Pre-operative measurement of heart rate variability predicts hypotension during general anesthesia

BACKGROUND: Peri-operative hymodynamic instability is one of the major concerns for anesthesiologists when performing general anesthesia for individuals with autonomic dysfunction. The purpose of this study was to examine the potential usage of pre-operative measurement of heart rate variability (HRV) in identifying which individuals, with or without diabetes, may be at risk of blood pressure (BP) instability during general anesthesia. METHODS: We studied 46 patients with diabetes and 87 patients without diabetes ASA class II or III undergoing elective surgery. Participants' cardiovascular autonomic function and HRV were assessed pre-operatively, and hymodynamic parameters were monitored continuously intra-operatively by an independent observer. RESULTS: Only 6% of the participants were classified as having cardiovascular autonomic neuropathy (CAN) based on traditional autonomic function tests whereas 15% experienced hypotension. Total power (TP, P = 0.006), low frequency (LF, P = 0.012) and high frequency (HF, P = 0.028) were significantly lower in individuals who experienced hypotension compared with those who did not. Multivariate logistic regression analysis revealed that TP [odds ratio (OR) = 0.15, 95% confidence interval (CI) = 0.05-0.47, P = 0.001] independently predicted the incidence of hypotension, indicating that each log ms2 increase in total HRV lowers the incidence of hypotension during general anesthesia by 0.15 times. After stepwise multiple linear regression analysis (R2= 11.5%), HF (beta = -11.1, SE = 2.79, P < 0.001) was the only independent determinant of the magnitude of systolic blood pressure (SBP) reduction at the 15th min after tracheal intubation. CONCLUSIONS: Spectral analysis of HRV is a sensitive method for detecting individuals who may be at risk of BP instability during general anesthesia but may not have apparent CAN according to traditional tests of autonomic function.     

Sudden vocal cord closure during general anesthesia using remifentanil

We experienced three cases of ventilatory difficulty through a Proseal laryngeal mask airway was encountered during general anesthesia using remifentanil and sevoflurane. General anesthesia was induced with propofol and maintained with remifentanil (0.2-0.25 microg x kg(-1) x min(-1)) and sevoflurane (1-1.5%). Increased airway pressure was noticed suddenly. Initially in cases 1 and 2, we suspected insufficient depth of anesthesia as a cause of this event. However, in case 3, we observed vocal cord closure by fiberoptic bronchoscopy, suggesting that airway obstruction occurred at the level of the glottis. The patient could be easily ventilated after administration of muscle relaxant (suxamethonium). The inability to ventilate patients with opioids has been ascribed to increased thoracic wall rigidity or vocal cord closure or combination of both factors. In our three cases, the closure of vocal cord after remifentanil administration seems to be the major cause of difficult ventilation during general anesthesia. Therefore, supraglottic airway devices should be applied with caution during general anesthesia with remifentanil and sevoflurane without muscle relaxant.     

Severe bradycardia during spinal and epidural anesthesia recorded by an anesthesia information management system

BACKGROUND: Bradycardia and asystole can occur unexpectedly during neuraxial anesthesia. Risk factors may include low baseline heart rate, first-degree heart block, American Society of Anesthesiologists physical status 1, beta-blockers, male gender, and high sensory level. Anesthesia information management systems automatically record large numbers of physiologic variables that are combined with data input from the anesthesiologist to form the anesthesia record. Such large databases can be scanned for episodes of bradycardia. METHODS: To select spinal and epidural anesthetics that did not also involve general anesthesia, 57,240 automated anesthesia records were scanned. Obstetrical patients and patients younger than age 12 yr were excluded. The electronic records selected were then scanned for episodes of moderate (heart rate < 50 and >/= 40 beats/min) or severe (heart rate < 40 beats/min) bradycardia. RESULTS: A total of 6,663 cases (11.6%) met the inclusion criteria. Among the 677 cases of bradycardia (10.2%) were 46 cases of severe bradycardia (0.7%). In the final multivariate logistic regression analysis, baseline heart rate less than 60 beats/min (P 相似文献   

