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A 69-year-old man with a past history of hypertension on angiotensin II receptor blocker (ARB) for three months presented for radical prostatectomy. Immediately after induction of anesthesia with fentanyl and propofol, mask ventilation became difficult, although no significant hemodynamic changes occurred. Fiberoptic examination revealed severe oropharyngeal edema, but, the trachea was successfully intubated. Afterward, the operation proceeded without complications. He stayed in the ICU for 4 days until the trachea was extubated successfully. He was diagnosed with DIAE because of his history of dyspnea with exclusion of other possible pathophysiological conditions.

Isolated unilateral absence of the right pulmonary artery without any intracardiac anomaly (APA) is a rare congenital cardiovascular disorder. We report a case of a 47-day-old female infant with right APA who underwent pulmonary angiogram under general anesthesia. Induction and maintenance of anesthesia consisted of total intravenous anesthesia with propofol, remifentanil and vecuronium. Hemodynamic status and oxygenation were stable throughout the examination. Mean pulmonary artery pressure was 22 mmHg. During bronchofiberscopic examination through an endotracheal tube, SpO2 rapidly decreased from 98% to 50% in 10 s despite sufficient preoxygenation with 100% oxygen. Our case suggests that a care must be taken for desaturation during procedures without ventilation in PAP patients.

Background: Dexmedetomidine (DEX), a highly selective alpha2-adrenergic receptor agonist, has sedative and analgesic properties with minimal respiratory depression. We retrospectively evaluated the hemodynamic effects of dexmedetomidine in pediatric patients following cardiac surgery., Methods: The subjects were twenty children aged 4 months to 15 years who had undergone cardiac surgery. After hemodynamics were stabilized in ICU, DEX was infused at a rate of 0.3-0.5 microg x kg(-1) min(-1), following initial loading (0.5 microg x kg(-1) over 10 min). Heart rate and blood pressure were analyzed just before starting infusion, following 1, 3, 6 hours during infusion, and at the end of the infusion., Results: There was no change in blood pressure during measurement. HR was slightly decreased during DEX infusion but not significantly. After discontinuation of DEX, HR was significantly increased from 109 +/- 17 to 124 +/- 19 beats x min(-1) (mean +/- SD) (P < 0.05). Two patients were excluded from the study, because clinically significant bradycardia developed during DEX infusion., Conclusions: DEX had little effect on blood pressure in patients after cardiac surgery. DEX, however, had a tendency to decrease HR. Therefore, it shoud be used with caution in patients with low heart rate.

We report a case of nesidioblastosis, which is characterized by hyperinsulinism due to a diffuse increase in the number of beta-cells in the pancreas and, consequently, severe hypoglycemia. The patient was a 79-day-old boy. He had been suffering from severe hypoglycemia despite aggressive treatment, including glucose loading and administration of glucocorticoid and diazoxide. Pancreatectomy was performed. Anesthesia was induced by thiamilal 25 mg and vecronium and was maintained by 1 to 2% sevoflurane in 65% nitrous oxide and fentanyl 5 micrograms. No hemodynamic instability was observed during anesthesia. Blood glucose level was maintained around 200 mg.dl-1 without any hyperglycemic event by continuous infusion of 20% glucose at the rate of 14.5 mg.kg-1.min-1, which was calculated from the daily glucose demand to prevent hypoglycemia preoperatively.

A 5-month-old boy was diagnosed as having complete atelectasis of the right lung due to RS virus infection at the age of 1 month. Conventional respiratory physical therapy, inhalation therapy and mechanical ventilation through an endotracheal tube failed to re-expand the right lung, while the left lung gradually became overinflated. We therefore tried differential lung ventilation by using a combination of a laryngeal mask airway and an extra long endotracheal tube (ID, 3.5 mm; length, 280 mm; Portex Pediatric Tracheal Tube, Extra length; SIMS Portex Co., Ltd. UK). Following induction of anesthesia, a laryngeal mask airway #2 was inserted. Then, an extra long endotracheal tube was inserted through the laryngeal mask airway and was guided to the right main bronchus with the aid of a fiberscope. The right lung was selectively lavaged and inflated with high pressure while ventilation was maintained through the laryngeal mask airway. The SpO2 value was maintained at more than 95% throughout the procedure despite some leakage from the ventilation system. The case demonstrates that differential lung ventilation by use of a combination of a laryngeal mask airway and extra long endotracheal tube is useful for the treatment of a pediatric patient with severe atelectasis.

