堀田 訓久

Bell麻痺の多くは予後良好であるが,治療に難渋する患者をしばしば経験する.今回,発症後2ヵ月間の治療で全く改善の見られなかった重度Bell麻痺の患者に対して鍼灸治療を行い,麻痺の改善を認めた症例を経験したので報告する.症例は67歳の女性.Bell麻痺の発症当日からステロイドが投与されたが,発症1ヵ月後の麻痺スコアは,柳原40点法で0点と重度であった.麻酔科を受診し,星状神経節ブロック(SGB)およびsilver spike point(SSP)療法を9回施行したが,麻痺の改善が全く見られなかったため,発症2ヵ月後から鍼治療および自宅での自己施灸を開始した.鍼治療は1～3週間に1回の頻度で実施し,自宅施灸はほぼ毎日行った.その後,麻痺は徐々に改善し,発症7ヵ月後の麻痺スコアは22点となった.薬物療法や神経ブロックで治療効果が得られなかったBell麻痺に対して,鍼灸で改善した症例を経験した.鍼灸治療は合併症リスクが低く,慢性の病態に対して長期間継続可能であり,自己施灸も利便性が高いことから,ペインクリニック診療で難渋するBell麻痺に対して考慮すべき治療法の一つと考えられた.(著者抄録)

BACKGROUND: Postherpetic itch has not commonly received attention as a complication of herpes zoster because pain predominates over itch in most patients with herpes zoster. Most cases of postherpetic itch are mild; however, cases of severe postherpetic itch reducing quality of life are rare. CASE PRESENTATION: A 52-year-old woman complained of severe itch in her left pinna and cheek 1 month after the first onset of herpes zoster at the same site. Owing to her scratching, she developed ulcers on her left pinna and cheek. Pregabalin was prescribed, and the itch subsided immediately, with the ulcers disappearing within 1 month. DISCUSSION: Severe itch was thought to be caused by neural injury from herpes zoster. Pregabalin may be a useful treatment option for neuropathic itch induced by herpes zoster.

BACKGROUND: Anaphylactic shock during pregnancy is a rare but life-threatening event for both the mother and the newborn. CASE PRESENTATION: A 42-year-old woman, who was pregnant with twins, was scheduled for cesarean delivery under combined spinal and epidural anesthesia. An epidural catheter was placed uneventfully. After spinal anesthesia, the patient exhibited skin symptoms and severe hypotension. The patient was diagnosed with anaphylaxis, and subsequently, treatment was started. Fetal heart rate monitoring revealed sustained bradycardia, and it was decided to proceed with cesarean delivery. After delivery, the mother's vital signs recovered. Both infants were intubated due to birth asphyxia. Currently, the twins are 4 years old and exhibit no developmental problems. Clinical examination identified mepivacaine as the causative agent of anaphylaxis. CONCLUSIONS: This case report highlights that upon occurrence of anaphylaxis during pregnancy, maternal treatment and fetal assessment should be started immediately. Indication for immediate cesarean delivery should be considered and a definite identification of the causative factor pursued.

区域麻酔は強力な鎮痛作用を有し、多角的な術後鎮痛戦略において重要な役割を担う。近年、超音波ガイド下に行う末梢神経ブロックは、小児麻酔の領域でも広く行われており、新たな神経筋膜面ブロックの小児への適用も報告されている。小児の末梢神経ブロックは全身麻酔下で行われることが多いが、合併症のリスクは高くならないと考えられている。また、末梢神経ブロックに使用する局所麻酔薬は、患児の体格に応じて安全な用量の範囲内とする。タンパク結合しないフリーの局所麻酔薬の血中濃度が高くなりやすい6ヵ月未満の乳児は、局所麻酔薬中毒のリスクが高く、注意が必要である。(著者抄録)

