[Cardiac asystole in the postanesthetic care unit: a case report].

We report a patient without apparent heart disease who developed asystole postoperatively. A 24-year-old woman was scheduled for acetabulectomy under lumbar epidural anesthesia with intravenous propofol infusion. There was no profound hypotension or arrhythmia during anesthesia and surgery. She complained of nausea 50 minutes after the operation. The ECG showed an abrupt decrease in the heart rate followed by cardiac asystole 30 seconds after the onset of nausea. Prompt cardiac massage resumed the heart beats in eight seconds. There was no neurological deficit.

[Hypoxemia caused by retention of irrigation fluid to detect leaks from the lungs during subtotal esophagectomy].

We report a patient who developed hypoxemia caused by retention of irrigation fluid used to detect leaks from the lungs during subtotal esophagectomy. A 58-year-old man developed a sudden onset of hypoxemia with a decrease in tidal volume during subtotal esophagectomy. Chest X-ray revealed a homogeneous opacity of the left lung field, suggesting the presence of fluid in the pleural cavity on the left. The tidal volume and SpO2 increased after drainage of the fluid from the left pleural cavity. The postoperative course was uneventful and the patient was discharged on the 16th postoperative day.

[Atelectasis after induction of general anesthesia in an infant with cleft palate].

We report an infant with cleft palate who developed atelectasis as a result of aspiration of food residue after induction of general anesthesia. A 12-month-old girl with cleft palate was scheduled for palatoplasty. The trachea was intubated after 6.5-hour fasting. Breath sounds were not audible on the left. Chest X-ray demonstrated complete atelectasis of the left lung. Bronchoscopy revealed that the left primary bronchus was blocked by a white stick. Pathological examination showed that the white stick consisted of milk residue with abundant candida species. It was speculated that the milk residue accumulated in the cleft palate had been aspirated during induction of general anesthesia.

[Rhabdomyolysis after prolonged surgery in lateral decubitus position].

We report an obese patient who developed rhabdomyolysis after prolonged surgery in lateral decubitus position. A 55-year-old woman, with a body mass index of 29.3 kg x m(-2), underwent removal of an acoustic neurinoma in lateral decubitus position which lasted 20 hours. There was no intraoperative muscle rigidity, redness of the urine or rapid elevation of PET(CO2) and body temperature. The patient developed skin ulcer in the left flank after the surgery. There were elevated levels of serum creatinine phosphokinase, AST, ALT, and myoglobin in the urine. CT of the abdomen taken two days after the surgery suggested the presence of rhabdomyolysis of the transverse abdominal muscles.

[Aseptic precautions in epidural catheterization for surgery].

We describe aseptic precautions in epidural catheterization for surgery. Every patient has to be checked for immunodeficiency, atopic dermatitis, preoperative use of antibiotics, and local infection of the epidural puncture site. Physicians who perform epidural catheterization should wear a mask and a cap and take off a wrist watch and rings on the fingers before an epidural kit is opened. Fingers and hands should be disinfected before wearing surgical gloves. The skin for epidural puncture site should be disinfected with 0.5% chlorhexidine in 80% ethanol. A micropore filter should be used when epidural catheterization is expected to remain over 24 hours.

[Postherpetic neuralgia].

Varicella-zoster virus (VZV) causes two clinically distinct diseases: varicella and herpes zoster. Herpes zoster, recurrent infection of VZV occurs when the cell-mediated immunity to VZV declines. Since the cell-medicated immunity to VZV declines with aging, herpes zoster occurs more frequently in the elderly. Most frequent and dreaded complication of herpes zoster is postherpetic neuralgia (PHN). The first line of treatment of PHN is medication with tricyclic antidipressants and anticonvulsants. Double-blind studies showed that effective tricyclic antidepressants for the treatment of PHN are amitriptyline and nortriptyline, and effective anticonvulsants gabapentin and pregabalin. When tricyclic antidepressant and/or anticonvulsant cannot relieve PHN, opioids should be considered in some selected patients. Although neuroablative procedures have been performed for the treatment of PHN, their effectiveness was not confirmed by double-blind studies. They rather aggravate PHN with time. Recent research with a live attenuated varicella vaccine to prevent herpes zoster indicated that the vaccine decreased the occurrence of herpes zoster and postherpetic neuralgia by almost half as compared with placebo. Vaccination of high risk subjects with the varicella vaccine seems to be the most effective measure for the prevention of postherpetic neuralgia.

[Propofol-induced generalized tonic-clonic seizure: a case report].

A 23-year-old man with no history of convulsion underwent removal of the nails in his upper arm. He received propofol infusion after axillary brachial plexus block. Ten minutes after propofol infusion (15 minutes after axillary block), generalized tonic-clonic seizure occurred. The rate of propofol infusion was increased, and midazolam was given intravenously ; however, the seizure continued. Propofol infusion was withheld, and anesthesia was maintained with sevoflurane. The seizure gradually decreased in 15 minutes after termination of propofol infusion, and it finally stopped 30 minutes after termination of propofol infusion.

[Spontaneous spinal subdural and epidural haematoma in a pregnant patient].

