Stroke Volume Variation and Stroke Volume Index Can Predict Fluid Responsiveness after Mini-Volume Challenge Test in Patients Undergoing Laparoscopic Cholecystectomy.

Background and Objectives: For using appropriate goal-directed fluid therapy during the surgical conditions of pneumoperitoneum in the reverse Trendelenburg position, we investigated the predictability of various hemodynamic parameters for fluid responsiveness by using a mini-volume challenge test. Materials and Methods: 42 adult patients scheduled for laparoscopic cholecystectomy were enrolled. After general anesthesia was induced, CO2 pneumoperitoneum was applied and the patient was placed in the reverse Trendelenburg position. The mini-volume challenge test was carried out with crystalloid 4 mL/kg over 10 min. Hemodynamic parameters, including stroke volume variation (SVV), cardiac index (CI), stroke volume index (SVI), mean arterial pressure (MAP), and heart rate (HR), were measured before and after the mini-volume challenge test. The positive fluid responsiveness was defined as an increase in stroke volume index ≥10% after the mini-volume challenge. For statistical analysis, a Shapiro-Wilk test was used to test the normality of the data. Continuous variables were compared using an unpaired t-test or the Mann-Whitney rank-sum test. Categorical data were compared using the chi-square test. A receiver operating characteristic curve analysis was used to assess the predictability of fluid responsiveness after the mini-volume challenge. Results: 31 patients were fluid responders. Compared with the MAP and HR, the SVV, CI, and SVI showed good predictability for fluid responsiveness after the mini-volume challenge test (area under the curve was 0.900, 0.833, and 0.909, respectively; all p-values were <0.0001). Conclusions: SVV and SVI effectively predicted fluid responsiveness after the mini-volume challenge test in patients placed under pneumoperitoneum and in the reverse Trendelenburg position.

Face-to-face intubation using a lightwand in a patient with severe thoracolumbar kyphosis: a case report.

BACKGROUND: Severe deformity of the thoracolumbar spine may cause difficulty in airway management during induction of anesthesia. Therefore, special attention must be devoted to patient safety. CASE PRESENTATION: A 65-year-old male with severe thoracolumbar kyphosis was scheduled to undergo posterior spinal fusion under general anesthesia. Due to his inability to lie supine, conventional tracheal intubation under direct laryngoscopy was difficult. Alternatively, face-to-face tracheal intubation using a lightwand in the semi-recumbent position was performed. Intubation was successful on the first attempt without any complications. CONCLUSIONS: The face-to-face intubation technique using a lightwand is one of several alternative techniques for tracheal intubation in patients who cannot lie supine.

Rocuronium anaphylaxis in a 3-year-old girl with no previous exposure to neuromuscular blocking agents.

During the perioperative period, anaphylactic reactions rarely occur. Neuromuscular blocking agents (NMBAs) are responsible for 60-70% of perioperative anaphylactic reactions. This case, we report a case of rocuronium-induced anaphylaxis in a 3-year-old girl with no previous exposure to NMBAs. This case cautions and informs practitioners that an IgE-mediated anaphylactic reaction with rocuronium is possible even in young children with no previous exposure to NMBAs.

A suspected case of serotonin syndrome induced by palonosetron and ramosetron administration.

Serotonin syndrome occurs when serotonin (5-hydroxytryptamine, 5-HT) levels increase and is accompanied by symptoms of mental status changes, neuromuscular abnormalities, and autonomic hyperactivity. Serotonin receptor 3 antagonists, such as palonosetron or ramosetron, are commonly used for their antiemetic effects during general anesthesia. However, overdosage of these drugs carries a risk of serotonergic toxicity as they increase serum serotonin levels due to inhibition of serotonin reuptake. Serotonin syndrome caused by 5-HT3 antagonists is thought to be caused by the synergistic effects of high doses of serotonergic drugs or the combination of two or more serotonergic drugs with different mechanisms of action. The incidence of serotonin syndrome is unknown because it is a rare condition that cannot be selected for in randomized clinical trials. Therefore, physicians must focus on the clinical manifestations of the syndrome and manage patients before the condition becomes life-threatening.

Remifentanil prevents tourniquet-induced arterial pressure increase in elderly orthopedic patients under sevoflurane/N2O general anesthesia.

