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Regarding postoperative respiratory management in infants, their postoperative circulatory and respiratory conditions are quite different among medical centers. The lung functions of infants are still immature. Respiratory rate of infants decreases from the birth (just after birth ; 47, 12 months ; 26 cycles x mimute(-1)). Tidal volume increases with body weight (just after birth ; 23.8, 12 months ; 89.1 ml), and tidal volume per body weight is constant (6.9-9.0 ml x kg(-1)). When we perform postoperative respiratory managements, we must discuss the ventilatory mode to use, permissible airway pressure, and values of blood gas analysis among postoperative care team. In infants with acute lung injury, we should select high frequency oscillation (HFO) according to lung protective ventilatory strategy theory (low tidal volume+open lung approach).

Background: Recently, the deficiency in anesthesiologist's man power became a social problem in Japan. Therefore, we tried outsourcing of anesthesia support system., Methods: The questionnaire was sent to anesthesiologists after an anesthesia support system had started., Results: All anesthesiologists answered reduction in the burden of work., Conclusions: Anesthesia support system outsourcing is effective in reducing the workload of anesthesiologists.

Background: We performed a retrospective analysis to evaluate the usefulness of combined spinal epidural anesthesia (CSEA) in emergency cesarean section compared with conventional spinal anesthesia., Methods: A retrospective chart analysis of patients who had undergone emergency cesarean section over a 7 year period was performed. We extracted at random 150 patients planned by spinal anesthesia, and 150 patients planned by separate-needle CSEA. Patient's data were gathered and analyzed according to the anesthetic technique used., Results: There were no significant differences between the two groups in age, weight, and BMI. Although the time to incision and the time to delivery were significantly faster in spinal anesthesia group than in CSEA group, there was no significant difference in Apgar score between the groups. Moreover, failure of anesthesia and post-dural puncture headache were higher in spinal group than in CSEA group., Conclusions: CSEA is useful as anesthesia for an emergency cesarean section.

Background: Syringe swap is an important problem in anesthetic care, causing harm to patients. We examined the effect of colored syringe and a colored sheet on the incidence of syringe swaps during anesthetic management., Methods: We determined the color code. The blue-syringe contains local anesthetics; yellow-syringe, sympathomimetic drugs; and white-syringe with a red label fixed opposite the scale, muscle relaxants. The colored sheet displays the photographs of the syringe with drug name, dose and volume. The colored syringe and colored sheet were supplied for use from February 2004. We compared the incidence of syringe swaps during the period from February 2004 to January 2005 with that from February 2003 to January 2004., Results: Although five syringe swaps were recorded from February 2003 to January 2004, in 5901 procedures, we encountered no syringe swaps from February 2004 to January 2005, in 6078 procedures. The colored syringe and colored sheet significantly decreased the incidence of syringe swaps during anesthetic management (P <0.05)., Conclusions: The use of the sheet together with colored syringes can prevent syringe swaps during anesthesia.

This report describes a case of awareness and recall during propofol anesthesia combined with epidural anesthesia in a 32-year-old woman scheduled for a resection of left ovarian tumor. After induction, anesthesia was maintained with propofol and epidural anesthesia. About one hour into maintenance, the patient was moving with haemodynamic signs suggesting inadequate analgesia. Immediately after extubation, the patient could recall the abdomen being touched during laparotomy. This case indicates that even if appropriate dose of propofol is administrated, intraoperative awareness may occur especially with inadequate analgesia.

The purpose of the present investigation is to examine whether induced hypotension can improve the dryness of the surgical field in endoscopic sinus surgery (ESS). ASA physical status I and II adult patients with chronic sinutitis undergoing ESS were studied. All patients were not premedicated. Anesthesia was induced with propofol and maintained with sevoflurane and fentanyl. The patients were allocated randomly into two groups. In patients of Group C, mean arterial blood pressure (MAP) was maintained around 80 mmHg. In Group H, sodium nitroprusside was infused to maintain controlled hypotension with MAP around 60 mmHg. Blood loss, dryness of the surgical field, volume of fluid infusion and urine output, and surgical as well as anesthetic time were compared. Blood loss and dryness of the surgical field were significantly different between the groups. Volume of infused fluid, urine output, and surgical as well as anesthetic time were not significantly different. Induced hypotension with sodium nitroprusside improved surgical conditions and decreased blood loss in ESS.

A 76-yr-old male presented for leg amputation above the knee. The patient complained of dyspnea due to pulmonary embolism occurring 3 weeks before operation. In addition, the patient could not report paresthesias because he had suffered from a cerebral infarction. Anesthesia was performed with combined block of femoral, sciatic, obturator nerves and the lateral cutaneous nerve of the thigh. The nerves were anesthetized with 0.75% ropivacaine solution 31 ml by use of an electrical nerve stimulator and an insulated needle. Nerve stimulation technique is the best choice for patients who are unable to report paresthesias reliably.

