[Assessment of intraoperative hemodynamics, infusion volume, urinary output and dose of circulatory drugs in general anesthesia with transversus abdominis plane block for cholecystectomy].

We retrospectively reviewed intraoperative hemodynamics, infusion volume, urinary output and dose of circulatory drugs in patients undergoing cholecystectomy in 3 types of anesthesia group: General anesthesia (GA group), general anesthesia with epidural anesthesia (EPI group) and general anesthesia with transversus abdominis plane (TAP) block (TAPB group). TAP block was performed using ultrasound-guided subcostal method and 20-30 ml of ropivacaine (0.2-0.3%) was injected to TAP bilaterally. Though, the blood pressure in TAPB group was lower than that in GA group, the degree of low blood pressure was smaller than that in EPI group. Less changes in intraoperative blood pressure, infusion volume and dose of phenylephrine in TAPB group compared to those in EPI group can be the advantage of TAP block alternative to epidural anesthesia.

[Anesthetic management of an emergency open-heart surgery for entrapment of a circular mapping catheter by chordae tendineae with mitral valve damage undergoing atrial fibrillation ablation].

The entrapment of a circular mapping catheter by chordae tendineae during catheter ablation is a very rare but serious complication requiring, in some cases, surgical treatment. We report a case that required open heart surgery for catheter removal and mitral valve repair. A 79-year-old man underwent catheter ablation for paroxysmal atrial fibrillation in other hospital. During the operation, he moved accidentally, despite circular mapping catheter was in the left atrium. The circular mapping catheter was uncontrolable due to resistance interfering with catheter removal, and the patient was brought to our hospital for open heart surgery to remove catheter. General anesthesia was induced and maintained with midazolam, fentanyl. Transesophageal echocardiography was performed to monitor catheter position and mitral valve condition. Transesophageal echocardiography revealed that circular catheter tip was located adjacent to the posterior mitral leaflet and the presence of moderate mitral valve regurgitation. Circular catheter tip was entraped by chordae tendineae and caused posterior mitral leaflet damage. Intracardiac foreign body removal and posterior mitral leaflet repair were completed uneventfully under cardiopulmonary bypass. The postoperative course was uneventful. It is expected that catheter ablation for atrial fibrillation will increase in number. This rare complication of catheter ablation may become a threat to cardiologist, cardiac surgeon and anesthesiologist.

[Anesthetic management for laparoscopic adrenalectomy in a pregnant patient with Cushing's syndrome].

Cushing's syndrome is extremely rare during pregnancy, because it often causes amenorrhea and infertility. We experienced a case of Cushing's syndrome in the 23rd week of pregnancy receiving laparoscopic surgery. It was difficult to control the blood pressure and heart rate, but we succeeded in the safe management of both mother and fetus.

[Esophageal injury after insertion of a transesophageal echocardiography probe in a patient with an aberrant right subclavian artery].

We describe a case of an esophageal injury caused by insertion of a transesophageal cardiac echo probe in a 66-year-old man with an aberrant right subclavian artery, who was scheduled for Bentall surgery for aortic regurgitation and annuloaortic ectasia. Preoperative CT scan showed an aberrant right subclavian artery compressed from the back of the esophagus. General anesthesia was induced with midazolam and fentanyl, and maintained with midazolam, remifentanil and fentanyl. After induction of anesthesia, a transesophageal cardiac echo probe was inserted without abnormal resistance. The operation was performed uneventfully. On the second day after surgery, gastrointestinal bleeding was suspected and the upper gastrointestinal endoscopy (GIF) was performed. GIF revealed ulceration at the mid-esophagus and gastroesophageal junction, and a large amount of fresh blood in the stomach. The location of the ulcer at mid-esophagus was likely to be over the aberrant right subclavian artery. Ulcers were treated conservatively. GIF on the postoperative day 16 revealed that ulcers had healed. Transesophageal echo probe insertion is potentially hazardous in a patient with an aberrant right subclavian artery. Although aberrant right subclavian artery is rare, transesophageal echocardiography should be performed with extreme caution.

[Endotracheal tube selection in children: which is the better predictor for the selection, tracheal internal diameter in X-ray photograph or age-based formula?].

