[Two Cases of Tension Pneumothorax during Posterior Spinal Fusion -Diagnosis and Decision on Emergency Drainage-].

We experienced two cases of tension pneumothorax during posterior spinal fusion. Case 1 : A 67-year-old female underwent posterior thoracic-lumbar spinal fusion. One hour after the operation had started, a sudden elevation of airway pressure and decreased Pa02 were observed. Then occasional decrease in blood pressure, tachycardia, and premature ventricular contractions followed. SpO2 re- mained stable throughout the surgery. Case 2 : A 57-year-old female underwent posterior thoracic-lumbar spinal fusion. During the surgical pro- cedure, a sudden decrease in SpO2 accompanied by an air leak from pleura occurred. No remarkable change was observed in hemodynamics. Immediately after the operation had finished, chest X-ray on supine position revealed tension pneumotho- rax in both cases. Patients were extubated after effec- tive lung expansion by insertion of thoracic drainage tube. Tension pneumothorax is a potentially lethal compli- cation during anesthesia, resulting in cardiac arrest Though rapid diagnosis is crucial, physical examination and assessment are limited in patients on prone posi- tion. The possibility must be considered that several conditions as increased airway pressure, impaired oxy- genation and hemodynamics suggest tension pneumo- thorax. Image diagnosis using radiography or ultra- sound can be of value. If once patient on prone position develops cardiac arrest, resuscitation is extremely difficult Emergency drainage should be considered in case of highly im- paired hemodynamics.

[Anesthetic management using auto-transfusion and hypothermia for massive bleeding].

A 51-year-old woman was scheduled for emergency enterectomy and vascular repair under general anesthesia for active bleeding from internal iliac artery caused by repeated radiotherapy for cervical cancer and subsequent hypovolemic shock. For the first two hours of operation, the blood loss exceeded 6,000 ml and the hemoglobin level decreased to a low of 3.8 g x dl(-1) despite administration of 38 units of packed red cells. Intraoperative blood salvage was used in order to minimize further loss of hemoglobin. Mild hypothermia technique was also introduced to prevent brain ischemia. Total bleeding volume was approximately 10,000 ml, and total transfused volume was 8,740 ml. No neurological deficit and no systemic infection were found during the postoperative course. Although clinical risks of cell salvage in patients undergoing surgery for malignant tumor remain controversial, we conclude intraoperative blood salvage using Cell Saver could be utilized as a life-saving means and mild hypothermia might have been efficacious for protecting the brain from ischemia in our case.

Anaphylactic shock decreases cerebral blood flow more than what would be expected from severe arterial hypotension.

The effects of acute reduction in arterial blood pressure in severe anaphylactic shock (AS) on cerebral blood flow are of paramount importance to be investigated. We studied cerebral circulation and oxygenation in a model of severe AS and compared it with a pharmacologically induced arterial hypotension of similar magnitude. Anaphylactic shock was induced by 1 mg intravenous ovalbumin (OVA) in sensitized rats. Rats were randomized to three groups: (i) no resuscitation (OVA; n = 10) (ii) intravenous volume expansion (10 mL in 10 min after OVA injection) (OVA + VE; n = 10); (iii) control hypotension (100 µg of nicardipine followed by continuous infusion of 1 mg · 100 g · h intravenously; NICAR; n = 10). Mean arterial pressure (MAP), carotid blood flow (CBF), cardiac output, cerebral cortical blood flow (CCBF; estimated by laser Doppler technique), and cerebral tissue oxygen pressure (PtiO2) were recorded over the 15 min following AS induction in all three groups. Results are expressed as mean (SD). One minute after OVA or nicardipine injection, there was a rapid and significant 50% decrease in MAP from basal values. In the OVA group, AS severely altered systemic and cerebral hemodynamics in 5 min: 93% (SD, 4%) decrease in CBF, 66% (SD, 8%) in CCBF, and 44% (SD, 8%) in PtiO2; the decrease in CBF was significantly (P < 0.05) attenuated in the OVA + VE group; however, CCBF and PtiO2 were not statistically different in the OVA versus OVA + VE groups. On the contrary, nicardipine-induced hypotension had only a limited impact on CBF, cardiac output, CCBF, and PtiO2 for a similar MAP decrease. There was a linear relation between CCBF and blood pressure in the OVA (regression slope: 0.87 [SD, 0.06]; median r = 0.81) but not in the NICAR group (regression slope: 0.23 [SD, 0.32]; median r = 0.33). Anaphylactic shock resulted in severe impairment of cerebral blood flow and oxygenation, beyond what could be expected from the level of arterial hypotension.

