A 68-year-old woman with severe cardiac dysfunction due to dilated phase of hypertrophic cardiomyopathy was diagnosed with sigmoid cancer and scheduled for high anterior resection. Preoperative left ventricular ejection fraction (EF) was 16% by transthoracic echocardiography. After placement of an epidural catheter at the T12-L1 interspace, and artery catheters in the left radial artery for invasive blood pressure monitoring and in the right femoral artery for stand-by IABE general anesthesia was induced by midazolam, fentanyl and sevoflurane, and maintained with sevoflurane. Analgesia was obtained by epidural administration of 1% lidocaine and 0.2% ropivacaine. A central venous catheter was placed in the right internal jugular vein through which dobutamine was infused throughout the operation. Cardiac function monitored by transesophageal echocardiography showed EF of 9% just after insertion. After arbitrary administration of phenylephrine and landiolol, the operation and anesthesia were completed without serious problems. However, congestive heart failure worsened on postoperative day 2, and was improved by increasing dobutamine and by administration of milrinone.
The evaluation of the lung has usually been considered off-limits for ultrasound, because ultrasound energy is rapidly dissipated by air. Lung ultrasound is not useful for the evaluation of the pulmonary parenchyma and the pleural line. However ultrasound machines have become more portable, with decreased start-up time, while simultaneously providing improved image quality and ease of image acquisition. Additionally, lung ultrasound is highly accurate for the diagnosis of pneumothorax, hemothorax. pleural effusions, pulmonary edema (cardiogenic or noncardiogenic), interstitial syndrome, and pneumonia. These factors make lung ultrasound suitable for operating rooms, intensive care units, and emergency departments. Adequate interpretation of lung ultrasonographic findings, including artifacts, requires some training and experience. Since lung ultrasound abnormalities, however, are well defined and easy to recognize, learn and reproduce, operator dependence is minimal. So let's try lung ultrasound! In this article, the author will discuss the examination method for adequate lung ultrasonographic images, lung ultrasonographic findings and signs, leading to the diagnosis.
Respiratory complications are the major causes of anesthesia-related death or irreversible brain damage. Recently, the incidence and severity of bronchial asthma, obesity and sleep apnea are increasing, and because of advancement of medical care, surgery is increasingly carried out in patients with moderate or severe respiratory complications. In this special issue, preoperative assessment and treatment methods of patients with upper respiratory tract infection, bron- chial asthma, sleep apnea, deformed airways, chronic obstructive lung disease, or restrictive respiratory dis- ease are discussed, followed by anesthesia and airway management methods during anesthesia, including treatment of each respiratory disease.
BACKGROUND:Fetoscopic laser coagulation is an ef- fective treatment for the vascular anastomoses present in twin to twin transfusion syndrome (TTTS); how- ever, anesthetic management during the procedure has not yet been standardized. We hypothesized that dex- medetomidine could produce excellent maternal seda- tion during fetoscopic surgery. Therefore, we per- formed a prospective study to compare dexmedetomi- dine with fentanyl infusion, which had been previously used for sedation.METHODS:Patients scheduled for fetoscopic laser coagulation for TTTS were randomized into 2 groups. In the first group (n =19), fentanyl (2 μg · kg-1) was intravenously infused, followed by a maintenance dose of 1-2,μg · kg⁻¹ · hr⁻¹. The second group (n=18) received a loading dose of dexmedetomidine (1 μg · kg⁻¹) for 10 min, followed by a maintenance dose of 0.7 μg · kg⁻¹ · hr⁻¹. Both groups received 1% lidocaine administered locally. Adverse event incidence, hemo- dynamic parameters, and face scale were evaluated.RESULTS:One patient in the dexmedetomidine group required conversion to general anesthesia. Vomiting, nausea, and respiratory depression were significantly more frequent with fentanyl than with dexmedetomi- dine. Face scale scores were significantly better with dexmedetomidine than with fentanyl.CONCLUSIONS:Continuous dexmedetomidine infusion provides acceptable maternal analgesia and sedation during endoscopic treatment of TTTS.
