The birth of conjoined twins remains an extremely rare event. Most of such twins are stillborn and one third of the live births die within first day of life. In Korea, there are only three reports on the anesthesia for separation of different kinds of conjoined twins. In view of anesthesia for separation of such twins prematurity, low birth weight, and anomalous shared organ play the major role on the perioperative morbidity and mortality. Such anesthesia therefore is one of the exceedingly complex fields among the pediatric anesthesia and require mobilization of all possible methods and monitoring devices used for pediatric anesthesia. We performed careful preoperative evaluation of extent of joining, discussion and rehearsal of separation procedure between separation team, and anesthetic care such as all possible monitoring, preservation of body temperature, appropriate fluid therapy, awake intubation, avoid neuromuscular blockers, and thorough separation of duty. The separated twins showed normal weight gain postoperatively and discharged postoperative 31th day without any complications.
Anesthesia* ; Body Temperature ; Fluid Therapy ; Humans ; Infant, Low Birth Weight ; Infant, Newborn ; Intubation ; Korea ; Live Birth ; Mortality ; Neuromuscular Blockade ; Neuromuscular Blocking Agents ; Parturition ; Twins, Conjoined ; Weight Gain

BACKGROUNDS: This study was investigated for assessing of the sedative dose of midazolam and its influence on neonatal Apgar score that intravenously injected immediately before operation during epidural anesthesia for cesarean section. METHODS: Midazolam, 1 mg, was given into a freely running IV line every 30s 2 min after 2 mg of midazolam was initiately injected. Ten seconds prior to each injection patients were asked to open the eye. No response, as determined by the anesthesiologists, to three promptly repeated and increasingly louder commands was considered the end-point for the study and no further midazolam was given. RESULTS: The sedative dose of midazolam in our study was 3.3 1.1 mg and interindividual variation (range: 2~7 mg) were wide. Respiratory depression was occurred in one of pregnant women with midazolam. All of the Apgar scores of the newborn infants at 1 and 5 min in both groups were higher than seven. CONCLUSIONS: When the intravenous injection of midazolam for sedation immediately before operation is required in pregnant women during epidural anesthesia for cesarean section, we would like to suggest that one should initiately administer the small dose and then inject the incremental dose with careful observation of the respiratory status.
Anesthesia, Epidural* ; Apgar Score ; Cesarean Section* ; Female ; Humans ; Infant, Newborn ; Injections, Intravenous ; Midazolam* ; Pregnancy ; Pregnant Women* ; Respiratory Insufficiency ; Running

BACKGROUND: We evaluated laryngeal mask airway (LMA) insertion conditions, hemodynamic changes and bispectral index (BIS) responses during the induction of anesthesia with target controlled infusion (TCI) of propofol. METHODS: Ninety patients (ASA 1 or 2, 18-64 years) were allocated randomly to receive an infusion to achieve and maintain target blood concentration of a 4, 5 and 6micro gram/ml. LMA was inserted after loss of consciousness. LMA insertion conditions, hemodynamic and BIS responses were evaluated. RESULTS: Loss of consciousness and LMA insertion were more rapid in patients with propofol target blood concentration of a 6micro gram/ml than at the other concentrations. Also, full attenuation of larygeal reflexes on the first try was greater in the 6micro gram/ml group than the other groups. CONCLUSIONS: We conclude that propofol administration at a target blood concentration of 6micro gram/ml allow successful insertion of LMA without major hemodynamic changes.
Anesthesia ; Hemodynamics ; Humans ; Laryngeal Masks* ; Plasma* ; Propofol* ; Reflex ; Unconsciousness

