To assess right ventricular function in 18 patients undergoing mitral valve replacement surgery, pulmonary artery blood flow (PABF) was measured by transesophageal echocar-diography (TEE) and right ventricular ejection fraction (RVEF) was measured using an RVEF volumetric catheter. The patients were divided into 2 groups: a PH(+) group (n=8) composed of patients with a mean pulmonary artery pressure (MPAP) higher than 30mmHg, and a PH(-) group (n=10) composed of patients with MPAP lower than 30mmHg. RVEF values, cardiac output and pulmonary arterial peak velocity (PV) at weaning from cardiopulmonary bypass were significantly higher than the values after tracheal intubation in the PH(+) group. In the PH(+) group, the ratio of PV after termination of tracheal intubation to PV after weaning from cardiopulmonary bypass correlated closely with that of the RVEF values. The ratio of acceleration time to ejection time of PABF was more than 0.3 and the reverse wave of PABF was seen in the PH(+) group. In contrast, no significant hemodynamic changes were seen in the PH(-) group. In conclusion, PV assessment by TEE provides a noninvasive method for obtaining useful information about rigth ventrcular function.

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We studied 421 surgical patients at Sendai Red Cross Hospital who were anesthetized with spinal anesthesia. The incidence of Post-Spinal Headache (PSH) in 212 patients using a 25-gauge Quincke needle and in a further 209 patients with a 24, 26-gauge double-stage needle was investigated. There was no significant difference between the two groups with regard to the incidence of PSH, which occurred in 5.3% of patients with a 26-gauge needle compared to 8.5% with a 25-gauge needle.
In female patients less than 40 years old, the incidence of PSH with a 26-gauge needle was significantly less frequent (p<0.05) than with a 25-gauge needle.

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Recently extended radical operations involve patients in serious stressful situations and induce a metabolic derangement during the post-operative period, resulting in a high incidence of surgical complications and poor porgnosis.
In this study, to clarify the post-operative metabolic disturbance, fat and carbohydrate metabolism in patients who received severe surgical stress were examined using the methods of indirect calorimetry and the analyses of urinary nitrogen and glucose excretion.
Fourteen patients with radical esophageal operation were observed for four days following surgery. Energy expenditure increased to 144-152% of basal energy expenditure (BEE) through the 1st to 4th post-operative day (POD).
The rate of fat oxidation was up to 55 and 46% of total enegy expenditure on the 1st and 2nd POD, respectively, while the rate of carbohydrate oxidation was only 30 and 36%, respectively.
Under stressful situations such as the early phase of the post-operative period, a significant increase in fat metabolism and depressed carbohydrate metabolism were found despite an adequate supply of carbohydrate.
We concluded that fat was an important energy source in the early phase of the postoperative period in the patients who received radical esophageal surgery in this study.

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We compared two methods of fiberoptic tracheal intubation through the laryngeal mask airway (LMA), the tube method and the guide method, in 50 adult patients.
In the case of the tube method, first, the endotracheal tube (6.5mm ID cuffed tube, ETT) was advanced into the # 3 or # 4 LMA shaft until the tip of the ETT protruded from the LMA grill (ETT/LMA) . After induction of anesthesia and paralysis, the ETT/LMA was inserted and the LMA cuff was inflated. A fiberscope was inserted through the ETT and advanced into the trachea. The ETT passed over the fiberscope into the trachea. The fiberscope was then withdrawn, and the LMA cuff was deflated (n=28).
In the case of the guide method, the LMA was inserted and a fiberscope with the proximal end jacketed with a handmade flexible guide tube was inserted into the trachea. The guide tube was passed over the fiberscope into the trachea, and the fiberscope was withdrawn. A gum-elastic bougie (GEB) was then inserted into the trachea through the guide tube. After this, the guide tube and the LMA were withdrawn leaving the GEB in place. Lastly, an appropriate-sized ETT was passed over the GEB (n=22).
The success rate was 79% with the tube method and 77% with the guide method (NS). The times required for intubation were 236±106sec (mean±SD) and 463±219sec, respectively (P<0.001).
Although the tube method procedure is simpler, the ETT does not always pass over the fiberscope, the 6.5mm ID ETT is sometimes insufficient for ventilation, and the LMA always remains in the larynx. With the guide method, the ETT size is appropriate for the patient and the LMA does not remain in the larynx, but this method is rather time-consuming and complicated.