A 64-year-old male patient with pheochromocytoma underwent an off-pump coronary artery bypass graft- ing. Determination of order of surgeries, preoperative medical management and intraoperative hemodynamic management are important in these cases. Al- though bolus administration of phenylephrine showed poor response, the surgery was uneventful and the patient remained hemodynamically stable throughout the procedure and perioperative period.
BACKGROUND:The McGRATH® MAC (McGRATH) laryngoscope is a newly developed video device, which enables us to perform tracheal intubation minimally invasive. The aim of this study is to evaluate and com- pare the hemodynamic changes triggered by intuba- tion using either the McGRATH or the Macintosh laryngoscope.METHODS:Thirty-seven patients, between 20 and 42 years of age with ASA status I or II, were randomly assigned to two groups : the McGRATH (n=19) or the Macintosh laryngoscope (n=18). Anesthesia was induced with fentanyl 2 μg · kg⁻¹, propofol 2 mg · kg⁻¹, sevoflurane 2%, and rocuronium 0.6 mg · kg⁻¹. We recoded the hemodynamic changes (blood pressure, heart rate) every minute up to 5 minute after intuba- tion. We also recoded the time needed to complete the tracheal intubation. In all cases, the same certified anesthesiologist performed tracheal intubation. Data were presented as mean ± SD. Statistical analyses were performed using the t-test for comparisons of the patients' demographic data, blood pressure, and heart rate between groups.RESULTS:There were no significant differences in two groups regarding age, weight, height, and sex. Comparing the average time needed to complete the tracheal intubation, the McGRATH group took longer than Macintosh group (40.5 ± 15.3 seconds vs. 29.4? 4.73 seconds, P=0.01). There was no significant differ- ence in blood pressure and heart rate just before tra- cheal intubation. The McGRATH laryngoscope had a significantly lower value than the Macintosh laryngo- scope in systolic pressure (101.2?7.9 vs. 111 ?16.8 mmHg, P=0.03) and heart rate (71.5?9.9 vs. 79.7? 12.3 mmHg, P=0.02) at one minute after tracheal intu- bation.CONCLUSIONS:The McGRATH laryngoscope is less invasive for hemodynamic parameters than the Macin- tosh laryngoscope. These findings suggest that the McGRATH laryngoscope may enable us to perform tracheal intubation less invasively.
We report the anesthetic management during the laparoscopic cholecystectomy in a 60-year-old woman (height 150 cm, 'Weight 46 kg) with mitochondrial encephalopathy (chronic progressive external ophthal- moplegia, or CPEO). CPEO causes a disorder of aero- bic energy metabolism in various organs due to mito- chondrial dysfunction. It is thus very important in anesthetic management to maintain energy balance of demand and supply in organs and to protect the patient's respiratory muscles. Our patient had devel- oped CPEO 46 years earlier, and at her presentation she was bedridden and receiving both respiratory assistance via tracheostomy and tube feeding. Her hearing and understanding were intact, but she was blind due to lagophthalmos. We performed intravenous anesthesia with propofol (TCI) and remifentanil com- bined with epidural anesthesia. Rocuronium was injected under a train-of-four (TOF) monitoring. The operative time for the laparoscopic cholecystectomy was 4 hours. A total of 50 mg of rocuronium and 2,050 ml of bicarbonic ringer was injected during the opera- tion. The patient's blood lactate and glucose remained at normal levels throughout the operation. Because of severe adhesion, the laparoscopic procedure was changed to a laparotomy. However, during the peri-and post-operative periods, epidural anesthesia was valuable for analgesia during the management of the patient's respiratory care with a decreasing amount of narcotic medication. Post-operatively, the patient was monitored in an intensive care unit with the spontaneous respira- tory rate of 15 · min⁻¹ under oxygen 1l without any analgesics. The day after the operation she was returned to the ward, as her general condition was satisfactory.
