[Anesthetic Management with Propofol Alone in a Patient with Hereditary Sensory and Autonomic Neuropathy].

Hereditary sensory and autonomic neuropathy (HSAN) is a rare peripheral nerve disorder associated with sensory dysfunction (pain, touch, and pressure) and various degrees of autonomic dysfunction. We administered general anesthesia for a 54-year-old woman with HSAN type II undergoing amputation of the left hallux. She had reduced sensation for pain, pressure, and temperature since birth and frequently injured her hands and legs. Before the operation, she did not report pain in the hallux. Only propofol was given for anesthesia without use of analgesia. Intraoperatively, her vital signs were stable. To evaluate the sympathetic nervous response to surgical stimulation, we measured the plasma catecholamine levels before tracheal intubation and just before and during surgery. Plasma catecholamine levels were normal at all time points, indicating no sympathetic responses to surgical stimulation. This case suggests that anesthesia for HSAN II patients can be safely managed with propofol alone.

[A Case of General Anesthesia for a Cardiac Transplanted Patient Undergoing Inguinal Hernia Repair under Laparoscopic Surgery].

A 52-year-old man was scheduled for the repair of inguinal hernia recurrence. When he was 48 years of age, he received a heart transplantation due to severe heart failure resulting from ischemic heart disease. When he was 50 years old, he suffered from inguinal hernia, and it was repaired under spinal anesthesia. During this surgery, he experienced pain because of the inadequate effect of anesthesia, but his blood pressure and heart rate were stable. We suspected that this was because of denervation of the heart. On hernia repair for inguinal hernia recurrence, general anesthesia was chosen, induced with midazolam, rocuronium, and fentanyl and maintained with sevoflurane, rocuronium, fentanyl, and remifentanil. The blood pressure was mostly stable during anesthesia, but we noted an increase in the heart rate when the trachea was intubated and extubated and when surgical incision started. This phenomenon may indicate reinnervation of the transplanted heart. We could safely manage anesthesia without invasive monitoring because the transplanted heart functioned favorably and surgery was minimally invasive.

[Fiberoptic-guided tracheal intubation through the i-gel supraglottic airway].

BACKGROUND: The i-gel is a rescue device for ventilation or tracheal intubation in patients with a difficult airway. The aim of this study was to evaluate the safety and reliability of fiberoptic-guided intubation through the i-gel in anesthetized patients with no history of difficult intubation undergoing elective surgery. METHODS: Patients were enrolled in the study with prior informed consent. After insertion of the i-gel, the larynx was observed by bronchoscopy, and the bronchoscopic view through the i-gel was graded. Tracheal intubation was performed under fiberoptic guidance, and the i-gel was removed. The outcome was evaluated using the success rate of initial intubation as the primary variable, and complications were evaluated as a secondary variable. RESULTS: The first attempt at intubation was successful in all 52 patients evaluated, and there was no problem with i-gel removal. No arterial oxygen desaturation was noted throughout the induction of anesthesia, and no serious complication was observed. CONCLUSIONS: Fiberoptic-guided intubation could be performed safely through the i-gel. The i-gel is considered to be potentially useful as an alternative conduit for fiberoptic-guided intubation.

[Case of Leriche's syndrome treated with safe and effective analgesia after laparotomy by transversus abdominis plane block, rectus sheath block, and continuous wound infusion with ropivacaine].

Ultrasound-guided peripheral nerve blocks in the abdominal wall, such as transversus abdominis plane block (TAP block) and rectus sheath block, are now widely used. We report a case of Leriche's syndrome treated with safe and effective analgesia after laparotomy by abdominal wall block and continuous infusion. A 61-year-old man diagnosed with Leriche's syndrome underwent Y-graft replacement for an abdominal aortic aneurysm. Preoperative enhanced and 3-dimensional CTs showed many collateral arterial systems, especially in the right abdominal wall. It was suggested that the right internal iliac artery had been completely occluded, and the left one showed severe stenosis. After the induction of general anesthesia, we recognized collateral arteries through an ultrasound view as on preoperative CTs. We lowered the pulse repetition frequency more than usual in order not to injure them. We injected 0.1875% ropivacaine 60 ml as TAP block, and 20 ml as rectus sheath block. When the wound was closed, a catheter was passed through an 18-gauge Tuohy needle placed above the fascia along the supraumbilical site. After the operation, 0.2% ropivacaine was continuously delivered at a rate of 6 ml hr-1 through the catheter. We could provide the patient with effective analgesia after surgery.

Flurbiprofen axetil provides a prophylactic benefit against mesenteric traction syndrome associated with remifentanil infusion during laparotomy.

PURPOSE: Mesenteric traction syndrome (MTS) is caused by PGI(2) release during abdominal procedures and is often observed during abdominal surgery. We have demonstrated that MTS occurs more frequently in cases using remifentanil than in those that are not. The aim of this study was to assess the prophylactic benefit of flurbiprofen axetil on MTS in patients undergoing abdominal surgery using remifentanil. METHODS: Thirty ASA physical status I and II patients were enrolled. They were scheduled to undergo abdominal surgery under general anesthesia with remifentanil and were randomly assigned to receive flurbiprofen axetil (group F) or saline (group C) preoperatively (n = 15 each). MTS was defined according to our simplified diagnostic criteria. Arterial blood pressure and heart rate were recorded, and the plasma 6-keto-PGF(1α) (a stable metabolite of PGI(2)) concentration was measured just before skin incision and at 20 and 60 min after skin incision (T(0), T(20), T(60)) to confirm the diagnosis of MTS. RESULTS: Twelve of 15 (80%) patients developed MTS in group C, whereas only 1 of 15 (6.7%) patients in group F developed MTS. At T(20), the group C patients showed significantly lower arterial blood pressure (P < 0.05) and a faster heart rate (P < 0.01) than those in group F. The mean plasma 6-keto-PGF(1α) concentration was significantly elevated in group C at T(20) (P < 0.01), whereas the plasma 6-keto-PGF(1α) level remained low throughout the observation period in group F. CONCLUSIONS: We found that preoperative administration of flurbiprofen axetil reduced the incidence of MTS during abdominal surgery with remifentanil analgesia.

Remifentanil increases the incidence of mesenteric traction syndrome: preliminary randomized controlled trial.

PURPOSE: The use of remifentanil is often associated with the observation of mesenteric traction syndrome (MTS) soon after manipulation of the intestine during abdominal surgery. MTS symptoms include facial flushing, hypotension, and tachycardia. In the study reported here, we prospectively investigated the effects of remifentanil on the incidence of MTS in abdominal surgery. METHODS: One hundred patients scheduled for abdominal surgery were randomly assigned to two groups. In one group (n = 50), fentanyl alone was used as intravenous analgesic (control, group C); in the second group (n = 50), both fentanyl and remifentanil were used (remifentanil group, group R). In all patients, anesthesia was induced with propofol and rocuronium and then maintained with sevoflurane inhalation. Remifentanil was continuously infused for patients in group R as an analgesic. Plasma concentration of 6-keto-PGF(1α) was measured before surgery and 20 min after the skin incision was made in six patients of group R and seven patients of group C. RESULTS: MTS occurred in 20 cases in group R (40.0%), but in only five cases in group C (10.0%). In both groups, the incidence of MTS was higher in laparotomy than in laparoscopic surgery. The plasma concentration of 6-keto-PGF(1α) was low in both groups before surgery and was elevated 20 min after skin incision in both groups in patients in whom MTS appeared. CONCLUSIONS: The results of this study suggest that the use of remifentanil in laparotomy facilitates MTS.