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Background: A Safe Wing Cath (SWC) is a novel intravenous catheter which has a unique needlestick injury safety mechanism., Methods: We investigated the success rate of intravenous catheterization using SWC by questionnaire. Anesthesiologists were recruited who had no previous experience of using SWC. Two or three consecutive trials were subjected for investigation., Results: During four months in 2012, 8 anesthesiologists were asked to do the job 23 times. The success rate was 62.5% at first use by each anesthesiologist 87.5% at second use, and 100% at third use., Conclusions: Experienced anesthesiologists can learn the technique of SWC on its second or third use.

We gave anesthesia for tracheal separation in a patient with Creutzfeldt-Jakob disease. The patient, a 33-year-old woman, was bedridden and unable to communicate, and was going to undergo a tracheal separation procedure for repeated bouts of aspiration pneumonia. After a tracheostomy with local anesthesia and sedation with propofol, general anesthesia was induced and maintained with propofol (1.5-3.0 microg x ml(-1), target controlled infusion) and remifentanil (0.05-0.15 microg x kg(-1) x min(-1)). We did not use an anesthetic apparatus from the standpoint of infection control, and provided manual ventilation with a disposable Jackson-Rees circuit. During the operation, an entropy monitor indicated alternating extremely low (0-10) and high (90-100) values without circulatory change, probably due to a previously existing electroencephalographic abnormality. The surgery was uneventful, and spontaneous breathing and eyelid opening occurred about 10 minutes after discontinuation of remifentanil and propofol. In such infected patients, abnormal prion proteins can exist outside of the central nervous system throughout the period of anesthetic management. Therefore, careful infection control must be undertaken, even if the surgical site is not directly related to the central nervous system.

Porphyria is a hereditary disorder due to reduction in enzyme activity of heme synthesis system, resulting in accumulation of heme precursors. Erythropoietic protoporphyria (EPP) is a type of porphyria. There are varieties of clinical expressions of EPP such as hepatic damage and photosensitivity, caused by the accumulation of protoporphyrin in the liver and the skin. Therefore it is important to prevent development of these clinical expressions. A 36-year-old woman with EPP was scheduled for a laparoscopic appendectomy. Anesthesia was induced with remifentanil, sevoflurane and rocuronium, and maintained with remifentanil, fentanyl and sevoflurane. She had performed normal daily activities without taking countermeasures against photosensitivity, so we did not change the light in the operating room, and allowed using endoscopy. The surgery was performed without any complications. No skin symptom was observed perioperatively. The level of aminotransferase was elevated temporally after the operation, while the level of protoporphyrin was unchanged. Therefore, we considered there was no manifestation of EPP perioperatively. In general, patients with EPP do not develop acute attacks induced by drugs like barbiturates. Since there was a case report of severe liver dysfunction of EPP, we did not use any contraindicated drugs in patients with acute intermittent porphyria in this patient. Considering a possibility of motor nerve damage in severe EPP, we carried out anesthetic management without epidural anesthesia.

Hunter syndrome, manifested by mucopolysaccharidosis II (MPS II), is a hereditary disorder caused by accumulation of glycosaminoglycans. An important issue in regard to anesthesia in affected individuals is airway management, because of gargoylism. An 8-year-old boy with MPS II was scheduled for adenotonsillectomy. We performed slow induction with sevoflurane, then utilized an Airway Scope (AWS; HOYA Corporation Tokyo, Japan), which enables operators to observe tube passage through the vocal cords with an LCD monitor, for tracheal intubation, because intubation guided by a fiberoptic bronchoscopy (FOB) was considered to be risky for glottic damage. Attempted tracheal intubations with the AWS alone and in combination with an FOB inserted through the tracheal tube failed, even though a clear image of the glottis was obtained. Finally, we inserted a stylet into the tracheal tube attached to the blade of the AWS and successful tracheal intubation was accomplished. The operation was completed uneventfully and the patient entered the ICU with his trachea intubated, because of pharyngeal and laryngeal edema. Although useful for difficult airway management, tracheal intubation with the AWS may be difficult when used in patients with a narrow oral cavity or small tracheal tube.

