Bupivacaine (Marcain ®) spinal anesthesia has been used for 10 years in Japan and is said to be highly suitable for orthopaedic and urological operations in the elderly, especially when compared to the spinal anesthesia with other local anesthetics. However, there is some argument against its use because the Marcain sold in Japan contains preservatives. Moreover, Marcain is not adapted for spinal anesthesia by the Ministry of Health and Welfare. Nevertheless, it is widely used especially in orthopaedic surgery.
We sent questionnaires to 1, 416 registered hospitals of The Japanese Orthopaedic Association and made inquiries about the use of bupivacaine for spinal anesthesia. We received answers from 870 hospitals (with a reply rate of 61.4%). In 85.7% of these hospitals orthopaedic surgeons anesthetize their patients, before performing surgical operations on their hips or lower extremities. In 41.4% of these hospitals, they use Marcain for spinal anesthesia. During the 6 month period between January and June of 1988, 39, 690 patients were anesthetized by orthopaedic surgeons (in those 870 hospitals). 27, 287 cases were for spinal anesthesia and Marcain spinal was used in 7, 321 cases. The most common side-effects were hypotension, but its degree was mild and controllable. No neurological side-effects were reported. Ninty point fire percent of the surgeons who used the Marcain spinal anesthesia replied that they need preservativefree bupivacaine for spinal anesthesia.

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We examined the change of blood gases during the surgical procedure in 60 patients who were undergone TUR-P under epidural or spinal anesthesia.
ΔPaO₂ were correlated negatively with operation time, volume irrigation fluid, excision gram, and correlated positively with ΔTP, ΔCosm, ΔNa. The safety limits of these operation were considered within 50min of time, 16L of used irrigating fluid, and 9g of excision. PaO₂ was dropped lowest at 1st day after operation, and rised at 3 rd day after operation gradually.
The cause of the PaO₂ dropping was attributed to the drop of colloid osmotic pressure by irrigating fluid absorbed from the surgical field. If the operation takes a long time, and the water leaks from pulmonary capillary vessels to interstitial tissues and alveoli, patients will get into the hydrostatic lung edema.
The facts suggest that TUR-P might be unexpectedly violated operation.

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During the past four and a half years, we have experienced 14 cases of patients with postoperative separation of the wound and sternum following median sternotomy.
We compared these cases with ones without such a complication and examined the factors of onset and prevention.
The results indicated that the most important risk factor for the onset of this complication was diabetes mellitus.
For intraoperative anesthetic management, strict respiratory and circulatory management was considered necessary because there were a number of cases with hypotension and hypoxia during reoperation. This occurred during a period of unstable hemodynamics following open heart surgery.
From the viewpoint of ICU management, strict nutritive management, long-term pneumatic stabilization via a respirator for the rest of the wound and sternum was considered necessary.

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Six patients with ischemic heart disease were studied to determine plasma levels of isosorbide dinitrate (ISDN) and its metabolites, isosorbide-2-mononitrate (2-ISMN) and isosorbide-5-mononitrate (5-ISMN), using gas chromatography. These patients ranging in age from 43 to 80 years were administered intravenous isosorbide dinitrate at a rate of 1μg/kg/min during anesthesia and surgery. Surgery included gastrectomy, radical mastectomy and removal of lip tumor under either enflurane anesthesia or original neuroleptanesthesia.
Plasma ISDN levels increased to 13.5±1.2 (mean±SE)ng/ml 30 min after the start of intravenous infusion of ISDN, and reached a plateau with the value of 28.1±5.2ng/ml 3hrs after the start of the infusion.
Plasma 2-ISMN and 5-ISMN levels increased gradually up to 18.3±2.3ng/ml and 63.3±8.1ng/ml 4hrs after the start of intravenous infusion of ISDN, respectively. Plasma ISDN levels increased above the minimum effective plasma concentration (MEC) during intravenous infusion of ISDN. However, plasma 5-ISMN levels were below the MEC during the procedure. Pharmacological effect of intravenous ISDN was thought to depend on plasma concentration of ISDN.

