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Respiratory failure is a common complication in patients with myotonic dystrophy (MD) and might be a presenting symptom in the perioperative setting. We report the case of a 59-year-old woman with MD who underwent open cholecystectomy and developed postoperative respiratory failure. Without reintubation, the patient was successfully managed with bilevel positive airway pressure (BiPAP) and was discharged uneventfully. BiPAP may be considered as an alternative for postoperative respiratory failure in patients with MD. Careful observation of patients' postoperative condition and an earlier application of BiPAP are instrumental in avoiding retracheal intubation, which may cause further serious problems in patients with MD.

Some patients experience severe chronic pain after intramedullary spinal cord tumor (IMSCT) resection, but the underlying mechanisms have yet to be fully elucidated. We aimed to investigate perioperative factors associated with chronic pain after IMSCT resection.We analyzed data from a postal survey and the medical records of patients who had undergone IMSCT resection in our institution between 2000 and 2008. Chronic pain was assessed using the Neuropathic Pain Symptom Inventory score, and its associations with factors related to tumor pathology, patient demographics, neurological findings, surgery, anesthesia, and perioperative management were determined.Seventy-eight consecutive patients (55 men and 23 women; age 17 to 79 y) were included in the statistical analysis of the present study. In univariate analyses, sex, body mass index, preoperative tumor-related pain, preoperative nonsteroidal anti-inflammatory drugs, intraoperative hypotension, postoperative corticosteroids, and decrease in Japanese Orthopaedic Association (JOA) scores were found to be associated with postsurgical chronic central pain. Logistic regression analysis identified 3 significant factors: a decline in JOA scores compared with preoperative values (odds ratio [OR], 3.33; 95% confidence interval [CI], 1.18-9.42; P=0.023), intraoperative hypotension (OR, 3.01; 95% CI, 1.02-8.97; P=0.047), and postoperative corticosteroids (OR, 3.21; 95% CI, 1.02-10.09; P=0.046).Decline in JOA score, intraoperative hypotension, and postoperative corticosteroids are independently associated with postsurgical chronic central pain. Intraoperative hypotension and the use of postoperative corticosteroids can be avoided or modified during perioperative management. As results from animal studies have indicated that the administration of corticosteroids may intensify chronic pain, further studies in larger cohorts are required to definitively determine the effect of corticosteroids on postsurgical central pain.

In general, preoxygenation is performed using a face mask with oxygen in a supine position, and oxygenation is maintained with manual mask ventilation during electroconvulsive therapy (ECT). However, hypoxic episodes during ECT are not uncommon with this conventional method, especially in morbidly obese patients. The most important property of ventilatory mechanics in patients with obesity is reduced functional residual capacity (FRC). Thus, increasing FRC and oxygen reserves is an important step to improve oxygenation and prevent oxygen desaturation in these individuals. Head-up position, use of apneic oxygenation, noninvasive positive pressure ventilation, and high-flow nasal cannula help increase FRC and oxygen reserves, resulting in improved oxygenation and prolonged safe apnea period. Furthermore, significantly higher incidence of difficult mask ventilation is common in morbidly obese individuals. Supraglottic airway devices establish effective ventilation in patients with difficult airways. Thus, the use of supraglottic airway devices is strongly recommended in these patients. Conversely, because muscle fasciculation induced by depolarizing neuromuscular blocking agents markedly increases oxygen consumption, especially in individuals with obesity, the use of nondepolarizing neuromuscular blocking agents may contribute to better oxygenation in morbidly obese patients during ECT.

Background Von Willebrand disease (VWD) is the most common inherited bleeding disorder in humans. Coagulopathies such as VWD are evidently risk factors for post-surgical bleeding. Perioperative management of patients with VWD remains controversial and is a major clinical concern. Case presentation A 5-year-old girl was scheduled for tonsillectomy under general anesthesia. Preoperative laboratory tests revealed prolongation of activated partial thromboplastin time and a mild decrease in von Willebrand factor (VWF) activity. Prophylactic administration of desmopressin or VWF was not performed. During tonsillectomy, oozing from the surgical wound was uncontrollable by conventional hemostasis techniques, but complete hemostasis was ensured by plasma-derived coagulation factor VIII concentrate containing VWF. Conclusion Pediatric patients with mild abnormalities in preoperative laboratory tests may have coagulopathies. Prophylactic intervention and/or the preparation of a sufficient amount of coagulation factor VIII concentrate containing VWF may be required in patients suspected of having VWD or with mild VWF deficiency.

