[Anesthetic Management for Patients with Chronic Obstructive Lung Disease].

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.

[Anesthetic Management for Cervicomedullary Decompression in a Patient with Achondroplasia--A Case Report].

This is a case report of a 42-year-old man who underwent suboccipital craniectomy and C-1 laminoplasty under general anesthesia. His weight and height were 32 kg and 110 cm, respectively. The patient had short limbs, a protruding forehead, a large tongue, and a short neck. Preoperative magnetic resonance imaging showed marked stenosis of the foramen magnum and cervicomedullary compression and malacia, with the smallest anteroposterior diameter of 4.5 mm. Mask ventilation and tracheal intubation were not feasible; therefore, an Airtraq® laryngoscope and a bronchial fiberscope were used. Anesthesia was maintained with propofol, remifentanil, and fentanyl. After intubation and postural change, the patient was awakened, and we confirmed the absence of any limb movement disorder. Intraoperative motor evoked potentials were normal. After extubation, he experienced numbness of the limbs. Postoperative magnetic resonance imaging revealed an enlargement of the foramen magnum and the foramen of the atlas. However, the cervicomedullary malacia remained unchanged. The cause of numbness was unknown. After rehabilitation, he became ambulatory and could walk continuously for about 300 m at a slow pace.

[OPCAB].

Off-pump coronary artery bypass grafting (OPCAB) has some advantages in reduction of postoperative complications including systematic inflammatory response, myocardial injury, renal injury and cerebral injury, compared to on-pump coronary artery bypass grafting. It is important to reduce myocardial oxygen consumption during anesthesia for OPCAB. The anesthesiologists should collaborate with the cardiac surgeons and plan the best perioperative strategy for rapid recovery. The anesthesiologists should pay attention to hemodynamic instability and myocardial ischemia during anastomosis. Fast-track anesthesia offers many benefits which lead to earlier ambulation, earlier discharge and earlier rehabilitation. Further fast-track anesthesia including extubation after OPCAB in the operating room is needed, but can only be performed in selected patients.

Noninvasive ventilation in pulmonary edema complicating acute myocardial infarction.

BACKGROUND: Because it remains unclear whether noninvasive ventilation (NIV) is an effective therapy for cardiogenic pulmonary edema secondary to acute myocardial infarction (AMI), we retrospectively evaluated our experience with NIV in the treatment of pulmonary edema secondary to AMI and other cardiac conditions. METHODS AND RESULTS: The study group included 206 patients with cardiogenic pulmonary edema, divided into an AMI group (53 patients) and a non-AMI group (153 patients). The weaning rate from NIV was similar in the AMI and non-AMI groups (90.6% vs. 90.8%, P=0.950). Heart rate, blood pressure, and respiratory rate decreased significantly 1h after initiation of NIV in both groups, and were maintained until weaning from NIV. The frequency of endotracheal intubation after weaning from NIV was higher in the AMI group than in the non-AMI group (7.5% vs. 0.7%, P=0.016), although the overall frequency of intubation was similar in both groups. The in-hospital mortality rate was similar in the AMI and non-AMI groups (13.1% vs. 9.8%, P=0.489). CONCLUSIONS: NIV effectively improved vital signs and oxygenation and lowered the intubation rate in patients with cardiogenic pulmonary edema of all etiologies, including AMI. The outcome in patients with AMI treated with NIV depends primarily on the severity of the course of AMI and not on the severity of acute respiratory failure.

Noninvasive positive pressure ventilation in patients with perioperative negative pressure pulmonary edema.

Negative pressure pulmonary edema (NPPE) is a noncardiogenic pathological process that is treated with invasive ventilation via a tracheal tube. To investigate the feasibility and safety of noninvasive positive pressure ventilation (NPPV) as an alternative treatment for NPPE, we retrospectively reviewed charts of 15 perioperative NPPE patients. Eight patients were treated by NPPV and 7 were treated by invasive ventilation. Patient characteristics, duration of NPPV, duration of intensive care unit (ICU) stay, and maximum airway pressure were investigated for the NPPV-treated patients. All patients treated by NPPV had a patent airway after complete relief of the airway obstruction and recovered from NPPE symptoms within one postoperative day. Arterial blood gas analysis showed a significant improvement in the PaO(2)/FiO(2) ratio from 132 + or - 30 mmHg in the operating room to 282 + or - 77 mmHg at discontinuation of NPPV. Serious complications, such as ventilator-associated pneumonia or aspiration pneumonia, did not occur, and intubation was not required for any patient. Favorable outcomes in these cases suggest that NPPV could be a feasible and safe alternative for treating NPPE if the patency of the airway is restored.

The efficacy of dexmedetomidine in patients with noninvasive ventilation: a preliminary study.

BACKGROUND: Agitation is associated with failure of noninvasive ventilation (NIV). We investigated the effect of dexmedetomidine in patients with NIV. METHODS: This was a prospective clinical investigation in an intensive care unit. Dexmedetomidine was infused in 10 patients in whom NIV was difficult because of agitation. RESULTS: Ramsay and Richmond Agitation-Sedation Scale scores were maintained at 2.94 +/- 0.94 and -1.23 +/- 1.30, respectively. All patients were successfully weaned from NIV, and the respiratory state was not worsened. CONCLUSION: This study shows that dexmedetomidine is an effective sedative drug for patients with NIV.

