[A case of anesthetic management for re-expansion pulmonary edema of the dependent lung saved by superimposed HFJV during one lung ventilation for the thoracoscopic operation associated with bilateral pneumothorax].

A 21-year-old male with bilateral pneumothorax underwent thoracoscopic bullaectomy in the lateral decubitus position. General anesthesia was induced using thiopental 250 mg and suxamethonium 80 mg and maintained using the combination of the thoracic-epidural anesthesia with assisted spontaneous respiration. He was intubated with a tube equipped with mobile bronchial cuff. On the left bullaectomy, two lung ventilation (TLV) was applied and its course was uneventful. On the right, one lung ventilation (OLV) was done. Fifty minutes after the start of OLV of the left lung, percutaneous arterial hemoglobin saturation (SpO2) declined to 60% with PaO2 36 mmHg. Then, under super imposed HFJV (high frequency jet ventilation) added to manual assisted ventilation through the bronchial brocker, SpO2 increased rapidly to 100%. Postoperative chest X-p showed signs of re-expansion pulmonary edema (RPE) in the dependent, left lung. PaO2 after 25 minutes of hypoxic episode increased to 339.2 mmHg. About 2 hours later he was extubated uneventfully. We conclude that superimposed HFJV is very beneficial for treatment of the RPE of the dependent lung during OLV applied for thoracoscopic operation with bilateral pneumothorax.

[Perioperative change of ionized magnesium concentration--effect of blood transfusion].

In order to evaluate the effect of intra-operative blood transfusion on post-operative decrease of ionized Mg (Mg2+), we performed following studies. 1) We measured ionized Mg (Mg2+), total Mg, ionized Ca (Ca2+), total Ca and citrate before and after operation in 70 patients. 2) We evaluated the effect of citrate on Mg2+ and Ca2+ in vitro. 3) We also measured these values during blood transfusion in 8 patients. There was no significant difference between post-operative Mg2+ of 45 patients without blood transfusion (0.49 +/- 0.07 mmol.l-1, % decrease from pre-operative value was 13.4 +/- 9.2%; mean +/- SD), and that of 25 patients with blood transfusion (0.48 +/- 0.09 mmol.l-1, 17.9 +/- 10.2%). Mean value of post-operative citrate concentration of patients with blood transfusion was 0.15 +/- 0.11 mmol.l-1, and this value decreased Mg2+ about 2% in in vitro study. During blood transfusion, Mg2+ (0.41 +/- 0.05 mmol.l-1) and ionized % (54.5 +/- 8.3%) decreased significantly just like Ca2+ with elevated citrate concentration (0.95 +/- 0.59 mmol.l-1). In conclusion, intra-operative blood transfusion had minor effect on the post-operative decrease of Mg2+, and the major cause was thought to be the dilution of extracellular fluid by Mg-free fluid administered during operation.

[Surface-induced mild hypothermia anesthesia for hepatectomy in a patient with a giant hemangioma of the liver (Kasabach-Merritt syndrome)].

A 63-year-old woman presenting with thrombocytepenia and signs of intravascular coagulation (prothronbin time, 59%: FDP, 100 micrograms.ml-1) due to a giant hemangioma of the liver (Kasabach-Merritt syndrome) was scheduled for the resection of the right lobe of the liver. In order to protect the liver on occlusion of the right hepatic artery and portal vein, we induced mild hypothermia technique with vasodilation and surface cooling by convecting warming device together with hepatoprotective agents of PGE1 and ulinastatin. Severe, acute massive bleeding occurred due to the injury of the middle hepatic vein and from the resected surface of the liver. Her rectal temperature was 31.9 degrees C during massive bleeding. Her hemoglobin decreased to 3.9 g.dl-1. Total estimated blood loss was 22,000 ml. The weight of the resected liver was 2.5 kg. The maximum postoperative levels of T-Bil and GOT were 2.47 mg.dl-1 and 171 IU.l-1, respectively. The liver seemed to have been well preserved and no other complications were observed. The hemangioma was completely removed by excision of the right lobe of the liver. Subsequently, all coagulation parameters returned to normal, indicating a complete reversibility of the coagulopathy. Surface-induced mild hypothermia is a useful and valuable method for protecting the liver during severe massive bleeding.