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Background: In Japan, every year more than 9,000 patients with congenital heart disease reach adulthood due to improved medical treatments. Adult coarctation of aorta (CoA) patient is likely to need surgery for re- CoA, progressive CoA and/or aortic aneurysm. There- fore, it is necessary to consider anesthetic management of complicated aortic surgery of CoA patient Methods: This is a retrospective study of six pa- tients with CoA who underwent the CoA repair sur- gery in adulthood from 2005 to 2013., Results: Pre-operative CoA diameter was 7.8?2.5 mm and pressure gradient was 37±13 mmHg. Four patients had aortic aneurysm. Three patients received lateral thoracotomy and one-lung ventilation; five patients underwent selective cerebral perfusion. As perioperative complications, all two patients with re-CoA surgery had pneumothorax; two of five patients with arch repair surgery had recurrent nerve paralysis; a patient with left subclavian artery ischemia/reperfu- sion, and elevation and flexion of left upper extremity position had left upper extremity paralysis., Conclusions: In anesthetic management of adult CoA repair, it is important to understand various surgical approach and corresponding ventilation and extracorporeal circulation methods and possible complications.

A 3-month-old female infant was admitted because of tachypnea and retractive breathing. Chest X-ray and computed tomography demonstrated right pneumo- thorax and severe subglottic stenosis. She was sched- uled for chest drainage and diagnostic fiberoptic bron- choscopy (FOB), and securing airway by tracheal intubation or tracheostomy. Continuous infusion of dexmedetomidine(DEX, 1.25 iμ · kg(-1) · hr(-1))was started and it was increased to 3.75,μg · kg(-1) · hr(-1) ten min- utes later. Chest drainage was performed with regional anesthesia under deep sedation and she responded only to painful stimulus. After the completion of the chest drainage, chest X-ray revealed the expansion of her right lung. Then, FOB was performed under regional anesthesia with DEX sedation. Moderate sub- glottic stenosis under spontaneous breathing, and the disappearance of the stenosis under positive pressure ventilation was observed by FOB. FOB findings sug- gested that she had acquired tracheomalacia due to external compression by cervical cystic lymphangioma. Therefore, to avoid deterioration of her tracheomalacia, we did not perform tracheal intubation or tracheos- tomy, which could provoke tracheal edema, deforma- tion and subsequent further deterioration of airway stenosis. Although the dose of DEX was higher than the rec- ommended dose, high dose DEX led to adequate seda- tion and analgesia for pediatric FOB without respira- tory distress or hemodynamic instability. We believe that DEX is useful for an infant with difficult airway requiring preservation of airway smooth muscle tone and spontaneous breathing.

We report a case of subarachnoid hemorrhage due to rupture of a cerebral aneurysm in a 29-year-old woman in the 34th week of pregnancy. The aneurysm at the anterior communicating artery was up to 10 mm in diameter on magnetic resonance imaging and scheduled for emergent coil embolization. Simultaneously, obstetricians determined that cesarean section should be performed. Maintaining anesthesia by propofol and remifentanil, coil embolization was first performed to avoid aneurism re-rupture, and the patient was then transferred from an angiography room to an operating room where a cesarean section was performed. After delivery, fentanyl 600 μg was intravenously administered, and the patient was extubated immediately after the operation without any complaints. The neonate (weighing 1,882 g, Apgar score 4 at 1 min and 5 at 5 min) also recovered with no complications after 24 hr artificial ventilation. In conclusion, intravenous anesthesia mainly with remifentanil is adequate for a pregnant patient receiving cesarean section preceded by neurosurgery.

We report a case of an oral penetrating injury caused by a toothbrush in a 4-year-old 17-kg boy. The toothbrush was lodged in the right cervical region through the oral cavity, and emergency surgery for removal was planned under general anesthesia. Although mask ventilation was not possible because of the protruding toothbrush handle, awake nasotracheal intubation was successfully performed with a fiber-scope and intravenous fentanyl 25 μg. We conclude that appropriate analgesics could facilitate awake intubation in pediatric patients.

