[Efficacy of the cuffed oropharyngeal airway in spontaneously breathing patients]

A cuffed oropharyngeal airway (COPA) was used in 20 adult patients for airway management under epidural and brachial plexus block supplemented with light general anesthesia. Insertion of a COPA was successful at first attempt in 17 of 20 patients (85%). Sore throat developed in one patient (5%). Aspiration regurgitation, or laryngospasm was not observed. We conclude that a COPA can be an efficient airway device is spontaneously breathing patients under anesthesia.

[Cardiac asystole in the postanesthetic care unit: a case report]

We report a patient without apparent heart disease who developed asystole postoperatively. A 24-year-old woman was scheduled for acetabulectomy under lumbar epidural anesthesia with intravenous propofol infusion. There was no profound hypotension or arrhythmia during anesthesia and surgery. She complained of nausea 50 minutes after the operation. The ECG showed an abrupt decrease in the heart rate followed by cardiac asystole 30 seconds after the onset of nausea. Prompt cardiac massage resumed the heart beats in eight seconds. There was no neurological deficit.

[Anesthetic management of patients with Poland syndrome: report of two cases]

Poland syndrome is a rare anomaly characterized by unilateral absence of the pectoral muscles and ipsilateral syndactyly and microdactyly. Associated anomalies include defect of ipsilateral ribs and costal cartilages. We report two cases of Poland syndrome. The first case, 24 year old female patient underwent mammoplasty. Although her pectoral muscles were absent, there was no rib or costal cartilage defect. General anesthesia was maintained with assisted spontaneous respiration through laryngeal mask airway. The second case, 18 year old male patient had rib cage defect. Although the patient was asymptomatic when he was awake, paradoxical respiratory movement could have caused inadequate ventilation during general anesthesia. Anesthesia was maintained with intermittent positive pressure ventilation through endotracheal tube during skin flap plasty of latissimus dorsi muscle. In both cases, there was no respiratory complication during perioperative period.

[Anesthetic management of a cesarean section in a patient with schizophrenia receiving a large amount of antipsychotic agents]

We experienced perioperative management of a patient with schizophrenia who had been taking a large amount of antipsychotic agents until the cesarean section. A 31-year-old woman in 38th week gestation with schizophrenia underwent a cesarean section. Anesthesia was maintained with light plane of general anesthesia combined with epidural anesthesia. Perioperatively, the mother experienced no complications and the baby only developed slight generalized tremor and hypotonus for a short period after delivery.

[Anesthetic management for a patient with hyper-IgE syndrome]

Hyper-IgE syndrome is a rare immunodeficiency disorder characterized by recurrent skin and pulmonary infections and extremely elevated serum levels of IgE. A 6-year-old girl with hyper-IgE syndrome underwent appendectomy. Anesthesia was induced with sevoflurane. After insertion of a laryngeal mask, anesthesia was maintained with nitrous oxide, sevoflurane, and oxygen. There were no perioperative complications related to anesthesia and surgery.

Trimetaphan may cause coronary artery spasm

We describe a patient in whom possible coronary artery spasm occurred during the infusion of trimetaphan. A 55-year-old man with a meningioma was scheduled for surgical excision of the tumour. He denied any previous history of chest pain. Anaesthesia was maintained with nitrous oxide (67%) in oxygen. The blood pressure before commencement of the surgery was 114/70 mmHg, and the pulse rate was 60 beats min-1. The blood pressure rose to 152/94 mmHg (the pulse rate to 62 beats min-1) during incision of the scalp, and intravenous infusion of trimetaphan was initiated. The blood pressure gradually decreased to 113/58 mmHg (the pulse rate 64 beats min-1) 10 min after start of this infusion, and premature ventricular contractions were evident on the electrocardiogram. Trimetaphan was withheld, and lignocaine was given intravenously. The premature ventricular contractions disappeared but ST segments were elevated. Glyceryl trinitrate was then infused intravenously. The ST segments remained elevated for 5 min, were depressed for 2 min and finally became isoelectric. There were no wide swings in blood pressure or pulse rate during the event. Post-operative laboratory examination revealed no evidence of myocardial infarction. Recovery of the patient was uneventful.

[Extrapyramidal reactions after epidural droperidol]

We report two patients who developed extrapyramidal reactions after epidural droperidol given to prevent postoperative nausea and vomiting. The reactions may have been related to interactions of drugs given perioperatively. One patient had been taking amlodipine and amitriptyline preoperatively, capable of causing extrapyramidal reactions, and developed akathisia after 2.5 mg of droperidol given epidurally. The other patient had received 1.5 mg of prophylactic epidural droperidol and 10 mg of metoclopramide for postoperative nausea and vomiting, and developed acute dystonia shortly after 0.5 mg of intravenous droperidol.