We present a case of complicated postoperative nerve injury. A 70-year-old man complained of partial paralysis and numbness of the left forearm 1.5 hour after operation for femoral artery bypass graft. Postoperative cervical spine MRI revealed cervical spondylotic radiculopathy. The MRI findings could account for his symptom. Not only peripheral nerve injury but the cervical radiculopathy may play an important role in perioperative neuropathy.

A 28-year-old parturient with acute cortical blindness and eclampsia was scheduled for an emergency cesarean section. Computed tomography (CT) of the head revealed low-density areas suggesting cerebral edema in posterior regions. The operation was performed under general anesthesia with sevoflurane. The brain edema was managed by concentrated-glycerin and steroid. The operation was performed uneventfully. Her consciousness returned to normal by the following day and visual recovery was complete within 72 hr postpartum. The patient and the infant showed no complication on their discharge.

Two patients with chronic low back pain and sciatica failed to respond to conservative treatments. In these patients, magnetic resonance imaging (MRI) showed no remarkable findings corresponding to their symptoms. We treated these patients using epiduroscopy. Epiduroscopic visualization of the spinal canal permits efficient adhesiolysis and irrigation. One patient got better after two epiduroscopic procedures, and the other did not. Epiduroscopy may be an effective, minimally invasive treatment as well as examination for patients with chronic low back pain without remarkable findings on MRI.

We describe a successful anesthetic management of a morbidly obese patient, weighing 170 kg, height of 170 cm and body mass index of 58.8 kg.m-2, who received gastric bypass surgery performed using laparoscopic assist. After arriving in the operating room, an epidural catheter was inserted into the epidural space at the T 7-8 intervertebral space. The trachea was intubated nasally under bronchofiberscopic assist, after which anesthesia was induced with propofol and maintained with nitrous oxide and oxygen (FIO2 = 0.5), i.v. propofol, fentanyl, and epidural anesthesia. Propofol infusion rate was determined using the corrected body weight drawn by Servin et al. Anesthetic management and recovering from anesthesia were uneventful. For propofol anesthesia, infusion rates determined using the corrected body weigh, was preferable for morbidly obese patients.

The May-Hegglin anomaly is a rare hereditary disorder characterized by the presence of giant platelets and platelet deficiency. This report presents a successful management of a patient with May-Hegglin anomaly. A 5-year-old girl with May-Hegglin anomaly was scheduled for closure of fistulae of her ears. Although preoperative physical examination revealed platelet count of 8,000 mm-3, she had no bleeding tendency. No premedication was given. Anesthesia was induced with inhalational agents of a mixture of sevoflurane, nitrous oxide and oxygen. Neuromuscular blockade was achieved with vecuronium 0.1 mg.kg-1 and the trachea was gently intubated. Anesthesia was maintained with sevoflurane, nitrous oxide and oxygen. Five units of platelet were transfused during the operation. No bleeding tendency was observed perioperatively. It is important to plan the management of anesthesia for a patient with bleeding tendency.

We successfully anesthetized a 14-year-old boy with myotonic dystrophy for orthopedic surgery using sevoflurane. Sevoflurane enabled anesthetic induction and tracheal intubation without intravenous anesthetics and muscle relaxants. Sevoflurane also provided stable anesthetic maintenance without intravenous anesthetics. The patient showed rapid anesthetic recovery and adequate spontaneous breathing. We conclude that sevoflurane is a useful anesthetic for patients with myotonic dystrophy.

We report the management of anesthesia for emergent tracheostomy in a patient with severe tracheal stenosis. A 63-year-old male was scheduled for an emergency tracheostomy for severe tracheal stenosis due to the invasion of a thyroid cancer. A preoperative neck CT revealed the tracheal stenosis, extending from 1-2 cm below the vocal cord to the upper end of the sternum. The narrowest caliber was about 7 mm in transverse diameter. Moreover, the cancer was suspected to have a bleeding tendency. General anesthesia with endotracheal intubation was considered necessary to provide an open airway during tracheostomy. Anesthesia was induced with thiopental, and a 6.0 mm endotracheal tube with cuff was successfully introduced with a balloon introducer (AIRGUID E) using suxamethonium. We were able to perform tracheostomy uneventfully.

