Spontaneous Thrombolysis of Multiple Thrombi at Distal Region of Hypoplastic Vertebral Artery After Stent-assisted Angioplasty on Vertebral Artery Origin Stenosis: Angiographic Follow-up

Vertebral artery hypoplasia (VAH) can be easily overlooked if the contralateral side vertebral artery is intact, because of compensation by the contralateral artery or cerebral collateral network. The clinical relevance and hemodynamic impact of VAH is still controversial. However, VAH has recently been considered a risk factor for posterior circulation ischemia. Ischemic stroke is seldom caused by free floating thrombi (FFT) in the artery. Pathophysiology of FFT has not yet been clarified. The state of reduced blood flow such as a vertebral artery origin stenosis may cause FFT. Their instability may make them sources of recurrent artery to artery embolism. Patients with FFT will require appropriate medical and endovascular treatment. The current case illustrates a short-term angiographic change of spontaneous thrombolysis of VAH and multiple thrombi at the distal region of the stenosed lesion after stent-assisted angioplasty for a vertebral artery origin stenosis.

The cardiovascular effects of midazolam co-induction to propofol for induction in aged patients / 대한마취과학회지

BACKGROUND: The aim of this study was to investigate whether a small dose of midazolam and lessening the propofol dosage could prevent cardiovascular change at tracheal intubation for induction in aged patients. METHODS: Eighty patients over 65 years (ASA physical status 1, 2) scheduled for elective surgery received general anesthesia with remifentanil and propofol or midazolam. Patients in group P (n = 40) were induced with 0.9% NaCl 0.03 ml/kg, propofol 1. 2 mg/kg and remifentanil. Patients in group MP (n = 40) were induced with midazolam 0.03 mg/kg, propofol 0.8 mg/kg and remifentanil. The time taken to reach loss of consciousness (LOC) and the value of bispectral index score (BIS) at LOC were recorded. After LOC, 0.8 mg/kg of rocuronium was given and tracheal intubation was performed. The mean blood pressure (MBP) and heart rate (HR) were recorded before induction as the base value, before intubation, immediately post-intubation and 3 minutes after intubation. RESULTS: Compared with the base values, MBP at before intubation and 3 minutes after intubation was significantly decreased in group P and group MP (P < 0.05). Compared with group P, the decrease of MBP was significantly less at before intubation, immediately after intubation and 3 minutes after intubation in group MP (P < 0.05). The time taken to reach LOC was significantly decreased in group MP compared with that in group P (P < 0.05). There were no significant differences of HR at any time between the two groups. CONCLUSIONS: Co-induction with midazolam and propofol could prevent a marked BP decrease at tracheal intubation for induction in aged patients.

The cardiovascular effects of midazolam co-induction to propofol for induction in aged patients / 대한마취과학회지

BACKGROUND: The aim of this study was to investigate whether a small dose of midazolam and lessening the propofol dosage could prevent cardiovascular change at tracheal intubation for induction in aged patients. METHODS: Eighty patients over 65 years (ASA physical status 1, 2) scheduled for elective surgery received general anesthesia with remifentanil and propofol or midazolam. Patients in group P (n = 40) were induced with 0.9% NaCl 0.03 ml/kg, propofol 1. 2 mg/kg and remifentanil. Patients in group MP (n = 40) were induced with midazolam 0.03 mg/kg, propofol 0.8 mg/kg and remifentanil. The time taken to reach loss of consciousness (LOC) and the value of bispectral index score (BIS) at LOC were recorded. After LOC, 0.8 mg/kg of rocuronium was given and tracheal intubation was performed. The mean blood pressure (MBP) and heart rate (HR) were recorded before induction as the base value, before intubation, immediately post-intubation and 3 minutes after intubation. RESULTS: Compared with the base values, MBP at before intubation and 3 minutes after intubation was significantly decreased in group P and group MP (P < 0.05). Compared with group P, the decrease of MBP was significantly less at before intubation, immediately after intubation and 3 minutes after intubation in group MP (P < 0.05). The time taken to reach LOC was significantly decreased in group MP compared with that in group P (P < 0.05). There were no significant differences of HR at any time between the two groups. CONCLUSIONS: Co-induction with midazolam and propofol could prevent a marked BP decrease at tracheal intubation for induction in aged patients.