Decision to avoid general anesthesia on 3 cases with anterior mediastinal masses

We report 3 cases of anterior mediastinal masses in which we avoided providing general anesthesia for a biopsy and a central venous catheter placement. In all cases, chest X-rays on admission showed mediastinal mass ratio (MMR) greater than 44% and thoracic computed tomographic scans demonstrated cross sectional area (CSA) of the trachea 60% less than expected and the main stem bronchi narrowing. We made a decision not to provide general anesthesia, considering the risk of airway obstruction after induction of general anesthesia. In case 1, a 6-year-old boy, preoperative corticosteroid therapy relieved respiratory complaints without improvement of MMR and %CSA. On hospital day 3 the patient developed airway obstruction during induction of anesthesia and the surgery was postponed. After 3 days of additional chemotherapy MMR decreased to 34% and %CSA increased to 94%. On day 6 surgery under general anesthesia was performed safely. In case 2, a 15-year-old boy presented with MMR 44% and %CSA 48% and left bronchial stenosis and underwent surgery under local anesthesia. In case 3, a 3-year-old boy, preoperative corticosteroids and chemotherapy improved MMR 67% to 34% and %CSA 60% to 95%. On day 8 of admission a biopsy was performed under general anesthesia uneventfully. We emphasize not only clinical signs but also radiological signs are important to evaluate the safety in induction of general anesthesia for the management of the cases of anterior mediastinal masses.     

Three cases of perioperative brain infarction]

In recent years, the number of elderly patients who require operation has been increasing. We experienced three patients with perioperative brain infarction, occurring respectively, during the preoperative period, just after operation, and three days after operation. All three patients had more than one of the common risk factors for cerebrovascular accidents, including hypertension, advanced age, hyperfibrinogenemia, diabetes mellitus, and past history of cerebrovascular accident. On the basis of our experience with these three patients, we suggest the following: (1) Waiting period of elective surgery should be reconsidered in some cases with a past history of stroke. (2) Some high-risk patients may benefit from anticoagulative or antiaggregative drugs (e.g. low-molecular dextran or prostaglandin E1) to prevent brain ischemia. (3) Abrupt control of hypertension or diabetes mellitus status undoubtedly adversely affects the patient's general condition; and (4) A practical monitoring system to detect regional brain ischemia during operation under general anesthesia should be developed.     

Postoperative phases of spinal anesthesia

The preoperative and immediate postoperative intake of carbohydrates and fluids made possible by a spinal anesthesia presents the patient as a better risk and prevents many postoperative complications. There is absence of surgical shock and a marked decrease in cases of postoperative nausea and vomiting. Spinal anesthesia is a great advantage in cases of hypertension, diabetes, nephritis, pulmonary tuberculosis, pulmonary influenza, pneumonias, eclampsia, and when patients are aged and debilitated. There is less urinary retention and no tendency toward urinary suppression as in general anesthesia. Cases of myocarditis are a much better risk under spinocain than under drugs used in the early days of spinal anesthesia or under general anesthesia. There is much less tendency toward postoperative gastric dilation and adynamic ileus. General behavior of patients is better both preoperative and postoperative than under general anesthesia. Mortality in over 4000 cases has been nil. Spinal anesthesia, as developed today, has renewed interest in and has advanced the ideal method for, surgical anesthesia of the future.     

General versus epidural anesthesia for femoral-popliteal bypass surgery

This study examines whether epidural anesthesia is more effective than general anesthesia using an inhalation agent in controlling cardiovascular responses during femoral-popliteal bypass surgery. Nineteen patients were randomized into two groups: general anesthesia (n = 10) and epidural anesthesia (n = 9). The patients who underwent general anesthesia received sodium pentothal and succinylcholine for induction of anesthesia and 60% N2O, 40% O2, and 1% to 1.5% isoflurane for maintenance. Fifteen minutes before extubation, the patients received morphine sulfate 0.05 mg/kg intravenously (IV). The group that underwent epidural anesthesia received anesthesia to T-10 (through a catheter placed in the L4-5 interspace using 3% 2-chloroprocaine). Thirty minutes after the last dose, 0.05 mg/kg IV was administered. Hemodynamic variables were recorded at selected intervals during the operation and for 60 minutes in the recovery room. In the general anesthesia group, mean arterial pressure (MAP) and rate pressure product (RPP) significantly decreased (p less than 0.05) during the operation as compared with preoperative values. Following intubation and skin incision, 5 minutes after extubation, and after 60 minutes in the recovery room, MAP, heart rate (HR), and RPP were significantly greater (p less than 0.05) as compared with intraoperative periods. In the epidural anesthesia group, there were clinically important decreases in MAP and RPP after reaching T-10 and skin incision. The general anesthesia patients showed higher MAP, HR, and RPP 5 minutes after extubation and after 60 minutes in the recovery room. Epidural anesthesia patients showed stable hemodynamic patterns throughout the study.(ABSTRACT TRUNCATED AT 250 WORDS)     