Patients with amyotrophic lateral sclerosis (ALS) present an increased risk of postoperative respiratory failure after general anesthesia. We report the case of a 71-year-old man with ALS who underwent emergency laparotomy for small bowel strangulation. After surgery, he remained intubated and was transferred to the high care unit under mechanical ventilation, due to unstable hemodynamics requiring inotropic support. On postoperative day (POD) 3, he was extubated under stable hemodynamics and respiratory status. Immediately after extubation, bilevel positive airway pressure (bilevel PAP) was prophylactically applied to prevent postoperative respiratory failure, which may have been caused by respiratory muscle fatigue, attributed to general anesthesia and surgical stress. On POD 7, bilevel PAP was smoothly weaned off because no signs and symptoms of respiratory failure were observed. On POD 10, he achieved 30 m-walk without rest. No postoperative complications were observed up to one month after surgery. Postoperative respiratory failure may lead to death in patients with neuromuscular disorder. Non-invasive ventilation (NIV) reduces respiratory muscle fatigue, resulting in easy sputum expectoration, promoting CO2 washout, and better oxygenation. Consequently, the prophylactic use of NIV to avoid postoperative respiratory insufficiency should be considered in patients with ALS after emergency operation under general anesthesia.

Tracheal intubation is challenging in patients with severe cervical spine pathology. In such cases, awake fiberoptic intubation is the gold standard and safest option for tracheal intubation. However, this technique requires the patient's understanding and cooperation, and therefore, may be contraindicated in patients with refusal or poor tolerance. Herein, we report successful orotracheal intubation in a patient with limited mouth opening and severe cervical spine rigidity under general anesthesia using an extraglottic airway device and a gum-elastic bougie under C-arm fluoroscopic guidance.

This study aimed to examine the incidence, case fatality rate, and characteristics of perioperative symptomatic pulmonary thromboembolism (PS-PTE) throughout Japan.From 2002 to 2011, confidential questionnaires were mailed annually to all Japanese Society of Anesthesiologists-certified training hospitals for data collection to determine the incidence and case fatality rate of PS-PTE patients. Data from 10,537 institutions in which a total of 11,786,489 surgeries had been performed were analyzed using the Mann-Whitney and Chi-square tests.In total, 3,667 PS-PTE cases were identified. The average incidence of PS-PTE was 3.1 (2.2-4.8) per 10,000 surgeries, and the average case fatality rate was 17.9% (12.9-28.8%). The incidence of PS-PTE began to significantly decrease in 2004 compared with that of 2002 (0.0036 vs. 0.0044%: p0.01). The case fatality rate temporarily increased toward 2005 (17.9 to 28.8%); however, it gradually decreased since 2008 (15.7%) and was the lowest (12.9%) in 2011. Regarding the trends in prophylaxis, the rate of mechanical prophylaxis increased significantly in 2003 compared with that of 2002 (59.5 vs. 35.0%: p0.01), and almost plateaued (73.1-83.1%) after 2004. Furthermore, the rate of pharmacological prophylaxis started increasing in 2008 (17.6%) and reached around 30% after 2009 (28.8-30.2%).The results of our 10-year survey study show that the incidence of PS-PTE decreased significantly since 2004, and the case fatality rate seemed to show a downward trend since 2008. Major changes in the distribution of prophylaxis in PS-PTE patients were observed.

