[Prolonged paralysis after long-term administration of vecuronium in the intensive care unit].

A 51-year-old woman with renal failure requring hemodialysis received a total of 446 mg of vecuronium over a period of 4 days to help mechanical ventilation and developed generalized muscle weakness after its discontinuation. It took 2 wks to wean her from mechanical ventilation and 3 wks for her to be able to walk. She did not receive drugs which might alter neuromuscular transmission such as corticosteroid and aminoglycoside antibiotics. Electromyogram and nerve conduction studies were normal. We believe that the cause is the accumulation of vecuronium and active metabolites due to renal failure. The case suggests that we should minimize the duration of neuromuscular block in patients with renal failure by aggressive use of sedatives and analgesics and the optimization of ventilator settings.

[Successful resuscitation of intractable hyperkalemic cardiac arrest].

We report on a 42-year-old oliguric uremic man on regular hemodialysis who developed sudden cardiac arrest, secondary to severe hyperkalemia, with a plasma potassium concentration of 9.7 mEq x l(-1). The cardiac arrest persisted after the initiation of cardiopulmonary resuscitation and intensive treatment for marked hyperkalemia for an hour and 55 minutes. Therefore a portable percutaneous cardiopulmonary support (PCPS) system had to be instituted while the patient had very prolonged refractory ventricular fibrillation. His cardiac rhythm was restored immediately after application of PCPS and he recovered without neurological sequelae. We therefore suggest that PCPS should be considered as a therapeutic option during cardiopulmonary resuscitation for life-threatening cardiac arrest secondary to severe hyperkalemia.

[The usefulness of monitoring hepatic venous oxygen saturation and mild hypothermia anesthesia in two patients with portal vein tumor emboli during combined portal vein and pancreas resection].

Two patients, a 48-year-old woman and a 61-year-old man, with portal vein tumor emboli underwent pancreaticoduodenectomy combined with portal vein resection. In order to protect the liver during occlusion of the portal vein, we induced mild hypothermia with surface cooling and hepatic oxygen status was monitored by hepatic venous oxygen saturation (ShvO2). During the temporary occlusion of the portal vein, the woman showed a marked decrease in ShvO2, significantly lower than 20%, and continued for about one hour, but on the other hand the man did not. But as the body temperature was raised, they showed the same tendency of decreased ShvO2. Postoperatively, her serum GOT, GPT, T-bilirubin were 104 UI.dl-1, 58 UI.dl-1, 1.95 mg.dl-1 and his data were 62, 42, 1.01 respectively. No other complication were observed. These results suggest that ShvO2 monitoring and mild hypothermia are clinically useful in detecting hepatic oxygen supply/demand unbalance and in protecting the liver.

[A case of adrenocorticotropic hormone (ACTH) deficiency].

We report a case of ACTH deficiency. A 75-year-old man complained of anoxia, nausea and vomiting. Three years ago, he had an attack of loss of consciousness. On admission, his serum sodium level was down to 119.6 mEq.l-1. Plasma osmolality was low and urinary osmolality was high without edema, and he was diagnosed as having SIADH. After CRH test, rapid ACTH test and continuous ACTH test, he was diagnosed as having ACTH deficiency, and he was treated with steroids. One year later, he received urethrotomy due to urethrostenosis under spinal anesthesia with no trouble. In the next year, he was scheduled for sigmoidectomy due to sigmoid colon cancer under general anesthesia combined with epidural anesthesia. In the morning of his operation, he took hydrocortisone 10 mg per os. During operation, hydrocortisone 300 mg was given intravenously divided for three times. Plasma ACTH and aldosterone levels were below normal ranges, but serum cortisol was above the normal range. His operation was finished without troubles. Regarding this case, we discussed steroid therapy during anesthesia and operation.

[Management of intraoperative anticoagulantless CHD with EVAL-dialyzer in four patients on maintenance hemodialysis].

It is difficult to correct fluid balance during operation in patients under hemodialysis. We managed intraoperative anticoagulantless continuous hemodialysis (CHD) with ethylene vinyl alcohol copolymer (EVAL) dialyzer in four patients on maintenance hemodialysis. All patients could be managed satisfactorily with no coagulation. Only in the first patient, we used nafamostat mesilate to avoid coagulation in the dialyzer. In this patient, activated clotting time (ACT) was 151 seconds. Their recovery from anesthesia was good, and they showed no complications perioperatively. This is a good method to manage these patients during operation, because EVAL dialyzer is cheap and we need not take care of hemorrhage. Using a small amount of nafamostat mesilate may be useful to avoid coagulation.

[Recurrent cardiac arrest after splenectomy in a patient with ITP and diabetes mellitus].

We report a case of 58-year-old man who had repeated cardiac arrests on the first post-operative day. The patient underwent splenectomy due to ITP (idiopathic thrombocytopenic purpura). He also had diabetes mellitus and nephrotic syndrome. There was no abnormal finding at the preoperative examination, except bleeding time of 6 minutes. The operation was finished without complications under general anesthesia. Midnight on the day of surgery, the first cardiac arrest occurred, and lasted for about 10 seconds. He recovered soon from the incident, but at 6 o'clock next morning, he developed severe bradycardia and cardiac arrest. He recovered again, but around 10 o'clock, he developed bradycardia and arrest again, and fell into a fit of convulsions and lost his consciousness. Again he recovered soon and no bradycardia and cardiac arrest occurred after this episode. Two years later, he was scheduled for vitrectomy due to diabetic retinosis. There were a few PACs and PVCs in his Holter-ECG, but no typical bradycardia and ST changes. During the operation, we injected atropine sulfate, dopamine hydrochloride and bucladesine sodium to increase his heart rate above 60 per minute. The operation was finished smoothly and there was no trouble perioperatively. A year later, he also underwent bilateral cataract extraction under local anesthesia without any troubles.