Although rare, intraoperative anaphylaxis can lead to significant morbidity and mortality. Aquafol® (Daewon Pharmaceutical Co. Ltd., Seoul, Korea), a microemulsion propofol, was developed to eliminate lipid solvent-related adverse events, and was used in clinical anesthesia since 2009 with little data about severe side effects such as anaphylaxis. A healthy 16-yr-old male patient who had past medical history with two previous operations of no complications developed cardiovascular shock with generalized erythema following administration of microemulsion propofol during anesthesia induction. Intravenous injection of epinephrine and steroid rescued him. He remained in a stable state without any problems postoperatively and was discharged. Clinicians should consider this rare but serious complication during induction of anesthesia with propofol.

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We report a case of failed epidural anesthesia despite successful identification of the epidural space, loss of resistance technique, hanging drop method and drip infusion. This case evaluated the use of computed tomography to confirm epidural catheter position, which showed the catheter accidentally positioned at the T2 lamina. Because epidural anesthesia can even after successful procedure using standardized techniques such as loss of resistance, we recommend performing the procedure under fluoroscopic guidance to improve success rate and patient safety.