[Effect on fetal umbilical arterial blood of administration of vasopressors for hypotension after spinal anesthesia during cesarean section].

Spinal anesthesia was performed in 40 patients undergoing cesarean section. When systolic blood pressure dropped below 100 mmHg, phenylephrine 100-200 microg (P group) or ephedrine 5-10 mg (E group) was administered. The pH of the umbilical arterial blood was collected after delivery of the baby. Apgar scores, and maternal systolic blood pressure and heart rate before and after each drug administration were compared retrospectively. The umbilical arterial pH and Apgar scores tended to be slightly higher in the P group, but there was no significant difference between the two groups. The rate of blood pressure elevation was 27% in the P group and 41% in the E group. The heart rate decreased significantly in the P group. There was no significant difference in the systolic blood pressure before administration of each drug. Recently, it is reported that the umbilical arterial pH is higher in cases in which phenylephrine is used for hypotension after spinal anesthesia during a cesarean section. However, the optimal dose of phenylephrine is debatable and has not been established. More studies are necessary to determine which drugs should be selected according to the maternal condition.

[Case of abdominal compartment syndrome (ACS) associated with perforating appendicitis].

A 4-year-old girl with perforating appendicitis developed abdominal compartment syndrome (ACS). Appendicitis in children of preschool age is highly likely to rupture, resulting in serious condition. Although we gave priority to systemic management in this ACS case since the child showed disturbed consciousness due to intracranial hypertension as well as hypercytokinemic encephalopathy. However, we should have performed abdominal decompression by laparotomy early. ACS causes progressive multiple organ failure through compromising the respiratory and circulatory systems and injuring multiple organs, leading to generalized inflammatory reactions. We should, therefore, manage ACS patients systemically sharing a notion that they must be treated early with abdominal decompression by laparotomy.

[Case of pulmonary edema due to excessive hypertension following extubation].

A 54-year-old man had emergency laparoscopic chelecystectomy for acute cholecystitis. General inflammatory change (CRP 26.6 mg x dl(-1), WBC 26,800) was noted preoperatively. Anesthesia was induced with propofol and remifentanil and maintained with sevoflurane in oxygen and remifentanil. Operation was performed uneventfully within 128 min. At the end of the surgery, 0.1 mg of fentanyl was administrated. After confirming adequate respiration and oxygenation, endotracheal tube was removed. At that period, hypertension (SBP 220 mmHg) and tachycardia (HR 122 beats x min(-1)) developed. Soon thereafter, he became agitated and complained of dyspnea with desaturation (Spo2 < 70%). After reintubation, massive pinkish babbly secretion flowed out from the endotracheal tube. Chest X-ray revealed diffuse bilateral infiltration of the lungs without cardiomegaly. He was transferred to the intensive care unit for mechanical ventilation. His condition improved progressively and was extubated on the POD 6. The cause of pulmonary edema is thought to be profound centralization of circulating volume associated with catecholamine-induced vasoconstriction due to rapid disappearance of remifentanil effect. Adequate analgesia is necessary during remifentanil-based anesthesia especially in patients suffering from general inflammatory changes.

[Anesthetic management for cesarean delivery in a patient with May-Hegglin anomaly].

May-Hegglin anomaly (MHA) is a rare hereditary disorder characterized by thrombocytopenia and giant thrombocytes and continuous appearance of inclusion bodies (Dohle like corpuscles) in the cytoplasm of granulocytes. A 26-year-old woman with MHA underwent cesarean delivery under general anesthesia, although she had no history of bleeding. The platelet count was 4.9x10(4) microgl(-1) the day before surgery. There was no unusual bleeding during and after the operation and we did not give her platelet transfusion.