[Combined spinal-epidural anesthesia for abdominal surgery in a patient with chronic obstructive pulmonary disease].

A 69-year-old man (150 cm, 57 kg)who had been diagnosed as having COPD, was admitted to our hospital because of abdominal pain and drowsiness. He was diagnosed as CO2 narcosis and perforation of appendix. When he recovered from CO2 narcosis, he was scheduled for elective ilectomy. Because his pulmonary function was impaired, combined spinal and epidural anesthesia was selected. With the patient in the right lateral position, an epidural catheter was inserted at T12-L1 interspace, and spinal anesthesia was performed at L3-4 interspace with 0.5% isobaric bupivacaine 4 ml. When the patient was positioned laterally, SpO2 decreased from 82% to 77%. After completion of injection, the patient was returned to the supine position, and SpO2 immediately recovered. Spinal block level was not satisfactory, and fentanyl 0.1 mg and 2% mepivacaine 4 ml were administered through epidural catheter to achieve a T4 level of block. Because severe intraperitoneal inflammation was observed, ilectomy was changed to drainage of intra-abdominal abscess. The patient did not complain of dyspnea, pain, or nausea, intraoperatively. SpO2 was 85-93% with O2 inhalation at 1l x min(-1) during the operation. Post-operative course was uneventful. Although lateral position is popular in performing epidural and spinal anesthesia, sitting position could be suitable for this patient. Decrease in SpO2 may have occurred due to ventilation-perfusion mismatch. Since combined spinal and epidural anesthesia can preserve spontaneous respiration and it is possible to titrate anesthetic level, it would be preferable for abdominal surgery in patients with COPD.

[Spinal anesthesia for a inguinal hernia repair in a small child with laryngeal stenosis].

We experienced spinal anesthesia for inguinal hernia repair in combination with general anesthesia in a 4-year-old child with functional laryngeal stenosis and tendency of laryngeal edema. His airway was managed without endotracheal tube or laryngeal mask airway because these devices could worsen the upper airway stenosis. Spinal anesthesia offered reliable and potent analgesia leading to safe anesthetic management under spontaneous breathing. Although spinal anesthesia in combination with general anesthesia is not common in pediatric patients, it is effective and safe to apply for a case requiring more reliable and potent analgesia with understanding anatomical and physiological characteristics in children.

[Total intravenous anesthesia with propofol and remifentanil for a patient with myotonic dystrophy].

A 54-year-old woman, complicated with myotonic dystrophy, underwent laparoscopic cholecystectomy for cholelithiasis. The patient was given total intravenous anesthesia using propofol, remifentanil and vecuronium, combined with epidural anesthesia using ropivacaine. No complication occurred, and the patient recovered from anesthesia without delay. For the relief of postoperative pain, ropivacaine (0.2%) was given epidurally. The postoperative course was uneventful. The anesthesia with remifentanil is extremely useful for patients with myotonic dystrophy.

[Grand mal convulsion after an interscalene block with ropivacaine].

We report a case of grand mal convulsion due to inadvertent intravascular injection of ropivacaine. An 83-year-old woman was scheduled for upper limb surgery. The interscalene block was performed with neurostimulator and 0.5% ropivacaine 30 ml was injected after careful negative aspiration. Approximately 3 min after the injection, the patient lost consciousness and developed generalized convulsion, which was repeated 7 times. The seizures stopped after administration of diazepam 10 mg and thiamylal 250 mg i.v. Trachea was intubated and lungs were mechanically ventilated. During the seizure, arterial blood pressure increased from 180/110 mmHg to 190/120 mmHg and heart rate changed from 90 beats x min(-1) to 88 beats x min(-1). Ventricular premature beats were observed sporadically but stopped spontaneously. After the episode, the operation was performed under general anesthesia (nitrous oxide 50% and sevoflurane 1.5-2% in oxygen 50%). The patient recovered uneventfully after the operation. Although careful aspiration was done before the injection of ropivacaine, inadvertent intravenous injection could have occurred during the administration. Intermittent aspiration should be indispensable during the administration, because a large dose of local anesthetic is necessary for interscalene block. In this case, the only cardiovascular manifestation was ventricular premature beats indicating that ropivacaine has less cardiotoxicity.

[Two occasions of anesthetic management for a patient with Williams syndrome].

A 5-year-old boy with Williams syndrome received open reduction of fracture of the antebrachium twice. He had been diagnosed as having Williams syndrome with some characteristic symptoms, including elfin face, mental retardation and primary pulmonary hypertension. Williams syndrome has a tetrad of cardiovascular disease, elfin face, mental retardation and hypercalcemia. Operations were performed twice under general anesthesia. Airway management with mask technique was easily performed. Tracheal intubation was accomplished successfully. Anesthesia was induced with propofol, fentanyl, and vecuronium, and maintained with propofol, fentanyl and the inhalation of oxygen with nitrous oxide. Both anesthetic courses were uneventful and he was discharged without any complications. Special anesthetic considerations should be taken for difficulties of intubation, management of circulatory system, malignant hyperthermia, and hypercalcemia in this syndrome.

[Anesthetic management of two patients with the history of SMON].

Patients of subacute myelo-optico-neuropathy (SMON) suffer from neurological disorders for a long time. The authors report anesthetic management of two patients with SMON. One patient was a 82-year-old woman suffering from SMON for 49 years. Sensory examination revealed numbness and hypesthesia in the both lower extremities. She underwent open reduction for femoral neck fracture. The other patient was a 91-year-old man suffered from SMON for 31 years. Sensory examination revealed weakness of leg muscles. He underwent transurethral resection of prostate. We chose general anesthesia for both patients instead of spinal anesthesia because of reported complications related to spinal anesthesia in patients with the disease. Intraoperative courses were uneventful and there were no neurological deteriorations postoperatively in both patients. One of the chief symptoms of patients with SMON is numbness of the lower extremity. Therefore patients of SMON may feel uncomfortable to the numbness by spinal or epidural anesthesia. This is the main reason we recommend general anesthesia for patients with SMON.