Showing papers in "Masui. The Japanese journal of anesthesiology in 2010"

Failed back surgery syndrome

Abstract: The most confusing point in management of the patients with failed back surgery syndrome (FBSS) is that the presence of FBSS is judged not by the objective symptom such as neurological deficit evaluated by medical staff but by the subjective symptom including feeling of pain, disability and satisfaction on medical treatment. In this paper, diagnosis, cause and prevention of FBSS are summarized.

[Ropivacaine-induced late-onset systemic toxicity after transversus abdominis plane block under general anesthesia: successful reversal with 20% lipid emulsion].

Abstract: We report a case of late-onset systemic toxicity due to ropivacaine over dose, and its successful reversal with 20% lipid emulsion (20% Intralipos). A 40-year-old woman, 40 kg, ASA-I, was scheduled for laparoscopy-assisted myomectomy of the uterus in which 40 ml of 0.375% ropivacaine was injected for bilateral US guided transversus abdominis plane block (TAPblock) under general anesthesia. Anesthesia proceeded uneventfully and she could go back to the ward 15 min later, but 3 hours after TAPblock, her blood pressure dropped to seventies and she became unresponsive. She also displayed clonic seizure/twitching of limbs. Immediately after diazepam 2 mg injection, clonic seizure disappeared and she could obey verbal commands. Within a few minutes clonic seizure was noted again, and she was hypotensive despite administration of vasopressors. A presumptive diagnosis of local anesthetic toxicity was made, and she received 100 ml bolus of 20% Intralipos. She regained consciousness with spontaneous return of blood pressure. She received a total of 230 ml 20% Intralipos, which was discontinued due to her rapid emergence with no further seizure episodes. This case suggests that early and sufficient use of lipid emulsion may lead to a good outcome. We recommend the immediate availability of lipid emulsion along with other emergency therapeutics at the ward after TAPblock.

GlideScope video laryngoscope

Abstract: Increasing evidence indicates that the GlideScope" video laryngoscope (GVL) has an established role in endotracheal intubation. The GVL has been on the market in Japan. In this report, we introduced the clinical performance of the GVL. The GVL has been reported to provide a better glottic exposure compared with the direct laryngoscope in normal and difficult airways. In addition, the GVL has been reported to have superior performance, compared with direct laryngoscope when used for nasotracheal intubation. The GVL is a novel indirect rigid laryngoscope for routine endotracheal intubation.

[Long-term efficacy and safety of pregabalin in patients with postherpetic neuralgia: results of a 52-week, open-label, flexible-dose study].

Abstract: Background The efficacy of pregabalin was demonstrated in a randomized double-blind placebo-controlled 13-week trial in 371 Japanese patients with postherpetic neuralgia (PHN). In this study, we evaluated the long-term efficacy and safety of pregabalin for relief of PHN. Methods 126 patients were enrolled from the preceding double-blind study into the 52-week open-label study. Patients were given pregabalin 150 to 600 mg x day(-1). Pain intensity was measured using the Short-Form McGill Pain Questionnaire (SF-MPQ: total score, visual analogue scale and present pain intensity). Results The efficacy parameter SF-MPQ showed a decrease over the treatment-term. The changes of visual analogue scale and present pain intensity at the endpoint were -28.3 mm and -1.1 score, respectively. The commonly reported adverse events were dizziness, somnolence, peripheral edema and weight gain, and most of them were mild to moderate in intensity. No new adverse events were observed due to long-term pregabalin administration. Conclusions These results suggest that long-term treatment of pregabalin may be beneficial in patients with PHN.