We report a pregnant woman who developed non-traumatic spinal subdural and epidural hematoma. A 31-year-old woman at 28 weeks of gestation developed progressive ascending paralysis. MRI suggested the presence of spinal subdural hematoma at T4-6 and spinal epidural hematoma at T4-9. An emergency cesarean section followed by spinal decompression was performed 60 hours after the onset. The patient's neulogical function recovered completely after the surgey.

[Postoperative contralateral brachial plexus palsy after prolonged operation in lateral decubitus position].

We report a patient who developed postoperative contralateral brachial plexus palsy after prolonged surgery in lateral decubitus position. A 58-year-old man underwent hepatectomy because of metastatic liver tumor in left decubitus position. The surgical table was rotated anteriorly at 15 degrees. The surgery lasted for 7 hours and 50 minutes. After the surgery, he complained of limited arm elevation, hypesthesia of the arm, impaired flexion and extension of the elbow, on the right. These sensory and motor impairements resolved after rehabilitation for 7 days.

[Drug errors during anesthesia].

We report drug errors during anesthesia. The data were retrieved from the incident reports in a period of June 2000 to June 2003 at the Department of Anesthesiology, Fukuoka University Hospital. Drug errors occurred in 18 (0.12%) of 15,271 patients who were managed by anesthesiologists during the period. Among the 18 events, most frequent errors were 12 events of administration of wrong drugs. Errors in dosage were five, and wrong route of administration in one. There were no serious sequelae in the 18 patients.

Ventricular tachycardia without preceding electrocardiogram change after hypertonic mannitol administration: a case report.

BACKGROUND: Mannitol is widely used during neurosurgery, but it has a serious complication including lethal arrhythmia due to mannitol-induced hyperkalemia. CASE PRESENTATION: We report on a 62-year-old man scheduled for the clipping of an unruptured cerebral artery aneurysm. During surgery, approximately 20 min after the end of 200-mL 20% hypertonic mannitol administration, ventricular tachycardia (VT) occurred without preceding electrocardiogram (ECG) change, such as peaked T waves, and VT was recovered to sinus rhythm after chest compression. A potassium concentration after recovery from VT was 6.4 mEq/L, which was normalized by the administration of calcium gluconate, furosemide, and insulin with glucose. CONCLUSIONS: Physicians must be aware that VT without preceding ECG change can occur after hypertonic mannitol administration.

Reduction of Blood Pressure Following After Renal Artery Adventitia Stripping During Total Nephroureterectomy: Potential Effect of Renal Sympathetic Denervation.

BACKGROUND Catheter-based renal sympathetic denervation has been reported to be effective for treatment resistance hypertension in Australia and Europe. However, in the blinded SYMPLICITY HTN-3 trial, renal denervation did not achieve a significant decrease in blood pressure (BP) in comparison to sham controls. There have been various discussions on the factors that influenced this result. CASE REPORT Two men on antihypertensive therapy underwent unilateral radical nephroureterectomy for cancer of the renal pelvis. When the renal artery adventitia was stripped and cauterized just before renal artery ligation, the measured BP of the 2 men increased after stripping adventitia and decreased gradually after cauterization of the renal artery. This was presumably due to removal of renal artery sympathetic nerves, similar to the mechanism of catheter-based renal sympathetic denervation, although anesthesia, fluid infusion, and/or mesenteric traction may have had an influence. CONCLUSIONS A similar strategy involving thoracolumbar sympathectomy was reported about 50 years ago. The clinically significant blood pressure reduction in these patients suggests renal denervation is effective.

[Postoperative profound hypoglycemia after resection of adrenaline-predominant pheochromocytoma].

A 54-year-old woman was scheduled for resection of pheochromocytoma. Anesthesia was maintained with general anesthesia combined with thoracic epidural anesthesia. The blood glucose decreased to 30 mg x dl(-1) about four hours after the tumor resection, despite intravenous administration of glucose at a rate of 15 g x hr(-1) with intermittent boluses of 5 g of glucose. The blood glucose levels increased over 100 mg x dl(-1) with intravenous administration of 15 g x hr(-1) glucose, 6 hours after tumor resection.

Vecuronium in a patient with late cerebellar cortical atrophy.

Little information is available regarding the sensitivity to neuromuscular blocking drugs in patients with spinocerebellar degeneration and associated diseases. We report the response to vecuronium in a patient with late cerebellar cortical atrophy, a nonhereditary type of cerebellar ataxia. Onset time and time to 25% recovery of T1/T0 after vecuronium 0.1 mg.kg(-1) under sevoflurane anesthesia were 156 seconds and 43 minutes, respectively. Recovery index was 27 minutes. We believe this is the first report describing a response to neuromuscular blocking drugs in this disease.

[Lymphangioleiomyomatosis: a case report].

We report anesthetic management of a patient with lymphangioleiomyomatosis. A 41-year-old woman underwent lung biopsy under video-assisted thoracoscopic surgery to confirm the presence of lymphangioleiomyomatosis. She had hypoxemia due to obstructive lung disorder. Anesthesia was maintained with epidural block and general anesthesia with sevoflurane. During the operation, there were repeated episodes of hypoxemia, which required manual ventilation of the independent lung. After the operation, the tracheal tube was replaced with a laryngeal mask airway to minimize the risk of pneumothorax. There was no postoperative anesthesia-related complication.