Ultrasound-guided neuraxial block has provided safe and accurate analgesia. Although the classic anatomical landmark technique is still standard for completing epidural or subarachnoid puncture, it is difficult to identify the anatomical structure in some cases such as pregnant women, obese patients and patients with spinal deformity. Preparatory ultrasound scanning enables to identify the midline and determine the point of insertion, which reduces the number of puncture attempts and failure rate of procedure. Moreover, there are reports about the efficacy of ultrasound guidance in children. Usually, neuraxial block for children is performed under general anesthesia which has some risk for nerve injury and inadequate catheterization. Visualization of epidural and subarachnoid space facilitates an appropriate insertion. Additionally, the utility of ultrasound-guided lumbar puncture has also been reported in emergency department. Cerebrospinal puncture is an important procedure for diagnosis of some critical conditions such as subarachnoid hemorrhage and central nervous system infections. Ultrasound imaging contributes to smooth procedure and fewer complications. This review summarizes the basic ultrasound-guided technique for expected difficult neuraxial block patients, presenting recent findings.

We report three cases (73-year-old, 69-year-old and 76-year-old men) of bronchospasm induced by adenosine triphosphate (ATP) during thoracic endovascular aortic repair (TEVAR). Severe broncospasm occurred soon after administration of ATP to obtain transient asystole during TEVAR. All three cases were complicated with asthma or chronic obstructive pulmonary disease (COPD) before TEVAR, and airway hyper-reactivity was suspected. One case (73-year-old) required postoperative intensive care to treat bronchospasm, and the other two cases recovered during the operation. The possible mechanism of adenosine-induced bronchoconstriction is selective interaction with active mast cells with subsequent release of preformed and newly formed mediators. Careful attention should be paid when ATP is injected during TEVAR in patients with asthma or COPD.

We reviewed the indications for and features of preoperative epidural catheterization under radiographic monitoring. This technique allows easy epidural catheterization and achieves reliable effects for postoperative analgesia, reducing the burden on patients, particularly those with morbid obesity, strong transformation of spine or unilateral operations such as total knee arthroplasty or pneumectomy. Standard methods are as follows: (1) the patient is placed in a prone position on the fluoroscopic table; and (2) the operator usually stands to the left of the patient. First, a 23 G, long needle is introduced for local anesthesia and to confirm depth and angle from the skin to the basal part of the spinous process. An 18 G Tuohy needle is advanced to the epidural space under real-time radiographic monitoring. It is important that the operator advances the catheter to the epidural space on the operative side (right, left or middle). Finally, confirmation is made under radiographic imaging that the catheter remains at the back of the epidural space. Preoperative epidural catheterization under radiographic monitoring is a safe, reliable, and educational method.

Background: Mid-axillary transversus abdominis plane block (TAP-B) and subcostal TAP-B have become well-known blocks to provide considerable analgesia for abdominal surgery. However, proper approach and adequate volume of injectate have not still been clarified. In this study, a combination of mid-axillary TAP-B and subcostal TAP-B was performed in cadavers to establish the spread of injectate and segmental nerve involvement., Methods: Ultrasound-guided dye injections (10 ml each) into the TAP were performed with mid-axillary and subcostal approaches. Injections were performed for hemiabdominal walls of 4 Thiel's embalmed human cadavers. Dye spread and nerve involvement were evaluated by dissection 10 min after the injections., Results: All 7 hemiabdominal walls were successfully injected and dissected after 1 pilot study. Thoracic nerves (T7-12) and the first lumbar nerve (L1) were found. Segmental nerves T7 (14%), T8-11 (100%), T12 (71%), and L1 (43%)were involved., Conclusions: This study demonstrated that the combination of ultrasound-guided mid-axillary TAP-B and subcostal TAP-B involve T8-L1 nerves. This technique can be used not only in lower abdominal surgery but also in upper abdominal surgery.

