we studied the efficacy and safety of diltiazem for the treatment of intraoperative hypertension in 21 patients. Patients in L-group (n=7) selected randomly were administered diltiazem as a bolus of 10mg intravenously followed by drip infusion of 2.5μg•kg^-1•min^-1. In M-group, other patients (n=7) were administered a bolus of 10mg followed by 5μg•kg^-1•min^-1 in the same fashion as the L-group. In H-group, the remainder (n=7) were administered a bolus of 10mg followed by 10μg•kg^-1•min^-1. After the administration of diltiazem, the mAP decreased significantly in all groups, but no significant differences between the three groups were observed. The HR decreased significantly in the M-group and the H-group. The HR remained unchanged in the L-group, however. Plasma diltiazem levels decreased progressively in the L-group, but was maintained mostly at 200ng•ml^-1 in the M-group in the period between 15 minutes after the administration and the end of operation. However, the plasma diltiazem level increased following the drip infusion and was up to 368ng•ml^-1 at the end of operation in the H-group. Arrhythmia appeared in 3/7 patients in the H-group (one was I° A-V block and others were junctional rhythms), occurring when the plasma diltiazem levels increased above 400ng•ml^-1. However, arrhythmia recovered spontaneously or by administration of atropine sulfate. No specific change on ECG was observed in the other groups.
We concluded that 10mg bolus administration of diltiazem followed by drip infusion of 5μg•kg^-1•min^-1 should be useful for the treatment of intraoperative hypertension.

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To study whether the heart rate variation in atrial fibrillation is chaos or not, R-R intervals in three patients with atrial fibrillation were analyzed by computing fractal dimensions, the largest Lyapunov exponent and power spectrums. The analysis was performed before and after anesthesia with high dose of fentanyl. In all patients, the fractal dimensions did not saturate, and the largest Lyapunov exponent approached zero. Spectral analysis revealed that variation of R-R intervals in the patients is similar to white noise. These findings were unaffected by fentanyl anesthesia. These results suggest that heart rate variations in atrial fibrillation are not chaotic and that high-dose fentanyl anesthesia dose not influence the noise-like property of the variations.

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We designed a new type of respiratory circuit, the "inverted T piece." The usefulness of this device was evaluated with a model lung and on nine patients who were undergo-ing respiratory care in ICU. Using the "inverted T piece, " the concentration of O₂ and N₂O in the model lung was analyzed by respiratory gas monitor (5250 RGM, Ohmeda), and was compared with that of the T piece. It was also clinically evaluaed by comparing blood gases (PaO₂ and PaCO₂) with the "inverted T piece" to those with T piece.
In the experiment with a model lung, the concentration of O₂ with the "inverted T piece" was higher than with the T piece, and the concentration of N₂O was lower. Clinically, the respiratory conditions of all six unconscious patients were unchanged, although PaO₂ increased and PaCO₂ decreased when the T piece was changed to the "inverted T piece." In two patients who underwent long-term artificial respiration, respiratory muscle fatigue was reduced with improvement of blood gases.
We concluded that the "inverted T piece" had both an increasing effect on PaO₂ and a decreasing effect on PaCO₂ under fixed respiratory conditions, and that it might become a useful new method for decreasing PaCO₂ without using a respirator and for aiding weaning patients from ventilators.

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Two methods of post-operative pain management were compared retrospectively.The present method consists of continuous infusion of a mixture of local anesthetics and morphine through an epidural catheter with Drug InfusionBallooncatheter (DIB) for 48hrs post-operatively (DIB group, n=124). Contents of the mixture were 10mg morphine in 40ml of 0.125% bupivacaine. The DIB group had been administered a single dose of morphine (1.5'-2.5mg) with saline into epidural space during surgery, the same as the control group (n=25). After operatoin was completed, the control group received local anesthetics or buprenorphine solution through an epidural catheter or NSAIDs intermittently on demand. In order to assess the efficacy of post-operative pain relief, a scoring system of four grades was introduced. 53% of patients in the DIB group needed no additional analgesics for 48hrs post-operatively, while all control group patients needed additional analgesics. DIB group was much superior in analgesia to the control group (p<0.0001). As for the subjecive index of pain relief, 72% of patients in the DIB group were satisfied with the method. Though complications such as nausea, itching and CO₂ retention appeared in 19%, 15% and 6.5% of patients, respectively, in the DIB group, no patient needed mechanical ventilation.