In the period from April 1995 to March 2000, 11 parturient patients were diagnosed as having HELLP syndrome and underwent Caesarian section at our institution. All of the patients also had eclampsia or preeclampsia. Six of the operations were performed under general anesthesia and 5 were performed under regional anesthesia (one epidural and 4 spinal blocks). Subarachnoid anesthesia was well tolerated and clinically serious decreases in blood pressure with onset of block were not common. In the cases in which general anesthesia was used, control of blood pressure was difficult and the Apgar scores of the babies were low. No major complications occurred during the postoperative periods. Anesthetic management of a parturient patient with HELLP syndrome is modeled on the underlying preeclamptic condition. Determination of the appropriate anesthetic should be based on the patient's condition, condition of the fetus, and the urgency of the situation.

Electroconvulsive therapy (ECT) was scheduled for a 61-yr-old woman with major depression who had been taking a beta-blocker for hypertension. She underwent the first ECT under thiamylal anesthesia uneventfully. The second ECT was performed under propofol anesthesia on the next day. Immediately after ECT, the heart rate dropped from 56 to 19 beats.min-1, which was remedied by intravenous atropine. Then, the blood pressure increased to 204/108 mmHg but it was controlled by nicardipine. However, the SpO2 decreased to 84-88% under oxygen administration by mask at a rate of 3 l.min-1. The patient complained of chest discomfort and had a bloody secretion from the trachea. A chest X-ray showed a butterfly shadow. The patient was diagnosed as having neurogenic pulmonary edema and was treated in the ICU by artificial ventilation and administration of diuretics and catecholamines. These treatments proved to be successful, and the patient was discharged from the ICU 4 days later uneventfully. This case indicates that hemodynamics should be carefully monitored following ECT and that care should be taken to prevent the occurrence of complications after ECT.

We reported two patients who developed skin eruptions and severe hypotension immediately after scrubbing their wound in the leg using 4% chlorhexidine solution. Both patients were successfully treated by epinephrine administration. Patient-1 (a 42-year-old man) had his wound scrubbed using this antiseptic several times before the operation. He showed a positive skin scratch test for chlorhexidine. Patient-2 (a 74-year-old man) had no prior treatment with chlorhexidine. Positive lymphocyte transformation test was not demonstrated in these patients. It has been reported that more than 10% of patients with anaphylactic shock induced by chlorhexidine use had previous exposure to it and 80% of them had it used for mucosa or wound washing. From these results, we should keep it in mind that chlorhexidine is not likely to be a safe antiseptic and can possibly induce anaphylactic shock.

We investigated postoperative hypoxemia after spinal anesthesia in 24 adult patients by monitoring SPO2 with a pulse oximeter for 5 hours in the ward. The patients received spinal anesthesia with 0.5% hyperbaric tetracaine and sedated with midazolam during operation. Twelve patients inhaled 3 l.min-1 oxygen via a mask for initial 3 hours, and the other breathed room air all the time. In two of the patients breathing room air, SPO2 decreased to less than 94%. In patients inhaling oxygen, SPO2 was maintained above 98% but decreased significantly after stopping oxygen inhalation (below 94% in five patients). The postoperative SPO2 value correlated significantly with BMI (body mass index) and preanesthetic SPO2, but not with the dose of midazolam or supplemental pentazocine, and postoperative conscious states. In conclusion, there are some incidences of postoperative hypoxemia after spinal anesthesia irrespectively of the dose of midazolam used intraoperatively. Inhalation of 3 l.min-1 oxygen via a mask is sufficient to prevent such postoperative hypoxemia.

