[Anesthetic management for emergency cesarean section in a patient with intracranial hemorrhage due to ruptured arteriovenous malformation].

A 30 year-old pregnant woman (36 weeks) had intracranial hemorrhage due to arteriovenous malformation in the left frontal lobe. She underwent an emergency cesarean section under general anesthesia. To avoid hemodynamic changes and increasing intracranial pressure, intravenous lidocaine and inhaled sevoflurane were given prior to tracheal intubation, and a bolus dose of nicardipine was given prior to tracheal extubation. Emergence from anesthesia was uneventful, and no exacerbation of neurological signs and symptoms were recognized. It is important to control hemodynamic changes during anesthesia for a patient with intracranial hemorrhage due to ruptured arteriovenous malformation.

[Tracheal intubation for emergent tracheostomy in a patient complicated with tracheal stenosis].

We report the management of anesthesia for emergent tracheostomy in a patient with severe tracheal stenosis. A 63-year-old male was scheduled for an emergency tracheostomy for severe tracheal stenosis due to the invasion of a thyroid cancer. A preoperative neck CT revealed the tracheal stenosis, extending from 1-2 cm below the vocal cord to the upper end of the sternum. The narrowest caliber was about 7 mm in transverse diameter. Moreover, the cancer was suspected to have a bleeding tendency. General anesthesia with endotracheal intubation was considered necessary to provide an open airway during tracheostomy. Anesthesia was induced with thiopental, and a 6.0 mm endotracheal tube with cuff was successfully introduced with a balloon introducer (AIRGUID E) using suxamethonium. We were able to perform tracheostomy uneventfully.

[Serum and urinary magnesium during and after cardiac surgery].

To investigate the effects of cardiopulmonary bypass (CPB) on the serum magnesium (Mg) level, we observed the perioperative changes in serum and urinary Mg in 20 patients undergoing open heart surgery. The serum Mg was in the normal range (mean +/- SE, 1.98 +/- 0.04 mg.dl-1) at the induction of anesthesia, and began to fall during CPB, reaching its lowest level (1.43 +/- 0.05 mg.dl-1) on the first postoperative day, and returned to normal level on the second postoperative day. We found a good correlation between the decrease in serum Mg and increase in urinary Mg excretion, suggesting that the decrease in serum Mg level may be attributed to the increase in urinary excretion of Mg. But, compared to the increase in urinary loss of Mg, the observed decrease in serum Mg on the first operative day was not as great as expected. Furthermore, the level of serum Mg returned to normal spontaneously on the second operative day. These observations suggest that Mg was transferred from the intracellular to the extracellular compartment during and after CPB.

[Premixing lidocaine reduces the incidence and severity of pain on injection of propofol].

The purpose of this study was to confirm the effect of premixed lidocaine for the reduction of pain during injection of propofol in adult patients. We conducted a prospective, randomized, double-blind trial on 106 patients. In the study group (n = 54), lidocaine 40 mg (2 ml of lidocaine 2%) was added to 180 mg of propofol (18 ml). In the control group (n = 52), 2 ml of normal saline was added to 180 mg of propofol. The pain on injection was rated as none, mild, moderate, or severe. Eleven patients (20.4%) in the study group experienced pain compared with 25 (48.1%) in the control group. Thirteen in the control group complained moderate or severe pain compared with only one in the study group. In conclusion, lidocaine 40 mg premixed with 180 mg propofol significantly reduces the incidence and severity of pain associated with propofol injection.

Airway management for patients with a tracheal bronchus.

A tracheal bronchus is an aberrant, accessory or ectopic bronchus arising almost invariably from the right lateral wall of the trachea, causing hypoxaemia, atelectasis, or both, during anaesthesia. We describe two patients with a tracheal bronchus found before anaesthesia. One tracheal bronchus was found by tracheobronchoscopy and the other by chest x-ray. Because of recognition of the anomaly before operation, anaesthesia was uneventful in each patient.

[Spinal anesthesia for oophorectomy in a patient with pulmonary lymphangiomyomatosis accompanied by hypochondriasis].

