Sevoflurane is widely used for its rapid onset and offset due to a lower blood/gas coefficient. However, involuntary movements, tachycardia, and hypertension have been observed in some patients despite a continuing constantly delivered concentration of sevoflurane during 1-lung ventilation (OLV), indicating the possibility of insufficient depth of anesthesia. We observed a temporary but obvious decrease in arterial sevoflurane concentration and pulse oximeter readings in a patient during OLV. This may have resulted in the depth of inhaled anesthesia being insufficient during OLV because the arterial sevoflurane concentration was lower than expected in spite of constantly delivered and inspiratory/expiratory sevoflurane concentrations.

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SummaryDuring one-lung ventilation, ventilation-perfusion mismatch decreases the arterial concentration of inhaled anaesthetics due to the arterial-to-venous concentration difference. This study tested the hypothesis that in humans, the 'presumed effect-site concentration' (taken as the mid-point between the arterial and superior jugular venous concentrations) of inhaled anaesthetic falls during one-lung (vs two-lung) ventilation. Four patients scheduled for elective prostatectomy (two-lung ventilation) and four patients for elective thoracotomy (one-lung ventilation) were randomly selected and assigned to receive sevoflurane (vaporiser-dial setting, 1.5%). Sevoflurane concentrations were measured periodically from radial artery and superior jugular vein (via a catheter advanced cephalad from the jugular vein). During one-lung ventilation, the end-expiratory sevoflurane concentration was stable at 1.3% but the mean (SD) presumed effect-site concentration declined initially from 58 (6.7) to 43 (4.7) lg.ml )1 (p = 0.011) before slowly recovering. A period of insufficient depth of anaesthesia is thus a risk during one-lung ventilation. Minimum alveolar concentration (MAC) -awake (MAC awake ) is the minimum alveolar concentration of inhaled anaesthetic at which 50% of anaesthetised patients respond appropriately to spoken commands [1]. It is considered an appropriate target for anaesthetic concentration when using a balanced-anaesthesia regimen that incorporates regional or local anaesthesia supplemented with opioids for analgesia and with neuromuscular blocking agents for immobilisation, provided that the concentration of inhaled anaesthetic is constant. However, in a recent report of a single case we noted that during one-lung ventilation (OLV), ventilation-perfusion mismatch caused a decrease in the arterial anaesthetic concentration as a result of the gap it created between the arterial and venous anaesthetic concentrations [2]. This alerted us to the need for a quantitative analysis of changes in the depth of inhalation anaesthesia during OLV.

We report a case of a patient treated by retroperitoneoscopic partial nephrectomy who developed nitrogenous subcutaneous emphysema (SCE) as a complication. The use of a nitrogen gas-pressured fibrin tissue adhesive applied as a spray caused excessively increased pressure in the closed retroperitoneal space and resulted in widespread SCE with protracted clinical course. To the best of our knowledge, this is the first report of nitrogenous SCE associated with pneumoperitoneum. The clinical significance of nitrogenous SCE is emphasized, and the risks associated with the use of fibrin glue as a spray during laparoscopic surgery are discussed.

Pulmonary arterial catheter (PAC) placement under fluoroscopy is a useful and safe method to diagnose certain congenital cardiac anomalies [1]. However, when a PAC for intraoperative monitoring is placed without the aid of fluoroscopy, it may be inadvertently placed into anomalous veins. The following report presents a case of persistent left superior vena cava (PLSVC) with absence of right superior vena cava, which was not detected by a PAC inserted via the right internal jugular vein.

Malignant hyperthermia (MH) occurred during anesthesia with volatile inhalation anesthetics in a patient under treatment with multiple oral antipsychotic drugs and with a history of multi-acting receptor-targeted antipsychotic drug (MARTA)-induced elevation of serum creatine kinase (CK). Since the patient was considered to be at high risk for neuroleptic malignant syndrome (NMS) based on this history, differential diagnosis between MH and NMS was difficult at the time of onset. Later, the patient was found to be predisposed to MH based on abnormal high rate of the Ca2+-induced Ca2+ release (CICR). We concluded that MH was induced by the volatile inhalation anesthetics.

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Background Several types of antiarrhythmic drugs are known to induce QT prolongation and torsades de pointes. Case presentation An 84-year-old man was scheduled for open gastrectomy for residual cancer. He had been prescribed bepridil for atrial fibrillation that converted to sinus rhythm with prolonged QT interval in the operating room. After the surgery was initiated under general and epidural anesthesia, the patient’s heart rate decreased to 50/min and multifocal premature ventricular contractions appeared, followed by several episodes of torsades de pointes, each lasting for 5 to 15 s. Infusion of isoproterenol was started (0.01 μg/kg/min), and the heart rate was maintained at around 80/min. Premature ventricular contractions disappeared, and torsades de pointes did not recur during the surgery. The operation was completed uneventfully. The serum bepridil concentration was found to be extremely high postoperatively. Conclusions Bepridil-induced intraoperative episodes of torsades de pointes were successfully treated by increasing the heart rate with isoproterenol.