This study investigated the effect of alkalinization of mepivacaine on epidural anesthesia. Fifty-four patients scheduled for elective gynecologic laparotomy were randomly divided into two groups. Group A received 20 ml of a standard 2% mepivacaine solution (pH 6.101±0.016) and group B receuved 20 ml of a standard 2% mepivacaine with 2 ml sodium bicarbonate (pH 7.017±0.015) through the epidural catheter. The onset of sensory blockade was evaluated by pin-prick stimulation at the L1, T10 and S2 segments, and motor blockade was assessed by the grade of immobility of knee and ankle jounts. The spread of sensory blockade was measured at 5, 10, 15 and 30min after injection. The onset of sensory and motor blockade was significantly shortened for all tested modalities in group B. The spread of sensory blockade was also significantly wider in group B for all measurements than in group A. We concluded that the addition of sodium bicarbonate to mepivacaine solution improved the efficacy of epidural anesthesia.

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The effects of isosorbide dinitrate (ISDN) on the pressor response to laryngoscopy and endotracheal intubation were studied in 33 patients scheduled for elective surgery. The patients were pretreated with either ISDN 20μg/kg (n=8), 30μg/kg (n=9), or 40, μg/kg (n=8) iv immediately before thiopental 5mg/kg iv. The remaining 8 patients did not receive ISDN and served as a control group. The trachea was intubated 1 min after succinylcholine 1.5mg/kg iv. Compared with the control group, pretreatment with ISDN20μg/kg did not significantly attenuate the increase in systolic blood pressure (SBP) associated with laryngoscopy and endotracheal intubation. Pretreatment with either ISDN 30μg/kg or 40μg/kg significantly attenuated pressor response to intuba-tion, whereas ISDN 40μg/kg also significantly decreased SBP before intubation (after anesthetic induction). These results suggest that, if ISDN is administered immediately before thiopental in order to minimize pressor response to laryngoscopy and endotra-cheal intubation, the dose of 30μg/kg may be recommended.

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An atrioventricular pacing thermodilution pulmonary artery catheter with atrial pacing capabilities utilizing a transluminal atrial bipolar pacing probe was tested in 24 patients undergiong coronary artery bypass graft surgery.
Satisfactory atrial pacing was achieved in all patients at the thresholds 5.1+1.3mA(mean±SD).It was very difficult to acquire atrial pacing in 2 patients.
In 11 patients whose heart rate decreased to under 60 beats/min after induction, cardiac output was recorded at the correct and the atrial pacing.
The stroke volume index was lower at the atrial pacing than the selfbeats. This change could be attributed to the reduction of the end diasystolic time. Cardiac output, on the other hand, was higher at the atrial pacing than the selfbeats. No major complications could be found. Minor complications included diaphragmatic stimulation in 5 patients after operation.
It is concluded that this catheter is a reliable and clinically useful device for patients who have intact AV conduction but require artificial pacing.

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Banked blood, which is known to contain various substances derived from granulocytes which may affect recipients, has recently been reported to contain high concentration of granulocyte elastase and α₁-antitrypsin complex (E-α₁AT).Granulocyte elastase is known to be a causative factor of organ damage, such as in disseminated intravascular coagulation, respiratory distress syndrome, and multiple organ failure. We investigated the effect of transfusion of banked blood on perioperative changes in plasma E-α₁AT concentrations in ₁4 childern undergoing surgery, of whom 7 received banked blood transfusion (Group A), and 7 received crystalloid infusion (Group B). Blood samples were drawn periodically for measurement of plasma concen-trations of E-α₁AT, α₁-antitrypsin, white blood cell counts, and PaO₂. E-α₁AT concen-trations in banked blood increased with length of storage. In Group A, plasma E-α₁ AT concentration increased and remained elevated postoperatively, while the concentration was unchanged in Group B. Although increased plasma E-α₁AT concentration during stressful operation has been reported, there was no difference in plasma cortisol concentration between the two groups, indicating that both groups were subjected to similar surgical stress. In Group A, the elastase index was significantly higher than in Group B at all post-transfusion measurements, although there was no significant difference between the groups in white blood cell counts during the study. No significant difference between the two groups in oxygen index (PaO₂/FiO₂) was observed perioperatively. The mechanism by which plasma E-α₁AT concentration increased in the transfusion group as well as the clinical implications of it remain to be elucidated.

