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An 18-year-old male patient who had been diagnosed with chronic granulomatous disease at 2 years old and suffering from repeated severe infections underwent human leukocyte antigen haploidentical bone marrow transplantation from his mother using reduced intensity conditioning. After engraftment, donor lymphocyte infusion was initiated to decrease donor chimerism on day 96. On day 120, acute graft-versus-host disease occurred; hence, steroid administration was initiated. On day 173, a generalized convulsion occurred; multiple abscesses were observed in the brain, lung, kidney, and prostate. Aspergillus siamensis of unknown pathogenic status was cultured in the abscess fluid from the brain, prostate, and kidney; accordingly, he was diagnosed with disseminated aspergillosis involving the brain, prostate, lungs, and kidney. Despite using a combination of various antifungal drugs, he died of multiple organ failure on day 239. Disseminated aspergillosis following the hematopoietic stem cell transplantation is a fatal complication. If infection symptoms are observed, the presence of any fungal antigens should be examined. Appropriate samples should be promptly collected, and adequate antifungal drugs should be administered based on the fungal species and drug sensitivity results.

Background: Major abdominal surgery accompanies the higher magnitude of physiological stress response and may require an additional replacement fluid for the redistributed volume. Intraoperative volume restriction strategy is recommended to avoid fluid overload leading to increased mortality. We conducted a comparative study of the perioperative effects of intraoperative fluid restriction in abdominal versus thoracic surgery., Methods: Each 15 patients having major abdominal or thoracic surgery were studied prospectively. All participants were identically given intraoperative iv crystalloid of 5 ml · kg(-1) · hr(-1) under combined epidural/general anesthesia. Plasma level of AVP, aldosterone, angiotensin II and IL-6 as well as body water composition by bioelectrical impedance analysis was examined at preoperative period, at the end of surgery and on the first postoperative day., Results: In abdominal surgery group there was significantly less intraoperative urine output compared with thoracic surgery group. No significant differences were found between two groups in extracellular water volume chnages, AVP, aldosterone angiotensin II, IL-6 level and postoperative renal function., Conclusions: Restrictive fluid therapy with intraoperative crystalloid of 5 ml · kg(-1) · hr(-1) can be safely used with no serious adverse events in abdominal surgery. In conclusion we had better not make any traditional difference in intraoperative fluid management between abdominal and thoracic surgery even if their stress response differs in magnitude.

Background: Optimal pain management after video-assisted thoracic surgery (VATS) remains an open issue. We prospectively studied the analgesic effect of intercostal analgegia (ICA) by comparison with epidural analgesia., Methods: Twenty-two patients undergoing VATS procedures were randomly divided into ICA (n = 8) or epidural (n = 14) group. Postoperatively 2 ml x hr(-1) of 0.2% ropivacaine was delivered continuously through intercostal or epidural catheter. Moreover, each group received the equal dose of fentanyl (0.25 x μg(-1). kg(-1) x hr(-1)) intravenously or epidurally. When no pain relief was achieved, iv fentanyl was given as a rescue. Requirement of additional fentanyl and pain score using a visual analogue scale (VAS) were documented for 19 hours., Results: The mean pain scores at rest, mobilization and with coghing were slightly higher in the ICA group. Total additional dose of iv fentanyl was significantly different between the groups (ICA 147 ± 41 vs Epidural 39 ± 15 μg; P = 0.015). Pain scores and fentanyl requirements spread over the lower range. The mean of VAS in ICA group was less than 5 even at coughing, suggesting clinically irrelevant., Conclusions: In patients with coagulopathy, multimodal approach using intercostal analgesia supplemented by intravenous patient-controlled analgesia may be an alternative to epidural analgesia for postoperative pain management.

