We evaluated the incidence of post-operative delirium and related factors in 170 patients of over 60 years of age who were scheduled for elective surgery under general anesthesia. We also investigated the efficacy of prophylactic administration of Haloperidol. The incidence of postoperative delirium was estimated using various psychiatric and intelligence tests. Delirium was evaluated by a psychiatrist using Trzepacz's Derilium Rating Scale.
The incidence of post-operative delirium was 21.2 % and significantly high in men. The patients who had thoracotomy or laparotomy were more likely to develop the disease than the patients who had laparoscopic surgery or mastectomy. There was no significant difference between patients who were given different types of anesthesia. However, the incidence of post-operative delirium tended to decrease when general anesthesia with nitrous oxid and isoflurane in combination with epidural anesthesia was given.
We conclude that preoperative identification of patients at the risk of post-operative delirium, and its eary diagnosis are important.

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Performance of the artificial nose with the heat and moisture exchangers (HME) and a bacterial/viral filter (Hygrobac S, Mallinckrodt Co.) was compared to that with HME and another bacterial filter (BB25A, Pall Co.) and that with HME alone (Humid-Vent, Gibeck Co.) in mechanically ventilated patients. Eighty adult patients (ASA PS 1 or 2) undergoing elective surgery were randomly assigned into 4 Groups: Group C, (neither HME nor bacterial filter), n=20: Group HS (Hygrobac S), n=20: Group BB (BB25A), n=20: Group HV (Humid-Vent), n=20. Airway humidity was measured by the psoriometric method. In each patient, measurements were started after induction of anesthesia without the artificial nose. Then, artificial noses were placed next to the tracheal tube except for Group C. Measurements were performed every 5min for a 30min period thereafter. The absolute humidity at 30min was 12.2±3.3mg•l-1 in Group C, 28.1±1.9mg•l-1 in Group HS, 16.5±1.9mg•l-1 in Group BB, and 24.2±1.6mg•l-1 in Group HV. HS and HV had better humidifying capability than BB, and HS did better than HV.

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There are many perioperative problems in severely retarded children suffering from gastroesophageal reflux. The intraoperative anesthetic management is expected to be difficult because of pre-existing repeated aspiration pneumonia and hematemesis. We have studied retrospectively 12 patients aged from 2 to 18 year-old who underwent Nissen fundoplication surgery which prevents gastroesophageal reflux. The patients were treated perioperatively with the flow chart protocol we made. We found that meticulous respiratory care, management of postoperative pain and mental stress, and control of convulsions were essential to safe perioperative patient care.

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Flexible bronchial fiberscopy has recently become commonly utilized at tracheal intubation in the difficult airway. We used a confirmation of a McCoy laryngoscope and a fiberoptic stylet in patients whose Cormack grade was considered to be III or more. With this technique, we could intubate 7 patients with difficult airway in a short duration without any complication. It was concluded that the fiberoptic stylet could be an efficient assisting device to patients who might have difficulty in tracheal intubation.

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In this study we measured serum S-100 protein concentration using a monoclonal two-site immunoradiometric assay (Sangtec^® 100 IRMA, Sweden) during the perioperative period in ten patients undergoing aortic arch replacement (AAR) and five patients undergoing resection of brain tumor (RBT) . In AAR patients, serum S-100 protein concentrations at the end of extracorporeal circulation (ECC) were significantly higher (remarkably high values) than those at post-anesthetic induction and pre-ECC, but promptly declined at 24 and 48hours after ECC. No AAR patients had apparent postoperative cerebral complications. In short, highly abnormal values immediately after ECC did not predict postoperative cerebral complications and neurological prognosis. In RBT patients close to S-100 levels were approximately within the normal range during the perioperative period and this group had no apparent cerebral complications postoperatively. We must conduct further studies to assess the clinical significance of S-100 protein changes by measuring its concentrations in patients with postoperative neurological complications.