Nasotracheal intubation using GlideScope videolaryngoscope or Macintosh laryngoscope by novice laryngoscopists

Abstract: BACKGROUND: We compared the performance of GlideScope videolaryngoscope with that of the conventional Macintosh laryngoscope for nasotracheal intubation by non-anesthesia residents. METHODS: Forty patients requiring nasal endotracheal intubation for surgical convenience were allocated to intubation with the GlideScope videolaryngoscope or Macintosh laryngoscope. Each intubation was performed by non-anesthesia residents. RESULTS: The time to secure the airway was shorter with GlideScope laryngoscopy than with the Macintosh laryngoscopy. Magill forceps were not needed for any patient during GlideScope videolaryngoscopy, while Macintosh laryngoscopy required Magill forceps utilization for 75% of the patients. CONCLUSIONS: The unobstructed view of the glottic opening on the video monitor helped the laryngoscopist performing the nasal endotracheal intubation while an assistant provided laryngeal manipulation to improve the coordinated effort. GlideScope seems to facilitate nasotracheal intubation for individuals training in airway management.

Preoperative evaluation and management of arrhythmia

Abstract: Cardiac arrhythmias are often observed in patients during perioperative period. There are many types of arrhythmias, and some of these can be independent predictors of morbidity and mortality in patients undergoing both cardiac and non-cardiac surgery. In accordance with patients' condition, advanced cardiac testing may be needed for predicting and reducing the perioperative risk. The preoperative management is also an important component of the preparation of the surgical patients with arrhythmias. Most arrhythmias may be associated with cardiac or non-cardiac problems, such as cardiopulmonary disease, myocardial ischemia, drug toxicity, endocrine disease, or metabolic derangements. Since perioperative arrhythmias may increase their risk dependent on the underlying cause, these abnormalities should be corrected if possible before surgery.

The effect of transversus abdominis plane block for pediatric patients receiving bone graft to the alveolar cleft

Abstract: BACKGROUND Transversus abdominis plane block (TAP block) is useful for lower abdominal operations. Recently, ultrasound guided nerve block has been performed with ultrasound scanning. METHODS We investigated the effectiveness of TAP block in 64 pediatric patients (aged 5-12 years, F/M = 21/43) receiving bone graft from the ilium to the alveolar cleft. We compared the dosages for postoperative analgesics between the groups of TAP block and non-TAP block. RESULTS In the TAP block group, the frequency of using the postoperative analgesics was lower compared with non TAP block group (P < 0.05). CONCLUSIONS We concluded that TAP block was effective in pediatric patients receiving bone graft to the alveolar cleft.

Case of bladder perforation due to the obturator nerve reflex during transurethral resection (TUR) of bladder tumor using the TUR in saline (Turis) system under spinal anesthesia

Abstract: Bladder perforation due to the obturator nerve reflex (ONR) is a serious complication during TUR of bladder tumor using the conventional TUR system; requiring monopolar electrocautery and non-conductive solution as perfusate. Recently, the TURis system, which employs bipolar electrocautery and physiological saline as perfusate, has been developed. Electrical resistance of physiological saline and human tissues are approximately 40 and 500 omega, respectively. Thus, theoretically, electrical current flows between the resection loop and the recovery electrode integrated in the outer sleeve of the endoscope, without forming electrical circuit in the patient's body; suggesting possible elimination of the ONR. Here we describe a case of bladder perforation during surgery using the TURis system; the ONR was exaggerated during the procedure to stop bleeding at the lateral wall using bipolar electrocautery. In addition to this case, there have been a few reports of the ONR during surgery using the TURis system, and it is reported that weak electrical current may pass through the patient's body in the TURis system. We consider that evaluation of the necessary precautions, such as the obturator nerve block, for the prevention of the ONR is important even in the surgery using the TURis system.

Morbidly obese patient with a huge ovarian tumor who was intubated while awake using airway scope in lateral decubitus position

Abstract: A morbidly obese woman with a huge ovarian tumor was scheduled to undergo tumor resection under general anesthesia. Under slight sedation with midazolam and fentanyl, a tracheal tube was inserted smoothly using Pentax-AWS Airway Scope, and general anesthesia was thereafter maintained by sevoflurane. To avoid circulatory collapse and reexpansion pulmonary edema, the content of the huge ovarian tumor was aspirated through a small drainage tube to reduce volume and weight of the tumor. Then resection of the ovarian tumor and abdominal wall tissue was performed in supine position. Periooperative course was uneventful.

