[Combined General and Spinal-Epidural Anesthesia under Spontaneous Breathing in a Patient with a Giant Bulla].

This paper reports the successful perioperative management of a patient with a giant bulla, who underwent radical prostatectomy under general anesthesia performed under combinet spinal-epidural anesthesia while maintaining spontaneous respiration. A 61-year-old man was scheduled for radical prostatectomy. He had undergone conservative treatment using a drainage tube for right-sided pneumothorax at the age of 23. Preoperative chest CT revealed the presence of a giant bulla in the left upper lobe, multiple bullae in the entire right lung, and emphysematous alterations in both lungs. On respiratory function testing, mild obstructive impairment was observed. In the operating room, an epidural catheter was inserted at T11-12, and spinal anesthesia was performed at L3-4. Under anesthesia with propofol and fentanyl, i-gel® was inserted. During anesthesia, spontaneous respiration was managed at oxygen concentration 40% and sevoflurane 1.5%, while continuing the epidural administration of levobupivacaine. The circulatory and respiratory conditions were stable during surgery. The durations of surgical and anesthetic procedures were 2 hours and 16 minutes and 3 hours and 33 minutes, respectively. In the absence of respiratory complications, the patient was discharged 8 days after surgery.

[Mild hemophilia A diagnosed at the onset of acute epidural hematoma after lumbar epidural block].

The patient was a 36-year-old man who had been aware of a mild bleeding tendency since childhood, but did not show any history of severe bleeding. After lumbar epidural block was performed for pain caused by lumbar disc herniation, the patient developed paraplegia due to an acute epidural hematoma, and rectovesical disorder. He was admitted to our hospital, and wide fenestration and hematoma evacuation were performed. Because of persistent bleeding, reoperation was performed to achieve hemostasis. Although factor VIII antigen was 138%, its activity was decreased to 18% of normal. A diagnosis of cross-reacting material positive mild hemophilia A was made. Postoperative injection of a factor VIII preparation resulted in complete hemostasis. The activated partial thromboplastin time was within normal range. A thrombin generation test showed reduced endogenous thrombin potential, peak thrombin levels, and prolonged time-to-peak levels. The thrombin generation test, which allows comprehensive assessment of the coagulation profile, was useful for diagnosis and treatment of this case.