BACKGROUND: Age-based formula has been widely used to predict the appropriate size of the endotracheal tube in children. Tracheal internal diameter in X-ray photograph is reported to show higher correlation with a correct tube than age. In our institution, X-ray photographs were stored as digital images, enabling us to measure tracheal internal diameters more accurately than conventional X-ray films. Therefore, we investigated whether tracheal size in digital X-ray photograph is a better predictor for the tube selection than age. METHODS: We reviewed data from children aged 1 to 8 years for the past 5 years. The data included age, tracheal internal diameter at 6th cervical (C6), 2nd thoracic vertebrae (T2) in X-ray photograph and selected tube size. The tube size was estimated by the age-based formula or on the basis of tracheal size. RESULTS: The endotracheal tube size correlated significantly with the age, and tracheal internal diameter at C6 or T2 in X-ray photograph (correlation coefficients P=0.898, 0.653, and 0.771 respectively; P<0.0001). The tube size predicted by the age allowed appropriate intubation in 62.2%, but that by the tracheal size at C6 and T2 in 42.8% and 43.7% respectively. CONCLUSIONS: The age-based formula is more reliable and appropriate to decide the size of endotracheal tube for children than the tracheal size.

[Prevention of postoperative nausea and vomiting by metoclopramide combined with dexamethasone in gynecological surgery].

BACKGROUND: The authors evaluated the efficacy of a combination of dexamethasone and metoclopramide for the prophylaxis of postoperative nausea and vomiting (PONV) after gynecological abdominal surgery. METHODS: One-hundred and seventeen patients scheduled for gynecological abdominal surgery were analyzed retrospectively. Patients were classified into three groups by anti-emetics administered; none (Group C, n = 38); metoclopramide 10 mg (Group M, n = 39); or a combination of metoclopramide 10 mg with dexamethasone 8 mg (Group MD, n = 40) at 30 to 60 minutes prior to the end of surgery. Anesthesia was induced by propofol and maintained with isoflurane-nitrous oxide inhalation and intermittent administration of fentanyl. Postoperative pain was treated with continuous subcutaneous infusion of pentazocine via a patient controlled analgesia device. PONV was assessed using a 5 rating verbal score in early (0-6 hr) and in late (6-24 hr) period. RESULTS: The 3 groups were similar in demographic characteristics. The incidence of nausea and vomiting in early period was significantly lower in Group MD compared with Group C and Group M. Rescue anti-emetic requirements were fewer in Group MD compared with Group C. There are no severe complications. CONCLUSIONS: A combination of metoclopramide and dexamethasone was more effective in preventing PONV compared with metoclopramide alone.

[Anesthetic management of three patients with myotonic dystrophy in a family].

Case-1: A 24-year-old woman was admitted because of pressing hydramnion. She was treated by ritodrine hydrochlorides leading to rhabdomyolysis, and she was diagnosed as myotonic dystrophy. She underwent cesarean section because of urgent premature birth. The surgery was performed with spinal anesthesia using tetracaine. Case-2: A 1-year-old boy, the son of Case 1, underwent orchiopexy. He showed respiratory distress at birth and needed respiratory support for 140 days. The surgery was performed under general anesthesia combined with caudal anesthesia. Anesthesia was induced with nitrous oxide-oxygen-sevoflurane. He was intubated without muscle relaxants. Since he recovered consciousness soon after the surgery, he was extubated and returned to the ward. Case-3: A 30-year-old woman, the sister of Case 1, underwent tonsillectomy. At the age of 27 she underwent salpingectomy under general anesthesia with nitrous oxide-oxygen-halothane, after which she was diagnosed as myotonic dystrophy. She was anesthetized with propofol and fentanyl. Because severity of the myotonic dystrophy varies among the patients, the strategy for anesthesia should be planned on each patient. Generally speaking, regional anesthesia including spinal and epidural anesthesia is preferable.

[Double-lumen tracheostomy tube (Tracheopart) used in two patients for one-lung ventilation under general anesthesia].

Double-lumen tracheostomy tube (Tracheopart, RUSCH) is now available in Japan. We used the device to perform one-lung ventilation in two patients with previous laryngectomy and permanent tracheostomy. Reliable fixation and observation of the right position during the operation are especially important throughout the procedure. We think that this device needs more improvements regarding its size and length.

[Two occasions of anesthetic management for a patient with Williams syndrome].

A 5-year-old boy with Williams syndrome received open reduction of fracture of the antebrachium twice. He had been diagnosed as having Williams syndrome with some characteristic symptoms, including elfin face, mental retardation and primary pulmonary hypertension. Williams syndrome has a tetrad of cardiovascular disease, elfin face, mental retardation and hypercalcemia. Operations were performed twice under general anesthesia. Airway management with mask technique was easily performed. Tracheal intubation was accomplished successfully. Anesthesia was induced with propofol, fentanyl, and vecuronium, and maintained with propofol, fentanyl and the inhalation of oxygen with nitrous oxide. Both anesthetic courses were uneventful and he was discharged without any complications. Special anesthetic considerations should be taken for difficulties of intubation, management of circulatory system, malignant hyperthermia, and hypercalcemia in this syndrome.