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Adrenoleukodystrophy (ALD) is a genetic disorder with demyelination of the central nervous system and adrenal insufficiency. A 24-year-old man with ALD was scheduled for dental treatment under general anesthesia. He was diagnosted as having ALD at the age of 5. Past medical history included recurrent cervical cellulitis, adrenal insufficiency, mental retardation, muscle weakness and seizure disorder. General anesthesia was induced using betamethasone as a steroid cover, sevoflurane and nitrous oxide-oxygen and maintained with sevoflurane and nitrous oxide-oxygen. Nasal intubation was performed without using a muscle relaxant. Patients with ALD cannot metabolize very long chain fatty acid, so we did not use propofol containing long chain fatty acid. Operation and anesthesia were uneventful. There were no complications during and after anesthesia.

Background: The effect of pentazocine on the bispectral index (BIS) has not been reported. In this study, we have examined whether pentazocine alters the bispectral index during nitrous oxide-sevoflurane anesthesia., Methods: Thirty surgical patients were enrolled in this double-blind, randomized study. Anesthesia was induced with thiopental and vecuronium and maintained with nitrous oxide-sevoflurane with the bispectral index maintained at approximate 40. Under stable anesthetic condition before surgery, patients were assigned to receive either a bolus of pentazocine 0.3 mg x kg(-1), 0.6 mg x kg(-1) or the same volume of saline 15 min after induction. Blood pressure (BP), heart rate (HR) and BIS were measured every 2.5 min from 2.5 min before induction until 30 min after induction., Results: BP and HR showed no changes after pentazocine administration compared with control group. BIS showed no significant change in the saline group, but it increased significantly in the pentazocine group. When pentazocine was administered 15 min after induction, BIS increased significantly 20, 22.5, 25, 27.5 and 30 min after induction compared with the control group. The increase of BIS by pentazocine showed no dose-dependent effect in our present study., Conclusions: We observed that intravenous pentazocine caused a significant increase in BIS under nitrous oxide-sevoflurane anesthesia. The depth of sedation should be assessed carefully using a bispectral index monitor when pentazocine is used together.

Pompe or glycogen storage disease type II is a genetic disorder affecting the cardiac and skeletal muscle. A 4-year-old boy with this disease was scheduled to undergo an orthopedic operation for clubbed foot. He had cardiomyopathy and skeletal muscle weakness; but his cardiac function was normalized by the long-term enzyme replacement therapy. General anesthesia was slowly induced with oxygen, nitrous oxide, and sevoflurane, and tracheal intubation was achieved without any muscle relaxants. In combination with a caudal blockade with 6 ml of 0.375% ropivacaine, general anesthesia was successfully maintained with oxygen, nitrous oxide, and sevoflurane. We did not use muscle relaxants to avoid prolonged respiratory depression. The perioperative course was uneventful and no complication was observed.

Background: Occasionally emergence from anesthesia is delayed. We examined the factors which exert influence on the emergence time., Methods: The emergence time was assessed in 1133 surgical patients who received balanced anesthesia. Balanced anesthesia was maintained with infusion of propofol, ketamine, vecuronium, and buprenorphine, with nitrous oxide. OT time was defined as the time from the end of operation to extubation, TA time from extubation to leaving the operation room, and these times were examined retrospectively., Results: The emergence time of OT was 3.9 +/- 2.6 min, and that of TA was 3.7 +/- 2.2 min, for all subjects who were extubated in the operating room. Factors affecting the emergence delay were ASA classification, JCS classification, ages, department of surgery, the time of anesthesia, and the anesthesiologists., Conclusions: When the anesthesiologists keep in mind early emergence and become accustomed to this balanced anesthesia, the emergence time will be shorter, and the extubated cases in the operating room will increase.