A patient suffered massive bleeding from the ruptured liver and laceration of the inferior vena cava due to traffic accident, and developed hypotension and decreased level of consciousness. The patient was transferred to our hospital for an emergency operation against intra-abdominal massive bleeding. This massive bleeding was controlled with autotransfusion using washing salvaging autotransfusion device (Cell Savor). Suspected brain ischemia was treated with intended mild hypothermia. When blood pressure decreased to 30 mmHg of systolic pressure over 7 minutes during the operation, suggesting the possible brain ischemia, mild hypothermia was maintained at 33.8 degrees C. Total bleeding volume was 16,700 ml, and total transfused volume was 10,700 ml. Of total transfused volume, 4,500 ml was washed salvaged blood using the intraoperative autotransfusion device. No neurological deficit was found during the postoperative course. The patient was discharged uneventfully on the 20th postoperative day. In conclusion, intraoperative autotransfusion with washed salvaged blood is a useful method for treatment of massive bleeding, and mild hypothermia is efficacious for protecting the brain from ischemia resulting from accidental hypotension.

The purpose of this study was to confirm the effect of premixed lidocaine for the reduction of pain during injection of propofol in adult patients. We conducted a prospective, randomized, double-blind trial on 106 patients. In the study group (n = 54), lidocaine 40 mg (2 ml of lidocaine 2%) was added to 180 mg of propofol (18 ml). In the control group (n = 52), 2 ml of normal saline was added to 180 mg of propofol. The pain on injection was rated as none, mild, moderate, or severe. Eleven patients (20.4%) in the study group experienced pain compared with 25 (48.1%) in the control group. Thirteen in the control group complained moderate or severe pain compared with only one in the study group. In conclusion, lidocaine 40 mg premixed with 180 mg propofol significantly reduces the incidence and severity of pain associated with propofol injection.

To evaluate the effect of prostagrandin E1 (PGE1)-induced hypotension on cerebral blood flow (CBF) and carbon dioxide (CO2) reactivity of CBF, regional cerebral hemoglobin oxygen saturation (rSo2) was measured in non-neurosurgical patients (n = 10) under sevoflurane-anesthesia using near infrared spectroscopy. PGE1 was infused intravenously to maintain arterial pressure at a level of about 75% of the MAP (hypotensive group) under sevoflurane-anesthesia alone (normotensive group). Ventilation was controlled to adjust PaCO2 to hypocapnia (25-30 mmHg), normocapnia (35-40 mmHg) and hypercapnia (45-50 mmHg) in both normotensive and hypotensive groups. rSo2 during hypotension did not change by hypocapnia and normocapnia, but significantly increased by hypercapnia, compared with rSo2 during normotension. Significant correlations between rSo2 and PaCO2 during both normotensive and hypotensive groups were observed. Slope of the regression line of rSo2 and PaCO2 did not differ between the normotensive and hypotensive groups. When arterial oxygen content and cerebral metabolic rate of oxygen are constant, changes in rSo2 correlate with those of CBF. Therefore, CBF and CO2 reactivity of CBF that indicates autoregulation in response to changes in CO2 during hypotension were maintained as those during normotension. The results show that PGE2-induced hypotension maintains CBF and CO2 reactivity well in non-neurosurgical patients under sevoflurane anesthesia.

A 26-yr-old morbidly obese parturient with a body mass index of 62 kg.m-2 underwent elective cesarean section for preeclampsia under epidural anesthesia. The distance between the skin and the epidural space was about 9 cm at the L3-4 interspace via mid approach. Epidural catheter was inserted 5 cm cephalad in the sitting position and a bolus of 17 ml of mepivacaine 1.5% was given in the supine position. The T5 level of analgesia was obtained 10 min later. Forty minutes after the start of the surgery, a female newborn weighing 3,206 g was delivered with an Apgar score 8 at 1 min and 9 at 5 min. Throughout the surgery, sufficient analgesia was obtained and any complications such as severe hypotension and respiratory depression did not develop. Postoperative pain was relieved sufficiently with a continuous epidural infusion of 0.25% bupivacaine at a rate of 0.5 ml.h-1 for two days. Both maternal and neonatal postpartum courses were uneventful. In conclusion, elective cesarean section in a morbidly obese parturient was successfully managed with epidural anesthesia. This indicates that an elective cesarean section under epidural anesthesia reduce the risk of perioperative complications in a morbidly obese parturient.

A new programmable syringe infusion pump, Auto Syringe Model AS 40 A, was evaluated for infusion of muscle relaxants, vasodilators and opioids in 4 surgical patients. Every drug mentioned above was easily adjusted according to surgical requirement in these patients. Auto Syringe Model AS40A is light and compact. Its major advantages lie in the mechanisms for delivery of a bolus dose and automated delivery of intermittent doses, automatic rate calculation, and the applicability to various sizes of syringes. Auto Syringe Model AS40A was found to be very useful for intravenous infusion of drugs.

