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A male baby was delivered by emergency cesarean section due to fetal distress at 30 weeks of gestational age with a birth weight of 813 g. By fetal echocardiography, the patient had been diagnosed with transposition of great arteries (type 1). Early two-staged arterial switch operation was planned after 34 gestational age avoiding intracranial hemorrhage under cardiopulmonary bypass. At 19 days of life, vegetation was revealed on the pulmonary valve by echocardiography, so he was diagnosed as infectious endocarditis. Cefotaxime and gamma-globulin were given intravenously for 4 weeks. While waiting for the increase in the body weight, desaturation from chronic respiratory distress syndrome was exacerbated. At 8 months old, urgent Senning operation was performed to improve desaturation. The patient was discharged at 20 post operative day. We conclude that Senning operation can be feasible operation in such a complicated case.

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BACKGROUND: Sore throat and hoarseness are common complications, but these have not been studied after total i.v. anaesthesia. METHODS: We prospectively studied 418 surgical patients, aged 15-92 yr, after total i.v. anaesthesia with propofol, fentanyl and ketamine to assess possible factors associated with sore throat and hoarseness. RESULT: We found sore throat in 50% and hoarseness in 55% of patients immediately after surgery. This decreased to 25% for sore throat and 24% for hoarseness on the day after surgery. Both sore throat and hoarseness were more common in females and when lidocaine spray had been used. Cricoid pressure during laryngoscopy was inversely associated with the risk of sore throat. CONCLUSION: Knowledge of these factors may reduce postoperative throat complications, and improve patient satisfaction.

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This study was conducted to evaluate the postoperative analgesic effects of epidural bolus administration of bupivacaine and morphine in patients after vaginal hysterectomy and vaginoplasty. A total of 100 patients who had received the elective vaginal hysterectomy and vaginoplasty were investigated retrospectively by separating them into two groups. Fifty patients who had received epidural analgesics (E group) showed significantly lower pain scores for 12 hrs after the surgery compared with 50 patients who had received intramuscular buprenorphine hydrochloride (C group). The patients in E group needed significantly less supplemental analgesics than those in C group for 2 hrs after the operation. The incidence of side effects was not significantly different between the two groups. But the incidence of postoperative complications was significantly lower in the patients in E group than those in C group. These results show that epidural bolus administration of bupivacaine and morphine is effective for postoperative pain relief and decreases the incidence of postoperative complications after vaginal hysterectomy and vaginoplasty.

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We experienced anesthetic management of two patients with hypergammaglobulinemia undergoing thoracoscopic lung biopsy, one of whom suffered from multiple cerebral infarction during anesthesia. Pathogenesis of this serious complication could not be elucidated. However, decrease in cerebral regional circulation caused by increase in blood viscosity would be most probable. We should preoperatively carry out measurement of blood viscosity and brain CT scan, and consider plasma exchange in patient with hypergammaglobulinemia, in whom symptoms and signs of hyperviscosity syndrome do not exist.

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This report describes the rescue activities and the exposure of rescue and hospital personnel from the first unexpected nerve gas terrorist attack using sarin (isopropyl methylphophonofluoridate) in the city of Matsumoto at midnight on June 27, 1994. The details of the emergency activities in the disaster were studied based on the records from emergency departments of the affiliated hospitals and records from the firehouse. About 600 people, including residents and rescue staff, were exposed to sarin gas. Fifty-eight residents were admitted to hospitals, and 7 died. Among 95 rescuers and the duty doctor from the doctor car, 8 had mild symptoms of poisoning. All the rescue activity took place without gas masks or decontamination procedures. In this case of unexpected mass exposure to sarin gas, the emergency rescue system for a large disaster in Matsumoto city, which had been established for a conflagration or a local earthquake, was effective.

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We encountered three cases of hyperkalemia after the reperfusion of ischemic limbs associated with revascularization surgery for acute arterial occlusions. Two patients died because of uncontrollable hyperkalemia in spite of intravenous insulin and forced diuresis. Careful attention should be paid to hyperkalemia and metabolic acidosis for several hours after the reperfusion in cases of ischemia and/or extensive ischemia of long duration. The aggressive prophylaxis and treatment for MNMS are vital to the anesthetic management of revascularization for acute arterial occlusions.