We experienced an anesthetic management for a patient of myotonic dystrophy with pheochromocytoma. Much attention is required to manage myotonic dystrophy on surgical manipulation. This disease interacts with anesthetic drugs. It may cause prolongation of drug action used during anesthesia compared with the usual case. It also may cause dangerous interactions such as severe arrhythmia and malignant hyperthermia. That is why we were faced with serious limitation in choosing anesthetic and adjuvant drugs. At the same time, the case of pheochromocytoma must be handled with scrupulous care. Pheochromocytoma causes severe hypertension and sometimes tachycardia leading to intracranial hemorrhage or adrenaline-induced severe hypovolemia. Besides, laparoscopic operation was scheduled to resect the pheochromocytoma. This operation demanded the anesthetic management with artificial ventilation. It must be difficult to cope with these conditions by limited number of drugs. This time, we managed this case by epidural anesthesia with propofol and nitrous oxide without opioid and muscular relaxant. Though, this patient was not fully awake from anesthesia and could not take enough breaths on his own. We extended the period of spontaneous breathing with careful check whether the patient has resumed spontaneous breathing. It took us fourteen days till extubation.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome, described by McCarty et al., is a form of "seronegative rheumatoid arthritis" characterized by an acute-onset polyarthritis with pitting edema of the dorsum of both hands and/or both feet. The syndrome is prevalent in elderly men, completely remitted with a small dose of steroid over a relatively short period, and has a benign clinical course. We describe a case of RS3PE syndrome in a 61-year-old man undergoing a lobectomy of the lung and discuss anesthetic management for the syndrome.

A 6-year-old child with Schwartz-Jampel syndrome (SJS) underwent tenotomy of bilateral lower limbs under general anesthesia. Patient with SJS has problems such as difficulty of intubation owing to microstomia and jaw muscle rigidity, and is susceptible to malignant hyperthermia by using volatile inhalation anesthetics. In this case, we used a laryngeal mask for airway management and anesthesia was maintained with inhalation of nitrous oxide and continuous i.v. infusion of propofol with caudal block, and his clinical course was uneventful.

Background: We assessed the nitrous oxide (N2O) gas-barrier properties of a new endotracheal tube cuff, the Profile Soft-Seal Cuff (Resistant: R) (Sims Portex, Kent, UK)., Methods: The tracheas of randomly selected patients were intubated with the Profile Cuff (Permeable: P) (Sims Portex) tuble or with Portex Soft-Seal Cuff (R) (n=20 each) endotracheal tube. Cuffs were inflated with air, and intracuff pressure was measured during anesthesia using 67% N2O. Postoperative sore throat was assessed. In addition, the volume-pressure relationship of the cuff was determined in vitro., Results: Cuff pressure increased gradually during anesthesia in both groups. The mean cuff pressure of the group R was significantly lower than that of the group P from 10 minutes to 230 minutes. The inflated gas and the deflated gas were not significantly different in both groups. The incidence of postoperative sore throat was not significantly different between the two groups. In vitro, the mean cuff pressure of the group R was significantly lower than that of the group P., Conclusions: The difference of cuff pressure is considered due to the difference in cuff compliance.

Background: The bispectral index (BIS) has been shown to be useful in monitoring a degree of hypnosis in anesthetized adults. Although several studies have been performed to evaluate BIS in pediatric patients, it is unclear whether BIS monitor can be applied to infants. This study was designed to evaluate if the BIS monitor can be used in infants as a measure to monitor a degree of hypnosis., Methods: Forty-three infants were divided into two age groups according to their age: group A (3-6 months; n = 31) and B (7-12 months; n = 12). And the patients in the younger group were randomly allocated to one of two groups, A (+) (premedicated with oral midazolam 0.5 mg.kg-1; n = 19) and A (-) (without premedication; n = 12). BIS values and other parameters were recorded at a steady state of end-tidal sevoflurane concentration (2.5, 2, and 1.5%) and immediately before extubation., Results: At each concentration of sevoflurane and extubation, the BIS values were lower in group A (+) than in group B (P < 0.05). In infants < or = 6 months of age, premedication did not affect the BIS values., Conclusion: There were significant differences of BIS values between < or = 6 months and > or = 7 months old infants. BIS values should be interpreted cautiously in infants younger than 6 months.

A 65-year-old woman who had been diagnosed as having Charcot-Marie-Tooth disease (CMTD) 8 years ago and was scheduled to undergo excision of a spinal tumor in the prone position. General anesthesia using propofol was selected as the anesthetic method in order to avoid possible occurrence of malignant hyperthermia due to inhalation anesthetics. The patient was given 80 mg of propofol for anesthetic induction, and then propofol was infused at a rate of 4-5 mg.kg-1.h-1 with intermittent administration of fentanyl (total dose of 0.25 mg) for anesthetic maintenance. Vecuronium 4 mg was injected for intratracheal intubation, and then vecuronium 1 mg was injected at 50 min intervals. The operation proceeded uneventfully. The necessary time for anesthesia was over 460 minutes. There was no delay in wakening, and the patient experienced no problems in the postoperative course. Intravenous anesthesia using propofol is thought to be a safe and effective method of anesthesia for patients with CMTD.

