[Anesthetic management of laparoscopic cholecystectomy for a patient with Churg-Strauss syndrome: a case report].

Churg-Strauss syndrome (CSS) is an uncommon disease characterized by bronchial asthma, eosinophilia and systemic vasculitis. Many patients with CSS are suffering from cardiovascular disorders, neurological disorders and/or renal disorders which are associated with systemic vasculitis. Cardiac diseases are considered as the main cause of the death in patients with CSS. Steroid administration is the standard pharmacological therapy for CSS. There are very few clinical reports concerning anesthetic management for the patients with CSS. We suppose that precise perioperative managements are required for the patients with CSS, including the appropriate control of bronchial asthma and the careful treatments of disorders in cardiovascular system, neurological system and/or kidney. In addition, we believe that the steroid cover should be considered during the perioperative period of the patients with CSS. Here, we describe an anesthetic management of a 28-year-old man with CSS undergoing laparoscopic cholecystectomy. General anesthesia was induced with midazolam and fentanyl. Rocuronium was administered to facilitate tracheal intubation. After tracheal intubation, anesthesia was maintained with sevoflurane and remifentanil. Prior to the surgery, 100 mg of hydrocortisone was administered for the steroid cover. The surgery was uneventful. The patient emerged from general anesthesia smoothly, and was extubated safely.

[Desflurane anesthesia without muscle relaxant for a patient with myasthenia gravis undergoing laparoscopic high anterior resection: a case report].

Myasthenia gravis (MG) is an autoimmune disease affecting neuromuscular junction, which is characterized by fluctuating muscle weakness and abnormal fatigability. The use of muscle relaxants is major concern in anesthetic management for patients with MG. Muscle relaxant is a practical tool to assure immobilization during surgery under general anesthesia Anesthetic management without muscle relaxants for patients with MG is challenging, because it is difficult to assure immobilization. However, pharmacological effects of muscle relaxants can be prolonged in patients with MG, resulting in the increased incidence of postoperative respiratory support. We, here, describe an anesthetic management of an 82-year-old man with MG undergoing laparoscopic surgery. Anesthesia was induced with propofol and remifentanil Desflurane was administered via a face mask, and the patient was manually ventilated for 10 min, and the trachea was intubated safely without muscle relaxants. Anesthesia was maintained with desflurane and remifentanil. We did not administer muscle relaxants to the patient during surgery. Throughout laparoscopic procedures, no movements of the patient were observed, and there were no problems concerning the laparoscopic view of the operation filed. The surgery was uneventful. The patient emerged from anesthesia smoothly, and was extubated safely. The postoperative course of the patient was also uneventful.

[A case of acute renal failure following compartment syndrome after the surgery for femoral neck fracture].

Compartment syndrome is known to develop after a prolonged surgery in the lithotomy position. We experienced acute renal failure following compartment syndrome after the surgery in hemilithotomy position. A 62-year-old man underwent a left hip fixation for femoral neck fracture. The surgical leg was placed into traction in a foot piece and the intact leg was placed in the hemilithotomy position. Because of the difficulty in repositioning and the trouble with fluoroscope, the surgery took over 5 hours. He suffered acute pain, swelling and spasm in his intact leg placed into hemilithotomy after the surgery. Creatine kinase, blood urea nitrogen and creatinine markedly increased and myoglobinuria was recognized. We diagnosed an acute renal failure following compartment syndrome and treated him in the ICU on close monitoring. In spite of the treatment with massive transfusion and diuretics, he needed hemodialysis twice and then his renal function improved. Prevention is most essential for compartment syndrome after a prolonged surgery in the lithotomy position. Risk factors should be recognized before surgery and appropriate action should be taken such as using Allen stirrups and avoiding hypotension, hypovolemia and the prolonged lithotomy position with exaggerated elevation of legs.

Effects of acetaldehyde on action potentials and Ca2+ currents in single atrial myocytes from the bullfrog.

AIM: The purpose of the present study was to examine the effects of acetaldehyde on the contractile force and membrane potentials and currents in the bullfrog heart. METHODS: Contractile force was recorded using right atrial tissues, and membrane potentials and currents were measured by using whole cell patch clamp methods in right atrial myocytes. RESULTS: Acetaldehyde at 500 µmol/l and 1 mmol/l increased the contractile force significantly. Acetaldehyde at 300 and 500 µmol/l increased the overshoot and the plateau of electrically induced action potentials in a concentration-dependent and reversible manner, while the resting membrane potential did not change. The duration of the action potential (APD(90)) measured at the 90% repolarization level was shortened. The L-type Ca(2+) current (I(Ca)) increased significantly when 300 and 500 µmol/l were applied. The fast transient inward current, the inward rectifying potassium current and the outward delayed-rectifier potassium current were not changed following acetaldehyde application (500 µmol/l or 1 mmol/l). CONCLUSION: These results suggest that acetaldehyde increased the I(Ca), thereby increased the contractile force, the overshoot and the plateau of action potentials. The shortening of APD(90) may be due to the acceleration of the current decay during the I(Ca) inactivation phase.

Hypotensive and hypertensive effects of acetaldehyde on blood pressure in rats.

