[Anesthesia in a Patient with Giant Goiter in Whom Tracheotomy Was Performed with Standby of Percutaneous Cardiopulmonary Support].

In a 53-year-old female patient total thyroidectomy for a giant goiter under general anesthesia was scheduled. On talking, airway stenosis sounds were heard. Cervical to thoracic CT revealed left and right lobe tumors measuring 5.3 x 5.6 x 10.0 and 9.1 x 8.6 x 10.0 cm, respectively. The trachea showed stenosis at a site 3.8 to 6.5 cm below the glottis, and the narrowest lumen diameter was 3.1 mm. Due to marked tracheal stenosis, awake intubation was not selected. To maintain the airway, tracheotomy was performed under local anesthesia. Considering the risk of difficulty in ventilation during tracheostomy, 4 Fr catheter sheaths were inserted into the right femoral artery and vein for percutaneous cardiopulmonary support (PCPS). Subsequently, tracheotomy was conducted in an area peripheral to the site of stenosis. After tracheotomy, general anesthesia was started. During general anesthesia, there were no problems regarding ventilation. The tracheal cannula was removed 7 days after surgery, and the patient was discharged after 14 days. For general anesthesia in patients with giant goiter, it is important to select an airway management method in consideration of tumor-related compression of the trachea. Airway management by tracheotomy under local anesthesia with standby of PCPS may be a treatment option.

[Anesthetic Management of Open Reduction for a Femoral Neck Fracture in a Patient Complicated with Fat Embolism Syndrome.]

We experienced anesthetic management of open reduction for a femoral neck fracture in a patient com- plicated with fat embolism syndrome. An 83-year-old woman with a femoral neck fracture was admitted to our hospital after suffering an injury. She developed hypoxemia on admission. Chest X-ray showed a decrease in permeability of the right lung and chest CT scan showed ground glass opacities of the right lung. A blood test showed anemia, thrombocytopenia, and elevation of C-reactive protein. She was diagnosed with fat embolism syndrome using the classification of Tsuruta. Oxygen was administered. C-reactive protein decreased gradually after hospitalization. Echocardiog- raphy showed normal left ventricular function without pulmonary hypertension. She was scheduled for open reduction for the femoral neck fractu-e with artificial grit insertion under general anesthesia 6 days after hospitalization. Her operation was performed with- out exacerbation of the fat embolism syndrome. She was extubated in the operating room, and was dis- charged from the recovery room without any conpli- cations. After surgery, chest X-ray showed further improvement and she was transferred to a rehabilita- tion hospital on the 27th hospital day.

[Perioperative Management of Emergency Operation for a Patient with Carcinoid Syndrome].

We report a case of carcinoid syndrome requiring an emergency operation for an upper gastrointestinal perforation. A 46-year-old man had undergone left lower lobectomy for a lung carcinoid tumor seven years previously, and liver metastasis was found five years previously. He developed cutaneous flushing and watery diarrhea, and was diagnosed with carcinoid syndrome one year previously. Although he was treated with octreotid, his symptoms became worse and he was admitted to our hospital. During the hospital stay, he underwent an emergency operation for an upper gastrointestinal perforation. Before the operation, hemodynamics were unstable. Anesthesia was induced with sevoflurane and propofol, and maintained with sevoflurane and remifentanil. Only vasopressin was used for the treatment of hypotension. Landiolol was used for perioperative tachyarrythmia. During anesthesia, there was no severe hypotension or hypertension. After the operation, he was managed with intubation in the ICU. Octreotid was administered again for the carcinoid syndrome. Vasopressin was necessary for the treatment of hypotension in the ICU. After improvement of hemodynamics, extubation was performed on the 3rd ICU day and he was discharged from the ICU on the 4th ICU day. In conclusion, we were able to perform good perioperative management of carcinoid syndrome accompanied by hemodynamic instability.

[Two cases of general anesthesia after recovery from ARDS].

There are few reports on general anesthesia in survivors of ARDS. Patients after recovery from ARDS are at risk for compromised pulmonary function, neuromuscular weakness and cognitive dysfunction. We report 2 cases of general anesthesia in survivors of ARDS. In Case 1, a 64-year-old man who had recovered from ARDS associated with Legionella pneumonia underwent carotid endarterectomy. In Case 2, a 69-year-old man who had recovered from ARDS associated with pneumococcal pneumonia underwent hepatectomy. Concerning the preoperative assessments, the spirometry data were almost normal but Hugh-Jones classification scale was II in both cases. Diffusion disturbance might be the cause of discrepancies between good respiratory functions and limited daily activities. In both cases, anesthesia was given with propofol, fentanyl remifentanil and sevoflurane. Peak airway pressure was maintained below 15 cmH2O with pressure control ventilation. They were extubated at the end of surgery and there were no serious complications during the perioperative period.

[A case of delayed awakening from general anesthesia caused by psychological unresponsiveness].

We report a case of an 85-year-old woman with delayed awakening from general anesthesia caused by psychological unresponsiveness. She underwent an open reduction of the right femoral bone fracture. Induction of general anesthesia was done with fentanyl, propofol, sevoflurane, and rocuronium. Anesthesia was maintained with sevoflurane and remifentanil without any incidents. After the operation she opened her eyes and tried to extubate the endtracheal tube and then she was extubated. She developed coma and did not respond to painful stimuli after extubation, but spontaneous breathing was maintained with stable hemodynamics. Although naloxone was given, she was still comatose. Her clinical neurological findings and the brain CT scan showed no organic abnormalities. The bispectral index showed the value of 85 to 95; 2.5 hrs after operation she moved her extremities in response to pain and 3.5 hrs after operation she gradually woke up and obeyed commands. After fully awakening she showed no clinical manifestations of psychological abnormality during her postoperative period and no sequela.

[Two cases of airway stent placement to treat tracheal and bronchial fistula using general anesthesia under spontaneous respiration].

Anesthesia for the tracheobronchial stent placement involves the risk of airway narrowing and obstruction. Controlled ventilation with relatively high airway pressure is usually used to maintain oxygenation and ventilation during anesthesia. However, controlled ventilation does not always provide tidal volume and oxygenation due to gas leakage from tracheobronchial fistula. We report 2 cases of general anesthesia under spontaneous respiration for the airway stent placement to treat tracheal and bronchial fistula. Case 1; A 55-year-old man with tracheoesophageal fistula due to the esophageal cancer was scheduled for the stent placement. Anesthesia was given with dexmedetomidine and sevoflurane preserving spontaneous respiration. The surgery was performed without complications of hypoventilation and hypoxemia throughout the procedure. Case 2; A 71-year-old woman developed empyema with large bronchopleural fistula as the result of the complication of radiation for the breast cancer. The stent placement was scheduled for closure of the fistula. Anesthesia was induced with remifentanil and sevoflurane with spontaneous respiration. When inserting the rigid bronchoscope, cough reflex occurred and propofol was added to deepen the anesthesia. The stent placement was performed with general anesthesia under spontaneous respiration without any complications.