Interpleural Displacement of Subclavian Catheter During Thoracotomy: A Case Report / 고신대학교의과대학학술지

Central venous catheterization is well used to provide a large mount of fluid and monitor central venous pressure. However, the procedure accompany various complication including pneumothorax, vascular injury, nerve injury and arrhythmia. To verify correct position of catheter, we checked free regurgitation of blood during catheterization. We experienced a case report of right hemothorax that occurred after right central venous catheterization nevertheless checking correct position by free regurgitation.

Reliability of Passive Knee Joint Position Sense Test

OBJECTIVE: To investigate the optimal number of repetition trials and to evaluate the test-retest reliability of passive knee joint position sense test. METHOD: Thirty healthy subjects were tested with isokinetic machine. The knee joints were placed in starting angle of 0degrees for flexion test and 90degrees for extension test. To memorize the target angle, the knees were passively positioned to the target angle (30degrees in flexion test and 60degrees in extension test) and left hold for 10 seconds, and returned to starting position. After these processes, knee joints were passively moved toward target angles. The subjects were instructed to press button when the memorized angles were estimated to be reproduced. The tests were performed 6 times for each test angle. After 48 hours, the tests were repeated. Intra-class correlation coefficients (ICC) were calculated with the values of test and retest. RESULTS: There were no significant differences in absolute angular errors (AAE) between dominant and non-dominant side. The ICC value of above five repetitions of test showed excellent reliability (0.807) whereas three and four repetitions showed moderate reliabilities (0.536~0.709). CONCLUSION: From the results of this study, we suggest that five repetitions of test could be appropriate for the passive joint position sense test.

Intramedullary Sarcoidosis of Cervical Spinal Cord Suspected as Intramedullary Tumor: A case report

Sarcoidosis is an idiopathic multisystem disorder that usually develops in the respiratory system, but rarely in spinal cord. A 54-year-old female patient was presented with progressive right side weakness and paresthesia below C4 level dermatome which began 3 months ago. Cervical MRI findings showed T2 weighted high signal nodular lesion with surrounding edema at the C4 and C5 vertebra level, suggestive of intramedullary spinal cord tumor. She went through the resection of the part of the mass. The result of biopsy revelaed chronic granulomatous inflammation without caseous necrosis. Despite of tuberculosis medication and proper rehabilitation program for 2 weeks, there was no improvement of symptoms with exacerbated findings on cervical MRI and increased serum angiotensin converting enzyme level. We concerned about the cervical intramedullary sarcoidosis at this point, we treated her with steroid. After 3 months, her MRI findings were improved without improvement in her symptoms.

The expression of survivin and its related genes in adipocyte-derived stem cell by demethylation / 대한마취과학회지

BACKGROUND: Survivin is thought to contribute to stem cell maintenance partly by a hypomethylation mechanism. This study attempted to elucidate the signal transduction pathway of adipocyte-derived stem cells (ASCs) by using a demethylating agent, 5-aza-2'-deoxycytidine (ADC), to analyze the survivin, MEK/ERK, c-Myc and p53 gene expression. METHODS: Demethylation in the ASCs was induced by 1 micrometer ADC treatment. RT-PCR for survivin mRNA was preformed, before and 24, 48 and 72 hours (hr) after ADC treatment. Western blotting analysis was performed for p53, survivin, unphosphorylated and phosphorylated (p)-MEK, and p-ERK. Immunohistochemistry for ERK and survivin was done to evaluate the localization of the proteins. RESULTS: ADC inhibited the population growth of the ASCs and it increased the number of apoptotic cells 24, 48, and 72 hr after treatment. ADC treatment slightly decreased the expression of survivin mRNA after 48 hr and its level was restored after 72 hr of treatment. Otherwise, the level of survivin protein gradually increased up to 48 hr and it was decreased at 72 hr. The levels of p-MEK and p53 were increased time-dependently. c-Myc and p-ERK were elevated after ADC treatment and their highest levels were seen 48 hr after treatment. The ADC treatment increased the nuclear expression of ERK and survivin in the ASCs. CONCLUSIONS: The overexpression of p-MEK/ERK, p53, and c-Myc increased the survivin protein expression of the demethylated ASCs. These results suggest that demethylation could alter the expression of survivin, and p53, c-Myc and the MAPK (MEK/ERK) pathway might play a role in survivin's regulation in ASCs.

