The Comparison of Laryngeal Mask Airway and Laryngeal Tube in Spontaneous Breathing Anesthetized Pediatric Patients / 대한마취과학회지

BACKGROUND: During general anesthesia, the most commonly used way of keeping airway patency is endotracheal intubation. However, for relatively short and simple surgery, less invasive method using laryngeal tube (LT) or laryngeal mask airway (LMA) is generally accepted and the comparative study between the two apparatus is now being actively done. In this study, we evaluated the usefulness of two apparatus from pediatric patients. METHODS: We select 58 children from one to ten years old who are to be given short operation and then anesthetize 30 children by using LT and 28 children by LMA. The size of LT and LMA is chosen by body weight according to the manufacturer's recommendation. We evaluated the seal pressure of LT and LMA, ventilatory efficiency, attempt number, facility of insertion, proper positioning confirmed by fiberoptic bronchoscopy, and complications. RESULTS: There was no statistically significant difference in the attempt number and facility of insertion between the two groups. LT and LMA were both properly positioned and the ventilation efficiency was not different from the two groups. The LT group shows higher seal pressure than the LMA group and there is no correlation between sealing pressure and ventilation efficiency. There is close correlation between bronchoscopic grade and ventilatory efficiency. complications are not different between two groups. CONCLUSIONS: Both LT and LMA are useful for simple surgery of children and LT has higher sealing pressure.

Unilateral Atelectasis during Total Hip Replacement Surgery under Regional Anesthesia: A case report / 대한마취과학회지

Even though atelectasis develops rare during anesthesia and/or surgical operation, it may be very important complication because it can be fatal. Atelectasis may be due to airway or bronchus obstruction, compression of the lung by position, primary surfactant deficiency, increased pleural pressure due to fluid or air in the pleural space, chest wall restriction due to skeletal deformity and/or muscular weakness. We report a case of acute intraoperative unilateral lobar atelectasis in 87-years-old woman patient undergoing regional anesthetic for total hip replacement surgery.

ED50 of Nicardipine for Preventing Hypertensive Response to Tracheal Intubation during Induction with Thiopental, Propofol or Etomidate / 대한마취과학회지

BACKGROUND: Laryngoscopy and tracheal intubation often provoke an undesirable increase in blood pressure and heart rate. This study was done to determine median effective dose (ED50) of nicardipine for prevention of hemodynamic response to tracheal intubation during induction of anesthesia with thiopental, propofol, or etomidate. METHODS: Fourty-five ASA physical status 1 adult patients were allocated into three group; thiopental group (n = 15), propofol group (n = 15), and etomidate group (n = 15). The first patient of each groups received 10microgram/kg of nicardipine 1 minute before induction. Subsequent dose was determined by the hemodynamic response of the previous patient to tracheal intubation based on Dixon's up and down sequential allocation. The test dosing interval was set at 3microgram/kg. If mean arterial pressure increased more than 20% after tracheal intubation, dose of the subsequent patient was increased by 3microgram/kg. If not, it was decreased by 3microgram/kg. Blood pressure was measured after arrival at the operating room, before tracheal intubation, and 1, 2, 3, 4, and 5 minutes following intubation by non invasive method. RESULTS: ED50 of nicardipine for attenuation of hypertensive response after tracheal intubation were 18.0microgram/kg (95% Confidence Limit [CL], 14.8-22.0microgram/kg), 6.2microgram/kg (CL, 2.6-9.5microgram/kg), and 16.7microgram/kg (CL, 13.6-20.7microgram/kg) in thiopental group, propofol group andetomidate group, respectively. CONCLUSIONS: We concluded that less nicardipine dose in propofol group was needed to prevent hypertensive response after tracheal intubation (P < 0.05).

Chest Pain due to an Aortic Pseudoaneurysm during Trans-Urethral Resection of the Prostate: A case report / 대한마취과학회지

Aortic pseudoaneurysms are rare. When aortic pseudoaneurysms are detected, they demand timely surgical intervention because they trend to increase in size and cause complications. We experienced a rare case of a chronic traumatic pseudoaneurysm located at the distal descending aorta associated with chest pain during trans-urethral resection of the prostate under spinal anesthesia. Diagnostic testing led to appropriate management.

