Masui. The Japanese journal of anesthesiology最新文献

We experienced two cases of tension pneumothorax during posterior spinal fusion. Case 1 : A 67-year-old female underwent posterior thoracic-lumbar spinal fusion. One hour after the operation had started, a sudden elevation of airway pressure and decreased Pa02 were observed. Then occasional decrease in blood pressure, tachycardia, and premature ventricular contractions followed. SpO2 re- mained stable throughout the surgery. Case 2 : A 57-year-old female underwent posterior thoracic-lumbar spinal fusion. During the surgical pro- cedure, a sudden decrease in SpO₂ accompanied by an air leak from pleura occurred. No remarkable change was observed in hemodynamics. Immediately after the operation had finished, chest X-ray on supine position revealed tension pneumotho- rax in both cases. Patients were extubated after effec- tive lung expansion by insertion of thoracic drainage tube. Tension pneumothorax is a potentially lethal compli- cation during anesthesia, resulting in cardiac arrest Though rapid diagnosis is crucial, physical examination and assessment are limited in patients on prone posi- tion. The possibility must be considered that several conditions as increased airway pressure, impaired oxy- genation and hemodynamics suggest tension pneumo- thorax. Image diagnosis using radiography or ultra- sound can be of value. If once patient on prone position develops cardiac arrest, resuscitation is extremely difficult Emergency drainage should be considered in case of highly im- paired hemodynamics.

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.

Sjögren-Larsson syndrome (SLS) is an autosomal recessive disease characterized by a triad of congenital ichthyosis, spastic quadriplegia and mental retardation. An 11-year-old girl (body weight 30 kg) diagnosed as SLS was admitted with Benett fracture of the right thumb. She was monitored with standard protocol. General anesthesia was induced by rapid induction method with propofol 50 mg and rocuronium 0.6 mg - kg⁻¹. She was ventilated with bag and mask, and intu- bated without difficulty. Neuromuscular function was continuously assessed by 40 mA-TOF-stimulation re- sponses with acceleromyography immediately after induction of general anesthesia by TOF-Watch® SX (Organon Ireland, division of MSD, Ireland). Anesthe- sia was maintained with total intravenous anesthesia with propofol 6-8-10 mg⁻¹ · hr⁻¹ in oxygen. No abnor- mal responses were observed by TOF-Watche SX despite the neuromuscular disease. Residual effect of the neuromuscular blocking agent was successfully reversed by sugammadex and she was extubated without any respiratory trouble. She was discharged on the postoperative day 1 without complications.

Perioperative management of the patient with anterior mediastinal tumor is challenging and should not be underestimated. The clinical presentation of the patient is variable because it depends on the size and localiza- tion of the tumor. Therefore, it is difficult to establish a structured protocol for anesthetic management of ante- rior mediastinal tumor. Anesthesiologists are required to make careful anesthetic plan with thorough assessment of preoperative status of the patient Confirmation of "comfortable position" for the patient is important and useful for safe management The induction of general anesthesia should be performed in step-by-step wise without muscle relaxants. Even after successful tracheal intubation, difficult ventilation may occur. Preparation of percutaneous cardiopulmonary support (PCPS) is essential for the emergency situation from both respiratory and circulatory collapses, especially during anesthesia induction. For emergency use of PCPS, cannulation of femoral vessels under local anesthesia should be performed before anesthesia induction in the patient with subjective respiratory symptom and severe tracheal compression.

We encountered a case of congenital aglossia accom- panied by upper airway obstruction and faucal con- striction, for which mask ventilation was straightfor- ward and nasal intubation under bronchofiberscopic guidance was effective. The faucal constriction was easily alleviated under anesthesia, facilitating the pas- sage of a laryngoscope blade. The absence of the tongue base, a target site for laryngoscope manipulation, prevented visualization of the glottis. Airway Scope® AWS-SIOOL (Nihon Kohden Corporation, Tokyo) equipped with PBLADE® (ITL-NL-NEO- NATE) for newborns facilitated detection of the glottis, suggesting its usefulness as an intubator.