AIMS: Prolonged tourniquet inflation produces a hyperdynamic cardiovascular response. We investigated the effect of continuous remifentanil infusion on systemic arterial pressure, heart rate, and cardiac output changes during prolonged tourniquet use in elderly patients under sevoflurane/N(2)O general anesthesia. METHODS: Thirty female patients scheduled for knee replacement arthroplasty were infused with either remifentanil at a target organ concentration of 2.0 ng/mL (remifentanil group, n = 15) or saline (control group, n = 15) after induction of anesthesia. Anesthesia was maintained with sevoflurane and N(2)O. Heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure (DAP), cardiac index (CI), total systemic vascular resistance index (TSVRI), BIS, end-tidal sevoflurane concentration (EtSEVO), and end-tidal carbon dioxide concentration (EtCO(2)) were measured during the study period. RESULTS: There were significant differences in mean HR, SAP, DAP, and EtSEVO over time between the groups (P = 0.047, P < 0.001, P = 0.017, and P < 0.001, respectively). There was a statistically significant time trend effect (P < 0.001) in HR, SAP, DAP, and CI between the groups, with a statistically significant time-group interaction between the two groups (P = 0.02, 0.007, 0.001, 0.01, respectively). CONCLUSION: The present study demonstrated that infusion with remifentanil prevented an increase in hemodynamic pressure during tourniquet inflation in elderly patients under sevoflurane/N(2)O general anesthesia.

Involvement of tryptophan hydroxylase 2 (TPH2) gene polymorphisms in susceptibility to coronary artery lesions in Korean children with Kawasaki disease.

Kawasaki disease (KD) is an acute vasculitis of childhood that predominantly affects the coronary arteries. We investigated single nucleotide polymorphisms (SNPs) of the tryptophan hydroxylase 2 (TPH2) gene as risk factors for KD with coronary artery lesions (CALs) in Korean children. We genotyped two SNPs [rs7305115 (exon 7) and rs4290270 (exon 9)] using direct sequencing in 101 KD and 256 control subjects. To analyze the genetic data, SNPStats, SNPAnalyzer, and Helixtree programs were used. The genotype analysis of rs7305115 and rs4290270 showed no significant differences between KD and control groups. However, we found a statistically significant association between the two SNPs and the development of CALs in KD (p < 0.05). The minor homozygous genotype (rs7305115, AA genotype and rs42901270, AA genotype) of each SNP showed increased susceptibility to risk of CALs in KD patients. These results suggest that TPH2 may be associated with the development of KD with CALs in Korean children.

Dexmedetomidine Improves Locomotor Function and Alleviates Thermal Hyperalgesia Following Sciatic Nerve Crush Injury in Rats.

PURPOSE: The effects of dexmedetomidine on locomotor function and thermal hyperalgesia in sciatic nerve crush injury (SNCI) were investigated using rats. METHODS: After exposing the right sciatic nerve, the sciatic nerve was crushed for 1 minute by a surgical clip. One day after nerve injury, dexmedetomidine (5, 25, and 50 µg/kg) was directly applied to the injured sciatic nerve once a day for 14 days. Walking track analysis was used to assess locomotor function and plantar test was conducted to assess thermal pain sensitivity. Immunohistochemistry was performed to determine the expression of c-Fos in the ventrolateral periaqueductal gray (vlPAG) and paraventricular nucleus (PVN). Western blot was used to evaluate the expression level of nerve growth factor (NGF) and myelin basic protein (MBP) in the sciatic nerve. RESULTS: SNCI resulted in deterioration of locomotor function and increased thermal pain sensitivity. The level of c-Fos expression in the PVN and vlPAG was increased and the level of NGF and MBP expression in the sciatic nerve was enhanced by SNCI. Dexmedetomidine treatment improved locomotor function and upregulated expression of NGF and MBP in the sciatic nerve of SNCI. Dexmedetomidine treatment alleviated thermal hyperalgesia and downregulated expression of c-Fos in the vlPAG and PVN after SNCI. CONCLUSION: Dexmedetomidine may be used as a potential new treatment drug for recovery of locomotion and control of pain in peripheral nerve injury.

Bedside prediction of airway length in adults and children.

