[Use of sugammadex in a patient with narrow angle glaucoma].

An 86-year-old woman was scheduled to receive fourth reconstructive surgery for femoral bone fracture under general anesthesia. She had been suspected with narrow angle glaucoma due to headache and bloodshot eyes during gastroscopy. During transfer to our hospital, she fell down and suffered from the right femoral neck fracture. The patient underwent femoral head replacement under spinal anesthesia. Later, she received surgeries twice uneventfully under spinal anesthesia; removal and re-implantation of the femoral bone head due to infection of the implanted head. Six months later, she fell down again and femoral bone was fractured during rehabilitation. Anesthesia was induced with propofol followed by rocuronium 0.9 mg x kg(-1) i.v. Anesthesia was maintained with propofol and remifentanil, and rocuronium was administered to maintain PTC of 10 or less. The surgery was completed in 150 minutes. At the end of surgery, a laryngeal mask was inserted and the tracheal tube was removed. TOF ratio recovered to 80% 8 minutes after sugammadex 2 mg kg(-1) i.v., and increased to 100% 3 minutes after additional 1 mg x kg(-1). Intraocular pressure stayed below 20 mmHg during the intervention. We could achieve full reversal of neuromuscular blockade and suppress increase in intraocular pressure with use of sugammadex.

[Spinal anesthesia in a patient with SMON disease].

We report a patient with subacute myelo-optico-neuropathy (SMON) in whom spinal anesthesia was employed to treat fracture of the femur neck. An 87-year-old woman was diagnosed as having SMON at the age of 45. The patient was admitted to our hospital with fracture of the femur neck. Aspiration pneumonia was also suspected with shadow in the right lung on the chest X-P The percutaneous oxygen saturation (Spo2) with room air was 77%. Spinal anesthesia with 5 mg of 0.5% hyperbaric bupivacaine and 20 mcg of fentanyl was performed at L3-4. The level of anesthesia was T4. During surgery, no severe pain in the lower limbs was observed. Three hours after the end of surgery, the level of anesthesia was T9. On the day after surgery, the extent of dysesthesia and reflex were similar to those before surgery. General anesthesia has been chosen in SMON patients, because there was a report of severe pain of the lower limbs after spinal anesthesia with dibucaine. In our patient, general anesthesia was considered inappropriate due to hypoxemia. We used a mixture of bupivacaine and fentanyl for spinal anesthesia, because the neurotoxicity of bupivacaine is weaker than that of dibucaine.

[Specific gravity of bupivacaine with fentanyl influences bispectral index value during spinal anesthesia combined with fentanyl in patients undergoing cesarean section].

BACKGROUND: Spinal anesthesia combined with fentanyl sometimes induces sedation. We previously reported that the bispectral index (BIS) value during spinal anesthesia with isobaric bupivacaine is reduced with intrathecal fentanyl but not with intravenous or epidural fentanyl. The current study investigated whether the specific gravity of bupivacaine combined with intrathecal fentanyl in spinal anesthesia for cesarean section effected the BIS values. METHODS: Thirty-one partrients scheduled for cesarean section were allocated into two groups: 0.5% isobaric bupivacaine 2 ml plus fentanyl 20 microg (I group, n = 14) or 0.5% hyperbaric bupivacaine 2 ml plus fentanyl 20 microg (H group, n = 17). BIS values were recorded throughout the anesthesia. RESULTS: The lowest BIS values in the I group and in the H group were 77 +/- 13 and 87 +/- 6, respectively. The cumulative time for BIS values of or below 80 in the I group was longer than that in the H group. The number of BIS decreased cases, defined as the cases in which the BIS values continuously fell down to or below 80 for more than 10 minutes, in the I group was higher than in the H group. CONCLUSIONS: The BIS values in patients who received intrathecal isobaric bupivacaine with fentanyl were lower than those with intrathecal hyperbaric bupivacaine and fentanyl.

[Fentanyl shows different effects by administration routes on bispectral index during spinal anesthesia in patients undergoing cesarean section].