Intravenous injection of acetaldehyde produced hypotensive actions in pentobarbital-anaesthetised whole rats, but hypertensive actions in pithed rats. The hypotensive effects of acetaldehyde in whole rats were abolished by pre-treatment with yohimbine. In pithed rats, the hypertensive effects of acetaldehyde were significantly attenuated by prazosin and phentolamine, and in rats that had been pre-treated with reserpine. Our results suggest that the hypertensive actions of acetaldehyde in pithed rats are due to the release of catecholamines, which subsequently leads to vasoconstriction. In whole rats the hypotensive actions of acetaldehyde may be due to alpha2-adrenoceptor stimulation in the central nervous or peripheral system.

[Preoperative evaluation and anesthetic management of a patient with Brugada syndrome-like ECG].

Brugada syndrome has been known as one of the causes of sudden death due to ventricular fibrillation. We experienced anesthetic management of seven patients with ECG showing Brugada syndrome before surgery, even though they had no symptoms nor family history. All of them showed no problems through-out the operation. Such patients are often untreated, but they have the risks of cardiac accidents such as ventricular fibrillation or sudden death. For preoperative evaluation of patients with Brugada syndrome-like ECG, it is important to ask them their experience of syncope and family history. Ultrasonic cardiography and Holter ECG recording should be done. External defibrillator should be prepared and parasympathetic dominant condition must be avoided during the anesthetic management.

[Successful anesthetic management of patients with poor ventricular function using the phosphodiesterase III inhibitor, olprinone, during major cardiovascular procedures].

We administered olprinone, a newly developed phosphodiesterase III inhibitor, commencing before induction of general anesthesia to patients with poor ventricular function during major cardiovascular procedures. Case 1 patient underwent off-pump CABG for acute myocardial infarction. Although he was in a shock state, olprinone improved the contractility of viable myocardium, increased the cardiac index, and decreased the pulmonary artery pressure. Case 2 patient underwent off-pump CABG for unstable angina. Olprinone significantly increased the cardiac index and the mixed venous oxygen saturation. Case 3 patient underwent graft replacement for rupture of a dissected descending aorta. Although he showed ischemic cardiomyopathy with diffuse hypokinetic left ventricle, olprinone drastically improved the contractility of the heart. Olprinone was very effective for improving ventricular dysfunction; its institution prior to induction of anesthesia made successful anesthetic management possible without resorting to a mechanical assist device like the intra-aortic balloon pump.

[Lessons learned from anesthetic management of pheochromocytoma resection: a report of three cases].

The anesthetic management of patients with pheochromocytoma, in which drastic hemodynamic changes may occur, is still a challenge to even the most experienced anesthesiologist, although the perioperative mortality has been reduced remarkably. We report three patients who developed unexpected major complications during elective resection of a pheochromocytoma. The Case 1 patient was a 46 year-old woman who developed ventricular tachycardia immediately after administration of ephedrine for transient hypotension induced by excessive phentolamine. Even a mild beta adrenergic agent may cause extraordinary stimulation to myocardium under alpha blockade. The Case 2 patient was a 44 year-old man who needed intensive vasodilating therapy due to an exaggerated cardiovascular response to intraoperative surgical stress. He developed severe metabolic acidosis resembling hyperdynamic shock before resection of the tumor, although blood pressure was controlled within the expected range. The Case 3 patient was a 60 year-old woman who did not receive preoperative alpha blocker therapy because she lacked cardiovascular symptoms. However, she revealed a high level of systemic vascular resistance after induction of general anesthesia and needed moderate inotropic support to compensate for an abrupt reduction of vascular resistance after resection of the tumor. The pathophysiology of the disease is complex and anesthetic care must be tailored in accordance with each patient's situation.

[Spinal anesthesia in a parturient complicated with idiopathic thrombocytopenic purpura].

A 27-yr-old parturient with idiopathic thrombocytopenic purpura was scheduled to undergo resection of a left ovarian cyst at 15 weeks gestation. Platelet counts were between 46,000 and 64,000.microliter-1, bleeding time was 2 min, and she denied having unusual bleeding diathesis. As the patient was reluctant to receive general anesthesia for fear of latent adverse effects of the drugs on the fetus, we selected spinal anesthesia and the perioperative course was uneventful. However, it is questionable to perform regional anesthesia in patients with coagulation disorders, for spinal hematomas leading to paraplegia can be a rare but devastating complication of regional anesthesia. According to our extensive literature review, it was revealed that platelet insufficiency, both in terms of function and count, did not represent a major risk factor for spinal hematomas associated with regional anesthesia, especially for spinal anesthesia. We suggest that spinal anesthesia may be safely performed in patients if their platelet counts exceed around 50,000.microliter-1.

[A case of acute ethanol intoxication with remarkable hyperglycemia by "ume-shu", a Japanese apricot liquor made with a large amount of sugar].

A 19-year-old woman ingested 2.2 L of "umeshu", a Japanese apricot liquor made with a large amount of sugar. She was unconscious and in shock. The estimated blood ethanol concentration was 607 mg/dl, and the blood glucose level was 576 mg/dl. Because her respiration and circulation was highly suppressed, blood purification was indicated. Continuous hemodiafiltration (CHDF) was performed instead of hemodialysis because her hemodynamics was unstable. After CHDF was instituted, her blood glucose level reduced to normal range, and her consciousness became alert. CHDF was effective in eliminating ethanol and stabilizing her hemodynamics within an early stage. Though acute ethanol intoxication is known to inhibit glucogenesis, leading to hypoglycemia, marked hyperglycemia was seen in this case. Ingestion of a large amount of glucose-rich liquor and being in shock seemed to be the causes of hyperglycemia.