We examined the preoperative mental status of 41 patients aged 70 years or more, who were selected from among patients scheduled for surgery between February and Novem-ber 1987 in order to clarify whether this was associated with postoperative mental disturbance. Mental status was investigated on the preoperative round by the anesth-esiologist. 1) Degree of dementia using Hasegawa dementia scale. 2) Extent of daily living activities. 3) Past history of mental disorders, for example night delirium. The patients who had cerebrovascular disease, psychiatric diseases and neurological diseases were excluded.
Eight patients suffered postoperative mental disturbance (Group A), and 33 patients did not (Group B). Significant differences in preoperative mental status were found between these two groups. Group A showed a more severe degree of dementia, lower levels of daily living and many more patients had a past history of mental disorders than in Group B.
We conclude that examination of the preoperative mental status of aged patient can be useful for predicting occurrence of postoperative mental disturbance, and for helping to prevent this complication

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We surveyed the present status of ambulatory anesthesia and the opinions for introducing this system to Japan by distributing questionnaires to the hospitals ap-proved by Japan Society of Anesthesiology(JSA). Of 474 hospitals, we received 329 answers(69.4%). The number of the hospitals that experienced at least once of am-bulatory anesthesia were 97(29.5%), but the number of the hospitals performing am-bulatory anesthesia regularly were only 20(6.1%). In children's hospitals, the prevalence rate was 9/11(81.8%, p<0.05 compared with other hospitals).
81(24.8%) of the anesthesiologists strongly suggested the necessity of ambulatory anesthesia. 184(56.4%) realized the necessity. 27(8.2%) were not in favour of this system.
Both contributing and limiting factors were clarified from the questionnaires. Now, in Japan, there are many different situations compared with United States and European countries. The shortage of qualified anesthesiologists and the related co-medical staffs, and an advanced medical insurance system might be the main factor to explain the low prevalence of ambulatory anesthesia system in Japan.

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Fifty four patients undergoing infrarenal abdominal aneurysmectomy were studied to observe perioperative renal function in association with hemodynamic and endocrine function and also to see the implication of anesthetic technics.
They were dev i ded into 4 groups: NLA (fentanyl 10mcg/kg, N=13), MDF (moderate dose fentanyl: 30mcg/kg, N=15), GOF (halothane 0, 5-1, 0%, N=12) and BTP group (butorphanol 75mcg/kg, N=14). Measurements of renal function, hemodynamics and plasma catecholamine (HPLC), renin activity, aldosterone and vasopressin levels (RIA) were serially repeated from preanesthesia through postoper-ative day 2.
Renal function was well maintained above preanesthesia level in all groups except in BTP group, throughout the entire study periods. GOF group showed the highest values in renal parameters, while GFR was slightly reduced following aortic cross-clamping in BTP group. Cardiac output decreased during aortic clamping without any difference between groups. Atrial pressures significantly increased during surgery, but these elevations were less in BTP group, which might reflect a relative hypovolemia. Intraoperative hypotension was less in GOF group. Although plasma catecholamine and vasopressin levels increased during surgery, these increases were the most pronounced in BTP group and the least in MDF group. However, renin-aldosterone system was highly activated in GOF group.
These results suggest that optimal fluid loading and blood replacement and avoidance of hypotension, in association with adequate anesthesia level to attenuate endocrine response may be required to prevent perioperative renal insufficiency in abdominal aneurysmectomy.

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The anesthetic management of 57 acute alcohol intoxicated patients was reported. The mean blood alcohol level soon after admission was 147mg/dl (34∼344mg/dl). It is important to remember that alcoholic intoxication can mask silent traumatic injuries, and to this end it is imperative to exclude any head or spinal cord injuries. Additionaly, in many cases it is difficult to obtain correct preoperative assessment because intoxicat-ed patients are not cooperative.
The anesthetic management of an acute intoxicated patient is not without its problems because of the general effects of alcohol on the body as a whole. Alcohol causes respiratory depression containing reduced cough and gag reflex, and a metabolic acidosis. This last condition would be compensated for by hyperventilation. A wide-spread cutaneous vasodilation renders intoxicated patients more susceptible to hypoten-sion and hypothermia. An inhibitory effect by alcohol on intestinal glucose absorption induces hypoglycemia even after a short period of fasting. The secretion of antidiuretic hormone is inhibited after acute alcoholic intoxication, resulting in free-water diuresis. At last, the possibility of alcohol withdrawal symptoms in delirium tremens should be remembered. There is a real need for prolonged post-operative supervision of the patient.