[Comparison of intraoperative stress hormones release between propofol-remifentanil anesthesia and propofol with epidural anesthesia during gynecological surgery].

BACKGROUND: Remifentanil recently comes to be used for intraoperative analgesia instead of epidural anesthesia in gynecological surgery. It seems to offer the same stability in vital signs, but stress response during remifentanil anesthesia has not been evaluated. Therefore, we compared remifentanil anesthesia with epidural anesthesia regarding stress hormones. METHODS: Fifty-one patients scheduled for surgery were randomized into two groups (epidural group: E and remifentanil group: R). Anesthesia was maintained with propofol and epidural ropivacaine in E, and with propofol and remifentanil in R. Plasma concentrations of adrenaline, noradrenaline, dopamine (DOA), cortisol, adorenocorticotropic hormone (ACTH), and blood glucose were measured at five points during the perioperative period. RESULTS: Adrenaline, noradrenaline and blood glucose were not significantly different between the groups at any point. DOA was significantly higher in R than E at skin closure. Cortisol was significantly higher in R than E at three points during operation. ACTH was significantly higher in E than R at skin closure. CONCLUSIONS: The inhibition of stress hormone secretion during operation was less in R than E. Regarding stress response, total intravenous anesthesia with remifentanil seems to be a proper method, but to have less potency than general anesthesia using epidural block.

[The direction and the position of epidural catheter tips inserted 5 cm or 7 cm cephalad did not differ].

BACKGROUND: Epidural catheter insertion is a common procedure in gynecological surgeries. At a previous study, we investigated the catheter's direction and position, inserted 7cm cephalad from T12-L1, with postoperative plain X-P using picture archiving communication system (PACS). 74% of the catheters advanced in cephalad direction and 71.4% of the catheter tips stayed within one vertebra from the puncture level. We estimated that the catheters were too long to advance straight. Then, we planned another prospective study to compare the catheter advanced 7 cm or 5 cm regarding its direction and tip position. METHODS: Fifty-one female patients receiving gynecological surgery were enrolled. Epidural catheters were inserted from T12-L1 intervertebral space in cephalad direction for the length of 5 cm confirmed with postoperative plain X-P using PACS. The catheter's direction, the length, and the position were verified and compared with the result of the previous study. RESULTS: The catheters going cephalad appeared more frequently among 5 cm group than 7 cm group. Those going caudalad appeared more frequently among 7 cm group than 5 cm group. However, the catheter tip final position and the length from the puncture levels were not significantly different between the groups. CONCLUSIONS: The direction and the position of epidural catheter inserted 5 cm or 7 cm cephalad did not differ.

[Efficacy of traditional herbal medicine, Yokukansan on patients with neuropathic pain].

BACKGROUND: Neuropathic pain that is the chronic, severe, and intractable pain, interferes with activities of daily living (ADL) and consequently reduces quality of life (QOL). We reported the efficacy of Yokukansan in patients with neuropathic pain, including acute herpetic pain, postherpetic neuralgia, central poststroke pain, post-traumatic spinal cord injury pain, thalamic syndrome, complex regional pain syndrome and symptomatic trigeminal neuralgia. Yokukansan was more effective compared with traditional medicines, such as tricyclic antidepressants, carbamazepine, gabapentin, and opioids etc., which are recommended to treat neuropathic pain. Recently, effects of Yokukansan is reported on the behavioral and psychological symptoms of dementia (BPSD) in elderly patients with dementia. Repeated administration of Yokukansan decreases expression of 5-hydroxytryptamine (5-HT) 2A receptors in the prefrontal cortex in mice, and Yokukansan also protects destruction of myelin sheaths in rats with thiamine deficient-induced encephalopathy. Mechanism of effectiveness of Yokukansan on neuropathic pain has not been established; however, efficacy of Yokukansan on neuropathic pain has been shown clinically. CONCLUSIONS: As far as we know, this is the first report that Yokukansan was effective on neuropathic pain. Yokukansan without serious adverse reactions may be a possible medicine for treatment of neuropathic pain in future.

