Vasopressin is a locally-injected vasoconstrictor used to reduce bleeding during gynaecological surgery. However, even in these cases, vasopressin can induce adverse effects, including bradycardia, myocardial infarction and cardiac arrest. Elevated blood concentrations of vasopressin may induce the sympathoinhibitory reflex by increasing blood pressure and augment the sympathoinhibitory reflex by activating the area postrema. In addition, pneumoperitoneum formation needed for laparoscopy as well as physiological changes caused by steep Trendelenburg positions used during robotic surgeries may cause bradycardia. Shoulder braces used to prevent slipping from a steep Trendelenburg position may also be hazardous. This case report describes a 31-year-old female patient who underwent a scheduled robotic-assisted laparoscopic myomectomy in a steep Trendelenburg position. The patient experienced a cardiac arrest 2 min after the vasopressin injection and was treated accordingly. There were no abnormal findings on the postoperative laboratory studies, chest X-ray and electrocardiogram. The patient also had clear consciousness with no other notable symptoms. The patient was discharged on postoperative day 2. The report discusses the potential adverse effects of local vasopressin injection during robotic-assisted laparoscopic myomectomy.

Recently, there has been a trend toward minimizing opioid use in obese patients to prevent opioid-related postoperative complications. Moreover, the use of opioid-free anesthesia has received growing interest. This case series reports the use of simple opioid-free anesthesia consisting of a mixture of dexmedetomidine, ketamine, and lidocaine in an obese male patient undergoing laparoscopic bariatric surgery and an obese pregnant woman undergoing cesarean section. These cases indicate that opioid-free anesthesia can be safely administered to obese patients and provides effective pain control without any postoperative adverse outcomes.

A 7-year-old child underwent surgical excision of a benign mesothelioma of the pleura near the right lower lung. Although insertion of a wire-reinforced endotracheal tube through the left main bronchus was attempted for one-lung ventilation to secure the surgical field of view, the attempt failed. Therefore, an endotracheal tube was inserted into the trachea, and an Arndt endobronchial blocker (Cook Medical, Bloomington, IN, USA) was placed in the right intermediate bronchus under bronchoscopic guidance to selectively block the right lower and middle lobes. The surgery was performed while ventilating the right upper lobe and left lung, and no specific intraoperative adverse events occurred.

Duchenne muscular dystrophy (DMD) is a recessive inherited genetic disorder caused by a mutation in the X chromosome and occurs in approximately 1 in 3,500 males. Generally, degeneration and atrophy of the respiratory muscles and myocardium lead to death before the age of 30 years. During anesthesia, rhabdomyolysis, malignant hyperthermia, and cardiac arrest are known risks caused by an inhalation anesthetic or succinylcholine; therefore, the selection of inhalation anesthetics or muscle relaxants requires caution. According to a study by Muenster et al. [1], 4% of DMD patients had difficult intubations and the frequency was especially high in older patients [2]. Thus, difficulty in securing the airway can be anticipated and sufficient muscle relaxation is required.The risks are known for depolarizing muscle relaxants. For non-depolarizing muscle relaxants, it is generally known that sensitivity increases, but the response and stability have not yet been established [2,3]. Therefore, preoperatively securing the airway and recovering respiratory function postoperatively can be considered the most challenging aspects in anesthesia.Thus, together with a review of the relevant literature, we report a case of general anesthesia management without muscle relaxation in a patient with DMD undergoing surgery for testicular cancer. CASE REPORTA 29-year-old male patient with a height of 160 cm and a weight of 40 kg was diagnosed with testicular cancer and ad- Duchenne muscular dystrophy (DMD) is a relatively rare muscle disease with severe symptoms. Owing to the commonly limited mouth opening, cervical spine immobility, and deformation, DMD patients often present with a difficult airway. Patients with DMD are sensitive to sedation, anesthesia, and neuromuscular blockade. This risk increases as the disease progresses with age. The anesthetic management of these patients can cause various issues, presenting a challenge to anesthesiologists. We administered anesthesia for an orchiectomy in a patient with testicular cancer using total intravenous anesthesia with propofol and remifentanil without muscle relaxants. Although the patient was Mallampati grade IV due to neck stiffness, tracheal intubation was successfully performed with a portable videolaryngoscope. The intraoperative course was uneventful and recovery was rapid without postoperative complications. In conclusion, anesthesia without a muscle relaxant was successful and the patient recovered rapidly, even with a difficult tracheal intubation.

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