Pediatric cardiac anesthesia

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Preoperative assessment of smoking patient

Abstract: Tobacco use can be the most common preventable cause of death. Smoking-related disorders such as pulmonary and cardiovascular diseases increase perioperative risk, and smoking itself could increase the risk of morbidity, which may be reduced by abstinence from smoking. Although the benefits of stopping smoking are generally accepted, the optimal timing of preoperative smoking cessation is an important clinical question. From the several reports, cessation should begin at least 6 to 8 weeks before surgery. However, it is important to know the fact that some important adverse effects in pulmonary and cardiovascular system induced by nicotine and CO could be restored within 24 to 48 hours of smoking cessation. Thus, even in the brief preoperative period, it is important that medical staff (including anesthesiologists, surgeons, and nurses) should advise patients to quit tobacco use.

[Incidence and clinical characteristics of perioperative pulmonary thromboembolism in Japan in 2008--results from the annual study of Japanese Society of Anesthesiologists, Committee on Patient Safety and Risk Management, Perioperative Pulmonary Thromboembolism Working Group].

Abstract: Background The Japanese Society of Anesthesiologists (JSA) has maintained records of the annual incidence and characteristics of perioperative pulmonary thromboembolism (perioperative PTE) since 2002. The aim of this paper was to provide recent results of the JSA annual study conducted in 2008, and to determine the current factors that tend to prevent perioperative venous thromboembolism (VTE) in Japan. Methods A comprehensive questionnaire designed by the JSA PTE working group was mailed to all institutions certified as teaching hospitals by JSA. The data tics of patients with perioperative PTE, such as types of diseases and surgeries, age, sex, methods used for the prevention of VTE (in some cases), and prognosis of perioperative PTE. Results The rate of effective responses was 56.1% (634/1116), and 1,177,626 surgeries were registered during the study period. There were 324 patients who were reported to have had PTE, and the incidence was 2.75 per 10,000 surgeries. The incidence of perioperative PTE in 2008 did not change significantly from that in 2005-07. The surgeries that most commonly resulted in perioperative PTE were limb and/or hip joint surgery (5.71 per 10,000 surgeries), craniotomy (4.64 per 10,000), and thoracotomy with laparotomy (3.46 per 10,000 surgeries). The mortality rate of perioperative PTE in 2008 was found to have significantly decreased from that in 2005-07 (15.6% vs. 22.4%; P = 0.01). Further, the rate of patients who received anticoagulant drugs in 2008 was significantly higher than that in 2005-07 (17.6% vs. 10.8%; P = 0.0018). Individual guidelines for the prevention of perioperative VTE were adopted in 55.4% of the training institutions. Conclusions The increase in the percentage of patients who received anticoagulant drugs around the time of the operation, and the decreased mortality of patients with perioperative PTE suggested that the prophylaxis for perioperative VTE with anticoagulant drugs reduces perioperative mortality.

Phantom limb pain originates from dysfunction of the primary motor cortex

Abstract: Accumulated knowledge indicates that phantom limb pain is a phenomenon of the central nervous system that is related to plastic changes at several levels of the nervous systems. Especially, reports using patients with neuropathic pain clearly indicate the sensorimotor cortex as underlying mechanisms of phantom limb and its pain. Here, we focus the notion that limb amputation or deafferentation results in plasticity of connections between the brain and the body, and that the cortical motor representation of the missing or deafferented limb seemingly disappears. Meanwhile, the sensory representation of the limb does not disappear and thereby patients feel phantom limbs. We propose that dissociation between motor and sensory representations in the primary motor cortex induces pathologic pain and reconcile of sensorimotor integration of the limb would alleviate pain, on the basis of our neurorehabilitation approaches and artificial neuromodulation strategies.