We studied severity and prognosis of congenital diaphragmatic hernia (CDH) by using preductal arterial blood gas analysis (BGA) and pulmonary function tests (PFTs) in 29 newborn infants. CDH was diagnosed within 24 hours of life, and surgical repair was performed through an abdominal approach after a period of stabilization. The infants were classified into the following three groups based on the highest preoperative alveolar-arterial oxygen tension difference (A - aDO2) and the lowest arterial carbon dioxide pressure (PaCO2) values; Group A (n = 15) : A - aDO2 < 500 mmHg, PaCO2 < 40 mmHg, Group B (n = 7) : A - aDO2 > or = 500 mmHg, PaCO2 < 40 mmHg, Group C (n = 7) : A - aDO2 > or = 500 mmHg, PaCO2 > or = 40 mmHg. Furthermore, the patients were classified into the following three groups based on the preoperative respiratory system compliance (Crs) and forced vital capacity (FVC) values; Group D (n = 8) : Crs < 0.5 ml.cmH2O-1.kg-1, FVC < 10 ml.kg-1, Group E (n = 4) : Crs < 0.5 ml.cmH2O-1.kg-1, FVC > or = 10 ml.kg-1, Group F (n = 17) : Crs > or = 0.5 ml.cmH2O-1.kg-1, FVC > or = 10 ml.kg-1. The mortality in the Group C was significantly higher than in the Group A and B, and the preoperative Crs and FVC values in the Group C were significantly lower than the other groups. The mortality in the Group D and E were significantly higher than the Group F. In conclusion, it is suggested that the preoperative Crs value less than 0.5 ml.cmH2O-1.kg-1 indicates severe pulmonary hypoplasia and is critical for survival.

We investigated postoperative hypoxemia by monitoring of SPO2 with a pulse oximeter for the first 5 hours in the ward. Forty-eight adults were divided into the general anesthesia along (G) group and the combination of epidural and general anesthesia (E) group. The patients were randomly administered either 3 l. min(-1) oxygen with face mask for the initial 3 hours or room air. Postoperative Spo2 values in the patients who breathed room air in both groups were less than 94% in 33% of G group and 50% of E group. 3 l. min(-1) oxygen inhalation through the face mask was enough to avoid postoperative hypoxemia in both groups; the mean values of Spo2 were 99% in G group and 97.9% in E group. Spo2 rapidly and significantly decreased after stopping the oxygen inhalation to under 94% in 25% of G group and 58% of E group. Significant correlations were found between Spo2 levels and both age (R = 0.75) and preanesthetic Spo2 (R = 0.66) in G group. Spo2 was significantly lower in the patients whose anesthesia was stopped after 5 p.m. than in those who were weaned before 5 p.m. In conclusion, there is a high incidence of postoperative hypoxemia for several hours in the ward, which can be relieved by 3 l. min(-1) oxygen inhalation with face mask.

We used acetated Ringer (AR) and lactated Ringer (LR) solutions as an intraoperative fluid during hepatectomy and evaluated their effects on intraoperative and postoperative hemodynamics, metabolism, blood gas and renal as well as liver functions. Twenty patients scheduled for hepatectomy were divided into two groups according to the type of infused solution, AR or LR. The infusion rate was 15 +/- 2 ml.kg-1.min-1 with the first 500 ml and thereafter reduced to 10 +/- 2 ml.kg-1.min-1. Intraoperative serum lactate levels increased significantly in both groups. However, the level of lactate in the LR group (48.6 +/- 16.4 mg.dl-1) was significantly higher than in the AR group (29.1 +/- 14.3 mg.dl-1) at the end of the operation. D-lactate level was significantly higher in the LR group than in the AR group during the operation. Although acetate level increased significantly during the operation in the AR group, it decreased to the normal range at the end of the operation. There were no significant differences in the other parameters between the two groups. These results suggest that AR may be more useful in hepatectomy than LR as an intraoperative fluid.