Background: Remifentanil is a powerful analgesic with fast onset and ultra-short duration of action. Its context-sensitive half-time is consistently short even after a prolonged infusion. Remifentanil is effective for providing better postoperative analgesia, but this method is not generally accepted in Japan. The present study was conducted to document efficacy and safety of low-dose remifentanil infusion in postoperative patients., Methods: Forty patients undergoing abdominal surgery were studied prospectively. They were randomly assigned to either remifentanil (0.02 microg x kg(-1) x min(-1)) or placebo group. Postoperatively all patients received continuous epidural anesthesia with lidocaine and IV patient-controlled analgesia with fentanyl. Flurbiprofen was administered only when no pain relief was achieved. Visual analogue scale (VAS), requirement of fentanyl and flurbiprofen, and the incidence of remifentanil-related adverse effects (respiratory depression, nausea, vomiting, pruritus) were examined at 3 hourly intervals for 12 hours., Results: There are no statistical differences between two groups in pain scores. No adverse events including respiratory depression occurred throughout the study in both groups., Conclusions: Remifentanil infusion at 0.02 microg x kg(-1) x min(-1) can safely be used without any serious adverse events, while it may not be enough for postoperative analgesia. The best dosage of this drug for postoperative analgesia remains to be elucidated.

Pseudomyxoma peritonei causes marked accumulation of jelly-like ascites in the peritoneal cavity. Removal of much mucinous ascites by irrigating the cavity appears to be an effective treatment. We describe a patient who underwent the irrigation with sodium bicarbonate solution and developed critical alkalemia. A 68-year-old woman with normal renal function was operated on for recurrent pseudomyxoma peritonei. Fol- lowing the excision of primary lesion, her intraperitoneal cavity was irrigated with 10 1 of 7% sodium bicarbonate in about 45 minutes. Thirty minutes after irrigation, blood gas analysis revealed severe metabolic alkalosis (pH 7.714, BE 25.6 mmol x l-1 ) with electrolyte disorder (Na 157.8 mmol x l-1 K 2.31mmol x l-1, Ca 0.73 mmol x l-1). Hypotension (<60 mmHg) and sinus tachycardia (>130 beats x min -1) supervened 75 minutes later. Transferring to the ICU, she was given KC1 solution intravenously based on serial blood analysis while on mechanical ventilation. The next day acid-base disturbance returned spontaneously to normal (pH 7.45, BE 8.0mmol x l-1), leading to endotracheal extubation. Electrolyte imbalance was gradually resolved on 2nd POD and she was discharged from the ICU. Intraperitoneal irrigation with sodium bicarbonate requires special perioperative considerations for lifethreatening alkalemia, especially in a patient with renal impairment.

Background: Hypotension is a common adverse effect of spinal anesthesia (SA). Preoperative fluid infusion is recommended to prevent hypotension during caesarean section. The aim of this study is to document relationship between preoperative total body water (TBW) and the amount of the vasopressors given intraoperatively and to evaluate the change of maternal body water composition (BWC)., Methods: In 57 patients scheduled for caesarean section under SA, maternal BWC was measured by bioelectrical impedance analysis method. SA was performed using 0.5% isobaric bupivacaine 2 ml and fentanyl 20 microg at L3-4 intervertebral space. After this procedure, the impedance was measured again. We investigated the correlation between TBW and the amount of the vasopressor and the change of maternal BWC before and after SA., Results: No positive linear correlation existed between the preoperative TBW and the amount of vasopressors given intraoperatively. SA produced a 3.8% increase in TBW and a 4.7% increase in extracellular water (ECW, P < 0.01)., Conclusions: Preoperative TBW does not affect the amount of vasopressors given during caesarean section, which suggested massive fluid infusion can not always prevent hypotension after SA. A slight changes in TBW and ECW may be induced by SA, while the exact physiological and clinical significance of these observation remains to be elucidated.