We anesthetized a patient who received an emergency internal carotid artery ligation. Regional cerebral oxygen saturation (rSO2) was measured with near infrared spectroscopy (NIRS) during the whole anesthetic course. The sensor was placed on the left forehead of the patient. Decrease in blood pressure was reflected in the decrease in rSO2. The rSO2 was not altered by internal carotid ligation. However, cerebral infarction in the middle cerebral artery region, the onset of which remained unclear, was revealed postoperatively, regardless of a stable rSO2 during the operation. This monitor may provide useful information regarding the cerebral circulation during the operation in such a case as the present one, but this monitor reflects only the oxygenation of the region on which the sensor was placed. Thus, we should keep in mind the limitation in detecting cerebral dysfunction using NIRS.

We described a case of anaphylaxis diagnosed by the evaluation of plasma mast cell tryptase and a case of anaphylactoid reaction. In a patient undergoing pulmonary lobectomy, anaphylaxis, showing the elevation of plasma tryptase, was provoked by physiological glue for hemostasis during the operation. During the operation, cardiovascular collapse occurred suddenly, at which time the cause was not diagnosed. After completion of the operation and removal of drapes, diffuse urticaria with wide erythema on the torso and the upper extremity was noticed. Suspecting allergic adverse reaction, plasma tryptase was measured 2h and 5h after the start of the episode, showing 34.6 ng.ml-1 at 2h and 15.3 at 5h. Because these elevations of plasma tryptase indicated degranulation of mast cells, evaluation of the causative drugs was performed 7 weeks after the episode. Physiological glue was confirmed to be causative drug. In another patient for total hysterectomy and bilateral oophorectomy, adverse reaction occurred after completion of the operation and extubation. Increase in plasma histamine concentration to 4.94 ng.ml-1 that could induce systemic reaction was noticed; however, concentrations of plasma tryptase 25 min, 3h and 7h after the episode were not elevated. This finding indicated that the adverse reaction was not based on degranulation of mast cell, and was anaphylactoid reaction provoked by nonspecific histamine-release. In conclusion, measurement of plasma tryptase is a useful method for differential diagnosis of anaphylaxis and anaphylactoid reaction.

This investigation was conducted to determine the analgesic efficacy of rectal diclofenac coupled with continuous epidural infusion with buprenorphine and bupivacaine for pain relief after upper and lower abdominal surgery. Forty patients in control group received epidural buprenorphine 0.1 mg in 8 ml of 0.25% bupivacaine immediately after surgery and subsequently infusion was started with the solution of epidural buprenorphine 15 micrograms in 1 ml of 0.23% bupivacaine at a rate of 1 ml.h-1 for 48 h. Forty patients in study group received rectal diclofenac 50 mg immediately after surgery in addition to the same epidural injection method described above. Adding rectal diclofenac to continuous epidural infusion of buprenorphine and bupivacaine produced enhanced analgesia and reduced pain scores measured by VAS after upper abdominal surgery. However, after lower abdominal surgery, such effects of rectal diclofenac obtained after upper abdominal surgery were not demonstrable.

The arterial oxygen saturation was continuously monitored in 50 patients under spinal anesthesia. Of the 50 patients, low oxygen saturation below 95% and/or its decrease of more than 5% was observed in 19 patients (38%). The remaining 31 patients (62%) showed a normal oxygen saturation. Pentazocine 0.5 mg.kg-1 i.v. correlated significantly with arterial oxygen desaturation (P = 0.0001). It is possible that laparotomy is associated with the desaturation (P = 0.0582). No correlation between desaturation and the other factors (level of analgesia, position during operation, and hydroxyzine premedication) was found.

We have studied the effect of horizontal lithotomy position on the spread of hyperbaric dibucaine spinal anesthesia. In three groups of 20 patients, 7.2 mg of hyperbaric dibucaine was injected intrathecally in the lateral decubitus position. In group supine, the patients were kept in supine horizontal position in which patient's legs and thighs were extended throughout the operation. In group lithotomy A, immediately after the spinal injection, the patients were placed into the lithotomy position. In group lithotomy B, after the spinal injection, the patients were placed immediately in the supine horizontal position for 15 min and then placed into the lithotomy position. There were no significant differences in height of sensory blockade among the three groups. The lithotomy position did not significantly affect the level of sensory blockade with hyperbaric dibucaine.

We examined the analgesic efficacy and side effects of continuous epidural infusion with buprenorphine in 340 surgical patients. The patients received epidural injection of 0.1 mg of buprenorphine in 8 ml of 0.25% bupivacaine immediately after surgery. The patients who underwent thoracotomy or intraabdominal surgery were subsequently infused with buprenorphine 15 micrograms in 1 ml of 0.25% buprenorphine at a rate of 1 ml.h-1 for 48 h. In the other kinds of surgery, patients were infused with buprenorphine 8 micrograms in 1 ml of 0.25% buprenorphine at a rate of 1 ml.h-1 for 48 h. The patients who did not need additional narcotics were 68% and 83% on the postoperative day 1 and 2, respectively. Visual analogue scale (VAS) was 22 +/- 2 mm at rest and 43 +/- 2 mm at movement on the postoperative day 1. Corresponding values on the postoperative day 2 were 16 +/- 2 mm and 37 +/- 2 mm, respectively. Nausea and vomiting were found in 12.4% of the patients.