Background: Entropy, a newly available electroencephalographic monitor, demonstrates two parameters, response entropy (RE) and state entropy (SE). The aim of this study is to compare RE and SE with bispectral index (BIS) during anesthetic induction with propofol., Methods: Fifteen patients received target controlled infusion of propofol starting at 3 microg x ml(-1). We measured RE, SE and BIS and recorded effect-site concentrations of propofol at three sedation levels: VR1; conscious state before infusion of propofol, VR2; no response to verbal command, and VR3; no response to verbal command and shaking. Spearman rank correlations and prediction probability for sedation level were analyzed., Results: Effect-site concentrations of propofol at VR1, VR2, and VR3 were 0, 1.8 +/- 0.7, and 2.4 +/- 0.7, respectively. All three parameters showed significant correlations with sedation levels. Prediction probability values of SE, RE, and BIS were 0.905, 0.894, and 0.890, respectively., Conclusions: Response entropy and SE can provide similar information as BIS about the sedation level with propofol.

Background: Creatinine clearance (Ccr) is an efficient index of renal function. However, measurement of Ccr is not routinely performed for preoperative patients. To predict preoperative renal impairment, we estimated the preoperative Ccr by using serum creatinine (sCr) and other laboratory findings., Methods: 702 patients served as the training samples and other 128 patients as the validation samples. (1) Values of sCr and BUN to predict lower Ccr levels were developed from the training samples. In the combination of sCr and BUN, we selected the optimal combination in receiver operating characteristics curve. This value was applied to the validation samples. (2) The predictive equation was derived from the training samples by multiple regression analysis, and it was compared with the equations previously reported., Results: (1) The optimal sensitivity and specificity for predicting Ccr less than 30 ml x min(-1) x 1.48 m(-2) were 60% and 84%, respectively. (2) Among the equations to predict Ccr, our equation showed the highest correlation coefficient (r), and the smallest differences between predicted and measured Ccr., Conclusions: We determined the values of sCr and BUN to predict renal impairment and derived predictive equation. Our equation was the best to assess the preoperative renal function.

A 50-year-old woman underwent tonsillectomy under general anesthesia. She developed progressive hoarseness two month after the tonsillectomy, and a large granuloma of the larynx was found. Surgical removal of the granuloma was performed by laryngo-microsurgery. We should keep in mind that postintubation granuloma of the larynx might develop after tracheal intubation, and careful airway manipulation is needed to avoid this potential complication.

A 55-year-old woman with rheumatic arthritis was scheduled for total hip replacement. The procedure was performed under combined spinal and epidural anesthesia. Intraoperatively, the part of acetabular roof was cracked by reaming the region but she did not complain of any symptom. However, during pulse irrigation she complained of abdominal pain. After the operation, abdominal distension was noticed and retroperitoneal emphysema was disclosed. She was managed in a ward without problems postoperatively.

A 78-year-old man with thoracic aortic aneurysm was scheduled for endovascular stent-graft surgery without cardiopulmonary bypass. He had a history of myocardial infarction five months before and echocardiography revealed ejection fraction of 37%. Deployment of the stent-graft was performed during third degree atrioventricular (A-V) block of 32 seconds produced by adenosine 5'-triphosphate (ATP) 30 mg. There were no complications during this procedure. ATP is a convenient and suitable agent to produce transient A-V block for the precise deployment of the stent-graft in these patients with severe cardiopulmonary complications.

A 74-year-old man was scheduled for coronary artery bypass graft surgery with cardiopulmonary bypass. After intravenous heparin (200 U.kg-1), the activated clotting time (ACT) increased from 124 to 436 sec. However, it decreased to 128 sec immediately after cardiopulmonary bypass. The bypass was discontinued because the addition of heparin (200 U.kg-1) proved heparin resistance. The coronary artery bypass procedure was completed uneventfully without cardiopulmonary bypass. Several recent articles have reported that heparin resistance was corrected with antithrombin III concentrates, fresh frozen plasma, or argatroban. In this case, these drugs could not be used because the mechanism of heparin resistance remains uncertain. Thus, the off-pump technique is useful for unknown heparin resistance.