BACKGROUNDEndoscopic hematoma evacuation is an established treatment option for patients with intra- cerebral hemorrhage (ICH). The purpose of this study is to investigate the benefit of mannitol use during en- doscopic hematoma evacuation.METHODSOne hundred patients with ICH treated by endoscopic surgery from June 2009 to November 2014 were retrospectively reviewed. We divided them into mannitol administered group (n=19) and non- administered group (n=81).RESULTSAs for the patient background, surgical time, amount of intraoperative bleeding, residual hema- toma, re-operation and postoperative 30-day mortality, no significant differences were found between the two groups.CONCLUSIONSThere was no clear clinical benefit of intraoperative mannitol use during endoscopic surgery for ICH.
BACKGROUND:Although breakage of the epidural catheter inside patients is a rare complication, plain X-ray or computed tomography (CT) image is useful for diagnosis of catheter remnant However, it is not well known whether the catheter materials are visible in these images.METHODS:We examined 3 types of X-ray permeabil- ity catheters and 6 types of X-ray impermeability cath- eters available in Japan. We obtained plain X-ray images of catheters alone, plain X-ray images of cathe- ters with bone dummy and CT images of catheters in the model of epidural space.RESULTS:On plain X-ray images of catheters alone, we could confirm all 6 types of X-ray impermeability catheters. However, on plain X-ray images of catheters with bone dummy, we could confirm only 3 types of catheters among 6 X-ray impermeability catheters. On CT images, we could confirm all 6 types of X-ray impermeability catheters, but not X-ray permeability catheters.CONCLUSIONS:Plain X-ray image can not provide the detection for some X-ray impermeability catheters. CT image is useful- for diagnosis of X-ray impermeability catheters.
In 1846, Ryoan Imamura joined the Gassuido school in Osaka, which was a branch of the Shunrinken school in Hirayama, Kishu. At that time the Gassuido school was presided by Nanyo Hanaoka, the son-in-law of Sei- shu Hanaoka. It remains unknown how long Imamura studied surgery at the school. In 1862, Imamura published a book titled Iji Keigen, wherein he disclosed the prescription of "Mafutsusan". Every disciple of the Hanaoka's schools was sternly asked not to leak the secrets of the prescription. In the background of his divulgence, there may have been the circumstances in which he had a deliberate intension to insist on the significance of traditional Kampo medicine, coping with emerging Western medicine.
BACKGROUND Anisocoria and abnormality of pupil- lary light reflex may indicate sight-threatening or life- threatening neurological injury. Many perioperative patients are given opioids for analgesia, and opioids produce miosis and make it hard to assess anisocoria or pupillary light reflex. This study was designed to determine the influence of induction of anesthesia on pupillary light reflex assessed by a hand-held point- and-shoot pupillometer. METHODS Eighteen patients receiving general anes- thesia were enrolled. Anesthesia was inducted by remifentanil, propofol and rocuronium after' pre-oxy- genation and tracheal intubation or insertion of supra- glottic airway device. The pupillary measurement data before induction and after intubation or insertion of supraglottic airway device were taken from records. RESULTS With eighteen patients, thirty six eye data were compared. After intravenous injection of propofol and remifentanil infusion, pupils were constricted from 4.0±1.1 mm to 1.8±0.4 mm, and average constriction velocity (CV), neurological pupil index (NPI) measured automatically from light reflex decreased for 2.5±0.9 mm, sec⁻¹ to 0.3±0.2 mm · sec⁻¹, 4.4±0.4 to 3.9±0.4, respectively (P<0.0001). CONCLUSIONS Propofol and remifentanil infusion in- fluence pupillary light reflex and decreases values of NPI and CV. When using these drugs, it is necessary to perform neurologic evaluation using NPI and CV.