44歳女。下腹部痛が出現し、著明な炎症反応、腹部造影CT所見から骨盤腹膜炎、左卵巣膿瘍、卵巣腸管瘻、子宮筋腫および腺筋症と診断され、緊急腹式子宮摘出術および左付属器切除術を予定した。合併症としてバセドウ病と慢性心房細動があり、複数回の通院中断歴、1週間前からの抗凝固薬の自己中断が判明した。なお、意識障害や夜間の検査体制のため、術前の甲状腺ホルモン値は不明であった。酸素投与下にプロポフォール、フェンタニル、レミフェンタニル、ロクロニウムで導入後に気管挿管し、維持はデスフルラン、レミフェンタニルを用いて行った。導入後に高度の頻脈を認めたためランジオロールの持続投与を開始し、また、急激に体温が上昇したため体表冷却を行った。術後は挿管のまま集中治療室に入室し、チアマゾール、ヒドロコルチゾンの投与、ヨウ化カリウムによるヨードブロックを行った。ランジオロールは長期継続を見据え、プロプラノロールへ変更した。頻脈、高体温は是正されたが、意識障害が数日遷延した。術後3日目に術前採取した検体の甲状腺ホルモン値が判明し、甲状腺中毒を認めたため甲状腺クリーゼと診断した。意識障害は徐々に改善し、術後10日目に内科病棟へ転院となった。その後、アイソトープ治療を施行し甲状腺ホルモン値は正常範囲内となり、外来での内服加療を継続している。

41歳女性。多発性子宮筋腫に対して下腹部正中切開による子宮筋腫核出術が予定された。術後鎮痛法として超音波ガイド下腹横筋膜面(TAP)ブロックを行い、静脈血栓塞栓症予防目的で抗凝固薬の投与を行った。だが、術後第3病日目に左側腹部のドレーン抜去時より右側腹部の痛みが出現し、第7病日目の腹部超音波検査ではTAPブロック部位に一致した腹斜筋内血腫が確認された。右側腹部の痛みは軽度であり、翌日には退院、術後第20病日には痛みは改善し、超音波では血腫の消失が確認された。

妊娠末期に重症急性膵炎を合併し、全身麻酔下の緊急帝王切開後に集学的治療により救命し得た症例(38歳、2経妊2経産)について報告した。妊娠36週1日に急性腹症で当院を受診し、便秘の診断で帰宅したが腹痛は改善せず、再受診し胎児徐脈と急性膵炎を認め緊急入院し、同日緊急帝王切開術を施行した。術後から急性膵炎に対する集学的治療を行い、母児ともに救命し得た。本症例では、子宮筋腫を合併していたこと、産褥期で子宮復古が不十分であること、すでに大量の胸腹水を認めていたことで、重症急性膵炎の合併症である腹部コンパートメント症候群(Abdominal Compartment Syndrome:ACS)のリスクが高いと予想されたため、腹腔内圧を膀胱内圧でモニタリングしたが、膀胱内圧は低値で推移し、ACSは発症しなかった。

微小血管減圧術後に再発した特発性三叉神経痛に対して五苓散が著効した症例を経験した。患者は89歳、女性で、14年前に特発性三叉神経痛に対して微小血管減圧術を受けていた。今回、特発性三叉神経痛が再発し、カルバマゼピン投与を開始したが、副作用のために増量ができなかった。そこで、五苓散7.5g/日を併用したところ、自発痛はほぼ消失した。五苓散は、微小血管減圧術後に再発した特発性三叉神経痛に対して効果を示す可能性が示唆された。(著者抄録)

Both single-injection transversus abdominis plane (TAP) block and continuous wound infiltration (CWI) provide postoperative analgesia, but no study has compared the two regional techniques. We tested the hypothesis that CWI is more effective for controlling postoperative pain compared with single-injection TAP block after laparotomy. We conducted a prospective randomized study of patients undergoing gynecologic laparotomy with midline incision through the umbilicus under general anesthesia. The patients were allocated to receive either single-injection TAP block (TAP group) or CWI (CWI group) for postoperative analgesia. All patients received intravenous patient-controlled analgesia with morphine and intravenous flurbiprofen twice daily after surgery. Postoperative pain at rest and on coughing, postoperative morphine consumption, incidence of postoperative nausea and vomiting (PONV), pruritus and urinary retention, ambulation, and satisfaction score were recorded. Patients were assessed at 3 h after surgery and twice daily on postoperative days (POD) 1 and 2. Data of 54 patients were analyzed. Compared to the TAP group (n = 27), pain score on coughing was significantly lower in the CWI group (n = 27) on POD1 and POD2 (P < 0.05). Pain score on coughing at 3 h after surgery, pain score at rest at all assessed time points, morphine consumption, incidence of PONV, pruritus and urinary retention, ambulation, and satisfaction score were not different between the two groups. CWI reduced pain on coughing after the day of surgery compared with single-injection TAP block when performed as part of multimodal analgesia in patients undergoing gynecologic laparotomy.