A 41-year-old woman with pulmonary lymphangiomyomatosis had been scheduled for bilateral oophorectomy which led to amelioration of the pulmonary pathology. The discrepancy between her dyspnea on exertion and lung function tests suggested that she had a marked tendency toward hypochondria. Therefore, we chose spinal anesthesia because of its technical simplicity, rapid onset, and effectiveness of some sedatives used perioperatively. Surgery was performed uneventfully. The anesthetic method mentioned above did not worsen respiratory function perioperatively. Spinal anesthesia is thought to be appropriate anesthesia for patients with pulmonary lymphangiomyomatosis, if feasible.

To evaluate postoperative analgesia and side effects of epidural buprenorphine, 60 patients after thoracotomy were divided into 6 groups. All patients received a bolus epidural administration of buprenorphine 0.1 mg in 8 ml of 0.25% bupivacaine. Following this epidural bolus, 10 patients in each group were given 0.25% bupivacaine alone (group A), buprenorphine 5 micrograms in 1 ml of 0.25% bupivacaine (group B), buprenorphine 8 micrograms in 1 ml of 0.25% bupivacaine (group C), buprenorphine 12 micrograms in 1 ml of 0.25% bupivacaine (group D), buprenorphine 15 micrograms in 1 ml of 0.25% bupivacaine (group E) or buprenorphine 18 micrograms in 1 ml of 0.25% bupivacaine (group F) with a portable disposable device at a rate of 1 ml.h-1 for 48 h. The percentages of patients who did not need additional narcotics for the first 24 hours postoperatively in group A, B, C, D, E, and F were 20%, 40%, 30%, 50%, 60%, and 70%, respectively. Those for the second 24 hours postoperatively in each group were 40%, 50%, 70%, 60%, 90%, and 90%, respectively. No significant difference in the incidence of side-effect was found among 6 groups. We concluded that optimal epidural doses of buprenorphine for post-thoracotomy pain relief are 15 and 18 micrograms.h-1 in the first and second 24 hours postoperatively, respectively.

Accidental subdural block occurred in a 47-year-old man who underwent gastrectomy under nitrous oxide-sevoflurane anesthesia combined with continuous epidural block. The development of subdural block was suspected from unexpectedly severe hypotension with small doses of mepivacaine during operation and was confirmed by a characteristic X-ray photograph after operation. The subdural block should be suspected from abnormal changes in vital signs and by careful observation of X-ray photographs, because it is not always easy to determine the presence of contrast media either in the subdural space or in the epidural space.

We reported an episode of sudden bradycardia and hypotension during spinal anesthesia, in which the patient complained of nausea before the bradycardia and hypotension were recognized by the monitors, such as, intermittent measurement of arterial pressure, electrocardiography, pulse oxymetry and continuous arterial blood gas analysis. We emphasize the importance of strict vigilance during spinal anesthesia.

The position of lumbar epidural catheters was confirmed by radiography in 71 patients. Catheters were advanced by 5 cm cephalad in the lumbar epidural space by paramedian approach (Group P: n = 28) or median one (Group M: n = 43) and contrast media was injected through the catheters. If the contrast media was present in the paravertebral regions, the catheter was considered to be in the abnormal position. The incidence of the abnormal position of the catheters was higher in group M than in group P significantly. To advance an epidural catheter longer into the lumbar epidural space, paramedian approach may be superior to median one.

The lateral and longitudinal spread of contrast media was investigated by lumbar epidurography with 8 ml of iohexol in 47 patients aged 25 yr to 86 yr. Iohexol was injected through the epidural catheter epidurally advanced by 5 cm cephalad from the L 1-4 interspace. A significant correlation was found between the longitudinal spread of iohexol and aging. No correlation was found between the leakage of iohexol from the intervertebral foramina and aging. This finding may deny the hypothesis that in elderly patients, the more extensive longitudinal spread of local anesthetics in the epidural space may be caused by its smaller leakage from the intervertebral foramina.

The effects of intravenous and intramuscular atropine on pulse rate have been studied in 40 patients undergoing gynecological surgery. Intramuscular atropine 0.5 mg was administered 30 min before induction of spinal anesthesia in 20 patients (i.m. group). Intravenous atropine 0.5 mg was administered immediately after induction of spinal anesthesia in 20 patients (i.v. group). Decrease in heart rate after spinal block was significantly less in i.v. group than in i.m. group. Although no one in i.v. group was given an additional atropine, 10% of the patients in i.m. group was given an additional atropine for bradycardia. Authors conclude that intravenous atropine has more significant effect on prevention of bradycardia during spinal anesthesia compared with intramuscular atropine.

