Comparison of the value of tissue-sealing devices for thoracoscopic pulmonary lobectomy in small children: a first report.

Accurate division and sealing of lung parenchyma particularly in cases of total or near total incomplete fissure are crucial for preventing air leakage following thoracoscopic pulmonary lobectomy (TPL). However, conventional endoscopic stapling devices cannot be used during TPL in small children because of limited space. Consequently, Ligasure (LS) and Enseal (ES) devices are being used instead. We are the first to compare LS and ES for efficacy and efficiency during TPL. Of 26 TPL (6 upper, 3 middle, and 17 lower) performed for congenital adenomatoid malformation (n = 16) and sequestration (n = 10), incomplete fissure was found in 14. TPL (LS = 11; ES = 15) was performed conventionally in the lateral decubitus position with single lung ventilation using four 5 mm trocars. All cases had a chest tube inserted intraoperatively that was left in situ. Patient demographics, location of pathology, incidence of incomplete fissure, mean age/weight at TPL, mean blood loss, and mean operative time were all similar. However, duration of chest tube insertion was significantly shorter in ES because there was less postoperative air leakage (1.3 vs. 3.9 days; p < 0.05). ES would appear to seal lung parenchyma more effectively during TPL based on the shorter duration of chest tube insertion.

[Perioperative management of patients with cardiomyopathies: preface and comments].

Cardiomyopathies are a heterogeneous group of diseases of the myocardium. Cardiomyopathies are characterized by myocardial dysfunction resulting in heart failure due to systolic dysfunction and/or diastolic dysfunction. Prognosis of the patients with cardiomyopathies is usually poor due to progressive heart failure. Sudden death due to serious arrhythmia is not uncommon. Because of the heterogeneity of cardiomyopathies, the perioperative management of the patients with cardiomyopathies varies according to the pathological physiology. Management of low cardiac output is important as well as arrhythmias. Because of arrhythmias such as atrial fibrillation and poor ventricular function, anticoagulation is also important. Through evaluation and management of implantable pacemakers and implantable cardioverter defibrillator are essential.

Antiemetic effect of naloxone in combination with dexamethasone and droperidol in patients undergoing laparoscopic gynecological surgery.

PURPOSE: We examined the effects of dexamethasone, droperidol, naloxone, and a combination of these three agents on postoperative nausea and vomiting (PONV) in female patients. METHODS: In this randomized, controlled study, 120 female patients with ASA PS I or II undergoing laparoscopic gynecological surgery were randomly allocated into four groups. Patients received dexamethasone 8 mg (Dx group) or droperidol 1 mg (Dr group) before induction of general anesthesia. Anesthesia was induced and maintained with propofol and remifentanil. Postoperative analgesia was provided by intravenous patient-controlled analgesia using a disposable infusion pump filled with fentanyl 20 µg/kg alone (Dx group), fentanyl 20 µg/kg with droperidol 2 mg (Dr group), fentanyl 20 µg/kg with naloxone 0.1 mg (Nx group), or fentanyl 20 µg/kg with droperidol 2 mg and naloxone 0.1 mg (Cm group) in a total volume of 80 ml, with a constant infusion rate of 4 ml/h and a bolus dose 2 ml with a 30-min lockout time. RESULTS: The number of patients who developed PONV and required a rescue antiemetic was significantly less in the Cm group than in the Nx group (p < 0.001 for all). The incidence of PONV was 43, 43, 70, and 17 % in the Dx, Dr, Nx, and Cm groups, respectively. CONCLUSION: A combination of naloxone, droperidol, and dexamethasone was effective for preventing PONV in patients receiving fentanyl for postoperative analgesia after laparoscopic gynecological surgery, although further investigations are required to examine the effect of adding naloxone to other antiemetics.

Replacement of gabapentin with pregabalin in postherpetic neuralgia therapy.

