[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.

[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.

Intrathecal gabapentin and clonidine synergistically inhibit allodynia in spinal nerve-ligated rats.

AIMS: The objective of this study was to elucidate the interaction between intrathecally administered gabapentin and clonidine on neuropathic pain associated with allodynia in the spinal nerve ligation model in the rat. MAIN METHODS: Thresholds for hind paw responses to mechanical stimuli were determined by delivering von Frey filaments to the plantar surface. The left L5 spinal nerve was ligated and a fine catheter was intrathecally implanted at the L3-4 interspace under sevoflurane anesthesia. After confirmation of the established allodynia, gabapentin at 10, 30, 60 and 100µg or clonidine at 5, 15, 30 and 50µg was injected as a monotherapy in conscious rats through the intrathecal catheter to obtain the dose-response curve of %MPE (maximum possible effect) of the antiallodynic effect and its ED(50). Gabapentin and clonidine were concomitantly administered in a fixed-dose ratio proportional to the predetermined ED(50) of these drugs, thereby obtaining a dose-response curve for the drug combination and its ED(50). The profile of the interaction between these drugs was analyzed using an isobolographic analysis. KEY FINDINGS: The ED(50) for gabapentin and clonidine were 57.3±4.0 and 20.2±1.0µg, respectively (mean±SEM). However, the co-administration of gabapentin and clonidine at a ratio of 20:7 contributed to a much smaller experimental ED(50) values (gabapentin 10.1±1.1µg, and clonidine 3.6±0.3µg) compared with their theoretical ED(50)s on the additive line in the isobologram. SIGNIFICANCE: In the L5 spinal nerve-ligated rats, the intrathecal co-administration of gabapentin and clonidine exerted a synergistic action on the mechanical antiallodynic effect.