We hypothesized that nonsteroidal anti-inflammatory drugs decrease the plasma fentanyl concentration required to produce immobility in 50% of patients in response to skin incision (Cp50incision) compared with placebo under target-controlled infusion (TCI) propofol anesthesia.Sixty-two unpremedicated patients scheduled to undergo gynecologic laparoscopy were randomly assigned to receive placebo (control group) or flurbiprofen axetil 1 mg·kg(-1) (flurbiprofen group) preoperatively. General anesthesia was induced with fentanyl and propofol, and intubation was performed after succinylcholine 1 mg·kg(-1). Propofol was administered via a target-controlled infusion (TCI) system (Diprifusor™) set at an effect-site concentration of 5 μg·mL(-1). Fentanyl was given by a TCI system using the STANPUMP software (Schafer model). The concentration for the first patient was set at 3 ng·mL(-1) and modified in each group according to the up-down method. Skin incision was performed after more than ten minutes equilibration time. Serum fentanyl concentration, bispectral index (BIS), and hemodynamic parameters were measured two minutes before and after skin incision. The Cp50incision of fentanyl was derived from the mean of the crossovers (i.e., the serum fentanyl concentrations of successive participants who responded and those who did not or vice versa).Ten and 11 independent crossover pairs were collected in the control and flurbiprofen groups, respectively, representing 42 of 62 enrolled patients. The mean (SD) fentanyl Cp50incision was less in the flurbiprofen group [0.84 (0.63) ng·mL(-1)] than in the control group [1.65 (1.15) ng·mL(-1)]; P = 0.007; however, there were no differences in BIS, blood pressure, or heart rate, between groups.Preoperative flurbiprofen axetil decreased the Cp50incision of fentanyl by 49% during propofol anesthesia without changing the BIS or hemodynamic variables.

背景·目的: 病院輸血部門は血液センターと輸血使用現場を中継する位置にあり，危機的出血発生時には迅速な対応が要求される．今回，病院輸血部門の体制をアンケート調査し，危機的出血発生時の対応における問題点を明らかにした． 対象·方法: 病床数500床以上の麻酔科認定病院385施設を対象とし，2007年11月に調査を実施した． 成績: 輸血管理体制はほぼ整備されていたが，緊急輸血や大量輸血時への対応マニュアルの記載内容は不十分であった．危機的出血への対応ガイドライン（危機的出血GL）は認識されていたが，院内周知は不足していた．異型適合血使用を阻む要因が多々あった．輸血検査の所要時間，緊急出庫要請から使用可能になるまでの時間は，時間外で延長していた．血液センターからの緊急搬送時間は，時間内·時間外で変わらなかった．過去1年間に未交差同型血の使用実績がある施設は時間内，時間外とも43%，異型適合血に関しては時間内24%，時間外28%であった． 結論: 危機的出血GLなどを参考に危機的出血発生時の院内手順を定め，異型適合血使用に対する啓発活動を行う必要がある．危機的出血発生時には，状況を迅速に判断し，未交差同型血や異型適合血の使用を躊躇しないことが必要である．

手術による出血死は麻酔関連偶発症による死亡症例の17%を占めている. 手術に伴う大量出血が発生し, 危機的状況へと拡大していく過程には, 術前の患者状態や病巣の癒着・浸潤のほかに, 手術の手技と判断, 麻酔管理, 血液製剤の準備と追加供給状況, 緊急避難的輸血による対応の有無など, さまざまなヒューマンファクターが関与している. 手術出血死を回避するためには, 医療機関の組織的対応能力と血液センターとの連携を向上させる必要がある.

Background: Statistical data of mortality and morbidity related to anesthesia have not been reported in Japan since World War II. The need to comprehensively examine the events of cardiac arrest as well as mortality prompted the first national study in Japan. Methods: Confidential questionnaires were sent to all Japan Society of Anesthesiologists Certified Training Hospitals every year from 1994 through 1998. Collected data were analyzed for incidence of cardiac arrest and other critical events during anesthesia and surgery, and their outcomes within 7 postoperative days. The principal causes of the critical incidents were also analyzed. Results: With an average response rate of 39.9%, a total of 2,363,038 cases were documented over 5 years. The average incidence per year of cardiac arrest during surgery due to all etiologies and that totally attributable to anesthesia was 7.12 [95%CI: 6.30,7.94] and 1.00 [0.88, 1.12]) per 10,000 cases, respectively. The average mortality per year in the operating room or within 7 postoperative days due to all etiologies and that totally attributable to anesthesia was 7.18 [6.22, 8.13] and 0.21 [0.15, 0.27] per 10,000 cases, respectively. The two principal causes of cardiac arrest during anesthesia and surgery due to all etiologies were massive hemorrhage (31.9%) and surgery (30.2%), and those totally attributable to anesthesia were drug overdose or selection error (15.3%) and serious arrhythmia (13.9%). Preventable human errors caused 53.2% of cardiac arrest and 22.2% of deaths in the operating room totally attributable to anesthesia. Conclusions: The rates in Japan of cardiac arrest and death during anesthesia and surgery due to all etiologies as well as those totally attributable to anesthesia are comparable to those of other developed countries.