Difference of the hemodynamic changes induced by tracheal intubation using remifentanil between smokers and nonsmokers / 대한마취과학회지

BACKGROUND: It was well-known that smoking affects the cardiovascular system, and remifentanil can suppress the sympathetic stimulations induced by tracheal intubation. The purpose of this study was to investigate whether there was any difference in the hemodynamic changes induced by tracheal intubation with using remifentanil between smokers and nonsmokers. METHODS: Eighty patients were enrolled: male smokers (MS), male nonsmokers (MN), female smokers (FS) and female nonsmokers (FN). Anesthesia was induced with diluted remifentanil (20 microgram/ml) at a rate of 10 microgram/kg/hr using an infusion pump, and 2 min later, midazolam 0.05 mg/kg and propofol 0.8 mg/kg were injected for achieving unconsciousness. Rocuronium 1 mg/kg was used for muscle relaxation, and tracheal intubation was performed 2 min after rocuronium injection. After tracheal intubation, the remifentanil was decreased to 2 microgram/kg/hr. The mean arterial pressure (MAP) and heart rate (HR) were checked before induction, on unconsciousness, just before intubation, just after intubation and 1, 2 and 3 minutes after intubation, and these values were compared between the groups. RESULTS: In men, the MAP and HR just after intubation and at 1, 2 and 3 minutes after intubation in Group MS were significantly higher than those of Group MN (P < 0.05). For the women, the HR in both groups (the FS and FN groups) were increased just after intubation and 1, 2 and 3 minutes after intubation compared with that at the baseline, respectively, but there was no difference between the two groups. CONCLUSIONS: There was a difference of the hemodynamic changes induced by tracheal intubation with using remifentanil between the male smokers and nonsmokers, but not in women.

A Case of Peritoneal Mesothelioma with Direct Invasion to Gastric Mucosa / 대한소화기학회지

Mesothelioma is a rare aggressive tumor arising from the mesothelial cell and regarded as universally fatal disease with average survival around 1 year. The incidence rate is varied from one to forty per million in different countries and increasing by the year. The most common site of tumor origin is the pleura and only 20% to 33% of mesothelioma arise from the peritoneum. There are increasing reports of malignant mesothelioma with forty to fifty fatal cases per year in Korea. Histological studies with immunohistochemical stain is helpful for the diagnosis of peritoneal mesothelioma and imaging modality alone is not sufficient for diagnosis, so it is difficult to confirm diagnosis. A 64-year-old male patient was admitted to the hospital with a palpable mass on abdomen. The 6x6 cm sized huge mass was seen on the body of stomach adjacent to the peritoneum. We report a case of malignant peritoneal mesothelioma without evident exposure to asbestos, of which direct invasion to the gastric mucosa was confirmed by endoscopic biopsy and immunohistochemical stain.

A Case of Sclerosed Hemangioma Mimicking Intrahepatic Cholangiocarcinoma / 대한소화기학회지

Hemangioma is one of the most frequently encountered benign hepatic neoplasm which can develop secondary degeneration. Sclerosed hemangioma is a rare disease histologically characterized by large amount of collagen and elastic fibril between sclerosed small vessels. Its differential diagnosis is very difficult. It should be included in the differential diagnosis of other hepatic lesions such as hepatocellular carcinoma, intrahepatic cholangiocarcinoma, and metastatic hepatic tumor. A 77-year old male was admitted with upper abdominal discomfort. Abdominal ultrasonography revealed GB stone, dilated common bile duct with bile duct stone, and a 4.6 cm sized hyperechoic mass at segment 5 and 6 of the liver. Abdominal dynamic computed tomography demonstrated dilated intrahepatic bile ducts and a 5x5 cm sized mass which showed minimally delayed enhancement. Abdominal magnetic resonance imaging revealed the mass with low signal intensity in T1 weighted image, high signal intensity and focal low signal in T2 weighted image which showed minimal enhancement. We removed common bile duct stone with endoscopic retrograde cholangiopancreatography then decided to undergo right lower segmentectomy of liver due to possibility of cholangiocarcinoma. Histopathological examination of hepatic mass showed large amount of fibrous tissue with occasional residual vascular channels. We describe one case of sclerosed hemangioma mimicking cholangiocarcinoma.