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We experienced the anesthetic management of 10 Jehovah's Witness patients. Some patients accepted either blood products, autologous blood transfusion with closed circuit, or Cell Saver. The patients' families expressed their wish that blood transfusion could be done in life threatening situations against the patient's wish in some cases. It would be desirable to clear up an acceptable standard and write out it in each medical institution to avoid conflicts with the patient and families. Prior agreement is required among medical staffs on refusal of blood transfusion.

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The effects of succinylcholine, which was given to facilitate tracheal intubation on the duration of action of subsequently administered vecuronium bromide, were evaluated in 54 adult patients who underwent abdominal surgeries under enflurane anaesthesia. The electromyographic response to train-of-four ulnar nerve stimulation was measured. Twenty-seven patients received 1 mg.kg-1 of succinylcholine, followed by 0.15 mg.kg-1 of vecuronium when the electromyographic response recovered to 50% of control after succinylcholine-induced neuromuscular blockade. The other 27 patients served as the control group, receiving 0.15 mg.kg-1 of vecuronium without prior administration of succinylcholine. In both groups, administration of supplemental 0.04 mg.kg-1 of vecuronium was repeated whenever the electromyographic response recovered to 25% of control during surgical procedures. The duration of blockade induced by the initial 0.15 mg.kg-1 of vecuronium was 56.5 +/- 12.8 (mean +/- s.d.) min for the group with succinylcholine, and 58.5 +/- 21.5 min for the control group. In both groups, the average duration of four consecutive supplemental doses of vecuronium was approximately 35 min. No significant differences between groups were found in the duration of neuromuscular blockade induced by initial and supplemental doses of vecuronium.

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This study was conducted to evaluate the effects of continuous epidural analgesia (CEA) on the incidence of postoperative complications and the early recovery after lower abdominal surgery. A total of 109 patients who had received elective lower abdominal surgery were investigated retrospectively by separating them into two groups. Compared to 35 patients who had received standard analgesic techniques without epidural analgesia, 74 patients who had been administered CEA with buprenorphine, mepivacaine and droperidol for 24 hrs after surgery could sit on the bed significantly earlier. But the patients with CEA could not stand on the floor and could not walk significantly earlier than the patients without CEA. The overall postoperative complication rate was not significantly different between the patients with and without CEA. These results show that postoperative CEA exerts a beneficial effects on the early recovery after the lower abdominal surgery, but the effect is not so strong as in upper abdominal surgery group. The results also suggest that CEA does not decrease the incidence of postoperative complications.

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After gastrectomy, 103 patients were investigated concerning the effects of postoperative continuous epidural analgesia on the postoperative complications and early recovery. Sixty-seven patients who received epidural analgesia after the operation (group E) were able to sit on the bed, stand on the floor and walk themselves significantly earlier than 36 patients who were given analgesics intramuscularly or transrectally (group C). The incidence of postoperative complications was significantly less in the patients of group E than those of group C. These results show that postoperative continuous epidural analgesia decreases the incidence of postoperative complication and supports the early recovery from the operation.

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We experienced the anesthetic management of a 72-year-old female with hyperkalemia, metabolic acidosis and renal insufficiency, undergoing right total hip replacement for rheumatic arthritis. She had been treated with nonsteroidal anti-inflammatory drugs (NSAIDs) for last several years. Anesthesia was maintained with isoflurane 0.2-1.0% and nitrous oxide in oxygen supplemented with vecuronium. Continuous infusion of prostaglandin E1 0.05-0.10 microgram.kg-1 x min-1 and bolus infusion of 7.0% NaHCO3 during the operation were useful in controlling blood pressure, improving hyperkalemia and maintaining renal function. Postoperatively, she was diagnosed to have hyperkalemic tubular acidosis due to interstitial nephritis induced by NSAIDs.

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Vecuronium was administered in an initial dose of 0.1 approximately 0.3 mg.kg(-1) and in supplemental doses of 0.03 mg.kg(-1) or 0.05 mg.kg(-1) in 74 patients (ASA class 1 or 2) scheduled for abdominal surgery. The duration of the neuromuscular blockade provided by vecuronium after both the initial and supplemental doses was determined using the evoked integrated electromyographic device. A statistically significant positive correlation (correlation coefficient: 0.83 approximately 0.91) was found between the duration of action of the initial dose and that of the first to fourth supplemental doses. The regression lines of each of the first four supplemental doses to the initial dose were very similar to each other. These results suggest that, since the duration of action of supplemental doses of vecuronium was prolonged in patients showing a long duration of action of the initial dose, it would be wise to avoid blind adherence to a predetermined schedule for supplemental administration. Rather, anesthesiologists should take into account the patient's response to the initial dose and then decide the most appropriate timing for supplemental doses. Moreover, since vecuronium shows little cumulative effect even after 4 supplemental administrations in clinical-range doses, it can be concluded that vecuronium can be safely used in a wide dose range.