BACKGROUND: Spinal anesthesia using a local anesthetic with fentanyl has been reported to induce sedation. We previously reported that the bispectral index (BIS) value was significantly decreased by spinal anesthesia using only bupivacaine and fetanyl after cesarean delivery. In the present study, we studied the effect of different fentanyl administration routes on BIS values during spinal anesthesia for cesarean section. METHODS: Forty-six women scheduled for cesarean section were allocated into five-groups according to the route of fentanyl administration and amount of local anesthetic: intrathecal 0.5% isobaric bupivacaine 2.5 ml plus fentanyl 20 microg (n = 11), intrathecal 0.5% isobaric bupivacaine 2.5 ml plus intravenous fentanyl 100 microg (n = 12), intrathecal 0.5% isobaric bupivacaine 2.5 ml plus epidural fentanyl 100 microg (n = 8), intrathecal 0.5% isobaric bupivacaine 2.5 ml (n = 8), and intrathecal 0.5% isobaric bupivacaine 3.0 ml (n = 7). BIS values were recorded during anesthesia. RESULTS: BIS values in intrathecal fentanyl group were lower than those of other groups (P = 0.03). The cumulative duration of BIS values 80 and below 80 was longer in the intrathecal fentanyl group than those of other groups (P = 0.004). CONCLUSION: The BIS value was significantly decreased only by intrathecal fentanyl for cesarean section.

[Anesthetic management of pneumonorrhaphy for one-lung patient].

Selective immobilisation of the lobes of the lungs with a bronchial blocker is sometimes a challenge for anesthesiologists. A pneumonorrhaphy was planned in a patient who had had undergone left pneumectomy, and selective immobilisation of the right upper lobe was requested. The initial attempt to place the cuff of a bronchial blocker was unsuccessful. We inserted a urethral guide-wire through fiberoptic bronchoscope and positioned the tip at the orifice of the right upper bronchus. We then threaded the bronchial blocker through the guidewire and placed the cuff at the right upper bronchus. The right upper lobe was successfully collapsed, which greatly facilitated the surgical procedure. The method is easy, fast, and safe and should be considered when difficulty in placement of the bronchial blocker is encountered.

[Appropriate dose of isobaric bupivacaine with fentanyl in spinal anesthesia for cesarean section].

BACKGROUND: Spinal anesthesia combined with fentanyl is commonly used for cesarean section. We studied the appropriate dose of isobaric bupivacaine for spinal anesthesia when combined with a fixed dose of 20 microg fentanyl. METHODS: Forty-seven women scheduled for cesarean section were allocated into four-groups according to the dose of 0.5% isobaric bupivacaine with 20 microg fentanyl; 1.0 ml (n=5), 1.5 ml (n=11), 2.0 ml (n=11), and 2.5 ml (n=20). RESULTS: The requirement of epidural anesthesia for pain relief or muscle relaxant was less in the 2.0 ml and 2.5 ml groups than the other groups. However, dyspnea due to high spinal anesthesia developed in 3 subjects out of 20 in the 2.5 ml group. CONCLUSIONS: Two ml of 0.5% isobaric bupivacaine was the most appropriate dose for cesarean section, when combined with 20 microg of fentanyl.

[Anesthetic management of an 18-trisomy neonate with high frequency ventilation].

Neonates with 18-trisomy syndrome have various anomalies including cardiac and facial anomalies. Active treatments for them have not been recommended due to a low survival over one year which is less than 10%. However, the survival over one year in our institute between 1985 and 2003 is higher at 22%, and we had a patient with survival of over 5 years. We report a case of anesthetic management in a male 18-trisomy neonate who received a radical repair of umbilical hernia immediately after his birth. Tracheal intubation was difficult due to small airway and facial anomalies; cleft clip, cleft palate, and macrognathia. Conventional ventilation was ineffective for elimination of carbon dioxide and oxygenation due to pulmonary hypoplasia and intra- and extra-cardiac shunts. A high frequency ventilation improved elimination of carbon dioxide and oxygenation.

[Anesthetic management of therapeutic angiogenesis with autologous bone marrow cells for medically intractable angina pectoris].

We report anesthetic management of therapeutic angiogenesis with autologous marrow cells for medically intractable angina pectoris. A 64-year-old man suffering from severe angina after multiple bypass surgery was presented for this novel procedure. Under general anesthesia with propofol, about 650 ml of bone marrow was aspirated from his ilium in prone position. Hypotension was treated with volume infusion and the use of vasoactive drugs. Next, left thoracotomy was performed with the patient in right lateral position. With the aid of one lung ventilation, the apex and the posterior wall of the heart, where ischemia had been localized, was exposed. An epicardial stabilizer was used to immobilize the apex where purified marrow cells were manually injected. Ventricular premature beats occurred when marrow cells were injected, but they were self-limited. The procedure was completed without any serious complications. Prevention of perioperative myocardial ischemia, volume supplementation during bone marrow aspiration and preparation for ventricular arrhythmia during injection were suggested to be the key issues in the management of this procedure.