A case of severe supine hypotensive syndrome in a parturient associated with breech presentation was presented. It is suggested that failure of left tilt to prevent the hypotension was associated with anatomical displacement of the uterus to the right. The importance of trying right tilt, if response to left tilt is poor, is emphasized.

The measurements of human hepatocyte growth factor (hHGF) in plasma and liver function tests were performed in 23 patients before and after major intra-abdominal surgery under nitrous oxide-sevoflurane anesthesia. Plasma concentrations of hHGF in 12 patients with normal liver function (Group 1) and in 11 patients with liver dysfunction (Group 2) were 0.34 +/- 0.07 and 0.44 +/- 0.12 ng.ml-1 (mean +/- SD) before the surgery, respectively. After the surgery, plasma concentration of hHGF remained unchanged in Group 1, but significantly increased to 0.61 +/- 0.32 ng.ml-1 in Group 2. Other routine laboratory data reflecting hepatic functions remained unchanged in both groups. These results suggest that liver damage during surgery and anesthesia occurs more likely in patients with liver dysfunction than in patients with normal liver function, and hHGF can be a more sensitive indicator of hepatic damage than conventional liver function tests.

We examined the analgesic effects of indomethacin as an adjunct to postoperative epidural analgesia in 40 patients who underwent upper abdominal surgery. Twenty patients in control group were epidurally given 0.1 mg of buprenorphine in 8 ml of 0.25% bupivacaine immediately after surgery and subsequently infused 15 micrograms buprenorphine in 1 ml of 0.25% bupivacaine at a rate of 1 ml.h-1 for 48 h. The remaining 20 patients were rectally given 50 mg of indomethacin in addition to the same epidural method described above. The patients who did not need additional narcotics in the control and indomethacin groups were 45% and 80%, respectively (P < 0.05). In upper abdominal surgery, postoperative pain relief by epidural buprenorphine and bupivacaine plus rectal indomethacin was more effective than that by epidural buprenorphine and bupivacaine.

A 10-yr-old boy with an injured lower extremity received sevoflurane anesthesia 5 times within 40 days. Laboratory tests for hepatic and renal function i.e., serum transaminase (glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, gamma-glutamyl transpeptidase), serum cholinesterase, plasma protein, serum cholinesterase, serum bilirubine, serum lactic dehydrogenase, serum prothrombin time, blood urea nitrogen, serum creatinine, beta 2-microglobulin, N-acetyl-D-glucosamidase and 24 hr-creatinine clearance remained within normal ranges throughout his perioperative period. Repeated sevoflurane anesthesia did not exert any adverse effect on hepatic and renal function in this patient.

We studied whether continuous interpleural infusion of bupivacaine would be effective in alleviating pain after thoracotomy compared with effect of continuous epidural infusion of bupivacaine and buprenorphine. Twenty patients who had received thoracotomy and lobectomy were randomly divided into two groups to receive continuous interpleural infusion (IP group) of 0.5% bupivacaine at the rate of 5 ml.h-1 or continuous epidural infusion (E group) of 0.25% bupivacaine and 0.025 buprenorphine at the rate of 1 ml.h-1. The patients assessed their level of pain using a 100 mm visual analog scale (VAS) at rest and on coughing or changing the posture, verbal descriptor pain scale (VDPS), and times of supplemental analgesic. Assessment was performed at 7 points (mornings and evenings) for 3 postoperative days. In the evening of the day of surgery, VAS at rest in IP group was significantly higher than one in E group, but VASs at rest were similar in both groups from the first postoperative day to the third postoperative day. VAS on coughing or changing the posture in IP group was significantly higher than in E group in the evening of the day of surgery, and VASs on coughing or changing the posture in IP group were higher than in E group for 3 postoperative days. Supplemental analgesics were administered significantly more often than in E group in the evening of the first postoperative day. We conclude that continuous interpleural infusion does not give better analgesia than continuous epidural infusion after thoracotomy.

We compared intraoperative circulatory and respiratory complications and changes in body temperature during laparoscopic cholecystectomy by intraperitoneal insufflation of carbon dioxide gas (24 cases) with those by abdominal wall lifting (16 cases). The abdominal wall lifting method tended to produce fewer complications than the intraperitoneal insufflation method, but not significantly. In conclusion, the former was thought to be safer than the latter.

In one case, analgesia level obtained with a 20 ml of 1.5% mepivacaine was unilateral and inadequate. In the other case, an epidural catheter was inserted after a 20 ml of 2% mepivacaine was injected through a Tuohy needle. Toxicity by local anesthetic was induced by an overdose of local anesthetic through the catheter. In both cases, transforaminal passage of a catheter was confirmed by epidurogram with iohexol. If an epidural catheter is advanced beyond 5 cm into the epidural space, it may migrate outwards through the intervertebral foramen. Therefore, the insertion of an epidural catheter should be limited to 3-4 cm.

