Tetsutaro Otagiri

Unexpected nerve gas exposure in the city of Matsumoto: Report of rescue activity in the first sarin gas terrorism

This report describes the rescue activities and the exposure of rescue and hospital personnel from the first unexpected nerve gas terrorist attack using sarin (isopropyl methylphophonofluoridate) in the city of Matsumoto at midnight on June 27, 1994. The details of the emergency activities in the disaster were studied based on the records from emergency departments of the affiliated hospitals and records from the firehouse. About 600 people, including residents and rescue staff, were exposed to sarin gas. Fifty-eight residents were admitted to hospitals, and 7 died. Among 95 rescuers and the duty doctor from the doctor car, 8 had mild symptoms of poisoning. All the rescue activity took place without gas masks or decontamination procedures. In this case of unexpected mass exposure to sarin gas, the emergency rescue system for a large disaster in Matsumoto city, which had been established for a conflagration or a local earthquake, was effective.

Combined neurolytic block of celiac, inferior mesenteric, and superior hypogastric plexuses for incapacitating abdominal and/or pelvic cancer pain

Thirty-five patients with extensive abdominal or pelvic cancer who suffered uncontrolled, diffuse, extensive, and incapacitating pain were treated with a combination of neurolytic celiac plexus block (CPB), inferior mesenteric plexus block (IMPB), and superior hypogastric plexus block (SHGPB). The combination of neurolytic CPB, IMPB, and SHGPB was performed with alcohol, mainly using a transintervetebral disc approach. The combination neurolysis produced effective immediate pain relief in all the patients (visual analog scale (VAS), reduced from 8.8 ± 0.2 to 0). This pain relief persisted during the first 3 months (VAS, 2.3 ± 0.5) or until death. Morphine consumption was significantly decreased for the first 1 month (from 96 ± 29 mg to 31 ± 10 mg per day) after the neurolysis and thereafter continued to be lower than before the surgery, though not significantly so. No serious complications were observed to have been caused by the neurolytic procedure on the three sympathetic plexuses. Our preliminary clinical results suggest that the combination of neurolytic CPB, IMPB, and SHGPB improves the quality of life of patients who have incapacitating cancer pain, by reducing both the intensity of the pain and their opioid consumption, without serious complications. This combination procedure may provide a new therapeutic option for pain relief in patients with advanced cancer.

Anesthetic management for a patient with Kearns-Sayre syndrome.

K earns-Sayre syndrome (KSS), a form of mitochondrial myopathy, is an extremely rare disease accompanied by progressive external ophthalmoplegia, pigmented degeneration of the retina, and heart block (1,2). We report a patient with KSS who underwent emergency surgery under general anesthesia uneventfully, but who developed respiratory depression and rate-dependent left bundle-branch block, postoperatively.

Two cases of chemical meningitis following spinal anesthesia

within the hospital. A puncture was made without any difficulty between L3 and L4 by using a disposable 25G needle for spinal anesthesia, and 2ml of 0.3% dibucaine HCl was injected by using a 5-ml glass syringe that had been sterilized in the hospital. At the completion of the surgical procedure, the patient experienced mild nausea. In the ward 3 h after spinal anesthesia, she developed nausea, headache, a slight fever, and chills. Five hours later, her temperature returned to 37.6°C. A neurological examination was conducted the next day, and no abnormalities of the cranial nerves were recognized; however, headache, nuchal rigidity, and positive Kernig sign were noted. Hematological examination revealed an inflammatory state (white blood cell count, 9990 ·mm23; C-reactive protein, 2.6mg·dl21). The results of a lumbar puncture indicated the following: cerebrospinal fluid, slightly turbid; initial pressure, 175 mmH20; cell counts 664/3mm3 (poly, 400 and mono, 264); protein, 152 mg·dl21; sugar, 57mg·dl21. The patient was treated with piperacillin sodium for 8 days under the diagnosis of meningitis. The cerebrospinal fluid culture yielded no bacterial growth. On the fifth day, she no longer suffered from neurological sequelae and was considered to have recovered completely.

Effects of lumbar sympathetic ganglion block for a patient with amyotrophic lateral sclerosis (ALS)

A 59-year-old man with amyotrophic lateral sclerosis (ALS) received lumbar epidural and sympathetic ganglion blocks to increase regional blood flow and improve his clinical symptoms. After a lumbar epidural block (0.5% mepivacaine), the skin temperature of his affected lower extremities rose by 7.0°C and became close to that of the intact side, and the distance he was able to walk with his cane increased from 2 to 8 m. The clinical effects produced by the lumbar sympathetic ganglion block (99.5% alcohol) were sustained for approximately 8 weeks after the first block and for approximately 6 weeks after the second block. There were no particular adverse effects or complications associated with these nerve block procedures. Epidural and sympathetic ganglion blocks for an ALS patient, albeit their effects are of a transient nature, may improve related clinical symptoms, and were thought to play a contributory role in improving our patients quality of life.

