[General Anesthesia with Remifentanil for Cesarean Section in a Patient with Moyamoya Disease].

A 31-year-old primigravida diagnosed with moyamo- ya disease at age 27, underwent an urgent cesarean section at 37 weeks of gestation. At age 27 the patient had a superficial temporal artery-middle cerebral artery bypass operation, but the blood flow was not enough. Because she had serious anxiety neurosis and could not endure the strain of vaginal delivery or spi- nal anesthesia, general anesthesia was selected. Anesthesia was induced with thiopental, remifentanil and rocuronium, and was maintained with sevoflurane in air oxygen mixture before delivery. After delivery, anesthesia was maintained with propofol and remifent- anil. Hypertension caused by tracheal intubation was successfully prevented by remifentanil. The cesarean delivery was uneventful and a neonate was delivered with Apgar scores of 3 and 9 at 1 and 5 min, respec- tively. No adverse symptoms occurred. Both she and the neonate were discharged without adverse events. Remifentanil was effective for treating perioperative hypertension undergoing caesarean delivery in a patient with moyamoya disease.

[A Successful Case of Recovery from the Amniotic Fluid Embolism with Cardiac Arrest during the Operation].

Amniotic fluid embolism (AFE) is a disorder with a high mortality rate. We present a case of AFE with cardiac arrest during the cesarean section who recovered sequela. A 28-year-old woman was diagnosed as low lying placenta and planned to undergo cesarean section in 38th gestational week. She had atypical genital bleeding in 32nd gestational weeks and she received emergency cesarean section under general anesthesia. After expulsion of her fetus, she lost many blood. We suspected obstetric DIC and started therapy immediately, but cardiac arrest occurred suddenly. She was resuscitated, and we decided to suspend the operation with temporary gauze-packing. After in better general condition, we removed the packed gauze from her abdomen. She could leave the intensive care unit 7 days after the first operation. In this case, the crucial points for successful resuscitation were prompt obstetric anesthesiologist involvement and good communication with obstetricians.

[Extrapyramidal reactions in three patients due to droperidol infusion for intravenous patient-controlled analgesia].

Intravenous patient-controlled analgesia (iv-PCA) has a great advantage for pain control in the postoperative period with occasional disadvantages of postoperative nausea and vomiting, which should be treated appropriately. Droperidol is commonly used as anti-emetic drug, but it also has a potential risk to induce extrapyramidal reactions. We report three patients who showed extrapyramidal reactions among 589 patients after droperidol administration. Although this complication is rare, we should be aware of the possible extrapyramidal reactions due to droperidol.

[Two patients with CICV (cannot intubate cannot ventilate) rescued by cricothyrotomy].

The first case was a 69-year-old woman with rheumatoid arthritis undergoing posterior occipito-cervical fusion. Although the operation was successfully performed, airway obstruction developed immediately after extubation. Her upper airway obstruction probably came from pharyngolaryngeal edema. The second case was a 59-year-old man with diabetes mellitus undergoing anterior cervical fusion. The day of surgery, he complained of dyspnea and his neck was swollen with hematoma. We used cricothyrotomy tubes (Mini-Trach II) in these two patients with postoperative upper airway obstruction and performed assist-ventilation via the tube. After starting ventilation through Mini-Trach II, we succeeded in intubation. We belive that cricothyrotomy in well-trained hands can be used safely for the management of the patient with a difficult airway.

[Anesthetic management of a patient with thrombocytopenia induced by methotrexate undergoing emergent clipping surgery].

A 70-year-old woman underwent emergent clipping surgery for subarachnoid hemorrhage under general anesthesia. Her laboratory data showed thrombocytopenia (4.0 x 10(4) microl(-1)). She had taken prednisolone (3 mg x day(-1)) and methotrexate (MTX) (10 mg x week(-1)) for rheumatoid arthritis for the last 10 years. Anesthesia was induced with remifentanil as well as propofol, maintained with remifentanil and sevoflurane in oxygen. The operation was performed uneventfully without platelet transfusion. Since the cause of thrombocytopenia was suspected to be MTX, we started rescue therapy by calcium folinate postoperatively. Platelet count was normalized two days later (11.6 x 10(4) microl(-1)). One month after the operation, she was discharged uneventfully.