This study evaluated whether a combination of recombinant human erythropoietin (rHuEPO) and hemodilutional autologous transfusion could reduce homologous blood transfusion in 37 patients who underwent elective urological surgery. A single dose of 6000 IU rHuEPO was administered 2 weeks before operation to patients whose preoperative hemoglobin was less than 12.0 g.dl-1 (8.5-12.0 g.dl-1) (EPO group, n = 15) and compared these with control subjects whose preoperative hemoglobin was more than 12.0 g.dl-1 (non-EPO group, n = 22). Both hemoglobin and hematocrit levels after administration of rHuEPO in the EPO group increased significantly to the same levels as in those in the non-EPO group and remained at these levels. The mean volume of donated autologous blood was 980 g in the EPO group and 110 g in the non-EPO group. The mean surgical blood loss was 1330 g in the EPO group and 1120 g in the non-EPO group. No homologous blood transfusion was required in 80 percent of the cases in both groups: however, homologous transfusions were added to 3 cases in the EPO group and 4 cases in the non-EPO group whose surgical blood loss was over 2500 g. We conclude that the combination of preoperative rHuEPO treatment and hemodilutional autologous transfusion can reduce homologous transfusion during surgery in anemic patients.

We evaluated the effect of prostaglandin E1 (PGE1) on arterial ketone body ratio (AKBR) in patients undergoing hepatectomy. Sixteen patients were divided into two groups. In the PGE1 group (n = 8), 0.02-0.05 micrograms.kg-1.min-1 of PGE1 was administrated intravenously throughout the operation. In the control group (n = 8) patients were not given PGE1. AKBR decreased significantly during the operation; the decrease was in the same degree in both groups. Although AKBR rose in both groups after the operation, it returned more rapidly to the normal level in the PGE1 group compared with the control group. On the third postoperative day, the value of AKBR in the PGE1 group was significantly higher than that of the control group. These findings suggest that the intraoperative administration of PGE1 is valuable for protection against postoperative hepatic dysfunction induced by hepatectomy.

We compared intubating conditions under sevoflurane (group S) and halothane (group H) anesthesia in pediatric patients for otorhinolaryngological surgery. One hundred and six patients were divided randomly into group S (n = 60) and group H (n = 46). Anesthesia was induced with nitrous oxide-oxygen-sevoflurane (GOS, end-tidal sevoflurane concentration; 4.5%) or nitrous oxide-oxygen-halothane (GOF, end-tidal halothane concentration; 1.6%). Intubating conditions were assessed according to the intubation score, which consists of the following three factors; mouth opening, visibility of vocal cord and body movement. Each factor is divided into three grades (0, 1, 2); total scores of 0 correspond to excellent. In comparing the groups with respect to anesthetic induction, group S required 180 sec for disappearance of spontaneous breathing and 660 sec for completion of intubation, while, in group H, the above time intervals were 188 and 676 sec, respectively. We achieved significantly better intubating conditions in group H than group S. There were significantly more cases in group S than in group H in which vocal cord visibility was insufficient. Body movement during intubation was observed in 27% and 26% of patients in group S and H, respectively. In conclusion, halothane anesthesia provides better intubating conditions than sevoflurane anesthesia in slow induction for pediatric patients.

We successfully anesthetized a 53-year-old female with hypercitrullinemia and severe liver cirrhosis. The hypercitrullinemia was accompanied with chronic hepatic encephalopathy due to hyperammonemia, which resulted from decreased activity of one of the urea cycle enzymes, argininosuccinate synthetase (ASS). She was scheduled for replacement arthroplasty of a fractured femoral neck. She suffered a consciousness disturbance due to hyperammonemia, which was successfully treated by oral administration of sodium benzoate before surgery. Spinal anesthesia was chosen because it would have the minimum metabolic load on the cirrhotic liver. During the operation, prostaglandin was continuously infused to maintain hepatic blood flow. Acetated Ringer solution was infused instead of lactated Ringer solution to reduce metabolic load on the liver. She was given a small dose each of fentanyl and midazolam for relief of pain and sedation. After the operation, naloxone and flumazenil were administered to antagonize the fentanyl and midazolam, respectively. Although the serum ammonia level temporarily increased during a postoperative interruption of oral administration of sodium benzoate, the patient did not develop loss of consciousness, which is a key sign of hyperammonemia. Surgery and anesthesia were uneventfully completed.

