[Tracheal rupture in a patient intubated with a double-lumen endobronchial tube]

We report a case of tracheal rupture associated with use of a double-lumen endobronchial tube. The patient was a 58-year-old woman with metastatic carcinoma of the right upper lung lobe. Her trachea was intubated easily with a left-sided double-lumen endobronchial tube (Broncho-Cath, #35Fr). She underwent right upper lobectomy under general anesthesia using isoflurane (0.4-1.0%) and nitrous oxide (50%) in oxygen. When the lungs were inflated before closure of the chest, an air leak at the membranous part of the trachea was detected. A tracheal rupture, beginning 3 cm above the carina and 7 cm long, was noted at the membranous part of the trachea, and the cuff protruded partially from the ruptured trachea. The trachea was sutured, and a tracheostomy was carried out. Mechanisms of tracheal rupture related to double-lumen endobronchial tubes are discussed.

[Emergency microlaryngosurgery for a huge post-intubation laryngeal granuloma]

A 55-year-old woman who had undergone esophagectomy 3 months earlier developed a huge post-intubation laryngeal granuloma. She was scheduled for emergency microlaryngosurgery. Anesthesia was induced with 8% sevoflurane in oxygen under spontaneous respiration. After confirming no airway compromise, the spontaneous respiration was obtunded by forced manual ventilation without using a muscle relaxant. The trachea was intubated easily with an endotracheal tube. Anesthesia was maintained with sevoflurane and nitrous oxide supplemented with intravenous fentanyl. The granuloma removed was 11 x 8 mm in diameter. There were no respiratory complications during and after anesthesia and surgery.

[Anesthetic management of a child with Russell-Silver syndrome]

A 2-year-old boy with Russell-Silver syndrome (RSS) was scheduled for corrective surgery for hypospadia. He had characteristic features of RSS, such as intrauterine growth retardation with subsequent marked postnatal growth impairment, body asymmetry and small triangular face. Anesthesia was induced with sevoflurane in oxygen-enriched air. The lungs were easily ventilated with a bag and mask. Tracheal intubation was extremely difficult because of the micrognathia and high arched palate, but finally successful with the use of a stylet in the endotracheal tube. Caudal epidural block was not performed because of a possible spina bifida. There were no complications related to anesthesia and surgery.

[Anesthetic management for partial lobectomy in a postpneumonectomy patient]

We report a postpneumonectomy patient who underwent partial lobectomy. A 74-year-old man was scheduled for right partial lobectomy because of metastatic lung cancer. He had undergone left pneumonectomy 19 months before because of lung cancer. Anesthesia was maintained with intravenous propofol and thoracic epidural block. During surgery, respiration was maintained with mechanical and intermittent manual ventilation. Percutaneous cardiopulmonary support and high frequency jet ventilation were at hand but were not needed. There was no intraoperative hypoxia and the postoperative course was uneventful.

[Anesthetic management of a patient with tetanus using epidural anesthesia]

A 75-year-old woman with breast cancer complicated with tetanus was scheduled for mastectomy. Since severe bradycardia (17 beats.min-1) was detected by preoperative Holter monitoring, a temporary pacing catheter was inserted. She underwent mastectomy under general anesthesia using propofol combined with thoracic epidural anesthesia. She also received postoperative thoracic epidural block. Her perioperative heart rate was 80-105 beats.min-1 and the rhythm was sinus. There was no marked perioperative cardiovascular derangement.

[Recurrence of bullous pemphigoid after surgery: report of a case]

We report a 38-year-old woman with myoma uteri and bullous pemphigoid controlled by oral prednisolone (7.5 mg.day-1). She underwent transabdominal hysterectomy under epidural anesthesia using mepivacaine supplemented with intravenous midazolam and butorphanol, without untoward event. On the postoperative day 2, recurrence of bullous pemphigoid was noted. The skin lesion of pemphigoid was improved after increasing the prednisolone dose up to 60 mg a day.

[A patient with Shy-Drager syndrome managed under general anesthesia with thoracic epidural anesthesia]

A 61-year-old man with Shy-Drager Syndrome underwent partial pulmonary lobectomy under general anesthesia combined with thoracic epidural anesthesia. The blood pressure decreased from 140/ 100 mmHg to 80/50 mmHg after thoracic epidural anesthesia. It increased after intravenous ephedrine. The blood pressure decreased when he was returned to the supine position postoperatively. It did not increase as expected with intravenous ephedrine. Intravenous etilefrine promptly raised the blood pressure. There was no postoperative cardiorespiratory complications.