[Confirmation of the position of the epidural catheter regarding its intended direction and location for lumbar epidural block].

BACKGROUND: Epidural catheter insertion is a common procedure for gynecological surgeries. Epidural puncture is usually performed according to the anatomical landmarks without radiographic means. The aim of his study was to confirm the actual level of puncture, and the distance as well as the direction of epidural catheters threaded. METHODS: Seventy-seven female patients receiving epidural anesthesia were enrolled. Epidural catheter was inserted from T12-L1 intervertebral space in cephalad direction for the length of 7 cm. The catheter was confirmed with postoperative plain X-P using picture archiving communication system. The intended direction and length were compared with the actual data. In addition, we retrospectively analyzed the factors including the performers (resident vs. specialist), the approaches of puncture (median vs. paramedian), and patient physical factors (age, height, body weight, and BMI). RESULTS: Of the catheters 54.6% was inserted from T12-L1, and 74% of them were advanced in cephalad direction. Of the tip of the catheter 71.4% stayed within one vertebra from the puncture level. The puncture accuracy, the frequency of catheter threaded over one vertebra, and the frequency of catheters threaded in cephalad direction did not differ significantly among performers, approaches and patients physical factors. CONCLUSIONS: Only 11.7% of the catheters were actually inserted from T12-L1 and advanced in cephalad direction over one vertebra as we had intended.

[The effects of early nerve blocks for prevention of postherpetic neuralgia and analysis of prognostic factors].

BACKGROUND: Herpes zoster causes acute pain and sometimes leads to postherpetic neuralgia (PHN). The previously reported risk factors of PHN such as old age, allodynia, paresthesia and so on are not based on evidence. Although nerve block is useful to relieve acute pain and recommended for prevention of PHN, evidence is scanty. METHODS: The patients with herpes zoster within 3 months after the onset were studied. The patient underwent nerve blocks and proper medical treatment, and were followed for up to one year. The risk factors of PHN were assessed. We evaluated whether nerve block prevented PHN. RESULTS: A total of 144 consecutive patients were studied. Twenty seven % of patients suffered PHN. Old age (> 65 y. o) and hypesthesia were confirmed to be the risk factors of PHN, whereas the intensity of acute pain was not. Patients who underwent nerve block within 1 month after the onset were less likely to suffer from PHN compared with patients of delayed nerve blocks. CONCLUSIONS: Old age, hypesthesia and delayed nerve blocks were the risk factors of PHN. Nerve blocks in the early phase of herpes zoster may be useful to prevent PHN, particularly in the younger patients.

[Retrospective evaluation of optimal doses of fentanyl by patient-controlled epidural analgesia in management of postoperative pain after gynecological surgery in the elderly].

BACKGROUND: Patient controlled epidural analgesia (PCEA) is a useful method in alleviation of postoperative pain; however, PCEA sometimes provided inadequate pain relief in the elderly. Therefore, we investigated optimal doses of fentanyl by PCEA in management of postoperative pain after gynecological surgery in the elderly. METHODS: We investigated the pain at rest using 100 mm visual analogue scale (VAS) on the 1st day and 2nd day after the operations. Patients were divided into two groups ; one was well-controlled group (WC group, VAS < 20 mm) and the other was poorly-controlled group (PC group, VAS > or =20 mm). In two groups, we retrospectively compared doses of fentanyl in PCEA, number of demand-PCEA, postoperative nausea as well as vomiting, and delirium during 48 hrs after the operations. RESULTS: The mean age in WC group was significantly higher than that in PC group. The total dosage of epidural fentanyl did not differ significantly between the groups. In WC group fentanyl of 0.172 microg x kg(-1) hr(-1) was given, and fentanyl 0.197 microg x kg(-1) x hr(-1) in PC group. CONCLUSIONS: We found that fentanyl 0.172 microg x kg(-1) x 1 hr(-1) by PCEA was the most appropriate dose for alleviation of postoperative pain after gynecological surgery in the elderly.