An 88-year-old man, 155 cm in height and 45 kg in weight, was scheduled for total stomach extirpation. Partial cerebral infarction and cerebral arterial stenosis were diagnosed 20 days before the operation. The patient's mean arterial pressure was 80 mmHg. Regional brain 0₂ saturation (rSO₂) obtained via non- invasive monitoring using the INVOS™ system was above 65% on both sides, and these were used as con- trol values before anesthesia induction. Anesthesia was induced with propofol 50 mg and rocuronium 40 mg intravenously after thoracic epidural catheter placement. Throughout the operation, mean blood pressure was over 70% of the control value. Stroke volume variation (SVV) was tracked during the operation by arterial pressure-based continuous cardiac output monitoring (FloTrac™); SVV values under 13 were maintained using vasopressors and fluid loading. The rS0₂ levels were consistently above control values on both sides. The operation was completed as a gas- tric-bypass surgery and the patient was discharged from the hospital without complications. Using the INVOS™ and FloTraTM systems to maintain mean pressure over 70% of the control value may have prevented a new cerebral ischemic event This potentially useful application of the INVOS™ and FloTrac™ systems should be validated in future stud- ies.
Here we report successful anesthetic management of emergency thrombectomy for a patient with undiag- nosed polycythemia vera. A 67-year-old man com- plained of numbness of the right lower limb and was diagnosed with acute artery obstruction. Emergency thrombectomy was scheduled. Preoperative blood exam revealed hemoglobin 21.0 g · dl⁻¹ (hematocrit, 63.4%). During central venous catheter placement, we con- firmed high backflow blood viscosity; blood was diluted with plasma substitute. Hemoglobin was main- tained at 14-15 g · dl⁻¹ with continuous administration of plasma substitute. On re-perfusion of the right lower limb, potassium increased to 7.6 mEq · ml⁻¹, which responded to calcium carbonate, GI therapy, and furo- semide. Surgery was uneventful and the patient was diagnosed with polycythemia vera postoperatively. As perioperative management of polycythemia vera is challenging, particularly in undiagnosed and untreated cases, efforts should be made to avoid further throm- bosis and cardiac events.
We anesthetized a patient with Rett syndrome pre- senting intense breath holdings and severe aerophagia for dental treatment The patient had shown an intense breath holding plunging into hypoxia during slow induction with sevoflurane in previous anesthesias. Therefore, we chose rapid sequence induction with intravenous propofol and rocuronium and intubated orally. The length of glottis to tracheal bifurcation was shorter than average patient After a gastric tube was inserted and the content was aspirated, the orotracheal tube was changed to nasotracheal one. When she recovered from anesthesia at the quite deep stage, her saliva poured from nose and orally and began severe aerophagia. Once again, deep depth of anesthesia was kept, and we minimized stimulations for her. By. this approach, anesthesia was achieved uneventfully. In this case, she had signs of early-awakening from anesthesia.
BACKGROUND Several reports have examined meth- ods to control pain after a laparoscopic cholecystec- tomy (LC) and have shown regional anesthesia to be an effective method. We had been performing LC using simple general anesthesia (G); however, in 2013, we adapted a rectus sheath block (RSB), and in 2014, we used a combination of RSB and a subcostal transversus abdominis plane block (TAPB) on the right side. We report on the transition from G to regional anesthesia in LC and its effect on postoperative pain. METHODS We anesthetized three groups of patients undergoing LC. Group 1 received G (n =32) ; group 2 received RSB (n=28); and group 3 received a combination of RSB and TAPB (n=31). Patients used the numeric rating scale (NRS) to record their levels of postoperative pain, and the scores were compared for each group. RESULTS No significant differences were noted in NRS scores between the G and RSB groups; however, the scores in the RSB group tended to be lower. NRS scores were significantly lower in the RSB-TAPB group than in both the RSB and G groups. CONCLUSIONS This study showed that the combina- tion of RSB-TAPB effectively controlled pain after LC and lowered NRS scores.
