[Anesthetic management of a patient with congenital antithrombin III Deficiency using temporal inferior vena cava filter].

We described the perioperative management of a patient with congenital antithrombin III deficiency using temporal inferior vena cava filter. A 30-year-old man with congenital antithrombin III deficiency was scheduled for artificial head replacement of the hip joint under general anesthesia. He was diagnosed as having congenital antithrombin III deficiency when he had had an episode of venous thrombosis after artificial head replacement of the right hip joint. He had been taking warfarin as an anticoagulant, and it was discontinued three days before surgery. To prevent perioperative thrombus formation, the plasma AT III activity was maintained above 80% before, during and after surgery using AT III concentrates. We also placed the temporal inferior vena cava filter. There was no serious thrombosis or embolism perioperatively. The use of the filter during the perioperative period helped to avoid development of serious thrombosis and embolism.

[Anesthetic management of two patients with essential thrombocythemia].

We report different methods of anesthetic management in two patients with essential thrombocythemia. Case 1 is a 69-year-old male scheduled for cholecystectomy. His blood platelet counts were maintained between 10 to 40 x 10(4).microliters-1 after myelosuppression therapy. His preoperative blood tests were within normal limits. Since he had no signs of hemorrhage or thrombus preoperatively, an epidural catheter was inserted for intraoperative analgesia and postoperative pain relief. Anesthesia was induced with propofol and fentanyl, and maintained with N2O-O2-sevoflurane. Mepivacaine 1% was injected through the epidural catheter for intraoperative analgesia and buprenorphine was injected through the catheter for postoperative pain relief. His perioperative course was uneventful. Case 2 is an 88-year-old female scheduled for emergency enterectomy. She had had recurrent bouts of thrombosis. Her blood platelet counts were 89.1 x 10(4).microliters-1. Since her preoperative management of thrombocythemia had been poor, epidural anesthesia was not performed. Anesthesia was induced with propofol, and maintained with N2O-O2-sevoflurane. Her perioperative course was uneventful. We conclude that spinal or epidural anesthesia is not contraindicated when preoperative platelet counts and aggregation test are within normal limits in a patient with essential thrombocythemia.

Pediatric caudal block with mepivacaine, bupivacaine or a mixture of both drugs: requirement for postoperative analgesia and plasma concentration of local anesthetics.

STUDY OBJECTIVES: To assess the effects of pediatric caudal block using mepivacaine, bupivacaine, or a mixture of both drugs on postoperative analgesia, and to examine plasma concentrations of the local anesthetics after caudal injection. DESIGN: Prospective, randomized, double-blind study. SETTING: Operating room and pediatric surgical ward. PATIENTS: 60 ASA physical status I children weighing 10 to 20 kg (26 females, 34 males), and scheduled for inguinal herniorrhaphy. INTERVENTIONS: Patients randomly received caudal block with 1 mL/kg of mepivacaine 1% (Group M, n = 20), 1 mL/kg of bupivacaine 0.25% (Group B, n = 20), or a mixture of 0.5 mL/kg of mepivacaine 1% and 0.5 mL/kg of bupivacaine 0.25% (Group MB, n = 20) after induction of anesthesia with sevoflurane in 50% oxygen (O2). Anesthesia was maintained with 66% nitrous oxide in O2 supplemented with sevoflurane at an end-tidal concentration of less than 1%. MEASUREMENTS AND MAIN RESULTS: Postoperative pain scores using a pediatric pain scale and plasma concentration of each local anesthetic were measured. In Group M, four patients required postoperative analgesics within the first 24 hours. However, no patients required postoperative analgesics in Groups B and MB. In Group M, the plasma concentration of mepivacaine of two patients exceeded 5 microg/kg of the level of toxicity. However, these patients did not show any toxic symptoms. Because a mixture of two local anesthetics halves the concentration of each local anesthetic, the plasma concentrations of mepivacaine and bupivacaine in Group MB were significantly lower than those of Groups M and B. CONCLUSIONS: Pediatric caudal block with a mixture of mepivacaine and bupivacaine is effective for intraoperative and postoperative analgesia.

[Anesthetic experience of emergency coronary artery bypass graft operation in a patient with cardioamyloidosis].

