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Anaphylactic reactions during the induction of general anaesthesia are rare. Anaesthetists should determine the pathogenesis of anaphylaxis in order to establish appropriate treatment and prevent recurrence. Very little clinical information has been published to date about anaphylaxis induced by the recently launched drug remimazolam. A 78-year-old man, scheduled for elective surgery for colon cancer, became profoundly hypotensive and hypoxic shortly following the induction of general anaesthesia with remimazolam, remifentanil and rocuronium. His physiological derangement was successfully managed with adrenaline, vasopressors and intravenous fluid resuscitation. His serum tryptase level was significantly elevated and an intradermal test with diluted remimazolam revealed a positive reaction, confirming the diagnosis of anaphylaxis. We believe this is the first case report of remimazolam-induced anaphylactic shock diagnosed with a serum tryptase elevation and positive skin test.

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In spontaneously breathing rats, a transient increase in cerebral blood flow (CBF) has been shown to be a predictor of hyperbaric oxygen (HBO)-induced convulsion. In the present study, we evaluated whether artificially ventilated animals also show an increase in CBF prior to the onset of HBO-induced convulsion. Rats were ventilated with 100% oxygen in 5 atmospheres. CBF, blood pressure, and an electroencephalogram were monitored continuously. Convulsion was observed at 41 +/- 12 min after the initiation of HBO treatment. A single abrupt increase in CBF, reaching 223 +/- 39% of the control level, was observed at 29 +/- 13 min after the initiation of HBO exposure and lasted until the onset of convulsion 12 +/- 2 min later. The time of the increase in CBF correlated strongly with the onset of convulsion (r = 0.99, P < 0.001). Further, the logistic regression curve demonstrated a close relationship between the duration of increased CBF and percentage of epileptiform electrical-discharge incidence (r = 0.92, P < 0.006). The durations of increased CBF causing convulsion in 10%, 50%, and 90% of the rats were 8.4 min, 11.7 min, and 15.1 min, respectively. These results indicate that an increase in CBF is a predictor of HBO-induced convulsion in artificially ventilated rats. The increase in CBF may be involved in the pathogenesis of HBO-induced convulsion.

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We examined 100 patients who had undergone VSD repair from 1988 to 1991 to determine the risk factors to induce PHC postoperatively. We analyzed age, weight, preoperative Pp/Ps, Rp/Rs, Qp/Qs, and postoperative Pp/Ps using discriminant analysis. We had 34 cases of pulmonary hypertension (PH: Pp/Ps > 0.7) preoperatively. Among 100 cases, PHC developed in 6 patients and 2 of them died postoperatively. Incidence of PHC in all patients was 6%, and that in patients with PH was 18%. PHC fatality rate was 33%. The analysis revealed that the occurrence of PHC was significantly higher among those whose ages were below 2.1 years, and with weight of under 9.85 kg, preoperative Pp/Ps > 0.73, Rp/Rs < 0.34, and postoperative Pp/Ps > 0.43. In those with preoperative PH, the risk for PHC increased significantly when their postoperative Pp/Ps exceeded 0.44.

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How to optimize cerebral perfusion pressure and flow during selective extracorporeal circulation is a crucial problem for cerebral protection in surgical repair of aortic arch aneurysm. Among 47 cases of aortic arch replacement between 1980 and 1992, extracorporeal circulation (ECC) for the first 17 cases [group-1] were hypothermic ECC with selective cerebral perfusion (SCP) and 8 cases [group-2] with hypothermic ECC with hypothermic cardiac arrest. For the latest 16 cases [group-3] we introduced continuous O2 saturation monitoring by oximetry catheter placed in internal jugular bulb (SIJVO2) and maintained SIJVO2 value above 90% to effectively adjust pump flow to optimize cerebral perfusion pressure and flow for cerebral protection. We have retrospectively compared the effectiveness of SIJVO2 monitoring among these three groups. The mortality was 35% (6 cases: group-1), 37% (3 cases: group-2) and 6% (1 case: group-3) respectively. Cerebral dysfunction which were diagnosed in immediate postoperative period were 23% (4 cases: group-1), 0% (0 case: group-2) and 6% (1 case: group-3) respectively. We conclude continuous monitoring of SIJVO2 during selective ECC in aortic arch replacement is useful to optimize cerebral perfusion pressure and flow thereby reducing postoperative cerebral damage by selective ECC.

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The effect of prostaglandin E1 was studied to examine if it works favorably for peripheral circulation in pediatric patients after cardiac surgery. Dose of 0.1 mcg.kg-1.min-1 increased temperature of dorsal pedis significantly. Difference of temperature of dorsalis pedis and that of rectum was significantly smaller than that in control group. A significant increase in heart rate and a decrease in systolic arterial pressure produced no clinical side effects. We conclude that prostaglandin E1 is a useful and safe vasodilator for circulatory management of pediatric patients after cardiac surgery.

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Two cases of massive hemorrhagic shock induced by tracheo-innominate artery fistula are reported. The first case is a 4 year-old girl with encephalitis under prolonged mechanical ventilation. The second case is a 6 year-old tracheostomized girl with mental and motor retardation of congenital origin who has been taken care of at her home. This catastrophic complication is usually caused by long term placement of tracheostomy tube with the cuff inflated especially in malnourished pediatric patients. The cuff pressure is apt to be concentrated on one side of the tracheal wall especially in mechanically ventilated immobilized patients. Although this complication is rare because cuffed tube is currently avoided in pediatric patient, sophisticated care should be taken in managing tracheostomized patients.

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The respiratory and hemodynamic responses to postoperative reversal by naloxone of high-dose fentanyl anesthesia were studied in 101 patients after open heart surgery. Respiratory and hemodynamic changes after drip infusion of naloxone were minimum. Change of systolic blood pressure (BPs), mean blood pressure (BPm), CVP and PO2 were statistically significant. BPs increased for 3.8 +/- 14.0 mmHg, BPm increased for 1.6 +/- 8.2 mmHg. CVP decreased for 0.4 +/- 2.1 mmHg, and PO2 decreased for 8.6 +/- 3.4 mmHg. Severe side effect was not observed. Multi-factorial analysis revealed that the abrupt recovery of consciousness from anesthesia and acidosis were the most important factors that attenuate hemodynamic response to naloxone.

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Twenty-one patients who underwent cardiac surgery were assigned to receive high-dose fentanyl rapid sequence anesthesia or conventional high-dose fentanyl anesthesia. In conventional method group, power of delta wave decreased with respect to time. But in rapid sequence group, no decrease was seen until the end of operation. Good maintenance of delta wave in rapid sequence group may be achieved by higher plasma fentanyl concentration and the absence of acute tolerance. In conclusion, high-dose fentanyl rapid sequence anesthesia is a useful method for cardiac surgery.

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We treated a 32-day-old baby suffering acute acquired methemoglobinemia induced by topical application of aniline cocaine. Although acute acquired methemoglobinemia with severe cyanosis and distress is potentially fatal, this rare syndrome is easily curable if it is correctly diagnosed.

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