Penile incarceration with metal objects--a review of procedure choice based on penile trauma grade

OBJECTIVE: To outline treatment guidelines according to level of penile trauma for penile incarceration by metal devices. METHOD: A post-1950 (hand-held powered cutting tool era) Medline search was performed. Cases were divided into four groups: string techniques and variants with and without aspiration of blood from the glans; aspiration techniques; cutting devices; and surgical techniques. Trauma grade (according to Bhat et al., 1991), site time (incarceration time), removal technique, removal time, anesthesia and recovery time were assessed. RESULTS: The string technique and variants were used for grades 1-3. They had short removal (30-120 min), site (3-72 h) and recovery (1-24 h) times. Occasional glans decompressive with blood aspiration was required. Anesthesias included none (wrapping without glans aspiration), i.m. morphine and general (glans aspiration). Pure aspiration techniques used multiple needle punctures for grades 2-3. Aspiration cases had short site times (8-14 h), but required a spinal or general anesthesia. Cutting device cases (grades 1-5) required general anesthesia, had a short removal times (45-90 min), but long site (7 h-30 days) and recovery (2-66 days) times. Surgical degloving was utilized mainly for grade 5 cases, required spinal or general anesthesia, had short site (2-30 days), but long recovery (9-28 days). CONCLUSIONS: The string, wrapping, aspiration techniques and cutting devices are suited for grades 1-3. Cutting requires a shield to avoid blade trauma and water-cooling to prevent thermal injury. Suspected underlying devitalized tissue (e.g. grade 4) is examined by Wood's lamp. Failure to identify gangrenous tissue will result in post interventional complications and a prolonged recovery time.     

硬膜外复合全身麻醉对梗阻性黄疸术后肠屏障功能的影响

目的探讨硬膜外复合全身麻醉对梗阻性黄疸患者术后肠屏障功能的影响。方法选择梗阻性黄疸拟行手术治疗患者40例,男15例,女25例,年龄26~65岁,ASAⅠ~Ⅲ级,手术时间90~320min,血清总胆红素(TBIL)水平100μmol/L。所有患者随机分为全凭静脉麻醉组(GA组)和硬膜外复合全麻组(GE组),每组20例。GA组患者面罩吸氧后快速诱导气管插管行全身麻醉,GE组患者取左侧卧位行T8~9或T9~10间隙硬膜外穿刺并置管,改平卧位后予以2%利多卡因5ml试验量,5min确认无麻醉并发症及其他异常后行全身麻醉。于入手术室后(T1)、术毕(T2)、术后24h(T3)和术后48h(T4)分别采集外周静脉血,采用ELISA法测定血浆D-乳酸(D-LA)浓度;PCR技术定性检测大肠杆菌特异性β-半乳糖苷酶基因BG;提取血浆标本中的细菌DNA,进行PCR扩增,凝胶电泳后扫描凝胶并分析结果。结果与T1时比较,T2~T4时两组血浆D-LA浓度明显逐步升高(P0.05);T2~T4时GA组D-LA浓度明显高于GE组(P0.05)。PCR技术定性检测大肠杆菌特异性半乳糖苷酶基因BG,扩增长度为762bp。T1时两组患者大肠杆菌DNA检测结果均为阴性,术后两组患者大肠杆菌DNA阳性例数随时间依次增多,且T4时GA组明显高于GE组(P0.05)。结论与全凭静脉麻醉比较,硬膜外复合全身麻醉能够减轻梗阻性黄疸患者术后肠屏障功能的损伤。     

Negative-pressure pulmonary edema after routine septorhinoplasty: discussion of pathophysiology, treatment, and prevention