A 48-year-old man was scheduled for repair of mycotic abdominal aortic aneurysm. Extraanatomic bypass was performed due to infection of the aneurysm. General anesthesia combined with continuous epidural anesthesia was performed. In spite of severe blood loss, hemodynamic state was stable during anesthesia and postoperative period. He was managed in the intensive care unit without any complication. In this anesthetic management, it is very important to maintain adequate cardiac output and circulating blood volume to prevent visceral ischemia.

The purpose of the present investigation is to examine whether induced hypotension can improve the dryness of the surgical field in endoscopic sinus surgery (ESS). ASA physical status I and II adult patients with chronic sinutitis undergoing ESS were studied. All patients were not premedicated. Anesthesia was induced with propofol and maintained with sevoflurane and fentanyl. The patients were allocated randomly into two groups. In patients of Group C, mean arterial blood pressure (MAP) was maintained around 80 mmHg. In Group H, sodium nitroprusside was infused to maintain controlled hypotension with MAP around 60 mmHg. Blood loss, dryness of the surgical field, volume of fluid infusion and urine output, and surgical as well as anesthetic time were compared. Blood loss and dryness of the surgical field were significantly different between the groups. Volume of infused fluid, urine output, and surgical as well as anesthetic time were not significantly different. Induced hypotension with sodium nitroprusside improved surgical conditions and decreased blood loss in ESS.

A 28-year-old patient with ankylosing spondylitis and cervical myelitis was scheduled for caesarean section. We selected general anesthesia because of her cervical myelitis. Her trachea was intubated using a flexible fiberscope. The patient and the infant had no complications on their discharge.

A 73-year-old woman was scheduled for right lower lobectomy. Her trachea was intubated with a left double-lumen endobronchial tube (Sheribronch, 35 Fr). There was no bleeding at the trachea or the bronchus during the operation. She received intravenous heparin (4000 IU.day-1) for anticoagulant therapy one hour after operation. On the first post-operative day, the mucosal bleeding in the left main bronchus was confirmed, which developed a granulomatous polyp on the 17th post-operative day. The anticoagulant therapy may have worsened slight mucosal damage caused by double lumen tube. It is important to select suitable tube size especially in patients who will receive anticoagulant therapy.

A 28-year-old parturient with acute cortical blindness and eclampsia was scheduled for an emergency cesarean section. Computed tomography (CT) of the head revealed low-density areas suggesting cerebral edema in posterior regions. The operation was performed under general anesthesia with sevoflurane. The brain edema was managed by concentrated-glycerin and steroid. The operation was performed uneventfully. Her consciousness returned to normal by the following day and visual recovery was complete within 72 hr postpartum. The patient and the infant showed no complication on their discharge.

We compared finger and nose probes in measurement of cardiac output (CO), blood volume (BV) and mean transit time (MTT) with pulse dye-densitometry. These probes were intraoperatively applied to 6 patients under general and continuous epidural anesthesia. Indocyanine green (ICG) 20 mg, was given via peripheral venous route, and CO, BV and MTT were measured with DDG-2001 (NihonKoden, Japan). Eighteen measurements were done successfully. There was no significant difference between F-CO (CO with a finger probe, 4.48 +/- 1.40 l.min-1, mean +/- SD) and N-CO (CO with a nose probe, 4.14 +/- 1.87 l.min-1). F-MTT (32.9 +/- 11.1 sec) was significantly longer than N-MTT (19.9 +/- 6.4 sec, P < 0.01). The limits of agreement of F-CO and N-CO (mean difference +/- 2 SD) were -3.6 and +4.2 l.min-1, respectively. There was a significant negative correlation between differences in MTT and F-CO/N-CO (R2 = 0.448, P < 0.01). There was no significant difference between F-BV (3.97 +/- 1.23 l) and N-BV (3.97 +/- 0.98 l). The limits of agreement of F-BV and N-BV were -1.3 and +1.3 l, respectively. In conclusion, the measured values in BV showed good agreement and reliability with both finger and nose probes, while CO was less reliable when differences in MTT increased.