BACKGROUND: Malpositioning of the endotracheal tube within the airway leads to serious complications such as endobronchial intubation. Prediction of the correct depth of an endotracheal tube is important and should be individualized. The manubriosternal joint (MSJ) is on the same horizontal plane with the tracheal carina. We compared the straight length from the upper incisor to the MSJ in the fully extended position (incisor-MSJ extension length) with the length from the upper incisor to the carina after intubation with a flexible fiberoptic bronchoscope through the endotracheal tube in the neutral position (incisor-carina neutral length). METHODS: One hundred adults and 50 children were studied. Induction of anesthesia was achieved with 1.5 mg/kg propofol and 0.6 mg/kg rocuronium IV. The incisor-MSJ extension length was measured after adequate mask ventilation. After intubation, the endotracheal tube was positioned properly at the upper incisor teeth, and the incisor-carina neutral length was measured with the fiberoptic bronchoscope at the carina. RESULTS: The correlation between the incisor-MSJ extension length and the incisor-carina neutral length is significant (P < 0.001) in both adults and children. A formula for the regression line in adults (children) can be obtained as the incisor-carina neutral length (cm) = 0.868 (1.009) x the incisor-MSJ extension length (cm) + 4.260 (0.468) with a high coefficient of determination; r(2) = 0.88 (0.98). CONCLUSIONS: The airway length from the upper incisor to the carina in the neutral position can be predicted by the straight length from the upper incisor to the MSJ in the fully extended position.

The effect of forced-air warming during arthroscopic shoulder surgery with general anesthesia.

PURPOSE: The aim of this study was to compare the change in body temperature between the cotton blanket group and forced-air warming blanket group during arthroscopic shoulder surgery. In both groups irrigation fluid at room temperature (22 degrees C) was used. METHODS: We randomly assigned 44 American Society of Anesthesiologists physical status I and II patients scheduled for elective shoulder arthroscopic surgery to receive 1 cotton blanket (group I, n = 22) or a forced-air warming blanket (group II, n = 22). Body temperatures were measured with an esophageal stethoscope, which was inserted immediately after intubation. RESULTS: A significant difference in body temperatures was observed at 60 minutes after induction (P = .0192), 90 minutes after induction (P = .0004), 120 minutes after induction (P = .0003), and 150 minutes after induction (P = .0228). Shivering on arrival in the postanesthesia care unit was found in 15 patients in group I (68.1%) and only 1 patient in group II (4.5%). CONCLUSIONS: We conclude that forced-air warming is significantly more efficient than a cotton blanket alone at maintaining perioperative normothermia during arthroscopic shoulder surgery. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

No supplemental muscle relaxants are required during propofol and remifentanil total intravenous anesthesia for laparoscopic pelvic surgery.

BACKGROUND: No administration of supplemental muscle relaxants may be beneficial to the recovery of the ambulatory laparoscopic surgery. For this study, we compared the cardiorespiratory factors during propofol and remifentanil anesthesia for laparoscopic pelvic surgery (LPS) with or without supplemental muscle relaxants. MATERIALS AND METHODS: In total, 56 healthy female patients scheduled to undergo laparoscopic pelvic surgeries were randomly assigned to two groups (A and B). Anesthesia was induced with lidocaine 30 mg, propofol target organ concentration 5.0 microg/mL, remifentanil 3.0 ng/mL, and rocuronium 0.6 mg/kg intravenously (i.v.). After tracheal intubation, anesthesia was maintained with 2.0-5.0 microg/mL of propofol and 1-4 ng/mL of remifentanil i.v. All the patients' lungs were mechanically ventilated in both groups and intermittent bolus doses of rocuronium (0.15 mg/kg i.v.) were administered in group A-however, not in group B. Heart rate (HR) and systolic arterial pressure (SAP), diastolic arterial pressure (DAP), end-tidal carbon-dioxide concentration (EtCO(2)), peak inspiratory pressure (PIP), expired minute ventilation (MV), intra-abdominal pressure (IAP), and temperature were measured during the pneumoperitoneum. RESULTS: There were no group differences in HR, SAP, DAP, EtCO(2), PIP, IAP, MV, PaO(2), PaCO(2), and temperature between groups A and B. CONCLUSIONS: No supplemental muscle relaxants are required during propofol and remifentanil total i.v. anesthesia for LPS.

Total Intravenous Anesthesia Maintained the Degree of Pre-Existing Mitral Regurgitation Better than Isoflurane Anesthesia in Cardiac Surgery: A Randomized Controlled Trial.