A 49-year-old female with mitochondrial encephalomyopathy underwent surgery for implantation of an artificial cochlear device. She had some characteristic clinical features, including muscle weakness, deafness and dementia. Anesthesia was induced with 5 mg.kg-1 of propofol, and the trachea was intubated without a muscle relaxant. The patient was mechanically ventilated also without a relaxant, and anesthesia was maintained with a continuous infusion of 4-8 mg.kg-1.hr-1 of propofol, a bolus injection of 50-100 micrograms of fentanyl, and nitrous oxide (66%) in oxygen (33%). Bispectral index (BIS) was monitored and maintained at approximately 40. No cardiovascular instabilities or increase in plasma lactate concentration were observed during surgery. The patient had a smooth recovery from the propofol anesthesia, and the BIS value returned to the pre-anesthetic level 10 min after completion of the anesthesia, suggesting that the use of propofol is a safe means for inducing and maintaining anesthesia in patients with mitochondrial encephalomyopathy.

In 15 transluminal placed endovascular graft (TPEG) operations for thoracic aortic aneurysm either from dissection or injury, we induced general anesthesia with propofol, and maintained with propofol or sevoflurane in nitrous oxide and oxygen. The temporary balloon occlusion technique used for prevention of stent migration caused hypotension (systolic pressure 30-60 mmHg) in all cases. After releasing the occluding balloon, blood pressure in each patient recovered to the prehypotension level without use of catecholamine. We experienced two emergency operations, a thoracotomy and a celiotomy, resulting from graft failure. We had sudden hypotension in two other cases. In the first patient with aortic regurgitation, coronary air embolism was suspected because of ST segment elevation, while in the other, the hypotension was due to unexpected bleeding from the femoral artery sheath. Two additional patients developed vascular injuries occurring during manipulation of the catheter or sheath. In order to manage anesthesia for TPEG, it is necessary to be aware of its complications.

We measured the intracuff pressure of two different tracheal tubes, Portex Profile Soft-Seal Cuff with high N2O gas-barrier property and "high-volume, low-pressure" cuff (Mallincrodt Lo-Contour). Twenty adult patients undergoing elective abdominal surgery, were maintained with total intravenous anesthesia combined with epidural block, and ventilated with oxygen in air (FIO2 = 0.4). Initially, intracuff pressure was adjusted to 25 mmHg with air, and monitored over 180 min. Intracuff pressure of both tubes decreased abruptly to near 20 mmHg within 20 min, and further went down gradually during the observation period. The decrease in intracuff pressure of Portex Profile Soft-Seal Cuff was significantly smaller than that of "high-volume, low-pressure" cuff 150-180 min later. We conclude that to prevent tracheobronchial aspiration during prolonged general anesthesia without N2O, tracheal tube cuff with gas-barrier property may be safer than usual "high-volume, low-pressure" cuff. We recommend to check the intracuff pressure especially during the first 30 min and at intervals of several hours.

We studied the effects of increases in isoflurane concentration on the bispectral index (BIS) in 16 patients undergoing lower abdominal surgery during isoflurane/epidural anesthesia. In 8 patients, the lungs were ventilated with an air/oxygen mixture (inspired oxygen fraction 0.33) [N(-) group], and in another 8 patients, the lungs were ventilated with 66% nitrous oxide in oxygen [N(+) group]. During surgery, patients received 1.0 MAC (1.15%) end-tidal isoflurane and the BIS was recorded after 10 min of unchanged end-tidal concentration. After this, we increased the end-tidal concentration of isoflurane by 0.2 MAC to 1.8 MAC. At each concentration step, the BIS was recorded again after 10 min of unchanged end-tidal concentration. At isoflurane concentration < 1.4 MAC, the BIS did not change with increasing isoflurane concentration in both groups (BIS values = about 40). In N (-) group, the BIS decreased in all patients at isoflurane concentration > 1.6 MAC. The mean BIS values were 22 (SD 18) at 1.6 MAC and 2(4) at 1.8 MAC, respectively. In N (+) group, the BIS decreased in four patients at isoflurane concentration > 1.6 MAC, and the BIS did not decrease at 1.8 MAC in another four patients. The mean BIS values were 27 (17) at 1.6 MAC and 21(21) at 1.8 MAC. The present data suggest that BIS may not correlate with anesthetic effect of isoflurane at isoflurane concentration > 1.0 MAC.