Large volume loading to prevent cisplatin-induced nephrotoxicity during negative-balance isolated pelvic perfusion.

PURPOSE: Negative-balance isolated pelvic perfusion (NIPP) is used to administer high doses of anticancer drugs such as cisplatin to patients with advanced cancer of the pelvic region. Although the drugs are intended to be specifically delivered to the pelvis, their leakage into the systemic circulation can cause acute renal failure. This study examines the loading volume required for preservation of renal function during anesthesia of NIPP. METHODS: Pelvic cancer patients were assigned to NIPP according to its enrollment criteria. Patients with heart failure, uncontrollable hypertension, renal failure, pulmonary disease or contraindication for the contrast media were excluded. We compared the current anesthesia management regime with a previous protocol, with regard to the loading volume and renal function as assessed by the calculated glomerular filtration rate (GFR). The correlation between the total loading volume and the GFR ratio (GFR after NIPP/GFR before NIPP) was evaluated to define adequate volume loading. RESULTS: The GFR ratios were 0.86 +/- 0.29 and 1.12 +/- 0.25 for the previous and current procedures, respectively. The regression line showed that a minimum loading volume of 28.8 ml kg(-1) h(-1) was required to maintain a GFR ratio of > or =1. CONCLUSIONS: A large volume infusion preserves the GFR despite high-dose cisplatin administration by NIPP.

Severe respiratory depression and bradycardia before induction of anesthesia and onset of Takotsubo cardiomyopathy after cardiopulmonary resuscitation.

A 69-year-old woman undergoing treatment for hypertension and epilepsy was scheduled to undergo cataract surgery. All preoperative examination results were within normal limits. Despite being tense, she walked to the operating room. Approximately 2 minutes after an intravenous line was established by an anesthesia resident, severe hypoxia and bradycardia developed, and she lost consciousness. Cardiopulmonary resuscitation was initiated immediately, and after 1 minute, she regained consciousness, and her breathing and circulation recovered. After admission to the intensive care unit, emergency coronary angiography was performed. The blood flow in all the coronary arteries was normal. However, a decrease in the apical left ventricular wall motion and an increase in the basal wall motion were observed. Based on these findings, Takotsubo cardiomyopathy was diagnosed. The wall motion gradually improved and the patient was discharged from the hospital on postoperative day 15. The respiratory depression and bradycardia were thought to be due to an inadvertent bolus of remifentanil. We surmised that the patient had received a slight amount of retained medication when the anesthesia resident established the intravenous line, which caused severe respiratory depression. It is important to note that adverse effects such as severe respiratory depression and bradycardia can be caused by even small doses of remifentanil.

Aggressive treatment with noninvasive ventilation for mild acute hypoxemic respiratory failure after cardiovascular surgery: retrospective observational study.

BACKGROUND: Acute hypoxemic respiratory failure (AHRF) is one of the most serious complications after cardiovascular surgery. It remains unclear whether noninvasive ventilation (NIV) has potential as an effective therapy for AHRF after cardiovascular surgery, although many reports have described the use of NIV for AHRF after extubation. The aim of this study was to investigate the effectiveness of NIV in the early stage of mild AHRF after cardiovascular surgery. METHODS: We retrospectively analyzed all patients admitted to the intensive care unit after cardiovascular surgery, whose oxygenation transfer (PaO(2)/FIO(2)) deteriorated mildly after extubation, and in whom NIV was initiated. A two-way analysis of variance and the Bonferroni multiple comparisons procedure, the Mann-Whitney test, Fisher's exact test or the χ(2)test was performed. RESULTS: A total of 94 patients with AHRF received NIV, of whom 89 patients (94%) successfully avoided endotracheal intubation (successful group) and five patients required reintubation (reintubation group). All patients, including the reintubated patients, were successfully weaned from mechanical ventilation and discharged from the intensive care unit. In the successful group, PaO(2)/FIO(2) improved and the respiratory rate decreased significantly within 1 h after the start of NIV, and the improvement in PaO(2)/FIO(2) remained during the whole NIV period. CONCLUSION: We conclude that NIV is beneficial for mild AHRF after cardiovascular surgery when it is started within 3 h after mild deterioration of PaO(2)/FIO(2). We also think that it is important not to hesitate before performing reintubation when NIV is judged to be ineffective.

Clinical evaluation of sivelestat for acute lung injury/acute respiratory distress syndrome following surgery for abdominal sepsis.

