Masui. The Japanese journal of anesthesiology最新文献

We experienced rocuronium-induced anaphylaxis in a 62-year-old man who was scheduled for laparoscopic ileocecal excision for cecal cancer under general anes- thesia. The patient did not have a preoperative history and examinations suggestive of heart disease, or pre- disposing factors for myocardial infarction. Just after induction of anesthesia, we noticed abnormally low blood pressure and ST segment elevation on his elec- trocardiogram. The surgery was postponed and percu- taneous coronary intervention was performed to treat coronary artery stenosis. Re-operation was planned 73-days after the first operation. The patient suffered cardiac arrest just after induction of general anesthesia At the same time, we noticed systemic erythema all over his body, which led to the diagnosis of anaphy- laxis. Cardiopulmonary resuscitation was performed and the surgery was postponed once again. Cardiovas- cular agents, including adrenaline, noradrenaline, atro- pine and amiodarone, improved his hemodynamics. In addition, steroids and anti-histamines were also admin- istered to treat anaphylaxis. We advised him to undergo skin tests to determine the causative agent of anaphylaxis, but he declined. Instead, a basophil activa- tion test was performed, which showed a positive reac- tion to rocuronium. Therefore, we planned general anesthesia without using muscle relaxants such as rocuronium for the third attempt at surgery. The sur- gery was performed safely with this protocol. It is likely that his symptoms in the first general anesthesia were caused by Kounis syndrome. We conclude that the basophil activation test seems to be valuable in determining the causative agent of anaphylaxis, partic- ularly when a patient does not agree to undergo skin tests.

Background: We established local guidelines of heparin bridging therapy. However, it is unknown how adherence to our guidelines was achieved and whether our guidelines improved adherence compared with other universal guidelines.

Methods: A retrospective chart review was con- ducted on compliance with 3 recommendations in the guidelines; these are initial unfractioned heparin dose, timing of unfractioned heparin administration, and two times measurements of activated partial thromboplas- tin time (APTT). We compared 3 recommendations in the guidelines with platelet monitoring which is not described in the guidelines. We also investigated bleed- ing and thromboembolic events during heparin bridg- ing therapy according to the guidelines.

Results: Initial unfractioned heparin dose, timing of unfractioned heparin administration, measurements of APTT, and platelet monitoring were concordant with the guidelines in 78.9%, 19.7%, 67.6%, and 46.5%, respectively. Bleeding events occurred in 3 cases, but no thromboembolic events occurred. Adherence to rec- ommendations for timing of unfractioned heparin administration was the lowest and significantly lower than platelet monitoring.

Conclusions: Our local guidelines were partially effective to improve adherence We have to alert phy- sicians to care bleeding complications during heparin bridging therapy in our hospital.

Pheochromocytoma is complicated with catecholamine cardiomyopathy, and preoperative care becomes considerably more difficult We report anesthetic management for an 48-year-old man brought to our hospital by ambulance and immediately hospitalized due to pheochromocytoma crisis complicated with catechol- amine cardiomyopathy presenting inverted-takotsubo pattern asynergy. Before surgery, α and β blocking drugs were used to control hypertension and tachycardia, and continuous hemodiafiltration was initiated and the patient was intubated for severe pulmonary edema. Seven days later, he underwent laparoscopic adrenalectomy. Total intravenous anesthesia was achieved with propofol, remifentanil, fentanyl, and rocuronium. During the operation, continuous infusion of landiolol, phentolamine, and nitroglycerin, and addi- tional bolus injections of landiolol were given to control hypertension. After severing the right adrenal vein, noradrenaline (0.15 μg · kg⁻¹ · min⁻¹), and dopamine (4μg · kg⁻¹ · min⁻¹) were started and the patient was placed in the intensive care unit Inverted-takotsubo pattern asynergy is not very common, and treatment consists of supportive care, as in the usual takotsubo. Preoperative CHDF (continuous hemodiafiltration) may be useful when it is difficult to control hypertension or tachycardia with medications.

We report a case of an 18-year-old man with Noonan syndrome, severe hypertrophic obstructive cardiomy- opathy and right ventricular outflow tract obstruction who underwent septal myectomy under general anes- thesia. In our case, the ventricular outflow tract pres- sure gradients were 108 mmHg at left and 79 mmHg at right. General anesthesia was induced deliberately by fentanyl, midazolam and sevoflurane. Anesthesia was maintained with sevoflurane. For treatment of hypotension, we performed volume loading and admin- istration of phenylephrine. We did not use drugs that increase heart rate or contractility. Preload and after- load were well maintained, and the operation and gen- eral anesthesia were completed without serious prob- lem.