A 46-year-old female with relapsing polychondritis (RP) was scheduled for surgical repair of saddle-nose and peri-chondritic ear. RP is a rare systemic, inflammatory, and destructive disease of the cartilaginous structures leading to multiple functional disorders in the affected organs. Preoperatively, her chest radiogram of the trachea showed narrowing in diameters which altered about 2 mm with expiration and inspiration. Propofol administered intravenously was given as induction and anesthesia was maintained with nitrous oxide-oxygen-sevoflurane with spontaneous ventilation using laryngeal mask airway. The operation was over uneventfully. Anesthesiologic management requires careful preoperative evaluation of vital organ functions, in particular, respiration.

We experienced the anesthetic management of a 39 year-old-male with hereditary spastic paraplegia (HSP) associated with pain due to pes cavus. He underwent orthomorphia ostectomy and tenodesis. Preoperative neurological examination revealed that he had slight dementia, symptoms of the pyramidal tract, lower limb bathyhypesthesia, and neurogenic bladder in addition to spastic paraplegia, and he was diagnosed as having combined type of HSP. Spinocerebellar degeneration is often accompanied with this type of HSP. To avoid the use of muscle relaxants and narcotics, we tried to induce anesthesia with inhalation of nitrous oxide (N2O), oxygen and sevoflurane (sevo). A laryngeal mask (LM) was inserted at the expiratory concentration of sevo 3.5%. Anesthesia was maintained by N2O, oxygen and sevo (2-3%) under spontaneous respiration. The patient recovered from anesthesia after the end of surgery, and the LM was removed smoothly. The patient's respiratory condition was stable, and no problems were found in the postoperative period.

A 70-year-old man, without history of angina pectoris, was scheduled for aorto-femoral bypass graft surgery under epidural anesthesia supplemented with nitrous oxide and sevoflurane. At the beginning of operation, twenty minutes after the start of low flow anesthesia (2 l.min-1), ECG showed an elevation of the ST segment during hypotension. Rising blood pressure and bolus injection of nitroglycerin relieved the elevation and his circulation became stable. It was suspected that a coronary spasm attack was induced by hypotension, as well as vagal stimulation from an inadequate amount of anesthesia. For prevention of intraoperative coronary spasm, it is important to maintain anesthesia at sufficient levels using monitors.

We investigated retrospectively the influence of anesthetic methods on the intraoperative managements and postoperative outcomes in 26 patients receiving emergency or early surgery for acute cholecystitis. Fourteen of the 26 patients received total intravenous anesthesia with propofol, fentanyl, and ketamine (PFK group), while the remainder received nitrous oxide and isoflurane or sevoflurane anesthesia (GO group). There were no significant differences between the groups with respect to demographic data. We found no significant differences between the groups in duration of operation and anesthesia, the incidence of intraoperative hypotension, and the use of ephedrine and dopamine during induction and maintenance of anesthesia. After surgery, the PFK group had significantly earlier bowel function than the GO group, with earlier starting of oral intake (54.0 +/- 25.1 vs 89.3 +/- 31.9 hours after surgery; P = 0.026). These data suggest that total intravenous anesthesia by propofol, fentanyl, and ketamine may provide the earlier recovery of bowel function than inhaled anesthesia after emergency or early surgery for acute cholecystitis.

We report a successful electrocorticography (ECoG) monitoring for a epileptic cortical focus resection in a 9-month-old girl with uncontrollable epileptic seizures. Anesthesia was induced and maintained with nitrous oxide, oxygen, and sevoflurane with vecuronium. After the craniotomy, ECoG monitoring was used to locate the epileptic cortical lesion. During the procedure of subpial resection and gyrectomy, ECoG was repeatedly recorded. It was necessary to maintain adequate depth of anesthesia throughout the procedure to clarify the epileptic waves. For this purpose, sevoflurane (2.5%) with and oxygen (97.5%) under controlled-hyperventilation (PaCO2 30 mmHg), was useful for monitoring the epileptic seizure wave from cortical focuses properly.