To evaluate the effect of obesity on spinal anesthesia for cesarean section, we retrospectively studied 90 parturients who had undergone cesarean section, dividing the patients into 2 groups: obesity group (body mass index > 30, n = 41); control group (body mass index < 30, n = 49). Total surgical time and anesthetic time were longer in the obesity group than in the control group. The amount of ephedrine administered was also greater in the obesity group than in the control group. However, there were no significant differences in time for spinal tap and the incidence of hypotension between the two groups. Spinal anesthesia for cesarean section in obese patients may be an acceptable method.

Thirty-one nurses in the surgical ward engaged in delivering postoperative analgesia using patient-controlled analgesia (PCA) were asked to complete questionnaires on postoperative analgesia and PCA. Ninety-seven per cent of respondents agreed that the postoperative analgesia is beneficial for postoperative recovery, and answered that the desirable goal in postoperative analgesia is "no pain at rest". Not only "pain at movement" or "pain on coughing", but also "decreased conscious level while analgesia is achieved" were selected as undesirable conditions during postoperative course. Although no one had learned the concept of PCA in their nursing schools, 94 per cent of respondents approved PCA as a method for postoperative analgesia. Seventy seven per cent responded that PCA is effective in the pain relief during position change, pulmonary physiotherapy and induced early ambulation. In addition, 65 per cent of respondents chose PCA as a method for postoperative analgesia when they receive thoraco-abdominal surgery. On the other hand, some problems on pain management using PCA, such as taking care of patients' ambulation with carrying a PCA pump, extra time for instruction of PCA and extra support for patients' psychological state were listed. In conclusion, these results suggest that PCA is accepted as an excellent method for postoperative analgesia among our nurses in the surgical ward, and education in postoperative pain management including PCA is required in nursing school as well as after graduation.

A 31-year-old man with pulmonary alveolar proteinosis underwent whole lung lavage using differential lung ventilation under general anesthesia with propofol and fentanyl. Left lung lavage was performed under the differential lung ventilation using extracorporeal lung assist. A month later, right lung lavage was performed under the differential lung ventilation alone. We compared left lung lavage with right one in the effects on heart rate variability and relationships between heart rate and arterial pressure. In the left lung lavage compared with the right one, arterial pressure was maintained higher; sympathetic nervous activity was kept tonic as shown in the power spectral analysis of heart rate variability; coherency showed lower; and a phase relationship analysis indicated a delay of almost 180 degrees. Therefore, we conclude that left lung lavage affected the cardiac autonomic nervous activity more than right one in differential lung ventilation.

The May-Hegglin anomaly is a rare hereditary disorder characterized by the presence of giant platelets and platelet deficiency. This report presents a successful management of a patient with May-Hegglin anomaly. A 5-year-old girl with May-Hegglin anomaly was scheduled for closure of fistulae of her ears. Although preoperative physical examination revealed platelet count of 8,000 mm-3, she had no bleeding tendency. No premedication was given. Anesthesia was induced with inhalational agents of a mixture of sevoflurane, nitrous oxide and oxygen. Neuromuscular blockade was achieved with vecuronium 0.1 mg.kg-1 and the trachea was gently intubated. Anesthesia was maintained with sevoflurane, nitrous oxide and oxygen. Five units of platelet were transfused during the operation. No bleeding tendency was observed perioperatively. It is important to plan the management of anesthesia for a patient with bleeding tendency.

