and 2) were higher in Group R than in Group P (P = 0.002). CONCLUSIONS: Deep sedation and impaired cooperation were observed only in Group P and spontaneously roused patients were higher in Group R, suggesting that remifentanil is more suitable for cooperative elimination of GR.

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BACKGROUND: Jaw-thrust is a noxious stimulus that might induce sympathetic responses. The purpose of this study, was to evaluate the effects of jaw-thrust on sympathetic responses. METHODS: We investigated seventy three patients. Patients who received general anesthesia were randomly divided into a control group (maintenance of combined airway maneuver with head tilt, open mouth by mouthpiece, and chin-lift, n = 30) and jaw-thrust group (maintenance of head tilt, open mouth and jaw-thrust, n = 30). In the jaw-thrust group, four minutes of endoscopy-guided force to the mandible to get the best laryngeal view were applied. For the control group, the combined airway maneuver was maintained during the same period. Arterial blood pressure (AP) and heart rate (HR) were recorded at predetermined time points (1 min before anesthesia induction, 2 min after fiberoptic bronchoscopy placement, and thereafter 1 min-interval during each airway maneuver) during jaw-thrust and chin-lift maneuver. The force amplitude applied for best laryngeal view during jaw-thrust was also measured. RESULTS: Peak systolic and diastolic AP increased 39.0 +/- 17.6 and 39.9 +/- 22.8 mmHg from the baseline (P 0.05). CONCLUSIONS: Performing the jaw-thrust maneuver induces significant sympathetic responses, irrespective of the force magnitude.

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BACKGROUND: The preoperative coexisting chronic systemic illness, delay in surgery, gender, and age were considered as risk factors for the complications after hip fracture surgery. The wider range of surgical delay and immobility-related pulmonary morbidity may affect postoperative complications and mortality. This study examined the risk factors for morbidity and mortality following the hip fracture surgery. METHODS: The patient data was collected retrospectively. The consecutive 506 patients with hip fracture surgery, aged 60 years or older, were included. The patients' age, gender, preexisting diseases, American Society of Anesthesiologists (ASA) classification, delay in surgical repair, duration of surgical procedure, and methods of anesthesia were noted. The thirty-day postoperative complications were reviewed, and cardiac complications, pulmonary complications, delirium, and death were recorded. The data was analyzed for postoperative complications and risk factors. RESULTS: Atelectasis was associated with postoperative pulmonary complications. Male gender and age > or = 80 years were associated with an increased incidence of postoperative delirium. ASA classification 3 was associated with death. A delay in surgery was not associated with any complications. Preexisting diseases and methods of anesthesia did not affect mortality and postoperative complications. CONCLUSIONS: The results suggest that a delay in surgery did not affect the postoperative complications and morbidity.

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This report describes a rare case of postoperative hyperventilation attack after an endoscopic third ventriculostomy in a 46-year-old woman. About 60 min after the termination of the operation, an intractable hyperventilation started with respiratory rate of 65 breaths/min and EtCO2, 16.3 mm Hg. Sedation with benzodiazepine, thiopental sodium, fentanyl, and propofol/remifentanil infusion was tried under a rebreathing mask at a 4 L/min of oxygen. With aggressive sedative challenges, ventilation pattern was gradually returned to normal during the 22 hrs of time after the surgery. A central neurogenic hyperventilation was suspected due to the stimulating central respiratory center by cold acidic irrigation solution during the neuroendoscopic procedure.

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The trans-sphenoidal resection of a recurred pituitary tumor was performed in a 42 years old man under general anesthesia with propofol and remifentanil. Neither massive bleeding nor hypotension was observed intraoperatively, but bradycardia was sustained over five hours. The patient did not suffer from hypertriglyceridemia and there was no evidence of drug toxicity or vigorous intervention during the surgery, however hyperamylasemia was observed one day after the surgery. It is presumed that vagal stimulation by propofol and remifentanil infusion might induce bradycardia and abnormal pancreatic enzyme secretion consequently.