OBJECTIVE: To provide rhinologic surgeons with an understanding of acute negative-pressure pulmonary edema (NPPE) and its treatment. DESIGN: Case report and literature review of all published adult cases of NPPE. Patient factors, anesthetic variables, and outcomes are assessed. RESULTS: A total of 146 cases in 45 case reports and series were compiled. There was approximately a 2:1 male-female patient ratio. The average age of the patients was 33 years. Fifty percent of patients had surgery on the upper aerodigestive tract, and 8% had intranasal surgery. No patients received laryngotracheal anesthesia, and 5 of the 146 received intravenous lidocaine prior to extubation. One patient had NPPE following laryngeal mask airway treatment, and 2 patients experienced this complication after conversion from monitored anesthesia care to general endotracheal anesthesia; 33.5% of patients were treated with continuous positive airway pressure alone, while 66.5% required intubation and mechanical ventilation. The average time to resolution was 11.75 hours. Three patients died. CONCLUSIONS: It is known that surgical procedures involving the upper aerodigestive tract have a higher risk of NPPE than other procedures. Rapid diagnosis and treatment is necessary to achieve early resolution and avoid significant patient morbidity. A thorough understanding is integral to the practice of nasal and paranasal sinus surgery, especially with the rising use of outpatient and office-based surgical suites. Therefore, we present a review of pathophysiologic mechanisms, possible risk factors, treatment options, and potential steps that can be taken to minimize this potentially devastating complication of general anesthesia.     

Interscalene block combined with general anesthesia under spontaneous breathing in a patient with a giant bulla

Respiratory management for patients with a giant bulla during anesthesia should avoid positive-pressure ventilation to reduce the risk of barotraumas. We report a case of anesthetic management of a 42-year-old man with a giant bulla who had an elective surgery for biopsy of a tumor on his left elbow. Balanced anesthesia consisting of general anesthesia was given under spontaneous breathing combined with interscalene brachial plexus blockade for intra- and postoperative analgesia for the elbow surgery. The patient was monitored by electrocardiography, non-invasive arterial pressure, SpO2, endtidal CO2 tension and bispectral index. Ultrasound-guided interscalene block was performed with the patient awake. After injection of 0.75% ropivacaine 20 ml and 1% lidocaine 16 ml for brachial plexus block, general anesthesia was induced with a bolus of fentanyl 100 microg to reduce cough reflex and propofol using target control infusion with a 2 microg x ml(-1) plasma concentration. The airway was maintained with a size 4 LMA-Proseal, which was inserted with care under spontaneous breathing. There were no serious complications such as pneumothorax in perioperative period. We performed successful anesthetic management, without any complications, combined with interscalene brachial plexus block and spontaneous breathing in a patient with a giant bulla.     

Calibrated pneumoperitoneal venting to prevent N2O accumulation in the CO2 pneumoperitoneum during laparoscopy with inhaled anesthesia: an experimental study in pigs

Nitrous oxide (N2O) accumulates in the CO2 pneumoperitoneum during laparoscopy when N2O is used as an adjuvant for inhaled anesthesia. This may worsen the consequences of gas embolism and introduce a fire risk. In this study, we quantified the pneumoperitoneal gas venting necessary to prevent significant contamination by inhaled N2O. Four domestic pigs (26-30 kg) were anesthetized and ventilated with 66% N2O in oxygen. A CO2 pneumoperitoneum was insufflated and maintained at a pressure of 12 mm Hg. Each animal underwent three experimental conditions, in random sequence, for 70 min each: 1) no pneumoperitoneal leak, 2) leak of 2 L every 10 min (12 L/h), and 3) leak of 4 L every 10 min (24 L/h). Every 10 min, pneumoperitoneal gas samples were analyzed for fractions (FPn) of N2O and CO2. Without leaks, FPnN2O increased continually and reached 29.58% +/- 3.15% at 70 min. With leaks of 2 and 4 L every 10 min (12 and 24 L/h), FPnN2O reached a plateau of <10% after 30 min. We conclude that calibrated pneumoperitoneal venting of 12 or 24 L/h is enough to prevent the constitution of potentially dangerous pneumoperitoneal gas mixtures if venting is constant. IMPLICATIONS: External venting calibrated at four or eight initial pneumoperitoneal volumes per hour with compensation by fresh CO2 is sufficient to prevent nitrous oxide buildup of more than 10% in the pneumoperitoneum during laparoscopy with inhaled general anesthesia if venting is constant.     