A 76-year-old woman with acute myocardial infarction underwent an emergency coronary artery bypass graft operation. She developed cardiac failure and sick sinus syndrome before the surgery because she was with cardioamyloidosis. Therefore, intra-aortic balloon pumping and the pacemaker were used to maintain the hemodynamics prior to the operation. Anesthesia was induced with midazolam 5 mg, morphine 30 mg and pancuronium 5 mg, and maintained with 0.3-0.5% isoflurane in 50% nitrous oxide and 50% oxygen. Morphine 10 mg was also injected during the surgery, and the total dose of morphine 40 mg was administered. The pacemaker at 80 bpm was inserted and mexiletine 0.5 mg.kg-1.h-1 was given to prevent ventricular arrhythmias at weaning from cardio-pulmonary bypass. The surgical operation was successfully performed and the postoperative course was uneventful. A combination of light inhalation anesthesia with narcotics may be a choice for anesthetic management of patients with cardioamyloidosis as this method has less influence on hemodynamics.

Acute cigarette smoking reduces vasodilative effect induced by sympathetic block in dogs.

BACKGROUND AND OBJECTIVES: The aim of this study is to clarify the influence of acute cigarette smoking on vasodilation induced by sympathetic block. METHODS: We measured mean arterial pressure, heart rate, left brachial artery blood flow (BABF), right femoral artery blood flow (FABF), and plasma catecholamines in dogs to examine the effect of acute cigarette smoking after stellate ganglion block (SGB). The experimental protocol was: (1) Left SGB using 1.0 mL 0.5% mepivacaine without smoking (sham smoking); and (2) left SGB using 1.0 mL 0.5% mepivacaine followed by a single cigarette smoking (nicotine 1 mg) 15 minutes after the block. RESULTS: SGB induced a significant increase of BABF during the study (baseline, 100%; peak at 10 minutes after SGB, 176% +/- 9%; P <.05) in sham smoking and a significant decrease of FABF from 10 minutes after the block to 20 minutes after sham smoking (baseline, 100%; bottom at 5 minutes after sham smoking, 82% +/- 8%; P <.05). Smoking after SGB induced a significant decrease of BABF 60 minutes after smoking (baseline, 100%; 69% +/- 11%; P <.05) and a significant decrease of FABF during the study (baseline, 100%; bottom at 20 minutes after smoking, 74% +/- 20%; P <.05). Smoking significantly increased plasma norepinephrine and epinephrine through the study. CONCLUSIONS: Sympathetic block induces a significant increase of peripheral blood flow, but smoking produces a significant decrease in the blood flow in the SGB-induced dilated vessels.

High concentration sevoflurane induction of anesthesia accelerates onset of vecuronium neuromuscular blockade.

PURPOSE: To investigate neuromuscular block using accelography after administration of vecuronium under sevoflurane 8% induction and maintenance with sevoflurane 2% in adults. METHODS: Patients were allocated to three groups: (1) group I: anesthesia was induced and maintained with propofol and fentanyl (n= 15), (2) group II: anesthesia was induced with propofol and maintained with N2O(66%)-O2-sevoflurane 2% (n = 15), (3) group III: anesthesia was induced with sevoflurane 8% using a vital capacity inhalation induction and maintained with N2O(66%)-O2-sevoflurane 2% (n = 15). 0.1 mg x kg(-1) vecuronium was used for paralysis three minutes after anesthetic induction and reversed using intravenous 0.04 mg x kg(-1) neostigmine with 0.02 mg kg atropine when the train-of-four (TOF) ratio returned to 25%. RESULTS: The onset time from initial administration of vecuronium to maximal block in the group III was shorter than that in the groups I and II (139 +/- 35, 193 +/- 35 and 188 +/- 47s, respectively: P < 0.05). The clinical duration from maximal block to 25% recovery of TOF ratio in group II and III was longer than that in the group I (47 +/- 15, 48 +/- 14 and 36 +/- 10 min, respectively: P < 0.05). The reversal times from administration of neostigmine to 75% of TOF ratio in groups II and III were longer than that in the group I (196 +/- 53, 208 +/- 64 and 136 +/- 28s, respectively: P < 0.05). CONCLUSIONS: Vital capacity inhalation induction of anesthesia with sevoflurane accelerates onset and prolongs duration of vecuronium neuromuscular block compared with propofol-fentanyl anesthesia.

