The Elevation of Double-Lumen Tube Cuff Pressure During Lung Surgery: A Single-Center Prospective Observational Study☆,☆.

OBJECTIVES: Excessive tracheal tube cuff pressure can cause postoperative complications; however, the variations in the double-lumen tube cuff pressure in lung surgery have not been investigated. This study aimed to determine the incidence and variations in excess double- lumen tube cuff pressure during one-lung ventilation. DESIGN: A prospective observational study. SETTING: Single secondary-care hospital. PARTICIPANTS: Patients aged ≥18 years scheduled for elective lung surgery using a left-sided double-lumen tube. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Each cuff of the double-lumen tube was connected to a pressure transducer, and the cuff pressure was continuously measured. The excess cuff pressure and its duration (%) were defined as ≥22 mmHg, and the ratio of the duration of excess cuff pressure to the duration of one-lung ventilation, respectively. In total, 147 patients were included in the final analysis. Eighty patients (54.5%) developed cuff pressure elevation in either cuff and 28 patients (19%) in both cuffs. Younger age, male sex, and left-sided surgery were associated with elevated bronchial cuff pressure. Concurrently, younger age, maximal peak inspiratory pressure, and obstructive respiratory dysfunction were associated with an elevated tracheal cuff pressure. A duration of excess cuff pressure >50% in either cuff was found in 34 patients (23%), and both cuffs in 5 patients (3.4%). The correlation between the duration of tracheal and bronchial excess cuff pressure was poor. CONCLUSIONS: A high incidence and long duration of excess tracheal and bronchial cuff pressure were observed during one-lung ventilation for lung surgery.

[Does the Residual Regurgitation on Intraoperative Transesophageal Echocardiography after Valve Surgery Deteriorate in Early Postoperative Period?].

BACKGROUND: Residual regurgitation after valve surgery affects patients' long-term prognosis. Whether post-repair regurgitation deteriorates postoperatively or not remains unclear, but this issue is a primary concern of the anesthesiologists responsible for intraoperative evaluation by transesophageal echocardiography (TEE). This study was conducted to assess changes in the severity of residual regurgitation during the early postoperative period. METHODS: Among 160 consecutive patients who underwent valve repair or valve replacement surgery during April 2010-June 2013 at our institution, 38 (24%) were found to have residual regurgitation by intraoperative TEE. We retrospectively evaluated these patients by reviewing follow-up transthoracic echocardiographic examination records. RESULTS: Residual regurgitation improved in 14 (37%), remained unchanged in 21 (55%), and worse in 3 (8%). All three patients showing worse regurgitation had undergone valve repair. Of them, one had reoperation one year later. No worsening of regurgitation, including perivalvular leakage, was found in patients who had undergone valve replacement. CONCLUSIONS: In valve repair, even mild residual regurgitation deteriorates postoperatively. Therefore, it should be observed cautiously. In valve replacement mild residual regurgitation did not deteriorate, irrespective of the regurgitation mechanism.

[Transesophageal Echocardiography Was Useful to Determine a Therapeutic Strategy for Coronary Artery Ischemia during Surgery for Acute Type A Aortic Dissection: A Case Report].

A 57-year-old woman presented with acute back pain, diagnosed with acute type A aortic dissection, and we performed emergency ascending aortic replacement. During surgery, until cardiopulmonary bypass was started, the dissection did not extend to the orifice of the both coronary arteries. When aortic replacement was completed and just after the return of spontaneous beating, ventricular fibrillation (Vf) suddenly occurred. At that time, transesophageal echocardiography (TEE) revealed that dissection extended from the left main trunk (LMT) to the left circumflex artery (LCX). Recurrent Vf and circulatory collapse necessitated the application of a percutaneous cardiopulmonary support system (PCPS), while the surgeons performed cardiac massage. Additional emergency coronary artery bypass surgery (CABG) was immediately implemented. After the CABG, TEE showed that the true lumens of the LMT and LCX were dilated, allowing an increased flow to the LAD and LCX. The patient was discharged 2 months later. Although rare, coronary ischemia can be a complication of acute aortic dissection, resulting in decreased survival. Development of dissection to the coronary artery can also occur both intra- and postoperatively. In such instances, rapid diagnosis and treatment are important to save the patient.