Bradycardia during propofol anesthesia is well known, but bradycardia after propofol anesthesia has not been studied well. We compared perioperative heart rates in patients who had undergone gynecological surgery under lumbar epidural anesthesia supplemented with light general anesthesia using isoflurane and nitrous oxide in oxygen (Group Iso, n = 25) with those who had received lumbar epidural anesthesia supplemented with propofol (Group Prop, n = 25). The heart rates for the Group Prop were significantly lower (P < 0.05) than those for the Group Iso after the induction of anesthesia up to 2 hours after surgery. Two patients in the Group Prop developed bradycardia below 50 bpm 1 and 2 hours after surgery. In one of them intravenous atropine was necessary to treat bradycardia. We conclude that more attention should be paid to postoperative as well as intraoperative bradycardia in patients who receive propofol.

The authors investigated the effect of anesthesia with nitrous oxide and propofol on intraoperative involuntary movement, muscle relaxant usage, postoperative nausea and vomiting, the total amount of propofol used, and recovery time from anesthesia. Eighty-eight patients for gynecological surgery were randomly divided into group PE: propofol/epidural (n = 44), and group PEG: propofol/epidural/nitrous oxide (n = 44). The frequency of postoperative nausea and vomiting were assessed at 24-h postoperatively by blinded observers. There were significant decreases of the mean amounts of propofol and muscle relaxant used between group PEG and group PE. The authors found no correlation between the use of nitrous oxide and intraoperative involuntary movement, subsequent development of postoperative quality of awareness, recovery time, nausea and vomiting. We recommend PEG method for gynecological surgery rather than PE from an economical viewpoint because it is associated with the reduction of mean propofol and muscle relaxant used.

We studied the influence of the ketamine maintenance dose on propofol infusion speed, blood pressure change and recovery time in anesthesia using propofol, ketamine and nitrous oxide. Anesthesia was maintained with ketamine 0.6 or 0.2 mg.kg-1.hr-1. The ketamine maintenance dose exerted no influence on propofol infusion speed, the occurrence of hypertension or hypotension. The recovery time correlated with the total amount of ketamine. From these results we conclude that 0.2 mg.kg-1.hr-1 is an appropriate maintenance dose of ketamine in anesthesia using propofol, ketamine and nitrous oxide.

In 30 patients (ASA-1) for elective Cesarean section who had given informed consent, characteristics of amnesia induced by midazolam (M) and their modulation by flumazenil (F) were examined. Spinal anesthesia was performed with dibucaine. After the delivery, the baby was shown to the mother. Then 21 patients were given bolus intravenous injection of M until the patient got into sleep and the inhalation of nitrous oxide mixed with oxygen was started. At the end of surgery bolus injection of F 0.1 mg was cumulatively repeated until the patient awoke. Nine patients were given only nitrous oxide and oxygen inhalation after the delivery. The remembrance of the baby face and the doses of M and F were compared. In group given M, 14 patients recalled their baby's face whereas 7 did not. The average doses of M and F in patients with memory were 69 micrograms.kg-1 and 2.5 micrograms.kg-1, respectively, whereas the average dose of M and F in patients without memory were 94 micrograms.kg-1 and 4.2 micrograms.kg-1, respectively. In the patients without M injection, all could recall the face of the baby. These results suggest that M could produce retrograde amnesia, when combined with nitrous oxide inhalation, which is not reversed by F.