Spinal progressive muscular atrophy (SPMA) is a rare lower motor neuron disease in which anesthetic management is often difficult as a result of muscle weakness and hypersensitivity to neuromuscular blocking agents. A 43-year-old female patient with SPMA was scheduled to undergo laparotomy for ovarian teratoma. Her vital capacity was only 530 ml and % volume capacity was 22.2%, indicating a severe restrictive pulmonary disfunction. We selected general and epidural anesthesia for the surgery. Anesthesia was induced by propofol and the trachea was intubated with additional topical anesthesia. Spontaneous ventilation was kept during anesthesia without neuromuscular blocking agents, and systemic and epidural opioids were avoided to evade their respiratory depression. Because of severe spine scoliosis syndrome, we inserted an epidural catheter into the epidural space under radiographic monitoring for safety and precision. Postoperative pain control was stable using continuous epidural infusion of 0.2% ropivacaine without neurological adverse effects. One day after surgery, the trachea was extubated and respiratory function did not aggravate. Despite the controversy surrounding the use of neuraxial blocks in motor neuron diseases, in this case, epidural anesthesia was useful to keep the respiratory function stable.

Background: The radial artery cannulation is often associated with damped arterial waveforms with the hand moving. We used cannulation of the dorsal branch of the radial artery (DRA) and compared the stability of measurement, safety and complications with those of the radial artery(RA)., Methods: The study was a prospective single-blinded comparative study. Seventy-six patients undergoing general anesthesia requiring arterial cannulation were included. Patients were divided randomly into two separate groups of 35 patients each according to cannulation site: the radial artery (RA group) or the dorsal branch of the radial artery (DRA group). After induction of general anesthesia, cannulation was performed. Three hours after the successful cannulation, the changes of waveforms were noted with the hand moving. We examined whether there were any complications around the cannulation site after cannula removal., Results: With the wrist flexion at all angles (30, 60 and 90 degrees), the frequency of worsening of arterial waveforms was significantly higher in RA group compared with DRA group. Some difficulties in catheter placement were observed in DRA group. No concomitant complication was noticed., Conclusions: Arterial line monitoring from DRA had better waveforms compared with RA monitoring without any complications.

Background: We investigated the efficacy of glucose infusion for the inhibition of breakdown of fat tissue and muscle protein under remifentanil anesthesia., Methods: Twenty adult patients (ASA I or II) were enrolled in this study and randomized into two groups: a control group receiving acetated Ringer's solution without glucose (n = 10) and a glucose group receiving acetated Ringer's solution containing 1% glucose (n = 10). Anesthesia was induced by propofol and fentanyl and maintained by sevoflurane and remifentanil. Plasma concentrations of glucose and cortisol were measured. Acetoacetic acid and 3-hydroxybutyrate acid were measured as parameters for breakdown of fat tissue. Urine 3-methylhistidine/plasma creatinine was measured as a parameter for breakdown of muscle protein during surgery. Data were analyzed by the unpaired t-test, Friedman's chi2-test, Wilcoxon's t-test and Mann-Whitney U test. P < 0.05 was considered significant., Results: Plasma concentrations of cortisol and glucose were not increased in either group during the study. Plasma concentrations of acetoacetic acid and 3-hydroxybutyrate acid and urine 3-methylhistidine/plasma creatinine significantly increased in the control group but did not increase in the glucose group., Conclusions: Infusion of glucose suppresses breakdown of fat tissue and muscle protein under remifentanil anesthesia.

Although epidural blood patch (EBP) is an effective treatment for postdural puncture headache (PDPH), the adequate blood volume has not been determined. We reported two cases of EBP for PDPH after caesarean section with spinal anesthesia using ultrasound imaging with a 2-5 MHz convex probe. In case 1, the dura mater was expanded and subarachnoid space was compressed by 8 ml of autologous blood with paresthesia at bilateral L5 area during EBP and blood infusion was finished at 10 ml. In case 2, although the area of the epidural space was unchanged by 17 ml of EBP, contrast of the epidural space was altered in as a mosaic pattern. We conclude that ultrasound imaging is useful to confirm the adequate blood infusion during EBP Therefore, there is a possibility of estimating the optimal blood volume by ultrasound imaging.