A 41-year-old woman with pulmonary lymphangiomyomatosis had been scheduled for bilateral oophorectomy which led to amelioration of the pulmonary pathology. The discrepancy between her dyspnea on exertion and lung function tests suggested that she had a marked tendency toward hypochondria. Therefore, we chose spinal anesthesia because of its technical simplicity, rapid onset, and effectiveness of some sedatives used perioperatively. Surgery was performed uneventfully. The anesthetic method mentioned above did not worsen respiratory function perioperatively. Spinal anesthesia is thought to be appropriate anesthesia for patients with pulmonary lymphangiomyomatosis, if feasible.

[Psychological evaluation of out-patients in our pain clinic using self-rating depression scale and state-trate anxiety inventory questionnaire].

In 98 out-patients who visited our pain clinic, we evaluated their psychological status before the first examination and one month after the treatment, using self-rating depression scale (SDS) and state-trate anxiety inventory (STAI). SDS, state anxiety, and trate anxiety scores were significantly higher in the patients with pain (trigeminal neuralgia, neck-shoulder-arm pain syndrome, lumbago and psychological pain, n = 55) compared with the patients without pain (sudden deafness and facial nerve palsy, n = 43) (P < 0.01, 0.05, 0.01). Of the patients with pain, patients with psychogenic pain showed the highest score in every test. The scores of SDS and state anxiety became significantly lower one month after the treatments compared with ones before the first examination (P < 0.01). It was considered that the decline in every score was due to the treatments in our pain clinic. In patients whose score of trate anxiety before the first examination was more than 50 points, the SDS and state anxiety showed high scores even one month after the treatments. This finding suggests that these patients need psychosomatic managements.

[Diagnosis of accidental subdural block].

Accidental subdural block occurred in a 47-year-old man who underwent gastrectomy under nitrous oxide-sevoflurane anesthesia combined with continuous epidural block. The development of subdural block was suspected from unexpectedly severe hypotension with small doses of mepivacaine during operation and was confirmed by a characteristic X-ray photograph after operation. The subdural block should be suspected from abnormal changes in vital signs and by careful observation of X-ray photographs, because it is not always easy to determine the presence of contrast media either in the subdural space or in the epidural space.

[Psychological evaluation of patients by state-trait anxiety inventory in pain clinic].

In 84 outpatients who visited our pain clinic, we evaluated their anxiety before the first examination, using State-Trait Anxiety Inventory. State anxiety scores were high in all the patients regardless of their underlying disease. Trait anxiety scores in patients with chronic pain such as postherpetic neuralgia or cervic-shoulder-hand syndrome were higher than in patients with facial nerve palsy, sudden hearing loss or herpetic pain. This study indicates that psychosomatic management is mandatory for patients with chronic pain.

[Changes in plasma concentrations of human hepatocyte growth factor before and after major intra-abdominal surgery under nitrous oxide-sevoflurane anesthesia].

The measurements of human hepatocyte growth factor (hHGF) in plasma and liver function tests were performed in 23 patients before and after major intra-abdominal surgery under nitrous oxide-sevoflurane anesthesia. Plasma concentrations of hHGF in 12 patients with normal liver function (Group 1) and in 11 patients with liver dysfunction (Group 2) were 0.34 +/- 0.07 and 0.44 +/- 0.12 ng.ml-1 (mean +/- SD) before the surgery, respectively. After the surgery, plasma concentration of hHGF remained unchanged in Group 1, but significantly increased to 0.61 +/- 0.32 ng.ml-1 in Group 2. Other routine laboratory data reflecting hepatic functions remained unchanged in both groups. These results suggest that liver damage during surgery and anesthesia occurs more likely in patients with liver dysfunction than in patients with normal liver function, and hHGF can be a more sensitive indicator of hepatic damage than conventional liver function tests.

[Usefulness of continuous intra-arterial blood gas monitoring in a patient undergoing tracheal transection and reconstruction].

