Ductus Aneurysm Ruptured Into the Esophagus With Massive Bleeding.

We report a patient with life-threatening hematemesis caused by the rupture of a ductus aneurysm into the esophagus, which was successfully treated by coil embolism for the esophageal fistula through the aorta and subsequent thoracic endovascular aortic replacement. Second-stage therapy was performed surgically after proactive antibiotic treatment and in consideration of the patient's improved general condition. This included debridement with drainage, aortic encasement with remnant aneurysmal wall, omentopexy, and jejunostomy. The esophagus was preserved, and satisfactory healing and natural closure of the fistula were achieved. Although repeated aspirations were later required for pleural fluid, such inflammatory complications finally subsided.

Pathological findings of uterine tumors preoperatively diagnosed as red degeneration of leiomyoma by MRI.

PURPOSE: Venous infarction of a leiomyoma is known as red degeneration of leiomyoma (RDL) and can be a cause of acute abdomen. Although magnetic resonance imaging (MRI) is the only modality that can depict the inner condition of a leiomyoma, the typical MR findings of RDL are sometimes identified incidentally even in asymptomatic patients. The purpose of this study is to clarify common pathological findings of uterine tumors preoperatively diagnosed as RDL by MRI. METHODS: We diagnosed 28 cases of RDL by MRI from March 2007 to April 2015. The ten lesions subjected to pathological analysis after resection were included in the study and reviewed by a gynecological pathologist. The average time from MRI to operation was 4.7 months. RESULTS: The typical beefy-red color was not observed on the cut surface of the tumor except in one tumor resected during the acute phase. All lesions diagnosed as RDL by MRI had common pathological findings consistent with red degeneration of leiomyoma, including coagulative necrosis. Other common pathological features of RDL besides extensive coagulative necrosis appear to be a lack of inflammatory cell infiltrate or hemorrhage in the entire lesion. CONCLUSIONS: Although RDL is known to cause acute abdomen, its typical MR findings can be observed even in asymptomatic patients in a condition that manifests long after red degeneration. The characteristic pathological findings in both the acute phase and the chronic phase that we found in this study, along with radiology reports, will be helpful references for gynecologists and pathologists in suspecting a history of red degeneration and confirming the diagnosis.

[Monitoring of muscle relaxation at the corrugator supercilli muscle in a patient with atrophied upper limbs].

We report a patient whose muscle relaxation was monitored at the corrugator supercilli muscle. In a 51-year-old woman with markedly atrophied upper limbs, anesthesia was induced with propofol and fentanyl. Muscle relaxation was monitored at the adductor pollicis and corrugator supercilli muscles with accelomyography. Train-of-four ratio (TOFR) could be evaluated at the corrugator supercilli muscle; however, it could not be evaluated at the adductor pollicis muscle. The trachea was intubated when the TOFR was 0.09 at the corrugator supercilli muscle after intravenous vecuronium. As the TOFR was 1.44 when the surgery completed, the trachea was extubated without giving neostigmine to antagonize the effect of vecuronium. There was no recurarization after extubation. We conclude that evaluation of TOFR at the corrugator supercilli muscle is useful in some patients who have atrophied adductor pollicis muscle.

[Cesarean section in a morbidly obese parturient with borderline personality disorder under combined spinal and epidural anesthesia].

A 21-year-old morbidly obese parturient with a body mass index of 45.5 kg x m(-2) underwent an emergent cesarean section for obstructed labor under combined spinal and epidural anesthesia. At age 15, she was diagnosed as borderline personality disorder. In spite of the drug therapy, her mental status was unstable. During anesthesia and surgery, her psychiatrist attended beside her to ease her anxiety and mental stress. An experienced anesthesiologist encouraged her and maintained her in the sitting position during epidural catheterization and spinal puncture. The distance between the skin and the epidural space was about 6.5 cm at the L3-4 interspace via midline approach. An epidural catheter was inserted 5 cm cephalad. Subsequently, the L4-5 subarachnoid space was accessed at a depth of about 7.0 cm. A 3 ml bolus of 0.5% hyperbaric bupivacaine was given. The anesthetic level was T4 at the start of the operation. Throughout the surgery, sufficient analgesia was obtained and any complication such as severe hypotension or respiratory depression did not develop and her postoperative course was uneventful.