PURPOSE: Although both gabapentin and pregabalin are first-line drugs for neuropathic pain including postherpetic neuralgia (PHN), no report has directly compared the magnitude of pain relief and the incidence of side effects of both drugs. By substituting gabapentin with pregabalin in postherpetic neuralgia therapy, we can compare the two drugs. METHODS: In 32 PHN patients being administered gabapentin, without changing the frequency of dosing, the drug was substituted with pregabalin at one-sixth dosage of gabapentin. After 2 weeks, an interview was conducted about the visual analog scale (VAS) pain score, changes in the time of onset of action and duration of action after the substitution of drug and side effects (such as somnolence, dizziness, and peripheral edema). In addition, the dosage was increased while paying careful attention to the side effects (titration) in 22 patients who requested a dosage increase among those whom VAS pain score of ≥25 mm remained even after the substitution. RESULTS: No significant changes were observed in VAS pain scores after the substitution of gabapentin with pregabalin. Regarding the time of onset of action and the duration of action after the substitution, the highest number of patients answered that no change occurred compared with the previous drug, followed by the patients who answered that the time of onset of action became quicker, and the duration of action became longer. The incidence of somnolence and dizziness showed no significant difference before and after the substitution, but peripheral edema showed a significant increase after the substitution. The level of side effects of both drugs was mild, and continued medication was possible. In the patient group where pregabalin dosage was increased, the VAS pain score decreased significantly compared with that before and after increase the dosage (P < 0.05). On the other hand, in nine out of 22 patients in the group where the dosage was increased, side effects appeared or were exacerbated. In two out of nine patients, it was necessary to reduce the dosage to the initial volume. CONCLUSION: It was suggested that the analgesic action of pregabalin in PHN was six times that of gabapentin in terms of effectiveness in dosage conversion. Regarding the side effects, although the incidence of the peripheral edema was higher with pregabalin compared with gabapentin, this finding is not conclusive because the present study was conducted in a small number of subjects. Although pain reduction can be expected to increase with pregabalin dosage, it is necessary to increase the dosage gradually and carefully because of exacerbation of side effects.

[Successful anesthetic management of a postpartum patient with amniotic fluid embolism].

We report a case of amniotic fluid embolism (AFE) after cesarean section (C/S). A 35-year-old primigravida with placenta previa and myoma underwent C/S because of nonreassuring fetal status caused by medical induction of labor. C/S was performed smoothly under general anesthesia and the baby had no problems. Immediately after the end of C/S, she went into sudden cardiovascular collapse and massive postpartum hemorrhage (PPH) became apparent. The mechanical ventilation with 100% oxygen was continued. Cardiovascular stabilization was attained with immediate administration of noradrenaline and blood transfusion. As her clinical course indicated coagulopathy due to disseminated intravascular coagulation (DIC), we gave transfusion of fresh frozen plasma and red cell concentrate before the diagnosis of DIC was established by laboratory tests. Since we thought that manual pressure and uterotonics were not adequate to stop PPH, we performed uterine artery embolization additionally. The PPH with DIC was stopped by these measures seven hours after C/S. The patient and her baby left the hospital with no complications. AFE is a rare and often fatal obstetric condition, characterized by sudden cardiovascular collapse, and massive bleeding with DIC. The prompt awareness and initiation of appropriate measures are mandatory for patient's survival.

[Suspected case of peripartum cardiomyopathy during perioperative period--a case report].

A 31-year-old primigravida was admitted for control of twin gestation and delivery. At 36-week gestation, an emergent cesarean section was performed under combined spinal-epidural anesthesia because of progression of PIH. Anesthetic course was uneventful until the operation was finished. An hour later, systolic blood pressure started to decline to reach about 70 mmHg and Sp(O2) about 80%. Pleural effusion was observed in the chest X-ray on post-operative day 1. Echocardiography showed akinesis of the antero-septal wall with ejection fraction (EF) of 47%. Peripartum cardiomyopathy (PPCM) was strongly suspected. HELLP syndrome and DIC were also combined with PPCM, so intensive care was given to her from the 1st POD. Symptoms of heart failure were alleviated by furosemide and carperitide by the 12th POD. The EF increased to 58% on the 11th POD.

[The effects of early nerve blocks for prevention of postherpetic neuralgia and analysis of prognostic factors].