[Examination of the optimal midazolam dose required for loss of puncture memory at the time of spinal anesthesia].

BACKGROUND: We examined midazolam ED50 according to age that was necessary for loss of puncture memory at the time of spinal anesthesia and determined whether we could estimate the presence of puncture memory from the degree of sedation after midazolam administration. METHODS: We enrolled patients with ASA PS 1 or 2 and patients from 50 to 80 years of age who had been planned for surgery with spinal anesthesia. We divided the patients into groups according to their age--50s, 60s, and 70s as L, M, and H groups, respectively. We evaluated the degree of sedation with six phases of scores after intravenous administration of midazolam and spinal anesthesia was performed. The midazolam dose was based on the ups and downs method. RESULTS: The midazolam ED50s required for the loss of puncture memory in groups L, M, and H were 0.043, 0.035, and 0.026 mg x kg(-1), respectively. We estimated the association between the sedation degree score after midazolam administration and the puncture memory from ROC curve, but AUC was 0.56 for all cases. CONCLUSIONS: The midazolam ED50 required for the loss of puncture memory decreased with age but it was difficult to estimate puncture memory from the degree of sedation.

Efficacy of enterotoxigenic Escherichia coli vaccine for bovine clinical mastitis.

An enterotoxigenic Escherichia coli (ETEC) vaccine designed to prevent diarrhoea was inoculated into dairy cows, and the occurrence of clinical mastitis was investigated for 2 years. Half of 480 cows in five farms were subcutaneously inoculated with ETEC vaccine (Imocolibov) twice with a 1-month interval in 2007 and 2008. Fisher's exact test and survival (time to event) analysis with the log-rank test were used to compare vaccinates and controls. In 2007, there was no significant difference in the incidence rate of mastitis between vaccinate (20.3%) and control (17.1%) cows. The rate of death or culling due to mastitis was lower in vaccinated cows (7.4%) than in control cows (29.2%, P=0.07, Fisher's exact test; P=0.02, log-rank test). In 2008, there was no significant difference in both the incidence rate of mastitis and the rate of death or culling due to mastitis. Milk productivity was compared between vaccinates and controls in one farm. Multi-way analysis of variance (ANOVA) was performed for the amount of 4% fat-corrected milk, and there was no significant difference between vaccinates and controls. These results suggest that ETEC vaccine inoculation reduces death or culling due to mastitis, whereas no preventive effect on the development of mastitis was observed.

[Preoperative intravenous administration of droperidol (1.25 mg) reduced postoperative nausea and vomiting after intrathecal morphine administration].

BACKGROUND: Intrathecal morphine (ITM) is an excellent postoperative analgesic, but may often cause postoperative nausea and vomiting (PONV). We designed this prospective, randomized and controlled study to evaluate the antiemetic efficacy of low-dose droperidol for the treatment of PONV caused by ITM. METHODS: Two hundred female patients undergoing elective total hip arthroplasty were enrolled. They received spinal anesthesia with isobaric bupivacaine and 0.08 mg ITM, and 100 patients were randomly administered with 1.25 mg droperidol intravenously before operation. We observed the incidence of PONY and pain score until 24 hr after operation, and investigated the doses of anti-hypotensive drugs (ephedrine and phenylephrine) and fluid administered intraoperatively. RESULTS: The incidence of PONV was lower in the droperidol group within 6 hr after operation (control group 47%, droperidol group 15%), and especially lower within 2 hr (43% vs. 3%), but was not different 6 hr after operation. The pain score was very low throughout the observation period in both groups and especially within 12 hr. The respective doses of the anti-hypotensive drugs and fluid administered intraoperatively during the operation were higher in the droperidol group. Severe arrhythmia was not observed in any patient throughout the observation period. CONCLUSIONS: Single intravenous administration of 1.25 mg droperidol before operation showed prophylactic efficacy in early PONV caused by ITM. The duration of droperidol action was shorter than that of ITM. Hence we recommend that droperidol should be administered more frequently or continuously in the postoperative period.

