Fibrosing cholestatic hepatitis (FCH) is the most devastating manifestation of recurrent hepatitis C in transplant recipients with hepatitis C virus (HCV), possibly leading to death or retransplantation. Although FCH was first described as a complication of hepatitis B, this manifestation has been well documented in association with HCV in the setting of liver transplantation, bone marrow transplantation, heart transplantation, and end-stage human immunodeficiency virus infection. We report the clinical course and antiviral response in a patient with FCH due to recurrent hepatitis C after cadaveric liver transplantation who was treated with pegylated interferon alpha-2a and ribavirin.
Antiviral Agents/*administration & dosage ; Cholestasis, Intrahepatic/*diagnosis/pathology ; Combined Modality Therapy ; Hepacivirus/drug effects ; Hepatitis C, Chronic/diagnosis/*drug therapy/pathology ; Humans ; Interferon Alfa-2a/*administration & dosage ; *Liver Transplantation ; Male ; Middle Aged ; Polyethylene Glycols/*administration & dosage ; RNA, Viral/analysis ; Recurrence ; Ribavirin/*administration & dosage ; Tomography, X-Ray Computed

BACKGROUND: The inhalation of high concentrations of desflurane transiently increases the cardiovascular responses. This study examined the effects of age on the cardiovascular response to desflurane. METHODS: Eighty two patients were divided into one of three groups: under 3 years (Group 1), 2050 years (Group 2), and over 65 years (Group 3). In each group, the inspired concentration of desflurane was increased abruptly to 12.0 vol% 2 minutes after a thiopental injection. The heart rate, blood pressure (BP), cardiac index (CI), End-tidal concentration of desflurane (ETdesf), and end-tidal concentration of CO2 were measured at the baseline and every 30 seconds. RESULTS: The heart rate, BP, and CI increased transiently in the three groups compared with the baseline. The ETdesf increased more rapidly in Groups 1 and 3 than in Group 2. The ETdesf to reach the maximal mean arterial pressure (MAP) was highest in Group 3 among three groups. The relative maximal HR to the baseline value was similar in the three groups, but the relative maximal MAP to baseline value was significantly highest in the elderly patient group. The times to reach the maximal HR and BP were shortest in Group 1 among three groups. There were no significant differences in the CI between three groups. CONCLUSIONS: The inhalation of a high concentration of desflurane increases the HR, BP and CI transiently in all age groups. In pediatric patients, HR and BP increases more rapidly than in young adults and elderly patients. The relative maximal MAP to the baseline value is higher in elderly patients.
Aged ; Arterial Pressure ; Blood Pressure ; Heart Rate ; Humans ; Inhalation ; Thiopental ; Young Adult

An intracranial hemorrhage is a fatal complication associated with general anesthesia. It can occur in patients with an intracranial aneurysm, hypertension, cerebral vascular malformation, and blood dyscrasia, etc. A sudden hemodynamic change during intubation and extubation in general anesthesia is dangerous, particularly in these patients. We encountered an intraventricular hemorrhage in a 42 year old pregnant woman after a cesarean section. The patient was induced with 300 mg of thiopental and 45 mg of rocuronium. The anesthesia was maintained with N2O/O2 and sevoflurane after endotracheal intubation. Five hours after surgery, the patient had a seizure at the ward. A MRI and CT scan of the brain showed a right intraventricular and basal ganglia hematoma. The CT 3-D brain angiography showed an unruptured small aneurysm on the right posterior communicating artery.
Adult ; Anesthesia ; Anesthesia, General* ; Aneurysm ; Angiography ; Arteries ; Basal Ganglia ; Brain ; Cerebral Hemorrhage ; Cesarean Section* ; Female ; Hematoma ; Hemodynamics ; Hemorrhage* ; Humans ; Hypertension ; Intracranial Aneurysm ; Intracranial Hemorrhages ; Intubation ; Intubation, Intratracheal ; Magnetic Resonance Imaging ; Pregnancy ; Pregnant Women ; Seizures ; Thiopental ; Tomography, X-Ray Computed ; Vascular Malformations