To evaluate postoperative analgesia and side effects of epidural buprenorphine, 100 patients who underwent upper abdominal surgery were divided into 5 groups. All patients were given initially 0.1 mg of buprenorphine in 8 ml of 0.25% bupivacaine in bolus. Following an epidural bolus, 20 patients in each group were given 0.25% bupivacaine alone (group A), 5 micrograms buprenorphine in 1 ml of 0.25% bupivacaine (group B), 8 micrograms buprenorphine in 1 ml of 0.25% bupivacaine (group C), 12 micrograms buprenorphine in 1 ml of 0.25% bupivacaine (group D), or 15 micrograms buprenorphine in 1 ml of 0.25% bupivacaine (group E) with a portable disposable device at a rate of 1 ml.h-1 for 48 h. The analgesic efficacy in group E was superior to that in groups A, B, C and D. No significant difference was found in the incidence of side-effect among 5 groups. Therefore, epidural buprenorphine 15 micrograms in 1 ml of 0.25% bupivacaine given to patients at a rate of 1 ml.h-1 was thought to be optimal for postoperative pain relief in upper abdominal surgery in terms of its efficacy and side effects. However, 35% of these patients required supplementary systemic analgesics in the early postoperative period.

We could successfully perform spinal anesthesia with bupivacaine for open reduction of tibial fracture in a patient with late cerebellar cortical atrophy (LCCA). LCCA is a very rare neurologic degenerative disorder localized chiefly in the cerebellum, and it may be followed by various complications. His postoperative course was uneventful, followed by no neurological complication. Regional anesthesia including spinal anesthesia seems to be safe for operations in patients with LCCA.

We have compared the responses to thoracic epidural anesthesia in 14 controlled hypertensive patients with those in 36 normotensive patients. Arterial pressure and heart rate were measured on the day before surgery, before and after the establishment of the epidural anesthesia, during light general anesthesia combined with epidural anesthesia, and after extubation. No significant difference in systolic, diastolic and mean arterial pressures were found between hypertensive and normotensive patients on the day before surgery. Changes in systolic and mean arterial pressures were greater in hypertensive patients than in normotensive ones, but absolute values of systolic, diastolic and mean arterial pressures after the establishment of the epidural anesthesia were similar between hypertensive patients and normotensive ones. Although no significant difference was found between the groups with respect to the highest and lowest systolic arterial pressure during operation, systolic arterial pressure after extubation was significantly higher in hypertensive patients than in normotensive ones. These suggest that the combination of epidural and general anesthesia is a safe technique for patients with medically controlled hypertension.

A 24-year-old pregnant woman was scheduled for Caesarean section during the 31st week of pregnancy. The patient had been treated with MgSO4 for premature labor and toxemia. During anesthesia, cardiac arrest occurred twice. The first cardiac arrest occurred immediately after induction of anesthesia and seemed to be due to combined effects of hypermagnesemia, thiopental and supine hypotensive syndrome. Three babies were delivered during cardiac massage. The second one occurred immediately after administration of methyl-ergometrine malate and seemed to be due to combined effects of hypermagnesemia and methyl-ergometrine malate. The patient and three babies did not develop any complication. In giving anesthesia for patients with hypermagnesemia, anesthetists should take account of interactions between magnesium, anesthetics and other drugs.

Intramuscular atropine 0.5 mg as an anticholinergic premedicant for spinal anesthesia was studied in 14 patients. Twelve patients of a control group did not receive atropine. No significant difference was found between the groups with regard to changes in blood pressure during spinal anesthesia whose analgesic level reached T4. A significant difference was found between the groups with regard to changes in heart rate during spinal anesthesia, but the incidence of bradycardia below 60 beats.min-1 was similar between the groups. Intramuscular atropine 0.5 mg as a premedicant offered little vagal blockade of the heart during spinal anesthesia.

The effect of a cardiopulmonary bypass circuit (CPB) on serum nitroglycerin (TNG) concentrations was studied in eight patients scheduled for cardiac surgery. The CPB consisted of polyvinyl chloride tubes and polypropyrene membrane oxygenator. TNG was administered intravenously at a rate of 1 microgram.kg-1.min-1 after induction of anesthesia. Blood samples were obtained from the radial artery, central vein, venous inlet of the CPB, and arterial outlet of the CPB. No significant difference in serum TNG concentration was found between the venous inlet of the CPB and arterial outlet of the CPB. Serum TNG concentration tended to increase during complete extracorporeal circulation. This suggests that the hypothermic inhibition of TNG metabolism may be greater than the adsorption of TNG by the CPB.