[Propofol-induced generalized tonic-clonic seizure: a case report].

Abstract: A 23-year-old man with no history of convulsion underwent removal of the nails in his upper arm. He received propofol infusion after axillary brachial plexus block. Ten minutes after propofol infusion (15 minutes after axillary block), generalized tonic-clonic seizure occurred. The rate of propofol infusion was increased, and midazolam was given intravenously ; however, the seizure continued. Propofol infusion was withheld, and anesthesia was maintained with sevoflurane. The seizure gradually decreased in 15 minutes after termination of propofol infusion, and it finally stopped 30 minutes after termination of propofol infusion.

[Experience of ultrasound-guided popliteal sciatic nerve block and femoral nerve perineural catheter placement in a morbidly obese patient undergoing total knee arthroplasty].

Abstract: A 60-year-old morbidly obese woman (150 cm, 112 kg, BMI 49.8) underwent total knee replacement under general anesthesia combined with sciatic nerve block and continuous femoral nerve block. Following induction of general anesthesia and tracheal intubation, the sciatic nerve was blocked using the popliteal approach with the patient in the supine position. Then the femoral nerve block was performed, followed by perineural catheter placement for postoperative continuous local anesthetic infusion. For both procedures, real-time ultrasound imaging was used to facilitate needle placement and confirm the adequate local anesthetic deposition. Twenty-five and 30 ml of 0.375% ropivacaine was injected around the sciatic and femoral nerves, respectively. Postoperatively 0.15% ropivacaine was infused at the rate of 5 ml x hr(-1) for 60 hours through the femoral catheter, which provided satisfactory pain relief in combination with scheduled loxoprofen administration. No block-related complications were noted. Our experience suggests that the ultrasound-guided technique may prove useful to facilitate safe and accurate block when technical difficulties are anticipated with anatomic landmark-based approaches.

[Multiple cerebral infarction by air embolism associated with remarkable low BIS value during lung segmentectomy with video assisted thoracic surgery (VATS) technique: a case report].

Abstract: A 64-year-old woman (151 cm, 43 kg) with well controlled hypertension was diagnosed as having right lung cancer at S8 segment. She underwent right S8 segmentectomy by video assisted thoracic surgery (VATS) under general anesthesia combined with epidural anesthesia. Her vital signs were stable and BIS value was around 45 before the surgeon injected the air using a syringe with a 22 G needle to confirm the lesion resected. After the injection of air, her systolic blood pressure rapidly increased from 120 to 170 mmHg and the BIS value suddenly decreased to 5. Blood propofol concentration was reduced from 3 microg x ml(-1) to 2 microg x ml(-1) in the target-controlled infusion technique, and thereby the BIS value increased slowly. She did not wake up nor maintain sufficient spontaneous breathing even 2 hours after the discontinuation of opioids, and was transferred to ICU with tracheal intubation. In ICU, she showed clonic convulsions. Urgent CT and MRI confirmed cerebral air embolism. Her vital signs were too unstable to choose hyperbaric oxygen therapy as her first treatment. Her consciousness was recovered and her trachea was extubated on 11th postoperative day. She was discharged with left hemiparalysis from hospital.

Ultrasound-guided rectus sheath block for upper abdominal surgery

Abstract: Upper abdominal surgery leads to severe postoperative pain. Insufficient postoperative analgesia accompanies a high incidence of complications. Therefore, postoperative analgesia is very important. The epidural analgesia has many advantages. However it has a high risk of epidural hematoma in anticoagulated patients. Rectus sheath block provided safer and more reliable analgesia in recent years, by the development of ultrasound tools. We experienced two cases of the rectus sheath block in upper abdominal surgery under ultrasound guidance. Ultrasound guided rectus sheath block can reduce the risk of peritoneal puncture, bleeding, and other complications. Rectus sheath block is very effective to reduce postoperative pain in upper abdominal surgery as an alternative method to epidural anesthesia in anticoagulated patients.