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To determine the risk against aspiration pnemonitis and the effects of H₂-blocker, gastric pH and volume were measured after endo-tracheal intubation in two groups; control group and famotidine group. Futhermore, to investigate the age-related risk, each group was divided into four subgroups according to age; subgroup I: 12-19yrs, subgroup II: 20-39yrs, subgroup III: 40-59yrs, subgsoup IV: above 60yrs. Control group did not recieve H₂-blocker, and famotidine group received famotidine (H₂-blocker) orally 20mg the night before operation and 2hr prior to induction of anesthesia.
In Control group, the proportion of patients with pH≤2.5 and or volume≥0.4ml/kg decreased significantly with age.In famotidine group, mean pH did not change significantly among four subgroups, but mean volume decreased significantly with age, and the proportion of patients with volume≥0.4ml/kg in subgroup I was significantly high compared with other sub-groups.
Administration of famotidine decreased the risk of aspiration pneumonitis significant-ly. However, the effects of famotidine were different among four subgroups, and were significantly less in subgroup I.These results demonstrate that it is necessary to take preventative measures against aspiration pneumonitis in the young patients, especially 12-19yrs, even if they have received H₂-blocker preoperatively.

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The effect of epidural anesthesia and surgery on cell-mediated immunity was inves-tigated in 8 patients undergoing either total or subtotal gastrectomy. Peripheral lymphocytes and their functional subpopulations were analyzed by single and two-color analysis using monoclonal antibodies against lymphocyte membrane surface markers. The number of helper and inducer T cells (using Leu3a and Leu8), suppressor and cytotoxic T cells (using Leu2a and Leul5), natural killer cells (using Leull and Leu7) and active T cells (using Leu4 and HLA-DR) were measured before induction, one and two hour after skin incision. Each subpopulation did not change significantly during epidural anesthesia. This result suggested that the epidural anesthesia did not change cell-mediated immunity, which was usually suppressed during halothane or enflurane anesthesia.

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It is known that the effect or duration of epidural analgesia may decrease as epidural block is continued long term. The purpose of this study is to examine the radiographical changes of epidural space due to continuous epidural analgesia in order to determine the causes which attenuate epidural analgesia's effect.
We performed this epidurographies before and after the continuous epidural block in twenty-two patients. Each patient has a catheter inserted 5cm into epidural space for chronic pain relief. After analgesic levels were checked following 6ml of 1% lidocaine, first epidurography was done immediately and five minutes after the injection of 6ml iopamidol. Then, all patients had received 6ml of 0.25% bupivacaine four or six times a day via the catheter for the next two weeks, thereafter second epidurogaraphy was performed in the same way. We read the spinal segmental numbers of spread and catheters position from the epidurograms.
Consequently, we could perform two epidurograms in ten of twenty-two patients. The rest twelve patients were excluded because of the leak of anesthetics and so on. There was no change of catheter tip location found between the first and the second epiduro-grapies in the ten patients. The mean segmental number of radiographic spread de-creased significantly from 21 to 18 immediately and from 24 to 21 five minutes after the injection(p<0.05).
We concluded that continuous epidural block over 2 weeks could produce adhesion of epidural space and may cause inadequate epidural block.