The effects of remifentanil and lidocaine on the cardiovascular responses to tracheal intubation in hypertensive patients / 대한마취과학회지

BACKGROUND: Hypertensive patients are more prone to exhibit an exaggerated hemodynamic responses to laryngoscopy and tracheal intubation. We compared the effects of remifentanil and lidocaine on the cardiovascular responses during intubation in hypertensive patients. METHODS: Fifty adult hypertensive patients (>140/90 mmHg) were divided into 2 groups (remifentanil group; 1.0 microgram/kg, n = 25, lidocaine group; 1.5 mg/kg, n = 25). After 3 minutes'oxygenation, anesthesia was induced using 0.2 mg glycopyrrolate, 1.5 mg/kg propofol, and 1 of experimental drugs (30 seconds) bolus administration. Tracheal intubation was facilitated 90 seconds after administration of rocuronium; anesthesia was maintained with 2% sevoflurane and air in oxygen. Arterial blood pressure and heart rate were measured at the following times: resting state (baseline), after oxygenation; before intubation; just after intubation; and at 1, 3, and 5 minutes after intubation. RESULTS: There was significant attenuation of mean systolic and diastolic arterial blood pressures, after intubation of the remifentanil group compared to the lidocaine group at just after intubation and at 1 minute after intubation (P < .05). The difference in heart rate was not significant between both groups. CONCLUSIONS: Bolus administration of remifentanil was found to be superior to lidocaine in the attenuation of the blood pressure during intubation in hypertensive patients.

Effect of Normal Saline and Distilled Water Used for Dilution of 4% Plain Lidocaine in Epidural Anesthesia / 대한마취과학회지

BACKGROUND: Lidocaine blocks sodium channels in nerve membranes, which inhibits sodium influx and prevents development of an action potential. For epidural anesthesia, we usually use lidocaine diluted in normal saline or distilled water. However, diluents containing sodium ions may affect lidocaine activity. METHODS: Fifty patients, ASA physical status class I or II, scheduled for elective epidural anesthesia were randomly divided into two groups.For epidural anesthesia, we used 14 ml of 2% lidocaine solution made with 7 ml of 4% lidocaine plus an equivalent of distilled water (Group DW) or normal saline (Group NS).In the right lateral decubitus position, a 19 G Arrow catheter was inserted 3 cm in the cephalad direction in the L3-4 intervertebral space.In the supine position, 3 ml of 2% lidocaine was injected as a test dose, and the remaining 11 ml of lidocaine was injected 2 minutes later.We used a pinprick test for evaluation of sensory block levels and a Bromage grade for degrees of motor block every 2 minutes during the first 30 minutes. RESULTS: Levels of sensory block were higher in Group DW than Group NS at 12, 14 and 30 minutes. The degree of motor block was also higher in Group DW at 12 and 14 minutes. CONCLUSIONS: Diluent containing sodium ions reduces sensory and motor block compared to sodium-free solution in epidural anesthesia.

Antiemetic effect of oral ramosetron in women undergoing thyroidectomy / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) after thyroidectomy in women is especially frequent. Ramosetron and dexamethasone prevent cancer chemotherapy-related nausea and vomiting- and PONV. METHODS: Ninety three women undergoing thyroidectomy under general anesthesia with sevoflurane and remifentanil were allocated to one of three groups: Control (n = 30), ramosetron (Group R, n = 30), ramosetron with dexamethasone (Group RD, n = 33). Doses of ramosetron (0.1 mg) oral tablet by oral route and intravenous dexamethasone (5 mg) were used. The incidence and severity of PONV, and postoperative blood glucose level in each group were studied. RESULTS: The incidence of PONV in the control and R and RD groups were 43%, 20%, and 18% respectively. The incidence and severity of PONV were similar in the R and the RD groups. Blood glucose levels postoperatively were higher in RD group compared with control and R groups. CONCLUSIONS: Oral ramosetron reduced the incidence of postoperative nausea. The combination of ramosetron and dexamethasone increased postoperative blood glucose levels significantly without additional effect on PONV.

Optimal Dose of Remifentanil and Propofol TCI for Minimizing Cardiovascular Changes to Tracheal Intubation during Total Intravenous Anesthesia / 대한마취과학회지