We report a case in which spinal anesthesia induced a severe lightning limb pain. A 71-year-old man presented for prostate biopsy. Preanesthetic examinations revealed slight hypesthesia in the L 5-S 1 dermatomal segments in the right leg. The patient reported that he had received "local anesthetic" in the lumbar spine 16 years previously because of severe lumbago, and that his hyposthesia had originated from the "local anesthetic". Unfortunately we had no way to know the anesthetic technique performed 16 years ago. The spinal anesthesia was uneventfully introduced with a 25 G Quincke needle at the L 3-4 interspace using 2.0 ml 0.3% hyperbaric dibucaine in the left lateral positions. As soon as the patient was put into the supine position, he started to complain about severe lightning pain in the region of his hyposthesic segments. Severe lightning pain completely diminished 4 hours later when the effect of spinal anesthesia disappeared.

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.

We successfully anesthetized a 14-year-old boy with myotonic dystrophy for orthopedic surgery using sevoflurane. Sevoflurane enabled anesthetic induction and tracheal intubation without intravenous anesthetics and muscle relaxants. Sevoflurane also provided stable anesthetic maintenance without intravenous anesthetics. The patient showed rapid anesthetic recovery and adequate spontaneous breathing. We conclude that sevoflurane is a useful anesthetic for patients with myotonic dystrophy.

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.

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.

Gastroesophageal variceal hemorrhage is a rare complication during an operation. We present a case of gastric variceal re-rupture during an emergent operation for devascularization of the gastric veins. The patient was a 72-year old man with liver cirrhosis, who developed gastric variceal hemorrhage on the day of surgery. Sclerotherapy with an endoscope was performed, and the hemorrhage was controlled four hours before entering the operating theater. The induction of anesthesia and tracheal intubation were done with rapid sequence because the patient was regarded as full stomach. Induction was completed successfully. However, gastric varix ruptured immediately after the beginning of the surgery. The hemorrhage into the stomach amounted to 2,165 ml. The patient developed hypotension of 40 mmHg of systolic pressure for 15 minutes. With fluid resuscitation, continuous infusion of dopamine and ligation of varix, the patient recovered from this hypotensive event. No neurological deficit developed postoperatively. Portal hypertension results from increased resistance to portal venous blood flow or increased portal venous blood flow. Therefore, increased intravascular volume may play a significant role in precipitating variceal hemorrhage. In this case, abrupt circulatory change due to inadequate depth of anesthesia may partly cause massive hemorrhage. In conclusion, since potential adverse effects of increased blood volume and hepatic resistance on variceal hemorrhage must be considered during anesthesia, patients with episode of variceal hemorrhage should be treated as full stomach although endoscopic findings before the surgery indicate controlled hemorrhage from varix.

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.

To evaluate the effect of prostagrandin E1 (PGE1)-induced hypotension on cerebral blood flow (CBF) and carbon dioxide (CO2) reactivity of CBF, regional cerebral hemoglobin oxygen saturation (rSo2) was measured in non-neurosurgical patients (n = 10) under sevoflurane-anesthesia using near infrared spectroscopy. PGE1 was infused intravenously to maintain arterial pressure at a level of about 75% of the MAP (hypotensive group) under sevoflurane-anesthesia alone (normotensive group). Ventilation was controlled to adjust PaCO2 to hypocapnia (25-30 mmHg), normocapnia (35-40 mmHg) and hypercapnia (45-50 mmHg) in both normotensive and hypotensive groups. rSo2 during hypotension did not change by hypocapnia and normocapnia, but significantly increased by hypercapnia, compared with rSo2 during normotension. Significant correlations between rSo2 and PaCO2 during both normotensive and hypotensive groups were observed. Slope of the regression line of rSo2 and PaCO2 did not differ between the normotensive and hypotensive groups. When arterial oxygen content and cerebral metabolic rate of oxygen are constant, changes in rSo2 correlate with those of CBF. Therefore, CBF and CO2 reactivity of CBF that indicates autoregulation in response to changes in CO2 during hypotension were maintained as those during normotension. The results show that PGE2-induced hypotension maintains CBF and CO2 reactivity well in non-neurosurgical patients under sevoflurane anesthesia.