A 41-year-old woman with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis, characterized by vari- ous psychiatric disturbances, was scheduled for laparo- scopic salpingo-oophorectomy. Anesthesia was induced with fentanyl, propofol and rocuronium, and maintained with intravenous propofol combined with epidural anesthesia (T10-11). The patient received 20 mEq of MgSO4 after induction. MgSO4 administrations were repeated at the end of surgery and every 12 hours for 48 hours after the operation. The operation was per- formed successfully, without any troubles. Trachea was extubated in the operating room. The cognitive dys- function was not observed postoperatively. There was no complication and no unexpected event postopera- tively. One month after surgery, the patient's clinical symptom began to improve. The resection of tumor is recommended as a thera- peutic treatment ; however, there has been few report of the management of postoperative cognitive dysfunc- tion for patients with NMDA receptor antibodies. These patients were more likely to experience a post- operative cognitive dysfunction associated with a poor outcome. We, therefore, administered magnesium sul- fate, NMDA antagonist to prevent postoperative delir- ium. In the present case, magnesium sulfate might have prevented the incidence of postoperative delirium without any complications. The prophylactic magne- sium administration could prevent postoperative delir- ium and agitation safely.
Securing of airway is one of the most important issues during cardiopulmonary resuscitation, and oro- tracheal intubation has been a gold standard proce- dure. We experienced a case in which the esophageal intubation was overlooked for 2 hours after the intuba- tion at the bedside of general ward and in the inten- sive care unit A 71-year-old male patient without marked medical history was transferred to our hospital with severe symptom of lower gastrointestinal ileus. After admitting to the ward, transrectal drainage tube was placed. On the night of the admission, the patient called the staff from his bed ; however, he lost con- sciousness and monitoring electrocardiogram showed sudden bradycardia followed by cardiac arrest Emer- gency cardiopulmonary resuscitation was initiated and the intubation was conducted by the physician on call. The cardiovascular status was unstable despite recov- ery of spontaneous circulation (ROSC) and the patient was transferred to the intensive care unit The arrest and ROSC by resuscitation was repeated. After 2 hours from the start of resuscitation, temporal ROSC was obtained, but the absence of a wave of capnogram was identified. The observation using laryngoscopy revealed esophageal intubation and oro-tracheal intuba- tion was facilitated. Although the mechanical ventila- tion was established, the condition of the patient dete- riorated with pulseless electrical activity followed by death.
BACKGROUND:The proportion of obese people is gradually increasing. In recent years, laparoscopic sleeve gastrectomy has been performed as a weight loss surgery. We reported the extent of respiratory complications and the keys of anesthetic management in this procedure.METHODS:Forty consecutive morbidly obese patients received laparoscopic sleeve gastrectomy. A sample for arterial blood gas analysis was taken after intubation and at the end of the operation. Moreover, to examine the risk of silent aspiration, 16 patients were subjected to measuring the gastric juice volume and pH of the pharynx.RESULTS:Oxygenation index (P/F ratio) after intuba- tion was markedly reduced, but there was no correla- tion with the BMI On the other hand, P/F ratio at the end of surgery improved in patients with low BMI Hypercapnia was rare after extubation, but respiratory rate was increased in the patients with high BMI Gas- tric secretion after induction was increased, but there was no overt sign of silent regurgitation of gastric juice.CONCLUSIONS:Oxygenation was extremely deterio- rated immediately after intubation in the morbidly obese patients. There is a need for aggressive respira- tory management because intraoperative oxygenation was not improved in the patients with high BMI.
A male patient in his eighties was admitted to our hospital complaining of right coxalgia. Total hip arthro- plasty was performed under general anesthesia com- bined with epidural anesthesia. During the operation, massive bleeding occurred accidentally due to meta- static bone tumor. Intraoperative autologous blood transfusion was useful for maintenance of hemody- namics of the patient Intraoperative autologous blood transfusion may be effective in an oncologic operation with massive bleeding.
Go-rei-san is a Japanese traditional medicine that is used to treat motion sickness, nausea, and vomiting. We report here four patients for whom Go-rei-san was effective in treating pain associated with intractable trigeminal neuralgia. Three patients could not continue carbamazepine due to drug-induced rash, liver damage, and gastrointestinal injury, and suffered from pain. One patient experienced severe dizziness upon combination treatment with pregabalin and carbamazepine. All patients exhibited symptoms of water poisoning on their tongues. All patients experienced significant pain relief without major complications after daily adminis- tration of 7.5 g Go-rei-san. Our findings suggest that Go-rei-san can effectively alleviate pain associated with intractable trigeminal neuralgia without major compli- cations.