[Anesthesia for a patient with olivopontocerebellar atrophy]

Olivopontocerebellar atrophy (OPCA) is one of the spinocerebellar degenerative diseases. Reports of patients complicated with OPCA are scarce in anesthetic literature. We managed a 79-year-old woman with sialolithiasis of the left submandibular gland complicated with OPCA. She underwent a removal of the gland under general anesthesia using oxygen, nitrous oxide, and isoflurane (0.6-2.0%). Blood pressure decreased transiently after induction of anesthesia, but, no vasopressors were needed to maintain the blood pressure during the surgery. There were no untoward cardio-respiratory events after the surgery. Perioperative anesthetic management of patients with OPCA is also discussed.

[Anesthetic management of tracheal stent insertion under total intravenous anesthesia--a report of two cases]

Tracheal stent insertion is a useful method for patients with malignant tracheal stenosis. Expandable metal stents were inserted in two patients with severe dyspnea due to tracheal stenosis caused by lung cancer and esophageal cancer. The tracheas were intubated after spraying the pharynx with 4% lidocaine solution. The respiration was assisted. Anesthesia was maintained by intravenous propofol. There were no episodes of coughing during and after the procedure.

[Anesthetic management of a patient with tuberous sclerosis]

Tuberous sclerosis is characterized by facial angiofibromatosis, epilepsy, and mental retardation. There have been only a few reports of anesthetic management of patients with tuberous sclerosis. We managed a 22-year-old patient with tuberous sclerosis using nitrous oxide (67%) in oxygen supplemented with fentanyl and midazolam. There were no untoward events related to anesthesia and surgery. Problems in managing patients with tuberous sclerosis are also discussed.

[Subdural block which appeared 21 days after beginning continuous epidural block]

An epidural catheter was inserted at the T10-11 interspace for the treatment of acute herpetic pain in a 68-year-old woman. Loss of resistance method with saline was used for identifying the epidural space. After negative aspiration test for cerebrospinal fluid and blood, continuous epidural infusion of 0.2% ropivacaine 2 ml x hr(-1) with intermittent injections of 1% mepivacaine 3 ml was performed for 20 days without side effects. However, on the 21st day, Horner's syndrome and weakness of the left arm and leg appeared 10 minutes after injection of 1% mepivacaine 3 ml. The symptoms and signs suggested subdural block. Migration of the epidural catheter into the subdural space may have occurred. Subdural block may occur even if the catheter is initially properly placed in the epidural space.

[Anesthetic management of a patient with single atrium and single ventricle]

A 41-year-old woman with single atrium and single ventricle at 6 weeks of gestation was scheduled for dilation and evacuation of the fetus. The PaO2 was 39 mmHg, while she was breathing room air. Dilatation of the uterine cervical canal was performed under spinal anesthesia using 2.0 ml of 0.5% hyperbaric bupivacaine one day before dilatation and evacuation of the fetus. A sensory anesthesia level of T 10-S 5 was achieved. The systolic blood pressure decreased to around 70 mmHg. On the next day, dilation and evacuation of the fetus was performed under spinal anesthesia using 1.5 ml of 0.5% isobaric bupivacaine. Sensory anesthesia level was L 1-S 5. There was no precipitous decrease in blood pressure. However, intravenous fentanyl was needed during the procedure. There was no cardiovascular or respiratory complication after anesthesia and surgery. The patient was discharged on the next day.

[Anesthetic management of a patient with diaphragmatic relaxation and megacolon]

We managed an 87-year-old man with diaphragmatic relaxation under general anesthesia. He had dyspnea and severe constipation. The chest X-ray revealed that two thirds of the left chest cavity were compressed by the megacolon gas. The Spo2 before the operation was 93%. The colon gas was deflated before and after the induction of anesthesia. There was no significant improvement in the tidal volume and the arterial oxygen tension. The postoperative chest X-ray showed that the shift of the left diaphragm was improved. He was able to walk 100 meters and the severe constipation disappeared after the operation.

[Aseptic precautions in epidural catheterization for surgery]

We describe aseptic precautions in epidural catheterization for surgery. Every patient has to be checked for immunodeficiency, atopic dermatitis, preoperative use of antibiotics, and local infection of the epidural puncture site. Physicians who perform epidural catheterization should wear a mask and a cap and take off a wrist watch and rings on the fingers before an epidural kit is opened. Fingers and hands should be disinfected before wearing surgical gloves. The skin for epidural puncture site should be disinfected with 0.5% chlorhexidine in 80% ethanol. A micropore filter should be used when epidural catheterization is expected to remain over 24 hours.