We surveyed the attitudes of general surgical patients to the management of their postoperative pain relief. Elective surgical patients (n = 232) were asked postoperatively about their experienced pain which was expressed according to verbal pain scale, the duration of experienced pain, satisfaction with pain relief and medication, and expectations of pain on the 5th to 7th postoperative day. Thirteen percent of the patients had no pain, 47% of whom had no rest pain but pain on moving or coughing, 32% of whom had rest and moving pain, and 0.4% of whom experienced horrible and excruciating pain. Duration of postoperative pain was 2.5 +/- 1.9 days, and 76% of the patients experienced pain only for 3 postoperative days. Results of the interviews indicated that 80% of these patients were satisfied with their postoperative pain relief. Although 80% expressed satisfaction, 39% of whom did have rest pain. In the patients with continuous epidural infusion of buprenorphine and 0.25% bupivacaine, incidence of complained rest pain was significantly low compared with those with intermittent i.v. and/or im injection of analgesics on demands of patients. Lag between patient's demand and nurse's response concerning medication correlated significantly to the satisfaction. There was no relation between satisfaction and age, the nature of operation or sex. Fifty-two percent of the patients reported that degree of experienced pain had been less than expected preoperatively. In conclusion, 80% of the patients were satisfied, but our postoperative pain therapy was still insufficient because 39% of them had rest pain.(ABSTRACT TRUNCATED AT 250 WORDS)

Induction of anesthesia with inhalation of sevoflurane was evaluated in 45 patients. Inhalation anesthesia was induced by a single vital capacity breath followed by spontaneous breathing. The compositions of anesthetic gases were as follows: 5% sevoflurane in oxygen, 5% sevoflurane in 67% nitrous oxide and oxygen, and 7% sevoflurane in 67% nitrous oxide and oxygen. The time (mean +/- SEM) necessary for the loss of consciousness was 85 +/- 6, 56 +/- 4, and 42 +/- 3 seconds, and breathing frequency was 8 +/- 1, 5 +/- 0.6, 1.4 +/- 0.2, in each composition of anesthetic gasses, respectively. Changes in blood pressure and heart rate were relatively small. The technique was found to be acceptable to all of the patients studied. We conclude that the technique of single breath induction with sevoflurane is a safe and acceptable alternative to intravenous induction in cooperative adult patients.

The effects of age, weight, height, weight.height ratio, and body mass index on the spread of spinal anesthesia with 3.0 ml of 0.5% isobaric bupivacaine was examined in 185 patients. No significant correlation was found between the spread of analgesia and the age, weight, height, weight.height ratio, or body mass index. A significant correlation was found between the decrease in mean arterial pressure and the height of sensory analgesia (rho = -0.21, P < 0.05) as well as the aging (rho = -0.35, P < 0.001).

Postoperative analgesia with epidurally injected buprenorphine and its side effects were investigated in 100 patients who had received lower abdominal surgery. All patients received initially 8 ml of bupivacaine and 0.1 mg of buprenorphine. Following bolus epidural injection, five different groups of 20 patients each received either bupivacaine alone (group A), 5 micrograms.ml-1 buprenorphine.bupivacaine mixture (group B), 8 micrograms.ml-1 buprenorphine.bupivacaine mixture (group C), 12 micrograms.ml-1 buprenorphine.bupivacaine mixture (group D), or 15 micrograms.ml-1 buprenorphine.bupivacaine mixture (group E) by a portable disposable device at a rate of 1 ml.h-1 for 48 h. The analgesic efficacy in group E was superior to those in groups A, B, C or D. No significant difference in the incidence of side-effect was found among groups C, D, E. We conclude that a dose of a approximately 15 micrograms.h-1 might be optimal for postoperative pain relief after lower abdominal surgery.

Different factors influence the severity of postoperative pain. Personality and cultural factors as well as anxiety and fear modify the degree of postoperative pain. The site of surgery is also a major determinant. We evaluated the severity of postoperative pain in patients after three different surgeries, thoracic, upper abdominal and lower abdominal surgeries, from 24 h to 72 h postoperatively. Thirty patients were divided into three groups: thoracic, upper abdominal and lower abdominal groups (n = 10, respectively). All patients received continuous epidural infusion of 0.25% bupivacaine (2 ml.h-1) and buprenorphine (0.2 mg x 24 h-1). Additional analgesics were given when the patient complained of pain. Analgesia was evaluated by 100 mm visual analog scale and demands of analgesics. Pain scores at rest were not different among three groups. Pain after lower abdominal surgery tended to be less severe compared with that after thoracic surgery. Demands of analgesics were not different among three groups at any evaluated point. Pain after thoracic surgery was consistent during 72 postoperative hs, but in the upper and lower abdominal surgery groups pain at 72 hs was significantly weaker than that at 24 hs. We conclude that postoperative pain was not different among the three surgery groups, but pain after upper and lower abdominal surgery decreased more rapidly compared with that after thoracic surgery.