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In twelve patients, the relationship between changes in pulse wave velocity and the pressure gradient of the aortic-to-radial arteries after cardiopulmonary bypass (CPB) was investigated. The changes in arterial pressure through aorta-to-radial arteries were measured using a guide wire of 0.37mm diameter tipped with a miniature transducer before and after CPB. The changes in the pulse wave velocity were calculated by measuring the propagation time between the QRS complex of the ECG and the corresponding arterial pressure wave. Thereafter, they were converted into volume distensibilities using the Bramwell-Hill equation. We found that in the patients showing a pressure gradient after CPB (7 out of 12), intravascular pressure and pulse wave velocity decreased gradually from aorta to radial arteries, and that corresponding volume distensibility increased gradually. Measurements by pulsed Doppler ultrasound showed no significant changes in artery diameter or wall thickness after CPB. These results suggest that the aortic-to-radial artery pressure gradient is attributed to gradual changes in volume distensibility, that is, to arterial elasticity gradient. It might be possible that the decreased elasticity prevents the intravascular pressure rise. The cause of elasticity gradient is a subject for future study.

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Continuous subcutaneous infusion of meperidine was compared with infusion of morphine for pain relief in 19 patients (9-19 years, weight 19.2-57.6kg) after major orthopedic surgery. 11 children received meperidine, and 8 received morphine. After surgery, a 25-gauge butterfly needle was inserted subcutaneously in the anterior chest.
Patients received meperidine at a rate of 38-687μg•kg-1•h-1 for 45.0-115.8hours, and morphine at 4.5-46μg•kg-1•h-1 for 38.5-83.3hours. The total amount of drug per patient was 185.0-1, 207.5mg for meperidine, and 19.8-71.1mg for morphine. Both of them brought about a satisfactory analgesia.
Abdominal distension, nausea or vomiting occurred in 7 of 8 patients taking morphine, but only 7 of 11 patients suffered from mild gastrointestinal side effects in the meperidine group. Neither respiratory depression nor excessive sedation was observed in any patient.
Meperidine was as effective as morphine for postoperative analgesia but with less gastrointestinal side effects.
We concluded that continuous subcutaneous meperidine infusion is a safe and effective method for postoperative pain relief.

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We had a case of a successful recovery from prolonged cardiac arrest without airway protection sufficient for artificial breathing through the airway.
An 85-year-old male patient, who had undergone surgery for removal of an oro-pharyngeal cancer tumor and upper cervical lymph node resection, showed dyspnea just after the extubation of a naso-tracheal tube due to his upper airway obstruction, and went into cardiac arrest several minutes after. Re-intubation was tried but resulted in failure because of a huge hematoma-like mass around his larynx and pharynx. Cardiac massage by closed chest compression and oxygen insufflation by a mask with the conventional drug therapy was continued for more than 40 minutes of his cardiac arrest. His heart beats recovered immediately after completion of the tracheotomy and the start of artificial breathing. He regained full consciousness at our intensive care unit on the next day and was discharged from the hospital three months later without any sequelae.
This case suggests that airway protection and artificial breathing may not be essential for successful recovery from cardiac arrest in the initial interventions of cardiopulmonary resuscitation.

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A 48-year-old female with palpitation and dyspnea underwent emergency surgery after diagnosis of an aorta-right ventricle fistula due to a knife injury was established. Anesthesia was induced with the inhalation of oxygen and intravenous morphine and diazepam with the patient in the sitting position after preparing her for an F-F bypass. The fistula was closed under cardiopulmonary bypass, and postoperative recovery was uneventful.
In the present case, profound hemodynamic changes did not appear at the induction of anesthesia. In an emergency operation for thoracic trauma, preoperative, adequate assessment of the patient's condition (i.e., evaluation of cardiac function and blood volume) and treatment are essential. Preparation of the F-F bypass and good contact with cardio-surgeons are also extremely important.