Etomidate and midazolam are newly developed and used in clinical trials. Etmoidate, a carboxylated imidazole derivative, decreases systemic vascular resistance and increases the pulmonary artery pressure in vivo. Midazolam, a water soluble derivative of benzodiazepine, decreases pulmonary artery pressure and is useful for pulmonary hypertensive patients. This study was designed to investigate the direet effects of etomidate and midazolam on vascular tension of the rabbit abdominal aorta and the pulmonary artery in vitro. In the vascular preparations with or without endothelium, changes in tension were measured following cumulative administration of etomidate (10(-6)M, 10(-5) M, 5X10(-4) M) and midazolam (10(-6)M, 10(-5)M, 10(-4)M). Vascular effects of these drugs were also studied in the preparations pretreated with indomethacin, nitro(w)-L-arginine methyl ester (L-NAME) and methylene blue. The results wer as follows; 1) Etomidate and midazolam induced vasorelaxation and the degree of relaxation depended on the concentration. 2) After denudation of the endothelium, vasorelaxant effect of etomidate and midazolam was efficiently decreased in abdominal aorta but not in pulmonary artery. 3) Indomethacin reduced vasorelaxing effect of etomidate efficiently, but didn't affect vasorelaxing effect of midazolam. 4) Following pretreatment of vascular preparations respectively with L-NAME and methylene blue, the relaxing responses to etomidate (10(-5) and 5X10(-5) M) of both abdominal aorta and pulmonary artery were depressed. Also, depressed was the relaxing response of abdominal aorta to midazolam (10(-5) M). The results of present study suggest that etomidate and midazolam possess vasorelaxing effects in both rabbit aMominal aorta and pulmonary artery. The vascular effect of etomidate is mediated via the nitric oxide pathway and also in part, by PGI2, whereas part of the vascular effect of midazolam is associated with the nitric oxide pathway.
Aorta ; Aorta, Abdominal* ; Benzodiazepines ; Endothelium ; Epoprostenol ; Etomidate* ; Humans ; Indomethacin ; Methylene Blue ; Midazolam* ; NG-Nitroarginine Methyl Ester ; Nitric Oxide ; Pulmonary Artery* ; Relaxation ; Vascular Resistance ; Vasodilation

Etomidate and midazolam are newly developed and used in clinical trials. Etmoidate, a carboxylated imidazole derivative, decreases systemic vascular resistance and increases the pulmonary artery pressure in vivo. Midazolam, a water soluble derivative of benzodiazepine, decreases pulmonary artery pressure and is useful for pulmonary hypertensive patients. This study was designed to investigate the direet effects of etomidate and midazolam on vascular tension of the rabbit abdominal aorta and the pulmonary artery in vitro. In the vascular preparations with or without endothelium, changes in tension were measured following cumulative administration of etomidate (10(-6)M, 10(-5) M, 5X10(-4) M) and midazolam (10(-6)M, 10(-5)M, 10(-4)M). Vascular effects of these drugs were also studied in the preparations pretreated with indomethacin, nitro(w)-L-arginine methyl ester (L-NAME) and methylene blue. The results wer as follows; 1) Etomidate and midazolam induced vasorelaxation and the degree of relaxation depended on the concentration. 2) After denudation of the endothelium, vasorelaxant effect of etomidate and midazolam was efficiently decreased in abdominal aorta but not in pulmonary artery. 3) Indomethacin reduced vasorelaxing effect of etomidate efficiently, but didn't affect vasorelaxing effect of midazolam. 4) Following pretreatment of vascular preparations respectively with L-NAME and methylene blue, the relaxing responses to etomidate (10(-5) and 5X10(-5) M) of both abdominal aorta and pulmonary artery were depressed. Also, depressed was the relaxing response of abdominal aorta to midazolam (10(-5) M). The results of present study suggest that etomidate and midazolam possess vasorelaxing effects in both rabbit aMominal aorta and pulmonary artery. The vascular effect of etomidate is mediated via the nitric oxide pathway and also in part, by PGI2, whereas part of the vascular effect of midazolam is associated with the nitric oxide pathway.
Aorta ; Aorta, Abdominal* ; Benzodiazepines ; Endothelium ; Epoprostenol ; Etomidate* ; Humans ; Indomethacin ; Methylene Blue ; Midazolam* ; NG-Nitroarginine Methyl Ester ; Nitric Oxide ; Pulmonary Artery* ; Relaxation ; Vascular Resistance ; Vasodilation

From January 2007 to June 2012, 55 autopsy cases were reviewed, in which death occurred outside the hospital and the patients were declared dead on arrival at the emergency departments, in order to compare the clinical and postmortem examination diagnoses of death-on-arrival patients in tertiary hospitals in Busan, Yangsan and Ulsan city. Of 22 non-traumatic deaths, 21 occurred from natural causes and 1 from unknown cause (sudden infant death syndrome, SIDS). Clinical diagnoses were cardiovascular diseases or "non-traumatic" / "unknown" while autopsy diagnoses were majorly cardiovascular diseases, especially coronary artery diseases (72.7%). Of 33 unnatural deaths, the cause of death was blunt trauma in 4 patients, sharp-force injury in 6, falling in 10, gunshot injury in 1, traffic accidents in 3, asphyxia in 2, drowning in 2, fire-related death in 1, and intoxication in 4. There were no definite discrepancies between clinical and autopsy diagnoses, except for 5 non-traumatic deaths and 2 unnatural deaths. These results suggest that the role of the emergency department may be crucial in postmortem investigations.
Accidents, Traffic ; Asphyxia ; Autopsy ; Cardiovascular Diseases ; Cause of Death ; Coronary Artery Disease ; Drowning ; Emergencies ; Humans ; Infant ; Tertiary Care Centers

