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Malignant hyperthermia occurred 10 hours after surgery in a 72-year-old man who had received emergency laparoscopic cholecystectomy for severe acute cholecystitis with cholelethiasis. He had a high fever (39.4 degrees C) with liver damage before surgery. Anesthesia was induced with propofol and fentanyl and maintained with sevoflurane and epidural block using ropivacaine. Rocuronium was used as a muscle relaxant During surgery, body temperature decreased by cooling the body surface, but tachycardia continued. Ten hours after surgery, body temperature increased to the maximum of 40.6 degrees C and he went into shock. Then another 10 hours later, he developed cardiac arrest He recovered, but 22 hours later, second cardiac arrest occurred. After his second recovery, dantrolene was administered and body temperature decreased. He had hypoxic brain damage, but was dischanged from the hospital after tracheostomy on the 150th hospital day. From his clinical course, especially decrease in body temperature by dantrolene, he was suspected to have developed malignant hyperthermia. We should consider malignant hyperthermia when patient had a severe high fever postoperatively.

A few cases of the pituitary apoplexy have been reported after spinal anesthesia in patients with pituitary tumor. A patient with giant pituitary adenoma underwent open reduction of the ankle fracture. This 69-year-old man had no symptoms related to pituitary adenoma. Femoral and sciatic nerve blocks were chosen to avoid pituitary apoplexy, cerebral herniation and other complications related to spinal anesthesia. The surgery was successfully done without any complications and the patient was discharged uneventfully 25 days after surgery. When patient has a giant pituitary tumor, peripheral nerve block might be a good choice for anesthesia.

A 60-year-old female with anti-phospholipid syndrome underwent amputation of her left lower limb. She had had a history of cerebral infarction, cerebral hemorrhage, coagulation abnormalities, thrombocytopenia, and pneumothorax, and just recovered from disseminated intravascular coagulation. After intravenous fentanyl 25 microg, ultrasound-guided sciatic, femoral and lateral femoral cutaneous nerve blocks were performed. We used 0.75% ropivacaine 15 ml and 1% lidocaine 15 ml for sciatic nerve block, 0.75% ropivacaine 5 ml and 1% lidocaine 5 ml for femoral nerve block and 0.75% ropivacaine 5 ml for femoral cutaneous nerve block. For femoral nerve block, a catheter was inserted and ropivacaine was infused at 4 ml x hr(-1) after surgery. Amputation at the left thigh was successfully performed and postoperative course was uneventful. The sciatic, femoral and lateral femoral cutaneous nerve blocks were useful for amputation of a patient with severe coagulopathy by anti-phospholipid syndrome.

An 83-year-old woman was scheduled for surgery of the left upper and lower extremity fracture. She had past history of lung partial resection for lung cancer and rheumatoid arthritis, and recent history of pneumonia. She also had fluid retention in the thoracic cavity. Open resection of the femoral neck fracture was first performed uneventfully under spinal anesthesia with bupivacaine 0.5% 2 ml. Then, interscalene blaxioplexus block was performed with 0.75% ropivacaine 15 ml and 1% lidocaine 10 ml for tension band wiring of the fractured olecranon. Midazolam 1 mg and propofol 1.5 mg x kg(-1) x hr(-1) were administered for sedation. Thirty minutes after the block, oxgen saturation decreased to 92% under O2 3 l x min(-1) by a mask. She was intubated and arterial carbon dioxide tension was above 150 mmHg. A few hours later, she became conscious and mask CPAP was used after extubation for one day. Pa(CO2) was 90-100 mmHg for 3 days and decreased to 56.9 mmHg on the 6th day, but her consciousness had been clear. Phrenic nerve palsy and sedation in the patient with decreased lung function might have induced prolonged hypercapnea.

An 85-year-old woman recieved emergency repair of left obturator hernia under general anesthesia. The surgery was completed uneventfully. Shortly after the admission to the recovery unit, blood pressure dropped to 80mmHg and ECG showed negative T wave. Hypotension was successfully treated with colloid infusion and dopamine administration, but negative T wave was unchanged by nitrate infusion. The serum CK-MB examination indicated no cardiomyogenic problems. On postoperative day 13, she received emergency colostomy under general anesthesia. Large negative T wave still persisted. Immediately after induction of anesthesia, she showed hypotension, which recovered by fluid infusion and intravenous ephedrine. The UCG after surgery showed hypokinesis of the apex of left ventricle. She was diagnosed as Tako-tsubo myocardiopathy. One month after the second surgery, she received closure of colostomy under general anesthesia combined with continuous epidural anesthesia, when negative T wave was seen on the ECG. Negative T wave returned to normal 10 weeks after the first surgery. When unknown tachycardia and negative T waves are seen, Tako-tsubo cardiomyopathy should be considered.

The aim of our study was to clarify how catheter products are purchased by urinary homecare patients and to find problems associated with such purchases. We conducted a survey using a self-made questionnaire for 26 catheterized patients from Prefecture A, who were regular outpatients of the urology department. The results indicated that 17 patients(65. 4%)purchased catheter supplies on their own(13 males and 4 females, the mean age was 57. 9 years). The products purchased by the 26 patients were diverse including urine bags, syringes, catheters and tissues paper. Seven of the 17 patients(41%)responded that purchasing catheter supplies on their own was difficult, and 8(47%)responded that purchasing catheter supplies was an economic burden for them. The cost of purchasing catheter supplies varied greatly among the patients, and the price range was from 400 yen to 12, 000 yen. The cost was generally associated with the feelings of economic stress: it happens every month; it is a burden for some patients who need them for life time.