肺がんによる難治性胸部痛に対し，オピオイド，放射線治療にアルコールを用いた超音波ガイド下胸部傍脊椎ブロック（US-TPVB）を併用し，良好な除痛効果が得られた症例を経験した．症例は右下葉肺がんの61歳，女性．原発巣の増大，右肋骨転移，胸膜播種に伴う右胸部痛を認めた．オピオイドの増量，肋間神経ブロック，間欠的硬膜外ブロックでは対処困難であったため，アルコールを用いたUS-TPVBを行い，いったんは鎮痛が得られた．しかし，痛みが悪化し，病巣の拡大が判明したため，放射線照射と1回目より尾側でのアルコールによるUS-TPVBを行った．以後6カ月間，痛みとオピオイド投与量は減少し，患者の活動性は改善した．TPVBは，体幹片側を除痛でき，術後鎮痛では硬膜外ブロックと鎮痛効果が同等で，合併症が少ないことが示されている．これらの特徴を考慮すると，神経破壊薬を用いたUS-TPVBは適切な症例を選べば，がん性痛治療の選択肢になると考えられる．進行肺がんによる難治性がん性痛に対し，アルコールによるUS-TPVBを併用することで良好な除痛効果が得られた．

We report three cases of continuous wound infiltration (CWI) for postoperative analgesia in upper abdominal surgery using the multi-holed epidural catheter. Ropivacaine 0.2% at a rate of 8 ml·hr-1 was administered through the catheters after surgery. Intravenous-patient controlled analgesia was used as a rescue. The postoperative pain was well controlled, and all patients could walk the next day after surgery. The consumption of rescue morphine was little and no side effect of morphine was observed. CWI is an easy procedure and is indicated in the patients with hemostatic abnormality and a difficulty in the epidural anesthesia. CWI was an effective technique for postoperative pain control in the upper abdominal surgery patients.

Design: A prospective, randomized, open study. The regional technique used was not blinded. Setting: A university teaching hospital. Participants: Forty-eight patients undergoing video-assisted thoracoscopic surgery (VATS) for tumor resection. Interventions: Patients received either continuous extrapleural block or continuous epidural block using ropivacaine for a period of 60 hours after surgery. Measurements and Main Results: To evaluate postoperative pain control, the primary and secondary endpoints were the visual analog scale (VAS) on movement and the amount of rescue analgesia, respectively. There were no significant differences between the extrapleural and epidural block groups with regard to VAS at rest and during movement assessed at 4, 12, 24, 36, and 48 hours after surgery, dosage of intravenous morphine (extrapleural: 12.9 +/- 11.3, epidural: 10.2 +/- 6.9 mg), supplemental nonsteroidal anti-inflammatory drugs, incidence of postoperative nausea and vomiting (extrapleural: 12/20, epidural: 11/20), postoperative ambulation (extrapleural: 18 at postoperative day [POD] 1 and 20 at POD 2, epidural: 19 at POD 1 and 20 at POD 2) and hospital stay after surgery (extrapleural: 12.7 +/- 6.3, epidural: 12.6 +/- 4.7 days). Conclusions: Although this study did not show the superiority of continuous extrapleural block relative to continuous epidural in VATS patients, the results suggest that both methods provided effective analgesia with a relatively small dose of rescue morphine. Although the analgesic effects of these techniques were comparable, extrapleural block has the advantage of safety and precise placement of the catheter and can be considered an alternative to epidural block in VATS patients. (C) 2011 Published by Elsevier Inc.

Background: To evaluate obstetric and anesthetic problems relating to cesarean delivery, we investigated parturients who had undergone cesarean section at the Center for Perinatal and Neonatal Medicine in Jichi Medical University Hospital. Methods: Obstetric and anesthetic data were gathered from January 2007 to December 2007 for all cesarean sections. Results: In all, 607 parturients received cesarean section during the period. Of the 607 cesarean deliveries, 308 were performed in elective condition, and 299 were done in emergency situation. Of the 299 emergencies, 125 underwent cesarean section at nights and/or holidays. Population risk included maternal age (age&gt 35 year, 33.1%), preterm birth (31.5%), and obesity (BMI&gt 35kg·m-2, 3.3%). Complicated pregnancy included multifetal pregnancies (15.2%) and placenta previa(12.5%). Conclusions: At the center for perinatal and neonatal medicine, population risk is increasing because of increases in maternal age, obesity, placenta previa, and rates of multifetal pregnancies.