Minimum Effective Anesthetic Concentration of Hyperbaric Tetracaine 10 mg for Spinal Anesthesia / 대한마취과학회지

BACKGROUND: Minimum effective anesthetic concentration (MEAC) of local anesthetics for spinal anesthesia, defined as the concentration at which a spinal anesthetic agent produces surgical anesthesia within 20 minutes of administration in 50% of patients. This concept is similar to the concept of minimum alveolar concentration (MAC) for inhalation anesthetic. Furthermore, as MEAC may vary with the administered dose, it will be determined using 10 mg of hyperbaric tetracaine. METHODS: 10 mg hyperbaric tetracaine containing dextrose 10 % was administered intrathecally to 12 patients (ASA I-II, age 20~40 yr), who were undergoing lower limb or urological procedures within 90 minutes, at concentrations ranging from 0.07~0.1%. The choice of tetracaine concentration was determined by Dixon's up-and-down method. Complete anesthesia was defined as: (1) pinprick anesthesia at or higher than T10 and (2) complete leg paralysis; all occurring in both lower extremities within 20 min. General anesthesia was initiated if spinal anesthesia was incomplete. RESULTS: MEAC of 10 mg hyperbaric tetracaine was 0.083 %. Mean anesthetic duration was 75.2 minutes (range: 40~100 min). The maximum sensory block level ranged from T3~T8. CONCLUSION: The aim of this study was to establish new concept of minimum effective anesthetic concentration of hyperbaric tetracaine for spinal anesthesia. We recognized that spinal anesthesia can be accomplished with very dilute solution. As fixed dose, no correlation was found between concentration of the spinal tetracaine solution with the highest sensory level, anesthetic duration and the degree of mean arterial pressure decreased.

Minimum Effective Anesthetic Concentration of Hyperbaric Tetracaine 10 mg for Spinal Anesthesia / 대한마취과학회지

BACKGROUND: Minimum effective anesthetic concentration (MEAC) of local anesthetics for spinal anesthesia, defined as the concentration at which a spinal anesthetic agent produces surgical anesthesia within 20 minutes of administration in 50% of patients. This concept is similar to the concept of minimum alveolar concentration (MAC) for inhalation anesthetic. Furthermore, as MEAC may vary with the administered dose, it will be determined using 10 mg of hyperbaric tetracaine. METHODS: 10 mg hyperbaric tetracaine containing dextrose 10 % was administered intrathecally to 12 patients (ASA I-II, age 20~40 yr), who were undergoing lower limb or urological procedures within 90 minutes, at concentrations ranging from 0.07~0.1%. The choice of tetracaine concentration was determined by Dixon's up-and-down method. Complete anesthesia was defined as: (1) pinprick anesthesia at or higher than T10 and (2) complete leg paralysis; all occurring in both lower extremities within 20 min. General anesthesia was initiated if spinal anesthesia was incomplete. RESULTS: MEAC of 10 mg hyperbaric tetracaine was 0.083 %. Mean anesthetic duration was 75.2 minutes (range: 40~100 min). The maximum sensory block level ranged from T3~T8. CONCLUSION: The aim of this study was to establish new concept of minimum effective anesthetic concentration of hyperbaric tetracaine for spinal anesthesia. We recognized that spinal anesthesia can be accomplished with very dilute solution. As fixed dose, no correlation was found between concentration of the spinal tetracaine solution with the highest sensory level, anesthetic duration and the degree of mean arterial pressure decreased.

Anesthesia for Cesarean Section with HELLP Syndrome: A case report / 대한마취과학회지

Hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome is a variant presentation of severe preeclampsia/eclampsia. A 24-year old woman presented herself at 34 wk of pregnancy. Based on the clinical and laboratory assessment, HELLP syndrome was diagnosed. Cesarean section was performed under general anesthesia without invasive monitoring due to stable blood pressure. The course of anesthesia and surgery was uneventful and she delivered female neonate weighing 1770 gram. After the operation, the patient was transferred to the intensive care unit immediately. During the intensive care bleeding started and signs of disseminated intravascular coagulopathy showed up. Any improvement was not made after transfusion and every other supportive therapy. By the request of guardian, she was transferred to tertiary hospital, where she died.