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The effect of fentanyl-enflurane/nitrous oxide anesthesia on hemodynamic state was investigated in twelve patients with old myocardial infarctions undergoing noncardiac surgery. The anesthetic method cosisted of heavy premedication, induction with fentanyl and pancuronium, and enflurane andnitrous oxide in oxygen.
Heart rate decreased after administration of premedication without any changes in blood pressure. Induction with low-dose f entanyl (10μg•kg^-1) avoided unfavorable circuratory responses to tracheal intubation and maintenance with enflurane (0.3∼1.0%) decreased systemic arterial pressure with little depression of myocardial function. The only problem was an increase in heart rate after endotracheal extubation which could have produced an increase in myocardial oxygen demand. An injection of either lidocaine or β-adrenergic blocking agent prior to extubation might be considered to settle the problem.
Although the condition after extubation was not ideal enough for the patients with old myocardial infarction, this anesthetic method could be one of the safe and beneficial procedures for these cases.

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We measured the forced expiratory volume in 1 second (FEV _1.0), time constant (TC), respiratory resistance ^®, and total static lung compliance (C_st) in twenty two children in the supine and prone positions. under nitrous oxide-halothane anesthesia with muscle relaxant. There were no significant change in FEV_1.0, TC, and R, but a significant change in C_st, which was decreased in children older than two months, and increased in those under two months when turned to the prone from the supine position.
These results suggest that it is important to keep the abdominal compression free in a prone position, for older children under general anesthesia. An increase in C_st was noted, however, in young infants in the prone position.

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The present study was designed to investigate the effect of glucose infusion on concentrations of plasma glucose, free fatty acid (FFA) and ketone bodies, and to determine an appropriate concentration of intravenous glucose infusion during surgery lasting about 6hrs. Thirty-three children aged between 1.5 years and 9 years were studied. They were divided randomly into three groups according to concentrations of glucose infused as follows; A: lactated Ringer's solution (LRS) alone, B: LRS containing 2% glucone, and C: LRS containing 5% glucose. All fluids were infused at a rate of 6ml/kg•hr until 1hr after anaesthesia. In groups A and B, the plasma glucose concentration remained unchanged perioperatively compared with each of basal value. On the other hand, in group C, it increased markedly both during and after operation.
Furthermore, three of 11 Patients had severe hyperglycemia (more than 300mg/dl) during anaesthesia. There was no evidence of lipid mobilization because plasma FFA and ketone bodies levels were maintained within normal ranges throughout the sample period in the three groups. These data suggest that even in pediatric minor surgery, intravenous administration of glucose less than 0.12g/kg•hr is accepted not only to maintain blood glucose concentrations within normal ranges but also to prevent the compensatory increase in lipid mobilization.

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The respiratory effect of epidural morphine injection was assessed after minor gynecological surgery and was compared to that of intramuscular pentazocine injection. Patients received either morphine or pentazocine immediately after the emergence from anesthesia and the respiratory status of each subject was monitored for 6 hours there-after with the aid of respiratory inductive plethysmography (RIP). Although minute volume and PaCO₂ were not significantly changed on intermittent measurements, cotinuous monitoring by RIP revealed several transient episodes of hypopnea in the epidural morphine group. In the intramuscular pentazocine group, the inadequate pain relief seemed to cause respiratory stimulation. In addition, transient hypopnea was also seen in the latter group. These results suggest that possible risks of transient ventilatory disturbance may exist following epidural mophine. Thus, continuous monitoring tech-nique such at RIP would be useful for assessment of respiratory status in patients who receive epidural morphine.

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59 healthy adult patients undergoing elective surgery with halothane anesthesia were randomly allocated to eight groups (n≥6) and their electromyographic activity was monitored. Effects of vecuronium 0.1mg•kg^-1 given alone or at various time intervals following incomplete or complete recovery of muscle paralysis induced by succinyl-choline 1mg•kg^-1 were investigated. The onset time of vecuronium was significantly shorter and its duration to 25% recovery was significantly longer in previous succinyl-chonine administration groups than in non previous administration group. These phe-nomena persisted still 45min after full recovery from neuromuscular blockade by succinylcholine. Still there are many cotroversies on the occurrence of desensitization block following the administration of clinical dose of succinylcholine, and we could not confirm the mechanism of drug interaction between succinylcholine and vecuronium. Further studies should be done to clarify these phenomena.