Objectives: This study investigated the current status of goods supplied by medical facilities to outpatients practicing ISC., Methods: The status of goods supplied was investigated by interviewing 4 medical facilities and 26 outpatients practicing ISC, using a questionnaire., Results: 1. Of all goods supplied for use by outpatients practicing ISC, 53. 0%were supplied by medical facilities. The outpatients bought some goods required for ISC by himself. Moreover, some goods were supplied by prescription. 2. When a hospital was consulted, while there were those to whom goods are not supplied from a hospital, there were those to whom much kinds and quantity are supplied from the hospital. As for the patient to whom many kinds and the goods of quantity are supplied, goods expense formed about 70% of ISC administration fee., Discussion: In order to establish goods feed system, it was necessary to examine a common knowledge of the structure of goods supply to doctors or nurses and the validity of the ISC administration fee system from now on.

The aim of this study was to clarify why a homecare patient had an anxiety and the type of difficulties while having an intermittent self-catheterization at home. We used a questionnaire survey to conduct an oral interview for 25 homecare patients, who regularly had an intermittent self-catheterization. The survey results were codified into single phrase units of meaning, and then separated into categories. The results revealed that 70 to 80% of patients who had an intermittent self catheterization in their own homes experienced an anxiety and encountered difficulties during the process. The findings emphasized the importance of providing a sort of support for homecare patients when they have an intermittent self-catheterization for the first time, as well as the importance of providing continued support until the patients are comfortable with the procedure. For a future support, these patients' anxiety need to be reduced and difficulties related to an intermittent self catheterization resolved during an outpatient visit.

Background: Although administration of heparin is a useful method for preventing deep venous thromboembolism, one limitation is the increased risk of bleeding. In this retrospective investigation, we evaluated the effect of heparin on the activated partial thromboplastin time (APTT) in parturients who received caesarean section under combined spinal and epidural anesthesia., Methods: In order to prevent deep venous thromboembolism, heparin 5000 units twice daily, was subcutaneously given in 199 parturients who received caesarean section under combined spinal and epidural anesthesia. Measured APTT was compared between before and after administration of the heparin., Results: The heparin extended APTT from 29.6 +/- 2.5 sec to 35.4 +/- 5.9 sec (P < 0.05). An extended APTT by 1.5 times or more was found in 1.1% of the patients. There was no deep thromboembolism nor increased bleeding, including intra-abdominal and epidural hematoma., Conclusions: Subcutaneously administered heparin, 5000 units twice daily, might have a role in preventing deep venous thromboembolism in parturients undergoing caesarean section. Strict vigilance, however, should be provided against increased bleeding associated with epidural hematoma in parturients with an indwelling epidural catheter.

Fire accident is one of the most severe complications that can occur in the perioperative period. We report a case of an episode of electrosurgical burn. An 80-year-old woman was scheduled for ascending colectomy due to ascending colon carcinoma. The skin of the surgical site was sterilized with alcoholic antiseptic containing chlorhexidine before the operation. On coagulating the bleeding point of the subcutaneous fatty tissue, a spark of the electric scalpel ignited the alcoholic antiseptic. She had burn on her right thorax, lower abdomen and femoral region. Two-degree burn occupied 2% of the body surface and three-degree burn 3%. She underwent dermatoplasty 14 days later. Postoperative course was uneventful and she left the hospital on the 58th postoperative day. An alcoholic antiseptic is the most useful and has an immediate effect for preoperative disinfection of the skin according to the CDC guideline. However, electric scalpel and alcoholic use are always accompanied with the risk of ignition and sufficient caution is required.

Two patients with chronic renal failure on hemodialysis, received rapid transfusion of packed red blood cells (PRBCs) because of massive intraoperative bleeding. To eliminate the excessive potassium in PRBCs, a potassium adsorption filter (Kawasumi KPF-4, Kawasumi Laboratories, INC., Tokyo, Japan) was applied during surgery. The potassium adsorption filter successfully reduced the potassium concentration from 14.4-22.0 mEq x l(-1) to 1.9-3.7 mEq x l(-1). A potassium adsorption filter is a simple and useful alternative for removal of excessive potassium in PRBCs.

A 48-year-old woman with aortitis syndrome underwent clipping of dissecting aneurysm of the left posterior inferior cerebellar artery following subarachnoid hemorrhage. Preoperative echocardiography demonstrated moderate aortic regurgitation and pulmonary hypertension. Intravenous infusion (1900 ml.day-1) was performed to avoid cerebral vasospasm, but the patient developed lung edema. She received delayed surgical treatment after the improvement of lung symptoms. Anesthesia was induced with fentanyl (0.1 mg), propofol (90 mg) and vecuronium (6 mg). Radial arterial flow was judged to be insufficient for cannulation, and a cannulation was therefore performed on the dorsal pedis artery. During induction of anesthesia, there was a significant decrease in the arterial pressure, that required a total of 32 mg of intravenous ephedrine. Following tracheal intubation, a central venous catheter was inserted and dopamine was continuously administered. The patient was positioned in the park bench position. We thought that the placement of the introducer for Swan-Ganz catheter was difficult under the position and Swan-Ganz catheter was not inserted. Anesthesia was maintained with sevoflurane, air, and oxygen. We continuously monitored the central venous pressure as an indicator of fluid balance. In this case, we monitored dorsal pedis arterial pressure directly, which might not be sufficiently reliable to predict the decrease in cerebral blood flow.