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To determine whether the prior administration of a sub-paralyzing dose of vecuronium would make a short of the onset time of vecuronium with an intubating dose, 50 anesthetized patients were assigned to receive divided doses of 0.15mg/kg vecuronium. In group A (n=12), priming dose 0.02mg/kg was administered followed by intubating dose 0.13mg/kg. In group B (n=18), priming dose 0.01mg/kg was administered foll-owed by intubating dose 0.14mg/kg. In group C (n=20), only single bolus intubating dose 0.15mg/kg was administered. The indirectly evoked integrated compound action potential (EMG) of hypothenar muscles to supramaximal stimulation of ulnar nerve was measured and recorded by Relaxograph (Datex). After the administration of 2mg/kg thiamylal, control responses were obtained. At three minutes after priming dose, additional dose of thiamylal and intubating dose of vecuronium were administered.
Onset times were as follows : 118±26sec in group A, 140±36sec in group B, and 183±70sec in group C respectively. Intubation scores were demonstrated to be excellent or good, but diaphragmatic movements were observed in 14.3%.
In conclusion, priming principle technique at 3 minutes interval, hastens the onset time of vecuronium with intubating dose.

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We examined the effect of a bacterial filter on the flow rate of a disposable balloon infuser in use for epidural analgesia. Forty female patients scheduled for gynecological operation were randomly divided into two groups : group F received continuous epidural morphine infusion with the filter, and group C received similar maneuver without the filter. The mean flow rate of balloon infusers was calculated from the lost weight of equipment during the observation period. The mean flow rate in group F was 0.43±0.10 ml•hr-1 that was significantly less than in group C (0.52±0.11ml•hr-1). These data indicate that the resistance of bacterial filter incorporated into the structure is likely to reduce the flow rate of balloon infuser.

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Maintenance of peripheral circulation and body temperature is one of the primary objectives during general anesthesia. We evaluated the effect of low-dose (0.02mcg/kg/min) continuous intravenous infusion of prostaglandin E₁ on the intraoperative changes of temperature measured at three sites. Seventeen adult patients without significant increased intracranial pressure who were scheduled for elective craniotomy were studied. Temperatures were monitored at urinary bladder, anterior neck and left index finger. Nine patients in the prostaglandin E₁ group received the continuous infusion of prostaglandin E₁ from anesthetic induction until the end of operation. Eight patients in the control group received the continuous infusion of normal saline instead of prostaglandin E₁. Anesthesia was induced with thiopental and maintained with oxygen, nitrous oxide and enflurane in both groups. Difference between central and peripheral temperature was significantly smaller in the prostaglandin E₁ group compared to the control group during the first 210 minutes from the start of operation. Incidence of postoperative shivering was not statistically different between two groups. It is concluded that low-dose infusion of prostaglandin E₁ is effective in order to maintain peripheral circulation and to keep the peripheral extremities warm during elective neurosurgical anesthesia.

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Plasma levels of α-atrial natriuretic peptide (α-hANP), renin activity, angiotensin II and aldosterone were studied in 3 groups of patients undergoing coronary-artery-bypass grafts (group1, n= 7), valve replacement (group2, n=5) and other cardiac surgery (group3, n=5). During partial cardiopulmonary bypass (partial CPB), plasma α-hANP levels significantly increased from 48.2±7.0 (mean±SE) pg/ml immediately after anesthetic induction (baseline) to 231.5±32.6pg/ml. An increase in α-hANP levels was associated with rewarming, return of sinus rhythm and tachycardia.
At the end of the operation, α-hANP levels decreased to 97.7±9.9pg/ml, but remained higher than the baseline. In the 3 groups, there was no difference in plasma α-hANP levels during the operation.
Plasma renin activity and plasma angiotensin II levels markedly increased during partial CPB, and were higher than their normal levels at the end of the operation. Plasma aldosterone levels did not increase during partial CPB, but elevated significantly at the end of the operation. In conclusion, cardiac surgery can cause an elevation in the plasma α-hANP levels and activation of renin-angiotensin-aldosterone system.