Determination of the Depth of Subclavian Catheter Insertion Using Chest Anteror-Posterior Film / 대한마취과학회지

BACKGROUND: Cardiac tamponade is a rare but fatal complication of subclavian catheter insertion and maintenance. This happens due to erosion of the cardiac wall or the superior vena cava distal to the CLPR (cephalic limit of pericardial reflection). This study is designed to present a method of locating the catheter tip proximal to the CLPR, and to evaluate its results. METHODS: Forty adult patients with intracranial hemorrhages who needed craniotomies and central venous catheter insertions were recruited. The right subclavian vein was selected as the insertion route. On Chest AP film, clavicle, supraclavicular notch and trachobronchial tree were used as landmarks. The CLPR was assumed to be at the level of the angle between the right main bronchus and the trachea. Needle depth was measured from the skin puncture site to the point where blood was regurgitated by the Chest AP landmarks. Intravascular depth was measured from the point where blood was regurgitated to the CLPR. The sum of these two points was regarded as being the appropriate depth of the subclavian catheter insertion. In the control group (n = 40), the right subclavian catheter was inserted to the depth of height (cm)/10 minus 2 cm. RESULTS: In study group, the catheter tips were located proximal to the CLPR in about 2/3 (27/40) of the patients, and there was no case in which catheter tip was distal to the superior vena cava-right atrium junction. In the control group, catheter tips were proximal to the CLPR in only 10% of the patients and distal to the SVC/RA junction in 42.5%. CONCLUSIONS: This method decreased the incidence of locating the tip of the catheter distal to the CLPR, and prevented any intracardial location of the catheter tip.

Determination of the Depth of Subclavian Catheter Insertion Using Chest Anteror-Posterior Film / 대한마취과학회지

BACKGROUND: Cardiac tamponade is a rare but fatal complication of subclavian catheter insertion and maintenance. This happens due to erosion of the cardiac wall or the superior vena cava distal to the CLPR (cephalic limit of pericardial reflection). This study is designed to present a method of locating the catheter tip proximal to the CLPR, and to evaluate its results. METHODS: Forty adult patients with intracranial hemorrhages who needed craniotomies and central venous catheter insertions were recruited. The right subclavian vein was selected as the insertion route. On Chest AP film, clavicle, supraclavicular notch and trachobronchial tree were used as landmarks. The CLPR was assumed to be at the level of the angle between the right main bronchus and the trachea. Needle depth was measured from the skin puncture site to the point where blood was regurgitated by the Chest AP landmarks. Intravascular depth was measured from the point where blood was regurgitated to the CLPR. The sum of these two points was regarded as being the appropriate depth of the subclavian catheter insertion. In the control group (n = 40), the right subclavian catheter was inserted to the depth of height (cm)/10 minus 2 cm. RESULTS: In study group, the catheter tips were located proximal to the CLPR in about 2/3 (27/40) of the patients, and there was no case in which catheter tip was distal to the superior vena cava-right atrium junction. In the control group, catheter tips were proximal to the CLPR in only 10% of the patients and distal to the SVC/RA junction in 42.5%. CONCLUSIONS: This method decreased the incidence of locating the tip of the catheter distal to the CLPR, and prevented any intracardial location of the catheter tip.

Effects of both Clonidine Premedication and Esmolol Administration on the Hemodynamic Changes by Tracheal Intubation / 대한마취과학회지

BACKGROUND: Tracheal intubation by direct laryngoscopy induces frequently transient hypertension, tachycardia and arrhythmia. The purpose of this study was to examine the effect of esmolol and clonidine in attenuating the changes of blood pressure and heart rate by tracheal intubation. METHODS: Eighty patients were randomly divided into four groups: Group 1 (control , n=20), Group 2 (esmolol 0.5 mg/kg IV, n=20), Group 3 (clonidine 4 mcg/kg PO, n=20) and Group 4 (clonidine 4 mcg/kg PO and esmolol 0.5 mg/kg IV, n=20). The clonidine premedication were given orally with a sip of water 90 minutes before induction of anesthesia. Anesthesia was induced with thiopental 5 mg/kg, vecuronium 0.1 mg/kg, 50% nitrous oxide in oxygen and 2 vol % enflurane. After 5 minutes, tracheal intubation was performed. Patients in the group 2 and group 4 were given esmolol 0.5 mg/kg 90 seconds prior to tracheal intubation. Blood pressure and heart rate were measured at ward, preinduction, preintubation, immediately after intubation, 1, 3 and 5 minutes after intubation. RESULTS: After tracheal intubation, the increase in systolic blood pressure was supressed significantly in the clonidine-treated patients (Group 3, Group 4) compared with control group (p<0.05). The attenuating effect on increase of mean arterial pressure(MAP) was sustained longer in group 4 than group 3. Heart rate increased after tracheal intubation in all groups, but were markedly increased in the control group (p<0.05). The differences of MAP which measured at preinduction and immediately postintubation were smaller in group 4 than control group (p<0.05). The differences of heart rate which measured at preinduction and immediately postintubation were smaller in group 4 than group 1 or group 3 (p<0.05). CONCLUSIONS: Esmolol 0.5 mg/kg given as bolus, is effective for controlling the increase of heart rate but not in attenuating increase of blood pressure. Oral clonidine is effective for controlling the increase of blood pressure but not in attenuating increase of heart rate. Therefore esmolol combined with oral clonidine results in effective control of both heart rate and blood pressure.

