Spinal Epidural Hematoma Following Epidural Catheter Removal in a Patient with Postoperative Urgent Coronary Intervention and Intra-Aortic Balloon Pumping (IABP): A Case Report.

BACKGROUND It is still challenging to remove an epidural catheter in a postoperative patient receiving urgent antiplatelet and anticoagulation therapy for acute coronary syndrome. CASE REPORT While under general anesthesia combined with thoracic epidural anesthesia, a 72-year-old male patient underwent right radical nephrectomy for renal cell carcinoma. On postoperative day 1 (POD1), the patient experienced bradycardia and a decrease in blood pressure, and he was diagnosed acute myocardial infarction. Intra-aortic balloon pumping (IABP) was induced for cardiogenic shock, and urgent thrombus aspiration and coronary balloon angioplasty were performed. On POD3, the surgeon removed the epidural catheter under both antiplatelet and anticoagulation therapy. At that time, the platelet count was 45×109/L and the activated partial thromboplastin time (APTT) was 72.2 seconds. Four hours after the epidural catheter was removed, the patient complained of bilateral fatigue in legs and developed a loss of sensation. Six hours after the epidural catheter was removed, he developed motor paralysis and became completely paralyzed in both limbs after 9 hours. At 19 hours after the epidural catheter was removed, emergency magnetic resonance imaging detected a spinal epidural hematoma at the level of Th9-11 with compression of the spinal cord. Emergency laminectomy was performed to decompress and remove the spinal epidural hematoma at 18 hours after the onset of sensorimotor symptoms. After surgery and rehabilitation, these symptoms had only slightly improved. CONCLUSIONS In patients with urgent antithrombotic therapy for urgent percutaneous coronary intervention (PCI) with an IABP for acute coronary syndrome, the epidural catheter should not be removed until the IABP and heparin are discontinued, and platelet counts have recovered.

[Hypoxemia caused by retention of irrigation fluid to detect leaks from the lungs during subtotal esophagectomy].

We report a patient who developed hypoxemia caused by retention of irrigation fluid used to detect leaks from the lungs during subtotal esophagectomy. A 58-year-old man developed a sudden onset of hypoxemia with a decrease in tidal volume during subtotal esophagectomy. Chest X-ray revealed a homogeneous opacity of the left lung field, suggesting the presence of fluid in the pleural cavity on the left. The tidal volume and SpO2 increased after drainage of the fluid from the left pleural cavity. The postoperative course was uneventful and the patient was discharged on the 16th postoperative day.

[Drug errors during anesthesia].

We report drug errors during anesthesia. The data were retrieved from the incident reports in a period of June 2000 to June 2003 at the Department of Anesthesiology, Fukuoka University Hospital. Drug errors occurred in 18 (0.12%) of 15,271 patients who were managed by anesthesiologists during the period. Among the 18 events, most frequent errors were 12 events of administration of wrong drugs. Errors in dosage were five, and wrong route of administration in one. There were no serious sequelae in the 18 patients.

[Anesthetic management of an infant with Cornelia de Lange syndrome].

We report anesthetic management of an infant with Cornelia de Lange syndrome. A 12-month-old girl with Cornelia de Lange syndrome was scheduled for ureterocystoneostomy because of vesicoureteral reflux. Preoperative physical examination suggested difficult tracheal intubation. After induction of anesthesia with sevoflurane (5%) in nitrous oxide (70%) and oxygen, a laryngeal mask airway (# 1.5) was inserted. A guide wire was inserted in the trachea through a laryngeal mask airway under direct vision of a fiberoptic bronchoscope. A tube-exchanger stylet was inserted around the guide wire after the laryngeal mask airway and fiberoptic bronchoscope had been removed. An endotracheal tube (ID 4.0 mm) was easily intubated around the tube-exchanger stylet. During the surgery, anesthesia was maintained with sevoflurane (2-3%) in nitrous oxide (50%) and oxygen. There was no perioperative pulmonary complication.

[Anesthetic management for gastrectomy of a patient after coronary artery bypass graft with gastroepiploic artery].

We report anesthetic management of an 80-year-old man who had received coronary artery bypass graft with the gastroepiploic artery 5 years before the present gastrectomy. Preoperative angiography did not show patency of the grafted gastroepiploic artery. He underwent partial distal gastrectomy under general anesthesia with isoflurane in oxygen-enriched air combined with epidural block. The gastroepiploic artery was severed after temporary clamping which did not produce evidence of myocardial ischemia. There was no postoperative cardiovascular event after the surgery.

[Anesthetic management for nephrectomy in a 2-year-old girl with abdominal aortic aneurysm].

We report anesthetic management for nephrectomy in an infant with aortic aneurysm. A 2-year-old girl with renovascular hypertension and abdominal aortic aneurysm, who had shown repeated episodes of heart failure, was scheduled for nephrectomy. Anesthesia was induced with sevoflurane in nitrous oxide (70%) and oxygen. During the surgery, anesthesia was maintained with sevoflurane (1.5%) in nitrous oxide (50%) and oxygen, supplemented with intermittent epidural block. The blood pressure did not show marked changes during the surgery. There was no perioperative cardiovascular complication.