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To assess postoperative recovery of pulmonary function following upper abdominal surgery, we made a comparison between preoperative and 3-weeks postoperative pulmonary function. Twenty-seven ASA physical status 1 or 2 patients without pulmonary diseases scheduled for elective gastrectomy or cholecystectomy were divided into two groups according to the method of postoperative pain management ; 11 patients aged 61.8±11.2 years received intramuscular pentazocine and hydroxyzine ; 16 patients aged 56.4±10.1 years received intrermittent epidural bupurenorphine with normal saline. In both groups, FEV1.0% and RV/TLC significantly increased, and BSA, %VC, FVC, V50/V25 and %DLCO significantly decreased. However, simultaneously measured PaO₂ showed no significant reduction. There was no different in any measurements between the two groups.
It was concluded that in elderly patients postoperative pulmonary function following upper abdominal surgery does not recover completely even three weeks later, and thus the method of pain management probably makes no difference in the long term recovery of pulmonary function.

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Endocrine responses to laparotomy in patients under long-term massive steroid therapy (steroid treatment group) were compared with endocrine responses to a similar operation in patients without a history of steroid therapy (control group). Although mean blood pressure did not differ between the two groups, the incidence of tachycardia and hypoglycemia during operation tended to be higher in the steroid treatment group than in the control group. Plasma ACTH level showed a similar increase in both group, while the increase plasma cortisol level was smaller in the steroid treatment group. In cases where the response to the preoperative rapid ACTH test was low, excessive ACTH serration was noted during operation although cortisol secretion was not enhanced. These results endorse that the preoperative rapid ACTH test is indispensable because it is an excellent index of the reserve force of the adrenal cortex function in patients under long-term massive steroid therapy. If patients under long-term massive steroid therapy show a normal response to the rapid ACTH test preoperatively, steroid supplimentation is not necessary. However, considering the slow response of the adrenocortical system to surgical stress, these case require careful anesthesiological management.

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Transesophageal two-dimensional Doppler echocardiography (TEE) was used as an intraoperative monitor in 95 patients undergoing cardiac or noncardiac surgeries. Fourteen cases were regarded to have intraoperative events, nine were myocardial ischemias, two prosthetic valve malfunctions, and three miscellaneous events. The majority of the events (11), including all of nine ischemic events, occurred around the termination of cardiopulmonary bypass. As for the preceding findings of the ischemic events ; segmental wall motion abnormalities (SWMAs) with mitral regurgitation were noticed in coronary artery bypass grafting. However, microcavitation was revealed first and was followed by SWMAs in open heart surgery. The incidence of microcavitation was as high as 43% (16/37) in our open heart series, and six cases (16%) were suggested to have coronary air embolism because SWMAs occurred soon after the increment of microcavitation. It remains true that myocardial ischemia could be caused not only by pathophysiologic changes of coronary arteries, but also by coronary air embolism. Our observation suggests that the incidence of coronary air embolism is not rare. Thus, the importance of careful de-airing procedures should be recognized.
In summery, TEE provides the qualitative but useful informations, which is especially vital for actual diagnosis and rapid decision-making in case of intraoperative cardiovascular events.

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The spread and duration of analgesia, and systemic toxicity during epidural anesthesia with lidocaine or mepivacaine were compared in a double-blind manner. Two hundred patients undergoing extracorporeal shock wave lithotripsy (ESWL) were randomly selected to receive either plain 2% lidocaine (L) or plain 2% mepivacaine (M). The initial doses were 16.7±2.1ml for the L group and 17.2±2.2ml for the M group respectively. The time counted from the drug injection to the start of ESWL, upper limit of analgesia and duration of the procedure and analgesia were similar in both groups. The analgesic effect was evaluated by incidence of pain sensation and administration of analgesics during the ESWL. Among the patients whose upper limit of analgesia was above Th6, 13 patients of the L group and 15 patients of the M group complained of pain sensation, and 3 patients of the L group and 6 patients of the M group needed analgesics. Mild systemic toxicity such as drowsiness, numbness of tongue, lightheadedness and speach disturbance were observed in 8 patients in both groups, while serious complication such as convulsion did not occur.
It is concluded that there are no significant differences in analgesic spread, duration, quality and systemic toxicity with the same doses of lidocaine and mepivacaine injected epidurally and both drugs can be used equally safely,