BACKGROUND: Herpes zoster causes acute pain and sometimes leads to postherpetic neuralgia (PHN). The previously reported risk factors of PHN such as old age, allodynia, paresthesia and so on are not based on evidence. Although nerve block is useful to relieve acute pain and recommended for prevention of PHN, evidence is scanty. METHODS: The patients with herpes zoster within 3 months after the onset were studied. The patient underwent nerve blocks and proper medical treatment, and were followed for up to one year. The risk factors of PHN were assessed. We evaluated whether nerve block prevented PHN. RESULTS: A total of 144 consecutive patients were studied. Twenty seven % of patients suffered PHN. Old age (> 65 y. o) and hypesthesia were confirmed to be the risk factors of PHN, whereas the intensity of acute pain was not. Patients who underwent nerve block within 1 month after the onset were less likely to suffer from PHN compared with patients of delayed nerve blocks. CONCLUSIONS: Old age, hypesthesia and delayed nerve blocks were the risk factors of PHN. Nerve blocks in the early phase of herpes zoster may be useful to prevent PHN, particularly in the younger patients.

[Suspected case of peripartum cardiomyopathy developed during elective cesarean section].

A 35-year-old primigravida with twin gestation was admitted for elective cesarean section. She had no preoperative systemic diseases including heart disease. At 37 weeks of gestation, elective cesarean section was performed under combined spinal-epidural anesthesia. Anesthetic course was uneventful until the delivery when the patient started to cough and complained of dyspnea. At the same time, Spo2 started to decline to reach 95% despite the oxygen supplement. Pleural effusion was observed on the chest X-ray on postoperative day 2. An echocardiography showed diffuse hypokinesis of the left ventricle with ejection fraction (EF) of 36%. Peripartum cardiomyopathy was strongly suspected. Symptoms of heart failure were alleviated by water restriction and furosemide by the 9th POD. The EF increased to 50% on the 15th POD.

[Risk management in cardiac anesthesia].

Cardiac anesthesia carries high risk because of the patient's cardiac and coexisting diseases and rapid and complex hemodynamic changes during surgery. We should be ready to treat hemodynamic changes which may rapidly deteriorate into a vicious cycle. Many potent drugs and life-support devices are used. The drugs should be properly labeled to avoid drug error. Prefilled drug syringes and ready-to-use bags are helpful to avoid mixture error. Syringe and infusion pumps should be properly set. All the infusion systems should be checked in a systematical way. Blood management including blood transfusion and coagulation is important. Heparin-induced thrombocytopenia (HIT) may cause thrombosis. Heparin and heparin-coated catheter should be avoided in patients with HIT. Causes of bleeding tendency should be sort out and treated accordingly. Protamine reactions including hypotension and pulmonary hypertension can be catastrophic. Lastly, intimate communication between surgeons, anesthesiologists, medical engineers, and nurses is essential to perform cardiac surgery safely.

High-flow oxygen via tracheostomy facilitates weaning from prolonged mechanical ventilation in patients with restrictive pulmonary dysfunction: two case reports.

BACKGROUND: Weaning from prolonged mechanical ventilation is extremely difficult in tracheostomized patients with restrictive pulmonary dysfunction. High-flow oxygen via tracheostomy supplies heated and humidified oxygen gas at > 10 L/minute. However, little has been reported on the use of high-flow oxygen via tracheostomy during weaning from ventilators in patients with restrictive pulmonary dysfunction. We report successful weaning from ventilators in patients with restrictive pulmonary dysfunction using high-flow oxygen via tracheostomy. CASE PRESENTATION: The first patient is a 78-year-old Japanese man with severe pneumococcal pneumonia who was mechanically ventilated for more than 1 month after esophagectomy for esophageal cancer. After he underwent tracheostomy because of prolonged mechanical ventilation, restrictive pulmonary dysfunction appeared: tidal volume 230-240 mL and static compliance 14-15 mL/cmH2O with 10 cmH2O pressure support ventilation. He was weaned from the ventilator under inspiratory support with high-flow oxygen via tracheostomy over a period of 16 days (flow at 40 L/minute and fraction of inspired oxygen of 0.25). The second patient is a 69-year-old Japanese man who developed aspiration pneumonia after esophagectomy and received prolonged mechanical ventilation via tracheostomy. He developed restrictive pulmonary dysfunction. High-flow oxygen via tracheostomy (flow at 40 L/minute with fraction of inspired oxygen of 0.25) was administered with measurement of the airway pressure and at the entrance of the tracheostomy tube. The measured values were as follows: 0.21-0.3 cmH2O, 0.21-0.56 cmH2O, 0.54-0.91 cmH2O, 0.76-2.01 cmH2O, 1.17-2.01 cmH2O, and 1.76-2.01 cmH2O at 10 L/minute, 20 L/minute, 30 L/minute, 40 L/minute, 50 L/minute, and 60 L/minute, respectively. The airway pressures were continuously positive and did not become negative even during inspiration, suggesting that high-flow oxygen via tracheostomy reduces inspiratory effort. He was weaned from the ventilator under inspiratory support with high-flow oxygen via tracheostomy over a period of 12 days. CONCLUSIONS: High-flow oxygen via tracheostomy may reduce the inspiratory effort and enhance tidal volume by delivering high-flow oxygen and facilitate weaning from prolonged mechanical ventilation in patients with restrictive pulmonary dysfunction.