[Anesthetic management of a patient with Osler-Weber-Rendu disease undergoing mitral valvuloplasty].

Osler-Weber-Rendu disease (OWRd) is an autosomal dominant disease with an incidence of 1-2 per 100,000 of population. The triad of OWRd is fibrovascular dysplasia characterized by telangiectases, arteriovenous malformations and recurrent bleeding. We experienced anesthetic management of a patient with OWRd undergoing mitral valvuloplasty. The patient was a 79-year-old woman admitted to our hospital with diagnosis of heart failure, mitral regurgitation, and chronic atrial fibrillation. Massive nasal bleeding before admission caused severe anemia (Hb 4.8 g dl(-1)), and she received transfusion. Preoperaitve examination revealed moderate mitral regurgitation with prolapsed anterior leaflet, pulmonary hypertension, high cardiac output (6.85 l min(-1)), and multiple hepatic angiomas. After induction of anesthesia, a pulmonary catheter was inserted. High cardiac output and high saturation of mixed-venous oxygen were found until the end of surgery. Blood gas analyses of samples from several sites suggested left to right shunt below the inferior vena cava. Mitral valvuloplasty and tricuspid annuloplasty were completed under mild hypothermic cardiopulmonary bypass. Despite our attention to abnormal bleeding, perioperative course was uneventful. For anesthetic management of OWRd, we must recognize the abnormal bleeding and the systemic vascular malformations preoperatively, and prepare for the possible complications.

[Are transcutaneous blood gas measurement monitors (SenTec Digital Monitor system) useful for the respiratory management of chronic respiratory failure?].

BACKGROUND: The level of arterial carbon dioxide partial tension (PaCO2) is a sine qua non for the determination of the adequacy of ventilation. The aim of this study was to assess the usefulness of SenTec Digital Monitor System in measuring transcutaneous arterial carbon dioxide partial tension (PCO2) non-invasively for the management of chronic respiratory failure. METHODS: Three ICU patients suffering from chronic respiratory failure were enrolled. We recorded the data of PCO2 measured by a transcutaneous ear sensor (V-Sign : SenTec Inc.) and the data of PaCO2 (GASTAT-603ie Techno Medica Co., Ltd., Japan) obtained from arterial blood gas analysis. RESULTS: The mean PCO2 was 67.2 mmHg (min. 65.9 mmHg, max. 80.2 mmHg, n = 10), and the mean PaCO2 was 71.2 mmHg (min. 67.2 mmHg, max. 79.0 mmHg, n = 10). Regression analysis showed good correlation between PCO2 and PaCO2 (PCO2 = .95 x PaCO2-0.18 mmHg; R = 0.74). Bland-Altman analysis of PCO2 yields a bias of d = 3.9 mmHg with limits of agreement (1SD) -0.4 mmHg, +8.2 mmHg. CONCLUSIONS: SenTec Digital Monitor System enables non-invasive and reliable trend monitoring of PCO2 levels in patients with chronic respiratory failure.

Contralateral tension pneumothorax during video-assisted thorascoscopic surgery for lung cancer: a case report.

Contralateral tension pneumothorax during one-lung ventilation is a rare but catastrophic surgical complication. A 72-year-old Japanese male with lung cancer underwent right upper lobectomy with video-assisted thoracoscopic surgery. Despite use of various methods for maintaining oxygenation during one-lung ventilation, percutaneous oxygen saturation was unstable from the start of surgery and suddenly decreased with a drop in blood pressure. An intraoperative chest X-ray revealed a tension pneumothorax of the dependent lung. Insertion of a chest drain saved the patient's life. This case suggests that a contralateral tension pneumothorax should be considered as a possible cause when adequate oxygenation cannot be maintained during one-lung ventilation.

[Questionnaire survey on perioperative management of diabetic patients undergoing cardiovascular surgery].