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We report a case of central sleep apnea syndrome (CSAS) presenting a Cheyne-Stokes like respiration that was normalized following a cardiac surgery. A 58-year-old male patient with insomnia, 156cm in height, and 60kg in weight was diagnosed as having severe nocturnal bradycardia by means of a 24hour EKG recording. Polysomnography performed prior to surgery revealed CSAS as well as bradycardia with concomitant hypoxia. After mitral commissurotomy and aortic valvuloplasty, the examinations showed improvements of CSAS, bradycardia and concomitant hypoxic episode. It suggested that CSAS of the present case was cured by the surgical intervention to the cardiac pathology. After improvement of cardiac performance, the patient might regain the compensatory property for nocturnal circulatory depression associated with the sleep apnea and the concomitant hypoxia. As a consequence, the instability of the respiratory center might be prevented. The clinical implication of this report might be that pre-existing cardio-respiratory diseases could worsen cardio-respiratory depres-sion induced by sleep apnea and concomitant hypoxia, and vice versa.

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We administered general anesthesia for a 21-year-old patient with mitochondrial encephalomyopathy for lensectomy and intraocular lens implantation. The disease is characterized by progressive multiple-organ dysfunction due to compromized ATP production and conversion. This patient had complex IV (cytochrome c oxidase) deficiency, resulting in mental retardation, muscle weakness, scoliosis, poor development, cataracts, and spastic paralysis.
The patient was premedicated with diazepam, hydroxyzine, and scopolamine. Anesthesia was induced with thiamylal and vecuronium, and maintained with enflurane, nitrous oxide in oxygen. Severe metabolic acidosis and increases in lactic acid occurred in the perioperative period despite stable hemodynamics and good oxygenation. Metabolic acidosis was not treated because of stable hemodynamics and its nonprogressive nature. Postoperative course was uneventful. The patient had an emergency surgery for irial prolapse under general anesthesia on the next day. The patient again developed metabolic acidosis under enflurane-nitrous oxide-anesthesia without significant sequelae.

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We experienced 16 cases required insertion of a dialytic catheter because of combined with acute renal failure and/or acute aggravation of chronic renal failure.
Patients with renal failure use to have abnormalities in cardiovascular, waterelectrolytic, metabolic and coagulative systems, therefore we have to pay attention to cases of emergent operation.
In case of emergent operation, preoperative assessments are required. We have to take care to use anesthetics and muscle relaxants to avoid pulmonary edema due to cardiac failure or fluid overload.
In case of patients with impairment of consciousness preoperatively, it is probably necessary that patients should be cared with mechanical ventilation under intratracheal intubation and should be extubated after dialysis.

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The hemodynamic and respiratory effects of the intravenous sedative midazolam at different doses were studied in 61 patients undergoing simple hysterectomy under spinal anesthesia. Eighteen patients received midazolam at the dose of 0.05mg/kg, 23 received 0.1mg/kg, and 20 received 0.05mg/kg as well as 2.5mg droperidol as prophylaxis against the nausea which sometimes occurs during intraabdominal procedures.
Satisfactory sedation was provided by midazolam at either 0.1 or 0.05mg/kg with or without droperidol, and hemodynamic changes caused by midazolam were minimal and within acceptable limits. On the other hand, there was significant reduction in both tidal volume and arterial oxygen saturation monitored with pulse oximeter (SpO₂) at all dosages. Administration of 0.1mg/kg midazolam was associated with greater degree of upper airway obstruction and more marked reduction in SpO₂ than was that of 0.05mg/ kg. In droperidol-treated patients, nausea was noted less often but hypotension was observed more frequently than in patients given midazolam only.
It is concluded that midazolam at the dose of 0.05mg/kg provides adequate sedation and is suitable for sedation during spinal anesthesia. However, after administration of even a small dose of midazolam, marked reduction of SpO₂ may ensue.

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We performed an anesthesia for patient with hyperthermia undergoing splenectomy. Postoperative diagnosis was malignant histiocytosis. Preoperatively, the patient showed high fever, pancytopenia and splenomegaly. Although there is no established rule for the management of the patient with hyperthermia, we carried out surface cooling before induction of the anesthesia and used the Jackson-Rees circuit for heat reduction. Anesthesia was induced with droperidol and fentanyl (intravenously), followed by vecuronium for endotracheal intubation and maintained with nitrous oxide (Fio₂=0.33) and supplemental fentanyl. Neuromuscular function was monitored continuously. Anesthetic course was uneventful. However, the effect of vecuronium was decreased. It may be due to the changes of pharmacokinetics and pharmacodynamics of vecuronium in hyperthermic condition.