We hypothesized that propofol dose requirement for total intravenous anesthesia is varied with the analgesic methods during anesthesia if the depth of anesthesia is maintained at the same level with bispectral index. Adult gynecological patients without any complications were randomly allocated to four groups; propofol with 1) continuous epidural block-oxygen-nitrous oxide (n = 18), 2) continuous epidural block-oxygen-air (n = 21), 3) fentanyl (total 5 micrograms.kg-1)-oxygen-nitrous oxide (n = 18) and 4) fentanyl (total 5 micrograms.kg-1)-oxygen-air (n = 21) group. Propofol 1.5 mg.kg-1 and vecuronium 0.15 mg.kg-1 were administered intravenously for endotracheal intubation. Propofol was titrated to maintain bispectral index between 40 and 60. Total dose of propofol except the dose for induction was compared among the groups with one-way ANOVA and Scheffé's F test and P < 0.05 was considered as significant. Results were expressed as means +/- SDs. The age, body weight, height and hemodynamic changes during anesthesia among the groups were not significantly different. Total required dose of propofol for continuous epidural block-oxygen-nitrous oxide, continuous epidural block-oxygen-air, fantanyl-oxygen-nitrous oxide and fentanyl-oxygen-air group were 4.78 +/- 0.87 mg.kg-1.h-1, 6.10 +/- 0.93 mg.kg-1.h-1, 5.79 +/- 0.75 mg.kg-1.h-1 and 6.58 +/- 1.19 mg.kg-1.h-1, respectively. Nitrous oxide was able to reduce the dose of propofol significantly either with epidural anesthesia or fentanyl used for analgesia.

We experienced anesthetic management of a 45-yr-old female patient with a 12-yr history of multiple sclerosis who underwent orthopedic surgeries three times under general anesthesia. We chose rapid induction with propofol and maintained the anesthesia with nitrous oxide, oxygen, and sevoflurane. We monitored both core and peripheral temperatures to avoid the rapid increase of core temperature, which might worsen the symptoms of the disease. There is no other report of anesthesia using propofol as induction agent for a patient with multiple sclerosis. We succeeded in the satisfactory perioperative management of the patient.

We gave anesthesia 4 times to a patient (19-year-old female) with allergic granulomatous angitis (AGA). She had asthma, myopathy and detrimental side effect in her eyes of steroid therapy for AGA. Two of the 4 operations were emergency laparotomy for peritonitis due to colon perforation, and the other 2 operations were elective eye surgeries. General anesthesia was induced with thiamylal (1st operation) or midazolam (2nd-4th operation). Intraoperative anesthesia was maintained with N2O-O2-isoflurane combined with thoracic epidural anesthesia (1st operation) or N2O-O2-sevoflurane (2nd-4th operation). Asthmatic attack, which AGA accompanies frequently, did not occur during these anesthetic managements. The steroid therapy, which is a fundamental means to control the allergic syndrome, might suppress asthma. However, asthmatic attack and systemic vasculitis should be kept in mind in anesthetic management of AGA.

A randomized, prospective and multi-institutional study was performed to investigate whether different anesthetic methods affected differently the quality of recovery from anesthesia. Two hundred and eleven patients were allocated to one of two groups; total intravenous anesthesia (TIVA) with propofol and fentanyl (group P, n = 107) and general anesthesia with thiopental, sevoflurane and nitrous oxide (group TS, n = 104). The rapidity of emergence from anesthesia and postoperative incidence of nausea, vomiting, and headache were compared between the two groups. The group P showed significantly shorter emergence times for verbal command responses (7.4 +/- 5.6 min), extubation (10.0 +/- 6.0 min) and orientation (13.1 +/- 7.8 min) than the group TS (9.1 +/- 5.0 min, 11.7 +/- 6.2 min, 16.4 +/- 7.9 min, respectively). The postoperative incidence of vomiting was not significantly different between the two groups (3.7% in the group P and 9.6% in the group TS), but the postoperative incidences of nausea and headache were significantly lower in the group P compared with the group TS (10.3%, 17.8%, respectively in the group P and 34.6%, 29.8%, respectively in the group TS). We conclude that TIVA with propofol is advantageous than thiopental-sevoflurane anesthesia in the recovery phase.

We present a child with Lenz dysplasia associated with panhypopituitarism. Lenz dysplasia is characterized by small eyeball, small head, hydronephrosis, cleft lip and palate, and mental retardation. A 12 month-old boy with Lenz dysplasia was scheduled for plasty of the lip and basis of the nasal cavity under general anesthesia. We had to pay attention for airway management and hormone supplementation. Anesthesia was induced with sevoflurane and nitrous oxide in oxygen. Tracheal intubation was facilitated with vecuronium bromide. We had no difficulty in airway management. Since this patient could not release enough endogenous cortisol in response to the stress of surgery, we supplemented hydrocortisone after anesthesia induction. Urine output and serum electrolyte concentrations were carefully monitored during surgery because of the impaired ADH response. We encountered no complications in the anesthetic management of this patient.

