[Acute pulmonary thromboembolism after multiple injuries, despite performing anticoagulant therapy].

We report here a patient with acute pulmonary thromboembolism after multiple injuries, despite performing an anticoagulant therapy precisely according to a guideline. A 56 year-old-woman with multiple fractures was transferred after a motor vehicle accident. She was diagnosed with a pelvic fracture, a left clavicular fracture, and a right radius fracture. For preventing deep vein thrombosis DVT, elastic stockings were attached immediately on arrival. Then we started administration of unfractionated heparin on the second day. An operation was performed for the left clavicular fracture and the right radius fracture on the fifth day. We restarted subcutaneous injection of heparin on the sixth day and 1 mg day(-1) of warfarin was added from the ninth day. On the 12th day, sudden dyspnea suggested acute pulmonary embolism and a pulmonary arteriography confirmed occlusion of the left main pulmonary artery with thombocyte. Interventional anti-thorombotic procedure was performed, and she was discharged with no complications on the 72nd day. Despite "A Guideline for Prevention of Venous Thromboembolism", arranged in Japan, was issued in June 2004, it is difficult for us to prevent DVT at the recovery phase as in this case. The guideline should be revised after further examinations.

[Combined spinal-epidural anesthesia for cesarean section in a patient with dilated cardiomyopathy].

We report successful anesthetic management of elective cesarean section in a 31-year-old patient with dilated cardiomyopathy (DCM) using combined spinal-epidural anesthesia (CSEA). After inserting an arterial catheter and central venous catheter, isobaric bupivacaine (0.5% ; 5 mg) with fentanyl 10 microg was injected intrathecally at the L4-5 interspace under administration of dopamine 3 microg kg(-1) min(-1). 10 min and later, a total of ropivacaine (0.5%; 70 mg) with fentanyl 50 microg was titrated at 2-3 min intervals through the epidural catheter inserted at the L1-2 interspace resulting in analgesic level of T4 25 min after induction of spinal anesthesia. A baby was delivered uneventfully with good Apgar score, and the patient's perioperative hemodynamic change was minimal. CSEA is a reliable, titratable technique, which provides excellent analgesia with minimal hemodynamic changes for patients with DCM undergoing cesarean section.