[Anesthetic management of a hemodialysis-dependent patient implanted with a CRT-D device undergoing an operation for perforated peritonitis].

A 53-year-old man was admitted to our hospital for hematochezia, and an emergency operation was scheduled for his perforated sigmoid colon. He had received a CRT-D (cardiac resynchronization therapy with defibrillator) device for dilated cardiomyopathy two years before and had been receiving hemodialysis for the past year. Anesthesia was induced with midazolam and remifentanil and maintained with remifentanil and sevoflurane in oxygen. Before surgery, we disabled the defibrillation function of the CRT-D device and changed its pacing mode from VVI to VOO, and electrodes of an external defibrillator were attached to the chest wall. Dopamine and norepinephrine were administered via a central venous catheter, and systolic blood pressure was maintained between 70 and 80 mmHg and CVP between 8 and 13 mmHg. Sigmoidectomy was performed and he was transferred to the ICU intubated. Although intensive care procedures, such as mechanical ventilation, continuous hemodiafiltration, and direct hemoperfusion with polymyxin B-immobilized fibers were performed, he died of multiple organ failure on postoperative day 48. CRT-D has become mainstream cardiac resynchronization therapy and will require attention for anesthetic management of patients implanted with the CRT-D device.

[Uncrossmatched type O red blood cell transfusion and cell saver autologous blood transfusion effective for intraoperative massive bleeding].

We experienced rapid and massive bleeding in a 57-year-old woman undergoing resection of ovarian tumor metastasis. One hour after the start of operation, blood loss increased due to adhesion of the tumor. The blood hemoglobin level decreased from 11.7 to 4.6 g x dl(-1). Since available matched homologous blood had been consumed, we transfused type O uncrossmatched red blood cells followed by cell saver autologous blood. For the treatment of uncontrollable hyperkalemia and metabolic acidosis, continuous hemodiafiltration was started. A total of 66 U of red blood cells, 48 U of FFP, and 40 U of platelets were transfused intraoperatively. No neurological deficit, pulmonary edema, renal failure, or hemolysis was found postoperatively.

[Conscious sedation and amnesic effect of intravenous low-dose midazolam prior to spinal anesthesia].

BACKGROUND: The pain associated with spinal puncture is severe, and the memory of this uncomfortable procedure often deters patients from undergoing the procedure again. Therefore, it is important to make the patient as comfortable as possible when this procedure is performed. METHODS: We administrated a low-dose (1-2.5 mg) of midazolam intravenously several minutes before conducting a spinal-tap in 200 patients undergoing elective surgery of the lower limb. The dose of midazolam used was based on the patient's age and weight, and we investigated remaining of a memory concerning the spinal-tap procedure and side effects of midazolam at the end of surgery. RESULTS: Memory of the spinal-tap procedure remained in 14.0%, 1.9%, and 32.7% of the patients who had received benzodiazepine preoperatively and in 25.0%, 40.0%, and 60.9% of the patients who hadn't received benzodiazepine preoperatively in the age group <60, 60-70, and > or =70 years, respectively. No patient experienced severe respiratory depression, but an excessive sedation or restlessness was experienced in 1.6%, 4.8%, and 5.2% of the patients. CONCLUSIONS: In the patients aged <70 years, intravenous administration of 0.023-0.044 mg x kg(-1) of midazolam was very effective in preventing a bad memory concerning the spinal-tap procedure; however, it is important to note that the number of side effects associated with this procedure increases in patients aged > or =60 years.

[Anesthetic management for wake-up test during reconstruction surgery of the anterior crucial ligament].

