[Anesthesia management for fetoscopic treatment of twin-to-twin transfusion syndrome].

BACKGROUND: The fetoscopic laser coagulation of the vascular anastomoses on the monochorianic placenta for twin-to-twin transfusion syndrome (TTTS) has recently been shown to be effective. There have been few reports on the anesthetic techniques used for the fetoscopic laser coagulation. We report cases in which midazolam and fentanyl were used for the anesthetic management of the fetoscopic laser coagulation. METHODS: Twenty-two healthy (ASA I, II) women in the second trimester of pregnancy, carrying twins and scheduled for the fetoscopic laser coagulation for TTTS, were included. Midazolam 1 mg and fentanyl 2 microg x kg(-1) were infused intravenously before insertion of urethral catheter. Thereafter, fentanyl was infused at a rate of 2 microg x kg x hr(-1) lidocaine (1%, 5 ml) was administered locally. RESULTS: The procedure was performed successfully in 21 of 22 cases with acceptable pain. In one case, general anesthesia was necessary because the pain was not controlled. Maternal respiratory rate and end-tidal CO2 remained stable during the procedure. No patient had the respiratory rate below 10 breaths x min(-1). CONCLUSIONS: Continuous fentanyl infusion with midazolam provided acceptable maternal analgesia and sedation during endscopic treatment of TTTS. Careful titration with simulation of fentanyl concentration and respiratory monitoring enable safe and effective anesthesia management.

[Case of electrocardiogram showing ST depression after nonionic contrast media (iopromide) administration].

A 77-year-old man with coronary artery stenosis underwent the left limb artery bypass grafting. When the contrast media was administered on intraoperative limb reperfusion after revascularization, electrocardiogram showed ST depression without skin symptoms and blood pressure decline. The change was not in the right coronary artery area (99% stenosis), but in the left coronary artery area (50% stenosis). The nonionic contrast media may elicit coronary artery vasoconstriction, although there are few side effects including anaphylactic in comparison with the ionic contrast media. In administration of the nonionic contrast media to the patient with coronary artery stenosis (50% or more), it is important to examine electrocardiogram, and is advisable to administer coronary artery dilating drug before-hand.

[Anesthetic management for a patient with Huntington disease].

A 41-year-old man (169 cm, 48 kg), having a 10 year history of Huntington disease, was presented for percutaneous endoscopic gastrostomy because of repeated aspiration episodes. He had suffered from choreiform movements, misswallowing and progressive mental deterioration. Midazolam 2 mg i.v. was given on transferring the patient to the operating room. On arriving, the patient was somnolent but responded to call. BIS index was 55. Anesthesia was induced with thiopental 120 mg i.v. and fentanyl 100 microg i.v. followed by vecuronium 4 mg i.v. After tracheal intubation, anesthesia was maintained with sevoflurane 1.5% in 33% oxygen. Bispectral index and train of four ratio were monitored throughout the anesthesia. BIS index and TOF ratios were proper for the drug dose used. At the end of the procedure, neuromuscular blockade was antagonized with neostigmine 2.0 mg and atropine 1.0 mg i.v. with no worsening of symptoms. The duration of anesthesia was 85 minutes. The patient woke up (BIS index 78) and spontaneous respiration returned and he was extubated. The postoperative course was uneventful. In this case, BIS index was abnormally low before induction of anesthesia as well as after anesthesia. Whether Huntington disease is responsible for the abnormally low bispectral index remains uncertain. But, anesthesiologists should be aware of this phenomenon to avoid an inappropriate adjustment of the anesthetic depth.

Tight glycemic control by insulin, started in the preischemic, but not postischemic, period, protects against ischemic spinal cord injury in rabbits.

BACKGROUND: It is not well established whether insulin protects against ischemic spinal cord injury. We examined the effects of a single dose of insulin that corrects mild hyperglycemia on the outcome after transient spinal cord ischemia in rabbits. METHODS: We assigned rabbits to four groups (n = 8 in each); untreated control (C) group, preischemic insulin (Pre-I) group, preischemic insulin with glucose (GI) group (glucose concentrations were maintained at levels similar to the C group by the administration of glucose), and postischemic insulin (Post-I) group. Insulin (0.5 IU/kg) was administered 30 min before ischemia in the Pre-I and GI groups, and just after reperfusion in the Post-I group. Spinal cord ischemia was produced by occluding the abdominal aorta for 13 min. Neurologic and histopathologic evaluations were performed 7 days after ischemia. RESULTS: The mean blood glucose concentration before ischemia in the Pre-I group (118 mg/dL) was significantly lower than in the other three groups (158-180 mg/dL) and those of 30 min after reperfusion in the Pre-I (92 mg/dL) and Post-I (100 mg/dL) groups were significantly lower than in the C (148 mg/dL) and GI (140 mg/dL) groups. The motor function score and number of normal neurons in the anterior lumbar spinal cord in the Pre-I group were significantly greater than in the other three groups. CONCLUSIONS: These results suggest that a relatively small dose of preischemic insulin protects against ischemic spinal cord injury, and that the protective effects result from tight glycemic control before ischemia.