A new programmable syringe infusion pump, Auto Syringe Model AS 40 A, was evaluated for infusion of muscle relaxants, vasodilators and opioids in 4 surgical patients. Every drug mentioned above was easily adjusted according to surgical requirement in these patients. Auto Syringe Model AS40A is light and compact. Its major advantages lie in the mechanisms for delivery of a bolus dose and automated delivery of intermittent doses, automatic rate calculation, and the applicability to various sizes of syringes. Auto Syringe Model AS40A was found to be very useful for intravenous infusion of drugs.

We anesthetized a patient who received an emergency internal carotid artery ligation. Regional cerebral oxygen saturation (rSO2) was measured with near infrared spectroscopy (NIRS) during the whole anesthetic course. The sensor was placed on the left forehead of the patient. Decrease in blood pressure was reflected in the decrease in rSO2. The rSO2 was not altered by internal carotid ligation. However, cerebral infarction in the middle cerebral artery region, the onset of which remained unclear, was revealed postoperatively, regardless of a stable rSO2 during the operation. This monitor may provide useful information regarding the cerebral circulation during the operation in such a case as the present one, but this monitor reflects only the oxygenation of the region on which the sensor was placed. Thus, we should keep in mind the limitation in detecting cerebral dysfunction using NIRS.

A 38-year-old woman was admitted for intranasal ethmoidectomy. She had a history of serious anaphylactic reactions, including respiratory distress, hypotension and unconsciousness, to nonsteroidal anti-inflammatory drugs (Loxonin, Niflan) and antibiotics (Kefral, Minomycin). Preoperative intradermal skin tests against anesthesia-related drugs showed positive reactions to succinylcholine and vecuronium. After bilateral maxillary nerve block with 0.5 % bupivacaine (negative intradermal test) 3 ml, anesthesia was induced with diazepam, nitrous oxide, oxygen and sevoflurane. Trachea was intubated smoothly without muscle relaxants. Anesthesia was maintained with nitrous oxide, oxygen and sevoflurane 0.5-1 %. The anesthesia and postoperative course of this patient were uneventful. To confirm the initiation of allergic reaction to anesthetics used in the patient, serum histamine, tryptase, and complement 1, 3 and 4 factors were measured at 3 points: preoperatively, immediately after the induction, and after extubation. They showed normal levels. These results showed that no allergic reaction occurred perioperatively. In conclusion, the valuable information was provided for the choice of anesthetics by thorough evaluation of the past history and intradermal testing.

We described a case of anaphylaxis diagnosed by the evaluation of plasma mast cell tryptase and a case of anaphylactoid reaction. In a patient undergoing pulmonary lobectomy, anaphylaxis, showing the elevation of plasma tryptase, was provoked by physiological glue for hemostasis during the operation. During the operation, cardiovascular collapse occurred suddenly, at which time the cause was not diagnosed. After completion of the operation and removal of drapes, diffuse urticaria with wide erythema on the torso and the upper extremity was noticed. Suspecting allergic adverse reaction, plasma tryptase was measured 2h and 5h after the start of the episode, showing 34.6 ng.ml-1 at 2h and 15.3 at 5h. Because these elevations of plasma tryptase indicated degranulation of mast cells, evaluation of the causative drugs was performed 7 weeks after the episode. Physiological glue was confirmed to be causative drug. In another patient for total hysterectomy and bilateral oophorectomy, adverse reaction occurred after completion of the operation and extubation. Increase in plasma histamine concentration to 4.94 ng.ml-1 that could induce systemic reaction was noticed; however, concentrations of plasma tryptase 25 min, 3h and 7h after the episode were not elevated. This finding indicated that the adverse reaction was not based on degranulation of mast cell, and was anaphylactoid reaction provoked by nonspecific histamine-release. In conclusion, measurement of plasma tryptase is a useful method for differential diagnosis of anaphylaxis and anaphylactoid reaction.

