Search

A 73-year-old man suffering from ankylosing spondylitis with limited motion of the whole spine was scheduled for right total hip arthroplasty. Ten years before, the patient had undergone left total hip arthroplasty under general anesthesia, in which epidural anesthesia impossible, intrathecal anesthesia insufficient, and tracheal intubation difficult. In the present operation, an 18 gauge epidural catheter was inserted into the epidural space at L3-4 using paramedian approach. Six ml of contrast medium was administered via the catheter, with high resistance on injection and the spread of epidural contrast medium was limited to L2 and L3. Therefore, the catheter was removed and reinserted into the intrathecal space at L3-4. Two ml of contrast medium demonstrated good spread in the intrathecal space from T12 to S2. Next injection of 0.5% isobaric bupivacaine 2.4ml produced bilateral cold sensory blockade from T10 to S5. Two hours after this injection, a single bolus of 1 ml followed by a continuous infusion at a rate of 0.5 ml x hr(-1) with 0.5% isobaric bupivacaine was commenced. There was no pain at rest and on movement, and no additional analgesics and hypertensive drugs were used until 4 hours following the discontinuation of the continuous intrathecal anesthesia in the morning after the operation. No adverse events including post-dural puncture headache were observed. Continuous intrathecal anesthesia may be effective for total hip arthroplasty in patients with ankylosing spondylitis.

The "afterdrop" in body temperature (TEMP) following adequate rewarming from hypothermic cardiopulmonary bypass (CPB) is frequently observed. This temperature drop sometimes accompanied by shivering results in increased myocardial oxygen demand. We investigated the relations between the afterdrop and use of vasodilators after CPB. For vasodilator therapy, PGE1 at the rate of 0.025-0.088 microgram.kg-1.min-1 (Prostaglandin Low Doses, PLD; n = 8), 0.107-0.136 microgram.kg-1.min-1 (Prostaglandin High Doses, PHD; n = 7), or phentolamine at 4.1-5.9 micrograms.kg-1.min-1 (PHENT; n = 8) were intravenously infused in 23 adult patients after CPB. During three hour period after CPB, esophageal, rectal, and forehead TEMP are lower in PHENT than in PGE1 groups. There were significant differences between PHD and PHENT group. Finger tip TEMP was lower in PGE1 groups than in PHENT group. There were significant differences between PHD and PHENT group. There were no differences in systemic arterial pressure, cardiac index (CI) and systemic vascular resistance (SVR) at any point between PHD and PHENT groups. It is concluded that PHENT increases the peripheral skin blood flow and TEMP but decreases the visceral TEMP possibly due to vasodilatation of the skin vessels, while PGE1 decreases skin blood flow and TEMP but increases the visceral TEMP, although SVR clearly decreases at the same rate in the two groups.

Plasma growth hormone (GH), insulin, prolactin and blood glucose levels were measured to evaluate postoperative pain relief either with epidural morphine or systemic analgesics in 16 patients who underwent gastrectomy. Continuous epidural morphine with a pump (CADD-PCA, Model 5200P, Pharmacia) was given to eight (epidural morphine group) patients. A bolus of epidural morphine was administered through an indwelling thoracic (Th8.9) catheter at 3 hrs prior to the expected end of surgery, which was followed with continuous epidural infusion of morphine at a rate of 0.167-0.042 mg.hr-1 with the pump during and after anesthesia and surgery with gradually decreasing dose until the third postoperative day. The remaining eight patients (systemic analgesics group) repeatedly received intravenous or intramuscular pentazocine and buprenorphine when needed. Plasma GH levels increased significantly only on the first postoperative day in both groups. Plasma insulin levels increased significantly on the first postoperative day in both groups. Blood glucose levels increased significantly at the end of surgery and during the following three postoperative days in both groups. There are no statistical differences in plasma GH, insulin and blood glucose levels between the two groups. Plasma prolactin concentrations increased significantly at the end of surgery and they were significantly higher in the systemic analgesic group than in the epidural morphine group. They, however, returned to the previous day's levels on the first postoperative day in both groups. Our study suggests that continuous epidural infusion of morphine has no suppressing effect on postoperative changes in plasma GH, insulin, prolactin and blood glucose levels as compared with systemic analgesic regimen.

