Masui. The Japanese journal of anesthesiology最新文献

We present a case of masticatory muscle tendon- aponeurosis hyperplasia in a patient who underwent general anesthesia for gynecologic surgery. The patient's square-shaped mandible was noticed during preoperative assessment by an anesthesiologist. Further investigation revealed masticatory muscle tendon- aponeurosis hyperplasia. Anesthetic induction agents were administered, and facemask ventilation was initi- ated easily. As the anesthesiologist had predicted, the patient's mouth opening was reduced after administration of muscle relaxants, and keeping her mouth open was more difficult than when she was conscious. Nasotracheal intubation was performed successfully using a bronchoscope. Patients with muscle tendon- aponeurosis hyperplasia do not generally have associated pain, and do not know that they have a limited mouth opening. They are therefore sometimes unaware that they have the condition. Anesthesiologists need to predict that airway intubation will be difficult when the patient has a limited mouth opening associated with a square-shaped mandible.

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.

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.

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.

Background: Endoscopic 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.

Methods: One 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).

Results: As 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.

Conclusions: There was no clear clinical benefit of intraoperative mannitol use during endoscopic surgery for ICH.

A 48-year-old man (165 cm, 53 kg), was scheduled for an angioma resection. The tumor was so large that together with tongue, grew from the buccal region to the lower jaw and protruded out of the mouth. Mouth opening was only 2.5-finger-width. Expected as a case of difficult airway, we planned awake intubation using Airway Scope® (AWS) and gum-elastic bougie while maintaining spontaneous ventilation according to the difficult airway algorithm of American Society of Anes- thesiologists. Although fiberscope (FB) is a common choice for awake intubation, it requires proficient skills. In addition, as the distal end of endo-tracheal tube cannnot be visualized by FB, the angioma might be damaged during the intubation. Instead, AWS can visualize the tip of the tube without displacing oropha- ryngeal tissue and it is unlikely to damage the tumor because of a tube guide groove on the inner side of the AWS blade. We experienced successful awake intuba- tion with AWS for a patient with difficult airway due to an enormous angioma protruding out of the mouth.

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: 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.

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.

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.