神経芽細胞腫を伴う7歳患児に対し,モルヒネの静脈内PCAによる在宅疼痛管理を行った.痙痛に対する患児の訴えが的確であり,PCAに対する両親の理解も良好であったため,在宅における痙痛の訴えに応じたボーラス投与や副作用監視が可能であった.病勢の進行とともにモルヒネ必要量が漸増し,最高時960mg・d-1まで及んだが,患児の日常生活に悪影響は認めなかった.またモルヒネ抵抗性の疼痛出現に対してはケタミンの持続静注併用が有効であった.本症例では高用量のモルヒネを必要としたが,注意深い疼痛評価や副作用監視,家族と疼痛緩和チームとの協力により,PCAによる良好な在宅疼痛管理を行い得た.

慶應義塾大学病院で1996年9月から1997年2月までの6ヵ月間における麻酔科管理の手術件数は2,681例で,そのうち術前に麻酔科診療依頼が出されたのは432例であった.科別でみると,耳鼻咽喉科20.4%,整形外科18.3%,一般外科171%,産婦人科11,6%の順に多く,この4科で全依頼の67.4%を占めた.診療依頼の内容は呼吸•循環器系の合併症に関するものが多く,依頼理由の52.6%を占めた.一方,依頼の内容に不備があったり,必要性が低いと考えられるものが12.1%でみられた.麻酔科術前診療依頼をより有用なものとするために,今回の結果をもとに術前評価•術前依頼の手引きを作成した.加えて,効率のよい周術期管理のために診療依頼の新しいシステムを確立する必要があると考える.

OBJECTIVE To determine whether the segmental multifrequency bioelectrical impedance analysis may improve the prediction for intraoperative changes in extracellular water volume (deltaECW) compared with whole body multifrequency bioelectrical impedance analysis in abdominal surgical patients. DESIGN Prospective, consecutive sample. SETTING Surgical operative patients in a university-affiliated city hospital. PATIENTS Thirty patients who underwent elective gastrointestinal surgery. INTERVENTIONS Multifrequency bioelectrical impedance analysis was conducted preoperatively (before the induction of anesthesia) and postoperatively (after recovery from anesthesia). Resistance values fitted at zero frequency (R0) in the whole body and in each body segment (arm, trunk, and leg) were determined by performing nonlinear curve-fitting and subsequent extrapolation. DeltaECW values were estimated from the whole body resistance between wrist and ankle using two different prediction formulas. In segmental multifrequency bioelectrical impedance analysis, however, ECW was obtained as the sum of each body segment (arms, trunk, and legs) using the equation newly derived from the cell suspension theory. DeltaECW estimated from both measurements were compared with net fluid balances during surgery. MEASUREMENTS AND MAIN RESULTS R0 in whole body and all body segments significantly decreased after surgery (p < .0001). The most striking decrease in post/preoperative ratios was found in the R0 in the trunk. The post/preoperative ratio of the R0 value in the trunk was significantly lower than the post/preoperative ratio of the R0 value in the leg (p = .0007). DeltaECW from segmental multifrequency bioelectrical impedance analysis was similar to net fluid balance (r2 = .80, bias = -0.03 L), whereas whole body multifrequency bioelectrical impedance analysis resulted in considerable underestimations of deltaECW (r2 = .50, .51, bias = 0.95, 0.53 L). CONCLUSIONS The difference in the prediction of deltaECW between whole body and segmental multifrequency bioelectrical impedance analysis may be explained by the significant decrease in the resistance of the trunk, which contributed only minimally to the whole body resistance. Segmental multifrequency bioelectrical impedance analysis provides a better approach to predict ECW changes in critically ill patients with nonuniform fluid distribution.

To determine the necessary mean infusion rate of propofol during combined nitrous oxide (NTwelve elective gynecological patients were monitored by a Dräger pEEG monitor under NThe mean (SD) induction dose of propofol was 2.9 (0.4) mg·kgTitration of propofol infusion using SEF during combined general and spinal anesthesia provided a rapid recovery without any clinical signs of inadequate anesthesia.

Objective The aim of this study was to detect cyclic changes in the relative humidity (RH) occurring with spontaneous respiration using a rapid-response hygrometer, and to evaluate its potential applicability as an apnea monitor in nonintubated subjects.