Comparative Effects of Laryngeal Mask Airway Removal and Tracheal Extubation on Intraocular Pressure during Emergence from Propofol Anesthesia / 대한마취과학회지

BACKGROUND: It is important to control the intraocular pressure (IOP) during ophthalmic surgery. The emergence from the anesthesia is another challenging period to control the IOP. METHODS: The authors have compared IOP, blood pressure (BP) and heart rate (HR) with the removal of laryngeal mask airway (LMA-R) or tracheal extubation (ET) during the emergence from the propofol anesthesia. All data were recorded in the operating room upon arrival (Phase 1), just before the LMA-R or ET (Phase 2), immediately after (Phase 3), and 3 minutes (Phase 4) after the LMA-R or ET. RESULTS: The IOP with the LMA-R was significantly lower at Phase 2 and Phase 3 than that with the ET. The changes of the IOP between Phases 1 and 2, and 3 and 4 was insignificant in LMA-R but significant in ET. The differences in BP and HR were not significant between LMA-R and ET. CONCLUSIONS: The LMA-R offers advantages over ET for ophthalmic surgery in respect to the changes in IOP during the emergence of propofol anesthesia.

Combined Spinal-Epidural Anesthesia for Transurethral Resection of the Prostate / 대한마취과학회지

BACKGROUND: The technique of combined spinal-epidural anesthesia (CSE) may offer theoretic advantages for the various surgeries, because it produces the rapid onset of spinal anesthesia, with the option to extend the blockade and postoperative pain control with an epidural catheter. In this study, we attempt to evaluate both advantages and disadvantages of the CSE for transurethral resection of the prostate (TURP). METHODS: Fifteen patients scheduled to undergo TURP were involved in our study. In all patients, a 17 G Tuohy needle was introduced into the epidural space at L3-4 or L4-5 interspace. Using the needle-through-needle technique, each patients received a subarachnoid injection of 8 mg hyperbaric bupivacaine through a 25 G Whitacre needle. After withdrawal of the Whitacre needle, an epidural catheter was inserted into the epidural space. The level of sensory blockade was checked by pinprick test every 1~2 minute for 30 minutes. Epidural postoperative pain control was done after operation. Postoperatively, we evaluated the adverse effects and the quality of postoperative pain control. RESULTS: The time from start of anesthesia to the time for a T10 sensory block and the time to start of surgery were 6+/-2 min and 21+/-3 min, respectively. At 5, 10, 15 and 20 minutes after spinal anesthesia, sensory blockade level was T10+/-1, T7+/-2, T6+/-2, and T5+/-1, respectively. In general, the quality of anesthesia was good, and most of the patients were satisfied with postoperative pain control. CONCLUSIONS: CSE provided reliable anesthesia and excellent postoperative analgesia for TURP.

Inhibitory Effect of Nicardipine on Cardiovascular Stimulation by Tracheal Intubation / 대한마취과학회지

BACKGROUND: Direct laryngoscopy and tracheal intubation frequently induce transient hypertension, tachycardia and arrhythmia. This study was to evaluate the effect of nicardipine on the changes of the blood pressure and heart rate induced by direct laryngoscopy and tracheal intubation. METHODS: Sixty patients were randomly divided into three groups: Group 1 (nicardipine 0.02 mg/kg, n=20), Group 2 (diltiazem 0.2 mg/kg, n=20), Group 3 (normal saline 3 cc, n=20). Two minutes after intravenous injection of 2 mcg/kg of fentanyl, thiopental 5 mg/kg and nicardipine or diltiazem or normal slaine was administered intravenously. Then succinylcholine 1.5 mg/kg was administered. One minute after succinylcholine injection, direct laryngoscopy and tracheal intubation was done and vecuronium 0.1 mg/kg was injected. Anesthesia was maintained with 50% nitrous oxide in oxygen and 2 vol % of enflurane. Blood pressure and heart rate were measured at the period of preintubation, immediately after intubation, 1, 3 and 5 minutes following intubation by noninvasive method. RESULTS: After tracheal intubation, the increase of systolic blood pressure was supressed significantly in nicardipine and diltiazem group compared with control group (nicardipine group 11%, diltiazem group 13%, control group 24%). The increase of heart rate was greatest in nicardipine group (nicardipine group 38% diltiazem group 29%, control group 20%). CONCLUSIONS: Nicardipine was effective in attenuating pressor responses to laryngoscopy and intubation, but in nicardipine group, increase of heart rate was greater than control group.