This investigation was conducted to determine the analgesic efficacy of rectal diclofenac coupled with continuous epidural infusion with buprenorphine and bupivacaine for pain relief after upper and lower abdominal surgery. Forty patients in control group received epidural buprenorphine 0.1 mg in 8 ml of 0.25% bupivacaine immediately after surgery and subsequently infusion was started with the solution of epidural buprenorphine 15 micrograms in 1 ml of 0.23% bupivacaine at a rate of 1 ml.h-1 for 48 h. Forty patients in study group received rectal diclofenac 50 mg immediately after surgery in addition to the same epidural injection method described above. Adding rectal diclofenac to continuous epidural infusion of buprenorphine and bupivacaine produced enhanced analgesia and reduced pain scores measured by VAS after upper abdominal surgery. However, after lower abdominal surgery, such effects of rectal diclofenac obtained after upper abdominal surgery were not demonstrable.

The arterial oxygen saturation was continuously monitored in 50 patients under spinal anesthesia. Of the 50 patients, low oxygen saturation below 95% and/or its decrease of more than 5% was observed in 19 patients (38%). The remaining 31 patients (62%) showed a normal oxygen saturation. Pentazocine 0.5 mg.kg-1 i.v. correlated significantly with arterial oxygen desaturation (P = 0.0001). It is possible that laparotomy is associated with the desaturation (P = 0.0582). No correlation between desaturation and the other factors (level of analgesia, position during operation, and hydroxyzine premedication) was found.

We have studied the effect of horizontal lithotomy position on the spread of hyperbaric dibucaine spinal anesthesia. In three groups of 20 patients, 7.2 mg of hyperbaric dibucaine was injected intrathecally in the lateral decubitus position. In group supine, the patients were kept in supine horizontal position in which patient's legs and thighs were extended throughout the operation. In group lithotomy A, immediately after the spinal injection, the patients were placed into the lithotomy position. In group lithotomy B, after the spinal injection, the patients were placed immediately in the supine horizontal position for 15 min and then placed into the lithotomy position. There were no significant differences in height of sensory blockade among the three groups. The lithotomy position did not significantly affect the level of sensory blockade with hyperbaric dibucaine.

We examined the analgesic efficacy and side effects of continuous epidural infusion with buprenorphine in 340 surgical patients. The patients received epidural injection of 0.1 mg of buprenorphine in 8 ml of 0.25% bupivacaine immediately after surgery. The patients who underwent thoracotomy or intraabdominal surgery were subsequently infused with buprenorphine 15 micrograms in 1 ml of 0.25% buprenorphine at a rate of 1 ml.h-1 for 48 h. In the other kinds of surgery, patients were infused with buprenorphine 8 micrograms in 1 ml of 0.25% buprenorphine at a rate of 1 ml.h-1 for 48 h. The patients who did not need additional narcotics were 68% and 83% on the postoperative day 1 and 2, respectively. Visual analogue scale (VAS) was 22 +/- 2 mm at rest and 43 +/- 2 mm at movement on the postoperative day 1. Corresponding values on the postoperative day 2 were 16 +/- 2 mm and 37 +/- 2 mm, respectively. Nausea and vomiting were found in 12.4% of the patients.

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.

To evaluate postoperative analgesia and side effects of epidural buprenorphine, 60 patients after thoracotomy were divided into 6 groups. All patients received a bolus epidural administration of buprenorphine 0.1 mg in 8 ml of 0.25% bupivacaine. Following this epidural bolus, 10 patients in each group were given 0.25% bupivacaine alone (group A), buprenorphine 5 micrograms in 1 ml of 0.25% bupivacaine (group B), buprenorphine 8 micrograms in 1 ml of 0.25% bupivacaine (group C), buprenorphine 12 micrograms in 1 ml of 0.25% bupivacaine (group D), buprenorphine 15 micrograms in 1 ml of 0.25% bupivacaine (group E) or buprenorphine 18 micrograms in 1 ml of 0.25% bupivacaine (group F) with a portable disposable device at a rate of 1 ml.h-1 for 48 h. The percentages of patients who did not need additional narcotics for the first 24 hours postoperatively in group A, B, C, D, E, and F were 20%, 40%, 30%, 50%, 60%, and 70%, respectively. Those for the second 24 hours postoperatively in each group were 40%, 50%, 70%, 60%, 90%, and 90%, respectively. No significant difference in the incidence of side-effect was found among 6 groups. We concluded that optimal epidural doses of buprenorphine for post-thoracotomy pain relief are 15 and 18 micrograms.h-1 in the first and second 24 hours postoperatively, respectively.

