[Perioperative management for nephrectomy using combined spinal-epidural anesthesia with sedation in a patient with cerebral palsy under maintenance hemodialysis].

A 43-year-old man (166 cm, 53.5 kg) with cerebral palsy on maintenance hemodialysis underwent a right nephrectomy for gross hematuria under combined spinal-epidural anesthesia (CSEA) with sedation. The patient suffered from hemiplegia, speech disturbance and low intelligence (approximately 6 years and 8 months). Following premedication with midazolam 4 mg, he was calm and cooperative. An analgesic level below T 10 was obtained by spinal (L 4-5) anesthesia using plain 0.5% bupivacaine 4 ml. Further cephalad spread (below T 3) was secured by bolus (7 ml) and continuous (8.5 ml.h-1) administration of 2% mepivacaine for thoracic epidural (T 10-11) anesthesia. Intravenous sedation (midazolam 0.08 mg.kg-1.h-1 and pentazocine 0.24 mg.kg-1.h-1) with 2 l.min-1 oxygen via nasal cannula was given during surgery. The operation and anesthesia times were 216 min and 330 min, respectively. Intraoperative bleeding was 1,158 g and the extracted kidney weighted 2,333 g. Following a prompt recovery with exclamation at the end of surgery, a bolus dose of epidural buprenorphine 0.2 mg combined with droperidol 2.5 mg was administered. Three hours after surgery, sleep was induced by brotizolam 0.25 mg orally. We accomplished a giant nephrectomy under CSEA with sedation in a patient with cerebral palsy receiving hemodialysis. Sufficient premedication using midazolam was profitable for CSEA in mental-retarded patient.