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The pain of skin graft site after surgery is compara- tively severe. We present three cases of combined of ultrasound-guided femoral nerve block and lateral fem- oral cutaneous nerve block that was effective for har- vesting skin grafts. Case 1 : a 32-year-old man had a split-thickness skin grafting of lateral upper arm harvested from outside of the thigh under general anesthesia, brachial nerve block, femoral nerve block and lateral femoral cutane- ous nerve block. Case 2 : a 39-year-old man had split-thickness skin grafting of lower thigh harvested from outside of the thigh under general anesthesia, femoral nerve block and lateral femoral cutaneous nerve block. Case 3 : a 94-year-old man had split-thickness skin grafting of acrotarsium harvested from outside of the thigh under spinal anesthesia, femoral nerve block, lat- eral femoral cutaneous nerve block and sciatic nerve block. In all cases, there was no pain just after surgery, and postoperative pain was controlled well through the hospitalization with administration of oral analgesic agents.

We report a case of possible transfusion-related acute lung injury (TRALI). The patient is a 69-year-old man who underwent cervical supine surgery Platelet products were transfused pre-and intra-operatively. At the end of the operation, he was fully awake and extubated. Shortly after extubation he showed low oxygen saturation, and we started bag-mask ventilation. A chest X-ray revealed bilateral diffuse pulmonary edema without cardiac enlargement. Thus we inserted endotracheal tube and started positive pressure assist ventilation. Hypoxemia was improved gradually, and he was re-extubated on the fourth day after the operation. The prevalence of TRALI reactions is reported to be high for platelet product and is influenced by patients' underlying clinical condition. Serum anti-leukocyte antibody was negative, but we suspected the possibility of TRALI based on the clinical findings.

An 88-year-old woman was admitted with acute appendicitis. She had been treated with prednisolone and home oxygen therapy for interstitial pneumonia. Her respiratory state on admission was Grade 2 of Hugh-Jones' classification, and plasma KL-6 and SP-D levels were high. Seven days after the admission, appendectomy was performed under spinal anesthesia. Spinal anesthesia was initiated by injecting 0.5% hyperbaric bupivacaine 2.0ml into L3-4 interspace, and achieved block level was up to T4. During the operation, her respiratory state was stable, but after the operation, dry cough, increase of body temperature, and dyspnea were observed. Chest roentgenogram revealed severe ground glass appearance and reticular shadows bilaterally. Steroid therapy for acute exacerbation of interstitial pneumonia was initiated, but she died on the 13th POD. This case teaches us to take a lot of care in the management of a patient with high plasma level of KL-6 and SP-D.

Neroleptic malignant syndrome (NMS) is a serious side effect of antipsychotic medications. The risk factors for NMS are the patient's physiologic conditions such as dehydration, malnutrition, stress, and additional administration of sedative drugs including haloperidol. We report a case of 62-year-old schizophrenic man with bowel obstruction due to rectal cancer. Colostomy under general anesthesia was scheduled, and he had not taken oral medication. After intravenous injection of haloperidol for sedation, muscle rigidity, high fever, and an elevated serum level of creatine phosphokinase were observed. He was diagnosed as NMS, and sodium dantrolene was administered. After the improvement of NMS, colostomy was done. Dehydration and malnutrition of the patient were severe at the time of operation, and the possibility of NMS developing due to stress was thought to be very high. We administered sodium dantrolene to prevent NMS after the operation, and the management for prevention of NMS is discussed.

A 31-year-old woman with aplastic anemia was admitted for the management of delivery at 33 weeks of gestation. Platelet count was 2.3 x 10(4) x microl(-1) on admission. Corticosteroid therapy after admission was not effective, and we decided to manage the delivery with elective cesarean section after platelet transfusion. After forty units of platelet transfusion, platelet count was 8.1 x 10(4) x microl(-1), and we decided to perform cesarean section under spinal anesthesia. Spinal anesthesia was given using a 25-gauge Quincke needle at L3-4 interspace, and 0.5% hyperbaric bupivacaine 2.5 ml with 0.15 mg morphine was injected. Block level was confirmed as T8 by a pinprick method. Blood loss during operation was 858 g, and complications were not seen during operation. In the case of delivery with uncontrolled aplastic anemia, elective cesarean section is thought to be safe. If platelet count is over 5.0 x 10(4) x microl(-1) after platelet transfusion, spinal anesthesia should be used.