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The purpose of this study was to investigate the sedative effect of oral midazolam in preschool children. Forty-four preschool children (1-6 yrs) undergoing elective pediatric surgery were randomized into one of two groups to receive oral midazolam IV solution (Group M: 0.2mg•kg^-1 BW) or saline (Group P: same volume as midazolam solution for body weight). These solutions were pre-mixed with syrup (0.1ml•kg^-1 BW) containing 0.1mg•ml^-1 atropine sulfate. Group M showed a significantly greater sedative effect than Group P on arrival at the operating room and during induction of anesthesia. The sedative effect for agitated children was no worse than that for non-agitated children. We conclude that oral midazolam (0.2mg•kg^-1 BW) may provide a clinical advantage as a preanesthetic medication in children.

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To compare accelography with electromyography (EMG) as a method of evaluating neuromuscular blockade on the hand and the foot, train-of-four (TOF) stimuli were simultaneously applied to the right ulnar nerve and bilateral tibial nerves. Two accelographs were applied to the right ulnar and the left tibial nerves. EMG was applied to the right tibial nerve. Twenty adult patients, aged 21 to 65 years, were studied. Anesthesia was induced with an intravenous injection of thiopental, and vecuronium 0.1mg•kg^-1 was used for muscle relaxation. Anesthesia was maintained with nitrous oxide (66%)-oxygen and sevoflurane (1MAC). Times from initial administration of vecuronium to completion of maximal block were 136.5±25.7sec (the hand, accelograph), 180.8±32.5sec (the foot, accelograph) and 149.5±22.6sec (the foot, EMG), respectively. The maximal block of the foot (accelograph) was significantly longer than those of the hand (accelograph) and the foot (EMG). The times from maximal block to 25% recovery were 46.9±14.2min (the hand, accelograph), 36.1±8.9min (the foot, accelograph) and 47.4±8.9min (the foot, EMG), respectively. The result for the foot (accelograph) was significantly shorter than results for the hand (accelograph) and the foot (EMG). When the block was reversed at 25% of TOF ratio on the foot (accelograph), the TOF ratio on the hand (accelograph) and the foot (EMG) were 13.0±7.1% (P<.05) and 6.5±5.5% (P<0.01), respectively. We concluded from this study that accelography is more useful for assessing the degree of neuromuscular blockade than EMG and other methods after the administration of muscle relaxant. Head lifting, protruding of the tongue and sustaining a hand grip are also important in clinically evaluating the degree of blockade.

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We experienced anesthetic management of the removal of a hematoma due to AVM (cerebral arterio-venous malformation) rupture and Caesarean Section. The 28-year-old female patient, who was in the 32nd week of pregnancy, suffered from sudden onset of headache, vomiting, disturbance of consciousness and convulsion. Right cerebral hemorrhage due to ruptured AVM was diagnosed by computed tomography and cerebral angiography. The removal of the hematoma was performed promptly because it is necessary for correction of intracranial hypertension. Caesarean Section was performed under general anesthesia right after removal of the hematoma because of the threat of premature delivery after the neurosurgical operation.

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A 27-year-old female with total atelectasis of the left lung due to carcinoma of the left main bronchus and carina was scheduled for resection and reconstruction of the tracheal carina.
Anesthesia was administered using thoracic epidural local anesthetics and a nitrous oxide oxygen mixture supplemented with a low concentration of sevoflurane and a small dose of fentanyl. At the beginning of the operation, only the right lung was ventilated, but when the bilateral main bronchi were severed from the trachea and the resection of the carinal region began, manual ventilation of both lungs were accomplished using long endotracheal tubes inserted into the main bronchus of both sides. However, left lung ventilation was difficult due to copious secretions, and PaO₂ and PaCO₂ gradually worsened. Changing ventilation from IPPV to HFJV and frequent aspiration of the secretion improved PaO₂ and PaCO₂ to a nearly-normal level.

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During the last decade, there has been tremendous interest in antiphospholipid antibody syndrome (APS). We experienced the anesthetic management of a patient (61-year-old male) with this syndrome.
He was scheduled for amputation of the left lower leg. We diagnosed APS from preoperative examination of coagulation. We chose spinal anesthesia for the surgery to avoid general anesthesia, which may exacerbate the syndrome, and in order to observe any changes in clinical signs. We administered prednisolone at a dose of 40mg/day for 3 days before surgery and methylprednisolone 250mg/day for 3 days after surgery. Thereafter, the dose of methylprednisolone was tapered. Heparin was administered at a dose of 10, 000IU/day for 7 days after surgery. Heparin was then replaced by oral anticoagulants. During this management, there were no adverse reactions.

