Plasma ropivacaine concentration after TAP block in a patient with cardiac and renal failure.

We report a successful ultrasound-guided transversus abdominis plane (TAP) block as an analgesic option for minor abdominal surgery in a 66-year-old patient with cardiac, respiratory, and renal dysfunction caused by primary systemic amyloidosis. Bilateral TAP blocks with 120 mg (1.8 mg/kg) of ropivacaine provided sufficient intra- and postoperative analgesia for insertion of a continuous ambulatory peritoneal dialysis catheter. However, the plasma concentration of ropivacaine reached a maximum of 2.5 µg/mL at 15 minutes after the TAP block, a concentration that was potentially neurotoxic. Although apparent signs of local anesthetic systemic toxicity (LAST) such as convulsion or changes in an electrocardiogram were not observed, the patient became drowsy after the TAP block, which might be one of the mild symptoms of LAST. A TAP block by itself can thus be an anesthetic option for patients undergoing minor abdominal surgery. However, cardiac and renal dysfunction might influence the pharmacokinetics of a local anesthetic used, and attention should be paid to the possibility of LAST even with a low dose of a local anesthetic for patients with cardiac and renal failure.

Remifentanil for sedation and analgesia during awake division of tongue flap in children: a report of two cases.

BACKGROUND: The tongue flap is an accepted treatment method for cleft palate repair. Orotracheal or nasotracheal intubation using a fiberoptic scope is preferred for the division of the tongue flap. We report two cases of tongue flap division in which the patients received adequate sedation and analgesia without tracheal intubation. CASE PRESENTATION: Twelve- and 13-year-old male patients were treated at our hospital for tongue flap division, performed as part of a cleft palate repair. We planned to divide the tongue flap under sedation with remifentanil (1 µg/kg/min continuous infusion) and local anesthesia, followed by induction of general anesthesia, and orotracheal intubation after the tongue flap was divided. During the procedure, patients were breathing spontaneously and were cooperative. Patients were able to follow the surgeons' verbal cues to thrust out the tongue during the procedure, so that the surgeons could easily insert the sutures. CONCLUSIONS: During the division of the tongue flap in two children, excellent sedative and analgesic effects were achieved using continuous remifentanil infusion.

[Anesthetic Management with V-V ECMO in a Patient with Severe Tracheal Stenosis].

We here report a case in which tracheal stent insertion was performed using veno-venous extracorporeal membrane oxygenation (V-V ECMO). A 78-year-old man with severe tracheal stenosis due to thyroid cancer was suffering from dyspnea at rest. Computed tomography showed that the narrowest caliber of the trachea was 1.5 mm in diameter at 5 cm below the level of the vocal cords. Femoro-femoral V-V ECMO was established without hemodynamic instability. General anesthesia was induced with propofol 70 mg and fentanyl 50 µg and was maintained with propofol 150-200 mg x hr(-1) and remifentanil 0.3-0.5 mg x hr(-1) using target-controlled infusion devices. Mask ventilation was possible, and the trachea could be intubated. A rigid bronchoscope was advanced to the stenosis site after removing the endotracheal tube. Manual ventilation via a side port of the uncuffed bronchoscope could not achieve normal inflation of the both chest walls because of air leaks. Throughout the procedures, hypoxemia and hypercapnia could be prevented by manual ventilation supplemented with low-flow V-V ECMO. Stent implantation was performed successfully. This case suggests that V-V ECMO is useful for providing supplementary oxygenation and carbon dioxide elimination when adequate ventilation cannot be provided during tracheal stent implantation.

[Mechanisms underlying generation of cancer pain].

As advances in cancer detection and treatment have increased the life expectancy of cancer patients, more attention to improving patient's quality of life (QOL) is needed. Among symptoms accompanying cancer, pain has strong impact on QOL. Most of cancer patients will experience moderate to severe pain and/or neuropathy during the course of their disease. Cancer pain can arise from different processes, either by direct tumor infiltration/involvement, or toxicity relating to chemotherapy used to treat cancer. The World Health Organization (WHO) has proposed a structured approach to drug selection for cancer pain, known as the "WHO analgesic ladder". However, several types of pain including bone cancer pain and chemotherapy-induced painful peripheral neuropathy are difficult to treat. The development of optimal analgesics for cancer pain has been hampered by the lack of understanding basic mechanisms that contribute to cancer pain. Recently, preclinical models of bone cancer pain and paclitaxel-induced painful peripheral neuropathy have been developed. These models have begun to provide insight into the mechanisms by which cancer pain is induced and how cancer pain-related sensory information is processed. In this paper, we review mechanism of cancer pain.

[Usefulness of Epidrum for teaching identification of the epidural space].

BACKGROUND: Epidrum (ED) is a device to facilitate the epidural anesthesia procedure. Using ED, we can visually confirm the needle's penetration into the epidural space by collapse of the diaphragm. We investigated the usefulness of ED for teaching identification of the epidural space. METHODS: Forty parturients scheduled for cesarean section were randomly allocated to an ED group or loss of resistance (LOR) group. Epidural anesthesia was performed by residents (operators) under the instruction of advising doctors (observers). In the LOR group, the epidural space was identified by the conventional LOR technique using a glass syringe filled with normal saline. In the ED group, ED was attached to a Tuohy needle and was charged with 1.5 ml of air to expand its diaphragm. Ease of identification of the epidural space was scored by the operator and the observer. The time to identify the epidural space (TI) was recorded. RESULTS: TI in the ED group was significantly shorter than that in the LOR group. ED was superior to LOR for identification of the epidural space not only by operators but also by observers. CONCLUSIONS: The results suggest that ED is a useful device for teaching identification of the epidural space.