[Yokuininto improves treatment resistant burning pain in legs].

Yokuininto was effective in treating burning pain in both lower legs of a 58-year-old woman. She felt her lower legs feverish: however, no neurological deficit or abnormal finding in angiography was found. The burning pain was increased by cold and decreased by warm, but was alleviated by epidural block with local anesthetics. After 2-week medication of Yokuininto, burning pain was reduced to 20 to 30% and fever in legs disappeared. Yokuininto has been used for chronic pain in muscle and joint accompanied by swelling or local fever. This patient had no joint pain or swelling, but her burning pain was considered to have resulted from some abnormality in blood circulation due to disorder in discharge of water in the body.

[Effective treatment of acute pain and related symptoms in elderly with herpes zoster].

BACKGROUND: The incidence of herpes zoster increases with age. Immediate pain relief is required for prevention of postherpetic neuralgia (PHN) and also its related symptoms that worsen the general condition because acute herpetic pain often interferes with sleep, mood, and general activities in elderly patients. Nerve block is useful to relief acute pain and recommended for prevention of PHN. Tricyclic antidepressant drugs have antinoticeptive effect in acute pain in experimental models, in addition to its antidepressant effect. METHODS: Forty elderly patients with herpes zoster within 3 months after the onset underwent nerve blocks and received tricyclic antidepressant drugs. We assessed the effect of treatments and adverse effects. RESULTS: No significant adverse effects were found in elderly patients who had received nerve blocks and/or tricyclic antidepressant drugs. Alleviation of acute pain was obtained in more than 80% of patients, and in all patients depressive state and/or disturbance of the general condition were significantly improved. CONCLUSIONS: With careful technique and assessment of patients, both nerve block and tricyclic antidepressant drugs were beneficial and safe treatments in elderly patients with herpes zoster.

[Anesthetic management for video-assisted extended thymectomy of patients with myasthenia gravis].

BACKGROUND: Thymectomy is one of therapeutic modalities for patients with myasthenia gravis. Since 1998, we have performed video-assisted extended thymectomy, which is much less invasive than traditional method. However, its optimal perioperative management has not been established. METHODS: From April 1998 to December 2003, 40 patients with myasthenia gravis underwent video-assisted extended thymectomy in our hospital. Anesthesia was maintained with propofol, sevoflurane and epidural anesthesia. No muscle relaxant was used. Operations were performed in supine position and required differential lung ventilation of both sides in turn for manipulation. A central venous catheter was inserted in the femoral vein to prepare for unexpected bleeding or other hemodynamic changes. RESULTS: Seven patients presented hypoxemia under differential lung ventilation and needed bilateral lung ventilation or addition of CPAP to nondependent lung. Unexpected bleeding from the left innominate vein occurred in two patients and required median sternotomy. Severe hypotension caused by compression of the heart during operation was observed in twenty-one patients. Extubation in the operating room was successful in all patients except one with severe bulbar paralysis before preoperative period. CONCLUSIONS: It is important to examine both surgical techniques of video-assisted surgery and physiological features of myasthenia gravis for anesthetic management of video-assisted extended thymectomy.

[Preoperative evaluation, anesthetic management and postoperative complications of athetotic type cerebral palsy patients undergoing laminoplasty].