全身麻醉和硬膜外麻醉期间胃粘膜pH的变化及意义

目的 研究全身麻醉和硬膜外麻醉期间胃粘膜ｐＨ（ｐＨｉ）的变化及ｐＨ与术后应激性溃疡的关系。方法 ３０例择期下腹部手术患者,随机分为两组,全麻组,芬太尼＋依托咪酯＋琥珀胆碱诱导,维库溴铵＋安氟醚维持,硬膜外组２％利多卡因。麻醉前１小时将Ｔｒｉｐ导管置入内,麻醉诱导前（Ｔ１）诱导后６０分钟（Ｔ２）,１２０分钟（Ｔ３）分别测定ｐＨｉ,Ｐｈａ,ＰａＣＯ２,ＭＡＰ和ＨＲ,术后随访３天观察胃经流管的出血情况。     

老年患者髋关节置换术后早期认知功能障碍的因素分析

目的 分析影响老年患者髋关节置换术后早期认知功能障碍(POCD)的因素.方法 择期髋关节置换术老年患者33例,随机分为2组:静吸复合全麻组(G组,n=15)和脊椎.硬膜外麻醉组(E组,n=18).术中收缩压波动幅度不超过基础值的25%,SpO2≥95%.术后48 h静脉输注0.001%芬太尼2 ml/h镇痛.于麻醉诱导前、术后3 h、6 h、1 d、3 d时记录MMSE评分;采集颈内静脉血样,测定血清S-100β蛋白及神经元特异性烯醇化酶(NSE)浓度.计算麻醉诱导前MMSE评分的标准差,每例患者以麻醉诱导前评分为对照,术后评分与麻醉诱导前比较≥1个标准差时即判断发生POCD.根据术后3 h有无POCD分为POCD组(A组)和无POCD组(B组).结果 E组术后3 h时POCD发生率(22%)低于G组(67%)(P＜0.05).与麻醉诱导前比较,G组和A组术后3、6 h、1 d时、E组和B组术后3、6 h时S-100β蛋白和NSE浓度均升高(P＜0.05或0.01);与术后3 h比较.4组术后其余时点S-100β蛋白浓度均降低,G组和B组术后3 d时NSE浓度降低(P＜0.01);与G组比较,E组术后3 h时NSE浓度降低(P＜0.05);与A组比较,B组术后3 h时S-100β蛋白浓度降低,术后6 h时NSE浓度降低(P＜0.05或0.01).结论 髋关节置换术老年患者行全身麻醉较行脊椎.硬膜外麻醉术后早期POCD发生率高,且与S-100β蛋白和NSE浓度的升高有关.     

Risk management in regional anesthesia: current trends in medical professional liability insurance

This article aims to highlight current trends in medical professional liability insurance. We present two cases of the lawsuit associated with regional anesthesia. Case 1: Cardiac arrest during femoral neck fracture surgery under combined general anesthesia and epidural anesthesia. Case 2: Neurologic complications following cystectomy under combined general anesthesia and epidural anesthesia. To avoid malpractice risks, it is important to fully understand the risks of this clinical role and how to protect yourself from potential lawsuits. Every anesthesiologist should feel obliged to pay attention to legal questions concerning medical subjects, though judgments on the contents and the extent of the informationthat must be given to patients are complex and difficult to understand for anybody not experienced in law.     

Intraosseous lidocaine provides effective analgesia for percutaneous vertebroplasty of osteoporotic fractures

PURPOSE: To assess the safety and efficacy of intraosseous lidocaine (IL), in comparison with iv nalbuphine and propacetamol (NP) for analgesia during percutaneous vertebroplasty (PV) in order to avoid general anesthesia in elderly patients. METHODS: Patients (age 68 +/- 13 yr, weight 66 +/- 6 kg) undergoing PV for osteoporotic fractures were randomized prospectively into two groups: NP (n=50) and IL (n=50). All patients were premedicated (oral hydroxyzine 1 mg.kg(-1)) and had skin infiltration with 5 mL of 1% lidocaine prior to vertebral puncture. Thirty minutes before the procedure, Group NP received, in a blinded manner, 50 mL of iv nalbuphine (0.3 mg.kg(-1)) and propacetamol (30 mg.kg(-1)) while Group IL received 50 mL of iv saline. During vertebral puncture, Groups NP and IL received, in a blinded manner, 1 mL.10 kg(-1) of intraosseous saline and 1% lidocaine respectively. Pain was assessed during vertebral puncture and cement injection with a four-point verbal rating scale. Additionally, lidocaine plasma kinetics were obtained in 11 IL patients. RESULTS: Analgesic efficacy was similar in the IL and NP groups (85 vs 84%). Group NP had more side effects. Lidocaine peak recorded concentration was 2.6 +/- 0.1 microg.mL(-1) i.e., about three times less than the reported toxic limits. CONCLUSION: IL is as effective as the association of iv NP for analgesia in PV. However, considering that both protocols were insufficient in about 15% of cases, other modalities are needed to further improve analgesia and avoid general anesthesia during vertebroplasty.     

