Perioperative management of a neonate with Cantrell syndrome.

Cantrell syndrome is a congenital malformation with a pentalogy characterized by defects involving the abdominal wall, lower sternum, anterior diaphragm, and diaphragmatic pericardium, as well as congenital cardiac anomalies. We recently managed anesthesia in a patient with this syndrome and herein report our experience. The patient was a 14-day-old male neonate, who had been diagnosed with Cantrell syndrome, including ventricular septal defect, left ventricular diverticulum, abdominal wall defect, omphalocele, and sternal hypoplasia. Surgical interventions to close the ventricular septal defect, resect the left ventricular diverticulum, and close the omphalocele were scheduled. After cardiac surgery, the hernial contents were returned to their original compartment and, subsequently, an attempt was made to suture the abdominal wall. However, blood pressure fell markedly and the attempt was discontinued. The chest was left open postoperatively and the patient was transferred to the intensive care unit (ICU), during which time circulatory and respiratory management was very complex. Issues requiring particular attention in the management of anesthesia for patients with this syndrome include complications of diverse cardiac malformations, pulmonary hypertension, pulmonary hypoplasia, and respiratory and circulatory failure associated with increased intraabdominal pressure due to primary closure of the omphalocele. Accordingly, extreme caution must be taken to restore respiratory and circulatory control.

Anesthetic management of apicoaortic bypass in patients with severe aortic stenosis.

Apicoaortic bypass (AAB), or apicoaortic conduit insertion, is a conventional surgical method that has been regaining attention due to the aging population and the increasing number of repeat surgeries. The indication for the procedure has been extended as an alternative for aortic stenosis when the usual sternotomy or aortic clamping is considered to be difficult, e.g., in patients with severe calcification of the ascending aorta (porcelain aorta), or in patients with a patent coronary artery bypass graft located adjacent to the posterior surface of the sternum. Herein, we report our recent anesthetic management of three patients undergoing AAB. Once the apicoaortic conduit is inserted, blood from the left ventricle is ejected via two routes, the narrowed native aortic valve and the apicoaortic conduit. Thus, it is necessary to elucidate any change in blood flow after the withdrawal of the extracorporeal circulation, by using intraoperative transesophageal echocardiography. Furthermore, if a rigid apical connector is not used, anastomosis of the cardiac apex and conduit is conducted under ventricular fibrillation without the infusion of cardioplegic solution; thus, patients are deemed likely to suffer increased myocardial damage. As a rigid apical connector was not used in the three present patients, the administraction of adequate catecholamines was needed for the withdrawal of the extracorporeal circulation. In addition, because those undergoing AAB often have extremely poor cardiac reserve preoperatively owing to the administration of adequate catecholamines was needed for the withdrawal of the extracorporeal circulation. In the three present patients, anesthetic management was successful, and there were no intraoperative or immediate postoperative complications.

Outcome and characteristics of out-of-hospital cardiac arrest according to location of arrest: A report from a large-scale, population-based study in Osaka, Japan.

OBJECTIVE: To evaluate the outcome and the factors concerned with of out-of-hospital cardiac arrest patients according to the location of the collapse. METHODS: From May 1st, 1998 to April 30th, 2001, 15,211 consecutive out-of-hospital cardiac arrest cases considered for resuscitation were recorded. Of these cases 7540 arrests in subjects aged 18 years or older with cardiac aetiology were analyzed. The outcome and the related-factors, particularly incidence of ventricular fibrillation, were evaluated according to the location of the cardiac arrest. To analyze the factors that affect the incidence of ventricular fibrillation, a logistic regression model was used. RESULTS: About three-quarters of out-of-hospital cardiac arrests occurred at private residences. The outcome and characteristics were significantly different according to the location of the arrest. Arrest patients in public or in the work place had a higher chance of being found in ventricular fibrillation and survival than those at a private residence. The multivariate adjusted odds ratios for ventricular fibrillation in a public or work place were significantly higher than that in private residences, after adjusting for covariates affecting initial rhythm, such as age, sex, witnessed status, bystander cardiopulmonary resuscitation, and response interval. CONCLUSION: Although the majority of out-of-hospital cardiac arrests occur at private residences, arrests in public or in the work place had a higher chance of being found in ventricular fibrillation and survival than those at private residences. In order to establish a system to improve the outcome of out-of-hospital cardiac arrest, a well-considered strategy considering the location of arrest is necessary.

Incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrest with cardiac etiology in Osaka, Japan: a population-based study according to the Utstein style.

PURPOSE: To clarify the incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrests (OHCA) with cardiac etiology in Osaka Prefecture, Japan, with a population of nearly 9 million according to the Utstein style. SUBJECTS AND METHODS: 5047 consecutive OHCA cases were treated by ambulance personnel during the 12-month period starting since 1 May 1998. 974 cases were considered to be bystander-witnessed OHCA with cardiac etiology and analyzed using the Utstein style. RESULTS: Of the 974 cases (100%), 50 cases (5.1%) survived after 1 month and 28 (2.9%) of them after 1 year. The Ventricular fibrillation (VF)/ventricular tachycardia (VT) group comprised 164 (16.8%) cases and there were statistically differences between the two groups as below (the VF/VT group vs. the non-VF/VT group): gender (male: 76.8 vs. 60.7%), age (61.7+/-14.7 vs. 68.7+/-17.1), history of ischemic heart disease (IHD) (30.5 vs. 15.3%), performance rate of bystander cardiopulmonary resuscitation (CPR) (34.1 vs. 21.4%) and time interval between receipt of an emergency call and arrival at the scene (5.5+/-2.9 vs. 6.0+/-2.9 min). CONCLUSION: The incidence of bystander-witnessed (OHCA) with cardiac etiology and VF or VT were remarkably low compared with those reported by other studies conducted in some areas of Europe or the USA.