[Corneal abrasion after general anesthesia despite application of eye patches]

A 37-year-old man with exophthalmos underwent resection of the left apical peridontal cyst under general anesthesia. Eye patches (Opticlude) without adherence to epibulbar area were used during anesthesia and surgery. At the end of the surgery, his left eyelid was noted to be incompletely closed. His left bulbar conjunctiva showed marked conjestion with severe pain. Staining with fluorescein dye demonstrated corneal abrasion in the lower third of the left eye. The corneal abrasion healed in two days after topical treatment.

[Neuromuscular monitoring]

In patients receiving a neuromuscular blocking agent, quantitative monitoring of neuromuscular function is essential. For this purpose, neuromuscular monitoring devices which provide train-of-four ratio values are necessary In the absence of a quantitative monitoring device, neuromuscular function may be evaluated with the use of a nerve stimulator. Muscle responses can be monitored either using the mechanomyography, electromyography, acceleromyography, or phonomyography. Although, mechanomyography is still considred the gold standard for assessing the neuromuscular function, mechanomyography is not easy to set up and use in a routine clinical setting. At present we have only two commercially available devices which are easy to set up and useful in daily clinical practice. One is M-NMT monitor which comes with Datex AS/3 or S/5 monitor. The other is TOF-Watch acceleromyographic monitor. In clinical anesthesia, sites of monitoring can be any superficially located peripheral nerves and innervated muscles. Since different muscle groups have different sensitivity to neuromuscular blocking agents, results obtained for one muscle cannot be extrapolated to other muscles. Also, results from one monitoring method cannot be extrapolated to other methods. Anesthesiologists should be aware of these differences. In this article, the basics of neuromuscular monitoring are summarized.

[Drug errors during anesthesia]

We report drug errors during anesthesia. The data were retrieved from the incident reports in a period of June 2000 to June 2003 at the Department of Anesthesiology, Fukuoka University Hospital. Drug errors occurred in 18 (0.12%) of 15,271 patients who were managed by anesthesiologists during the period. Among the 18 events, most frequent errors were 12 events of administration of wrong drugs. Errors in dosage were five, and wrong route of administration in one. There were no serious sequelae in the 18 patients.

[Pulmonary edema due to upper airway obstruction after extubation]

We report a patient who developed pulmonary edema due to airway obstruction after extubation. A 22-year-old man underwent removal of the nails for thoracoplasty under general anesthesia combined with epidural anesthesia. Upper airway obstruction occurred after extubation. SpO2 decreased to 70%. Insertion of an oral airway relieved the airway obstruction. However, inspiratory wheezing was heard over both lung fields. Chest X-ray taken 90 minutes after the event revealed pulmonary edema. Pulmonary edema gradually resolved after intravenous furosemide and oxygen inhalation by mask.

[Bradycardia and cardiac asystole immediately after abdominal incision for removal of a huge pyometra]

We report a patient who developed cardiac asystole, which may have been caused by Bezold-Jarisch reflex as a result of hypovolemia and compression of the inferior vena cava by a huge pyometra. A 61-year-old woman with a huge pyometra with occasional supine hypotension, tachycardia, and oliguria was scheduled for removal of the tumor. The systolic blood pressure decreased from 80 mmHg to 55 mmHg with simultaneous development of bradycardia 5 minutes after incision of the abdominal wall. Atropine was given but cardiac asystole occurred. Intravenous epinephrine restored systemic blood pressure and heart beats. There was no postoperative cardiorespiratory complication.

[Transfusion-related acute lung injury: a case report]

We report a patient who was suspected of transfusion-related acute lung injury. A 60-year-old man underwent emergency thoracotomy and hemostasis after pneumonectomy. The SpO2, decreased abruptly to 66% 90 minutes after transfusion of packed red blood cells and fresh frozen plasma. He was ventilated with 100% oxygen. The SPO2 returned to 100% in 3 minutes. Postoperative chest radiography showed diffuse pulmonary infiltrates. The pulmonary edema improved in 12 hours with mechanical ventilation.

