A 33-month-old female weighed 15 kg visited us with chief complaints of deep flame burn with a 38% body surface area of grade 2 and 3 in such areas as face, body trunk, and both arms. The patient had no past history of recent upper respiratory tract infection, asthma, atopy, and allergic reactions to foods or drugs. On physical examination, the patient had no notable findings other than burn injury. On admission, the patient was transferred to an operating room for emergency care and then intravenously given thiopental sodium 80 mg. The patient received manual ventilation using N2O/O2 and sevoflurane. Without the administration of muscle relaxants, the patient underwent endotracheal intubation using an endotracheal tube with an inner diameter of 4.0 mm. Then, the patient underwent central venous, arterial, and urinary catheterization. This was followed by wound disinfection and dressing. At this time, the total anesthetic time was 60 minutes. The systolic and diastolic pressures were 90-100 mmHg and 45-60 mmHg, respectively, and the heart rate was 110-135 beats/min. Pulse oxymetry saturation (SPO2) was maintained at 100%. Thereafter, the patient was transferred to an intensive care unit (ICU) while having an endotracheal tube removed following a recovery of the mental alertness. Then, the patient underwent an intensive care through wound disinfection and fluid therapy.
Three days later, the patient was supposed to escharectomy and cadaver skin graft under general anesthesia and then transferred to an operating room. The preoperative vital signs and routine laboratory results were within normal limits. To induce the anesthesia, following the pure oxygenation, propofol 30 mg and rocuronium bromide 10 mg (Esmeron, Hanhwa Pharmaceuticals Corp., Korea) were intravenously injected. Approximately 1 minute after the administration of rocuronium, i.e., immediately before the endotracheal intubation, the resistance was perceived at a reservoir bag. Meanwhile, SPO
2 was abruptly decreased up to 84%. The heart rate was increased up to 170 beats/min. This was followed by an endotracheal intubation. At this time, the systolic pressure by an arterial catheter was decreased to 50-60 mmHg. On auscultation, the secretion sound was heard from the lung. The airway pressure was increased up to 30 cmH
2O, based on which the abnormal location of an endotracheal tube or its obstruction was suspected. Following removal of endotracheal tube, the endotracheal intubation was performed again with the use of an endotracheal tube with an inner diameter of 4.5 mm. To increase the blood pressure, the fluid was promptly administered at a rate of 150 ml/hr. Meanwhile, 100% oxygen was also administered and ephedrine 4 mg was administered twice. Following this, the systolic blood pressure was elevated to 110 mmHg, however, hypoxia and a tachycardia of >170 beats/min were continued. On arterial blood gas analysis, there were such measurements as pH 7.223, PCO
2 51.9 mmHg, PO
2 75.2 mmHg and BE -7.1 mmol/L. The patient was transferred to ICU and the mechanical ventilation was performed by using midazolam and vecuronium for sedation. As soon as the patient reached ICU, the patient received a chest X-ray. According to this, the patient had findings suggestive of the pulmonary edema accompanying a shadow in both lungs (
Fig. 1). Three days following an ICU treatment, the patient was found to have improved pulmonary edema. Then, the patient was transferred to an operation room in order to take the planned surgery in such a condition that an endotracheal tube was left. For anesthesia, the spontaneous respiration was maintained using N
2O/O
2 and sevoflurane with intermittent manually assisted ventilation. During the escharectomy on the abdominal area, the abdominal mobility due to a spontaneous respiration was severe. For the relaxation of abdominal msucles, the patient received an intravenous injection of rocuronium 10 mg. Approximately 2 minutes following an intravenous injection of rocuronium, without the abnormality of respiratory circuit, the airway pressure was increased. Meanwhile, SPO
2 was decreased up to 75%. The systolic pressure was decreased to 40-50 mmHg. On arterial blood gas analysis, there were such measurements as pH 7.351, PCO
2 41.1 mmHg, PO
2 49.7 mmHg and BE -3.1 mmol/L. Along with the administration of fluids, ephedrine 4 mg was intravenously injected twice. With the maintenance of anesthesia using sevoflurane, N
2O was discontinued and 100% oxygen was administered. Hypotension and hypoxia (SPO
2: approximately 75%) were persistently present. Accordingly, 1 : 1,000 epinephrine 0.15 mg was intramuscularly administered. Thereafter, the tachycardia was persistently present. Besides, the blood pressure and SPO
2 were recovered. At this time, there were such measurements as pH 7.329, PCO
2 42.9 mmHg, PO
2 124.3 mmHg and BE -3.9 mmol/L. A surgery was performed as planned. Intraoperatively, the cumulative packed red cells were administered at a volume of 80 ml. The total anesthetic time was 115 minutes. Immediately before a surgery was completed, dexamethasone 0.5 mg was administered. With an intravenous injection of neostigmine 1 mg and atropine 0.2 mg, the spontaneous respiration was recovered. Following the removal of an endotracheal tube, the recovery of mental alertness was confirmed. Then, the patient was transferred to ICU. Thirteen days later, the secondary escharectomy was planned. At this time, without the administration of muscle relaxants, the anesthesia was induced using propofol. Then, with the use of N
2O/O
2 and sevoflurane, the anesthesia was maintained. Thereafter, after the additional escharectomy was performed six times with volatile induction and maintenance of anesthesia with sevoflurane without muscle relaxants, skin graft was done. Two months and the extra ten days following an outpatient visit, the patient was discharged without notable complications.