BACKGROUND: The relation between pressure-derived fractional collateral flow (PDCF) and coronary arterial remodeling remains uncertain in acute myocardial infarction. METHODS: We evaluated the effect of arterial remodeling on the development of PDCF in 72 patients with first acute myocardial infarction (pain onset <12 h) treated with primary angioplasty. Intravascular ultrasound study was performed before intervention. The remodeling index (RI) was defined as a ratio of (lesion/proximal reference) external elastic membrane area. Positive remodeling was defined as a RI >1.0 and nonpositive remodeling as a RI < or =1.0. Using a 0.014-in. fiber optic pressure monitoring guide wire, the PDCF index was measured by simultaneous measurement of mean aorta pressure (Pao), distal coronary pressure during the balloon occlusion (Pocc), and central venous pressure (CVP):PDCF index=100x(Pocc-CVP)/(Pao-CVP). Sufficient collateral was defined as PDCF index >24% and insufficient collateral as PDCF index < or =24%. RESULTS: The RI was 1.04+/-0.15 in the lesions with sufficient collateral and 1.03+/-0.16 in the lesions with insufficient collateral (p=0.812). There was no significant difference in the frequency of positive remodeling between the 2 groups (55% vs. 54%, respectively, p=0.966). The PDCF index was 20+/-11% and 20+/-9% in positive and nonpositive remodeling, respectively (p=0.891). There was no significant correlation between RI and PDCF index (r=0.027, p=0.823). CONCLUSION: The pattern of coronary arterial remodeling might not influence the development of collateral blood flow in patients with acute myocardial infarction treated with primary angioplasty.
Angioplasty* ; Aorta ; Balloon Occlusion ; Central Venous Pressure ; Collateral Circulation ; Coronary Vessels* ; Humans ; Membranes ; Myocardial Infarction* ; Ultrasonography ; Ultrasonography, Interventional

Intraoperative pulmonary thromboembolism (PTE) is rare, but is nevertheless one of the important causes of morbidity and mortality in patient undergoing surgery. However, The detection of PTE is difficult because it's clinical symptoms and signs are nonspecific during surgery, and specialized diagnostic tools are not readily available in the operating room. We report a case of PTE due to cancer emboli with thrombi encountered during a nephrectomy in patient with renal cell cancer, and demonstrate that one-lung ventilation can aid in the diagnosis of massive PTE when the evaluation is suspected.
Carcinoma, Renal Cell ; Diagnosis ; Humans ; Mortality ; Nephrectomy ; One-Lung Ventilation* ; Operating Rooms ; Pulmonary Embolism*

BACKGROUND: In searching for a differential spinal block between dependent and nondependent sides, we evaluated the influence of the duration of lateral decubitus on the spread of hyperbaric bupivacaine during spinal anesthesia. METHODS: Spinal anesthesia with 1.2 ml of hyperbaric 0.5% bupivacaine (6 mg) was administered with a 25-gauge Whitacre unidirectional needle to 50 ASA 1 patients undergoing unilateral knee arthroscopy. The patients were allocated randomly to three groups according to the duration of lateral decubitus after spinal injection in the lateral position operation side dependent: Group 1, 10 min in lateral decubitus then supine; Group 2, 20 min in lateral decubitus then supine; Group 3, 30 min in lateral decubitus then supine. Sensory and motor block (pinprick/modified Bromage scale) as well as skin temperature were compared between the dependent and nondependent sides. Circulatory variables were recorded for 10 min after being turned supine. RESULTS: The sensory block between dependent and nondependent sides were significantly different in Group 3. In Group 1, the level of maximum sensory block was higher than Group 3 on nondependent side. There was no difference in the number of patients having achieved Grade 3 and 0 motor block among three groups on dependent and nondependent sides. The skin temperature in lateral decubitus was significantly higher on the dependent side than nondependent side in three groups. In Groups 1 and 2, the skin temperatures of nondependent side were increased after turned supine, but that was maintained during supine position in Group 3. The circulatory variables were stable in all 50 patients. CONCLUSIONS: We conclude that when a small dose of 0.5% hyperbaric bupivacaine is injected into patients in the lateral position, complete unilateral spinal anesthesia is achieved when the patients arekeep in a lateral position for more than 30 min after spinal injection.
Anesthesia, Spinal* ; Arthroscopy ; Bupivacaine* ; Humans ; Injections, Spinal ; Knee ; Needles ; Skin Temperature ; Supine Position

We reviewed the clinical characteristics and surgical results of patients who had consecutive esotropia after exotropia surgery with at least 6 months of follow-up. The number of transient esotropic cases with more than 10 prism diopter postoperatively was 105[9%] in total 1128 cases and persistent esotropic cases at least for six months after surgery was 24[2%]. Significant correlations were found between the development of consecutive esotropia and the presence of amblyopia[p=0.04], poor stereopsis[p=0.02], suppression of the Worth 4-dot test[p<.01], and recession-resction surgery[p=0.02]. The corrective surgery for consecutive esotropia was performed on 12 cases[1.1%] with unilateral lateral rectus advancement[7 cases], bilateral lateral rectus advancement[3 cases], unilateral medial rectus recession[1 case] and bilateral medial rectus recession[1 case]. All of them showed good results.
Esotropia* ; Exotropia* ; Follow-Up Studies ; Humans