Background: As for cervical spine injury, special consideration for airway management is required but the optimal strategy remains controversial. Direct laryngoscopy (DL) creates some degree of cervical extension leading to secondary neurologic deterioration. Fiberoptic bronchoscopy (FOB) may facilitate tracheal intubation with little cervical motion, but has several inherent limitations. A few objective data prompted us to compare the neurologic outcome relating to the orotracheal intubation using the different types of technique, the DL with a Macintosh blade or the FOB., Methods: To identify the effect of different methods on the intubation time, neurologic disability, and adverse effects, 68 cervical spine-injured patients with the use of DL (group L; 36 patients) or FOB (group F; 32 patients) were retrospectively reviewed using hospital records. Following the induction of general anesthesia, the trachea was intubated with no immobilizing forces in group L, while awake intubation was accomplished in group F after judicious application of local anesthesia to the larynx and trachea., Results: No significant differences were observed between the groups in age, BMI, intubation time, postoperative neurologic outcome or incidence of aspiration pneumonia. Moreover, no neurologic deterioration was shown after DL and orotracheal intubation., Conclusions: We found no evidence to support the routine practice of the bronchoscope-assisted awake intubation in patients with cervical spine injury. The clinical value of this technique in offering some neurologic advantage remains limited.

Background: Little information is available about anesthetic management in spine surgery for infectious spondylitis, in which major bleeding can be expected. The amount of blood loss may vary somewhat with pyogenic or tuberculous spondylitis. Limited data prompted us to get a clue to determine how best to care for these patients., Methods: To examine the amount of intraoperative bleeding, 71 patients with either pyogenic (group A; 44 patients) or tuberculous spondylitis (group B; 27 patients) were retrospectively reviewed using hospital records. They underwent posterior fusion with instrumentation and anterior radical resection of the lesion., Results: No significant differences were observed between the groups in age, gender, comorbidity or length of hospital stay. Operative time was longer in patients with group B (A: 126 +/- 41 vs B: 197 +/- 76 min, P<0.01). There was a trend toward greater blood loss in group B, especially massive bleeding (>1.5 l) occurred at a higher rate (13.6 vs 33.3%, P=0.05). The number of involved vertebrae was more in group B (1.8 +/- 0.9 vs 2.9 +/- 1.3, P<0.01). Both operative time and blood loss volume showed a good correlation with the number of vertebrae infected, suggesting that extensive eradication over several spinal segments may be indicated for tuberculous spondylitis., Conclusions: Spine surgery for tuberculous spondylitis is more likely to carry risks of longer operative time and higher rate of blood loss.

Adverse surgical outcomes appear to be more frequent in patients with known obstructive sleep apnea (OSA). However, OSA patients may present for surgery without a prior diagnosis. A 37-year-old man underwent craniotomy for surgical direct neck clipping of the right ruptured internal carotid aneurysm. His intraoperative and early postoperative courses were uneventful. At night, about 48 hr after surgery, he developed sudden generalized tonic-clonic convulsion and temporary depressed consciousness resulting in marked hypercapnea (Pa(CO2)>100 mmHg). His respiration was transiently supported by PSV mode via LMA. He soon got well without neurologic deficits. At night, about 74 hr postoperatively, a generalized convulsion was again observed with hypercapnea. Aside from the respiratory support, percutaneous cricothyroidotomy was performed using Minitrach II system for his airway control, leading to no further recurrence of seizure. He was suspected to have unrecognized OSA due to such characteristic findings of sleep apnea as obesity (BMI>30) and witnessed apneas by his family. Postoperative rapid eye movement (REM) sleep rebound has been suggested to contribute to two consecutive night appearance of seizure. Clinical suspicion for OSA should be required preoperatively and perioperative heightened awareness is recommended.

A 64-year-old woman with hypertension, diabetes mellitus and asymptomatic first degree AV block underwent low anterior resection of the rectum. Anesthesia was induced with propofol, vecuronium bromide and remifentanil and maintained with nitrous oxide in oxygen, propofol and remifentanil. We did not use epidural anesthesia. After the operation, the patient was admitted to the intensive care unit under general anesthesia with propofol and remifentanil. In addition, dexmedetomidine was given without loading dose. The EKG changed from first degree AV block to second degree AV block followed by complete AV block and finally cardiac arrest. As soon as we performed heart massage, sinus rhythm appeared. We should be careful in giving dexmedetomidine to a patient with AV block.