If you have conventional general anesthesia using muscle relaxants for video-assisted thoracic surgery, one lung ventilation with double lumen tube could be dangerous when residual lung volume of non-operated lung could be lacking, and positive pressure ventilation for maintenance of proper minute ventilation could be impossible when there could be too much air leakage. Also, if the abnormal bleeding tendency is, thoracic epidural anesthesia for maintenance of spontaneous breathing could be difficult to perform. A 66-year-old male with a consolidative lesion in involving right middle and lower lobe, and left pneumothorax and pleural effusion successfully underwent video-assisted thoracic bullectomy using ketamine with remifentanil for maintenance of spontaneous breathing and intermittent positive pressure support ventilation within 10 cmH2O for protection of excessive air leakage.

Patients with type II Alexander disease have white matter dysplasia, which may cause various symptoms due to nerve conduction impairment. When providing anesthesia to a patient with Alexander disease, careful and patient-specific individualized risk evaluation must be preceded by planning the method of anesthesia and anesthetic drugs. This is the first case report of a patient with type II Alexander disease who underwent general anesthesia. We performed general anesthesia on a 45-year-old male with type II Alexander disease for laparoscopic cholecystectomy, using remimazolam, remifentanil, and rocuronium. Despite the use of reversal agents including flumazenil, naloxone, and sugammadex, the patient manifested a delay in emergence but successfully recovered from anesthesia without postoperative complications. In consideration of the possibility that leukodystrophy may have altered responses to anesthetics, the action of an anesthetic agent may be prolonged or delayed in patients with type II Alexander disease. We recommend using drugs with a short duration of action and which can be reversed immediately by a reversal agent.

BACKGROUND: Recently, measurement of heart rate variability and the nonlinear complexity of heart rate dynamics have been used as indicators of cardiovascular health. Hypertensive patients showed alternation of cardiovascular homeostasis. We designed this study to evaluate the effect of anesthesia in hypertensive patients with approximate entropy (ApEn), representing the nonlinear complexity. METHODS: With informed consent, none premedicated normotensive (n=18) and hypertensive patients (n=18) were included in this study. ECG data were collected from 10 minutes before induction to 15 minutes after induction. Collected ECG data were stored into computer binary files. We calculated ApEn from the collected ECG data. RESULTS: Before induction, ApEn of hypertensive patients was significantly lower than that of normotensive patients (p<0.05). During induction and maintenance of anesthesia, there was no difference of ApEn between the two groups. ApEn of normotensive patients during induction and maintenance of anesthesia was significantly lower than that of pre-induction (p<0.05). ApEn during maintenance of anesthesia was lower than that of induction of anesthesia (p<0.05). ApEn of hypertensive group during maintenace of anesthesia was significantly lower than that of pre-induction of anesthesia (p<0.05). CONCLUSIONS: As the ApEn of hypertensive patients is lower than that of normotensive patients during pre-inducton period, the heart rate dynamics of hypertensive patients is more regular normotensive patients. The anesthesia is deepened, the heart rate dynamics of the both group is more regular. During the maintenance of anesthesia, the regularity of the heart rate dynamics that not different in both group from the results.
Anesthesia* ; Electrocardiography ; Entropy* ; Heart Rate ; Homeostasis ; Humans ; Hypertension* ; Informed Consent

This study was undertaken to evaluate the effects of general and epidural anesthesia for cesarean section on newborn Apgar scores prospectively. Forty patutients for elective cesarean section were divided into two groups. One group(I) of parturients was anesthetized with general anesthesia. The other group(II) was anesthetized with epidural anesthesia. Then, Apgar scores of group I were compared with that of group II. The results were as follows: 1) For elective cesarean section under general anesthesia, prolongation of induction-delivery time wasnt related to lowering of Apgar scores because all of that intervals were below 10 minutes. 2) For elective cesarean section under epidural anesthesia, there was no more neonatal depression accompanied by prolongation of local anesthetic injection-delivery time. 3) General anesthesia rather than epidural anesthesia had a low Apgar score. Therefore, we wish to recommand epidural rather than general anesthesia when prolongation of induction-delivery time such as repeat-cesarean section and/or lowering of Apgar score such as premature will be expected.
Anesthesia, Epidural* ; Anesthesia, General ; Apgar Score ; Cesarean Section* ; Depression ; Female ; Humans ; Infant, Newborn* ; Pregnancy ; Prospective Studies