We investigated effects of total body hyperthermia (TBH) on endocrine and hemodynamic responses. A total of five treatments were performed in five patients with gastric cancer under neuroleptanesthesia with morphine followed by 0.2 to 0.4% enflurane. TBH was extracorporeally induced with veno-venous shunt incorporating with heat exchanger to keep their temperature between 41.5 degrees C and 42.0 degrees C for three hours. The patients were administered angiotensin to maintain tumor blood flow. Lactated Ringer's solution was administered at the rate of 10 to 15 ml.kg-1.hr-1 for five hours. Plasma cortisol levels decreased significantly to about one third of the control value after heating and the levels recovered to the control value after cooling. Plasma norepinephrine level increased significantly to about 7 to 9 times the control value following TBH, but this hormonal response was insufficient to reveal marked direct hemodynamic effects. The magnitude of fall in SVR was more significant in spite of the administration of angiotensin. Cardiac index increased significantly to about 2.0 to 2.6 fold of control value, but mean arterial blood pressure (MAP) decreased significantly to about two thirds to four fifths of the control value. Morphine relieved the hormonal response in ACTH and cortisol strongly, but morphine suppressed hemodynamics by decreasing SVR. Neither norepinephrine released from sympathetic nerve endings nor even 50 to 200 ng.kg-1.min-1 of angiotensin administered failed to restore SVR or MAP during hyperthermia.

Plasma catecholamine levels were measured to evaluate postoperative pain relief either with epidural morphine or systemic analgesics in sixteen patients who underwent gastrectomy. Eight patients (epidural morphine group) obtained postoperative analgesia with continuous epidural morphine with a pump (CADD-PCA, Model 5200P, Pharmacia). A bolus of morphine was administered through an indwelling thoracic (Th8 X 9) epidural catheter 3 hrs prior to the proposed end of the surgery, which was followed with continuous epidural infusion of morphine at a rate of 0.167-0.042mg.hr-1 by the pump during and after anesthesia and surgery with gradual decrease in dose until the third postoperative day. The remaining eight patients (systemic analgesics group) received repeatedly intravenous or intramuscular pentazocine and buprenorphine when needed. Plasma epinephrine levels increased significantly at the end of surgery in both groups, and were higher in the systemic analgesics group than those in the epidural morphine group. In the epidural morphine group, the catecholamine levels decreased to the previous day's levels on the first postoperative day and afterward, but remained high during three postoperative days in the systemic analgesics group. Plasma norepinephrine levels increased significantly at the end of surgery and afterward in both groups. However, they were significantly higher in the systemic analgesics group than in the epidural morphine group. Plasma dopamine levels were unchanged in the epidural morphine group during the surgical procedures, but they increased significantly on the first postoperative day and thereafter in the systemic analgesics group. Our study suggests that continuous epidural infusion of morphine is adequate for postoperative pain relief and exerts a suppressing effect on plasma catecholamine levels as compared with systemic analgesics regimen.

Sevoflurane is reported to react with sodalime to resolve into several products. We examined the reaction products of sevoflurane when this anesthetic reacted with components of sodalime under various conditions. Analysis of reaction products was performed by gas chromatography using a 2m column packed with DOP. Six peaks including sevoflurane were detected on the gas chromatogram of sevoflurane after reaction with sodalime and five reaction products were obtained. These peaks were from P1 with the shortest retention time to P5 with the longest retention time. When sevoflurane was sealed with sodalime in a test tube at room temperature, only P1 was detected and all reaction products of P1 to P5 were identified when the test tube was heated at 50 degree C for 3 hours. Sodalime contains Ca (OH)2, NaOH, KOH and silicon dioxide. Reaction of sevoflurane with KOH produced P1 to P5 products even at room temperature. After the reaction of sevoflurane with NaOH or Ca (OH)2 at 50 degrees C, P1 to P5 or P1 only were detected on the chromatogram respectively. No peak of any reaction products was obtained after the reaction with silicon dioxide under various conditions. These results suggest that hydroxy group of sodalime component would increase reaction products of sevoflurane.

A case of general anesthesia for a 52 year old female with previously undiagnosed dystrophia myotonica was reported. The patient was diagnosed as flaccid paralysis of the bilateral lower extremities but myotonic symptoms were not found preoperatively. The patient underwent duodenal resection to have a benign tumor removed. Anesthesia was induced with thiamylal 250 mg and pancuronium bromide 4 mg intravenously to facilitate tracheal intubation. Anesthesia was maintained with enflurane (0.6-1.0%) in nitrous oxide (50%) and oxygen (50%). The course of anesthesia was uneventful except for a transient hypotension of 80 mmHg systolic for about 10 minutes. The patient did not recover smoothly from anesthesia and prolonged apnea was observed. 90 minutes after the end of surgical procedure, spontaneous ventilation appeared. Then the tidal volume increased gradually but it still remained around 100-150 ml even 3 hours after the end of the operation. She was on ventilator and observed carefully. The endotracheal tube was removed four days after the operation. The patient was examined again by a neurologist and a final diagnosis of dystrophia myotonica was made. Prolonged recovery from anesthesia and postoperative respiratory depression observed in this patient was due to preoperatively undiagnosed dystrophia myotonica. A careful preoperative examination should be made to minimize possible complication related to anesthesia in the disease.