Accurate assessment of mitral regurgitation (MR) is critical during mitral valve repair surgery. However, anesthesia may influence the degree of mitral regurgitation by changing pre- and after-load or cardiac contractility. Therefore, we compared changes in mitral regurgitation by total intravenous anesthesia (TIVA) and inhalation anesthesia in patients with pre-existing mitral regurgitation. This was a double-blind randomized controlled study conducted at a tertiary care center in 2018. Fifty-four mitral regurgitation patents undergoing elective cardiac surgery were randomly assigned to receive TIVA or isoflurane. Primary endpoint was change of regurgitation volume by anesthesia. The reduction of regurgitation volume by anesthesia was greater in the isoflurane group than in the TIVA group (mean (95% confidence interval CI): -0.20 (-6.15, 5.75) vs. -9.66 (-15.77, -3.56), mL·beat-1, p = 0.0266) and this phenomenon was more prominent with severe mitral regurgitation (grade 3 or 4) (mean (95% CI): -0.33 (-9.10, 8.44) vs. -16.20 (-24.22, -8.18), mL·beat-1, p = 0.0079). Among patients with MR grade 3 or 4, 94% remained the same with TIVA during anesthesia compared to 56% with isoflurane. In conclusion, TIVA maintained the pre-anesthetic state of mitral regurgitation relatively well, while the severity of mitral regurgitation tended to decrease with isoflurane anesthesia.

Dexmedetomidine ameliorates memory impairment in sleep-deprived mice.

The selective α2-adrenergic receptor agonist dexmedetomidine acts as an analgesic, sedative, and anesthetic adjuvant. The most common consequence of sleep deprivation is memory impairment. We investigated whether dexmedetomidine can counteract memory impairment caused by sleep deprivation and suppress the production of inflammatory factors. For inducing sleep deprivation, adult male mice were placed inside a water cage containing 15 platforms immersed in water up to 1 cm for 7 days. One day after sleep deprivation, dexmedetomidine at the respective dosage (5, 10, and 20 µg/kg) and α2-adrenoceptor antagonist atipamezole (250 µg/kg) were intraperitoneally injected into the mice, once per day for six days. The step-down avoidance task and the Morris water maze test were performed. Western blot analysis was performed to determine the levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-6, brain-derived neurotrophic factor (BDNF), tyrosine kinase B (TrkB), nuclear transcription factor-κB (NF-κB), inhibitor of κBα (IκBα), and ionized calcium binding adapter molecule I (Iba-1) in the hippocampus. Immunohistochemistry was performed for the determination of Ki-67 and glial fibrillary acidic protein (GFAP) expression in the hippocampal dentate gyrus. Dexmedetomidine ameliorated sleep deprivation-induced deterioration of short-term memory and spatial learning ability. Dexmedetomidine inhibited production of inflammatory mediators caused by sleep deprivation. Dexmedetomidine also prevented the decrease in BDNF, TrkB expression, and cell proliferation induced by sleep deprivation. Dexmedetomidine could be used to counteract the neuropathological effects of sleep deprivation.

Effect of Polydeoxyribonucleotide on Lipopolysaccharide and Sevoflurane-Induced Postoperative Cognitive dysfunction in Human Neuronal SH-SY5Y Cells.

PURPOSE: Postoperative cognitive dysfunction (POCD) is a complication of surgery characterized by acute cognitive dysfunction, memory impairment, and loss of attention. The effect of polydeoxyribonucleotide (PDRN) on the POCD environment induced by lipopolysaccharide (LPS) and sevoflurane exposure were investigated in human neuronal SH-SY5Y cells. METHODS: The 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and WST-8 assays were performed to determine cell viability. Cyclic adenosine-3,5'-monophosphate (cAMP), tumor necrosis factor (TNF)-α, interleukin (IL)-1ß, and IL-6 concentrations were measured using enzyme-linked immunoassay (ELISA). Immunocytochemistry was performed for vascular endothelial growth factor (VEGF) and brain-derived neurotrophic factor (BDNF), and western blotting for TNF-α, IL-1ß, IL-6, and cAMP response element-binding protein (CREB). RESULTS: Induction of the POCD environment reduced cell viability in the MTT and WST-8 assays. PDRN treatment reduced TNF-α, IL-1ß, and IL-6 expression in POCD conditions, and significantly increased cAMP concentrations and the p-CREB/CREB ratio. PDRN treatment activated adenosine A2A receptors and then increased the expression of VEGF and BDNF, which had been reduced by LPS and sevoflurane exposure. CONCLUSION: PDRN treatment showed a therapeutic effect on the LPS and sevoflurane-induced POCD environment. PDRN was shown to have an excellent therapeutic effect on POCD, not only by promoting rapid anti-inflammatory effects in damaged cells, but also by enhancing the expression of BDNF and VEGF.