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A 20-year-old man in Sapporo and a 10-year-old boy in Hiroshima were tested for malignant hyperthermia. Both of who were away from the laboratories of Shiga University of Medical Science in which the in vitro caffeine halothane contracture test (CHCT) and Hiroshima University Hospital in which the calcium-induced calcium release rate test (CICR) were done. Because of the viability of an excised specimen, CHCT was recommended to be performed within 5 hr and CICR within 48 hr after muscle biopsy. Therefore, we planned to move the CHCT laboratory close to the patients. All equipments of the CHCT test were transferred to a laboratory in Medical University close to a hospital in which the patients could be administered. Muscle specimens treated with special solution were transported to the laboratory of the CICR test by commercial shipping service. We successfully made the malignant hyperthermia susceptibility diagnosis of the two patients. We believe this is the first case reports in Japan that the patients were not able to travel to the laboratories where the tests were done.

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A mechanical deficiency in an anesthesia ventilator was identified during a preoperative machine check. A pressure regulator in a cold evaporator (CE) system and a higher pressure regulator in an anesthesia ventilator malfunctioned simultaneously and induced leakage in the ventilator circuit. The pressure regulator in the CE system failed probably due to a foreign body in the valve seat, which resulted in increased pressure in the supply system (from 4.0±0.5kgf•(cm²)^-1 to 6.3kgf•(cm²)^-1). In addition to this, the higher pressure regulator in the ventilator was also damaged and, consequently, non-reduced pressure was loaded into the ventilator circuit. As the circuit tubes were supposed to take lower pressures, only it eventually ruptured and leakage started. This accident indicates the importance of preoperative anesthesia machine checks, regular preventive maintenance, periodical overhauls and safety measures against unexpected increases in central supply pressures.

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A 65-year-old male with chronic renal failure underwent removal of an inserted tube for continuous ambulatory peritoneal dialysis because of infectious peritonitis. Preoperative examinations revealed severe congestive heart failure with the cardiothoracic ratio of 63% and the ejection fraction of 26%. The patient was in a drowsy state and was annoyed with persistent hiccups. Surgery was completed uneventfully under the combination of regional and inhalation anesthesia. The authors noticed appearing of Cheyne-Stokes respiration (CSR) in the patient while he was recovering from anesthesia. The patient repeated respiration and apnea periods alternately. Respiratory movements in the respiration period were not regular, but waxed and waned. Pulse oximetry indicated fluctuations of arterial oxygen saturation corresponding with the periodicity of respiratory movements. The arterial oxygen saturation took the minimum value immediately before the start of the respiration period and the maximum value at the turning point from waxing to waning in the respiration period. The minimum value was 93% under oxygen inhalation and 75% under room air inhalation. After surgery, clinical symptoms of peritonitis subsided and the laboratory data indicated that acute inflammation had improved. Then, CSR disappeared and normal rhythmic respiration returned. Postoperative cerebral examinations disclosed diffuse atrophy of the brain and extensive stenosis of the cerebral arteries.
It is most likely that infectious peritonitis worsened the preexisting heart failure and insufficient cerebral circulation, resulting in the development of CSR as a sign of cerebral dysfunction.

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For medical support in a developing country, education of the native medical staff, financial aid, and supply of medicines and hospital equipment are all very important. Especially for successful and successive non governmental organization (NGO) activities, restriction of funds is a big problem. After 9 years of NGO activity in Cambodia, we know that intravenous anesthetic drugs are easily obtained in Cambodia while inhalation anesthetic gases are not. Consequently, we have been offering intravenous anesthesia for oral surgery in Cambodia. In this study, we compared the cost of anesthesia in Cambodia with that of our hospital in Japan. Inhalation anesthesia has been widely adopted in Japan, and all our patients were also anesthetized with inhalation anesthesia. As a result, we compared the cost of intravenous anesthesia to that of inhalation anesthesia. The costs were calculated on the Japanese drug cost standard basis. The cost of inhalation anesthesia for each case is almost 8 times higher than that of intravenous anesthesia. Intravenous anesthesia is really cheap compared with that of inhalation anesthesia in Japan and this situation must be more prominent in Cambodia. Because of the easy intravenous drug supply and poor hospital equipment for inhalation anesthesia, including anesthetic machine and the scavenging system for waste gases in Cambodia, we have employed the intravenous anesthesia technique. Our study shows that the adoption of intravenous anesthesia in Cambodia is quite reasonable in terms of education of medical staff, transfer of medical technique and financial background for successful NGO activity.

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