[A retrospective study on perioperative bleeding in patients for hip fracture surgery in patients treated with or without antiplatelet/anticoagulating drugs].

BACKGROUND: Early operation for hip fracture patients is considered to have better outcome. Therefore, early operation was performed even if patients had been treated with antiplatelet and/or anticoagulating drugs (AP/AC) in our hospital for the past two years. This retrospective study was undertaken as excessive blood loss is expected in patients treated with AP/AC. METHODS: Elderly patients for hip fracture surgery were retrospectively studied in our hospital for the past two years. Perioperative decrease in hemoglobin level and the incidence of transfusion were compared between patients treated with AP/AC and those not treated. RESULTS: Sixty-four patients were treated with AP/AC and one hundred ninety-nine patients were not treated. Patients treated with AP/AC had more preoperative complications and worse ASA-PS scores. General anesthesia was used more frequently for patients with AP/AC. In the perioperative decrease in hemoglobin level and the incidence of transfusion, there were no significant differences between the groups. CONCLUSIONS: Perioperative bleeding for hip fracture surgery was compared between patients treated with and without AP/AC. No significant difference was observed, and, discontinuation of AP/AC might not be necessary for hip fracture surgery.

[Asystole after anesthetic induction with remifentanil].

A 45-year-old man was scheduled for laparoscopic cholecystectomy. He had hypertension controlled with beta-adrenergic, calcium channel and angiotensin II receptor blocking agents. Because he had complications of symptomatic cervical spondylosis and sleep apnea syndrome, we performed awake fiberoptic intubation with remifentanil at a dose of 0.05 microg x kg(-1) min(-1). After intubation and following administration of propofol and vecuronium, ECG unexpectedly changed to asystole. We administered atropine 1.5 mg and performed chest compressions, which successfully restored sinus rhythm within 10 seconds. However, no cardiac disease was detected by a cardiologist. The operation was scheduled a week later again. Anti-hypertensive agents were discontinued. A temporary pacing wire was inserted before surgery, and atropine 0.5 mg was administered before anesthetic induction with remifentanil. No cardiac event was noticed through the perioperative period. We suggest that even a low dose of remifentanil may cause asystole in patients taking beta-adrenergic and calcium channel blocking agents, and preemptive administration of atropine may be effective.

[Which anesthetic technique is more suitable for hip fracture surgery in patients above the age of 85, spinal or epidural?].

BACKGROUND: Anesthesia for hip fracture in elderly patients is a challenge because of their reduced functional reserve. We compared spinal and epidural anesthesia retrospectively in the operations of hip fracture in patients above the age of 85. METHODS: Two hundred and eighteen operations from April 1995 to September 2003 in our hospital were examined. Epidural anesthesia was scheduled in 94 operations, and bupivacaine spinal anesthesia in 86 operations. Successful anesthetic cases of each group were compared. Blood pressure, heart rate, doses of vasopressors used were recorded before anesthesia and first and second 30-minute periods after anesthesia. RESULTS: Failed anesthetic cases in epidural anesthesia were significantly more than those in spinal anesthesia. Blood pressure in the first 30-minute period after epidural anesthesia was significantly lower than that after spinal anesthesia. CONCLUSIONS: Spinal anesthesia is preferable for the operation for hip fracture compared with epidural anesthesia, because of fewer failed cases and smaller decreases of blood pressure.

[Combined paravertebral lumbar plexus and parasacral sciatic nerve block for reduction of hip fracture in four patients with severe heart failure].

We experienced four cases of anesthesia for hip fracture reduction in patients with severe heart failure, where anesthesia was attempted with combined paravertebral lumbar plexus and parasacral sciatic nerve block instead of spinal anesthesia. The anesthesia was successful without any sequelae. The patients' characteristics are as follows. Case 1: 97-year-old woman with severe heart failure and old myocardial infarction. Case 2: 91-year-old man with pacemaker, heart failure and heart valve disease. Case 3: 93-year-old woman with severe heart failure and multi-vessel coronary artery stenosis. Case 4: 83-year-old woman with congestive heart failure and heart valve disease. Paravertebral lumbar plexus block was performed with Touhy needle which was directed to lumbar transverse process, then re-directed caudally. Psoas compartment was felt with loss of resistance. Twelve ml of 0.25% bupivacaine was injected. Sciatic nerve block was performed with a needle which was inserted at the midpoint between the greater trochanter and the sacral hiatus without (case 1, 2) or with nerve stimulator (case 3, 4). Eight ml of 0.25% bupivacaine was injected. During the anesthesia, propofol was injected for light sedation. Although this combined nerve block is difficult to perform compared with spinal anesthesia, this could be applicable for hip fracture reduction anesthesia, especially in patients with severe heart failure.

[A case of re-expansion pulmonary edema after one lung ventilation for the radical operation of lung cancer].

A 64-yr-old man was admitted to our hospital for the examination of the abnormal shadow in his left lung field, which was diagnosed later as lung cancer. Radical operation was scheduled under combined epidural/general anesthesia. One lung ventilation was performed to facilitate the operative procedure for two hours and fifteen minutes. About two hours after the re-expansion of his left lung, he complained of dyspnea. He was hypoxic and moist rale was audible in his left lung. Cloudy shadow emerged in the left field of his chest X-P. Under bronchofiberoptic observation, excessive serous secretions was seen, but no obstructive lesions were found in his bronchial tree. Re-expansion pulmonary edema was suspected for these findings. It was improved with mechanical ventilation with PEEP. Re-expansion pulmonary edema seldom occurs in one lung anesthesia. Although radical operation of esophageal cancer performed six years before might have induced the development of re-expansion pulmonary edema in our case, complete collapse with quick re-expansion of the lung is clearly a potential risk of re-expansion pulmonary edema. Careful management is necessary after one lung ventilation.