[Inadequate gas supply to the patients after the repair of anesthesia delivery system].

We experienced inadequate gas supply to the patients from the breathing circuit of anesthesia delivery system with APL valve at full open position. It was hardly noticed after the check-up before starting work with anesthesia delivery system. This problem was caused by the mistake in installing the one-way valve when the repair of anesthesia delivery system was done. In addition to the check-up before starting work, we should check whether gas comes out from the breathing circuit.

[Antihypertensive drugs].

Lately, treatment for hypertension has changed in Japan, according to Japanese Society of Hypertension Guideline 2000 (JSH 2000). We present the characteristics of antihypertensive drugs, and directions for their preoperative use.

[Steroids].

We sometimes encounter preoperative patients with steroid treatment. These patients require steroid cover around the operative period because their adrenal cortical function is suppressed. Steroid supplementing therapy has changed since a generation ago. Therefore, steroid treatment is one of the items that anesthegiologists must study immediately.

[Anesthetic management for electroconvulsive therapy using target-controlled infusion of propofol].

A 66-year-old man received medical treatment of depression for several years. He had a suspected malignant syndrome and in addition the symptom had deteriorated, and the electroconvulsive therapy (ECT) was administered. Though suxamethonium chloride is usually used as a muscular relaxant in the electroconvulsive therapy, we used vecuronium bromide (VCB) considering malignant syndrome. Maintenance of anesthesia was necessary because of the long effect of VCB. Anesthesia was induced and maintained by target controlled infusion (TCI) of propofol. Because propofol suppresses the convulsion, it is necessary to adjust the depth of anesthesia by propofol, and we used TCI of propofol. When the predicted blood propofol concentrations were 1.5 microg x ml(-1) and 2.0 microg x ml(-1), electric stimulation was given to the patient and enough seizure duration was obtained. TCI of propofol is useful for ECT to patients for whom suxamethonium chloride can not be used.

Anesthetic management of an extremely obese patient.

We present the case of a morbidly obese woman, with a body mass index (BMI) of 73.7 kg.m(-2), who had a gynecological operation under combined general and epidural anesthesia. The patient's trachea was intubated, using a fiberscope, while she was breathing spontaneously after the intravenous injection of fentanyl and propofol as sedatives. Anesthesia was maintained with intravenous propofol and epidural mepivacaine. When the gynecologist placed a sponge in the abdominal cavity to retract the bowel, the patient experienced severe arterial deoxygenation and mild hypotension, due to massive atelectasis of the left lung. Both oxygenation and perfusion were corrected by the removal of the sponge and with the placement of a pillow under the patient's left shoulder. The atelectasis resulted from compression of the left lung by the fatty mediastinum and by the diaphragm being pushed up by the sponge. The hypotension resulted from impaired venous return and hypoxia. The patient suffered no perioperative complications other than atelectasis and a surgical-site infection. Key factors that contributed to the favorable outcome of this patient included a careful tracheal intubation technique, the choice and dose of anesthetic agents, immediate correction of the factors leading to atelectasis, early ambulation, and prophylaxis for deep vein thrombosis.