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Cardiovascular effects following postural change by Grassi's backboard were studied in ten adult patients who underwent upper abdominal surgery. After induction of general anesthesia in combination with epidural anesthesia, the posture of patients was changed from flat supine to supine with the thorax elevated and extended. Mean arterial pressure, cardiac index, stroke volume index and pulmonary artery wedge pressure measured five minutes after the change in postere decreased significantly compared with values measured before the change in position (p<0.05), whereas heart rate and systemic vascular resistance showed no significant change. We concluded that the postural change from flat supine to supine with thoracic extension by Grassi's backboard caused remarkable hypotension due to a decrease in venous return and consequent decrease in cardiac output. Adequate fluid administration and avoidance of abrupt postural change are necessary to manage severe hypotension following postural change.

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We investigated factors leading to fall in body temperature during surgery in five extensively burned patients (burn index>30), prospectively. The difference in the temperatures at the beginning and the end of the operation was regarded as the "temperature gradient". There was no significant correlation between the temperature gradient and burn index, duration of anesthesia or operation, amount of blood loss or transfusion, or operating area. The temperature gradient of the GOI (nitrous oxide+oxygen+isoflurane) group (-1.48±0.58(mean±SD)°C, n=10) was significantly lower than that of the GO+KM (GO+ketamine+midazolam) group (-0.80±0.30°C, n=16) (P<0.01). The temperature gradient of the group in prone position (-1.91±0.31°C, n=14) was significantly lower than that of the group in supine position (-0.08±0.34°, n=12) (P=0.001). For the intraoperative management of body temperature in exten-sively burned patients, we recommend Ketamine rather than inhalational anesthetics, and that the duration of skin sterilization, especially in patients in prone position, be shortened.

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The effects of PGE₁ on GOT and GPT in 43 patients who underwent hip joint surgery were studied. The patients were anesthetized with spinal anesthesia using tetracaine and lidocaine. PGE₁ was infused in 25 patients at the mean rate of 33 ng/kg/min (PGE₁ group) during operation to maintain systolic blood pressure below 90mmHg. In 18 patients, systolic blood pressure was maintained below 90 mmHg by spinal anesthesia alone (control group). During the 3 postoperative days, GOT and GPT was unchanged in the PGE₁ group and increased significantly in the control group. These results suggest that the low dose administration of PGE₁ was effective in preventing postoperative liver damage due to hypotensive spinal anesthesia for hip joint surgery, and that prolonged hypotension may play an important role in increasing GOT and GPT postoperatively.

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A 28-year-old woman in the 34th week of pregnancy, who had dyspnea as a mild symptom of right heart f ailuer, was admitted for delivery. She had no gestosis but suffered from congenital right pulmonary arterial defect. Cesarean section delivery was performed under spinal anesthesia with monitoring of pulmonary arterial pressure, because suddenly increased venous return after delivery might have caused exaggeration of right heart failure. Pulmonary arterial pressure decreased by spinal anesthesia and increased immeddiately after delivery. However, maximum pulmonary arterial pressure after delivery did not exceed the prespinal anesthesia value. We consider that reduction of preload for the right heart in spinal anesthesia prevented elevation of pulmonary arterial pressure after delivery.

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Patient-controlled analgesia is a relatively new and effective technique for patients with postoperative pain and intractable pain associated with terminal illness. However, few patients have enjoyed pain relief by this technique because of its expense. We therefore devised a new PCA system in order to provide many patients with a simple and easy method.
A DIB catheter consisting of a silicon balloon reservoir, flow control part and epidural catheter are attached to a microfilter and then conected with three-way cocks. Epidural administration of the drug (bupivacaine and buprenorfine) was done by the use of three way cocks by setting two inlets for infusion.
Thirty patients with severe pain from Herpes Zoster were subjected to this study to evaluate the PCA system after fundamental studies on issues such as changes in balloon pressure as powersource.
VAS was utilized to judge the effectiveness of this system. A clinical study proved that this new PCA system is very effective in lefting patients control their own severe pain with ease.