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We examined the incidence of pulmonary gas embolism in 12 consecutive patients undergoing urological laparoscopic surgery by perfusion lung scintigraphy with ^99mTc-macroaggregated albumin (MAA). Pulmonary gas embolism was detected in 7 patients without clinical symptoms in the postoperative period. Insufflatory times of patients with gas embolism (n=7) were over 250 minutes. End-tidal carbon dioxide pressure of patients with gas emboilsm was significantly greater than that of patients without gas embolism (n=5) in the post-insufflatory period, although arterial carbon dioxide pressure was not significantly increased. After laparoscopic surgery, we concluded that 1) pulmonary gas embolism lasts at least for a few days; 2) longer insufflatory time may increase the risk of pulmonary gas embolism; and 3) capnograph is a very useful monitor to detect pulmonary gas embolism.

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In 3 patients who fell into anaphylactic shock during general anesthesia, we noticed that hematocrit changes related closely to volume of plasma loss. The hematocrit value declined from 26.7±5.0% (mean±SD) before shock to 40.0±7.0% after anaphylactic episode. The alteration of hematocrit value indicated 1.4±0.1L of plasma depletion. Although there are some technical problems, the hematocrit value may give information important in judging the severity of anaphylactic shock and therapeutic efficacy.

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Right ventricular ejection fraction (RVEF) measured by a thermodilution catheter equipped with a fast-response thermister has been shown to be useful in hemodynamic assessment of patients with cardiac dysfunction. We evaluated RVEF in addition to other hemodynamic indices of a patient during resection of pheochromocytoma. Plasma catecholamine levels were elevated during extensive manipulation of the pheo-chromocytoma. Arterial blood pressure, cardiac index and right ventricular end-dias-tolic volume were increased in association with the elevation of plasma catecholamine levels while, in contrast, RVEF remained unchanged. RVEF in patients with normal cardiac function appears to be kept constant during a striking change of plasma catecholamine levels.

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Prevention of air embolisms is important when performing neurosurgery in the sitting position.
The authors have previously reported the beneficial effects of using a small pneumatic blood pressure cuff for jugular vein compression, and the continuous monitoring of the pressure proximal to the superior bulbus of the internal jugular vein (I. J. V. P.).
The patient's neck was compressed until the I. J. V. P. became slightly positive. In this case we continuosly monitored the patient's oxygen saturation (SjvO₂) at the I. J. V. site by using a fiberoptic intravascular catheter (OPTICATH^®).
The SjvO₂ was maintained at over sixty percent, which has been reported as being an acceptable level for this type of neurological surgery.
Continuous measurement of the SjvO₂ was shown to be a useful method for safe neck compression.

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We experienced anesthetic management of a patient who underwent simultaneous Caesarean section and removal of intracranial arteriovenous malformation (AVM). The patient, 35 years old and 31 weeks pregnant, suffered from a sudden onset of convulsion, headache, vomiting and disturbance of consciousness. She was referred to the critical care center, and intracranial hemorrhage due to ruptured AVM was diagnosed by computed tomography and cerebral angiography. She subsequently under-went emergency Caesarean section followed by removal of AVM, because the maternal circulatory state was unstable and the fetus seemed to be capable of surviving. The postoperative course was uneventful.
In terms of preoperative and anesthetic management in such a case, it is very important to determine the timing of operations and to select drugs correctly.
From this case, we recognized that anesthesiologists play a pibvotal role not only in perioperative care but also in inter-department management.

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Coronary artery spasm during anesthesia is accompanied by serious ventricular arrhythmias which can develop into ventricular fibrillation. The prevention and treat-ment of coronary artery spasm during anesthesia are important aspects of anesthetic management. We herein report a retrospective investigation of the background factors and treatment of coronary artery spasm during anesthesia.
Factors of intraoperative coronary artery spasm in seven patients (0.06% of 10, 665 patients who underwent anesthesia at our institution between October, 1986 and Septem-ber, 1991) were studied. All patients had been diagnosed as having hypertension and were taking antihypertensive agents. Preoperative electr o-cardiograms were abnor-mal, with four patients showing some change in ST segment and one positive finding on the Master's test. Enchocardiography revealed no remarkable findings in any patient.
In four patients, ventricular arrhythmias immediately progressed to ventricular fibrillation, and electrical defibrillation followed by external cardiac massage was performed. Severe bradycardia occurred in one patient and was treated by external cardiac massage. Ventricular tachycardia was noted on the electrocardiogram in two patients who were treated with nitroglycerin and lidocaine.
Two patients who underwent coronary arteriography after surgery demonstrated spastic lesions in the left and right coronary arteries and were diagnosed with typical variant angina.
We noted coronary artery spasm during anesthesia in seven patients, five of whom underwent external cardiac massage. All patients recovered without damage to the central nervous system or other systems.