Anesthetic management of a patient with β-thalassemia intermedia undergoing splenectomy : a case report

A 37-year-old man with β-thalassemia intermedia (βTI), a rare disease caused by partial or complete deficiency of β-globin chain synthesis, fell into a hemolytic crisis. Severe anemia persisted despite frequent transfusions. Therefore, he was scheduled for splenectomy to alleviate the anemia. The preoperative laboratory data showed marked anemia and liver dysfunction. Echocardiography revealed hyperkinetic left ventricular motion and increased cardiac index (CI), indicating a compensatory hyperdynamic circulation induced by persistent, severe anemia. Our strategy during general anesthesia was to keep the hyperkinetic cardiovascular system steady. Hence, the hemodynamic parameters including the CI were measured using a Swan-Ganz catheter, and other physiological parameters were monitored perioperatively. Anesthesia was maintained with balanced anesthesia: isoflurane at low concentrations and fentanyl to avoid cardiovascular depression. Throughout the operation, vital signs were kept stable and the lactate/pyruvate ratio was unchanged, indicating that anaerobic metabolism did not increase. We report successful anesthetic management with attention to hemodynamic changes in a patient with βTI.

Characteristic changes between core and peripheral surface temperature related with postanesthetic shivering following surgical operations

The relationship between changes in the core and the surface temperature and postanesthetic shivering was studied in 100 patients who underwent general anesthesia. Patients were classified into four groups by the patterns of change in the core and peripheral surface temperature. Type II and type IV groups of patients showed a decrease in surface temperature during the major operation such as gastrectomy and radical mastectomy. Type I and type III groups of patients showed no lowered peripheral surface temperature and with low temperature difference between core and surface temperature during the operation. The patients in type II and IV groups showed increased difference between core and surface temperature. The postanesthetic shivering occured at significantly higher rate compared to the other two groups. As possible reasons of the shivering, operation of long duration and insufficient circulating blood volume were considered. Shivering reduces the temperature difference in the thermoregulatory homeostasis. However, in patients in type I and III, the rate of shivering was low. Evaluation of the difference between core and peripheral surface temperature may be important to manage body temperature at a steady level during the operation. The monitoring of body temperature difference between core and peripheral surface during the operation may be useful for predicting to occurrence of postanesthetic shivering.

Anesthesia for laparoscopic cholecystectomy in an elderly patient with emphysematous bullae : combined general and epidural anesthesia with spontaneous respiration and abdominal wall-left method

Laparoscopic cholecystectomy is rapidly gaining popularity with surgeons and patients, but as the popularity of this technique increases and the selection of patients widens to older and sicker people, careful considerations in anesthetic management are required. We recently experienced a case of laparoscopic cholecystectomy with emphysematous bullae. To avoid the risk of barotrauma, we adopted an abdominal wall-lift method without peritoneal insufflation, and maintained anesthesia with spontaneous respiration.

Continuous positive airway pressure oxygenation during one-lung ventilation with 50% nitrous oxide and isoflurane in oxygen

Application of continuous positive airway pressure (CPAP) with an inspired oxygen concentration (FI02) of 1.0 to the nondependent lung has been reported to be an effective method of improving Pa02 during one-lung ventilation for elective thoracic surgery [1-5]. When nitrous oxide (N20)/oxygen/volatile anesthetics technique is employed during one-lung ventilation, the N20 decreases the inspired oxygen concentration and increases the chance of hypoxemia. However, the use of N20 allows maintenance of anesthesia with low concentrations of potent inhalational agents. We have constructed a CPAP unit from equipment readily available in our department. The purpose of this study was to determine whether the CPAP oxygenation, using this unit, can prevent hypoxemia during one-lung ventilation with N20 and isoflurane anesthesia (FI02 of 0.5).

Bronchial asthma-like attack after celiac plexus alcohol block

A 65-year-old woman weighing 35 kg was scheduled for left celiac plexus alcohol block to reduce intractable abdominal and back pain from the recurrent esophageal cancer. She had been surgically treated with colostomy for intestinal obstructive symptoms, and received epidural morphine (5 mg/day) for about 1 month for pain relief, postoperatively. She did not receive any antibiotics or anticancer drugs. Preoperative laboratory data showed slight anemia, hypoproteinemia, and liver dysfunction. There was no history of either bronchial asthma or alcohol use. She did not receive epidural morphine on the day of the block. Under an image intensifier, two 14-cm 22-gauge needles were placed in the preaorta area at the T12 and L1 levels. Mepivacaine (2%) 5 ml and iopamiron 5 ml were injected, and the patient obtained satisfactory pain relief without signs of acute complications. Thirty minutes later, 20ml of