Usefulness of a new continuous intra-arterial blood gas monitoring system (PB3300, Puritan-Bennett, Carlsbad, California) was evaluated in a patient with tracheal cancer who was undergoing tracheal transection and reconstruction. The PB3300 detected continuous changes in pH, PaCO2, and PaO2 during the surgical intervention and provided reliable information to take appropriate therapeutic measures. PB3300 was superior to pulse oximetry because the latter can not detect changes in PaO2 more than 100 mmHg accompanying pulmonary dysfunction caused by surgical procedures. We conclude that the PB3300 is a useful monitor when used during anesthetic management of the patient who needs frequent arterial blood gas analyses.

[Intravenous lidocaine in the treatment of post treatment neuropathy].

A 46-yr-old man with a 3-month history of post treatment neuropathy following insulin treatment for diabetes mellitus was suffering from severe pain and dysesthesia in his bilateral feet and legs. The patient described his pain as constant burning sensation which was severest in the soles and extended circumferentially over the legs. Previous trials of tricyclic antidepressants and nonsteroidal antiinflammatory drugs were uneffective. The patient received a trial dose of intravenous lidocaine (200mg), which markedly decreased his pain. Subsequently, mexiletine was administered orally in a dose of 300 mg a day and the dose was increased up to 450 mg a day, by which a severity of pain was halved and anxiety was relieved one month later. In conclusion, intravenous lidocaine and oral mexiletine may be useful drugs for post treatment neuropathy.

[Rapid induction of anesthesia with inhalation of sevoflurane].

Induction of anesthesia with inhalation of sevoflurane was evaluated in 45 patients. Inhalation anesthesia was induced by a single vital capacity breath followed by spontaneous breathing. The compositions of anesthetic gases were as follows: 5% sevoflurane in oxygen, 5% sevoflurane in 67% nitrous oxide and oxygen, and 7% sevoflurane in 67% nitrous oxide and oxygen. The time (mean +/- SEM) necessary for the loss of consciousness was 85 +/- 6, 56 +/- 4, and 42 +/- 3 seconds, and breathing frequency was 8 +/- 1, 5 +/- 0.6, 1.4 +/- 0.2, in each composition of anesthetic gasses, respectively. Changes in blood pressure and heart rate were relatively small. The technique was found to be acceptable to all of the patients studied. We conclude that the technique of single breath induction with sevoflurane is a safe and acceptable alternative to intravenous induction in cooperative adult patients.

[Serum nitroglycerin concentrations during extracorporeal circulation with a membrane oxygenator incorporated with a cardiopulmonary bypass circuit].

The effect of a cardiopulmonary bypass circuit (CPB) on serum nitroglycerin (TNG) concentrations was studied in eight patients scheduled for cardiac surgery. The CPB consisted of polyvinyl chloride tubes and polypropyrene membrane oxygenator. TNG was administered intravenously at a rate of 1 microgram.kg-1.min-1 after induction of anesthesia. Blood samples were obtained from the radial artery, central vein, venous inlet of the CPB, and arterial outlet of the CPB. No significant difference in serum TNG concentration was found between the venous inlet of the CPB and arterial outlet of the CPB. Serum TNG concentration tended to increase during complete extracorporeal circulation. This suggests that the hypothermic inhibition of TNG metabolism may be greater than the adsorption of TNG by the CPB.

[Right ventricular perforation and cardiac tamponade caused by a central venous catheter].

A 5 year old girl with ASD was scheduled for open heart surgery. A central venous catheter was placed via the right infraclavicular vein after induction of anesthesia. Thirty minutes after insertion of the catheter, a decrease in arterial pressure and pulse pressure, an increase in heart rate and central venous pressure were observed. Cardiac tamponade was revealed by rapid opening of the chest. Gushing blood out of a hole in the right ventricular free wall was confirmed by pericardiotomy. The hemodynamics were stabilized by blood transfusion and surgical closure of the hole on the ventricle. This perforation was thought to be caused by careless insertion of a relatively stiff central venous catheter.

[Postoperative pain relief by continuous epidural infusion of bupivacaine and buprenorphine].