Significant degrees of main-stem bronchial obstruction may not have a detectable effect on ventilation distribution at normal breathing frequencies. We determined the effect of graded left main-stem bronchial obstruction (area reduction of 50 and 70%) on the distribution of tidal volume (VT) and mean lung volume (VL) using radioactive 13NN and two-dimensional planar positron imaging in six supine anesthetized tracheotomized dogs. Measurements were made during eucapnic high-frequency oscillatory ventilation at frequencies (f) of 0.2, 1, 5, and 10 Hz. Right and left lung respiratory system complex impedance (Z) values were assessed by simultaneous measurements of dynamic regional lung volume by positron imaging and carinal pressure. The results show a progressive shift of VT away from the obstruction at f > 1 Hz, with VT left-to-right (L/R) ratios of 0.9, 0.9, 0.58, and 0.46 at f of 0.2, 1, 5, and 10 Hz, respectively, for 70% obstruction. VT shifts with f for 50% obstruction were similar but of lesser magnitude. VL L/R ratio was 0.88 and did not change with f or obstruction. The real part of Z was frequency dependent and increased at low f independent of obstruction. The real part of Z L/R ratio increased with obstruction at 5 and 10 Hz. At low f there was a difference between left and right imaginary parts of Z due to the difference in VL. There was no significant change in the imaginary part of Z as a result of obstruction. We conclude that up to a 70% unilateral bronchial obstruction is not detectable by distribution of ventilation at f < or = 1 Hz.(ABSTRACT TRUNCATED AT 250 WORDS)

Study Objective: To provide a brief review of the current status of high frequency ventilation in neonatal respiratory care. Data Identification: Publications appearing between 1980 and 1990 were identified by computer searches using the National Library of Medicine's data base, Medline , and by searching related to physiologic background and clinical reports Study Selection: Studies related to physiologic background and clinical reports of neonatal application were selected individually. Data Extraction: Data concerning the physiologic basis, clinical effectiveness and complications, and latest results of a multicenter randomized trial were evaluated and used to develop a curient concept. Results of Data Synthesis: In early clinical tests of high frequency ventilation, it was considered beneficial that airway pressure lower than that used in conventional mechanical ventilation might reduce the frequency of pulmonary barotrauma. When high frequency ventilation was applied to infants with respiratory distress syndrome, the development of chronic pulmonary complications also was expected to decrease. Although several reports supported this hypothesis, a recent controlled trial involving multiple clinical centers did not find significant improvement in the group treated with high frequency ventilation. Rather, they recognized the frequent occurrence of complications associated with high frequency ventilation and suggested the prior use of conventional ventilation. However, a possible defect of this study design requires further studies to elucidate the source of these conflicting results. Conclusions: As a mode of mechanical ventilation, high frequency ventilation is useful for maintaining ventilation in patients with air leak syndrome or bronchopulmonary fistula or during bronchoscopic examination. But in general, its role as an alternative to conventional ventilation still remains controversial.

We evaluated differences in individual peritoneal membrane transport function and nutritional status in patients with diabetes mellitus (DM) and nondiabetic (non-DM) patients on continuous ambulatory peritoneal dialysis (CAPD).We used a newly developed peritoneal function test, personal dialysis capacity, in 88 patients (44 DM and 44 non-DM) on CAPD for 1 to 210 months. Sex, age, past history of peritonitis, and duration of CAPD were matched in DM and non-DM patients.Serum albumin (mean +/- SEM) was lower in DM compared with non-DM patients: 3.0 +/- 0.1 g/dL (30 +/- 1 g/L) versus 3.5 +/- 0.1 g/dL (35 +/- 1 g/L), P0.001. Peritoneal area and dialysis protein loss were greater in DM versus non-DM patients. In multiple linear regression analysis, the only independent predictor of serum albumin in patients with DM was dialysis protein loss. In contrast, age, past history of peritonitis, duration of CAPD, caloric intake, protein nitrogen appearance and protein catabolic rate, and residual renal function did not correlate with serum albumin in DM patients. In non-DM patients, age, duration of CAPD, and past history of peritonitis, but not dialysis protein loss, were independent predictors of serum albumin. There was a significant correlation in DM patients, but not in non-DM CAPD patients, between dialysis protein loss and urinary excretion of protein (r = 0.866, P = 0.0005).In this multicenter study, peritoneal membrane transport and peritoneal protein permeability were significantly higher in DM than in non-DM patients. Hypoproteinemia in DM patients is attributable to the high permeability of the peritoneal membrane undergoing CAPD.