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Perioperative changes of renal function were studied for three weeks in patients who were administered induced hypotension anesthesia with prostaglandin E₁. A hypotensive group with trimetaphan and a normotensive group were also studied for comparison. Urine β₂ micro-globulin (BMG) concentration increased just after the operation in all three groups, which might show deterioration of the function of reabsorption in the proximal tubules. The urine BMG was normalized in two weeks in most patients in the three groups. The changes in serum BMG and intrinsic creatinine clearance were mostly within the normal range in the three groups. Untoward effects of general anesthesia and induced hypotension to the glomerulus and metabolic function of the proximal tubules were not detected in the present study. Since the difference between the PGE₁ group and trimetaphan group was not statistically significant, the safety of these two drugs was quite similar in regard to renal function.

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We studied the incidence of femoral nerve paralysis following combined general and epidural anesthesia in 343 patients who underwent gynecological operation in the lithotomy position. Femoral nerve paralysis was found in 11 cases (3%). It occurred in 8 cases (5%) when the inguinal ligaments were hyperextended in the flat lithotomy position, and the incidence was significantly (p<0.05) reduced to 3 cases (2%) when the position was corrected.
We have concluded that avoiding hyperextension of the inguinal ligaments is important to reduce the incidence of femoral nerve paralysis after gynecological operation in the lithotomy position.

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Meny drugs that suppress platelet aggregation have come to be used for antithrombosis therapy on cerebrovascular disease and peripheral angiopathy. In the case of operations for patients medicated with such drugs, no one has reported about preoperative management. We therefore studied the antiplatelet effect of a new plateletsuppressant, cilostazol on 7 healthy volunteers and 12 patients after open heart surgery. Suppression of platelet aggregation was seen in 5 of 7 healthy men and recovered 2 days after discontinuation of the medication. In patients after open heart surgery, the serum concentration of cilostazol decreased to below the effective level in 6-12 hours. These results suggest that administration of cilostazol should be stopped 2 days before operation to ensure safety.

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Tuberous sclerosis is a neuroectodermal disease marked by a classic triad of adenoma sebaceum, epilepsy, and mental retardation. This disease poses serious problems during anesthesia, but there has been little discussion of it in the literature. We used an intraoperative electroencephalogram monitor during anesthesia in a patient with epilepsy due to tuberous sclerosis.
A 5-year-old boy with tuberous sclerosis was scheduled for ophthalmologic and plastic surgery under general anesthesia. He had epilepsy, mental retardation, adenoma sebaceum and paroxysmal supraventricular tachycardia. In spite of anti-convulsant therapy, he was subject to some attacks of epilepsy everyday. To avoid the epileptic drug action of euflurane, anesthesia was induced and maintained not by enflurane but by oxygen-nitrous oxide-isoflurane. His electroencephalogram was taken with a Life ScanTM (NeurometricsTM) prior to anesthetic induction. He did not show any abnormal signs in the central nervous system and the surgery was performed without any complications. Isoflurane may be an appropriate anesthetic for patients with epilepsy.

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During the perioperative period after extirpation of a pheochromocytoma, marked hypotension occurs due to the sudden decrease in the blood catecholamine level. In this condition, for the purpose of examining whether the desensitization of the adrenoceptor caused by maintenance of high catecholamine concentration in the blood is concerned or not, the polymorphounclear leukocyte β-adrenoceptor density (referred to as β-adrenoceptor) and the blood catecholamine level were examined before surgery, immediately before extirpation of the tumor, after tumor extirpation, and on the 7th day after surgery.
After extirpation of the pheochromocytoma the number of β-adrenoceptors in the polymorphonuclear lymphocytes increased with the improvement of the circulatory dynamics noted during the perioperative period, despite decreasing blood catecholaminelevel.
In our two cases, it has been suggested that polymorphonuclear leukocyte β-adrenoceptor density could be concerned in hypotension after tumor extraction.

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