The autopsy of a 76-year-old Japanese female patient, which revealed thymic carcinoma with various tumor markers such as NSE, CYFRA, and CA-125, is presented. The patient died from hepatic failure because the liver was overtaken by the tumors. At autopsy, the thymic carcinoma was found to have metastased only in the liver. From microscopical analyses and electron microscopical findings, we diagnosed poorly differenciated squamous cell carcinoma of thymic origin. In the histochemical analyses, the tumor cells were positively stained in CA 125, CA 19-9, EMA, NSE, AE 1, AE 3, CEA, S-100, glimerius and Bcl-2. These date suggest that the tumor cells produced various tumor markers. In 222 autopsy cases of thymic malignant tumor observed in Japan over a period of 4 years, the dominant pathohistological image was squamous cell carcinoma. It is interesting that the greatest number of combined malignant tumors with thymic malignancies were thyroid papillary carcinomas.

Blood glucose and ketone body (3-hydroxy-butyrate) concentrations were measured in 8 children (4.2 +/- 2.8 years old) during the repair of lipomyelomeningocele (9.0 +/- 2.6 hours) to elucidate whether lipid mobilization can be prevented by glucose infusion at the rate of 0.2 +/- 0.05 g.kg-1.h-1. The operation was followed in about 4 hours by a significant increase in blood glucose and ketone body concentrations, with their maximum value of 195 +/- 75 mg.dl-1 and 656 +/- 75 mumol.l-1, respectively (P < 0.05), as compared with the preoperative level. The lipid mobilization soon returned to normal state by increasing the rate of glucose infusion, as indicated by ketone body level of 92 +/- 58 mumol.l-1 at the end of operation. These results show that glucose infusion rate should be adjusted based on serial analysis of both blood sugar and ketone body concentrations in the anesthetic management of children undergoing a long operation.

We studied the effects of prostaglandin E1 (PGE1) on hand-foot temperature gradients (foot temperature-hand temperature) induced by lumbar epidural anesthesia. Thirty-six ASA class 1 patients undergoing rotatory acetabular osteotomy were randomly assigned to receive 0 gamma (n = 13), 0.005 gamma (n = 10) and 0.02 gamma (n = 13) of PGE1. Thermometric probes were placed on the palm and sole of each patient. Bladder temperature was also monitored to evaluate the change of core temperature. Epidural catheter was indwelled at the level between L2 and L3 prior to induction and 2 % lidocaine was administered epidurally. All patients were warmed by water blanket at 37 degrees C and fluids for infusion warmed at 37 degrees C. Humidity and moisture exchanger was placed in breathing circuit. Hand-foot temperature gradients of patients given 0 and 0.005 gamma of PGE1 increased to 2.8 +/- 1.5 and 2.3 +/- 2.3 degrees C at extubation, respectively. In contrast, temperature gradient of patients given 0.02 gamma of PGE1 was 0.0 +/- 1.8 degrees C (P < 0.01). There was no difference among the values of bladder temperature in each group. The effects of PGE1 on mean arterial pressure, heart rate and central venous pressure were minimal. These data suggest that 0.02 gamma of PGE1 administration is effective to reduce hand-foot temperature gradient during epidural anesthesia.

Aldolase deficiency of red blood cell is a rare cause of hereditary hemolytic anemia and now there exists only three patients in the world. We had a 24-year-old man operated on for gallbladder stone secondary to this uncommon disease. He underwent a cholecystectomy under general anesthesia combined with thoracic epidural block, using isoflurane, fentanyl, vecuronium, midazolam and lidocaine. During the surgery serum concentrations of bilirubin, free hemoglobin and LDH showed no change, suggesting a lower incidence of drug-induced hemolysis in the case of aldolase deficiency than in other enzyme deficiency. This fact also provides a useful guide to the choice of anesthetics and related agents. In the postoperative period, however, we found a hemolytic response to fever with a drop in hemoglobin level to 2.5 g.dl-1. Aldolase activity of his red cell is heat labile and an increase in body temperature may aggravate a disturbance in the glycolytic pathway leading to hemolytic crisis. It is thus important to prevent the body temperature from rising when a patient is suffering from hemolytic anemia due to red cell aldolase deficiency.

