[Effect of epidural pressure gradient on buprenorphine flux through the dural hole after combined spinal-epidural anesthesia--comparison between bolus injection and continuous infusion]
Okada K. Okada S. Nishitani K.
Department of Anesthesia, Center for Adult Disease, Kurashiki.
Combined spinal-epidural anesthesia is a useful technique. However, there has been no attempt to investigate the risk of epidural opioid, especially buprenorphine, flux through the dural hole. The purpose of this study was to compare the effect of epidural buprenorphine administered across the dura into subarachnoid space, between two different methods of administration; bolus injection (Group I) and continuous infusion (Group II). Sixty patients for transvaginal hysterectomy were divided into two groups. Group I received buprenorphine 0.1-0.2 mg with 0.25% bupivacaine, and Group II 0.4 mg with 0.25% bupivacaine 40 ml continuously (infusion rate was 1.7 ml.h-1). Pain relief was similar in both groups, but the total buprenorphine requirement was lower in Group I than in Group II. The incidence of nausea and vomiting was significantly higher in Group I than that in Group II, 73% and 16%, respectively. It indicates that the increase of nausea and vomiting is predominantly determined by a high rate of flux into subarachnoid space and only partly determined by blood concentrations. In contrast to continuous infusion, the drug movement through the dural hole may increase by bolus injection due to its higher pressure. We recommend careful injection of epidural buprenorphine such as by continuous infusion with low pressure after combined spinal-epidural anesthesia.
[Unexpected anuria during Miles operation in a renal-transplant patient]
Fukuda T. Okutani R. Fukushima A.
Department of Anesthesiology, Hyogo Prefectural Nishinomiya Hospital.
We report a case of 33-yr-old-male after orthotopic renal transplantation 18 years ago, presenting with sudden anuria during Miles' operation. This anuria was caused by temporal compression of the transplanted kidney by retractor, neither by acute renal failure, the rejection nor the damage of the ureter by the surgical procedure. This case indicates that in the anesthetic management after renal transplantation, we have to be careful about renal dysfunction due to surgical procedure or positioning, in addition to side effects and pharmacokinetics of drugs used perioperatively.
[Anesthetic management of a patient with antiphospholipid syndrome]
Seima Y. Shiraishi Y. Sakai S. Yokoyama J. Igarashi H. Kimura T.
Department of Anesthesiology, Shizuoka General Hospital.
A 46-year-old woman with antiphospholipid syndrome (APS) underwent an emergent laparotomy. The symptoms and signs of APS are reported to be thrombosis, habitual abortion, thrombocytopenia and biological false positive (BFP) for syphilis' tests. Clinical symptoms are based on hypercoagulation of blood, while prothrombin time (PT) activity and activated partial thromboplastin time (APTT) are prolonged. Although we have selected general endotracheal anesthesia without epidural catheterization, we recommend that the regional analgesia is suitable for those APS patients with abnormality of coagulation. If PT and APTT differ from clinical symptoms, we have to think about APS and manage the patients carefully as APS.
[Intraoperative anaphylaxis caused by latex surgical gloves]
Tomita S. Sugawara K. Tamakawa S. Saitoh Y.
Department of Anesthesia, Asahikawa Kosei General Hospital.
A 17-year-old male encountered anaphylaxis caused by latex surgical gloves during emergency surgery under general anesthesia. He had undergone multiple surgical procedures, bladder catheterization and was suffering from atopic dermatitis. The patient developed bronchospasm and circulatory collapse 20 minutes after the start of surgery. Administration of dopamine, aminophylline and methylprednisolone helped to normalize airway pressure and blood pressure. Latex allergy occurs in persons considered at high risk including patient with spina bifida, urogenital abnormalities, atopic dermatitis, health care workers and rubber industry workers. These persons may develop hypersensitivity to latex products. If patients who are suspected to be latex allergy undergo surgical procedures, anesthesiologist should check past history and sensitivity to rubber in detail. In patients known to be allergic to latex, we must avoid latex products, such as surgical gloves, or anesthetic and surgical equipments.