[Anesthetic management of an infant with Cornelia de Lange syndrome].

We report anesthetic management of an infant with Cornelia de Lange syndrome. A 12-month-old girl with Cornelia de Lange syndrome was scheduled for ureterocystoneostomy because of vesicoureteral reflux. Preoperative physical examination suggested difficult tracheal intubation. After induction of anesthesia with sevoflurane (5%) in nitrous oxide (70%) and oxygen, a laryngeal mask airway (# 1.5) was inserted. A guide wire was inserted in the trachea through a laryngeal mask airway under direct vision of a fiberoptic bronchoscope. A tube-exchanger stylet was inserted around the guide wire after the laryngeal mask airway and fiberoptic bronchoscope had been removed. An endotracheal tube (ID 4.0 mm) was easily intubated around the tube-exchanger stylet. During the surgery, anesthesia was maintained with sevoflurane (2-3%) in nitrous oxide (50%) and oxygen. There was no perioperative pulmonary complication.

[A patient with Shy-Drager syndrome managed under general anesthesia with thoracic epidural anesthesia].

A 61-year-old man with Shy-Drager Syndrome underwent partial pulmonary lobectomy under general anesthesia combined with thoracic epidural anesthesia. The blood pressure decreased from 140/ 100 mmHg to 80/50 mmHg after thoracic epidural anesthesia. It increased after intravenous ephedrine. The blood pressure decreased when he was returned to the supine position postoperatively. It did not increase as expected with intravenous ephedrine. Intravenous etilefrine promptly raised the blood pressure. There was no postoperative cardiorespiratory complications.

[Anesthetic management for nephrectomy in a 2-year-old girl with abdominal aortic aneurysm].

We report anesthetic management for nephrectomy in an infant with aortic aneurysm. A 2-year-old girl with renovascular hypertension and abdominal aortic aneurysm, who had shown repeated episodes of heart failure, was scheduled for nephrectomy. Anesthesia was induced with sevoflurane in nitrous oxide (70%) and oxygen. During the surgery, anesthesia was maintained with sevoflurane (1.5%) in nitrous oxide (50%) and oxygen, supplemented with intermittent epidural block. The blood pressure did not show marked changes during the surgery. There was no perioperative cardiovascular complication.

[Emergency microlaryngosurgery for a huge post-intubation laryngeal granuloma].

A 55-year-old woman who had undergone esophagectomy 3 months earlier developed a huge post-intubation laryngeal granuloma. She was scheduled for emergency microlaryngosurgery. Anesthesia was induced with 8% sevoflurane in oxygen under spontaneous respiration. After confirming no airway compromise, the spontaneous respiration was obtunded by forced manual ventilation without using a muscle relaxant. The trachea was intubated easily with an endotracheal tube. Anesthesia was maintained with sevoflurane and nitrous oxide supplemented with intravenous fentanyl. The granuloma removed was 11 x 8 mm in diameter. There were no respiratory complications during and after anesthesia and surgery.

Optimum pain relief with continuous epidural infusion of local anesthetics shortens the duration of zoster-associated pain.

OBJECTIVE: To investigate effects of continuous epidural infusion (CEI) of 0.5% bupivacaine added to intermittent epidural boluses (IEB) on the duration of zoster-associated pain (ZAP), as compared with continuous infusion of normal saline placebo added to IEB. DESIGN: A prospective, double-blind, randomized, placebo-controlled study. SETTING: A university hospital and an affiliated clinic in Japan from 1996 through 1999. PATIENTS: 56 immunocompetent herpes zoster (HZ) patients, 50 years or older, within 10 days of rash onset and with severe pain and eruption. INTERVENTIONS: Patients were hospitalized and randomly allocated into 2 groups. CEI group given CEI of 0.5% bupivacaine (0.5-1.0 mL/h) plus IEB of 0.5% bupivacaine 4 times daily (n = 29). IEB group given normal saline infusion plus IEB of 0.5% bupivacaine 4 times daily (n = 27). All patients received oral acyclovir 800 mg, 5 times daily, for 7 days. OUTCOME MEASURES: The number of days required for complete cessation of ZAP and the proportion of subjects with allodynia beyond 30 days. RESULTS: The median time to cessation of ZAP was significantly shorter in the CEI group than in the IEB group (29 days vs. 40 days, P = 0.002). The number of patients whose allodynia persisted beyond 30 days of treatment was significantly lower in the CEI group than in the IEB group (10% vs. 37%, P = 0.027). CONCLUSIONS: CEI of 0.5% bupivacaine plus IEB was associated with a shorter duration of ZAP and fewer patients with allodynia beyond 30 days, compared with IEB plus normal saline infusion. Patients at high risk for developing postherpetic neuralgia (PHN) can be managed with intensive therapies at the early stage of disease, such as CEI, which maintains effective analgesia and may reduce the burden of PHN.