Background: Optimal dose of local anesthetics for supraclavicular brachial plexus block (BPB) is still unknown. We prospectively investigated the analgesic effect of ultrasound-guided continuous supraclavicular BPB with ropivacaine at different infusion rates., Methods: Thirty-nine patients scheduled to undergo shoulder surgery were randomly assigned to four groups; receiving no continuous BPB (control group, n = 10), BPB with 0.2% of ropivacaine at an infusion rate of 4 ml x hr(-1) (n = 12), BPB with 6 ml x hr(-1) (n = 12) or BPB with 8 ml x hr(-1) (n = 5). All patients were permitted to receive nonsteroidal anti-inflammatory drugs (NSAIDs) after surgery. Visual analogue scale (VAS) for postoperative pain was assessed and frequencies of the requirement of NSAIDs were recorded in each group., Results: The pain scores during 24 hours after surgery in the 6 ml x hr(-1) group (3-24 mm) were significantly lower than those in the 4 ml x hr(-1) group (4-42 mm) and control group (6-56 mm). Mean frequency of administrations of NSAIDs for 24 hours after surgery in the 6 ml x hr(-1) (0.8 +/- 0.8) group was significantly lower than that in the control group (1.7 +/- 1.0). Continuous administration in two cases in the 8 ml x hr(-1) group was discontinued due to leakage of local anesthetics and headache., Conclusions: Continuous supraclavicular BPB with 0.2% ropivacaine at 6 ml x hr(-1) is effective for the pain management after shoulder surgery and is not an excess dose.

Background: We investigated the onset time of obturator nerve block and time required for the nerve block comparing two groups in a prospective randomized study., Methods: Obturator nerve block was performed in 37 cases by either nerve stimulation guide (NS group) or nerve stimulation and ultrasound guide (US group) with 10 ml of 1.5% lidocaine adding 1:200000 epinephrine., Results: There was no significant difference between the onset time in the NS group (6.1 min) and that in the US group (5.7 min). The time required for the nerve block (4.2 min vs 1.7 min) was significantly shorter, and the frequency of needle advancement for the optimal position (4.7 vs 1.7) was significantly smaller in the US group than in the NS group (P<0.05)., Conclusions: Ultrasound imaging facilitated the identification of obturator nerves between adductor muscles. Ultrasound-guided obturator nerve block is a safe, quick and useful technique.

We reviewed the technique and anatomy for the ultrasound-guided obturator nerve block, especially interadductor approach. Although it is sometimes difficult to observe obturator nerve in the ultrasound image, obturator nerve block is completed observing three muscle layers, adductor longus muscle, adductor blevis muscle and adductor magnus muscle, in the ultrasound image. Local anesthetics are injected between the muscle layers confirming the needle tip and spread of the solution. This technique will reduce incomplete effect or side effects of the obturator nerve block.

Background: We compared the effects on intraoperative acid-base balance of bicarbonated Ringer (BR) and those of acetated Ringer (AR) solutions as an intraoperative fluid during long-term laparotomy., Methods: Forty patients scheduled for laparotomy expected to take more than 5 hours were divided into two groups according to the type of infused solution, BR or AR. Each solution was intravenously administered at a rate between 8 and 10 ml x kg(-1) x hr(-1). Arterial blood gases were analyzed before and during surgery., Results: Intraoperative arterial blood HCO3- and base excess (BE) significantly decreased in the AR group but not in the BR group. HCO3- and BE 2 and 4 hrs after the start of surgery and at the end of surgery were significantly higher in the BR group than in the AR group., Conclusions: These results suggest that BR has superior effects on the acid-base balance during long-term laparotomy.

Background: Combined administration of local anesthetics and an opioid is frequently used in order to minimize the dose of each drug and to reduce adverse effects. Although fentanyl is commonly administered with local anesthetic, side effects of fentanyl increase in a dose-dependent manner. In this study, we determined the optimal dose of epidural fentanyl after gynecological surgery., Methods: One hundred and sixteen adult patients scheduled for elective gynecological surgery were divided into 3 groups according to postoperative epidural analgesics; 0.2% ropivacaine (group R), 0.2% ropivacaine with 2 microg x ml(-1) fentanyl (group RF 2), or 0.2% ropivacaine with 5 microg x ml(-1) fentanyl (group RF 5). Each analgesic was infused at 5 ml x hr(-1) for 48 hr. Pain scores , incidence of NSAIDs administration and side effects were recorded for 48 hr after the surgery., Results and Conclusions: Ropivacaine alone could not provide sufficient analgesia. Although the addition of 5 microg x ml(-1) fentanyl to 0.2% ropivacaine at a rate of 5 ml x hr(-1) improved postoperative pain, side effects caused by fentanyl increased. Supplementing 2 microg x ml(-1) fentanyl provided sufficient analgesia with the least incidence of side effects.