BACKGROUND: A rapid increase in isoflurane concentration induces tachycardia and hypertension and increases plasma catecholamine concentration. The current study examined the effects of the rate of increase in inhaled isoflurane concentration on the circulatory responses. METHODS: Unpremedicated sixty three ASA physical status 1 patients, aged 20-40 years, scheduled for elective surgery under general anesthesia were randomly allocated into one of three groups. In each group, the inspired concentration of isoflurane via mask was increased up to 5 vol% at the rate different from other groups. The inspired concentration of isoflurane via mask was increased to 5.0 vol% abruptly (group 1), for 100 seconds (group 2), or 200 seconds (group 3). The target was to produce an end-tidal concentration of isoflurane (ETisof) of 2.6 vol% which was maintained until the end of the study by adjusting the vaporizer setting, when necessary. Heart rate (HR), mean arterial pressure (MAP), ETisof, end-tidal concentration of carbon dioxide, and peripheral oxygen saturation were measured at baseline and every 30 seconds for 5 minutes after inhalation of isoflurane and for 2 minutes after intubation. RESULTS: HR and MAP were significantly increased in all three groups compared with baseline, but significant differences in maximum values were not observed in three groups. There were significant differences among the groups in time from the onset of isoflurane inhalation to the maximal effect on HR and MAP. However, there were no significant differences among the groups of the ETisof at the maximal HR and MAP were seen. CONCLUSIONS: The high concentration of isoflurane transiently increase HR and MAP during inhaled anesthesia induction. However, the rate of increase in inhaled isoflurane concentration does not affect the circulatory responses.
Anesthesia ; Anesthesia, General ; Arterial Pressure ; Carbon Dioxide ; Heart Rate ; Humans ; Hypertension ; Inhalation ; Intubation ; Isoflurane* ; Masks ; Nebulizers and Vaporizers ; Oxygen ; Plasma ; Tachycardia

BACKGROUND: Bone cement implantation syndrome is characterized by hypotension, hypoxemia, cardiac arrhythmia, cardiac arrest, or any combination of these complications. The purpose of this study was to examine the effects of methylmethacrylate bone cement on cardiopulmonary variables during cemented hip arthroplasty in the elderly patients. METHODS: Twenty patients, aged over 65, undergoing cemented hip arthroplasty under general anesthesia were evaluated. Various cardiopulmonary variables with pulmonary and radial artery catheter, analysis of arterial blood gases, and capnography were measured at pre- and post-prosthetic insertion. RESULTS: The application of methylmethacrylate bone cement and femoral prosthesis resulted in an increase in pulmonary artery pressure and pulmonary vascular resistance, but there were no significant changes in blood pressure, heart rate, cardiac output, and systemic vascular resistance. Cemented hip arthroplasty was also associated with increased PaCO2 and dead space ventilation. Decreased PaO2 (1 atient) and hypotension (2 patients) were noted just after implatation of bone cement and prosthesis. CONCLUSIONS: In conclusion, hip arthroplasty with methylmethacrylate bone cement is associated with substantial risk in the elderly patients. We make recommendations of measures for the prevention and the management against hypotension and hypoxemia during cemented hip arthroplasty in the elderly patients.
Aged* ; Anesthesia, General ; Anoxia ; Arrhythmias, Cardiac ; Arthroplasty* ; Blood Pressure ; Capnography ; Cardiac Output ; Catheters ; Gases ; Heart Arrest ; Heart Rate ; Hip* ; Humans ; Hypotension ; Methylmethacrylate ; Prostheses and Implants ; Pulmonary Artery ; Radial Artery ; Vascular Resistance ; Ventilation

BACKGROUND: Recently, functional direct cortical stimulation mapping is frequently used during craniotomy for the surgery of brain pathology (tumors, epileptic foci etc.) within or close to the central motor area. We reviewed and analyzed our experiences to evaluate the safety and efficacy of our hospital's anesthetic management regimens. METHODS: We used three anesthetic regimens (isoflurane fentanyl; propofol fentanyl; awake craniotomy, conscious sedation analgesia) in 44 patients. We evaluated the success ratio of mapping and the incidence of intraoperative problems (seizures, changes in vital signs etc) in each regimens. RESULTS: In awake craniotomy group, functional mapping is performed successfully in all patients but there were some intraoperative problems (hypertension; 3 in 11 patients, hypercapnia; 3 in 11 patients, change to general anesthesia required; 1 in 12 patients). In general anesthesia groups, there were no significant differences between isoflurane treated patients and propofol treated patients in the success ratio of mapping (17/20 vs 11/12) and the incidence of intraoperative problems (seizure; 3/20 vs 1/12, hypertension; 2/20 vs 1/12). CONCLUSION: This results suggest that the anesthetic management regimens used in our hospital provide suitable conditions for craniotomies when brain mapping is required.
Anesthesia, General ; Brain Diseases ; Brain Mapping ; Conscious Sedation ; Craniotomy* ; Fentanyl ; Humans ; Hypercapnia ; Hypertension ; Incidence ; Isoflurane ; Propofol ; Vital Signs