Thoracoscopic plication for diaphragmatic eventration in a neonate.

BACKGROUND: Currently, thoracoscopic surgery is replacing thoracotomy for an ever increasing number of indications, even in pediatric surgery. However, there are few reports describing thoracoscopic plication (TP) for diaphragmatic eventration in children, particularly in neonates. We report a case of TP under single-lung ventilation in a neonate with diaphragmatic eventration. CASE REPORT: A 10-day-old boy was referred for surgical management of right diaphragmatic eventration. Birth was at term, following an uncomplicated pregnancy and delivery. Shortness of breath, labored respiration and chest retraction presented soon after birth, necessitating mechanical ventilation. Chest radiography and computed tomography revealed an elevated right hemidiaphragm. Attempted weaning off mechanical ventilation failed with persistence of respiratory symptoms, requiring nasal directional positive airway pressure. However, because there was no resolution of symptoms, TP was performed using a 3 port technique under single-lung ventilation on day 17 of life. The postoperative course was excellent with complete resolution of respiratory symptoms with no recurrence for 9 months. CONCLUSION: To the best of our knowledge, this is the youngest case of TP for diaphragmatic eventration performed under single-lung ventilation. TP is safe, effective and minimally invasive and should be considered actively for the treatment of symptomatic diaphragmatic eventration even in neonates.

Effects of sivelestat on bronchial inflammatory responses after esophagectomy.

Post-operative pulmonary complications such as systemic inflammatory response syndrome (SIRS), acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are strongly associated with morbidity and mortality after esophagectomy. Post-operative administration of sivelestat sodium hydrate (sivelestat), a selective inhibitor of neutrophil elastase (NE), has been shown to improve the post-operative clinical course after esophagectomy. This study aimed to evaluate the effect of prophylactic administration of sivelestat on bronchial inflammatory responses. We randomized 24 patients into two groups. One group received 0.2 mg/kg/h sivelestat from the induction of anesthesia to post-operative day 1 (sivelestat group) and the other group received the same amount of physiological saline (control group). Bronchial alveolar epithelial lining fluid (ELF) samples were obtained from both groups at the induction of anesthesia and at the end of surgery. The serum and ELF levels of interleukin (IL)-6 and IL-8 were measured by enzyme-linked immunosorbent assay, and NE activity was spectrophotometrically determined using the same samples. Although IL-6 levels in the ELF significantly increased at the end of surgery compared with the pre-operative levels in both groups, the IL-8 levels and NE activity did not significantly increase at the end of the surgery compared to the corresponding pre-operative values in the sivelestat group. Moreover, IL-8 levels and NE activity in the ELF were significantly reduced at the end of surgery in the sivelestat group compared with corresponding values in the control group. The durations of ALI and ARDS were apparently shorter in the sivelestat group and the duration of SIRS was significantly shorter in the sivelestat group compared to the control group. We demonstrated that prophylactic use of sivelestat mitigated bronchial inflammation by suppressing NE activity and IL-8 levels in the ELF and shortened the duration of SIRS after transthoracic esophagectomy.