Anesthetic management of a patient with tetanus using epidural anesthesia]

A 75-year-old woman with breast cancer complicated with tetanus was scheduled for mastectomy. Since severe bradycardia (17 beats.min-1) was detected by preoperative Holter monitoring, a temporary pacing catheter was inserted. She underwent mastectomy under general anesthesia using propofol combined with thoracic epidural anesthesia. She also received postoperative thoracic epidural block. Her perioperative heart rate was 80-105 beats.min-1 and the rhythm was sinus. There was no marked perioperative cardiovascular derangement.     

Anesthetic management of a patient with dilated cardiomyopathy under total intravenous anesthesia with propofol and ketamine combined with continuous epidural analgesia

We report our experience with total intravenous anesthesia (TIVA) with propofol and ketamine combined with continuous epidural analgesia in a 72-year-old-male patient with dilated cardiomyopathy scheduled for a total prostatectomy. After premedication with atropine 0.5 mg and pethidine 35 mg, anesthesia was induced with ketamine 50 mg, fentanyl 0.1 mg and using a step down method of propofol (6-->4-->2 mg.kg-1.hr-1). After hemodynamic parameters had been stabilized, the trachea was intubated. Then, 1.5% lidocaine 6 ml was injected through an epidural catheter, placed at the L 1-2 intervertebral space. Anesthesia was maintained with continuous infusion of propofol 1 mg.kg-1.hr-1 and ketamine 1 mg.kg-1.hr-1, and continuous epidural analgesia with 1.5% lidocaine 2 ml.hr-1. Hemodynamics remained stable throughout the operative procedure. No postoperative complications occurred. TIVA with propofol and ketamine in combination with epidural analgesia is useful for patients with dilated cardiomyopathy in order to maintain stable hemodynamics during anesthesia.     

Anesthetic management of a patient with mitochondrial encephalomyopathy under total intravenous anesthesia

This report describes a patient with mitochondrial encephalomyopathy who underwent tracheostomy under total intravenous anesthesia. This 15-year-old girl had been suffering from aspiration pneumonia repeatedly. Anesthesia was induced with propofol (30 mg) and fentanyl (50 microg), and the trachea was intubated without a muscle relaxant. The patient was mechanically ventilated also without a relaxant, and anesthesia was maintained with a continuous infusion of propofol 4-10 mg x kg(-1) x hr(-1) and a bolus injection of fentanyl 25 microg. Bispectral index (BIS) was monitored and maintained at 15-65. The patient showed smooth recovery from anesthesia, and the BIS value returned to the pre-anesthetic level 15 minutes after completion of the anesthesia. Her postoperative course was uneventful. We conclude that total intravenous anesthesia by propofol and fentanyl is a preferable method for the management of the patient with mitochondrial encephalomyopathy.     

Excision of spinal tumor in a patient with severe pulmonary dysfunction using combined spinal and epidural anesthesia with two epidural catheters.

BACKGROUND AND OBJECTIVES: Combined spinal and epidural anesthesia (CSEA) has become common practice. We performed CSEA using two epidural catheters in a 69-year-old female with severe pulmonary dysfunction caused by a diaphragmatic hernia, who underwent surgical excision of a lumbar spinal tumor. METHODS: Combined spinal and epidural anesthesia was performed using two epidural catheters to minimize postoperative pulmonary complications. One epidural catheter was inserted above the surgical region, at the T11-12 interspace, and another one below the surgical region, via the sacral hiatus. Spinal anesthesia was produced using the L5-S1 interspace and 3 mL 0.5% bupivacaine. Oxygen, 3 L/min, was administered through a face mask during surgery. RESULTS: Fifteen minutes after spinal anesthesia, analgesic level was confirmed below T7 using the pinprick method. The patient complained of pain in the surgical region 10 minutes after the dura mater was opened. We injected 5 mL 2% mepivacaine through the upper epidural catheter to relieve the pain. We also injected 10 mL 2% mepivacaine through the lower catheter when she felt pain in the right leg. The perioperative course was uneventful. Oxygen saturation was maintained above 95%. CONCLUSIONS: Combined spinal and epidural anesthesia using two epidural catheters was used successfully to excise a spinal tumor in a patient with severe pulmonary dysfunction.     