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For the purpose of obtainning appropriate depth of anesthesia and preventing severe hypotension during the anesthesia with enflurane, we examined the four methods; I: adjustment of concentration of inspired enflurane, II: Postural change of the patients, III: an increase in volume of infusion, IV: continuous administration at low concentration of dopamine.
Through the method IV, the decrease in blood pressure was the least and the duration of the time of hypotension was the shortest.
Those indicate that continuous administration of low concentration of dopamine is useful during enflurane anesthesia.

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Three cases of bilateral niphrectomy of children with congenital nephrotic syndrome (CNS) is reported. These patients were 1 to 4 years old and showed marked hypo-proteinemia, malnutrition, and evident edema.
In comparison with bil. nephrectomy with chronic renal failure, there are some difficulties such that the patients were younger and smaller, and had severe hypopr-oteinemia and didn't have received any dialytic treatment. So careful management is required for these congenital nephrotic patients.
The anesthetic technique we had carried out consisted of balanced technique using nitrous oxide-oxygen-fentanyl-pancuronium and relatively smaller amount of intraoper-ative fluid administration (7 to 8mg/kg/hr in contrast to 10 to 12ml/kg/hr in patients with chronic renal failure).
The intra-and postoperative course was satisfactory, and we didn't experience compli-cations such as prolongation of effects of fentanyl, pancuronium, or hypovolemia.
So we concluded that these anesthetic management described above is suitable for bil. nephrectomy of CNS children.

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A sixty-eight years old man who had been performed the right extended maxil-lectomy, has suffered from an acute respiratory failure due to aspiration of blood and secretion. Chest computed tomography were taken three times during artificial ventila-tion and after weaning from respirator. Although the chest X-ray showed diffuse shadow in both lung field, computed tomography revealed high density area only independent lung. One week later, computed tomography showed improvement in the central part of lung, except high density area in peripheral dependent lung along the chest wall. Not only the improvement of the clinical signs but also of computed tomography induced to the weaning from artificial ventilation.

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We report a case of giant cystic hygroma of the neck with critical problems in the airway management.
Via prenatally performed ultrasonography, a upper airway obstruction caused by the huge cervical mass of the infant was predicted.
When delivered by cesarean section, the baby was apneic and had no respiratory effort. Since the ventilation with a face mask did not work out efficiently, endotracheal intubation was immediately performed. Thereafter, the tracheostomy was unsuccessful because the anatomical identification around the trachea was impossible.
One and half year after the delivery, the endotracheal tube was replaced. Then, we employed the ureteral sprint catheter as not only the guide for the endotracheal tube but also the HFJV injector to ensure the patient airway while changing the endotracheal tube. SpO₂ values were above 95% and no signs of expiratory disturbance were observed in the course of the procedure. The technique we performed in this case when changing the endotracheal tube seems to be useful for the patients with difficult airway manage-ment.
The devices we used are illustrated and the airway management in the cystic hygroma of the neck is discussed.

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Systemic mastocytosis is an uncommon disease chracterized by abnormal aggregation of mast cells observed in all parts of the body and unpredictable attacks probably induced by mast cell containing chemical mediators. A-52-years old male with this disease was scheduled for ureterolithotomy. The patient was premedicated with intramuscular promethazine and cimetidine 30 minutes prior to the induction of anesthe-sia. Anesthesia was induced by ketamine and endtracheal intubation was done facilitat-ed by vecuronium. Anesthesia was maintained safely with nitrous oxide-oxygen-enflurane using by continuous administration of cimetidine and chlorpheniramine. However, immediately after extubation, skin flushing, tachycardia and syncope occur-ed, and at the same time, upper airway obstruction due to laryngeal edema was also recognized resulting in emergency reintubation. Serum histamine levels were high perioperatively. Further studies on anesthetic management to prevent the attack are mandatory.

