BACKGROUND Brugada syndrome is a potentially fatal cardiac arrhythmia characterized by incomplete right bundle-branch block (RBB) and characteristic ST-segment elevation in the anterior electrocardiogram (ECG) leads. This report is of a case of type 2 Brugada syndrome, and discusses the importance of preoperative history and ECG evaluation. CASE REPORT A 32-year-old man was scheduled for tympanoplasty. His preoperative ECG revealed saddleback-type J waves in V₂ (>2 mm) and ST increase (>1 mm) detected 1 week before elective surgery, but the ECG 1 year before showed normal. He had no notable past history. Anesthesia was induced with remifentanil and propofol, and maintained with sevoflurane in combination with remifentanil. Routine monitoring of vital signs was supplemented with V2 monitoring on the ECG. The heart rate was maintained at above 60 beats/min using ephedrine. The course of the operation was uneventful. CONCLUSIONS We managed anesthesia for a patient with a type 2 Brugada syndrome ECG without events, probably because he had no notable past history such as syncope. Type 2 and type 3 Brugada syndrome ECGs are difficult to recognize, and patients with them are considered to be less risky than a patient with a type I ECG. However, as Brugada syndrome ECG is dynamic and changeable, a type 2 or 3 Brugada syndrome ECG can change to a type I ECG under some conditions, and thus should not be overlooked, and the patient's past history or symptoms, such as syncope, should be carefully investigated.

Objective: To evaluate the preoperative prevalence of each type of J-wave syndrome electrocardiographic pattern and its association with perioperative cardiac events. Design: Retrospective study. Setting: Single hospital university study. Participants: The study evaluated 930 patients who underwent gynecologic, abdominal, neurosurgical, orthopedic, and urologic surgeries. Interventions: Preoperative standard 12-lead electrocardiogram (ECG) monitoring was performed, and each type of J-wave syndrome ECG pattern types 1, 2, and 3 and Brugada syndrome-type was evaluated. Incidence of perioperative cardiac events was investigated up to 1 year postoperatively using an electronic medical record system. Measurements and Main Results: Data from 789 patients were included in the final study. Of these, 16 patients (2.0%) had J-wave syndrome: 7 patients (0.9%) had type-1 patterns; 5 patients (0.6%) had type-2 patterns; 2 patients (0.3%) had type-3 patterns; and 2 patients (0.3%) had Brugada syndrome-type ECG patterns. A J-point elevation >= 0.2 mV, which is considered to be more dangerous, was found in only 2 patients with Brugada syndrome-type ECG patterns, both of whom suffered perioperative lethal arrhythmias. Conclusion: Patients with J-wave syndrome ECG patterns, even dangerous patterns, are not necessarily associated with a higher risk of perioperative cardiac events. However, Brugada syndrome type ECG patterns should be carefully monitored. (C) 2015 Elsevier Inc. All rights reserved.

A one-month-old baby with severe lung abscess was referred to our intensive care unit (ICU) due to dyspnea. When sudden bleeding from her bronchus occurred on the 18th day in the ICU, we tried to insert a Fogarty arterial embolectomy catheter through the tracheal tube to occlude her left bronchus with the aid of a bronchofiberscope. However, her tube was too narrow (Internal Diameter: 3.0 mm) to pass them, but we successfully inserted the catheter outside of the tracheal tube using Gride scope® and another endotracheal tube.

Transient sensory disturbances, including dysesthesia or neurologic deficits in the lower extremities or buttocks have been described as complications of neuraxial anesthesia. We report a case of transient lower limb pain following the accidental placement of an epidural catheter into the thoracic subarachnoid space. A 31-year-old woman was scheduled to undergo laparoscopic myomectomy. An epidural catheter was accidentally inserted subarachnoid at the T12-L1 intervertebral space with a 2-ml test dose of 2% lidocaine, and was promptly removed. Fulgurant pain and allodynia extending over the L2-5 areas of the left lower limb and buttock started immediately postoperatively. We treated the persistent pain in our patient with epidural infusion of local anesthetics and steroids during her hospital stay, and with carbamazepine and a tricyclic antidepressant after her discharge from the hospital. All signs of allodynia had disappeared on postoperative day 25. Sagittal and axial T2-weighted magnetic resonance imaging (MRI) at the Th12 level revealed a small high-intensity area without mass effect in the ipsilateral dorsal column. The patient's clinical course and MRI diagnosis suggested the inhibition of descending inhibitory pathways resulting from a lesion of the spinal cord as the possible etiology of the transient lower limb pain and allodynia.