[Anesthetic management of a patient with dilated cardiomyopathy using olprinone]
Yuasa H. Futagawa K. Shiokawa Y. Wakita K. Okuda T. Koga Y.
Department of Anesthesiology, Kinki University School of Medicine, Osaka-sayama.
A 51-year-old man with dilated cardiomyopathy, who had been treated with medication for five years, was scheduled for abdomioperineal resection of the rectum. Preoperative echocardiography demonstrated left ventricular dilation and hypertrophy, with an ejection fraction of 0.34. Anesthesia was induced with ketamine 40 mg and fentanyl 0.5 mg intravenously. Endotracheal intubation was facilitated by administration of vecuronium 10 mg. Anesthesia was maintained with nitrous oxide-oxygen-sevoflurane and fentanyl. In order to regulate myocardial contractility and after-load, use of a phosphodiesterase III inhibitor was considered, although phosphodiesterase III inhibitors are known to induce arrhythmias, which should be avoided in dilated cardiomyopathy patients. We chose olprinone, because its inotropic action is not associated with arrhythmogenecity. Before infusing olprinone, cardiac output was 4.5 l.min-1 and systemic vascular resistance was 1306 dynes.sec.cm-5. When olprinone was continuously infused for one hour, cardiac output increased to 5.2 l.min-1 and systemic vascular resistance decreased to 958 dynes.sec.cm-5. Some premature ventricular contractions occurred, but they were easily controlled by administration of 50 mg lidocaine. These clinical data demonstrate that olprinone enhanced myocardial contractility, and decreased after-load and arrhythmogenecity in a dilated cardiomyopathy patients. In conclusion, olprinone is useful in the perioperative cardiovascular management of surgical patients with dilated cardiomyopathy.
[A comparison of the incidence of postoperative nausea and vomiting after propofol-fentanyl anesthesia and that after nitrous oxide-isoflurane anesthesia]
Koyama S. Koh H. Noda K. Tagami N. Asada A.
Department of Anesthesia, Hoshigaoka-kohseinenkin Hospital, Hirakata.
We compared the incidence of postoperative nausea and vomiting after total intravenous propofol-fentanyl anesthesia (TIVA group) and that after thiamylal-nitrous oxide-isoflurane anesthesia (GOI group) in 60 ASA physical I and II patients for elective abdominal simple total hysterectomy. When the patients returned to the ward, the incidence of nausea was lower in TIVA group than in GOI group (P < 0.05), but no difference was found in the incidence of vomiting between the two groups. There were no differences in the incidence of nausea and vomiting 6 hours after the operation and on the next morning between the two groups. Postoperative pain scores were similar between the two groups, while total postoperative evaluation scores (nausea, vomiting, pain, fever, and sleep disturbance) were lower in TIVA group (P < 0.05). We conclude that TIVA with propofol-fentanyl reduced the incidence of nausea and improved total evaluation scores in the immediate postoperative period.
[Clinical indication of propofol for pediatric patients--pharmacokinetics of propofol and ketamine during and after total intravenous anesthesia with propofol, fentanyl and ketamine (PFK) in a neonate]
Sakai T. Mi WD. Komoda Y. Kudo T. Kudo M. Matsuki A.
Department of Anesthesiology, University of Hirosaki School of Medicine.
A 60-day-old neonate boy received hepatic portojejunostomy for biliary atresia under PFK. Pharmacokinetics of propofol and ketamine during and after PFK was also studied. Plasma levels of propofol (Cp) and ketamine (Ck) were maintained at 2 to 3 micrograms ml-1 and at 200 to 300 ng ml-1 during surgery, respectively. Both Cp and Ck decreased quickly after the end of infusions. From the pharmacokinetic point of view, PFK may be safely applied even for neonates.
[Anesthesia for a child with congenital sensory neuropathy with anhydrosis]
Mori S. Yamashita S. Takasaki M.
Department of Anesthesiology, Miyazaki Medical College.