Continuous postoperative pain relief produced by epidural block with bupivacaine and buprenorphine was evaluated in 12 patients after thoracotomy, 19 patients after upper abdominal surgery, and 14 patients after lower abdominal surgery. Patients initially received 8 ml of 0.25% bupivacaine and 0.1 mg of buprenorphine at recovery room in operating theater and continuously received the mixture of 0.25% bupivacaine and 5 micrograms.ml-1 buprenorphine at a rate of 1 ml.h-1 using a portable pump. About fifty percent of the patients did not need additional narcotics during 48 postoperative hours. About ninety percent of the patients needed one additional narcotics during 48 postoperative hours. The authors conclude that epidural analgesia with the mixture of bupivacaine and buprenorphine produces satisfactory postoperative pain relief.

The echocardiographic assessment of left ventricular performance during sevoflurane and halothane anesthesia.

The cardiovascular effects of sevoflurane were studied and compared with those of halothane in 30 healthy patients. The patients were assigned to receive 1 MAC sevoflurane (n = 10), 2 MAC sevoflurane (n = 10) or 1 MAC halothane (n = 10) in N(2)O 2 l.min(-1) and O(2) 4 l.min(-1). The changes in left ventricular diastolic and systolic dimension (Dd and Ds), fractional shortening (FS), mean velocity of circumferential fiber shortening (mVcf), left ventricular diastolic and systolic volume (Vd and Vs), stroke volume (SV), ejection fraction (EF) and cardiac index (CI) were evaluated by echocardiography. Sevoflurane produced significant dose-dependent decreases in FS, mVcf, EF and SV, but no significant changes in Dd and Vd. Therefore, the decrease in SV was due mainly to the increase in left ventricular residual volume (Vs). One MAC halothane produced a more significant decrease in FS, mVcf, EF and SV, when compared to values obtained at 1 MAC sevoflourane ( P < 0.01). CI was more significantly decreased with 1 MAC halothane than with 1 MAC and 2 MAC sevoflurane ( P < 0.01). This was brought about by a slight decrease in HR with halothane and a slight increase in HR with sevoflurane, in addition to a smaller decrease in SV with sevoflurane than with halothane. This study suggests that sevoflurane may better preserve cardiac function as a pump in healthy patients, when compared to halothane.

Anesthesia for a patient with recessive dystrophic epidermolysis bullosa.

Two different anesthetic methods were employed for a patient with recessive dystrophic epidermolysis bullosa (R-DEB). One was plexus brachial block in combination with ketamine infusion. The other was general anesthesia with N2O-O2-halothane via a face mask. In the former, no particular problem developed. In the later, however, some blisters were newly formed on the region where the anesthesist's fingers were attached to hold a face mask. Although mask anesthesia was considered to be not always suitable for patients with DEB, we chose it because tracheal intubation may cause more serious damage to the upper airway leading to airway obstruction.

The influence of ventricular extrasystoles and postextrasystoles on cardiovascular dynamics in anesthetized dogs.

The influence of ventricular extrasystoles and postextrasystoles on cardiovascular dynamics were assessed in terms of maximum rate of rise of left ventricular pressure (max dP/dt), ascending aortic flow, left ventricular stroke volume, and left ventricular end-diastolic transverse dimension in anesthetized dogs. A single ventricular extrasystole, two and three consecutive ventricular extrasystoles (couplet and triplet) were induced by applying mechanical stimulation to the surface of the right ventricule. In any of these ventricular extrasystoles, max dP/dt, stroke volume and end-diastolic transverse dimension were decreased, compared with those in preceding sinus beats, i.e., pre-extrasystoles. Over the several postextrasystoles, max dP/dt was increased and gradually returned to its control level. This increase in max dP/dt, i.e., postextrasystolic potentiation paralleled an increase in ascending aortic peak flow but did not always bring about an increase in stroke volume, even when a left ventricular contraction was initiated by a significantly greater end-diastolic transverse dimension. The postextrasystolic potentiation seems to be associated with the Frank-Starling mechanism and does not compensate for the decreased in stroke volume elicited by the ventricular extrasystoles. In conclusion, not only ventricular extrasystoles per se but also postextrasystoles exert the adverse influence on cardiovascular dynamics consecutively.