[Drug errors during anesthesia].

We report drug errors during anesthesia. The data were retrieved from the incident reports in a period of June 2000 to June 2003 at the Department of Anesthesiology, Fukuoka University Hospital. Drug errors occurred in 18 (0.12%) of 15,271 patients who were managed by anesthesiologists during the period. Among the 18 events, most frequent errors were 12 events of administration of wrong drugs. Errors in dosage were five, and wrong route of administration in one. There were no serious sequelae in the 18 patients.

[A patient with Shy-Drager syndrome managed under general anesthesia with thoracic epidural anesthesia].

A 61-year-old man with Shy-Drager Syndrome underwent partial pulmonary lobectomy under general anesthesia combined with thoracic epidural anesthesia. The blood pressure decreased from 140/ 100 mmHg to 80/50 mmHg after thoracic epidural anesthesia. It increased after intravenous ephedrine. The blood pressure decreased when he was returned to the supine position postoperatively. It did not increase as expected with intravenous ephedrine. Intravenous etilefrine promptly raised the blood pressure. There was no postoperative cardiorespiratory complications.

[Severe hyponatremia during transurethral resection of prostate].

We report a case of severe hyponatremia (Na 82 mEq x l(-1)) during transurethral resection of the prostate for benign prostatic hypertrophy. A 61-year-old man was managed with epidural anesthesia and intravenous propofol. Three percent sorbitol (Uromatic S) solution was used for irrigation fluid. The serum sodium level 1 and 3 hours after the start of operation was 103 mEq x l(-1) and 82 mEq x l(-1), respectively. One hour after cessation of propofol administration he did not wake up, although he responded to mechanical stimulation. Saline (1.7%) and sodium bicarbonate (8.4%) were infused. Thirteen hours after the operation, serum sodium level rose to 114 mEq x l(-1), and he opened the eyes on verbal commands. Twenty-eight hours after the operation, serum sodium level was 132 mEq x l(-1). Postoperative neurological deficit did not occur.

The effect of adenosine triphosphate on vecuronium-induced neuromuscular block.

Continuous IV adenosine triphosphate administration has been used during surgery in the expectation of analgesic and vasodilative effects. Because adenosine triphosphate inhibits neuromuscular transmission, we investigated whether the neuromuscular effect of vecuronium was enhanced by IV adenosine triphosphate in 29 patients randomly given either continuous IV adenosine triphosphate 0.1 mg.kg(-1).min(-1) or 0.9% NaCl when undergoing elective minor surgery. Anesthesia was induced and maintained with propofol. Neuromuscular monitoring was recorded from the adductor pollicis muscle using electromyography with train-of-four stimulation of the ulnar nerve. Vecuronium 25, 30, or 40 microg/kg was given and lag time, onset time, and maximum block were recorded. ED50 and ED95 values for each group were derived from least squares linear regression analysis. ED50 and ED95 values were 29 microg/kg and 44 microg/kg, respectively, for the adenosine triphosphate group and 26 microg/kg and 46 microg/kg, respectively, for the controls. Differences in lag time, onset time, and neuromuscular responses between the two groups were not statistically significant. A significantly larger number of patients in the adenosine triphosphate group showed hypotension (systolic blood pressure <80 mm Hg). Our results demonstrated that adenosine triphosphate 0.1 mg.kg(-1).min(-1) did not enhance the neuromuscular block induced by vecuronium.

[Malignant hyperthermia during emergency craniotomy: a case report].

An 18-year-old man underwent emergency craniotomy for acute epidural hematoma under general anesthesia using suxamethonium and isoflurane. Marked rises in end-tidal carbon dioxide, body temperature, and serum potassium occurred during the surgery. After intravenous dantrolene sodium administration, the body temperature dropped rapidly. No conspicuous postoperative elevation of serum creatine kinase levels were observed. Postoperative muscle biopsy specimen revealed increased calcium-induced calcium release.

[Anesthetic management for thoracoscopic partial lobectomy in a patient with one lung].

A 58-year-old man whose right lung had been removed due to lung cancer underwent thoracoscopic partial lobectomy of the left lung. Anesthesia was maintained with intravenous propofol and thoracic epidural block. During the surgery, respirations were controlled by high frequency jet ventilation. There was no intraoperative hypoxia. The postoperative course was uneventful.