[Reversal of rocuronium induced neuromuscular block with sugammadex in a patient with myasthenia gravis]

We report a patient with myasthenia gravis whose rocuronium induced neuromuscular block was reversed with sugammadex. A 26-year-old man, 175 cm and 76 kg, with myasthenia gravis, was scheduled for extended thymectomy under general anesthesia. An epidural catheter was inserted at the T5-6 interspace before induction of general anesthesia. Anesthesia was induced with propofol and remifentanil. Rocuronium was given in divided doses to obtain > 95% neuromuscular block to intubate the trachea. The ED50 and ED95 of rocuronium for this patient were 0.18 mg x kg(-1) and 0.39 mg x kg(-1), respectively. The values were similar to the ED50 and ED95 of rocuronium for normal patients. General anesthesia was maintained with propofol and remifentanil. Additional doses of rocuronium were given intermittently. Sugammadex, 2 mg x kg(-1), was given at the end of the surgery. The train-of-four ratio reached 93% 105 sec later. His postoperative course was uneventful.

[Postherpetic neuralgia]

Varicella-zoster virus (VZV) causes two clinically distinct diseases: varicella and herpes zoster. Herpes zoster, recurrent infection of VZV occurs when the cell-mediated immunity to VZV declines. Since the cell-medicated immunity to VZV declines with aging, herpes zoster occurs more frequently in the elderly. Most frequent and dreaded complication of herpes zoster is postherpetic neuralgia (PHN). The first line of treatment of PHN is medication with tricyclic antidipressants and anticonvulsants. Double-blind studies showed that effective tricyclic antidepressants for the treatment of PHN are amitriptyline and nortriptyline, and effective anticonvulsants gabapentin and pregabalin. When tricyclic antidepressant and/or anticonvulsant cannot relieve PHN, opioids should be considered in some selected patients. Although neuroablative procedures have been performed for the treatment of PHN, their effectiveness was not confirmed by double-blind studies. They rather aggravate PHN with time. Recent research with a live attenuated varicella vaccine to prevent herpes zoster indicated that the vaccine decreased the occurrence of herpes zoster and postherpetic neuralgia by almost half as compared with placebo. Vaccination of high risk subjects with the varicella vaccine seems to be the most effective measure for the prevention of postherpetic neuralgia.

[Anesthetic management of total hysterectomy in a patient with pulmonary thromboembolism]

We report anesthetic management of a 38-year-old woman with pulmonary thromboembolism for total hysterectomy. She had been taking oral contraceptives for adenomyosis of the uterus. She had thrombi in the arteries from pulmonary trunk to bilateral main pulmonary arteries. Thrombolytic and anticoagulant therapies did not decrease the thrombi. Removal of the swollen uterus suspected to be the origin of the thrombi, rather than thromboembolectomy, was scheduled. Cannulation for percutaneous cardiopulmonary support was set up just in case of hemodynamic derangement, before the surgery. Cardiac contraction was evaluated with transesophageal echocardiography during the surgery. There was no untoward perioperative event. Pulmonary thromboembolectomy was not done because the postoperative CT revealed shrinkage of the pulmonary thrombi after anticoagulation treatment.

[Hypoxemia caused by retention of irrigation fluid to detect leaks from the lungs during subtotal esophagectomy]

We report a patient who developed hypoxemia caused by retention of irrigation fluid used to detect leaks from the lungs during subtotal esophagectomy. A 58-year-old man developed a sudden onset of hypoxemia with a decrease in tidal volume during subtotal esophagectomy. Chest X-ray revealed a homogeneous opacity of the left lung field, suggesting the presence of fluid in the pleural cavity on the left. The tidal volume and SpO2 increased after drainage of the fluid from the left pleural cavity. The postoperative course was uneventful and the patient was discharged on the 16th postoperative day.

[Anesthetic management for nephrectomy in a 2-year-old girl with abdominal aortic aneurysm]

We report anesthetic management for nephrectomy in an infant with aortic aneurysm. A 2-year-old girl with renovascular hypertension and abdominal aortic aneurysm, who had shown repeated episodes of heart failure, was scheduled for nephrectomy. Anesthesia was induced with sevoflurane in nitrous oxide (70%) and oxygen. During the surgery, anesthesia was maintained with sevoflurane (1.5%) in nitrous oxide (50%) and oxygen, supplemented with intermittent epidural block. The blood pressure did not show marked changes during the surgery. There was no perioperative cardiovascular complication.