A 59-year-old man without a history of ischemic heart disease underwent elective laparoscopic cholecystectomy under general anesthesia with epidural anesthesia. About 15 min after pneumoperitoneum had been achieved, the patient developed ST elevation and hypotension. Vagal stimulation resulting from stretching peritoneum, the procedure and epidural anesthesia are thought to have induced vasospasm. The ST segment became normal after interruption of CO2 insufflation. A postoperative coronary artery angiogram showed normal coronary arteries, but diffuse coronary artery spasm was seen after intracoronary injection of acetylcholine. The patient was discharged on nitrates. Patients with gall bladder stones sometimes have coronary risk factors of obesity, hyperlipidemia and hyperglycemia. Careful attention should also be given to patients who do not have a history of coronary disease.

Background: Although patient-controlled epidural analgesia (PCEA) is widely known to provide good pain control after abdominal surgery, it has not been popular in Japan. We evaluated the effects of PCEA with background infusion after major abdominal surgery., Methods: Ninety patients scheduled for abdominal surgery were randomly allocated to two groups by treatment with postoperative epidural analgesia: infuser group (n = 48); continuous infusion 5 ml.hr-1 or PCEA group (n = 42); background infusion 5 ml.hr-1, PCEA 3 ml and lock out 30 min. Microject (Sorenson Medical Co, U.S.A.) was used for PCEA machine. 0.2% ropivacaine 100 ml with fentanyl 500 micrograms was administered into the epidural space in both groups., Results: Postoperative visual analogue scale (VAS) at rest and coughing were about 10 mm and 40 mm in both group, respectively, and there were no significant differences between the groups. NSAIDs were effective for rescue analgesia in infuser group to improve postoperative pain as PCEA. Vomiting and sedation were more frequent in infuser group than in PCEA group. Empty battery and machine troubles of unknown origin were observed in 2 and 4 patients, respectively in PCEA group., Conclusions: PCEA with background infusion could improve the management of postoperative pain, and adequate program of PCEA is important to reduce postoperative pain and its side effects.

An 80-year-old female with aortic regurgitation and angina was scheduled for aortic valve replacement and coronary artery bypass graft. After the induction of anesthesia, central venous catheter and pulmonary artery (PA) catheter were placed into the right internal jugular vein. At the weaning from cardiopulmonary bypass, we noticed pulmonary artery pressure (PAP) on the monitor indicating the PA catheter tip being wedged. Therefore, we pulled the PA catheter until the wedging PAP wave disappeared. However, immediately after repositioning of the PA catheter, massive fresh bleeding was found in the endotracheal tube. We estimated the cause of pulmonary bleeding was PA rupture due to malpositioned PA catheter because surgeons had not manipulated the PA during the operation. Soon after restarting the cardiopulmonary bypass, pulmonary bleeding was stopped. Examination with fiberoptic bronchoscope revealed no further bleeding and weaning from cardiopulmonary bypass was accomplished smoothly. Postoperative course was uneventful.

This review article focuses on the suppression of sensory transmission by inhalational anesthetics at the spinal cord level. Volatile anesthetics (e.g. halothane and isoflurane) suppress neuronal responses evoked by both noxious and non-noxious stimuli. This suppression is mediated largely by activation of GABAA and glycine receptors systems in the spinal dorsal horn. Depression of spinal glutamate receptor systems is also probably involved. The analgesic action of nitrous oxide is produced by activation of supra-spinal descending inhibitory systems, not by direct action on the spinal cord. Activation of the descending inhibitory systems by nitrous oxide causes release of noradrenaline in the spinal dorsal horn, and activates alpha 2 adrenergic receptor systems, resulting in depression of neuronal responses evoked by noxious stimuli. GABAA and glycine receptor systems in the spinal dorsal horn are also important components of nitrous oxide anesthesia in depressing neuronal responses evoked by non-noxious stimuli. Although excitation or inhibition of GABAA, glycine, alpha 2 adrenergic and glutamate receptors systems is an important action of inhalational anesthetics, influence of inhalational anesthetics on interactions among these receptor systems has yet to be studied.