Anesthetic management of a patient with severe hyponatremia

A 62-year-old woman was scheduled for an operation for ileus. Before the operation, we noticed severe hyponatremia (Na 117 mEq x l(-1)) probably due to dehydration. We corrected her hyponatremia slowly to avoid central pontine myelinolysis. Serum Na level increased to 131 mEq x l(-1) after surgery. She recovered from anesthesia without any neurologic problems.     

Anesthetic management for a patient with scoliosis combined with central core disease

We gave general anesthesia to a patient with scoliosis combined with central core disease (CCD). CCD is a slowly progressive autosomal dominant congenital myopathy. CCD is presented typically in infancy with hypotonia and delay of motor development, characterized by predominantly proximal weakness pronounced in the hip girdle. Orthopedic complications are common with congenital dislocation of the hips, scoliosis and foot deformity. CCD is due to mutations in the skeletal muscle ryanodine receptor (RYR1) gene at chromosome 19q13.1, which is also implicated in the malignant hyperthermia (MH). A patient with CCD is at risk of MH, with an abnormal response to suxamethonium and volatile anesthetics. The anesthetist ought to be aware of the diagnosis of CCD and to plan anesthetic management accordingly, avoiding potentially MH-triggering agents. We used total intravenous anesthesia (TIVA) in this case, and he showed no MH symptoms perioperatively. This report demonstrates that anesthesia in a patient with CCD could be successfully maintained with TIVA.     

Anesthetic management of a patient with severe hyponatremia]

A 79 year old man, with left femoral neck fracture, was scheduled for an elective operation. After admission, severe hyponatremia probably due to diuretics developed. No neurological abnormalities were observed before surgery. He recovered from anesthesia with no problems. But on the 5th postoperative day he showed transient unresponsiveness. Grand mal seizures were also seen after the serum Na level had recovered to around 130 mEq.l-1. This case shows that in the management of severe hyponatremia, the discrimination between acute and chronic hyponatremia seems to be important.     

Anesthetic management of endovascular repair for aortic abdominal aneurysm in a patient with severe chronic obstructive pulmonary disease

A 66-year-old man with severe chronic obstructive pulmonary disease (COPD) was scheduled for elective endovascular repair of an aortic abdominal aneurysm and femoral-femoral artery bypass. Because spirometry revealed marked reduction of percent forced expiratory volume in 1 second (%FEV1.0), postoperative respiratory failure was anticipated. Spinal anesthesia and no use of tracheal intubation were planned. When the patient entered the operating room, his oxygen saturation (SpO2) was 92%. Four ml of isobaric 0.5% bupivacaine was injected intrathecally at the L3-4 inter-space using a 25-gauge spinal needle. After the final analgesic level of the spinal anesthesia had been ensured at T6, 1.0% lidocaine 5 ml was injected intradermally in the right elbow for insertion of a catheter sheath. Additional analgesia was acquired with a total of 0.1 mg of fentanyl IV. The endovascular repair was completed uneventfully. In conclusion, spinal anesthesia combined with local anesthesia in the elbow is useful for management of endovascular repair of an aortic abdominal aneurysm in patients with severe COPD for whom postoperative respiratory failure is anticipated.     

