[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.

[Acute pulmonary thromboembolism during the surgery for bilateral lower extremity fracture].

A 50-year-old woman underwent open reduction and internal fixation for bilateral lower extremity fracture under general anesthesia. During the surgery, arterial oxygen saturation and expired CO2 concentration dropped suddenly when the left limb was fixed. Immediately, we performed aspiration of the pulmonary thrombus and inserted a temporary infra-vena cava filter followed by heparinization. Ten days later, we carried out the surgery on the right limb uneventfully. The major cause of APTE is deep vein thrombosis (DVT), which is extremely common during perioperative period. Therefore, we must perform antithrombotic therapy for the patient at high risk for DVT.

[Anesthetic management of a child with Schwartz-Jampel syndrome].

A 6-year-old child with Schwartz-Jampel syndrome (SJS) underwent tenotomy of bilateral lower limbs under general anesthesia. Patient with SJS has problems such as difficulty of intubation owing to microstomia and jaw muscle rigidity, and is susceptible to malignant hyperthermia by using volatile inhalation anesthetics. In this case, we used a laryngeal mask for airway management and anesthesia was maintained with inhalation of nitrous oxide and continuous i.v. infusion of propofol with caudal block, and his clinical course was uneventful.

Tin chloride pretreatment prevents renal injury in rats with ischemic acute renal failure.

OBJECTIVE: To investigate whether tin chloride pretreatment ameliorates renal injury in rats with ischemic acute renal failure (IARF) by virtue of its kidney-specific heme oxygenase-1 induction. DESIGN: Randomized, masked, controlled animal study. SETTING: University-based animal research facility. SUBJECTS: Sprague-Dawley male rats, weighing 200-230 g (n = 359). INTERVENTIONS: Rats were injected with tin chloride subcutaneously, because subcutaneous administration of tin chloride is known to specifically and potently induce renal heme oxygenase activity in the rat. Anesthetized rats were subjected to bilateral flank incisions, and the right kidney was removed. Renal ischemia for 40 mins was performed by left renal microvascular clamping, followed by reflow of the blood. MEASUREMENTS AND MAIN RESULTS: Tin chloride treatment specifically induced heme oxygenase-1 mRNA and protein in the proximal tubular epithelial cells of the kidney without apparent cell injury in the rat. Tin chloride treatment before renal ischemia augmented the induction of heme oxygenase-1 in IARF rats at both transcriptional and protein concentrations in the renal epithelial cells compared with IARF animals. Tin chloride pretreatment, which decreased microsomal heme concentration, ameliorated the ischemic renal injury as judged by the significant decrease in serum creatinine and blood urea nitrogen concentrations and the lesser tubular epithelial cell injuries. In contrast, inhibition of heme oxygenase activity by treatment with tin mesoporphyrin, which increased microsomal heme concentration, abolished the beneficial effect of tin chloride pretreatment. CONCLUSION: These findings indicate that tin chloride pretreatment significantly ameliorates renal injury in rats with IARF by virtue of its specific heme oxygenase-1 induction in renal epithelial cells. These findings also suggest that heme oxygenase-1 induction plays an important role in protecting renal cells from oxidative damage caused by heme.

Correlation between renal function and pharmacokinetic parameters of inorganic fluoride following sevoflurane anesthesia.

We studied the correlation between renal function and pharmacokinetic parameters of inorganic fluoride following sevoflurane anesthesia. In 30 neurosurgical patients aged 40-70 years, anesthesia was induced with midazolam and sevoflurane and maintained with sevoflurane and nitrous oxide in oxygen. Serum and urine inorganic fluoride (F-) levels and ß2-microglobulin (BMG), blood urea nitrogen (BUN), and serum creatinine (Cr) were measured during and after anesthesia. The decrease rate of serum F- level and the area under the curve (AUC) of serum F- were calculated. Correlations among sevoflurane dosage, duration of administration, peak serum F- level, AUC, the decrease rate of serum F- level, and the maximum values in BUN, Cr, and urine BMG during the study were investigated. Urine BMG increased significantly after surgery but returned to the preoperative level in a week. BUN, Cr, and serum BMG remained within normal ranges during the study. Sevoflurane dosage and duration of administration were significantly correlated with AUC and the maximum value of urine BMG, but not with the peak serum F- level or the decrease rate of serum F-. AUC was significantly correlated with the maximum value of urine BMG. In sevoflurane anesthesia, sevoflurane dosage, duration of administration, and AUC affected urine BMG level, but not peak serum F-.