Dental injury associated with general anesthesia and the preventive measures

Abstract: BACKGROUND: It is generally recognized that dental injury during general anesthesia is an important problem. We retrospectively evaluated the profiles of dental injuries during general anesthesia and associated factors for the development of dental injury. METHODS: From January 1999 to December 2008, all medical records of the patients with dental injury during general anesthesia were reviewed. RESULTS: Of 30,845 patients who underwent general anesthesia in the period, the dental injury developed in 110 patients (0.36%) during general anesthesia. The incidence of dental injury was higher in patients above 60 years of age, The patients who had received mouth guards had significantly lower incidence of dental injury compared with those without mouth guards (0.06% vs. 0.37%, P < 0.05). The left upper incisors were involved most commonly in the development of dental injury, and the timing of dental injury was most frequent at the time of tracheal intubation.

[Anesthetic management of emergency total gastrectomy in a patient with mitochondrial encephalomyopathy: a case of gastric perforation accompanied by systemic inflammatory response syndrome].

Abstract: There are several problems in anesthetic management for patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); susceptibility to malignant hyperthermia, metabolic disorders such as lactic acidosis and diabetes, and dysfunction of vital organs such as cardiomyopathy. Here we report an anesthetic management of emergency laparotomy in a 58-year-old woman with MELAS and systemic inflammatory response syndrome (SIRS). Pre-operative examinations revealed lactic acidosis, hyperglycemia, moderate cardiac depression, and slightly decreased renal function. We chose total intravenous anesthesia to avoid risks of malignant hyperthermia. Anesthesia was induced by rapid-sequence fashion and maintained using midazolam, propofol, ketamine, fentanyl and vecuronium. Based on arterial blood gas analyses, we adjusted ventilator settings, restored blood volume using acetated-Ringer's solution and alubumin preparation with transfusion, and administered sodium bicarbonate and catecholamines, to keep adequate oxygen demand/supply balance and improve acid-base balance. We applied a patient warming system to avoid the progression of hypothermia. After the surgery, the patient was transferred to the intensive care unit, and underwent the endotoxin absorption therapy as well as antibiotics therapy for the treatment of SIRS. The post-operative course was almost uneventful. We consider that careful anesthetic management was essential for the uneventful peri-operative course of this patient.

[Comparison of urinary output during general anesthesia, between patients administered with remifentanil and those without remifentanil administration].

Abstract: BACKGROUND: Transient renal failure during surgery is caused by increasing secretion of stress hormone such as ADH and renin. We suspected that urinary output varies according to administration of remifentanil with potent analgesic effects. Consequently, we studied intraoperative urinary output of two groups, patients administered with remifentanil and those without remifentanil administration. METHODS: We compared urinary output during general anesthesia, of 327 patients administered with remifentanil (Group R) and 314 patients without remifentanil administration (Group NR) retrospectively. Patients were excluded if they were under the age of eighteen, receiving epidural anesthesia, or having medicine with diuretic effect. RESULTS: There were no significant difference in background of the patients in each group, in particular, age, sex, body weight, and ASA grade. We found no significant difference in intraoperative factors; operation time, total blood loss, volume of infusion, anesthesia time, and given dose of fentanyl. Urinary output of Group R was estimated as 512 +/- 435 ml, and that of Group NR was 409 +/- 405 ml (P value was 0.02). CONCLUSIONS: We found a significance difference in urinary output during anesthesia, between patients administered with remifentanil and those without remifentanil administration. We suspect that remifentanil decreases urinary output in the perioperative period.