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Pulmonary alveolar microlithiasis (PAM) is a rare disease characterized by small calcific concretions in the alveoli. A 51-year-old woman, admitted for the surgical removal of a breast mass, who found to have fine mottling in both lung fields in the routine preope check up. She exhibited high RV/TLC (39%), %VC of 77%, slight obstructive and restrictive disorder. D_LCO was reduced slightly. Anesthesia was induced with fentanyl, droperidol, thiamylal and succynylcholine, and maintained with GOEPancuronium. Changes of airway pressure was watched closely, especially for overpressure due to bucking. Arterial Po₂ averaged 166.4mmHg and PCO₂ 29.1mmHg (FiO₂=0.4). Recovery from anesthesia was uneventful. No complication was observed during and after operation.

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We experienced a case of severe reexpansion pulmonary edema following rapid reexpansion of a collapsed lung due to spontaneous pneumothorax of 3 weeks duration. Following the reexpansion, the patient developed acute respiratory failure, shock and disseminated intravascular coagulopathy. Conventional mechanical ventilation couldn't improve PaO₂ and PaCO₂, because of increased dead space ventilation and increased pulmonary shunt flow. The etiology of shock was thought to be hypovolemia due to increased permeability of the capillaries of the reexpanded lung and to be the depression of the cardiac contractility due to hypoxia and acidosis. And the etiology of the edema seemed to be due to impairment of the basement membrane of the pulmonary capil-laries. Differential lung ventilation was applied. It rapidly improved PaO₂ and PaCO₂, then he recovered from the shock. Differential lung ventilation is very effective for reexpansion pulmonary edema which can't be treated by conventional mechanical ventilation.

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To evaluate a spread of nonionic radiographic contrast medium, forty-one patients who had a catheter inserted into epidural space for management of chronic pain were studied. After injection of 2ml Iopamidol through the epidural catheter, the spread of the contrast medium was examined radiographically. The mean segmental radiographic spread was 6.6×2.5 segments. In cases in which the spread of contrast medium was small, we could see the characteristic radiological findings of epidural space. On the other hand, we could see the characteristic findings both of subdural space and epidural space in cases in which the spread of contract medium was large. These radiographic findings showed a part of the contrast medium entered the subdural space and a part of contrast medium entered the epidural space. It is suggested that subdural injection is more likely to occur with the disposable touhy needles. When the contrast medium is injected, it might pass partically in the epidural space and in the subdural space. The subdural sitting of an epidural catheter probably occurs more frequently than was previously supposed.

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Anesthetic management for Removal of Carotid body tumor in four cases was reported. In two cases of four, carotid artery clamping had been scheduled preoperatively. However, carotid artery clamping was requiered in all cases to reduce blood loss during surgical procedure. Induced hypothermia was successfully applied in three cases, where any cerebral complication did not occur. In contrast, one case without induced hypothermia, in which carotid artery clamping was not scheduled, developed cerebral infarction. We recommend to actively protect the brain from ischemia with induced hypothermia during surgical removal of carotid body tumors, whether carotid artery clamping was scheduled or not.

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A retrospective survey on appropriateness of the use of blood products, colloid solution and crystalloid solution was carried out in 62 patients who were operated on in our hospital in 1990 and whose intraoperative blood loss exceeded over 2, 000ml. Homologous red blood cell transfusion was started when the blood loss was estimated 400ml. At this point the hemoglobin and hematocrit values were 9g/dl and 30%, respectively.
In 30% of all cases, red blood cell transfusion was started prior to colloid fluid infusion. Colloid fluid should be administrated prior to red blood cell transfusion. Whole blood was used in one fourth of the red blood cell transfusions. Because packed red blood cells contain the same amount of hemoglobin as whole blood, there was little need to transfuse whole blood, so packed red blood cells should be transfused instead of whole blood. Fresh-frozen plasma was administrated when the blood loss was estimated 1, 200ml. To keep the blood coagulation function, it is sufficient to start fresh-frozen plasma administration at 2, 000ml loss of blood. Blood should be transfused as appropriately as possible in patients with massive blood loss during operations.

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