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Five children (11-15 years, weight 22.2-46kg) undergoing spinal fusion for scoliosis received subcutaneous infusion of morphine for postoperative pain relief.
We diluted mophine hydrochloride with normal saline to 5mg/ml. After surgery, a 25-gauge butterfly needle was inserted subcutaneously in the anterior chest.
The infusion rate was 0.5-2mg/h (0.1-0.4ml/h). The rate was increased or decreased according to pain or the presence of side effects.
Consequently, patients received morphine at a rate of 10.9-31μg/kg/h for 38.5-61.5 hours.
Three of the 5 patients required additional analgesics once while receiving the morphine infusion. Abdominal distension, nausea or vomiting occured in all patients, but neither respiratory depression or excessive sedation were observed in any patients.
We concluded that morphine by continuous subcutaneous infusion is an effective analgesic, eliminating the problems inherent to multiple intramuscular injections and the risk of overdosage.

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Cesarean section was performed by epidural anesthesia in a 30-year-old patient with hypertrophic obstructive cardiomyopathy (HOCM). HOCM had been diagnosed when the patient was 19 years of age, and her father and sister had suffered from HOCM.
Prior to the induction of anesthesia, hemodynamics were monitored using a Swan-Ganz catheter. Epidural anesthesia produced relatively stable hemodynamics during and after surgery, and no complications, including postoperative pulmonary edema and atonic bleeding were seen.
Epidural anesthesia is not necessarily contraindicated for patients with HOCM if its severity is accurately evaluated, hemodynamics are carefully monitored, and adequate measures are employed during the perioperative period.

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A 42-year-old man with Shy-Drager syndrome underwent an operation for Gluteus maximus flap under fentanyl-N₂O anesthesia. A Swan-Ganz catheter was placed in this patient before surgery and 20μg/kg/min of dopamine was infused to maintain blood pressure during surgery. A relationship between hemodynamics and plasma catecholamine levels in the perioperative period was studied. Plasma adrenalin level was very low even during surgery. Plasma noradrenalin level was within the normal range before surgery, but significantly increased depending on the volume of dopamine infusion during surgery. Despite elevation of plasma noradorenalin level, marked rise in blood pressure did not occur and hemodynamics were not widely varied. We considered monitoring of pulmonary artery wedge pressure and management of blood pressure by infusion of dopamine to be important in this patient.

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Fetal anesthesia for replacing a pleuro-amniotic shunt catheter is described. The primary anesthetic goal was suppression of fetal movement during the procedure. After administration of famotidine, the mother was given epidural anesthesia with 10ml of 1.5% lidocaine, and 5mg of diazepam iv for her comfort. Pancuronium 0.3mg and fentanyl 0.02mg given via the umbilical vein were enough to reduce fetal movement. No complications were seen in mother or fetus with this method.

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We anesthetized a 23-year-old male with Noonan syndrome and hypertrophic cardiomyopathy (HCM) three times for a scoliosis operation. Patients with Noonan syndrome have facial, cardiovascular, and skeletal abnormalities, which should be properly evaluated pre-operatively. Each time, anesthesia was induced with fentanyl and midazolam, and was maintained with nitrous oxide, 0.5-1% isoflurane and fentanyl. Radial artery and pulmonary artery catheters were used for hemodynamic monitoring and for maintenance of appropriate hemodynamics for HCM. It is necessary in patients with HCM to avoid tachycardia and maintain preload and afterload during anesthesia.

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Congenital insensitivity to pain with anhidrosis is a rare disease. Patients are noted for insensitivity to pain, lack of sweating and mental retardation. They easily suffer from painless fractures and self-mutilation of the tongue, lips and fingertips with secondary osteomyelitis. We conducted general anesthesia for skin injuries, necrosis, fractures and osteomyelitis in the same child 10 times over a period of 8 years. The following points have already been reported: (1) adequate pre- and post-anesthetic sedation in order to prevent hyperthermia and injury; (2) tight control of fluid and body temperature because of anhidrosis; and (3) prudent administration of anticholinergics due to possible autonomic nerve dysfunction. Through these ten episodes of anesthesia in the patient, we learned that the following are important: (1) preanesthetic intravenous sedation for smooth induction of anesthesia; (2) endotracheal intubation following administration of neuromuscular blocking agents to secure airway and avoid aspiration pneumonitis; (3) adequate depth of anesthesia because of normal sensitivity except pain; and (4) prophylactic administration of antiemetics to prevent postoperative nausea and vomiting.

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