Masui. The Japanese journal of anesthesiology
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During an abdominal surgery, life-threatening events such as severe bradycardia and massive hemorrhage may occur. Reflex bradycardia may arise with surgical manipulation of abdominal contents. Anesthetic agents such as propofol or remifentanil increase the risk of bradycardia. ⋯ When we find critical hemorrhage, we have to manage the condition in accordance with "The guideline for critical intraoperative hemorrhage" published by JSA and the Japan Society of Transfusion Medicine and Cell Therapy. The pneumoperitoneum required for laparoscopy induces physiologic changes that complicate anesthetic management and could cause CO2-subcutaneous emphysema, pneumothorax, endobronchial intubation, and gas embolism. During laparoscopy, blood pressure, heart rate, electrocardiogram, end-tidal CO2, and oxygen saturation by pulse oximetry must be continuously monitored.
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Risk management in clinical practice is an impor part of medical audit. Although, medical audit consists of monitoring, data collection, peer review and establishing standards, these four steps should be regarded as a series of cyclical process. As a general rule, this concept should be applied to any field of clinical medicine and will contribute to the development of sound quality control scheme. ⋯ Auscultation, fiber-optic visualization and proper ventilatory management (eg. lower tidal volume with dependent lung PEEP, alveolar recruitment maneuver, application of CPAP to non-dependent lung) are the recommended technique required to correct these abnormalities. When life-threatening hypoxia is imminent, we should convert to two-lung ventilation without any delay. In this regard, verbal communication between surgical teams should be kept on even ground, each playing key roles in the management of such a critical situation.
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We describe the risk management of pediatric anesthesia. The most important risk management of pediatric anesthesia is airway and temperature management. ⋯ The management of patients' temperature, including control of room temperature should be taken into consideration. In addition, careful attention should be paid not to introduce air bubbles in any lines, especially in patients with congenital heart diseases.
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Control of the airway is fundamental for the safe anesthetic practice of head and neck surgery and careful assessment of airway must be undertaken preoperatively. Safe tracheal intubation method should be decided after the airway assessment. ⋯ Emergency anesthesia for neck and head surgery is most difficult. Experienced personnel and several kinds of devices for securing the airway should be gathered in the operating room before induction of anesthesia.
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Case Reports
[Anesthetic management of a patient with mitochondrial encephalomyopathy for renal transplantation].
A 52-year-old man with mitochondorial encephalomyopathy was scheduled for renal transplantation from a living donor. He had some characteristic features including muscle weakness, deafness, cerebellar ataxia, diabetes meritus and renal failure. Anesthesia was induced with bolus infusion of propofol 1 mg x kg(-1) and continuous infusion of remifentanil at 0.15 microg x kg(-1) x min(-1) was started. ⋯ After administration of naloxone 40 microg to antagonize the action of remifentanil, the patient recovered fully from the respiratory depression. The urine output was depressed initially after implantation of donor's kidney, but gradually increased to a usual recovery pattern. This case suggests that careful administration of remifentanil is mandatory in a patient with mitochondorial encephalomyopathy which enhances respiratory depression from opioids.