Propofol prevents lipid peroxidation following transient forebrain ischemia in gerbils.

PURPOSE: To ascertain whether propofol prevents lipid peroxidation on delayed neuronal death induced by transient forebrain ischemia in the hippocampal CA1 subfield in gerbils. METHODS: Forty gerbils were randomly assigned to five groups: Group I, control, sham operation treated with physiological saline solution (PSS); Group II, ischemia/reperfusion treated with PSS; Group III, ischemia/reperfusion treated with 50 mg x kg(-1) propofol; Group IV, ischemia/reperfusion treated with 100 mg x kg(-1) propofol; Group V, ischemia/reperfusion treated with 150 mg x kg(-1) propofol. Transient forebrain ischemia was induced by occluding the bilateral common carotid arteries for four minutes under N2O/O2/halothane anesthesia after propofol or PSS. Five days later, the cerebrum was removed and each forebrain was cut into two including the hippocampus. Lipid peroxidation was determined using the production of malondialdehyde (MDA), and histopathological changes in the hippocampal CA1 subfield were examined. RESULTS: In group II, the pyramidal cells were atrophic and pycnotic; vacuolation and structural disruption of the radial striated zone was observed. In the other four groups, these changes were not observed. Degenerative ratios of pyramidal cells were: Group I: 4.9 +/- 2.3, Group II: 94.1 +/- 4.5 (P < 0.01), Group III: 12.5 +/- 5.7, Group IV: 11.0 +/- 4.6, Group V: 9.6 +/- 4.9%. Production of MDA was: Group I: 83 +/- 22, Group II: 198 +/- 25 (P < 0.01), Group III: 153 +/- 39, Group IV: 113 +/- 34, Group V: 106 +/- 27 nmol x g(-1) wet tissue. CONCLUSION: Propofol attenuated delayed neuronal death by preventing lipid peroxidation induced by transient forebrain ischemia in the hippocampal CA1 subfield in gerbils.

[Damage of a laryngeal mask airway during anesthesia].

A 21-year-old man was scheduled for fixation of a fractured radius and ulna under general anesthesia using a laryngeal mask airway (LM). Anesthesia was induced with propofol 120 mg and fentanyl 0.1 mg. After administration of vecuronium 6 mg, we attempted insertion of the LM (# 5). The first trial was unsuccessful because the tube of the LM was bent in the pharynx. We attempted it again and the LM was successfully inserted. It was connected with the anesthetic circuit, and manual ventilation was started. However, the LM was suddenly broken at the basal part of the tube connector before the start of operation, and it became detached from the anesthetic circuit. Therefore, we removed the remaining LM from the mouth, and inserted a new LM (# 5). The peroperative course was uneventful. We conclude that inspection of a recycled LM is important before using it in order to prevent such an event as the present case.

Cremasteric reflex test as an objective indicator of spinal anaesthesia.

We studied 100 men who were scheduled for urological surgery (Group 1) and another 50 men for orthopaedic surgery (Group 2). We attempted to anaesthetise both sides of the lower body in Group 1 and to anaesthetise one leg in Group 2 by injecting 0.3% hyperbaric dibucaine intrathecally. The presence or absence of the cremasteric reflex and loss of sensation to pinprick higher than the first lumbar dermatome were examined by two researchers who were blind to each other's results. In Group 1, both the reflex and the pinprick sensation were always absent bilaterally 5 min after intrathecal injection. In Group 2, in 23 of 50 patients the reflex had become absent bilaterally; in all these patients, bilateral sensory loss was detected. In the remaining 27 patients, both the reflex and the pinprick sensation were absent on the operation side, whereas both were present on the nonoperation side. Sensitivity, specificity and positive or negative predictive value for the cremasteric reflex were all 100%. Disappearance of the cremasteric reflex is a simple objective indicator of spinal anaesthesia at the first lumbar dermatome. This test may be useful in patients who cannot give reliable answers to conventional tests, such as the pinprick test.