We managed a patient with an ultra huge ovarian tumor weighing 48 kg. The patient was a 45-year-old woman and could not keep the supine position because of the respiratory disorder. Under local anesthesia with sedation, 28,000 ml of fluid was suctioned from the ultra huge ovarian tumor within about 2 hours in the left lateral position. The patient was turned into the supine position, and general anesthesia was induced. During the surgery, temporary oxygen desaturation and slight hypotension were observed after rapid suction from the ovarian tumor, but hemodynamic condition was almost stable. After extubation, respiratory and hemodynamic condition was good, and the patient had no postoperative complications. Anesthetic management of an ultra huge ovarian tumor is discussed.

We report a 16-year-old woman with dentatorubral pallidoluysian atrophy (DRPLA) on a ketogenic diet. She was scheduled for dental treatment under general anesthesia. She was diagnosed as having DRPLA at the age of 10. Medication included clonazepam, chlordiazepoxide, ethosuximide, sodium valproate and piracetam. She had been placed on a ketogenic diet at the age of 15, and seizures decreased. Preoperative laboratory data were normal except for serum cholesterol level (228 mg x dl(-1)) and blood ketones (1.8 mmol x l(-1)) with the use of Medisense Xtra. General anesthesia was induced using thiamylal, vecuronium, sevoflurane and maintained with sevoflurane and nitrous oxide-oxygen. Fluid infusion employed Solita T1 (glucose content of 2.6%: total 150 ml). Operation and general anesthesia presented no problems. We continued to infuse Solita T1 (total 350ml) for about 4 hours postoperatively. Ketogenic diet and additional medicine were started after 5 hours postoperatively. We measured perioperative and postoperative BS and blood ketones with the use of Medisense Xtra. She recovered from anesthesia without any significant complication.

We report a case of cervical spontaneous intracranial hypotension (SIH). The patient is a 46-year-old woman with hard of hearing, dizziness and postural headache. Radionuclide cisternography (RNC) demonstrated a cerebrospinal fluid (CSF) leak at the low cervical region. Resolution of headache was obtained by conservative therapies of bed rest and intravenous (i.v.) drip infusion, but the dizziness remained. We performed epidural blood patch (EBP) with 8 ml of autologous blood at the C 6-7 interspace. Her dizziness disappeared after several days of EBP. SIH is an uncommon disease caused by CSF leakage. SIH is often self-limiting, responding to bed rest and/or i.v. drip infusion. However, if the symptoms of SIH do not show a complete recovery by conservative therapies, EBP or continuous epidural infusion of saline has reportedly been used for the management of these cases. Most of the reported cases of EBP are in the thoracic and lumbar spinal regions. We have performed cervical EBP without complications, and the 6 month-follow-up MRI and RNC demonstrated that the abnormal findings had disappeared.

We investigated the effect of epidural buprenorphine on diaphragmatic function using respiratory inductive plethysmography (RIP) in seven healthy patients after upper abdominal surgery. After surgery, changes of rib cage contribution to tidal volume (%RC) increased significantly from 25.3 +/- 7.3 (mean +/- SD) to 50.7 +/- 14.8% (P < 0.05). After the injection of epidural buprenorphine, visual analogue scale (VAS) score decreased significantly from 8.3 to 3.3 (P < 0.05). But, %RC was unchanged compared to the value before the injection. These results indicate that pain relief by epidural buprenorphine does not improve diaphragmatic function after upper abdominal surgery.

Hare lip and cleft palate surgery team activities in Cambodia were launched in 1989 by a non-governmental Japanese organization, Operations Unies. The objectives of the project are to provide appropriate surgical treatment and safe general anesthesia for local patients and also to conduct technology transfer of general anesthesia and surgery to the local medical staffs. From June 1991 to January 1993, a surgery/anesthesia team was dispatched 4 times and a total of 130 patients received surgical treatments under general anesthesia. Anesthesia techniques employed included total intravenous anesthesia in 70 patients (54%) and intravenous anesthesia with 0.3-0.7% of halothane in 60 patients (46%). There were no major complications, such as airway obstruction and apnea, in the recovery room and in the ward. The reasons why we chose intravenous agents are difficulty in obtaining inhaled agents in Cambodia and lack of scavenging system in a operating room. Although halothane anesthesia with spontaneous breathing has been recommended in developing countries, total intravenous anesthesia could be one of the applicable techniques in these countries. In Cambodia, shortage of medical doctors and the absence of anesthesiologist constitute a major barrier to technology transfer in clinical anesthesia.