BACKGROUND: Seven patients were subjected to intraoperative wake-up tests during reconstruction surgery of the anterior crucial ligament (ACL) to measure the tension of the reconstructed ligament. METHODS: The patients were of 18 to 28 of age with ASA physical status 1. Anesthesia was maintained with nitrous oxide-sevoflurane-fentanyl or propofol-fentanyl under orotracheal intubation. RESULTS: Patients anesthetized with nitrous oxide-sevoflurane-fentanyl did not perform smoothly in the wake-up test because of restless or delayed emergence from anesthesia, and two of them experienced intraoperative awareness. On the other hand, all patients anesthetized with propofol-fentanyl performed smoothly, and no patient experienced intraoperative awareness. CONCLUSIONS: Propofol-fentanyl is better than nitrous oxide-sevoflurane-fentanyl as the method of anesthesia for wake-up tests of ACL reconstruction surgery.

[A case of complete atrioventricular block after induction of general anesthesia].

A 75-year-old man with a past history of bilateral thalamic hemorrhage was scheduled for cholecystectomy and cholelithotomy under general anesthesia. Although the preoperative ECG showed a complete right bundle branch block, the echocardiogram revealed no abnormality. Anesthesia was induced with thiopental and vecuronium, and maintained with sevoflurane in oxygen. Soon after changing to the left decubitus position for the insertion of an epidural catheter, ECG showed complete atrioventricular block, which did not respond to atropine. Adrenalin was transiently effective, but arrhythmia continued. After administration of dopamine, norepinephrine and isoproterenol, we inserted a temporary transvenous pacemaker catheter, and the hemodynamics became stable by ventricular pacing. The operation was postponed. Subsequent cardiologic examination showed no ischemia. The atrioventricular block disappeared 7 hours after the induction of general anesthesia. We should be very careful with the anesthetic management of a patient with a complete right bundle branch block.

Factor XI mutation in a Holstein cow with repeat breeding in Japan.

Factor XI deficiency is an autosomal recessive coagulopathy in Holstein cattle. Affected cows have a tendency to show repeat breeding. Forty repeat breeding Holstein Friesian cows were selected and tested for the Factor XI mutation. Genomic DNA was isolated from the blood of the cows (n=40). Exon 12 of the Factor XI gene of the cows was amplified by PCR. One repeat breeding cow was heterozygous to the Factor XI mutation as indicated by the presence of two DNA fragments of 320 bp and 244 bp. The insertion of the 76 bp in the heterozygous cow was confirmed by DNA sequencing. The heterozygous cow was in her fourth lactation. She gave birth to male twins at the last calving. She was inseminated artificially four times after the last calving. Factor XI deficiency in cattle has been reported in different countries. However, no case was reported in Japan. This might be the first to report Factor XI mutation in Holstein cattle in Japan.

[Accurate placement of central venous catheter--ECG-guided method vs patient height method].

Correct positioning of central venous catheters (CVC) is important. We compared the positioning of CVCs by ECG-monitoring via the guidewire and that by method using patient height. "Certofix" triple-lumen CVCs were inserted in 60 cardiac surgical patients via right internal jugular puncture. Of these, 30 were placed with ECG guidance via the guidewire (Group ECG), and 30 with reference to patient height (modified Pere's method) (Group H). The distance from CVC tip to the superior vena cava/right atrial junction (C-J distance) was measured by postoperative chest X-ray. There was no difference in height between the two groups. The depth of insertion of CVC and C-J distance (cm) were 15.1 +/- 0.3 and 3.6 +/- 2.0 in group H and 14.3 +/- 1.5 and 4.9 +/- 1.2 in group ECG, respectively, with no statistically significant differences between the two groups. In one case of group H, the catheter tip was placed in the right atrium. In group ECG, there was a significant correlation between height and the depth of insertion of CVC. In conclusion, ECG guidance via the guidewire is useful for avoiding CVC displacement.