Background: Fibrinogen replacement therapy con- tributes to effective hemostasis and saving blood trans- fusions in critical hemorrhage. We retrospectively studied the efficacy and indication for cryoprecipitate or fibrinogen concentrate in thoracic aortic surgery.

Methods: In 169 patients undergoing thoracic aortic surgery, 92 (54.4%) patients received dryoprecipitate or fibrinogen concentrate and 77 (45.6%) patients did not We compared them with regard to postoperative bleeding and perioperative blood transfusion. We deter- mined the effective dose of the fibrinogen in cryopre- cipitate or fibrinogen concentrate for increasing the fibrinogen level.

Results: The cutoff value of the fibrinogen level at the end of cardiopulmonary bypass between both groups was 100 mg · dl⁻¹. For a fibrinogen level less than 130 mg · dl⁻¹ during cardiopulmonary bypass, the patients who received cryoprecipitate or fibrinogen concentrate had less postoperative bleeding (P<0.01) and fewer transfusions of total blood, fresh frozen plasma, and platelet concentrates (P<0.05). The effec- tive dose 50 of fibrinogen amount was 0.031-0.051 g - kg⁻¹.

Conclusions: The fibrinogen amount of 2-3 g (per 50-70 kg in body weight) in cryoprecipitate or fibrino- gen concentrate effectively reduces postoperative bleeding and perioperative blood transfusions when a fibrinogen level is less than 100-130 mg · dl⁻¹ during cardiopulmonary bypass.

Background: Postsurgical hoarseness is one of the major postoperative complications.

Methods: Risk factors associated with the postsur- gical hoarseness were investigated from medical records of 579 adult patients undergoing general anes- thesia with tracheal intubation. Postsurgical hoarseness was judged if a patient developed hoarseness at PODO or PODI by postanesthesia round. Multivariate logistic regression was performed to identify the parameters associated with postsurgical hoarseness.

Results: Postsurgical hoarseness developed in 16.1% of patients. None of the patients suffered hoarseness continuing more than 4 days. Multivariate logistic regression revealed increased BMI (odds ratio (OR) 1.06 [95% confidence interval (CI):1.00-1.131], depth of tracheal tube (OR 0.71 [95% CI : 0.57-0.86]), intu- bation performed by doctors in training (OR 4.07 [95% CI : 2.42-7.10]) and intubation with Airway Scope® (OR 2.03 [95% CI : 1.10-3.66]).

Conclusions: Increased BMI, depth of tracheal tube, intubation performed by doctors in training and intu- bation with Airway Scope® are risk factors of postsur- gical hoarseness.

We experienced a case of a patient with pulmonary atresia and intact ventricular septum (PAIVS) accompanying sinusoidal communication. PAIVS can be associated with coronary artery anomalies, including sinu- soidal communications from the right ventricle to coronary. In addition, the coronary circulation depends on the blood supply from the right ventricle. The patient was a 1-year-old boy with PAIVS (9.0 kg in weight and 74 cm in height). He had undergone balloon atrial septostomy, central shunt and Glenn procedure. Preopera- tive percutaneous oxygen saturation was 85% which decreased to 80% with agitation. He was scheduled for cheiloplasty. The goals of anesthetic management for the patient were to maintain a decrease in pulmonary vascular resistance and an increase in pulmonary blood flow to sinusoidal communications. Stable Pa0₂ was maintained by adjusting FI0₂ : 0.5, and Paco₂ : 30-35 mmHg. Hemodynamics was maintained by fluid trans- fusion, maintaining urine volume and α₁-adrenoceptor agonist We used Aesculon® for monitoring cardiac output which is a noninvasive cardiac function monitor based on impedance technology.

In the mid 18th century, Monro, Kite, and others stared to perform tracheal intubation during cardiopul- monary resuscitation. In 1790's, it was found that tra- cheal intubation using Kite's device and method was technically difficult and, because of the design of the tube, an inserted tube might frequently obstruct the airway. During 1790's to 1820's, several people (Cole- man, Curry, Desgranges, Fine, De Sanctis, and Leroy) attempted to improve the design of a tracheal tube. In addition, Leroy invented a device to facilitate tracheal intubation. Despite these efforts, tracheal intubation during cardiopulmonary resuscitation was abandoned afterwards because of "unexpected" reasons.

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: 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.