In 98 out-patients who visited our pain clinic, we evaluated their psychological status before the first examination and one month after the treatment, using self-rating depression scale (SDS) and state-trate anxiety inventory (STAI). SDS, state anxiety, and trate anxiety scores were significantly higher in the patients with pain (trigeminal neuralgia, neck-shoulder-arm pain syndrome, lumbago and psychological pain, n = 55) compared with the patients without pain (sudden deafness and facial nerve palsy, n = 43) (P < 0.01, 0.05, 0.01). Of the patients with pain, patients with psychogenic pain showed the highest score in every test. The scores of SDS and state anxiety became significantly lower one month after the treatments compared with ones before the first examination (P < 0.01). It was considered that the decline in every score was due to the treatments in our pain clinic. In patients whose score of trate anxiety before the first examination was more than 50 points, the SDS and state anxiety showed high scores even one month after the treatments. This finding suggests that these patients need psychosomatic managements.
This report describes a case of awareness and recall during propofol anesthesia combined with epidural anesthesia in a 32-year-old woman scheduled for a resection of left ovarian tumor. After induction, anesthesia was maintained with propofol and epidural anesthesia. About one hour into maintenance, the patient was moving with haemodynamic signs suggesting inadequate analgesia. Immediately after extubation, the patient could recall the abdomen being touched during laparotomy. This case indicates that even if appropriate dose of propofol is administrated, intraoperative awareness may occur especially with inadequate analgesia.
We present the case of a 4‐year‐old girl who developed anaphylactic shock during general anesthesia. Symptoms appeared 80 min into the operation and may have been an immediate allergic reaction to the transfused blood supplied from the child's mother based on the clinical signs, the decrease of components of complements and the elevated concentrations of histamine and tryptase. The blood type was the same and antibody screening test and crossmatch was negative. The blood was irradiated and we used a white cell‐reduction filter. This patient possibly has antibodies to her mother's plasma and this type of reaction cannot be prevented by these routine methods. It is reported that the risk of transfusion associated graft‐vs.‐host disease is high when a patient receives blood from a closely related donor. However, there are, no reports of anaphylactic reactions to blood supplied from mother to child. We suggest that there is a potential for anaphylactic reaction as well as transfusion associated graft‐vs.‐host disease when a child patient receives blood from the mother.
Satoshi Akazawa, M.D., Associate Professor, Department of Anesthesiology.Yasushi Nakaigawa, M.D., Instructor, Department of Anesthesiology.Kunihisa Hotta, M.D., Resident, Department of Anesthesiology.Reiju Shimizu, M.D., Professor and Chairman, Department of Anesthesiology.Hiroshi Kashiwagi, M.D., Research Fellow, Department of Surgery.Khoji Takahashi, M.D., Instructor, Department of Radiology, Jichi Medical School, Minamikawachi-machi, Kawachi-gun, Tochigi-ken, 329–04, Japan.To the Editor:--Although many complications of central venous catheterization, including fragmentation of a guidewire with pulmonary artery embolism, have been published, [1,2]intravascular migration of an entire guidewire has not been reported.A 69-yr-old woman underwent elective abdominoperineal surgery for advanced rectal carcinoma. After induction of anesthesia, an introducer needle attached to an Arrow Raulerson Syringe was inserted into the right jugular vein, followed by insertion of a J-tipped spring guidewire (0.89 mm in diameter, 60 cm in length) through the hole in the rear of the Raulerson Syringe plunger to a depth of 30 cm. After removal of a dilator, a 7-Fr double-lumen central venous catheter (CVC; Arrow International, CS-17702-E, Reading, PA) was inserted via the right jugular vein over the guidewire to a depth of approximately 12 cm. The CVC appeared to be inserted uneventfully, and both loss of the guidewire and abnormal findings on a chest radiograph taken 20 min after completion of the surgery went unnoticed (Figure 1).The postoperative course was uneventful, and the patient remained asymptomatic. On a chest radiograph taken on the 56th postoperative day, a metallic density forming loops in the cardiac silhouette was noted (Figure 2). The computed tomograph revealed the intravascular wirelike foreign body with both free ends in the hepatic vein and loops in the right pulmonary artery through the right intracardiac chambers.On the 64th postoperative day, with informed consent, a 6-Fr pigtail catheter was inserted via the right femoral vein to remove the foreign body under fluoroscopic nonsurgical technique. [2]The right pulmonary arterial and intracardiac portions of the foreign body were easily dislodged into the inferior vena cava (IVC) by caudad traction of a part of the foreign body. This technique failed to remove the foreign body from the IVC, because both free ends were fixed hard to the hepatic venous wall. A retrieval catheter with forceps at the tip was inserted, which enabled us to grasp a portion of the foreign body and remove it entirely from the IVC. The foreign body was confirmed to be identical in length to an entire guidewire. Cardiac dysrhythmias and signs and symptoms indicative of pulmonary embolism did not develop throughout the postoperative course.In conclusion, guidewire retrieval is a crucial step in a catheterization technique wherein a catheter is inserted over a guidewire.Satoshi Akazawa, M.D., Associate Professor, Department of Anesthesiology.Yasushi Nakaigawa, M.D., Instructor, Department of Anesthesiology.Kunihisa Hotta, M.D., Resident, Department of Anesthesiology.Reiju Shimizu, M.D., Professor and Chairman, Department of Anesthesiology.Hiroshi Kashiwagi, M.D., Research Fellow, Department of Surgery.Khoji Takahashi, M.D., Instructor, Department of Radiology, Jichi Medical School, Minamikawachi-machi, Kawachi-gun, Tochigi-ken, 329–04, Japan.
We report the perioperative management of three patients with streptococcal toxic shock syndrome (STSS) caused by group A streptococcal infection. Three of two patients survived but one patient died from multiple organ dysfunction in spite of vigorous treatments. These patients required the treatments including administration of antibiotics, circulatory and respiratory care, surgical debridement, anticoagulant therapy for disseminated intravascular coagulation and hemofiltration. The early diagnosis and surgical intervention play a key role in the successful management of this syndrome because it has a rapid course and frequent fatal outcome. The anesthetic management of these patients should be targeted to maintain perfusion of the vital organs and to control the blood clotting disorders.
A 78-year-old man with thoracic aortic aneurysm was scheduled for endovascular stent-graft surgery without cardiopulmonary bypass. He had a history of myocardial infarction five months before and echocardiography revealed ejection fraction of 37%. Deployment of the stent-graft was performed during third degree atrioventricular (A-V) block of 32 seconds produced by adenosine 5'-triphosphate (ATP) 30 mg. There were no complications during this procedure. ATP is a convenient and suitable agent to produce transient A-V block for the precise deployment of the stent-graft in these patients with severe cardiopulmonary complications.
Fire accident is one of the most severe complications that can occur in the perioperative period. We report a case of an episode of electrosurgical burn. An 80-year-old woman was scheduled for ascending colectomy due to ascending colon carcinoma. The skin of the surgical site was sterilized with alcoholic antiseptic containing chlorhexidine before the operation. On coagulating the bleeding point of the subcutaneous fatty tissue, a spark of the electric scalpel ignited the alcoholic antiseptic. She had burn on her right thorax, lower abdomen and femoral region. Two-degree burn occupied 2% of the body surface and three-degree burn 3%. She underwent dermatoplasty 14 days later. Postoperative course was uneventful and she left the hospital on the 58th postoperative day. An alcoholic antiseptic is the most useful and has an immediate effect for preoperative disinfection of the skin according to the CDC guideline. However, electric scalpel and alcoholic use are always accompanied with the risk of ignition and sufficient caution is required.