We experienced a case of difficult tracheal intubation in a 15-year-old boy with von Recklinghausen disease scheduled for resection of a right neck tumor. His scoliosis made it difficult to intubate and to manage airway because he easily developed dyspnea. We tried nasotracheal intubation with the patient awake under sedation using a bronchofiberscope, but we found an unexpected tumor jeopardizing his airway patency near his vocal cord. Preoperative examination of a tumor in the airway is essential in the anesthetic management of the patients with von Recklinghausen disease.

We investigated the effects of combined inhalational and lumbar epidural anesthesia on body temperature in 8 women for long-lasting lower abdominal surgery. Probes for forehead deep temperature and skin-surface temperatures were placed on the forehead, forearm, fingertip and toe tip on patients' arrival at the operating room. Tympanic membrane temperature was also measured. Lumbar epidural block was established with 2% lidocaine 10 ml. Twenty minutes later, general anesthesia was induced and maintained with nitrous oxide-oxygen-isoflurane. Epidural anesthesia was maintained with intermittent dose of 1% mepivacaine. Before the end of surgery, isoflurane concentration was increased from about 0.5% to 2% and was maintained at this level for 20 minutes, after which it was reduced. With the establishment of epidural blockade, toe tip temperature increased and fingertip temperature decreased, while core temperature remained unchanged. After induction of general anesthesia, fingertip temperature increased, while core temperature decreased. The core temperature drop during the anesthetic induction was significantly affected by the increase in toe tip temperature. Before the end of surgery, core temperature remained at a reduced but constant level, while fingertip temperature continued to decrease. With the application of 2% isoflurane, fingertip temperature increased, while core temperature decreased. The core temperature drop was significantly affected by the increase in fingertip temperature. After the reduction of isoflurane concentration, these temperature changes were reversed fully. At the end of surgery, fingertip temperature decreased, while core temperature increased. During mild hypothermia, isoflurane depressed thermoregulatory vasoconstriction dose-dependently until its concentration reached 0.6-0.7%. In conclusion, anesthetics-induced redistribution of body heat significantly affects the core temperature throughout anesthesia. Peripheral hypothermia results in core temperature drop when the redistribution is induced by anesthetics. Thermoregulatory vasoconstriction may not only suppress heat loss but also increase core temperature through centralization of body heat.

We experienced the anesthetic management of a 47-year-old woman with insulinoma. Removal of the tumor was performed under propofol, nitrous oxide, and epidural anesthesia. We tried the continuous infusion of glucose to maintain normal blood glucose level and to avoid intraoperative hypoglycemic event. The blood glucose and immunoreactive insulin (IRI) level were measured intermittently. After the removal of the insulinoma, the IRI level decreased rapidly to the normal range. In this case, neither hyperglycemic nor hypoglycemic episode was observed. The perioperative course was uneventful. Propofol has not been shown to significantly affect the release of insulin and glucose regulation. This case suggests that under the condition of continuous glucose infusion and blood glucose monitoring, propofol is an useful anesthetic agent for a patient with insulinoma.

We gave anesthesia for the suboccipital decompression in a 25-yr-old female patient with Arnold-Chiari deformity. The induction and maintenance of anesthesia were performed with fentanyl, continuous infusion of propofol 10-3 mg.kg-1.h-1 and inhalation of nitrous oxide and oxygen, and the operation was performed without any complication. Postoperative course of the patient was also uneventful except a short-term pneumonia. Propofol is more advantageous compared with volatile anesthetics for decreasing intracranial pressure. This suggests that propofol is a suitable anesthetic agent for a patient with Arnold-Chiari deformity.

In "Dove Cottage", the old house of the poet laureate William Wordsworth (1770-1850) in Grasmere, England, there is a portrait of Sir Humphry Davy (1778-1829). In 1804, Wordsworth invited his young friend to his home. Davy's works in the field of chemistry are well known. Interestingly enough, once he wished he could be a poet. His future seemed to be prosperous and delightful. He was highly evaluated by Robert Southey, poet laureate. But he has chosen the way of chemist. The author found some facts from literatures and received some information by courtesy of the Wordsworth Trust, Centre for British Romanticism. Davy's life and his works were introduced chronologically.