We have measured blood concentrations of glucose, 3-hydroxybutyrate (3-OHBA), non-esterified fatty acid (NEFA) and lactate before and after glucose administration in 105 patients to determine the optimal glucose dose during the period of preoperative fasting state. The patients, scheduled for laparotomy in the afternoon, received fluid infusion containing an arbitrary glucose dose for 4 hours prior to surgery. The glucose dose showed a negative correlation with the ratio of 3-OHBA or NEFA prior to and after glucose administration (r = 0.40, r = 0.41 respectively, P < 0.05). There was no correlation between lactate ratio and glucose dose (r = 0.06). Glucose administration more than 0.4 g.kg-1 significantly suppressed 3-OHBA production (P < 0.05). Hyperglycemia (> 200 mg.dl-1) developed more often in the groups given 0.5 g.kg-1 or more glucose (P < 0.05), while significant hypoglycemia (< 60 mg.dl-1) occurred in the groups given less than 0.2 g.kg-1 of glucose (P < 0.05). This study demonstrates that preoperative infusion of glucose 0.4-0.5 g.kg-1 is useful to maintain the energy metabolism during the fasting state in patients scheduled for operation in the afternoon.

We studied the effects of prostaglandin E1 (PGE1) on renal function during and after deliberate hypotension induced by epidural anesthesia. Twenty-seven ASA class 1 patients undergoing rotatory acetabular osteotomy were divided into three groups according to the dose of PGE1. Deliberate hypotension was induced and maintained during the surgery by epidural anesthesia combined with general anesthesia. PGE1 increased urine output and creatinine clearance (Ccr) during hypotension in dose dependent manner, and the changes were statistically significant compared with control at the dose of 0.02 micrograms.kg-1 x min-1 (gamma). PGE1 also tended to increase postoperative urine output and Ccr. Regardless of PGE1 administration, urine NAG/Cr ratio tended to increase during and after deliberate hypotension. Though total dose of local anesthetics was attenuated by PGE1, serum catecholamine levels of all patients were within normal ranges. In conclusion, PGE1 0.02 gamma is effective to maintain urine output during deliberate hypotension with epidural anesthesia. However, PGE1 is unlikely to prevent renal tubular damage at the dose less than 0.02 gamma.

Ninety total hip replacements (THRs) performed by one surgeon were reviewed to compare the effects of different anesthetic techniques on the perioperative bleeding. Half of the THRs were performed under either combined spinal and epidural (CSE) anesthesia with lidocaine or general anesthesia with N2O/O2, vecuronium, enflurane or isoflurane. Deliberate hypotensive technique was not employed in any THR. All patients were female and had suffered from osteoarthritis of the hip joints. The patients in the two anesthesia groups were similar as to age, body weight, height, perioperative hemoglobin level, duration of anesthesia and operation, and blood transfusion requirement. A positive linear correlation existed between total operative blood loss and operation time in each group (P < 0.01). The rate of operative blood loss was significantly higher in the CSE anesthesia (6.2 +/- 3.0 ml.min-1) than in the general anesthesia (5.1 +/- 2.0 ml.min-1), while the amount of blood loss itself was without statistical difference. A significant increase in total volume of perioperative blood loss was also observed in the group with CSE anesthesia (1520 +/- 90 ml) compared with the general anesthesia group (1279 +/- 58 ml). These results show that spinal and/or epidural anesthesia can not always lead to reductions in operative blood loss during THR.

We have studied common problems associated with the anesthetic management of Forestier's disease in 8 patients undergoing neurosurgery. This disease is a systemic degenerative disorder and is characterized by osteo-spur formation at anterior spinal body. In two of eight patients the trachea was intubated with great difficulty even by well-trained anesthesiologist. Its cause could be found not only in limited cervical mobility but also in constrained epiglottic elevation, suggesting that Forestier's disease requires special anesthetic considerations. It is thus important to predict the possibility of difficult tracheal intubation on both physical examination and the preoperative X-ray photography.