Evaluation of postoperative pain relief by infiltration of bupivacaine or epidural block after laparoscopic cholecystectomy]

We compared the analgesic effect of bupivacaine infiltration into surgical wounds with that of epidural block after laparoscopic cholecystectomy (LC). Forty-five patients (ASA physical status I-II) for LC were randomized into three groups (n = 15 in each group). Patients received only general anesthesia (Group C), received infiltration of 0.5% bupivacaine into the surgical wound before surgery combined with general anesthesia (Group L), or received epidural anesthesia combined with general anesthesia (Group E). Postoperative pain was assessed using visual analogue scale (scale: 0-10) at 1, 2, 6 and 12 hours after the operation, the need for additional supplemental analgesics, and the cost of anesthesia. Visual analogue scale in Group C at 1, 2, or 6 hours was significantly greater than that of Group L and E. The number of patients who needed supplemental analgesics was 9 in Group C, 5 in Group L, and 2 in Group E. The cost of pharmaceutical and anesthetic practice of Group E was more expensive than Group L and C. In conclusion, infiltration of bupivacaine combined with general anesthesia is an effective and economical method of postoperative pain relief.     

全身麻醉患者围手术期外周血白细胞源性及血浆β-内啡肽含量变化

目的 研究全身麻醉下患者围手术期外周血白细胞数量和白细胞源性及血浆β-内啡肽(β-endorphin,β-EP)含量变化. 方法 选取48例年龄24～65岁,ASA分级I、Ⅱ级患者,静脉全身麻醉下行择期手术.记录围手术期外周血白细胞总数及分类计数.于麻醉开始前(T1)、麻醉结束患者清醒后(T2)采集肘静脉血4 ml,流式细胞术检测白细胞中β-EP荧光阳性细胞百分数和平均荧光强度(mean fluorescence intensity,MFI),放射免疫分析法测定血浆β-EP水平. 结果 T2白细胞总数[(10.80±3.39)×l09/L]高于T1[(5.55±1.64)×109./L] (P＜0.01),T2粒细胞[(8.82±3.10)×109/L]显著高于T1[(3.27±1.32)×109/L],增高最为明显;T2单核细胞计数[(0.64±0.38)×109/L]高于T1[(0.43±0.18)×109/L](P＜0.01),而T2淋巴细胞数量[(1.29±0.47)×109/L]低于T1[(1.73±0.56)×109/L](P＜0.01).T2各类白细胞中β-EP的MFI均较T1降低(P＜0.05),血浆β-EP水平亦显著下降(P＜0.01). 结论 围手术期全身麻醉患者外周血白细胞总数增加,以粒细胞增高为主,而白细胞内和血浆β-EP水平均降低;细胞数量和β-EP水平的改变与围手术期镇痛及机体应激反应有关.     

Predisposing factors and prevention of emergence agitation

Agitation during the emergence from general anesthesia is a great post-operative problem that often injures the patients themselves and requires the medical staff to restrain and calm the patients. The predisposing factors for emergence agitation include anesthesia, operation, and patient. Sevoflurane anesthesia results in higher incidence of emergence agitation than halothane, because of the rapid emergence, and its effects on central nervous system inducing convulsion and post-operative behavioral changes. The otorhinolaryngologic and ophthalmologic surgeries, post-operative pain, young age, pre-operative anxiety, no past surgical history, and adjustment disorder of patients are risk factors for emergence agitation. The change from sevoflurane to propofol during anesthesia maintenance is a contributing factor to reduce incidence of emergence agitation. The medications including opioids, midazolam, alpha-2 agonists, ketamine, non-steroidal anti-inflammatory drugs, nitrous oxide, and propofol, and aggressive nerve block such as caudal epidural block for post-operative sedation and analgesia are effective to avoid incidence of emergence agitation. The calm emergence following general anesthesia would decrease the self-injuring behavior, and enhance the parent and caregiver satisfaction in general anesthesia and surgery.