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Autonomic hyperreflexia (AH) is a serious complication during pregnancy, labor and delivery in the patient with spinal cord transection above T6. We present a quadriplegic patient whose AH was well controlled by epidural anesthesia during pregnancy and labor for 3 weeks.
The 33-years-old woman was admitted at 37 weeks' gestation. She became quadri-plegic by spinal cord injury at C3-5 level at the age of 16. Despite there were no signs of preterm labor, an epidural catheter was placed 5 days after the administration, as she usually experienced AH when abdomen or bladder was distended. Epidural anesthesia was done in every vaginal examination, which usually had caused moderate AH. The AH was not observed during the examination with epidural injection of 5 to 10ml of 1% lidocaine. Labor was started and proceeded rapidly without any previous sign at 40weeks, and the symptom of AH such as pounding headache, hypertension, marked diaphoresis with piloerection and flushing above the level of the cord lesion were worsened. However, immediately after the epidural administration of lidocaine and meperidine, the arterial blood pressure decreased from 160/80 to 110/62 and the symp-tom of AH were relieved. A baby was delivered spontaneously only in 46 minutes of the labor.
Our experience might show that the epidural catheter should be placed 2 to 3 weeks prior to predicted labor, because the labor in the patient with quadriplegia is difficult to predict and proceeds very rapidly.

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We reported successful perioprative management of tracheal reconstruction in a 8-month-old female infant with cogenital tracheal stenosis by systemic cooperative work of anesthetists and surgeons.
During the operation, ventilation was maintained via a small-diameter tube, 25cm in length, 2.5mm in outer diameter and specially designed for insertion through a normally intubated orotracheal tube of 4.0mm I.D.
Effective ventilation was secured via the tube inserted through an outer tracheal tube without interference of the surgical manipulation during reconstruction of the trachea.
Use of an artificial lung was not indicated because the PaO₂ level being maintained at around 400mm Hg (FIO₂=1.0) with maximum PaCO₂ of 121mm Hg along with stable circulatory hemodynamics.

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We reported pulmonary embolism induced by position change during general anesthe-sia.
A 21-years-old man was scheduled to undergo posterior lateral fixation of thoracic vertebra fractured by traffic accident. The patient's general status was stable before induction of anesthesia. Blood gas analysis after induction of anesthesia was normal and circulatory state was stable. Immediately after the patient was placed on prone position, SaO₂ decreased from 99% to 90%, although circulatory state was stable. Severe hypoxemia was continued and elective surgery was postponed. Pulmonary embolism being suspected, pulmonary angiography was done, but apparent obstructive finding was not obtained. Administration of high dose urokinase and heparin under artificial respira-tion superimposed with HFJV was effective to improve hypoxemia. When the patient's position is changed, we should pay attention to the occurrence of pulmonary embolism especially in the patient immobilized for a long term.

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A 51-years-old man was admitted with loss of consciousness. In the emergency room he regained consciousness. A computerized axial tomography (CT) of the head showed no abnormal shadow. Electrocardiogram (ECG) changes of the patient was suggestive of myocardial infarction and ventricular pacing was required due to complete atrio-ventricular block. However, a cardiac evaluation, including coronary angiography, echocardiogram, and cardiac isoenzyme determinations, showed no apparent evidence of acute transmural myocardial infarction. As he lost consciousness again, the second CT of the head, 6 hours after admission, revealed right subdural hematoma and right intracerebral (frontal lobular) hematoma. Because the cardiac evaluation denied myocardial infarction, he underwent general anesthesia with fentanyl and thiopental for the urgent operative treatment of his hematoma. Although his intraoperative and post operative courses were uneventful, various types of arrhythmias, including A-V block, premature ventricular cotractions, and atrial fibrillation, were observed.
When ECG abnormalities are present, it is necessary to differentiate neurogenic from cardiogenic ECG changes. In case of neurogenic ECG changes, left ventricular pump function might be preserved mostly. But recent studies demonstrated focal myocytolysis occurs with subarachnoid hemorrhage. Therefore, careful monitorings of arrhythmia and hemodynamic status are mandatory in this kind of case.

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