Controversial issues regarding general anesthesia for cesarean section

Abstract: Although, general anesthesia for cesarean section still seems to be the method of choice in extremely urgent settings, past anesthetic evidence has shown that general anesthesia is with increased risk of anesthesia-related maternal mortality. The major disadvantage with general anesthesia is the risk of aspiration of gastric contents and a "cannot ventilate, cannot intubate" situation. Awareness is another concern. There has been a decrease in the number of cesarean section performed under general anesthesia, and a progress in the management of aspiration of gastric contents and difficult airway. This review examines the recent knowledge of these topics. We also describe the benefits and risks of new drugs, such as propofol, remifentanil and rocuronium in general anesthesia for cesarean section.

Management of needlestick injuries for healthcare workers in hospitals

Abstract: The needlestick injury (NSI) has been one of the major issues in the protection of the healthcare workers from the occupationally related blood borne pathogen infection, and vigorous preventive action has been practiced worldwide. In the United Sates, its preventive practices have been proposed nationwide by Centers for Disease Control and Prevention (CDC) providing the guidelines since mid-1980s when HBV and especially HIV infections were reported amomg healthcare workers. The hospitals were required to prepare the hard system to discard the blood contaminated sharp instruments and needles and to keep the official records of related injuries. It has been well recognized in Japan that we are facing a large numbers of NSIs, and the occupational infection from bloodborne pathogens is one of the serious problems in medical care.

Case of hyperkalemia after the administration of hypertonic mannitol during craniotomy

Abstract: We report a case of severe hyperkalemia which developed following administration of mannitol during craniotomy. The blood potassium levels rose from 4.8 mEq x l(-1) to 6.7 mEq x l(-1) 30 minutes after the infusion of mannitol 300 ml during the operation for brain tumor. Since the patient did not develop metabolic acidosis, the hyperkalemia was probably caused by a rise in plasma osmotic pressure resulting from mannitol infusion. The risk factors for hyperkalemia have not yet been determined, and it is necessary to monitor carefully the electrocardiogram and electrolyte levels during the infusion of mannitol.

[Changes in palmar skin blood flow, perfusion index and temperature during endoscopic thoracic sympathectomy].

Abstract: BACKGROUND In endoscopic thoracic sympathectomy (ETS), it is required to perform accurate cautery of the sympathetic trunk. Monitoring of palmar skin blood flow and temperature has been used to assess the efficacy of ETS. This study investigated whether Perfusion Index (PI) is useful in assessing palmar skin blood flow and temperature in ETS. METHODS We studied 5 patients (1 man, 4 women) with palmar hyperhidrosis who had undergone a total of 10 ETS procedures. We measured skin blood flow, temperature and PI during ETS and evaluated the results. RESULTS Significant correlations were found between increases in skin blood flow and PI after ETS in cases with the palmar skin temperature just before ETS of below 35 degrees C. CONCLUSIONS In these cases, we can substitute increases in PI with increases in skin blood flow during ETS.

[Spinal anesthesia for cesarean section--safe and effective anesthetic management].

Abstract: Spinal anesthesia is a safe and effective anesthetic technique for cesarean section, considering its simplicity, rapidity, accompanied maternal awareness and distribution of anesthetic agents. The problems of spinal anesthesia, hypotension, postdural puncture headache, failed spinal anesthesia, and its duration, have been investigated. Intravenous fluid therapy may reduce the incidence and severity of the hypotension. Colloid administration is one of the interventions for prevention of hypotension. Low dose phenylephrine is effective without fetal acidosis in healthy mother. The fluid and vasoconstrictor therapies for hypotension induced by spinal anesthesia were briefly reviewed. Postdural puncture headache is one of the troublesome problems. Epidural blood patch is one of the definitive treatments; however further randomized trials are required. Spinal opioid has improved the quality of spinal anesthesia. The recommended dose of spinal opioid in the recent obstetric anesthesia textbooks has been reviewed. The recent issue about safety and effectiveness in obstetric anesthesia has been briefly discussed.