BACKGROUND: The efficacy of sivelestat in the treatment of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) has not been established. In part, this is due to the wide variety of factors involved in the etiology of ALI/ARDS. In this study, we examined the efficacy of sivelestat in patients with ALI/ARDS associated with abdominal sepsis. METHODS: The subjects were 49 patients with ALI/ARDS after surgery for abdominal sepsis. The efficacy of sivelestat was retrospectively assessed in two treatment groups, ie, a sivelestat group (n = 34) and a non-sivelestat group (n = 15). RESULTS: The sivelestat group showed significant improvements in oxygenation, thrombocytopenia, and multiple organ dysfunction score. The number of ventilator days (6.6 ± 6.1 versus 11.1 ± 8.4 days; P = 0.034) and length of stay in the intensive care unit (8.5 ± 6.2 versus 13.3 ± 9.5 days; P = 0.036) were significantly lower in the sivelestat group. The hospital mortality rate decreased by half in the sivelestat group, but was not significantly different between the two groups. CONCLUSION: Administration of sivelestat to patients with ALI/ARDS following surgery for abdominal sepsis resulted in early improvements of oxygenation and multiple organ dysfunction score, early ventilator weaning, and early discharge from the intensive care unit.

Expressions of genes encoding drug-metabolizing enzymes are altered after sevoflurane, isoflurane, propofol or dexmedetomidine anesthesia.

We previously showed that sevoflurane anesthesia affected the expression ratios of 177 of 10,000 genes in multiple organs of rats by microarray analyses. The maximum number of altered genes was detected in the liver, and included several genes characterized as encoding drug-metabolizing enzymes (DMEs). Here, we investigated whether alterations of pharmacokinetic gene expressions after anesthesia differed between inhalation and intravenous anesthesia, and how long the alterations persisted after awakening from anesthesia. Livers were obtained from rats (n = 6 per group) anesthetized with sevoflurane, isoflurane, propofol or dexmedetomidine for 0 or 6 h, and rats awakened for 24 h after anesthesia for 6 h. The mRNA expression ratios of eight genes encoding DMEs that showed the greatest alterations in the previous study, namely Cyp7a1, Cyp2b15, Por, Nr1i2, Ces2, Ugt1a7, Abcb1a and Abcc2, were measured by quantitative real-time reverse transcriptase-polymerase chain reaction. The expression ratios were mostly increased after 6 h of anesthesia and returned to their control levels at 24 h after awakening from anesthesia. However, the expression ratios of some genes remained elevated for 24 h after awakening from anesthesia. There were differences between inhalation and intravenous anesthesia, and interestingly, between sevoflurane and isoflurane and between propofol and dexmedetomidine.

The influences of propofol and dexmedetomidine on circadian gene expression in rat brain.

INTRODUCTION: There are circadian genes whose expressions were affected by sevoflurane. We hypothesized that propofol and dexmedetomidine also have influences on the expressions of circadian genes. MATERIALS AND METHODS: Seven-week-old rats were cannulated and propofol (600 microg/kg/min, 1 ml/h, n=6: group P6H), dexmedetomidine (1 microg/kg/min, 1 ml/h, n=6: group D6H), 10% lipid (1 ml/h, n=6: group L) and normal saline (1 ml/h, n=6: group N) were infused intravenously for 6h; rats were decapitated soon or 24h after awakening from anesthesia (groups P24H n=6 and D24H n=6). Real time reverse transcription-polymerase chain reaction was performed using rat whole brain and the expressions of circadian genes were measured. RESULTS: In the P6H group and the P24H group, the whole expressions of seven genes were changed significantly compared with the L group. In the D6H group, the whole expression of seven genes was changed significantly compared with the N group. In the P6H group, all gene expressions except for Tef (thyrotroph embryonic factor) were changed significantly compared with the L group. In this group, the expression of Dbp (D site albumin promoter binding protein) was increased, and the others were decreased. In the D6H group, all gene expressions except for Dbp and Tef were decreased significantly compared with the N group. For the two anesthetics, the expression patterns were different only in Dbp. CONCLUSION: We showed that propofol and dexmedetomidine have influences on the circadian gene expressions.

Evaluation of arterial stiffness in patients with branch retinal vein occlusion.

PURPOSE: To assess the arterial stiffness in patients with branch retinal vein occlusion (BRVO). METHODS: Brachial-ankle pulse wave velocity (PWV) and ankle-brachial index were measured in 10 patients with BRVO (mean age 67.9 +/- 7.5 years) and in 18 age-matched controls (mean age 66.9 +/- 6.8 years). The controls were subjects with systemic essential hypertension having no retinal lesions. RESULTS: The PWV in the BRVO group was 1,946 +/- 254 cm/s which was significantly higher than that in the control group (1,688 +/- 274 cm/s; p = 0.014, Wilcoxon rank sum test). The ankle-brachial indexes were 1.16 and 1.15 in BRVO and control groups, respectively. There was no significant difference between the groups (p = 0.944). In the control group, there was a significant positive correlation between PWV and systolic blood pressure (Spearman correlation coefficient r(s) = 0.385, p = 0.043), while no significant correlation was found in the BRVO group (Spearman correlation coefficient r(s) = -0.188, p = 0.603). CONCLUSION: The arterial stiffness is increased in patients with BRVO which was thought to be due to the structural changes of the artery and not dependent on the blood pressure.