We studied the effects on hemolysis of our manually operated, portable cardiopulmonary bypass system with two self-inflatable reservoir-pumps in parallel by using bovine blood. The blood shed from both the jugular vein and the carotid artery, immediately after slaughter, was divided into three plastic containers, one for the control, one for manual circulation, and the other for conventional circulation with a roller-pump. Small bore catheters were intentionally placed into the inflow and outflow routes of both circulation systems to simulate clinical situations. Free hemoglobin and potassium in plasma were measured every 30 min during the experimental circulation for 120 min. The free hemoglobin in plasma increased gradually under manual circulation, but this increase was statistically insignificant when compared with the variances of those in the conventional circulation and the control blood groups. The values of the potassium in the plasma showed no differences among the three blood groups. Our manually operated, portable cardiopulmonary bypass system will be a valuable adjunct for emergency medicine.

Appropriate methods of anesthesia for the elderly people are being discussed as the ratio of elderly people in our society increases. During spinal anesthesia, hypotension was frequently observed in patients with hypertension, arteriosclerosis, coronary deficiency, and so on. It is also difficult to pass the needle between degenerated vertebrae. However, general inhaled anesthesia accompanies the respiratory complications and consciousness derangement after surgical operations more frequently than after spinal anesthesia. In this study, circulatory conditions during spinal anesthesia in elderly people (30-91 years old) were analyzed in 109 cases of spinal anesthesia. Hypotension occurred about 10 minutes and 40-60 minutes after injection of anesthetics and was frequent in patients of high aged group, but tachycardia was not observed among them. In addition, their blood pressure in the recovery room could not recover to the level before anesthesia. It is thought that hypotension during spinal anesthesia was induced by the vascular dilatation caused by sympathetic nerve block and the deficiency of reflective venous constriction in upper extremities and abdominal organs. Tachycardia may also produce hypotension. However, the reflexive vasoconstriction and tachycardia are thought to be poor on account of arteriosclerosis and down regulation of beta-receptor in elderly people. Therefore, during spinal anesthesia in the elderly people, the catecholamine released by the surgical stimulation could not increase blood pressure effectively. To prevent hypotension during spinal anesthesia in elderly people, it is advisable to employ the treatment for upregulation of beta-receptor before anesthesia and the administration of alpha . beta-receptor, epinephrine and dopamine for control of blood pressure during spinal anesthesia.

The usefulness of iontophoretic anesthesia with 10% lidocaine was evaluated on insertion of venous catheters on 38 blood donors in a blood bank and on 41 patients in a hospital, after the arm was charged for 3, 6 or 9 minutes with 1.5 mA of electricity by using a hand-made iontophoretic anesthesia apparatus. In the blood donor group, the pain-relief effect was observed in 25% of donors after charging for 3 min; in 68% after 6 min; and in 93% after 9 min. In the patient group, anesthesia was observed in 14% of patients after 6 min and in 65% after 9 min though the effect was observed in 81% after 6 min and in 65% after 9 min. But only 45-48% of subjects in both groups requested the anesthesia after charging for either 6 or 9 min. This suggests that the duration for 9 min was not liked by the subject despite the pain on insertion. Therefore it is concluded that the charging duration of the iontophoresis must be shorter for this method to become useful as local anesthesia.

During spinal anesthesia for appendectomy (sensory level: -Th7), apnea occurred for about 20 minutes by intravenous administration of diazepam. Since the patient showed hyperventilation sign before the incident, this apnea might be caused by low PaCO2 and stopping respiratory stimulation from psychological unrest when diazepam, pentazocine and droperidol were administered. In the postoperative period, this patient showed normal neurologic and psychosomatic functions. In such a case as this, long duration of apnea might damage brain by severe hypoxia. Apnea after hyperventilation during spinal anesthesia as observed in this case could lead to a serious accident.

The authors studied the influence on CO2 elimination in lungs of acetazolamide given before ophthalmic surgery. The changes in PaCO2, PETCO2, (a-ET) PCO2, ventilation volume (VE), and respiratory rate (RR) were measured before and 6 hours after administration of acetazolamide (500mg, p. o.). Comparison of PETCO2, PaCO2, (a-ET) PCO2, VE and RR after the operation with or without treatment with acetazolamide showed that (a-ET) PCO2 increased significantly and the increase of PaCO2 in post-anesthesia period was less with the treatment of acetazolamide. In other words, ventilation was stimulated by acetazolamide as the decrease in VE was less in post-anesthesia period. It may be concluded that oral administration of acetazolamide 500mg does not interfere with CO2 elimination.