We report two cases of elderly patients who underwent ultrasound-guided combined femoral nerve and lateral femoral cutaneous nerve blocks for osteosynthesis of femur neck fracture. In both cases, neuraxial anesthesia was contraindicated due to coagulopathy, and severe restrictive ventilatory disorder was observed. The femoral nerve and lateral femoral cutaneous nerve blocks were performed with 20 ml of 0.375% ropivacaine under ultrasonographic visualization using a high frequency linear probe. Ultrasonographic visualization was useful to identify the needle tip and to observe the spread of local anesthetics. Supplemental local infiltration of anesthetics and intravenous low-dose sedative drugs were administered during surgery. The perioperative course was uneventful in both cases. This combined block technique could be a choice for osteosynthesis of femur neck fracture especially in high-risk patients.

Epidural block is performed with surface landmark guidance and loss of resistance technique. Ultrasound visualization of the spinal column and surrounding structures gives additional anatomical information, which could make the block easier and safer. Previous studies revealed that there is strong correlation between the depth of the epidural space measured using ultrasound and the depth of the needle inserted. In order to obtain an image of the spinal canal, the ultrasound probe is positioned at the interspace of spinous processes in transverse and longitudinal planes. The dura mater is identified as an echogenic structure inside the spinal canal. Prepuncture ultrasound examination offers useful information for epidural block such as puncture point and depth as well as angle to the epidural space.

Spinal hematoma is a rare and serious complication of neuraxial anesthesia. Risk factors for spinal hematoma during neuraxial anesthesia are anatomic abnormalities, impaired hemostasis and difficult needle placement. Japanese guideline for prevention of venous thromboembolism recommends low-dose unfractionated heparin (LDUH) to patients with moderate and high risk in perioperative period. LDUH is not contraindication for neuraxial anesthesia in this guideline. In order to reduce the risk of spinal hematoma in patients receiving heparin, it is recommended that the needle placement and catheter removal should be done when the anticoagulant effect of heparin is at the minimum. Postoperative evaluation of the neurological status is also important for early detection of a spinal hematoma.

We describe the clinical use of a new video-laryngoscope (GlideScope®, GS) in patients with a difficult airway and morbid obesity. In 4 patients with a difficult airway, showing a Cormack-Lehane grade III view with Macintosh direct laryngoscope, the glottic opening (Cormack-Lehane grade I or II) was visualized with GS. In 2 patients, showing a Cormack-Lehane grade IV view with Macintosh direct laryngoscope, Cormack-Lehane grade II view of the glottic opening was obtained. GS also provided a good view of glottic opening in a patient with morbid obesity. GS will have a profound impact on the management of the difficult airway.

We describe a patient to whom ropivacaine 150 mg had been administered during obturator nerve blockade and developed grand mal convulsions because of inadvertent i.v. injection. Venous blood samples were taken 15, 32 and 52 min after the convulsion. The measured total plasma concentrations of ropivacaine were 4.5, 3.5 and 2.9 μg · ml-1 respectively. The peak plasma concentration at the time of the inadvertent i.v. injection was estimated to be 6.6 μg · ml-1. The patient recovered uneventfully.

Background: The anesthetic incident-reporting scheme in the department of anesthesia, Jichi Medical School Hospital, has been running for 3 years and 100 incidents have now been reported. Methods: An 'anesthetic incident' was defined as any incident related to anesthesia which either caused harm, or if uncorrected might have caused harm, to a patient. Results: There were 26 problems involving drugs, 18 airway and respiratory problems, 15 dental damages, 11 cardiovascular problems, 8 problems related epidural anesthesia, and 22 others. Conclusions: The scheme has successfully high-lighted weaknesses of the department.

A 76-yr-old male presented for leg amputation above the knee. The patient complained of dyspnea due to pulmonary embolism occurring 3 weeks before operation. In addition, the patient could not report paresthesias because he had suffered from a cerebral infarction. Anesthesia was performed with combined block of femoral, sciatic, obturator nerves and the lateral cutaneous nerve of the thigh. The nerves were anesthetized with 0.75% ropivacaine solution 31 ml by use of an electrical nerve stimulator and an insulated needle. Nerve stimulation technique is the best choice for patients who are unable to report paresthesias reliably.

A new programmable syringe infusion pump, Auto Syringe Model® AS 40 A, was evaluated for infusion of muscle relaxants, vasodilators and opioids in 4 surgical patients. Every drug mentioned above was easily adjusted according to surgical requirement in these patients. Auto Syringe Model® AS40A is light and compact. Its major advantages lie in the mechanisms for delivery of a bolus dose and autmated delivery of intermittent doses, automatic rate calculation, and the applicability to various sizes of syringes. Auto Syringe Model® AS40A was found to be very useful for intravenous infusion of drugs.