Anesthetic management for a patient with multiple sclerosis at exacerbation stage under general anesthesia

A 39-year-old woman with multiple sclerosis (MS) at exacerbation stage underwent dilatation and curettage. MS is characterized by chronic inflammation, demyelination, and gliosis in the central nervous system. Surgical stress often induces exacerbation of MS symptoms. Therefore, deep anesthesia is required for anesthetic management in cases of MS. We monitored electroencephalograph (EEG), spectral edge frequency 90 (SEF 90), spectral median frequency (SMF) and delta-amplitude for depth of anesthesia using pEEG (Dr?ger, Germany). In this case, anesthesia was induced with sevoflurane and gradually increased to 5% in oxygen 4 l.min-1 and maintained with sevoflurane 2-3% in 2 nitrous oxide l.min-1 and 2 l.min-1 oxygen. Surgery was completed and no spike wave was observed by pEEG monitoring during surgery. In conclusion, sevoflurane anesthesia was useful for a patient with MS during exacerbation stage.     

Gas exchange and pulmonary hemodynamics in obese patients during epidural anesthesia and spontaneous respiration

The function of external respiration, gas and ABB of blood, hemodynamics of the lesser circulation were studied during abdominal operations in patients with the IV degree obesity performed under conditions of epidural anesthesia with spontaneous respiration. On the basis of clinical and laboratory findings a conclusion was made on the adequacy of the method of epidural anesthesia with spontaneous respiration resulting in a considerably less amount of pulmonary complications.     

Anesthetic management for a patient with Huntington disease

A 41-year-old man (169 cm, 48 kg), having a 10 year history of Huntington disease, was presented for percutaneous endoscopic gastrostomy because of repeated aspiration episodes. He had suffered from choreiform movements, misswallowing and progressive mental deterioration. Midazolam 2 mg i.v. was given on transferring the patient to the operating room. On arriving, the patient was somnolent but responded to call. BIS index was 55. Anesthesia was induced with thiopental 120 mg i.v. and fentanyl 100 microg i.v. followed by vecuronium 4 mg i.v. After tracheal intubation, anesthesia was maintained with sevoflurane 1.5% in 33% oxygen. Bispectral index and train of four ratio were monitored throughout the anesthesia. BIS index and TOF ratios were proper for the drug dose used. At the end of the procedure, neuromuscular blockade was antagonized with neostigmine 2.0 mg and atropine 1.0 mg i.v. with no worsening of symptoms. The duration of anesthesia was 85 minutes. The patient woke up (BIS index 78) and spontaneous respiration returned and he was extubated. The postoperative course was uneventful. In this case, BIS index was abnormally low before induction of anesthesia as well as after anesthesia. Whether Huntington disease is responsible for the abnormally low bispectral index remains uncertain. But, anesthesiologists should be aware of this phenomenon to avoid an inappropriate adjustment of the anesthetic depth.     

Anesthetic management for a patient with Jansky-Bielschowsky disease

PURPOSE: To describe the anesthetic management of a patient with Jansky-Bielschowsky disease (JBD), the late infantile form of neuronal ceroid lipofuscinosis, characterized by dementia, severe and drug resistant grand mal, myoclonic seizures, and blindness. Clinical features: A 14-yr-old girl with JBD was scheduled for resection of a gingival tumour and an infected sinus in the sacral area. Her preanesthetic examination revealed extreme muscle atrophy and dementia. Grand mal, myoclonic seizures, and upper airway obstruction were frequent. Following iv induction with thiamylal, anesthesia was maintained with sevoflurane, N(2)O and O(2). Her trachea was intubated without using muscle relaxants. Muscle relaxants were not used during the operation. Apart from an intractable hypothermia, the intraoperative course was uneventful. The emergence of anesthesia was smooth, except for persisting seizures. CONCLUSION: General anesthesia using thiamylal and sevoflurane provided satisfactory conditions during operation in a patient with JBD. Intraoperative hypothermia required particular attention.     