[Two cases of extreme hemodilution caused by massive hemorrhage immediately after start of operation].

We describe two cases of extreme hemodilution due to large amounts of fluid infusion for unexpected massive hemorrhage. In both cases, unexpected hemorrhage with difficult hemostasis occurred within 60 min after the start of the operation. For lack of transfused blood, large amounts of fluid infusion using crystalloid and colloid solutions including 5% albumin, plasma expander and lactated Ringer's solution were administered to maintain circulatory blood volume. The hemoglobin concentration and hematocrit had been below 2.0 g.dl-1 and 10% for approximately one hour, respectively. The extreme hemodilution improved by the urgent blood transfusion. In one case, intraoperative autotransfusion with Cell-Saver was performed. In spite of intraoperative extreme hemodilution, their postoperative courses were uneventful. Intraoperative awareness was present in both cases.

[Anesthetic management of bilateral lung lavage for pulmonary alveolar proteinosis--comparison between sevoflurane and propofol].

A 55-year-old man with pulmonary alveolar proteinosis underwent lung lavage under general anesthesia using sevoflurane three years ago. Although transient hypoxia occurred postoperatively, there were no complications. Because of the recent deterioration of his symptoms, he was rescheduled for lung lavage. Anesthesia was induced with propofol 120 mg and fetanyl 0.2 mg. Vecuronium 7 mg was administered to facilitate tracheal intubation using a double-lumen tube. Anesthesia was maintained with propofol 4 mg.kg-1.h-1. Electrocardiogram, blood pressure, SPO2, EtCO2 and rectal temperature were monitored intraoperatively. We also checked PaO2 when necessary. Although transient hypoxia occurred after the procedure, it receded spontaneously. Since inhalation anesthetics inhibit hypoxic pulmonary vasoconstriction, intravenous anesthetics may be more useful for patients with severe pulmonary alveolar proteinosis.

[Anesthetic management of a patient with West syndrome].

A 21-year-old female with West syndrome was scheduled for resection of hordeolum. She had an episode of convulsion at three months of age, and was diagnosed as having West syndrome at one year of age. She had epileptic seizures twice a week in spite of administration of phenytoin, clonazepam and sodium valproate. These drugs had been administered till the morning of the surgery. After premedication with atropine 0.25 mg, anesthesia was induced with propofol (12-->10-->8 mg.kg-1.h-1). The tracheal intubation was performed with vecuronium 0.1 mg.kg-1 and anesthesia was maintained with continuous infusion of propofol 6-8 mg.kg-1.h-1 and local infiltration with 1.0% lidocaine 5 ml. We administered phenytoin to prevent epileptic seizures during the surgery. No epileptic seizures occurred perioperatively. We conclude that propofol may be useful for a patient with West syndrome, and we should be careful not to lower the threshold for convulsion during the perioperative period.

[Anesthetic management for transtracheal placement of a catheter for intracavity infusion of an antifungal drug in patients with pulmonary fungus ball of aspergillosis].

A catheter was inserted through the cricothyroid membrane under general anesthesia using a laryngeal mask airway in two patients with pulmonary fungus ball of aspergillosis to administer an antimycotic into the fungus ball. Anesthesia was induced with fentanyl and propofol in both patients. The laryngeal mask airway was inserted using intravenous injection of vecuronium. Anesthesia was maintained with continuous infusion of propofol. The catheter was inserted through the cricothyroid membrane and placed in the pulmonary fungus ball using bronchoscope. Perioperative and postoperative courses were uneventful in both patients. It was concluded that the laryngeal mask airway is useful for airway management when a catheter is inserted into a pulmonary fungus ball through the cricothyroid membrane.

[Anesthetic management of a patient with dilated cardiomyopathy under total intravenous anesthesia with propofol and ketamine combined with continuous epidural analgesia].

