[Anesthetic management of a pregnant woman scheduled for cesarean section under epidural anesthesia and simultaneous surgical removal of pituitary tumor under general anesthesia].

A 34-year-old woman who was 25 weeks pregnant showed neurological symptoms of bitemporal hemianopsia and vision loss on the left side. MRI study revealed a pituitary tumor requiring surgical removal. We planned cesarean section after 32 weeks of pregnancy and removal of pituitary tumor after the improvement of general conditions of the paturient following cersarean section. However, the above-mentioned neurological symptoms rapidly deteriorated. Therefore, we decided to perform the cesarean section at 30 weeks and 3 days of pregnancy and simultaneous surgical removal of the pituitary tumor. As soon as cesarean section was successfully performed with epidural anesthesia, the pituitary tumor was removed trans-sphenoidally under general anesthesia. Postoperative conditions of the mother and newborn were good and neurological symptoms of the mother improved markedly.

Use of acute normovolemic hemodilution in patients undergoing radical prostatectomy.

OBJECTIVES: To evaluate the efficacy and safety of acute normovolemic hemodilution (ANH) in patients undergoing radical prostatectomy. Preoperative autologous blood donation (PAD) is widely accepted as a means of reducing the need for allogeneic blood transfusion in radical prostatectomy. ANH is an alternative method for obtaining autologous blood. METHODS: On the basis of our previous report that showed the equivalence of PAD and ANH, we prospectively replaced PAD with ANH as a standard practice for radical prostatectomy after September 1999. Of 174 radical prostatectomy patients between September 1999 and June 2004, 153 underwent ANH alone, 15 chose to receive both PAD and ANH, and ANH was contraindicated in 15 because of comorbidities. RESULTS: For the 153 patients undergoing ANH alone, 1032 +/- 201 mL of autologous blood was collected. With an intraoperative blood loss of 1602 +/- 926 mL, 14 patients (9.2%) received allogeneic blood transfusion. The preoperative, intraoperative nadir, and postoperative hematocrit value was 43.6% +/- 3.4%, 25.8% +/- 3.8%, and 31.9% +/- 4.3%, respectively. No patient experienced a perioperative adverse event related to hemodilution or blood transfusion. CONCLUSIONS: Our continued experience has shown that ANH is a safe and effective means of autologous blood procurement. Given its advantages, including lower cost, lower risk, and simplicity, we conclude that ANH can replace conventional PAD for use in radical prostatectomy, although the true value of ANH should be determined by future randomized studies including a no-treatment control group.

[A case of intraoperative hyperkalemia induced with administration of an angiotensin II receptor antagonist (AIIA) and intake of dried persimmons].

An 87-year-old man was scheduled for cervical laminectomy. Anesthesia was maintained with nitrous oxide, oxygen, sevoflurane, and fentanyl with tracheal intubation. Thirty minutes after the start of operation, serum potassium was 7.41 mEq x l(-1). We immediately administered potassium-free fluid, furosemide, bicarbonate, calcium gluconate and insulin. We stopped the operation and returned the patient to supine position, but he fell into ventricular fibrillation. Immediate CPR and countershock successfully restored sinus rhythm within 5 minutes. He was discharged from ICU without any neurological complications. Daily he took Losartan potassium, an AIIA, due to hypertension and ate preoperatively dried persimmons, a potassium-rich food. We suspect that hyperkalemia was induced by administration of an AIIA in combination with excessive intake of dried persimmons. AIIA may cause severe hyperkalemia inhibiting aldosterone activity. We should pay attention to the serum potassium level and a preoperative intake of food especially in a patient medicated with an AIIA.

[Spinal anesthesia with bupivacaine for a patient with a history of severe leg pain after intrathecal dibucaine].

An 87-year-old man was scheduled for the 11th transurethral bladder tumor resection (TURBT). He had a history of non-active syphilis for 21 years, diabetes mellitus for 7 years, and severe emphysema. Preoperative physical examination of the lower extremities, revealed loss of knee-jerk reflex, and loss of vibratory and proprioceptive perception. Four years previously, he underwent TURBT twice under spinal anesthesia with dibucaine, which caused severe leg pain during anesthesia. Therefore, subsequent TURBTs (eight times) were performed under general anesthesia with tracheal intubation, which frequently caused postoperative respiratory distress. Recently, bupivacaine, less neurotoxic than dibucaine, was on the market in Japan for use in spinal anesthesia. Therefore we planned spinal anesthesia using 0.5% bupivacaine, 2.0 ml. This time, he did not complain of leg pain during anesthesia, and postoperative conditions were satisfactory. We can conclude that bupivacaine is very useful for spinal anesthesia especially in patients with a history of leg pain by spinal anesthesia with dibucaine.

[A case of severe septicemia due to Aeromonas hydrophila].

Septicemia by Aeromonas hydrophila (A. hydrophila) developed in a 69-year-old female with a history of uncompensated liver cirrhosis. She was admitted to our hospital, complaining of fever, vomiting, diarrhea, and pain as well as swelling of the left lower extremity. Seven hours later, skin of the left extremity developed bullae and became discolored. Although she was treated with infusion of antibiotics plus dopamine, continuous hemodiafiltration, glucose-insulin therapy and mechanical ventilation, she fell in severe septic shock, and died 23 hours after admission. A. hydrophila was isolated from both blood and bullous fluid. Mortality rate of septicemia due to A. hydrophila is reported ranging from 29% to 73%. Patients with liver disease have poor prognosis. Morbidity of this septicemia depends on pre-infection conditions, especially on liver functions. Early surgical debridement and antimicrobial therapy is recommended, but rapid worsening often results in death. We have to pay attention to infection of A. hydrophila especially in patients with liver cirrhosis.