Delayed preconditioning effect of isoflurane on spinal cord ischemia in rats.

Paraplegia is one of the most common complications following aortic aneurysmal surgery. This study was designed to determine if isoflurane-induced delayed preconditioning is mediated by nuclear factor kappaB (NF-kappaB) in the rat spinal cord. The animals were divided into four groups: the control group, the pyrrolidinedithio carbamate (PDTC, an NF-kappaB inhibitor)-treated group, the isoflurane-treated group, and the PDTC/isoflurane-treated group. In the PDTC-treated groups, 2% 100mg/kg PDTC was administered intraperitoneally at 1h before operation and at 24h and 48 h after reperfusion. The rats in the isoflurane-treated groups received 30 min inhalation of 2.8% isoflurane at 24h before spinal cord ischemia. Pretreatment with NF-kappaB inhibitor significantly reduced NF-kappaB expression and the number of intact motor neurons when compared to the control group. Preconditioning with isoflurane increased the number of normal motor neurons, whereas pretreatment with both PDTC and isoflurane significantly decreased them, compared to the isoflurane-treated group. Isoflurane-induced delayed preconditioning on spinal cord ischemia improved histopathological outcomes. This neuroprotective effect of isoflurane preconditioning on spinal cord ischemia is associated with NF-kappaB expression.

Effect of postnatal treadmill exercise on c-Fos expression in the hippocampus of rat pups born from the alcohol-intoxicated mothers.

Maternal alcohol-intoxication during pregnancy exerts detrimental effects on fetal development and is known to influence learning ability and memory capability by altering neuronal activity in the hippocampus. c-Fos expression represents neuronal activity and plays a crucial role in the brain development. Physical exercise is known to enhance neuronal plasticity and activity. In the present study, we investigated the influence of postnatal treadmill running on the c-Fos expression in the hippocampus of rat pups born from the alcohol-intoxicated mothers. The results obtained show that maternal alcohol-intoxication suppressed c-Fos expression in the hippocampus of rat pups and that postnatal treadmill exercise enhanced c-Fos expression in the hippocampus of these rat pups. The present study suggests that exercise should be considered as a therapeutic means of countering the effects of maternal alcohol-intoxication, and that it may provide a useful strategy for enhancing the neuronal activity of children born from the mothers who abuse alcohol during pregnancy.

Correlation between modified LEMON score and intubation difficulty in adult trauma patients undergoing emergency surgery.

Background: Prediction of difficult airway is critical in the airway management of trauma patients. A LEMON method which consists of following assessments; Look-Evaluate-Mallampati-Obstruction-Neck mobility is a fast and easy technique to evaluate patients' airways in the emergency situation. And a modified LEMON method, which excludes the Mallampati classification from the original LEMON score, also can be used clinically. We investigated the relationship between modified LEMON score and intubation difficulty score in adult trauma patients undergoing emergency surgery. Methods: We retrospectively reviewed electronic medical records of 114 adult trauma patients who underwent emergency surgery under general anesthesia. All patients' airways were evaluated according to the modified LEMON method before anesthesia induction and after tracheal intubation; the intubating doctor self-reported the intubation difficulty scale (IDS) score. A difficult intubation group was defined as patients who had IDS scores > 5. Results: The modified LEMON score was significantly correlated with the IDS score (P < 0.001). The difficult intubation group showed higher modified LEMON score than the non-difficult intubation group (3 [2-5] vs. 2 [1-3], respectively, P = 0.017). Limited neck mobility was the only independent predictor of intubation difficulty (odds ratio, 6.15; P = 0.002). Conclusion: The modified LEMON score is correlated with difficult intubation in adult trauma patients undergoing emergency surgery.

Dexmedetomidine Ameliorates Sleep Deprivation-Induced Depressive Behaviors in Mice.