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.

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.

We reported an episode of sudden bradycardia and hypotension during spinal anesthesia, in which the patient complained of nausea before the bradycardia and hypotension were recognized by the monitors, such as, intermittent measurement of arterial pressure, electrocardiography, pulse oxymetry and continuous arterial blood gas analysis. We emphasize the importance of strict vigilance during spinal anesthesia.

Severe bradycardia and hypotension developed suddenly in two patients undergoing hemorrhoidectomy under lumbar epidural anesthesia in the jackknife position, about 5 to 10 min after epidural administration of buprenorphine. Severe vago-vagal reflex was supposed to have been induced with buprenorphine in a situation where venous return was decreased by epidural anesthesia and the jackknife position.

The position of lumbar epidural catheters was confirmed by radiography in 71 patients. Catheters were advanced by 5 cm cephalad in the lumbar epidural space by paramedian approach (Group P: n = 28) or median one (Group M: n = 43) and contrast media was injected through the catheters. If the contrast media was present in the paravertebral regions, the catheter was considered to be in the abnormal position. The incidence of the abnormal position of the catheters was higher in group M than in group P significantly. To advance an epidural catheter longer into the lumbar epidural space, paramedian approach may be superior to median one.

The lateral and longitudinal spread of contrast media was investigated by lumbar epidurography with 8 ml of iohexol in 47 patients aged 25 yr to 86 yr. Iohexol was injected through the epidural catheter epidurally advanced by 5 cm cephalad from the L 1-4 interspace. A significant correlation was found between the longitudinal spread of iohexol and aging. No correlation was found between the leakage of iohexol from the intervertebral foramina and aging. This finding may deny the hypothesis that in elderly patients, the more extensive longitudinal spread of local anesthetics in the epidural space may be caused by its smaller leakage from the intervertebral foramina.

The effects of intravenous and intramuscular atropine on pulse rate have been studied in 40 patients undergoing gynecological surgery. Intramuscular atropine 0.5 mg was administered 30 min before induction of spinal anesthesia in 20 patients (i.m. group). Intravenous atropine 0.5 mg was administered immediately after induction of spinal anesthesia in 20 patients (i.v. group). Decrease in heart rate after spinal block was significantly less in i.v. group than in i.m. group. Although no one in i.v. group was given an additional atropine, 10% of the patients in i.m. group was given an additional atropine for bradycardia. Authors conclude that intravenous atropine has more significant effect on prevention of bradycardia during spinal anesthesia compared with intramuscular atropine.

A case of severe supine hypotensive syndrome in a parturient associated with breech presentation was presented. It is suggested that failure of left tilt to prevent the hypotension was associated with anatomical displacement of the uterus to the right. The importance of trying right tilt, if response to left tilt is poor, is emphasized.

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.

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.

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.

We examined the analgesic effects of indomethacin as an adjunct to postoperative epidural analgesia in 40 patients who underwent upper abdominal surgery. Twenty patients in control group were epidurally given 0.1 mg of buprenorphine in 8 ml of 0.25% bupivacaine immediately after surgery and subsequently infused 15 micrograms buprenorphine in 1 ml of 0.25% bupivacaine at a rate of 1 ml.h-1 for 48 h. The remaining 20 patients were rectally given 50 mg of indomethacin in addition to the same epidural method described above. The patients who did not need additional narcotics in the control and indomethacin groups were 45% and 80%, respectively (P < 0.05). In upper abdominal surgery, postoperative pain relief by epidural buprenorphine and bupivacaine plus rectal indomethacin was more effective than that by epidural buprenorphine and bupivacaine.