Unlabelled: We report here an efficient means of epidural catheter placement through atlanto-occipital membrane in rats., Methods: Male SD rats (n = 84) were divided into lumbar (n = 48) and cervical (n = 36) groups. Under sterile technique, PVC V-1 tubing was inserted and advanced caudally targeted to the C 4 or L 4 level. Analgesic efficacy and duration were measured by injecting increments of 2% lidocaine until a maximum paw withdrawal latency time from a radiant heat thermal stimulator. Rats (n = 6 each day) were sacrificed and an autopsy was performed to observe both the laterality of the catheter tip and the proliferation of fibrous tissue around the catheter., Results: The volume of lidocaine and its duration was 52 +/- 17 microliters and 27 +/- 13 min (mean +/- SD) in lumbar, 30 +/- 10 microliters and 26 +/- 9 min in cervical group. In lumbar group, two catheters penetrated the dura. The remaining catheters were confirmed to be in the epidural space within L 4 +/- 1 or C 4 +/- 2 segment. Lumbar catheter tips were almost equally distributed between the center, left and right, while cervical catheter tips were distributed between left and center portion of the epidural space. The severity of tissue proliferation was time dependent. The proliferation of fibrotic tissue seemed more rapid in cervical than lumbar group., Conclusion: Although this approach for epidural catheter placement is efficient and produces excellent drug effects on day 3 after implantation, as reported by others, rapid development of fibrous tissue around the catheter quickly limits the usefulness of the epidural catheter.

The hemodynamic response to the insertion of the laryngeal mask airway (LM) following induction with propofol 2 mg.kg-1 was assessed and compared in normotensive (Normal), hypertensive (HT) and chronic renal failure (CRF) patients (n = 23 in each group). Before induction, in HT and CRF groups blood pressure and rate pressure products (RPP) were higher than in Normal group (P < 0.05). Although blood pressure and RPP were decreased in every patient by induction with propofol, no patients needed vasopressor drugs. The decreases of blood pressure and RPP were larger in HT and CRF groups than in Normal group (P < 0.05). There were no differences between groups in heart rate and rate of successful LM insertion. We concluded that LM insertion with propofol 2 mg.kg-1 was an effective induction method preventing the adverse circulatory responses in normotensive, hypertensive and chronic renal failure patients.

The changes in body temperature induced by rapid intravenous infusion of lactated Ringer solution and the effect of a fluid warmer system (HOT LINE, Level 1 Technologies, Inc., Rockland, MD) were investigated in 35 patients undergoing cardiovascular surgery. The patients were divided into 5 groups by categories of the fluid temperature (-19 or -38 degrees C), infusion route (radial or right subclavian vein), and infusion rate of lactated Ringer solution (1000 or 250 ml for 30 min). Pulmonary arterial, esophageal, bladder, and forehead deep temperatures, which reflect core temperature, were significantly decreased by the rapid infusion of unwarmed solution (0.8-1.0 degree C, P < 0.05). In contrast, these temperatures were maintained in the warmed solution groups as well as in the group of slow infusion rate. With regard to the infusion route, there was no significant difference in the temperature between the radial vein and subclavian vein groups. Plantar deep temperature showed no significant change during this study. In conclusion, infusion of warmed solution using HOT LINE could prevent hypothermia induced by rapid intravenous infusion, and this effect is not greatly influenced by route of venous infusion.