Abstract：42歳女。嘔吐、下痢、更に発熱、著明な腹痛と腹部膨満感で他院に入院した。抗菌薬を投与するが発熱と著明な腹痛は持続し、CRP、CK、LDHの上昇で絞扼性イレウスを疑い緊急開腹を行ったが、トライツ靱帯から肛門側空腸に発赤と浮腫を認めたが絞扼所見はなかった。症状は改善せず血便が出現し、十二指腸水平脚から肛門側に浅い多発潰瘍を認めたが出血はなかった。炎症性腸疾患を疑い3日間のステロイドパルス療法を行なうも大量下血を来たしHb値も低下したため止血術目的に当院消化器内科に入院した。出血性ショックからICU入室となり気管挿管、人工呼吸、カテコラミン投与と輸血による循環管理を行なった。消化管出血シンチで出血源を同定し翌日に試験開腹術を施行した。術中内視鏡でトライツ靱帯から肛門側の空腸に多発する浅い円形の全周性潰瘍と露出血管を認め空腸15～100cmを切除した。病理所見より核内および細胞質内封入体を認め、サイトメガロウイルス(CMV)抗

25歳女。帝王切開の出産後1ヵ月の急性腸炎は保存的治療で軽快し、出産2ヵ月後の強い腹痛を急性虫垂炎穿孔による腹膜炎と近医で疑われ手術目的で当院紹介受診した。腹腔内に多量の膿性腹水を認めたが腹腔内臓器に異常はなく、腹腔内洗浄ドレナージ後に閉腹した。術後12時間に意識障害と血圧低下、WBCとCRPの高値、凝固能異常を認め敗血症性ショックと判断してICUに入室した。ドリペネム、ヘパリン、メシル酸ガベキサートを投与し、人工呼吸器による呼吸器管理を開始した。入室2日目に劇症型A群溶連菌感染を疑いアンピシリンとゲンタマイシンの先行投与を開始した。胸部X線、心エコーより心機能の高度低下による心原性肺水腫と診断し、PDEIII阻害薬、フロセミド、シベレスタットナトリウムを投与した。入室3日目に術前の腟分泌物および術中腹水培養よりA群β溶連菌が検出された。WBCとCRPの増悪は血漿交換施行で改善した。7日目に壁運動と透過性の改善を認め、8日目は人工呼吸

For the suppression of descending inhibitory pathways in animals, single-dose lidocaine blockade is reversible and causes less damage than chronic spinal cord injury, decerebration, and cold blockade of the spinal cord. However, single-dose blockade has a variable onset and is relatively short-lived. To surmount these disadvantages, we devised a continuous thoracic intrathecal lidocaine infusion and evaluated its effects in rats. Rats were administered continuous intrathecal infusions of 0, 0.25%, 0.5%, and 1% lidocaine at 10 &gml center dot h(-1) following a 10-&gml bolus. The effects of the continuous thoracic blockade on tail-flick (TF) latency (estimated by the percent maximum possible effect [%MPE]) and on the release of neurotransmitters in the cerebrospinal fluid (CSF) were evaluated. Continuous thoracic blockade with 0.5% and 1% lidocaine infusion reversibly shortened TF latency (%MPE, -22.0 +/- 11.0 % and -21.2 +/- 4.6 %, respectively, versus baseline; P < 0.05) during drug infusion. Compared with normal saline, thoracic intrathecal infusion of lidocaine significantly lowered norepinephrine and serotonin concentrations in the CSF at 1 h of infusion (P = 0.02 for both). Continuous thoracic blockade by local anesthetic resulted in reversible suppression of descending inhibitory pathways for varying durations. Such blockade may provide further information regarding nociceptive transmission and the mechanisms of antinociception in animals.

Although the etiology of neural blockrelated transient neurological sequelae following spinal anesthesia, such as transient neurological symptoms (TNS) and less serious sensory disturbances, is still unclear, previous reports have described the facilitation of ascending nociceptive pathways as the source of complications resulting from local anesthetic toxicity, needle trauma, and patient positioning. We hypothesized that, in addition to the facilitation of ascending nociceptive pathways, the intrathecal injection of local anesthetics might interrupt descending inhibitory pathways, leading to hypersensitivity. To test this hypothesis, changes in tail flick (TF) latency were evaluated under lidocaine blockade of descending inhibitory pathways at the thoracic spinal cord level and under lumbar intrathecal lidocaine injection in rats. Furthermore, the effects of lumbar intrathecal lidocaine injection on cerebrospinal fluid (CSF) concentrations of neurotransmitters related to nociceptive transmission were investigated. The results revealed that thoracic intrathecal lidocaine shortened TF latency immediately after injection, while lumbar intrathecal lidocaine injection initially prolonged TF latency to the cut-off point and subsequently reduced TF latency compared to the baseline. Lumbar intrathecal lidocaine caused a significant reduction in norepinephrine concentrations in the CSF. These results indicate that the reduction of TF latency following lumbar intrathecal lidocaine injection was caused by the suppression of nor adrenergic descending inhibitory pathways. We concluded that the enhanced activity of dorsal horn neurons due to the suppression of descending inhibitory pathways by intrathecal lidocaine injection is one of the possible mechanisms of transient neurological sequelae.

食道癌手術患者を,術中の輸液製剤としてMgイオン含有酢酸リンゲル液(フィジオ140)を用いた群(P群)とMgイオン非含有酢酸リンゲル液(ヴィーンF)を用いた群(V群)に分け,Mgイオン濃度の変動を執刀前,術中および術後(ICU入室1日目),ICU入室2日目,ICU入室3日目に計測し,濃度変化を検討した.術中および術直後のMgイオン濃度はP群,V群ともに執刀前値と比較して有意に減少した.V群では術中値と比較して術直後も有意に低下していたが,P群では術中濃度と術直後濃度の間に有意な低下を認めなかった.ICU入室2日目には,両群ともに執刀前値に回復した.Mgイオン含有酢酸リンゲル液は,術中から術直後までのMgイオン濃度の低下を抑制することができ有用であった.