BACKGROUND: The patients with athetotic type cerebral palsy need to have their necks fixed for preventing worsening of their symptoms during surgery. Cervical fixation with a halo vest leads to difficult tracheal intubation and possibility of aspiration. Therefore careful perioperative management is necessary, especially for respiratory complications. However, since it is difficult on the patients with cerebral palsy to perform spirogram correctly, their preoperative respiratory functions are hard to be evaluated. METHODS: We evaluated the relationships between preoperative condition and postoperative complications in 50 athetotic type cerebral palsy patients who had undergone laminoplasty. In addition, we also compared them with non-cerebral palsy patients for laminoplasty without a halo vest. RESULTS: The patients with cerebral palsy showed lower preoperative ADL score, severer symptoms of myelopathy, and decreased %VC in spirogram. We found all of these were related to prolonged postoperative recovery of ADL and longer hospitalization. Two patients with cerebral palsy suffered from aspiration pneumonia after operation, whereas any non-cerebral palsy patients had no remarkable complications. CONCLUSIONS: Careful perioperative management is necessary for cerebral palsy patients undergoing laminoplasty, especially for prevention of aspiration pneumonia.

Fine mapping of 16q-linked autosomal dominant cerebellar ataxia type III in Japanese families.

The autosomal dominant cerebellar ataxias (ADCAs) are a clinically and genetically heterogeneous group of disorders. To date, at least 11 genes and 13 additional loci have been identified in ADCAs. Despite phenotypic differences, spinocerebellar ataxia 4 (SCA4) and Japanese 16q-linked ADCA type III map to the same region of 16q22.1. We report four Japanese families with pure cerebellar ataxia and a disease locus at 16q22.1. Our families yielded a peak lod score of 6.01 at marker D16S3141. To refine the candidate region, we carried out genetic linkage studies in four pedigrees with a high density set of DNA markers from chromosome 16q22.1. Our linkage data suggest that the disease locus for 16q-ADCA type III is within the 1.25-Mb interval delineated by markers 17msm and CTTT01. We screened for mutations in 36 genes within the critical region. Our critical region lies within the linkage interval reported for SCA4 and for Japanese 16q-ADCA type III. These data suggest that the ADCA that we have characterized is allelic with SCA4 and Japanese 16q-linked ADCA type III.

[Thoracoscopic surgery for spontaneous pneumothorax and its anesthetic considerations].

BACKGROUND: Incidence of spontaneous pneumothorax (SPT) is increasing recently. Video-assisted thoracic surgery (VATS) is, at present, accepted generally as a procedure of choice for surgical treatment of SPT. This study was designed to investigate whether pre-operative complications and epidural anesthesia contribute to post-operative outcome following VATS for SPT. METHODS: From 1999 to 2002, 88 patients (78 men and 10 women, ranging in ages from 18 to 86, with an average age of 42 years) presented with SPT and received VATS at the Osaka Police Hospital. We evaluated the relationship between peri-operative risk factors and post-operative outcome after VATS for SPT. RESULTS: Age and epidural analgesia contributed to post-operative pain (P=0.0268 and P=0.0165, respectively). Moreover, old age and long duration of surgery extended a hospitalization period (P=0.0002, r2=0.393 and P=0.0394, r2=0.224, respectively). In addition, old age contributes to post-operative pneumonia (P=0.0405). The patient with history of smoking had prolonged duration of surgery (P=0.0040) and oxygen supply after surgery (P=0.0312). CONCLUSIONS: VATS for SPT is less invasive and contribute to short hospitalization. However, VATS also requires general anesthesia with one-lung ventilation. From our study, peri-operative careful management is necessary in a patient with old age and a habit of smoking.

[A case of intractable bone fracture pain due to metastasis of carcinoma treated with continuous epidural infusion using ropivacaine].

A 62-yr-old man presented with intractable pain due to sciatic and iliac bone fractures with metastasis of carcinoma. We treated this symptom using epidural infusion of ropivacaine over 8 weeks. He developed no complications related to epidural infusion of ropivacaine. Continuous epidural infusion of ropivacaine is useful for the management of pain from invasive carcinoma.