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Forty-five hypertensive patients for elective abdominal surgery were investigated regarding the effects of PGE1 on the cardiovascular responses to tracheal intubation. Administration of PGE1 at the dose of 0.10 or 0.20 micrograms.kg-1.min-1 for 10 minutes before tracheal intubation significantly reduced the blood pressure responses immediately after the intubation and 2 minutes later. The increases in heart rate were not altered with and without the administration of PGE1. So the increases in rate pressure products were markedly reduced with PGE1 compared with the control values. Plasma concentration of catecholamines was measured before and after tracheal intubation. Norepinephrine was elevated markedly immediately after the intubation and this change was not affected by the infusion of PGE1. These results demonstrate that PGE1 ameliorates the pressure responses by the release of norepinephrine and thus reduces the increases in rate pressure products immediately after tracheal intubation.

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The relationship between changes in the core and the surface temperature and postanesthetic shivering was studied in 100 patients who underwent general anesthesia. Patients were classified into four groups by the patterns of change in the core and peripheral surface temperature. Type II and type IV groups of patients showed a decrease in surface temperature during the major operation such as gastrectomy and radical mastectomy. Type I and type III groups of patients showed no lowered peripheral surface temperature and with low temperature difference between core and surface temperature during the operation. The patients in type II and IV groups showed increased difference between core and surface temperature. The postanesthetic shivering occurred at significantly higher rate compared to the other two groups. As possible reasons of the shivering, operation of long duration and insufficient circulating blood volume were considered. Shivering reduces the temperature difference in the thermoregulatory homeostasis. However, in patients in type I and III, the rate of shivering was low. Evaluation of the difference between core and peripheral surface temperature may be important to manage body temperature at a steady level during the operation. The monitoring of body temperature difference between core and peripheral surface during the operation may be useful for predicting to occurrence of postanesthetic shivering.

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Prostaglandin E1 was administered to 19 patients to induce hypotension during intracranial surgery. Urine volume during the operation and after the first day was well maintained, and serum BUN and creatinine were within normal ranges after the surgery. Serum GOT and GPT increased significantly on the 7th and 14th day after the operation compared with the control, but this did not seem to be the results of PGE1 administration. LDH and ALP showed no significant change. Thirty minutes and two hours after the administration of PGE1, arterial blood oxygen tension decreased significantly. These results suggest that PGE1 does not adversely affect the liver and kidneys, and it can be used safely and is useful to control blood pressure during intracranial operation.

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To determine the onset time, duration of action and recovery time of high-dose vecuronium, 70 patients were assigned to receive either 100, 150, 200 or 300 micrograms.kg-1 of vecuronium for muscle relaxation during elective surgery. Neuromuscular blockade was continuously quantitated by recording the EMG response to stimulation of the ulnar nerve. The onset time from the time of vecuronium administration to maximum blockade decreased from 4.6 +/- 1.1 to 2.4 +/- 0.5 min when the vecuronium doses increased from 100 to 300 micrograms.kg-1. Significant differences were observed in the onset time between the 100 micrograms.kg-1 dose and the other dose groups. Endotracheal intubating conditions were excellent in all patients except 3 in the 100 micrograms.kg-1 dose group. The duration of action from the time of injection to 25% recovery increased from 32 +/- 9 to 138 +/- 48 min in a dose dependent manner. The duration of action after increment doses of 40 or 50 micrograms.kg-1 up to 25% recovery of T1 did not vary significantly within the same dose group. With an initial dose of 150 micrograms.kg-1 and subsequent increment doses of 50 micrograms.kg-1 or less, the duration of action remained constant. The recovery time from 25 to 75% recovery was within 11 minutes when antagonists were administered. High-dose vecuronium may, therefore, be a useful alternative to SCC, when a rapid onset is required and to pancuronium, when a rapid recovery from neuromuscular blockade is requested.

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