BACKGROUND: The purpose of this study is to determine the optimal dose of remifentanil and propofol for minimizing the cardiovascular changes to tracheal intubation during total intravenous anesthesia (TIVA) using propofol target controlled infusion (TCI). METHODS: One hundred thirty five patients, aged 20-60 years, were randomly divided into three groups. Anesthesia was induced with remifentanil, propofol and rocuronium 1 mg/kg for intubation. Group I received remifentanil 0.1microgram/kg/min and a propofol target concentration 4microgram/ml. Group II received remifentanil 0.2microgram/kg/min and propofol 4microgram/ml. Group III received remifentanil 0.2microgram/kg/min and propofol 3microgram/ml. Remifentanil was infused continuously, and 2 minutes after remifentanil infusion, propofol was infused continuously. Mean arterial blood pressure (MAP) and heart rate (HR) were measured at pre-induction, 1 minute after remifentanil infusion, before propofol TCI, immediately before and after intubation and 1, 2, 3 minutes after intubation, respectively. RESULTS: Compared with pre-induction values, MAP at immediately after intubation was significantly increased in group I, but decreased in group II, with no change in group III. The HR immediately after intubation was significantly increased after intubation in all groups compared to the pre-induction values, but the rate of increase of HR in groups II, III were significantly lower than those of group I (p < 0.05). Hypotension was observed in 6 patients in group II and 3 in group III. CONCLUSIONS: Remifentanil 0.2microgram/kg/min and the propofol target concentration 3microgram/ml are optimal doses for minimizing cardiovascular changes and side effects to tracheal intubation during TIVA.

The Effect of Second Look Endoscopy in Patients with Peptic Ulcer Bleeding / 대한소화기내시경학회지

BACKGROUND/AIMS: Performing second look endoscopy has been suggested in order to reduce recurrent bleeding. We assessed whether second look endoscopy reduces the risks of recurrent bleeding and the mortality rate for patients suffering with peptic ulcer bleeding. METHODS: From February 2003 to June 2004, we have performed a prospective, randomized, controlled study of 141 patients with bleeding peptic ulcers, and these patients had been admitted to Kyungpook National University Hospital. Seventy patients in the study group were randomized to receive scheduled second look endoscopy. Seventy one patients in the control group were observed closely. RESULTS: Seventeen of the admitted 141 patients were found to have rebleeding after initial therapeutic endoscopy. The overall rebleeding rate was 12.1%. Although the duration of the hospital stay was significantly lower for the study group than for the control group (p<0.05), the rebleeding rate was similar for both groups (p<0.05). The two groups were similar in respect to the mortality during the period of hospitalization, the volume of hypertonic saline epinephrine that was injected and the number of hemoclips that were used. CONCLUSIONS: From these results, we can conclude that scheduled second look endoscopy with retreatment did not reduce the risk of recurrent bleeding for patients with peptic ulcer bleeding. Therefore, scheduled second look endoscopy should be selectively performed for the patients who are at a high risk for peptic ulcer bleeding.

Mechanism of Amelioration of Cisplatin Nephrotoxicity by Procaine Treatment in Mice / 대한마취과학회지

BACKGROUND: Procaine binds to DNA and reduces cisplatin nephrotoxicity, but the mechanism is poorly understood. We explored whether procaine amelioration of cisplatin nephrotoxicity was related to down-and/or up-regulation of inflammatory response gene tumor necrosis factor-alpha (TNF-alpha), oxidative stress indicator gene heme oxygenase-1 (HO-1) or cell cycle inhibitor gene p21. METHODS: Cisplatin and procaine were intraperitoneally injected to mice at a single dosage of 16 and 80 mg/kg, respectively. Renal evaluation was performed 72 hours after cisplatin administration. The expression of transcripts and proteins was analyzed using real time RT-PCR and Western blot, respectively. RESULTS: Procaine treatment moderately attenuated necrotic changes of renal proximal tubules and increases in BUN and creatinine concentration by cisplatin administration. Kidney platinum level between the cisplatin (cis) group and the cisplatin + procaine (CisPro) group was not different. Although the level of TNF-alpha mRNA increased 4-fold higher in the Cis group than in the control, this increase was not attenuated by procaine treatment. Gene expression of p21 and HO-1 was elevated 175 and 4-times higher in the Cis group than in the control, respectively. But their expression was no further elevated, rather significantly reduced in the CisPro group compared to the Cis group. Protein abundance of p21 and HO-1 was paralleled by their respective mRNA expression. CONCLUSIONS: Procaine amelioration of cisplatin nephrotoxicity is likely to be achieved through processes other than the regulation of TNF-alpha, HO-1 or p21 gene expression.

A Case of Russell Body Gastritis Associated with Helicobacter pylori Infection / 대한소화기내시경학회지

Russell body gastritis is a very rare disease with an uncertain cause. The disease is often misdiagnosed as xanthoma, signet ring cell carcinoma, MALT lymphoma and plasmacytoma. Russell body gastritis is characterized by the polyclonic nature of immunoglobulin and usually tests positive to the kappa and lambda light chains. It is different from a Mott cell tumor, which shows monoclonal nature of immunoglobulin. Until now, few cases have been reported and most were associated with a Helicobacter pylori infection. We encountered a case of Russell body gastritis associated with a Helicobacter pylori infection, which showed complete improvement after eradicating the Helicobacter pylori infection. We report this case with review of the relevant literature.

