[Combined General and Spinal-Epidural Anesthesia under Spontaneous Breathing in a Patient with a Giant Bulla].

This paper reports the successful perioperative management of a patient with a giant bulla, who underwent radical prostatectomy under general anesthesia performed under combinet spinal-epidural anesthesia while maintaining spontaneous respiration. A 61-year-old man was scheduled for radical prostatectomy. He had undergone conservative treatment using a drainage tube for right-sided pneumothorax at the age of 23. Preoperative chest CT revealed the presence of a giant bulla in the left upper lobe, multiple bullae in the entire right lung, and emphysematous alterations in both lungs. On respiratory function testing, mild obstructive impairment was observed. In the operating room, an epidural catheter was inserted at T11-12, and spinal anesthesia was performed at L3-4. Under anesthesia with propofol and fentanyl, i-gel® was inserted. During anesthesia, spontaneous respiration was managed at oxygen concentration 40% and sevoflurane 1.5%, while continuing the epidural administration of levobupivacaine. The circulatory and respiratory conditions were stable during surgery. The durations of surgical and anesthetic procedures were 2 hours and 16 minutes and 3 hours and 33 minutes, respectively. In the absence of respiratory complications, the patient was discharged 8 days after surgery.

Evaluation of twitch responses obtained from abductor hallucis muscle as a monitor of neuromuscular blockade: Comparison with the results from adductor pollicis muscle.

The twitch responses evoked from the abductor hallucis muscle (AHM) and the adductor pollicis muscle (APM) were examined simultaneously in 20 anesthetized patients following a single bolus intravenous administration of 0.04 mg·kg-1 of vecuronium bromide. The mean onset time of vecuronium-induced depression of AHM twitch responses was significantly slower than that of APM twitch responses (4.9±1.5 minvs 3.7±1.2 min, mean±SD,P<0.001), and when the clinical duration times of vecuronium were compared, AHM twitch responses recovered more quickly than APM twitch responses (15.3±4.1 minvs 19.6±6.7 min,P<0.01), although there was no statistically significant difference in the spontaneous recovery time between AHM and APM (9.8±2.9 minvs 10.0±3.6 min). It is concluded that the twitch responses of AHM may be a useful monitor of neuromuscular blockade in anesthetized patients in whom setting the blockade monitor on the patient's arms is difficult, although monitoring of twitch response of AHM is less sensitive than that of APM in case of vecuronium administration.