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Kearns-Sayre syndrome (KSS) is a mitochondrial disorder resulting in multi-system dysfunction. A 14-year-old boy with KSS underwent external levator muscle resection for correction of ptosis. There were no abnormalities on the pre-operative evaluation, except for low-grade heart block and ocular problems. General anesthesia was conducted with a minimum dose of thiopental sodium and sevoflurane under close monitoring, and a laryngeal mask was inserted without muscle relaxation. The surgery was uneventful; however, a careful approach was required during anesthesia because life-threatening complications may occur in patients with KSS.

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We present here the case of a 13-year-old male patient with Alexander's disease who underwent surgical correction of a femur fracture. Alexander's disease is a rare and fatal disorder that affects the white matter in the brain and it causes developmental delay, psychomotor regression, spasticity, megaloencephaly and seizure. The patient had the possibility of a seizure attack during the perioperative period. We discuss the anesthetic management of a patient with Alexander's disease and we review the relevant literature.

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Demyelination is characterized by the loss of myelin with the preservation of axons. Demyelinating diseases can be classified into several categories: demyelination due to inflammation, viral infection, osmotic derangements and hypoxic ischemia. In particular, osmotic myelinolysis is representative, and is associated with hyperosmolality, hypokalemia or rapid correction of hyponatremia. Osmotic myelinolysis was reported to be associated with underlying conditions, such as alcoholism, diuretics and malnutrition. A 67-year-old woman with hypertension was scheduled to undergo both total knee replacements (TKR). She was observed to be lethargic with dysphagia and quadriplegia after the second TKR. She had been taking diuretics for a long time, and did not have an adequate amount of food intake due to patient controlled analgesia and a gastric ulcer after the first TKR. A laboratory examination revealed hypokalemia but normonatremia. T2 weighted-MRI revealed abnormal high signal intensity in the basal ganglia and periventricular area. This case was diagnosed with osmotic myelinolysis associated with hypokalemia without an apparent sodium imbalance.

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BACKGROUND: Risk factors for postoperative pulmonary complication (PPC) after total hip arthroplasty (THA) are poorly studied. In addition, the risk factors associated with revision THA may differ from those associated with primary THA. The purpose of this study was to compare the incidences of PPC after revision THA with those observed after primary THA, and to evaluate the risk factors. METHODS: We reviewed data describing patients who underwent primary (n = 410) and revision THA (n = 90) during a 10 year study period. The data included age, gender, body mass index, concurrent cardiopulmonary comorbidity, anesthetic techniques, operative time, the number of perioperative transfusions, the amount of fluid replaced, and the American Society of Anesthesiologists physical status. PPCs were grouped together as a single outcome and the incidence and the risk factors for PPC were analyzed. RESULTS: The incidence of PPC after revision THA was significantly higher than after primary THA (23.3% vs. 11.5%, P = 0.004). The significant risk factors in revision THA were the amount of fluid replaced > or = 3,000 ml (P = 0.014) and operative time > or = 180 min (P < 0.001), while there were no risk factors identified by primary THA during univariate analysis. Furthermore, the only significant risk factor identified by multiple logistic regression analysis was operative time (odds ratio = 8.2, P < 0.05). CONCLUSIONS: Patients undergoing revision THA are at higher risk of PPC than primary THA. The operative time is an important factor in the occurrence of PPC after revision THA.

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The use of magnesium sulphate has recently increased in anesthesiology and pain medicine. The roles of magnesium sulphate are as an analgesic adjuvant, a vasodilator, a calcium channel blocker and reducing the anesthetic requirement. These effect are primarily based on the regulation of calcium influx into the cell and antagonism of the N-methyl-D-aspartate receptor. We discuss here the clinical effects of magnesium sulphate on anesthesiology and pain medicine.

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Thoracoscopic thoracic sympathectomy (TTS) is usually a safe and uncomplicated procedure for treating essential palmar hyperhidrosis. However, we report a case of cardiovascular collapse that developed in a healthy patient undergoing TTS. The surgeon performed the left sympathectomy without incident. However, scarcely had an incision been made in the skin of the right chest when the patient developed sinus bradycardia and sudden, severe hypotension. Pulseless ventricular tachycardia occurred immediately thereafter, which rapidly progressed to ventricular fibrillation and cardiovascular collapse. The patient required resuscitation with 200 J of direct current shock defibrillation along with an intravenous injection of epinephrine 1 mg. She recovered without sequelae. We believe the Bezold-Jarisch reflex was triggered by pooling of venous blood and surgical stimuli, and the patient developed cardiovascular collapse as a result.