Objective: To compare the hemodynamic effects of milrinone during weaning from cardiopulmonary bypass (CPB) in patients with a low pre-CPB cardiac index (CI) 2 ) and in patients with a high pre-CPB CI (≥2.5 L/min/m 2 ). Design: Prospective, randomized, double-blind study. Setting: University hospital. Participants: Forty-eight patients scheduled for elective coronary artery bypass graft surgery. Intervention: Patients were divided into 4 groups: (1) low pre-CPB CI/placebo, (2) low pre-CPB CI/milrinone, (3) high pre-CPB CI/placebo, and (4) high pre-CPB CI/milrinone. Patients received a loading dose of 20 μg/kg of milrinone followed by an infusion of 0.2 μg/kg/min or placebo 15 minutes before the anticipated weaning time. Measurements and Main Results: In the low pre-CPB CI/placebo group, low CIs and high systemic vascular resistances (SVRs) were observed after CPB. High doses of dopamine and dobutamine were needed, and infusion of epinephrine was used in 5 of the 12 patients for hemodynamic support. Milrinone improved CI and reduced SVR in the low pre-CPB CI/milrinone group. Norepinephrine was needed to maintain an adequate systemic blood pressure in 6 of the 12 patients, however. In the high pre-CPB CI/placebo group, satisfactory CIs and SVRs were observed during weaning from CPB with low doses of dopamine and dobutamine. Milrinone significantly increased CI and decreased SVR in the high pre-CPB CI/milrinone group: 10 of the 12 patients had CIs above the upper limit of normal, and 7 patients had SVRs below the lower limit of normal. Conclusion: Milrinone was effective during weaning from CPB in patients with a low pre-CPB CI. Milrinone in combination with norepinephrine was a good alternative to epinephrine for the treatment of myocardial dysfunction after CPB. Copyright © 2000 by W.B. Saunders Company

Simon, Brett A., Koichi Tsuzaki, and Jose G. Venegas.Changes in regional lung mechanics and ventilation distribution after unilateral pulmonary artery occlusion. J. Appl. Physiol. 82(3): 882–891, 1997.—Regional pneumoconstriction induced by alveolar hypocapnia is an important homeostatic mechanism for optimization of ventilation-perfusion matching. We used positron imaging of13NN-equilibrated lungs to measure the distribution of regional tidal volume (Vt), lung volume (Vl), and lung impedance ( Z) before and after left (L) pulmonary artery occlusion (PAO) in eight anesthetized, open-chest dogs. Measurements were made during eucapnic sinusoidal ventilation at 0.2 Hz with 4-cmH2O positive end expiratory pressure. Right (R) and L lung impedances ( Z rand Z l) were determined from carinal pressure and positron imaging of dynamic regional Vl. LPAO caused an increase in ‖ Z l‖ relative to ‖ Z r‖, resulting in a shift in Vt away from the PAO side, with a L/R ‖ Z‖ ratio changing from 1.20 ± 0.07 (mean ± SE) to 2.79 ± 0.85 after LPAO ( P < 0.05). Although mean L lung Vl decreased slightly, theVl normalized parameters specific admittance and specific compliance both significantly decreased with PAO. Lung recoil pressure at 50% total lung capacity also increased after PAO. We conclude that PAO results in an increase in regional lung Z that shifts ventilation away from the affected area at normal breathing frequencies and that this effect is not due to a change in Vl but reflects mechanical constriction at the tissue level.