Successful management of a patient with myotonic dystrophy under total intravenous anesthesia with propofol, remifentnil and rocuronium bromide, combined with epidural anesthesia

In general anesthesia for a patient with dystrophia myotonica (DM), respiratory depression and muscle weakness by opioid, as well as prolongation of the effect of muscle relaxant are seen postoperatively. Therefore it is desirable to choose agents with short duration of action and to dose these medicines to the minimum. We report a case of a 45-year-old woman with DM who underwent laparotomy for uterine cancer under general anesthesia combined with epidural anesthesia. Epidural catheter was placed from T 11-12, and anesthesia was inducted with propofol and remifentanil (RF). We administered rocuronium bromide (RB) 5 mg while watching TOF ratio with a muscle relaxation monitor (TOF-Watch). T1 became 0 after giving a dose of 10 mg, and intubation was performed. We maintained anesthesia by propofol and RF combined with epidural anesthesia. TOF ratio was restored to around 80% 90 minutes after RB administration, but we did not give supplemental doses because the operation went well smoothly. Recovery was smooth and fast. The respiratory depression and the muscle spasm were not noticed. RB and RE both with short duration of action, are useful in anesthesia management in DM cases.     

Anesthetic management for cesarian section in a patient with mitral stenosis and severe pulmonary hypertension

Mitral stenosis is one of the complicating cardiac diseases during pregnancy. We experienced cesarean section in a patient with mitral stenosis and severe pulmonary hypertension (94/41 mmHg). During surgery, complete analgesia below T 4 level was obtained by epidural anesthesia with two catheters inserted at L 3-4 and T 11-12 interspaces. By epidural anesthesia, pulmonary arterial pressure decreased to 60/30 mmHg and other hemodynamic variables were stable. A baby (BW:1880 g) was intubated because of tachypnea although Apgar scores were 6-8-8. The anesthetic course of the patient was uneventful.     

Anesthetic management of a patient with Osler-Weber-Randu disease]

Osler-Weber-Randu disease (Osler disease) is an autosomal dominant disease, sometimes known as hereditary hemorrhagic telangiectasia with its family history. It is not a popular disease and approximately seventy families are known as inheritance lineage in Japan. We experienced anesthetic management of a 49-yr-old woman with Osler disease. She was diagnosed to have the brain abscess following fever and clouding of consciousness for several days and was scheduled for the removal of the abscess. A chest X-ray revealed pulmonary arteriovenous fistula in the right middle lung field. The patient had had life threatening frequent massive bleeding from her nose and/or stomach for the past several years. Her brother and children also had the same symptoms. In addition to Osler disease, the patient had the prolonged coagulation time that was supposed to the due to chronic liver disease. Therefore, fresh frozen plasma (5 units) and platelet concentrates (10 units) were infused during the surgery. Intraoperative blood loss was about 700 grams. We had no difficulties in management of bleeding and respiratory controls during anesthesia.     

Interscalene block combined with general anesthesia under spontaneous breathing in a patient with a giant bulla

Respiratory management for patients with a giant bulla during anesthesia should avoid positive-pressure ventilation to reduce the risk of barotraumas. We report a case of anesthetic management of a 42-year-old man with a giant bulla who had an elective surgery for biopsy of a tumor on his left elbow. Balanced anesthesia consisting of general anesthesia was given under spontaneous breathing combined with interscalene brachial plexus blockade for intra- and postoperative analgesia for the elbow surgery. The patient was monitored by electrocardiography, non-invasive arterial pressure, SpO2, endtidal CO2 tension and bispectral index. Ultrasound-guided interscalene block was performed with the patient awake. After injection of 0.75% ropivacaine 20 ml and 1% lidocaine 16 ml for brachial plexus block, general anesthesia was induced with a bolus of fentanyl 100 microg to reduce cough reflex and propofol using target control infusion with a 2 microg x ml(-1) plasma concentration. The airway was maintained with a size 4 LMA-Proseal, which was inserted with care under spontaneous breathing. There were no serious complications such as pneumothorax in perioperative period. We performed successful anesthetic management, without any complications, combined with interscalene brachial plexus block and spontaneous breathing in a patient with a giant bulla.