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A 67-year-old woman with severe congestive heart failure (New York Heart Association, NYHA class IV) was set to receive general anesthesia for cardiac surgery. For several months, she had been in a constant sitting position from which the slightest change evoked dyspnea. A patient in such a condition is rarely considered a candidate for general anesthesia, because such patients are never eligible for any type of surgery other than that used to fix the heart problem itself. We report this case to explain how anesthesia was induced with the patient sitting in a crouching position and discuss other methods of induction that can probably be used in similar situations.

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Laryngo-tracheal perforation caused by the use of a stylet during tracheal intubation is a rare complication. We present a case of subcutaneous emphysema and connective tissue inflammation after tracheal intubation. The patient was a 41-year-old male undergoing general anesthesia for an appendectomy. The intubation was difficult during laryngoscopy (Cormack-Lehane Grade III). An assistant provided an endotracheal tube with a stylet inside while the laryngoscope was in place. During intubation, a short, dull sound was heard with a sudden loss of resistance after the distal tip of the endotracheal tube passed the rima glottis. A sonogram and computerized tomography revealed subcutaneous emphysema from the neck to the upper mediastinum and fluid collection between the trachea and the thyroid. This lesion appeared to have been caused by the protruded, loose stylet. Anesthesiologists should be aware of the damage a loose stylet protruding beyond the tip of the endotracheal tube can cause.

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The aims of this study were to verify the hypoxia-reoxygenation injury of primary cultured Kupffer cells and the effect of propofol against the hypoxia-reoxygenation injury through quantitating lactate dehydrogenase (LDH) release and superoxide dismutase (SOD) activity.The sequential treatments with hypoxia and reoxygenation induced significant increasement of LDH release (P.0.01) and decresement of SOD activity(P.0.05) in primary cultured Kupffer cell. The level of LDH release and SOD activity after sequential treatments with hypoxia and reoxygenation were restored to the control level by the propofol treatment in the concentration of 0.5 and 5 microgram/mL. Propofol in concentration of 50 microgram/mL induced significant increasement of LDH release (P.0.01) on both normal culture and hypoxia-reoxygenation culture of the Kupffer cell. As hypoxia and reoxygenation procedures and propofol treatment were concurrently added to the cultured Kupffer cell, propofol treatment in the concentration of 50 microgram/mL decreased significantly the SOD activity (P.0.01). In conclusion, propofol in this hypoxia-reoxygenation model could provide a valuable clue for the study of liver transplantation and of propofol.

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Spinal cord infarction as a complication of spine surgery occurs rarely. Herein, a case of spinal cord infarction, which developed in a 69 year old woman following posterior decompression and internal fixation for a T11 bursting fracture, is descirbed. The anesthetic induction and intraoperative course were uneventful, except at the end of the procedure, where her blood pressure suddenly dropped from 130/90 to 90/60 mmHg. The patient was aggressively treated with a transfusion and vasopressor, the blood pressure then returned to its usual value within 10 minutes. However, during a physical examination in the recovery room, the patient was found to have flaccid lower limbs, with impaired sensory function below the T8 level. Her cord diameter had increased, and a high signal lesion was observed within the thoracic spinal cord, from T9 to T12 level on T2-weighted MR images, which was diagnosing as a spinal cord infarction, was and showed no improvement despite the immediate and aggressive treatment.

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A cardiovascular collapse, due to preoperatively administered intravenous vitamin K (phytonadione), was experienced in a 59-year-old woman who was scheduled to undergo a left upper lung lobectomy. The patient developed sudden facial flushing, an upper torso rash, dyspnea, palpitation, and severe hypotension about 2 min after the intravenous administration of approximately 2 mg of vitamin K. Immediate hydration and an injection of 20 mg ephedrine restored her blood pressure to the preoperative level within 5 min. The patient recovered without any sequelae, but the operation was postponed. The patient's symptoms seemed to be due to an anaphylactoid reaction or anaphylaxis following the intravenous administration of vitamin K. This case report suggests that physicians should carefully review the indications of vitamin K prior to administration, even at low doses.

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