Intravenous Nitroglycerin Administration for Manual Removal of Retained Placenta: A Case Report / 대한마취과학회지

Retained placenta around which the uterus firmly contracted occurs in about 1% of all vaginal deliveries and may require uterine muscle relaxation to facilitate manual extraction. It is associated with profuse hemorrhage and life threatening shock. Therefore anesthesiologist may face the difficulty to provide analgesia and rapid uterine relaxation. A 32-yr-old multigravida was transferred to the emergency room in hypovolemic shock state at 1 hour after vaginal delivery. Ketamine 30 mg, fentanyl 50 mcg were given intravenously for analgesia and sedation. Oxygen 6 L/min was supplied via face mask. With ongoing fluid resuscitation, nitroglycerin 500 mcg was injected as an intravenous bolus. Within 80 seconds, the uterus relaxed enough to extract the retained placenta. The recovery of uterine muscle tone occurred approximately 1 minute after manual removal with administration of intravenous methylergonovine. In summary, the use of intravenous nitroglycerin may be a useful and safe alternative to general anesthesia in cases of manual removal of retained placenta.

Insertion of Laryngeal Mask Airway with Succinylcholine Administration / 대한마취과학회지

BACKGROUND: The purpose of this study was to assess the effects of succinylcholine(Sch) for insertion of laryngeal mask airway(LMA) during general anesthesia. We compare the bronchoscopic grade, incidence and severity of postoperative sore throat. METHODS: Seventy patients were randomly divided into two groups. The succinylcholine(Sch) group received Sch 1.0 mg/kg, saline group received the same volume of saline 1 minute before the insertion of LMA. Anesthesia was induced with fentanyl 2 g/kg and propofol 2.5 mg/kg. Once the LMA was in the hypopharynx and the cuff inflated, a fiberoptic bronchoscope was immediately passed down through the LMA, and its position was graded from the mask aperture bars. No. of attempts, postoperative sore throat and other complications were also noted. RESULTS: The bronchoscopic grade were aggravated in the Sch group(grade I, n=12; grade II, n=13; grade III, n=10), compared with saline group(22;9;4). The incidence and severity of postoperative sore throat in the recovery room were reduced in the Sch group. No. of attempts were not significantly different. CONCLUSION: The use of Sch for insertion of LMA during general anesthesia aggravated the bronchoscopic grade. However, the incidence and severity of postoperative sore throat could be reduced in the Sch group.

A Comparison of 10% Lidocaine Spray and Intravenous 2% Lidocaine on Mean ArterialPressure and Heart Rate Following Tracheal Intubation / 대한마취과학회지

BACKGROUND: Laryngoscopy and tracheal intubation for general anesthesia are potent stimuli to the cardiovascular system due to sympathetic stimulation. The aim of this study was to compare the hemodynamic responses with different administration routes of lidocaine on blood pressure and heart rate changes associated with tracheal intubation. METHODS: Sixty patients were randomly assigned to spray group (Group 1, n=20) received 10% lidocaine 1.5 mg/kg spray to intratracheally immediately before tracheal intubation, IV group (Group 2, n=20) received 2% lidocaine 1.5 mg/kg intravenously before 90 sec tracheal intubation and control group (Group 3, n=20). Anesthesia was induced with thiopental 5 mg/kg IV, vecuronium 0.1 mg/kg and 50% N2O-O2- 2vol % enflurane. After 5 minutes, tracheal intubation was performed. Mean arterial pressure and heart rate were measured at preintubation and immediately postintubation, 1, 3, 5 mins after tracheal intubation. RESULTS:The differences of mean arterial pressure which were measured at preintubation and immediately postintubation and 1 minute after intubation in group 1 were significantly lower than those in other group (p<0.05). The differences of heart rate which measured at preintubation and 1 minute after intubation were lower than those in group 3 (p<0.05). CONCLUSIONS: For the suppression of sympathetic stimulation following tracheal intubation, 10% lidocaine spray to the laryngotrachea is an effective method to suppress cardiovascular response.