[Transfusion of fresh frozen plasma for massive intraoperative bleeding before and after the new guidelines]

"Guidelines on Blood Products Use" published in 1999 recommends restricting the use of fresh frozen plasma (FFP) solely to correct multiple coagulation factor deficiencies. We retrospectively studied the use of FFP in patients with massive intraoperative bleeding before and after publication of the new guidelines. There were 22 patients whose blood loss was more than their circulating blood volume (7% of body weight) in the past two years. The mean blood loss was 1.4 times of the circulating blood volume both before and after publication of the new guidelines. FFP was given to all 22 patients. The mean dose of FFP decreased from 26.8 ml.kg-1 to 17.8 ml.kg-1 after publication of the new guidelines but the difference was not statistically significant. The volume infused was more than that recommended to improve blood coagulation in massive bleeding, i.e., 8-10 ml.kg-1.

[Manpower at private university hospitals in Japan]

We studied the numbers of teaching staff in anesthesiology departments and of patients operated on and managed by anesthesiologists at private university hospitals in 1999, in Japan. Questionnaires were sent to 49 institutions, and 36 responded (response rate, 73%). The mean number of patients managed by anesthesiologists in an institution was 3899 (range, 942-8135). The mean number of patients who were managed by a staff anesthesiologist was 428 cases (range, 118-980). The data indicate that a prompt increase in manpower at the private university hospitals is necessary to improve patient care, education, and research work.

[Spontaneous spinal subdural and epidural haematoma in a pregnant patient]

We report a pregnant woman who developed non-traumatic spinal subdural and epidural hematoma. A 31-year-old woman at 28 weeks of gestation developed progressive ascending paralysis. MRI suggested the presence of spinal subdural hematoma at T4-6 and spinal epidural hematoma at T4-9. An emergency cesarean section followed by spinal decompression was performed 60 hours after the onset. The patient's neulogical function recovered completely after the surgey.

[Anesthetic management for gastrectomy of a patient after coronary artery bypass graft with gastroepiploic artery]

We report anesthetic management of an 80-year-old man who had received coronary artery bypass graft with the gastroepiploic artery 5 years before the present gastrectomy. Preoperative angiography did not show patency of the grafted gastroepiploic artery. He underwent partial distal gastrectomy under general anesthesia with isoflurane in oxygen-enriched air combined with epidural block. The gastroepiploic artery was severed after temporary clamping which did not produce evidence of myocardial ischemia. There was no postoperative cardiovascular event after the surgery.

[Hypoxia after cesarean section in a patient with myotonic dystrophy]

A 28-year-old woman, 35 week-pregnant, underwent emergency cesarean section. Although she had no apparent symptoms before the operation, myotonic dystrophy was suspected from physical examination and laboratory data. The anesthesiologist in charge recognized only high creatine kinase. Combined spinal-epidural anesthesia was performed. During the operation and on the 1st postoperative day, Spo2 remained 99% with 3 l x min(-1) oxygen administration. However, on the 2nd postoperative day Spo2 decreased. The low Spo2 persisted for 4 days. Hypoventilation and difficulty in expectoration as a result of respiratory muscle weakness might have been the cause of the prolonged hypoxemia.

[History and current issues of anesthesia in Korea]

We report the history and current issues of anesthesia in Korea. Korean medical doctors have to take 1-year internship and 4-year residency to be qualified to take the national examination for a board-certified anesthesiologist. The national examination began in 1963, and there were 3,050 board-certified anesthesiologists as of 2006. The calculated patients who were managed by a board-certified anesthesiologist were 5.8 patients a day. The Korean government adopted nurse-anesthetists in 1973 because of shortage of board-certified anesthesiologists. The Korean Society of Anesthesiologists is now demanding its amendment.

[Myoglobinuria following anesthesia with enflurane and succinylcholine in an asthmatic child on theophylline]

An 8-year-old asthmatic child on theophylline was anesthetized with enflurane in nitrous oxide and oxygen. He developed a generalized muscle rigidity after intravenous succinylcholine. Although the maximum rectal temperature was 37.9 degrees C, a marked elevation in muscle-derived enzymes and myoglobinuria were observed. The relations among theophylline which is a derivative of xanthines, inhalation anesthetics, and myoglobinuria are discussed.