BACKGROUND: Not many cardiovascular surgeries of diabetic patients were performed with optimal preoperative glycemic control because there was no diabetologist in our hospital. To examine how this complication was treated in other hospitals, we conducted a questionnaire survey sent to anesthesiologists in Japan on perioperative management of diabetic patients undergoing cardiovascular surgery. METHODS: In April 2004, 250 hospitals where cardiovascular surgery was performed were chosen by Internet search. We mailed questionnaires consisting of 16 questions on perioperative management of diabetic patients to the department of anesthesiology of those hospitals. Self-addressed envelopes were attached for returning answers. RESULTS: Answers were collected from 122 hospitals (48.8%). Physicians and/or surgeons handled preoperative management of diabetes mellitus and there was little concern by anesthesiologists. This management satisfied anesthesiologists with satisfaction level of 70%. Postponement of surgery due to poor preoperative diabetic control was experienced in 55 (45%) hospitals. Seventy-one percent of anesthesiologists regarded perioperative glycemic control important, but the strict glycemic control method was not yet employed in most hospitals. CONCLUSIONS: The survey showed that many anesthesiologists regarded perioperative glycemic control important and were satisfied with the present preoperative management. For better management, better cooperation between anesthesiologists, surgeons and diabetologists is needed.

[Severe hypotension and atrio-ventricular block in a patient of left lung cancer associated with myocardial bridging].

A 74-year-old man with myocardial bridging was referred to our hospital for operation of the left lung cancer. He underwent upper lobectomy of the lung under general anesthesia. After lobectomy and bilateral lymph node resection, severe hypotension occurred without ECG change. The blood pressure was restored by cardiac massage and the administration of fluids and vasoactive agents. After the closure of the sternum, hypotension occurred again and complete A-V block appeared. After resuscitation, A-V block disappeared. He was extubated the day after surgery without any neurogical deficit. We consider that hypovolemia and myocardial bridging induced hypotension and complete A-V block.

[Hemoglobin levels and weight gain after coronary bypass grafting by use of intraoperative hemodilution and autologous blood transfusion].

We investigated the relationship between the degree of hemodilution during cardiopulmonary bypass (CPB) and weight gain after coronary bypass grafting by use of intraoperative hemodilution and autologous blood transfusion. There is no significant difference in weight gain between the higher hemoglobin group (Hb > or = 6 g.dl-1) and the lower hemoglobin group (Hb < 6 g.dl-1). Furthermore, there is no significant correlation between hemoglobin levels during CPB and weight gain after operation. We conclude that slightly excessive hemodilution than usual during CPB does not influence weight gain when cardiac and renal functions are fair.

[Clinical use of the VIA Blood Gas Monitor System].

VIA Blood Gas Monitor System (Baxter) withdrawals and reinforces blood automatically and measures pH, PaCO2, PaO2, sodium, potassium, and hematocrit. We evaluated VIA for use during cardiopulmonary bypass in 8 patients and during differential lung ventilation in 6 patients. The bias and precision were calculated on all the measured parameters. A total of 127 blood samples were obtained for comparison. Blood gas data measured by VIA were clinically acceptable except sodium. These findings suggest that VIA is useful for the management of patients in whom frequent arterial gas measurements are necessary.

[Sudden onset of EDTA-dependent pseudothrombocytopenia in a patient scheduled for open heart surgery].

A 60-year-old woman scheduled for mitral and aortic valve replacement had sudden onset of thrombocytopenia without clinical symptoms. The platelet count was found to decrease after the sampling. Microscopic examinations confirmed platelet aggregations. Changing anticoagulant added to blood samples from EDTA to heparin resolved such platelet aggregations. This phenomenon was diagnosed as demonstrating EDTA-dependent pseudothrombocytopenia and the operation was performed as scheduled without platelet transfusion. Postoperative course was almost uneventful and the patient was discharged on 26th day after surgery. EDTA-dependent pseudothrombocytopenia must be ruled out when patients have thrombocytopenia without certain causes such as infections, drugs, or autoimmune diseases.