The Effects of Tracheal Intubation with McCoy or Macintosh Laryngoscope on Blood Pressure, Heart Rate / 대한마취과학회지

BACKGROUND: The aim of this study was to compare the cardiovascular changes followed by laryngoscopy with the McCoy laryngoscope blade with those followed by laryngoscopy with the Macintosh laryngoscope blade. METHODS: Forty eight patients were randomly divided into two groups. Following induction with fentanyl 2 mcg/kg and thiopental 5 mg/kg, and muscle relaxation with vecuronium 0.1 mg/kg, the vocal cords were visualized with either the McCoy or the Macintosh laryngoscope blade, then tracheal intubation was performed. Heart rate and arterial blood pressure were measured just before and after laryngoscopy, and 1, 3 and 5 min later. RESULTS: There was a significant increase in both heart rate and arterial blood pressure after tracheal intubation using the Macintosh laryngoscope. Also, use of the McCoy blade resulted in a significant increase in both heart rate and arterial blood pressure. CONCLUSIONS: There was no significant difference on arterial pressure and heart rate to laryngoscopy and tracheal intubation with either the McCoy blade or the Macintosh.

Effect of High-dose Aprotinin on Postoperative Homologous Blood Requirement in Adult Cardiac Surgery / 대한마취과학회지

BACKGROUND: Post-CPB bleeding diathesis remains one of main causes of morbidity in open heart operation since it requires significant amount of homologous transfusion. Many approaches have been studied to reduce the amount of postoperative blood loss and blood use. Aprotinin is known to reduce postoperative bleeding. Therefore, hemostatic effects of aprotinin have been searched in open heart surgery. METHODS: Adult patients for open heart opeartion were randomly allocated to two groups, control group and study group. All anesthetic, surgical and bypass techniques were standardized. After induction, 10,000 KIU given for testing and then 2,000,000 KIU of aprotinin was infused for 20~30 minutes before sternotomy, and followed by at rate of 500,000 KIU/hr. Additional 2,000,000 KIU of aprotinin was mixed to pump prime of heart-lung machine. Aprotinin infusion was ended by the time of skin closure. Amount of postoperative bleeding as well as homologous blood requirement were measured. Urine output and serum creatinine were also documented during postoperative period. RESULTS: Postoperative-36hr summation of blood loss differed significantly(1858.4 1182.9 ml vs. 1256.7 688.4 ml, p<0.1). Postoperative homologous blood requirements were also reduced in the requirement of packed RBCs use(3.0 2.5 units vs. 1.0 0.8 units, p<0.01) and of fresh frozen plasma use(6.6 4.4 units vs. 3.9 2.6 units, p<0.05). Postoperative measurement of urine output and serum creatinine showed insignificant difference between groups while remained within normal range. CONCLUSIONS: High-dose aprotinin seems to have beneficial effect in reducing postoperative blood loss and blood use without renal complication.

A Case Report of Tracheoesophageal Fistula Found during General Anesthesia for Emergency Exploratory Laparotomy / 대한마취과학회지

Tracheoesophageal fistula (TEF) occurs in approximately 1 in 3,000 to 5,000 live births. TEF arises from failure of normal division of proximal foregut into separate respiratory and digestive tracts at 4 weeks' gestation. TEF and esophageal atresia are interrelated anomalies, and TEF usually occurs with esophageal atresia. These are usually diagnosed shortly after birth. However, the diagnosis is often delayed in TEF without esophageal atresia, because babies with this anomaly are usually normal in size and seldom have other anomalies. Therefore, sometimes TEF without esophageal atresia is found during operation for an unrelated condition when positive pressure ventilation causes massive inflation of the gastrointestinal tract. We report a case of TEF in adult patient found during general anesthesia for emergency exploratory laparotomy.

Respiratory Difficulty following Tracheal Extubation: A case of bilateral vocal cord paralysis / 대한마취과학회지

We had a case of respiratory difficulty following tracheal extubation due to bilateral vocal cord paralysis. The patient was a 66-year-old woman undergoing craniotomy for cerebellopontine angle meningioma. Anesthesia was uneventful. Spontaneous respiration resumed after reversal of neuromuscular blockade. Following extubation she showed inspiratory stridor, tachypnea, and chest retraction. Reintubation was done and then tracheostomy was performed. Every factor contributing vocal cord paralysis such as pressure on the nerve by an overexpanded endotracheal tube cuff, unique posture of the neck during the operation, and female gender, long operating time(about 11 hours) were seemed to be possible causes and we considered the interaction of these combinations responsible for the bilateral vocal cord paralysis. Eight weeks later, the patient's vocal cord function had returned to normal.