The effect of low-dose (20 ng·kg−1·min−1) infusion of prostaglandin E1 (PGE1) on vecuronium-induced neuromuscular blockade was studied. The study population consisted of 24 elderly patients (65–75 years old) and 24 younger adult patients (25–56 years old). They were randomly assigned to the control and PGE1 groups. The steady-state dose requirement (SSDR) of vecuronium was derived from ondemand infusion of the drug which produced a stable twitch height of 20% of its baseline reading, and recovery time after steady-state infusion was defined as the time for recovery from twitch height from 25% to 75%. The patients in the PGE1 group received an infusion of PGE1 20 ng·kg−1·min−1, while those in the control group received an infusion of normal saline. The SSDR (23.2±9.1 and 34.2±5.9 μg·kg−1. hr−1, respectively;P=0.02) was significantly less and the recovery time (35.0±9.5 and 19.9±4.2 min, respectively;P=0.01) was significantly longer in the elderly than in the younger patients. However, low-dose infusion of PGE1 significantly increased the SSDR (23.2±9.1 to 37.4±3.7 μg· kg−1·hr−1;P=0.01) and shortened the recovery time (35.0±9.5 to 23.5±4.0 min;P=0.02) in elderly patients. We concluded that low-dose infusion of PGE1 is effective in preventing the prolonged action of vecuronium in elderly patients.

The effect of respiratory frequency (f) on the distributions of ventilation, regional gas transport, lung volume, and regional impedance was assessed with positron imaging in lungs with nonuniform lung mechanics after unilateral lung lavage. Supine dogs were studied during eucapnic oscillatory ventilation at f between 1 and 15 Hz and at a constant mean airway pressure of 5 cmH2O. Substantial differences in mean lung volume and tidal volume (VT) between lavaged and control lungs were found at all f values, but pendelluft never exceeded 2% of mouth flow. For f < or = 10 Hz, VT distributed in direct proportion to lung volume, whereas gas transport per unit of lung volume, measured from washout maneuvers, was reduced by 20% in the lavaged lung. At 15 Hz, however, the distributions of VT and gas transport approached equality between both lungs. Regional impedance was analyzed with a model that included a Newtonian resistance, an inertance, and Hildebrandt's model of tissue viscoelasticity. The data obtained from this work provide useful insights with respect to the mechanisms of gas transport during high-frequency ventilation and suggest the impact of operating frequency in clinical situations where substantial interregional heterogeneity in lung compliance could be expected.

Apparently conflicting differences between the regional chest wall motion and gas transport have been observed during high-frequency ventilation (HFV). To elucidate the mechanism responsible for such differences, a positron imaging technique capable of assessing dynamic chest wall volumetric expansion, regional lung volume, and regional gas transport was developed. Anesthetized supine dogs were studied at ventilatory frequencies (f) ranging from 1 to 15 Hz and eucapnic tidal volumes. The regional distribution of mean lung volume was found to be independent of f, but the apex-to-base ratio of regional chest wall expansion favored the lung bases at low f and became more homogeneous at higher f. Regional gas transport per unit of lung volume, assessed from washout maneuvers, was homogeneous at 1 Hz, favored the bases progressively as f increased to 9 Hz, and returned to homogeneity at 15 Hz. Interregional asynchrony (pendelluft) and right-to-left differences were small at this large regional scale. Analysis of the data at a higher spatial resolution showed that the motion of the diaphragm relative to the excursions of the rib cage decreased as f increased. These differences from apex to base in regional chest wall expansion and gas transport were consistent with a simple model including lung, rib cage, and diaphragm regional impedances and a viscous coupling between lungs and chest wall caused by the relative sliding between pleural surfaces. To further test this model, we studied five additional animals under open chest conditions. These studies resulted in a homogeneous and f-independent regional gas transport. We conclude that the apex-to-base distribution of gas transport observed during HFV is not caused by intrinsic lung heterogeneity but rather is a result of chest wall expansion dynamics and its coupling to the lung.

Acute stress of anesthesia and surgery can precipitate thyroid crrsis postoperatively in uncontrolled thyrotoxic patients. Preexisted liver dysfunction may also be aggravated in the postoperative period. V ncontrolled thyrotoxic patient developed fulminant hepatic failure, and during the course she suffered acute panperitonitis due to upper gastrointestinal tract perforation and underwent emergency laparotomy. We describe our perioperative management of this patient.

過去10年間における127例の大動脈瘤手術の麻酔経験より麻酔管理に検討が加えられた. その結果, 最近1年間の31例の同症例では1. 前投薬と麻酔導入に使用した薬剤の検討, 2. 気管支遮断用ブロッカー付気管内チューブの使用, 3. 硬膜外麻酔による術後管理, 4. 麻酔導入よりのリドカインとニトログリセリンの使用, 5. 大量フェンタニール麻酔法の使用, 等の麻酔管理上の変化が見られ, 良い成績を得ることができた.