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During the past 2 years, we have experienced 14 cases of postoperative neurological paralysis of lower extremities.
All cases recieved lower laparotomy in the lithotomy position. Paralysis of 9 cases recovered within a week (3 cases had undergone simple abdominal hysterectomy under spinal anesthesia, and 6 cases had undergone amputation of the rectum or resection of the sigmoid colon under general anesthesia combined with epidural anesthesia).
Paralysis of 5 cases was severe, and lasted from one to two-and-a-half months. These 5 cases had undergone amputation of the rectum (1 case) or resection of the sigmoid colon (4 cases) under general anesthesia combined with epidural anesthesia.
Neurological nerve injuries after opration are considered to be associated with spinal or epidural anesthesia, and unphysiological position of the patient during the surgery. In these cases, however, it was found to be caused by continuous compression of the femoral nerves by the abdominal retractor.
To avoid postoperative nerve injuries, it is important to pay attention to the abdomi-nal retractor, positioning and surgical procedure as well as regional block.

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Congenital α₂-plasmin inhibitor (α₂-PI) deficiency is a very rare hereditory malady and its pathophysiological findings resemble those of hemophilia. We experienced the anesthetic management of a patient (15-year-old female) who has been suffering from this congenital disease.
She was scheduled for removal of a intramedullary hematoma in the left femur. Intramuscular drug injection as pre-anesthetic medication was not given in order to avoid hemorrhage. Anesthesia was induced with thiopental 250mg and atropin sulfate 0.5mg intravenously. After adequate muscle relaxation was obtained with vecuronium bromide, trachea was intubated and maintained with nitrous-oxide, oxygen and enflurane inhalation. As preliminary examination before the surgery an antifibrinolytic agent, tranexamic acid (20 mg/kg/day), was given we confirmed that the hemolytic parameters (euglobulin lysis time, total anti-fibrinolytic activity using fibrin clot lysis time with urokinase, fibrinogen and fibrin degradation product (FDP)) were maintaied within normal ranges. We administered tranexamic acid at a dose of 10 mg/kg/hr during surgery and 5 mg/kg/hr after the surgery, and 40 mg/kg/day for 2 weeks intravenously. The above parameters were maintained within normal limits during and following 2 weeks after the operation and no adverse reaction was recognized. This is the first report in the world of anesthetic management for a patient with congenital α₂-PI deficiency.

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We observed a case of cable trauma from a motorcycle accident resulting in incom-plete transection of cervical trachea. The patient suffered cervical subcutaneous em-physema and right vocal cord paralysis. We suspected perforation of cervical trachea, and, anticipating a small perforation, we attempted tracheal intubation with a rapid technique. When the endotracheal tube was inserted while cricoid ring was pushed down, the tip of the tube was visible protruding from the trachea under the skin. Reintubation was easily accomplished when the cricoid was released. The right recurrent nerve was found to have been severed at the level of the cricoid. There was a large transection between the cricoid and first tracheal ring though the posterior tracheal membrane remained intact.
Few exterior signs of tracheal damage may be present even after a major transection of cervical trachea. Tracheostomy is a safer method of airway establishment than Intubation in these cases.

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We experienced an outbreak of food poisoning caused by vibrio parahaemolytics. On September 9, 1991, 15 patients were scheduled for elective surgery, but 9 of them had symptoms of watery diarrhea, abdominal pain and fever. General conditions were worse in elder patients because of dehydration. Except for one patient scheduled for lung carcinoma lobectomy, eight operations were canceled. The source of food poisoning was determined to be crab meat served for dinner on September 7. Vibrio parahaemolytics is a common organism that causes food poisoning in Japan. We must be careful of the cytotoxic effects of direct thermostable hemolysin produced by vibrio parahaemolytics. We recommend that when an outbreak is suspected in patients who are scheduled for surgery, the feces be examined for organisms immediately, and that the operation be delayed at least two days until the factors of food poisoning are determined.

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We report three cases of complications following the administration of flumazenil in order to antagonize the effect of midazolam used pre- or intra-operatively. <Case 1>: A 25-year-old woman showed hyperventilation syndrome after operation on her hand under axillary block and midazolam sedation. <Case 2>: A 66-year-old man with a history of tonic and clonic convulsions due to traffic accident showed tonic convulsion after an operation on his hand under general anesthesia. <Case 3>: A 11-year-old girl with Down's syndrome who had myoclonus epilepsy during infancy showed myoclonus epilepsy after an examination of her hip joints under general anesthesia. We recommend that flumazenil be administered after careful consideration of the patient's background. Flumazenil should be avoided with patients who have histories of convulsions or epilepsy.

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