We gave anesthesia twice to a 4-year-old boy with congenital sensory neuropathy with anhydrosis. At the first surgery, anesthesia was induced with midazolam and maintained with nitrous oxide, oxygen and sevoflurane 0.5-0.8% under mask breathing. Surgery was performed without any trouble but the patient vomited postoperatively for three days. Next time, anesthesia was induced and maintained with propofol under mask. The patient often moved during surgery, and therefore, we changed from propofol to oxygen and sevoflurane 1.0-1.5% anesthesia. Nitrous oxide was not used. After the surgery, no vomiting occurred.
[Sudden ventricular tachyarrhythmia immediately following hepatectomy in a patient with hypomagnesemia]
Isayama S. Ushijima K. Sakanashi Y. Yano T. Terasaki H.
Department of Anesthesiology, Kumamoto University School of Medicine.
A 57-year-old male without pre- or intraoperative arrhythmia developed ventricular tachyarrhythmia immediately following hepatectomy. Postoperative examination of plasma electrolytes revealed severe hypomagnesemia (0.16 mmol.l-1). The arrhythmia may have been caused by hypomagnesemia and an imbalance between supply and demand of oxygen in the myocardium, due to hypovolemia and severe anemia from massive hemorrhage. We recommend that measurement of plasma magnesium concentration be included in all perioperative laboratory examinations.
[Epidural hematoma associated with epidural catheterization in a cirrhotic patient]
Tamakawa S. Ogawa H.
Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical College.
We present a case of epidural hematoma in a liver cirrhosis patient with a depressed platelet count but normal prothrombin and activated thromboplastin times. A 60-year-old woman hospitalized with liver cirrhosis was referred to us for low back pain. She suffered the fracture of the body of the 12 th thoracic vertebra in a fall. Her platelet count was below normal ranges, but, other coagulation tests were within normal ranges. We inserted an 18-gauge epidural catheter at Th 12-L1 interspace. Twenty-one days later, paresis and hypesthesia in both legs, and a loss of sphincter function occurred. Magnetic resonance imaging revealed a posteriorly placed hematoma extending from Th 12 to L1. Considering the hemorrhagic tendency and hepatic insufficiency, we did not perform laminectomy. After 4 days, the patient's strength began to recover, and after 7 days paresis and hypesthesia improved. We should avoid performing epidural catheterization to improve chronic pain for a patient with liver cirrhosis if his or her platelet count is below 100,000.mm-3.
[Anesthetic management for renal tumor extending to the inferior vena cava]
Kurokawa S. Hida S. Fukuda S. Denda S. Shimoji K.
Department of Anesthesiology, Niigata University, School of Medicine.
A 58 year-old woman underwent radical nephrectomy, thrombectomy and ileo-cecal resection for renal tumor with thrombus involving the inferior vena cava and ascending colon cancer. In a patient having tumor thrombus extending to the vena cava, recognition of the position of the thrombus is important for surgical and anesthetic management in pre- and intra-operative periods. Transesophageal echocardiography (TEE) enabled us to visualize the real-time movement and deformity of thrombus by surgical manipulation and compression during operation. TEE seemed also very useful not only in understanding the hemodynamics during operation but also in detecting the residual tumor and the blood flow in liver and the inferior vena cava after operation.
[Spinal anesthesia in a patient with spina bifida occulta]
Shima T. Tokutomi S. Momose K. Hashimoto Y.
Division of Anesthesia, Sendai Red Cross Hospital.
A 32-year-old woman with spina bifida occulta was scheduled for hemorroidectomy under spinal anesthesia. Preoperatively, computed tomography and magnetic resonance imaging (MRI) were performed. The MRI demonstrated the conus medul laris reaching the L 3 level and a lipoma connected with conus medullaris intrathecally. Spinal anesthesia was done successfully at the L 3-4 interspace using 0.3% dibucaine 1.2 ml with 5% glucose 0.8 ml. Postoperatively she showed no neurologic complications. With exact anatomical findings of MRI, spinal anesthesia can be safely performed for patients with spina bifida occulta.