[Spinal anesthesia in a patient with SMON disease].

We report a patient with subacute myelo-optico-neuropathy (SMON) in whom spinal anesthesia was employed to treat fracture of the femur neck. An 87-year-old woman was diagnosed as having SMON at the age of 45. The patient was admitted to our hospital with fracture of the femur neck. Aspiration pneumonia was also suspected with shadow in the right lung on the chest X-P The percutaneous oxygen saturation (Spo2) with room air was 77%. Spinal anesthesia with 5 mg of 0.5% hyperbaric bupivacaine and 20 mcg of fentanyl was performed at L3-4. The level of anesthesia was T4. During surgery, no severe pain in the lower limbs was observed. Three hours after the end of surgery, the level of anesthesia was T9. On the day after surgery, the extent of dysesthesia and reflex were similar to those before surgery. General anesthesia has been chosen in SMON patients, because there was a report of severe pain of the lower limbs after spinal anesthesia with dibucaine. In our patient, general anesthesia was considered inappropriate due to hypoxemia. We used a mixture of bupivacaine and fentanyl for spinal anesthesia, because the neurotoxicity of bupivacaine is weaker than that of dibucaine.

[Combined use of the airway scope and fiberoptic bronchoscopy for tracheal intubation in a patient with a large epiglottic cyst].

A 26-year-old man was scheduled for surgical extraction of a large epiglottic cyst. Mask ventilation was possible under propofol anesthesia without muscle relaxant. It was difficult to see the glottis using either a Macintosh laryngoscope or by fiberoptic bronchoscopy. When the AWS laryngoscope (Hoya, Tokyo Japan) with a part of the blade removed, was inserted orally, it became possible to see the glottis with a part of the epiglottic cyst. A reinforced tube was inserted nasally, and a fiberoptic bronchoscope was passed through the tube into the trachea. The tube was then passed over the fiberscope into the trachea. We believe that the Pentax AWS laryngoscope may lift the epiglottis and its cyst atraumatically, and may facilitate nasal fiberoptic intubation in a patient with a large epiglottic cyst.

[Anesthetic management of pneumonorrhaphy for one-lung patient].

Selective immobilisation of the lobes of the lungs with a bronchial blocker is sometimes a challenge for anesthesiologists. A pneumonorrhaphy was planned in a patient who had had undergone left pneumectomy, and selective immobilisation of the right upper lobe was requested. The initial attempt to place the cuff of a bronchial blocker was unsuccessful. We inserted a urethral guide-wire through fiberoptic bronchoscope and positioned the tip at the orifice of the right upper bronchus. We then threaded the bronchial blocker through the guidewire and placed the cuff at the right upper bronchus. The right upper lobe was successfully collapsed, which greatly facilitated the surgical procedure. The method is easy, fast, and safe and should be considered when difficulty in placement of the bronchial blocker is encountered.

[Bronchial blocking with a balloon wedge pressure Catheter in a small infant].

The need for one-lung ventilation has been increasing even in pediatric patients. However, the trachea is so narrow in pediatric patients that ordinary double-lumen tubes can not be used and there have been many reports on devices or measures to block one lung. We report our experience with a female infant weighing 2 kg who had severe chronic lung disease under mechanical ventilation, and underwent left lung lower lobectomy with one-lung ventilation technique. We chose a balloon wedge pressure catheter to block the left main bronchus, because it has a central lumen through which a guide wire can be passed and sucking is available. The infant was in need of continuous ventilation and the catheter was too soft to be inserted directly. We first inserted an 18G catheter of a needle-catheter assemble outside the tracheal tube through which a guide wire was inserted into the left main bronchus with the aid of direct vision of a 2-mm fiberoptic bronchoscope through the tracheal tube, and then inserted the balloon wedge pressure catheter placing it in an appropriate position. One-lung ventilation was successfully achieved and the operative and postoperative course was uneventful.