[A case of torsade de pointes in a patient with severe aortic stenosis during carotid endarterectomy].

An 87-year-old man with severe aortic stenosis developed torsade de pointes (TdP) during carotid endarterectomy before carotid artery stenosis. By prompt resuscitation and medication including lidocaine and magnesium, the patient recovered without complications in spite of high risk for refractory cardiac arrest or brain infarction. There was no other history or laboratory data suggesting arrhythmia except elongation on preoperative electrocardiogram. Inhaled anesthetics, catecholamine and sympathetic nerve stimulation were possible causes of QT elongation and induce TdP. Particularly in a patient with carotid and cardiac diseases, cardiac arrest is critical. Therefore we should avoid exacerbating factors of QT elongation or TdP even if patients have no particular history of arrhythmia.

[Fast-track cardiac anesthesia and perioperative management appropriate for early rehabilitation after coronary artery bypass graft (CABG) surgery].

BACKGROUND: Rapid mobilization and rehabilitation after CABG has a potential benefit of reducing both costs and pulmonary complications (such as atelectasis and pulmonary embolism). Moreover, it improves the patient's emotional recovery. We performed fast-track cardiac anesthesia aiming toward early rehabilitation. METHODS: Patients undergoing CABG surgery (total, 140: on-pump 97, off-pump 43) were studied. Anesthesia was induced and maintained with low doses of fentanyl and propofol. The outcome of our perioperative management was retrospectively reviewed on the basis of clinical records. RESULTS: The duration of the operation was 282 +/- 71 min. Anesthesia time was 353 +/- 72 min. The doses of fentanyl and propofol were 11.9 +/- 2.9 microg x kg(-1) and 16.8 +/- 5.4 mg x kg(-1), respectively. Time to extubation was 213 +/- 676 min, and the percentage of cases extubated within 3 h was 82%. As for outcome, the percentages of first oral intake, first rising from bed, and first gait performed on postoperative day 1 were 92%, 78%, 61%, respectively. The period of ICU stay was 2 days (median value). There were no perioperative complications related to early rehabilitation. CONCLUSIONS: We can safely manage fast-track cardiac anesthesia and perioperative management aiming toward early rehabilitation after CABG surgery.

Total spinal anesthesia provides transient relief of intractable pain.

PURPOSE: Intentional total spinal anesthesia (TSA) has been used for intractable pain treatment. However, the long-term effect of pain-relief is controversial. We investigate the short- and long-term effects of pain-relief by TSA. METHODS: Twelve patients with intractable pain participated in a crossover study. All participants received two different treatments in random order at a 30-day interval: i.v. infusion with 300 mg of lidocaine (i.v.-Lido), and TSA with 20 mL of 1.5% lidocaine (TSA-Lido). Pain level at rest was scored with the visual analogue scale (VAS: 0-100), and blood pressure and heart rate were measured before and at two hours, 24 hr, seven days, and 30 days after treatment. Plasma lidocaine concentrations were measured at 0.5, one, and two hours. RESULTS: Heart rate and mean arterial pressure during or after TSA-Lido were similar to those before TSA-Lido. Plasma lidocaine concentrations were similar between the two treatments. No significant difference in any value occurred in the i.v.-Lido treatment. VAS were similar before both treatments (87 +/- 6 for TSA-Lido; 86 +/- 7 for i.v.-Lido). After TSA-Lido, VAS decreased significantly until day seven (two hours, 17 +/- 22, P < 0.01; 24 hr, 43 +/- 20, P < 0.01; seven days, 66 +/- 16, P < 0.01). However, VAS returned to the pre-block values 30 days after TSA-Lido. CONCLUSION: Intractable pain was decreased significantly for several days after TSA, but pain-relief was not sustained.