A 42-year-old man was admitted to our hospital with subarachnoid hemorrhage, requiring the clipping of an intracranial aneurysm and removal of intracranial hematoma. Anesthesia was induced with thiamylal and maintained with oxygen-nitrous oxide-isoflurane. Trimethaphan was administered continuously and his systolic blood pressure was stably maintained between 100-110 mmHg. Seven minutes after insertion of an intraventricular drainage tube through the dura, his blood pressure increased to 146/76 mmHg. By transdural echogram, re-rupture of the aneurysm was confirmed, and after 6 minutes, a fresh intracranial hematoma was observed. The decrease of intracranial pressure following insertion of the intraventricular drainage tube or the stimulation by several intraventricular punctures seems to have caused re-rupture of the aneurysm. When hemodynamic change is observed without obvious cause in a patient with subarachnoid hemorrhage, it is important to speculate that a re-rupture of the aneurysm has occurred, and to treat the problem accordingly.

We have studied the effects of calcium-channel blocker, verapamil, on procaine-induced local sensory block. Standardized tail-flick (TF) test was used to investigate the duration and intensity of procaine-induced local conduction block in rats. After obtaining baseline TF latencies (mean; 3.3 sec), two 100 microliters of 0.4% procaine alone, a combination of 0.4% procaine and verapamil (100 micrograms, or 200 micrograms), or a large dose of verapamil (200 micrograms) were injected to the opposite sites of the tail base and TF test was performed every five minutes for 45 minutes. A large dose of verapamil showed no prolongation of TF latencies. The administration of 0.4% procaine alone produced a significant increase of TF latencies and the peak effect of % MPE (percent maximum possible effect) was demonstrated at 4 minutes after the drug injection (mean % MPE; 37.0%). Coadministration of 0.4% procaine and two doses of verapamil produced significant increases of % MPE in a dose-dependent fashion. It was concluded that sensory block by procaine of the peripheral nerves is potentiated by coadministration of calcium-channel blocker, verapamil.

A 63-year old man was scheduled for nephrectomy and cholecystectomy. Anesthesia was maintained by oxygen-nitrous oxide-isoflurane (0.5 approximately 1%) and epidural anesthesia. Operation was performed with the patient on left decubitus position. At this time, rectal temperature as his core temperature was 35.8 degrees C. Active warming with electrical warming mattress was started and the room temperature was maintained at 25 degrees C during the operation. Thirty minutes after the abdominal incision, rectal temperature decreased to 34.5 degrees C. Active warming was started with forced-air warming system (Warm Touch, Mallinckrodt Medical Co.) on his upper body. Ten minutes after warming, his body temperatures were restored gradually. Three hours after using Warm Touch, rectal temperature recovered to 36.1 degrees C. The intraoperative course was uneventful. At the end of the operation, the patient showed no shivering and general condition was good. In this case, Warm Touch is useful to restore body temperature against intraoperative hypothermia during abdominal surgery.

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.

During cardiac surgery, esophageal, rectal, or bladder temperature is usually monitored as an index of core temperature; however, these methods are invasive, and often inconsistently reflect the central body temperature, especially in pediatric patients. The purpose of this study was to evaluate the utility of tracheal temperature monitoring during cardiac surgery in pediatric patients. Fifteen children (ages; 8 m.-7 yr.) undergoing cardiac surgery with cardio-pulmonary bypass (CPB) were studied. Anesthesia was induced and maintained with high doses of fentanyl and intermittent doses of midazolam. After anesthetic induction, esophageal, rectal, bladder, tympanic, and forehead deep temperatures were monitored with a Core Temp Monitor (CTM-205, Terumo Co.). Simultaneously, the tracheal temperature was monitored with a specially made tracheal tube. A thermistor was attached by medical glue (Loctite Prism, Loctite Co.) at the anterior surface of a tracheal tube (Trachelon, Terumo Co.) without cuff (inside diameter 4.0-6.0 mm) where the tracheal tube tightly fits against the trachea. The inspired gas was warmed to 35 degrees C and humidified. During CPB, the blood temperature at the inlet to the patients was also recorded simultaneously. All indicated temperatures (Y) during CPB were analyzed for correlation with the blood temperature to the patients (X). The tracheal temperature had the highest correlation with the blood temperature from the patients (Y = 0.68X + 10.60, r = 0.89). There were also good correlations of the esophageal as well as bladder temperatures with blood temperature. There were no patients who suffered tracheal inflammation or laryngeal edema from the thermistor. Monitoring tracheal temperature is not only valuable for monitoring the core temperature, but also is convenient for pediatric patients in cardiac surgery.