We report our experience with total intravenous anesthesia (TIVA) with propofol and ketamine combined with continuous epidural analgesia in a 72-year-old-male patient with dilated cardiomyopathy scheduled for a total prostatectomy. After premedication with atropine 0.5 mg and pethidine 35 mg, anesthesia was induced with ketamine 50 mg, fentanyl 0.1 mg and using a step down method of propofol (6-->4-->2 mg.kg-1.hr-1). After hemodynamic parameters had been stabilized, the trachea was intubated. Then, 1.5% lidocaine 6 ml was injected through an epidural catheter, placed at the L 1-2 intervertebral space. Anesthesia was maintained with continuous infusion of propofol 1 mg.kg-1.hr-1 and ketamine 1 mg.kg-1.hr-1, and continuous epidural analgesia with 1.5% lidocaine 2 ml.hr-1. Hemodynamics remained stable throughout the operative procedure. No postoperative complications occurred. TIVA with propofol and ketamine in combination with epidural analgesia is useful for patients with dilated cardiomyopathy in order to maintain stable hemodynamics during anesthesia.

[Anesthetic management for urgent endoscopy in a child with heterotopic liver transplant].

A 6-year-old boy with heterotopic liver transplant underwent urgent endoscopy under general anesthesia because of bloody stool. He was taking cyclosporin as an immunosuppressant. His hepatic function was normal and no side effects of cyclosporin were observed. Preoperative blood transfusion was performed because of severe anemia. Anesthesia was induced with midazolam 2 mg, ketamine 20 mg and fentanyl 0.05 mg, and maintained with addition of midazolam and ketamine. We did not use any inhalation anesthetics to avoid postoperative hepatic dysfunction. The endoscopy was successfully performed and the postoperative course was uneventful. We conclude that preanesthetic evaluation of immunosuppressant state and the hepatic function of transplanted liver is important for anesthetic management of a patient with heterotopic liver transplant.

[A patient uninformed about his illness became aware of his lung cancer when an anesthesiologist visited him for pain control].

Much has been said about the importance of informed consent in Japan, but informing cancer to the patient has not been popular so far. We, as anesthesiologists, often treat pain in cancer patients, who occasionally, are not informed about the cancer. And we sometimes have patients with whom cautious consulting is necessary. This report presents our experience with a patient uninformed about the cancer but suspicious of his lung cancer. We met him as anesthesiologists, and this made the patient convinced that he had a cancer and was about to die soon.

[Differential lung ventilation using Fogarty catheter after accidental damage of bronchial blocker cuff].

We performed differential lung ventilation using a Fogarty catheter after accidental damage of a bronchial blocker. A 57-year-old-man underwent thoracoscopic surgery for right pneumothorax. Anesthesia was induced with fentanyl and midazolam, and maintained with propofol and continuous epidural block with 2% mepivacaine. We used a single lumen endotrachial tube with a bronchial blocker for differential lung ventilation. We inserted the tip of the bronchial blocker into the right bronchus under fiberoptic broncoscopy after the patient had been placed in the lateral position. Four milliliters of air were injected into the bronchial blocker cuff before inserting the thoracoscope and differential lung ventilation was started. The right lung expanded suddenly because of accidental damage of the cuff one hour after starting surgery. We inserted a Fogarty catheter (10 Fr.) into the right bronchus under fiberoptic broncoscopy. Its balloon was inflated for differential lung ventilation. The procedure was performed successfully and uneventfully. We conclude that Fogarty catheter is an effective replacement for a damaged bronchial blocker cuff during differential lung ventilation.

[A case of cardiac arrest after torsades de pointes due to prolonged QT interval syndrome possibly associated with subarachnoid hemorrhage].

An 58-year-old woman with prolonged QT interval syndrome possibly associated with subarachnoid hemorrhage underwent clipping for cerebral artery aneurysm. Anesthesia was induced with diazepam, fentanyl and vecuronium, and maintained with nitrous oxide (66%)-oxygen and sevoflurane (1%) with fentanyl. However, three hours after the start of operation, torsades de pointes suddenly appeared and cardiac arrest was followed. After cardiopulmonary resuscitation, sinus rhythm was restored. At that time, serum potassium was decreased to 2.7 mEq.l-1. Five days after the operation, she died despite cardiopulmonary resuscitation for frequent episodes of ventricular tachycardia including torsades de pointes. Ventricular tachycardia including torsades de pointes may have been caused by decreased serum potassium.