PURPOSE: Sleep deprivation induces depressive symptoms. Dexmedetomidine is a α2-adrenoreceptor agonist and this drug possesses sedative, anxiolytic, analgesic, and anesthetic-sparing effect. In this study, the action of dexmedetomidine on sleep deprivation-induced depressive behaviors was investigated using mice. METHODS: For the inducing of sleep deprivation, the mice were placed inside a water cage containing 15 platforms and filled with water up to 1 cm below the platform surface for 7 days. One day after sleep deprivation, dexmedetomidine at the respective dosage (0.5, 1, and 2 µg/kg) was intraperitoneally treated into the mice, one time per a day during 6 days. Then, forced swimming test and tail suspension test were conducted. Immunohistochemistry for tyrosine hydroxylase (TH), 5-hydroxytryptamine (5-HT; serotonin), tryptophan hydroxylase (TPH) and western blot for D1 dopamine receptor were also performed. RESULTS: Sleep deprivation increased the immobility latency in the forced swimming test and tail suspension test. The expressions of TPH, 5-HT, and D1 dopamine receptor were decreased, whereas, TH expression was increased by sleep deprivation. Dexmedetomidine decreased the immobility latency and increased the expressions of TPH, 5-HT, and D1 dopamine receptor, whereas, HT expression was decreased by dexmedetomidine treatment. CONCLUSION: In our results, dexmedetomidine alleviated sleep deprivation-induced depressive behaviors by increasing 5-HT synthesis and by decreasing dopamine production with up-regulation of D1 dopamine receptor.

Comparison of oncological benefits of deep neuromuscular block in obese patients with gastric cancer (DEBLOQS_GC study): A study protocol for a double-blind, randomized controlled trial.

PURPOSE: Many studies have demonstrated the advantage of maintaining intraoperative deep neuromuscular block (NMB) with sugammadex. This trial is designed to evaluate the impact of muscle relaxation during laparoscopic subtotal gastrectomy on the oncological benefits, particularly in obese patients with gastric cancer. MATERIALS AND METHODS: This is a double-blind, randomized controlled multicenter prospective trial. Patients with clinical stage I-II gastric cancer with a body mass index of 25 and over, who undergo laparoscopic subtotal gastrectomy will be eligible for trial inclusion. The patients will be randomized into a deep NMB group or a moderate NMB group with a 1:1 ratio. A total of 196 patients (98 per group) are required. The primary endpoint is the number of harvested lymph nodes, which is a critical index of the quality of surgery in gastric cancer treatment. The secondary endpoints are surgeon's surgical condition score, patient's sedation score, and surgical outcomes including peak inspiratory pressure, operation time, postoperative pain, and morbidity. DISCUSSION: This is the first study that compares deep NMB with moderate NMB during laparoscopic gastrectomy in obese patients with gastric cancer. We hope to show the oncologic benefits of deep NMB compared with moderate NMB during subtotal gastrectomy. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT03196791), date of registration: October 10, 2017.

Non-intubated thoracoscopic surgery for decortication of empyema under thoracic epidural anesthesia: a case report.

General anesthesia is the main strategy for almost all thoracic surgeries. However, a growing body of literature has reported successful cases of non-intubated thoracic surgery with regional anesthesia. This alternative strategy not only prevents complications related to general anesthesia, such as lung injury, incomplete re-expansion and intubation related problems, but also accords with trends of shorter hospital stay and lower overall costs. We experienced a successful case of non-intubated thoracoscopic decortication for a 68-year-old man who was diagnosed as empyema while the patient kept spontaneously breathing with moderate sedation under thoracic epidural anesthesia. The patient showed a fast recovery without concerns of general anesthesia related complications and effective postoperative analgesia through thoracic epidural patient-controlled analgesia device. This is the first report of non-intubated thoracoscopic surgery under thoracic epidural anesthesia in Korea, and we expect that various well designed prospective studies will warrant the improvement of outcomes in non-intubated thoracoscopic surgery.

Pectoral nerve block (Pecs block) with sedation for breast conserving surgery without general anesthesia.

Most regional anesthesia in breast surgeries is performed as postoperative pain management under general anesthesia, and not as the primary anesthesia. Regional anesthesia has very few cardiovascular or pulmonary side-effects, as compared with general anesthesia. Pectoral nerve block is a relatively new technique, with fewer complications than other regional anesthesia. We performed Pecs I and Pec II block simultaneously as primary anesthesia under moderate sedation with dexmedetomidine for breast conserving surgery in a 49-year-old female patient with invasive ductal carcinoma. Block was uneventful and showed no complications. Thus, Pecs block with sedation could be an alternative to general anesthesia for breast surgeries.