Two Cases of Gastric Mucosal Calcinosis / 대한소화기내시경학회지

Gastric mucosal calcinosis (GMC) is a very rare condition that is characterized by the nodular deposition of calcium salts in the gastric mucosa. It has been associated with renal failure, gastric cancer, ingestion of aluminum- containing antacids and the use of sucralfate in organ transplant patients. The etiology of this condition is uncertain, but several theories have been proposed; the condition is due secondarily to hyperparathyroidism in renal failure and to the alkalinization of the gastric mucosa. We report here on two patients who had long-term use of bismuth and/or aluminum-containing antacids to treat their gastro-esophageal reflux symptoms. The esophagogastroduodenoscopy revealed acute gastritis patterns, and GMC was confirmed histologically with biopsy. When one patient stopped ingesting bismuth-containing antacid solution, the follow-up esophagogastroduodenoscopy and the biopsy revealed a completely improved state. We report here on these interesting cases and we include a brief review of the literature.

The Analgesic Effects of Dose of Butorphanol Administered in Intravenous Patient Controlled Analgesia after Subtotal Gastrectomy / 대한마취과학회지

BACKGROUND: Butorphanol, a synthetic partial agonist-antagonist narcotic, produces adequate analgesia for postoperative pain. This study was designed to determine the appropriate dosage of butorphanol when administered with ketorolac by intravenous patient controlled analgesia (IV-PCA) after subtotal gastrectomy. METHODS: Ninety ASA physical status I or II patients undergoing subtotal gastrectomy were randomly allocated into one of three groups according to type of drug used (n = 30 for each group). The patients were divided into group B6 (butorphanol 6 mg), group B10 (butorphanol 10 mg) and group B14 (butorphanol 14 mg). Drugs for each group were mixed with 300 mg of ketorolac and normal saline (total amount: 100 ml) for infusion. Bolus dose, maintenance dose and lockout interval were 0.5 ml per each press, 1 ml/hr and 15 minutes, respectively. In each group, numerical rating scale (NRS) score, sedation score and incidence of side effect were checked. RESULTS: There were no significant differences in analgesic effects and sedation score among three groups but the NRS score of group B14 is lower than that of group B6 (P < 0.05) 3 hrs after the recovery room. CONCLUSIONS: We recommend 6 mg butorphanol, mixed with 300 mg of ketorolac, and normal saline for postoperative pain relief using IV-PCA.

Appropriate Dosage of 8.4% Sodium Bicarbonate for Preventing Injection Pain of Rocuronium during Anesthetic Induction / 대한마취과학회지

BACKGROUND: The administration of rocuronium is associated with severe burning pain on injection that lasts for approximately 10-20 seconds. Injection pain is probably caused by the acidic pH of rocuronium. Mixing rocuronium with 8.4% sodium bicarbonate might neutralize the acidic pH thereby decrease the level of injection pain. This study investigated the appropriate sodium bicarbonate dose for preventing injection pain. METHODS: The study examined 250 patients (aged 20 to 60 years) from ASA I and II groups who scheduled for elective surgery. The patients were divided randomly into five groups. The control group (SB0) received rocuronium 50 mg (5 ml) only and the experimental groups received rocuronium 50 mg mixed with 8.4% sodium bicarbonate 1 (SB1), 2.5 (SB2.5), 5 (SB5), 7 (SB7) ml, respectively. The level of pain was evaluated as the withdrawal response as follows: no movement, 0; hand and wrist movement, 1 point; ipsilateral arm movement, 2 points; and general movement 3 points. RESULTS: The incidence of a withdrawal response was 68% in the control group (SB0). On the other hand, the incidence of a withdrawal response was 38%, 28%, 14% and 12% in the SB1, SB2.5, SB5 and SB7 groups, respectively. The withdrawal response was significantly lower in the experimental groups than in the control group (P < 0.01). In the experimental groups, a significant difference was observed between the SB1 and SB5, SB7 groups. However, there was no significant difference observed between the SB2.5, SB5 and SB7 groups. CONCLUSIONS: Mixing 5 ml of 8.4% sodium bicarbonate with rocuronium 50 mg (5 ml) is the most effective in preventing the injection pain associated with rocuronium during the induction of anesthesia.