Accidental skin burns by fire of an antiseptic agent ignition by the spark of electric cautery

Abstract: Surgical fire is a rare complication during the operative period. But, it is a severe complication when it occurs. There are antiseptic agents with strong inflammability used for skin preparation. We report accidental skin burns caused by the spark of electric cautery. The patient was a 29-year-old (50 kg, 158 cm, physical status ASA1) woman who underwent laparotomy for acute abdomen. Anesthesia was induced and tracheal intubation was performed without trouble. Anesthesia was maintained with oxygen, air, remifentanil and sevoflurane. The skin of the surgical site was sterilized with an alcoholic antiseptic containing chlorhexidine before the operation. Several minutes after the start of operation, a fire occurred on using the electric cautery. Immediately, fire was extinguished by hands. The cover cloth is peeled off and it was confirmed that the burn extended from the right thoracic region to the buttocks. After cooling, it became a burn of II to III degrees. Operation was restarted, and at the end, the patient was allowed to breathe spontaneously for 5 minutes and extubated afterwards. The disinfectant with alcoholic content has a strong inflammability. It is necessary to dry it enough before using cautery.

Preoperative evaluation of patients with ischemic heart disease

Abstract: Perioperative myocardial infarction is associated with significant perioperative mortality and morbidity. Sys tematic approach including basic clinical assessment obtained by history, physical examinations and bio chemical tests is necessary for the appropriate evalua tion of patients with ischemic heart disease. Discontinuation of antiplatelet therapy increases the risk of cardiac events in the patients until at least 12 months after implantation of drug-eluting stent. If noncardiac surgery is planned within 12 months, drug-eluting stent should not be indicated. Cardioprotective effects of volatile anesthetic agents are beneficial for mainte nance of general anesthesia in hemodynamically stable patients at risk of myocardial ischemia.

Surgical site infection (SSI) and postoperative infection

Abstract: Infectious diseases, surgical site infections (SSI) in particular are the most popular perioperative complications, and not only the treatment but also prevention is extremely important. The inappropriate use of antibiotic prophylaxis in surgical patients accelerated the development of drug-resistant strains such as methicillin-resistant Staphylococcus aureus (MRSA) or multiple-drug resistant Pseudomonas aeruginosa (MDRP) infections. With this as a turning point, improvements in the choice and the usage of prophylactic antibiotic agents are being discussed in Japan. The importance of the preservation of the normal intestinal bacterial flora and the proper usage of the antibiotics became clear and guidelines have been established. It is important to make a distinction between prophylactic and therapeutic antibiotic administration in the perioperative period. The anti-cross infection measure with the observance of Standard Precautions is also important in infection control.

Epidural anesthesia with noninvasive positive pressure ventilation in a patient with compromised respiratory function

Abstract: We report successful epidural anesthetic management in a patient with severely impaired respiratory function. A 47-year-old woman (39 kg, 158 cm) was scheduled for right thoracoplasty. She had undergone fenestration surgery for empyema three months previously and required supplemental oxygen. Her vital capacity was 700 ml and forced expiratory volume in one second was 650 ml, indicating a severe restrictive pulmonary disorder. Hence, in order to avoid general anesthesia with tracheal intubation, we opted for epidural anesthesia. An epidural catheter was inserted in the T6-7 interspace and a bolus of 4.5 ml each of 1% mepivacaine and 1% ropivacaine was injected through the epidural catheter after a test dose. Ten minutes after the injection, the patient complained of difficulty in breathing and her oxygen saturation fell from 96% to 93%. We applied noninvasive positive pressure ventilation (NPPV) via a nasal mask to the patient, with the ventilator set at spontaneous/timed mode with inspiratory/expiratory positive airway pressure of 14/5 cmH2O. With this therapy, the patient's respiratory symptoms subsided rapidly and we could maintain adequate oxygenation and ventilation throughout the operation. We believe that epidural anesthesia with NPPV is a useful option for patients with compromised respiratory function.