[Predisposition to latex allergy undetected on preoperative evaluation: a case report].

A 70-year-old man was scheduled to undergo laparoscopic total gastrectomy for stomach cancer. He had no history of atopy, fruit allergies, or frequent exposure to natural rubber. Preoperative latex-specific IgE antibodies were negative. Anesthesia was induced, and the surgery was started uneventfully. Soon after the surgeon had begun to manipulate the intestine, the blood pressure suddenly dropped to 27/21 mmHg. Facial flushing was also observed. Anaphylactic shock caused by latex was strongly suspected, and surgery was immediately halted. The surgical gloves were changed to latex-free ones, and adrenaline was administered. The blood pressure was gradually normalized within 30 min, and the facial flushing mostly disappeared. Postoperative laboratory examination revealed that serum tryptase had increased to 34.4 microg l-1, 40 minutes after the onset of anaphylaxis, and decreased to 19.4 microg l-1, 24 hours than later. Latex-specific IgE antibodies and a prick test with latex were both positive. Consequently, the diagnosis of latex-induced anaphylactic reaction was confirmed. Because even detailed questioning and examination does not always identify such a predisposition, avoiding contactwith latex products is more rational exhaustively checking every preoperative patient for latex allergy

[Suspected diltiazem intoxication resulting in repeated asystole after the induction of anesthesia].

We present a case of diltiazem intoxication resulting in repeated asystole after the induction of anesthesia. A 39-year-old man was diagnosed as subarachnoid hemorrhage, and cerebral aneurysm clipping was scheduled on the next day. Electrocardiogram revealed normal sinus rhythm with complete right bundle branch block. Continuous intravenous administration of diltiazem, nicardipine and midazolam were started for intractable hypertension and tachycardia. In the operating room, electrocardiogram showed atrioventricular nodal rhythm. Nicardipine and midazolam were stopped and anesthesia was induced with thiamylal, fentanyl and vecuronium, and was maintained with sevoflurane. After tracheal intubation, the patient developed asystole, and cardiopulmonary resuscitation was provided immediately. Diltiazem was stopped. Cardiac rhythm was restored 8 min afterwards; however, asystole recurred six times. Temporary cardiac pacing was effective, and percutaneous cardiopulmonary support (PCPS), intraaortic balloon pumping (IABP), and continuous hemodiafiltration (CHDF) were initiated. The operation was canceled. On the next day, normal sinus rhythm was restored and the temporary pacing, PCPS, IABP, and CHDF were discontinued. Cerebral aneurysm was treated by endovascular coiling and the patient was discharged from the hospital without sequelae. This case illustrates asystole associated with diltiazem intoxication. It is necessary to consider this potential complication when diltiazem is used.

[Arterial to end-tidal carbon dioxide tension difference during laparoscopic colorectal surgery].

BACKGROUND: Determination of end-tidal carbon dioxide pressure (PET(CO2)) is effective to confirm adequate ventilation, because arterial to end-tidal carbon dioxide tension difference (deltaa-ET(CO2)) does not change normally during operation. But deltaa-ET(CO2) may change during laparoscopic surgery, because peritoneal insufflation of CO2 will increase CO2 production and reduce functional residual volume. Changes in deltaa-ET(CO2) were reported in laparoscopic cholecystectomy with cardiovascular complication, but there is controversy about how deltaaET(CO2) will change in more complicated and long laparoscopic surgery. In this prospective study, we examined changes in deltaa- ET(CO2) during laparoscopic colorectal surgery. METHODS: Fifty patients received combined general and epidural anesthesia. CO2 pneumoperitoneum was initiated after obtaining arterial blood for gas analysis. Mechanical ventilation was used to maintain PET(CO2) at a stable value between 30 and 40 mmHg during the procedure. Arterial blood gas analysis was performed 10, 60, 120 minutes after CO2 insufflation, and 10 minutes after the termination of insufflation. RESULTS: The mean +/- SD for deltaa-ET(CO2) was 5.8 +/- 4.1 before pneumoperitoneum, 7.1 +/- 4.8, 8.1 +/- 5.4, 6. 4 +/- 4.9 in 10, 60, 120 minutes after pneumoperitoneum, and 6.4 +/- 4.9 in 10 minutes after the termination of pneumoperitoneum. deltaa-ET(CO2) increased significantly during pneumoperitoneum, but did not increase further even if CO2 insufflation was longer than 60 minutes. CONCLUSIONS: In laparoscopic colorectal surgery, Pa(CO2) should be checked for at least the first 60 minutes to confirm adequate ventilation.

[Tracheal bleeding during awake fiberoptic intubation].

Fiberoptic intubation can cause laryngeal injury during blind insertion of a tracheal tube. A patient with hypopharyngeal cancer was scheduled for laser surgery and we selected nasal fiberoptic intubation due to laryngeal deformity. Just after insertion of a tracheal tube, tracheal bleeding occurred and ventilation because difficult. Emergency tracheostomy was required to restore adequate oxygenation. A piece of mucosa and blood clot was found in the lumen of the tracheal tube and hematoma was observed on the surface of arytenoid cartilage. Careful selection and optimal manipulation of the tracheal tube is important and surgical airway access should be immediately available before fiberoptic procedure in a patient with friable and vascular-rich laryngeal lesion.