We have studied the concentrations of catecholamines in collected autologous blood. The measured levels of the blood samples from Cell-stat collecting chamber were epinephrine 4.74 ng.ml-1 and norepinephrine 2.39 ng.ml-1. First wash of collected blood with 700 ml of saline diluted the catecholamine concentrations to epinephrine 3.13 ng.ml-1 and norepinephrine 1.6 ng.ml-1. The concentrations of catecholamines after second wash were epinephrine 2.19 ng.ml-1 and norepinephrine 1.11 ng.ml-1. These values were three to twenty folds of normal ranges even after the second wash, and still the same levels as intraoperative plasma catecholamine (the measured values; epinephrine 0.81-2.81 ng.ml-1 and norepinephrine 0.96-3.15 ng.ml-1). Since platelets actively concentrate catecholamines during their life span, the destruction of platelets by suction or centrifugation may probably play the most important role in the elevation of catecholamine concentrations in the collected autologous blood. We concluded that intraoperative autotransfusion in the resection of pheochromocytoma is likely to result in the elevation of systemic blood pressure by catecholamines of the transfused blood.

The pros and cons as to which anesthesia is more beneficial, either spinal or epidural, prompted us to perform combined spinal and epidural block in the elderly undergoing lower limb surgery. The selected epidural space was entered with a 17-gauge Tuohy needle and a longer 26-gauge spinal needle was passed through it and into the subarachnoid space. Following the injection of required dose of 2% preservative-free lidocaine (isobaric), spinal needle was withdrawn and an epidural catheter was inserted. We could use this combined technique on 17 patients older than 80 yr (mean age; 84.5 +/- 3.9 years) with satisfactory results and without any serious cardiovascular change, as with 17 middle-aged patients (57.5 +/- 5.2 years). This combination of techniques provides a rapid onset and reliability of spinal block with high quality analgesia by supplementation through the epidural catheter during and after surgery. In the orthopaedic procedures on the lower limbs, combined spinal and epidural block is more useful even for the elderly over the age of 80 yr than spinal or epidural anesthesia alone.

In a double blind test, the effects of ONO 3708, thromboxane A2 (TXA2) receptor antagonist, on hemodynamic responses after neutralization of heparin by protamine, were evaluated in 19 patients undergoing coronary artery bypass graft. Severe circulatory disturbances were not observed in all patients after intravenous administration of protamine (3 mg.kg-1) over 5 minutes, and in particular ONO 3708 (2.5 micrograms.kg-1.min-1 given with continuous infusion) group (n = 10) showed no deleterious hemodynamic responses to protamine. On the other hand, in placebo group (n = 9) the mean pulmonary artery pressure (mPAP) and the mean pulmonary/systemic artery pressure ratio (Pp/Ps) increased significantly, immediately following protamine administration, compared with the baseline values and ONO 3708 group. The results suggest that pulmonary hypertension after protamine is associated with TXA2 release and that ONO 3708 is useful to avoid this reaction.

With the development of medical ultrasonics, anesthesiologists have recognized the usefulness of transesophageal echocardiography as an intraoperative monitoring. Intraoperative transesophageal echocardiography is now used to monitor left ventricular function and to confirm the result of surgical correction immediately after cardiac operation. In this study, we evaluated the detectability of air embolism and the effect of hemodynamic changes on physiological mitral regurgitant flow by transesophageal Doppler echocardiography (TEDE). TEDE was more sensitive than precordial Doppler ultrasound in detecting intracardiac air. TEDE could detect air inflow to the right atrium earlier than alterations in pulmonary hemodynamics. The monitoring of intracardiac air by TEDE minimized the complication by air embolism. Regarding physiological mitral regurgitation, the degree of regurgitation increased with the elevation of BP in 70% of patients. An increase in afterload seemed to cause accidental volume loading on the left heart resulting in physiological mitral regurgitation. Intraoperative monitoring of regurgitant flow by TEDE was useful for the anesthesiologist as a guide of hemodynamic management. Transesophageal echocardiography is a useful intraoperative monitoring method regardless of its several disadvantages. With further improvement of mechanical device, transesophageal echocardiography will be more often and safely performed in operating room.