Breakage of an epidural catheter occurs rarely dur- ing the insertion or removal procedures. In previous reports, the broken epidural catheter fragment need not be removed in asymptomatic patients. However, late-onset neurological symptoms might occur. This is a case of delayed onset subdural hematoma due to a broken epidural catheter retained in the body for 18 years. We considered that the catheter fragment might induce chronic inflammation and vascular fragil- ity around the catheter. Antiplatelet therapy might lead to the hematoma because this patient took an aspirin (antiplatelet drug) for over 9 years. Antiplatelet and anticoagulant therapies are likely to be a risk of hematoma. Thus, even without neurological symptoms, it is necessary to consider the removal of the epidural catheter fragment in patients on anti- platelet and anticoagulant therapy.

The -most common cause of COPD is cigarette smoking. We use mMRD (Modified British Medical Research Council), CAT (COPD Assessment Test) and GOLD classification of airflow limitation, to evaluate severity of patients with COPD before surgery and create plans to manage their anesthesia. Known COPD is an important patient-related risk factor for postoperative pulmonary complications. Relative risks of postoperative pulmonary complications have ranged from 2.7 to 6.0. Cessation of smoking for four to eight weeks prior to surgery decreases risk of postoperative pulmonary complications. Preoperative instruction regarding inspiratory muscle training may be accomplished. This strategy is time-intensive and potentially expensive. We suggest monitored anesthesia care (MAC), neuraxial anesthesia, or other regional anesthetic tech- niques, but MAC and neuraxial or peripheral regional anesthetic techniques are not suitable for some patients. Non-invasive ventilation (NIV) should be readily available in the postanesthesia care unit to treat respiratory distress in COPD patients.

We present a case of a very rare complication of valvular surgery-suture loop jamming. A 77-year-old woman was admitted for surgical treatment of moderate aortic regurgitation, severe mitral regurgitation (MR) and severe tricuspid regur- gitation. She underwent mitral valve replacement (MVR) with porcine bioprosthetic valve and tricuspid annuloplasty by DeVega procedure. Before termination of cardiopulmonary bypass, transesophageal echocardiography (TEE) showed se- vere MR at the center of the bioprosthetic valve along the posterior left atrial wall In addition, echogenic fili- form structure which disturbed the movement of the leaflets was detected. The patient was placed on car- dioplegic arrest again and the heart was reopened, suture loop jamming around the stents of the biopros- thetic valve resulting in significant mitral regurgitation was diagnosed. The implanted bioprosthetic valve was removed and a new bioprosthetic valve was subse- quently re-implanted. Intraoperative TEE provided a visible assessment of mitral prosthetic valve dysfunction and we were immediately able to reach diagnosis of this rare and serious complication-suture loop jamming. Our case makes us recognize suture loop jamming as one of the complications of MVR.

Obstructive sleep apnea syndrome (OSAS) is a common abnormal breathing during sleep among surgical patients and severe perioperative complications may develop in these patients. Anesthesiologists need to know pathophysiology of OSAS, its clinical features, diagnosis and treatments for their proper perioperative airway and hemodynamic management We developed an OSAS management protocol(Chiba OSAS protocol) covering from screening to postoperative airway management of OSAS.

New anesthesiology residency education program requirements were launched in Japan. The main change was to specify which anesthesia cases a resi- dent must experience during the training period. We believe that comparing the educational requirements between anesthesiology specialty certification programs in Japan and the USA is a timely undertaking. This detailed comparison study is aimed to identify compo- nents to improve the current educational systems in each country. Three educational components are required in the USA, but not in Japan: daily clinical evaluations based on well-defined criteria, regular lectures and nation- wide annual achievement tests, and national board- accredited subspecialty fellowships. Conversely, in Japan, scholarly presentations at scientific meetings are mandatory for anesthesiology board certification, but the scholarly activity requirement in the USA is vaguely defined. These points identified through our comparison could help improve residency training programs in both Japan and in the USA.