To evaluate the anxiolysis property of midazolam, 60 patients undergoing minor gynecological surgery were given midazolam 0 mg (n = 20), 2.5 mg (n = 20) or 4 mg (n = 20) intramuscularly as premedication 1 h before their entrance to operating theater. The degree of anxiety was evaluated objectively using the State-Trait Anxiety Inventory (STAI). STAI test was performed twice: on the day before operation and 1 h after receiving preanesthetic premedication. In only midazolam 4 mg group, anxiety was reduced significantly in the operating room compared to the day before operation. It is concluded that midazolam (4 mg) is suitable to reduce the preoperative anxiety in patients who are to undergo minor gynecological surgery.

The safety and efficacy of epidural opioids as postoperative analgesics for children with cerebral palsy were studied in 85 pediatric patients with cerebral palsy. The patients were 5 to 15 years of age and were undergoing elective orthopedic operations on the lower extremities. These patients were divided into four groups. All the patients received inhalational anesthesia combined with caudal anesthesia, while the patients in groups 2, 3, and 4 were given epidural morphine (40 micrograms.kg-1), buprenorphine (3 micrograms.kg-1), or butorphanol (30 micrograms.kg-1) at the end of operation, respectively. Number of patients who received analgesics more than 2 times within 24 hours after operation was larger in group 1 than in groups 2-4. Although groups 2-4 compared with group 1 were still sedated at 24 hours after the operation, there was no difference in degree of sedation among the groups 2-4. The epidural opioids did not increase the frequency of side effects such as nausea, vomiting etc. The authors conclude that epidural opioids achieve safe and useful postoperative pain control in children with cerebral palsy.

Cardiac output (CO) measurement with transtracheal Doppler (TTD) was compared with that measured by transthoracic electrical bioimpedance (TEB) in normal children, and with that by thermodilution (TD) in children with heart disease. In CO measurement, TTD correlated significantly with TD (r = 0.65, P < 0.05), but not with TEB. Although aortic diameters, which were necessary for CO measurement with TTD, were far from the values in Woezik's nomogram of normal children, they correlated significantly with those measured from angiographies in children with heart disease (r = 0.92, P < 0.05). However, it is assumed that the significant correlation of diameters in children with heart disease might be produced by the offset of measurement errors in position and angle of the Doppler probe.

Facioscapulohumeral muscle dystrophy (FSHMD) is characterized by slowly progressive wasting of facial, pectoral and shoulder-girdle muscles that begins in adolescence. A 31 year-old man with FSHMD had dystrophic changes in the deltoid, anterior serratus and pectoralis major muscles but not in the distal muscle of his arms and legs. He underwent an operation for thoraco-scapula fixation under enflurane-nitrous oxide anesthesia with vecuronium 6 mg. At the end of the surgical procedure, the train-of-four (TOF) responses of a thumb and a toe, as measured by using an acceleration transducer, were recorded simultaneously. TOF stimulation in an arm demonstrated an apparent fade phenomenon (TOF; 0.54), while a TOF test in the leg showed complete recovery of the TOF ratio (TOF; 1.0). The patient revealed no clinical signs of residual neuromuscular blockade. It was clear that there was a difference in the degree of neuromuscular block between the arm and the leg in a FSHMD patient. Use of the peripheral nerve stimulator only in the arm may be an unreliable guide to assess neuromuscular block in FSHMD patients. Therefore, two sites should be chosen for monitoring neuromuscular blockade in a FSHMD patient.

Tracheal temperature was evaluated to monitor core temperature during cardiac, upper abdominal and lower abdominal operations. The tracheal temperature was measured by a thermistor attached to the intra-cuff of the tracheal tube. In cardiac surgery, there was a good correlation between tracheal temperature and forehead deep temperature (r = 0.93) before and after cardiopulmonary bypass, and also between tracheal temperature and the temperature of blood from the cardiopulmonary bypass (r = 1.00) during cardiopulmonary bypass. These results indicate that tracheal temperature accurately reflects carotid artery temperature. In upper abdominal operations, the tracheal temperature showed good correlations with forehead core, esophageal, bladder and rectal temperatures (r = 0.81-0.90). On the other hand, bladder and rectal temperatures were different from forehead deep (r = 0.43, 0.55) and tracheal temperatures in lower abdominal operations. These results suggest that the tracheal temperature is valuable to monitor core temperature.