Efficacy of endotracheal lidocaine administration with continuous infusion of remifentanil for attenuating tube-induced coughing during emergence from total intravenous anesthesia.

PURPOSE: Although attenuation of tube-induced coughing is necessary in specific types of surgery, the best method for such attenuation is still unclear. We studied the combined intervention of endotracheal lidocaine and intravenous remifentanil compared to intravenous remifentanil alone with respect to coughing during emergence from anesthesia. METHODS: We examined 60 ASA 1-2 patients (age, 20-69 years) undergoing tympanoplasty under general anesthesia. Anesthesia was induced with propofol, remifentanil, and rocuronium. The trachea was intubated using a laryngotracheal instillation of topical anaesthetic (LITA) tracheal tube. Anesthesia was maintained with propofol and remifentanil (0.1-0.3 µg/kg/min). Propofol was discontinued and remifentanil (0.1 µg/kg/min) was continued at the end of the operation. Patients were randomly allocated to the lidocaine (n = 30) and control groups (n = 30). We administered 3 ml 4 % lidocaine via the LITA tube to patients in lidocaine group at the end of the operation. The trachea was extubated when the patient regained consciousness and followed orders. Coughing was evaluated using a 4-point scale by an observer who examined the video records at extubation. RESULTS: Fewer patients in lidocaine group (8 of 30) than in control group (18 of 30, p < 0.01) coughed. Fewer patients in lidocaine group (2 of 30) than in control group (12 of 30, p < 0.01) had moderate or severe cough (scale 2 or 3). CONCLUSIONS: This study is consistent with the finding that endotracheal lidocaine administration and continuous infusion of remifentanil before extubation is useful to prevent coughing on emergence from anesthesia.

[Case of pulmonary hemorrhage suspected to be caused by pulmonary artery catheter after cardiac surgery].

We report a case of pulmonary hemorrhage suspected to be caused by a pulmonary artery catheter (PAC) after cardiac surgery. An 80-year-old woman underwent aortic valve replacement, mitral valve replacement, and tricuspid annuloplasty. After anesthesia induction, a PAC was inserted from the right jugular vein and fixed at 48 cm, but it could not be wedged. Therefore, the PAC was fixed at 59 cm to measure the pulmonary capillary wedge pressure during the operation. The catheter showed a postoperative bending. The chest X-ray radiograph obtained at the first postoperative day showed a shadow in the right middle and lower lung. PAC was pulled and fixed at 48 cm, but the shadow continued to grow in size. A large volume of bloody drainage fluid was obtained. Therefore, we operated again. No bleeding or hematoma was observed in the mediastinum or pericardium. However, a hematoma spreading from the hilum of the right lung was observed under the visceral pleura. The patient was discharged on the 23rd postoperative day. The lung hemorrhage may have been caused by PAC-induced pulmonary artery injury since no lung injury was observed during reoperation. Therefore, care should be taken to prevent pulmonary artery injury by excessively deep insertion of PAC.

[Anesthetic management of an adult patient with Fontan circulation for laparoscopic surgery].

Advances in the surgical and medical management of children with congenital heart disease have decreased the mortality of these patients. As a result, more patients are surviving into adulthood and are presenting for noncardiac surgery. We experienced a case of anesthetic management of an adult patient with Fontan circulation for laparoscopic surgery. A 29-year-old woman was scheduled for laparoscopic cholecystectomy for gallbladder stone. She had undergone single-ventricle procedures for a tricuspid atresia, and at the time of the laparoscopic surgery, her cardiac physiology was Fontan circulation. To reduce the influence of the increased intraabdominal pressure on hemodynamics, the insufflation pressure was maintained at 8 cmH2O during pneumoperitoneum. To reduce systemic and pulmonary vascular resistance, milrinon was administered intravenously. Throughout the operation, including the period of pneumoperitoneum, the hemodynamic status remained stable, and adequate oxygenation and ventilation were maintained. The surgery ended uneventfully, and the trachea was extubated in the operating room. In anesthetic management of patients with Fontan circulation for laparoscopic surgery, it is important to understand the physiology of the circulation, and consider the influence of the pneumoperitoneum on the hemodynamics.

[Case of paroxysmal atrial fibrillation after general anesthesia caused by undiagnosed and untreated hyperthyroidism].

A 21-year-old man was scheduled to undergo posterior cruciate ligament reconstruction under arthroscopic control. The patient did not have a previous history of thyroid disease. Low blood cholesterol was revealed in the laboratory data. On arriving at the operating room, he showed sinus tachycardia of 130 beats x min(-1). Anesthesia was induced with remifentanil and propofol intravenously followed by sevoflurane inhalation, and maintained with remifentanil at a rate of 0.3 microg x kg(-1) x min(-1) and 2% sevoflurane. Heart rate was stable around 70-90 beats x min(-1) during the operation. After remifentanil and sevoflurane were discontinued following surgery, his heart rate increased and paroxysmal atrial fibrillation occurred. Although verapamil was administered intravenously, atrial fibrillation and tachycardia persisted. Further investigations revealed an elevated serum free thyroxin level and suppressed thyroid-stimulating hormone (TSH). Serum TSH receptor antibody concentration was elevated. Upon postoperative examination, goiter and the protuberance of the eyes were noticed. We conclude that he was suffering from Basedow disease. Although he had no subjective symptoms in the preoperative period, the possibility of hyperthyroidism should have been predicted from the laboratory data such as hypolipidemia and by conducting a careful medical examination. It seems that remifentanil suppresses sympathetic activity, and is useful for patients with hyperthyroidism.

[Anesthetic management of a patient with pulmonary tuberous sclerosis complicated with renal angiomyolipoma].

A 55-year-old woman underwent total hysterectomy. She suffered from tuberous sclerosis and was complicated with lymphangioleiomyomatosis and renal angiomyolipoma. There have been only a few reports of anesthetic management on patients with these three diseases. Anesthesia was maintained with combined spinal-epidural anesthesia. Patients with tuberous sclerosis should be examined precisely. This case was managed carefully to avoid pneumothorax and acute bleeding from renal angiomyolipoma. There was no postoperative anesthesia-related complications.

[Efficacy of continuous intraoperative administration of low-dose milrinone during the circumflex artery anastomosis of off-pump coronary artery bypass].

BACKGROUND: We have experienced instability of hemodynamic state during off-pump coronary artery bypass (OPCAB), especially, circumflex (Cx) artery anastomosis. Although some reports have implied the efficacy of mirlinone in OPCAB anastomosis due to its characteristic inotropic effect without increasing myocardial oxygen consumption, we examined the effect of smaller doses of mirlinone during Cx anastomosis. METHODS: Fourteen patients received milrinone (M group) continuously at a rate of 0.15-0.30 microg x kg(-1) min(-1) after sternotomy until the end of operation. Sixteen patients in the control group (C group) received saline. Norepinephrine was concomitantly administered for maintaining systolic blood pressure above 100 mmHg. We measured hemodynamic parameters during Cx anastomosis and postoperative myocardial isozymes, and examined arrhythmias. RESULTS: In the M group mean pulmonary arterial pressure (MPAP) decreased significantly and cardiac index (CI) and SvO2 increased significantly, compared with C group. M group showed lower incidence of atrial fibrillation for 2 days. CONCLUSIONS: We conclude that low-dose milrinone has a good influence on intraoperative and postoperative managements of OPCAB surgery.

Lumbar epidural buprenorphine for postoperative pain relief following hepatectomy.

The induction of postoperative pain relief with lumbar epidural or intramuscular buprenorphine was studied in 30 patients undergoing hepatectomy. When patients first complained of pain after surgery, 0.06 mg or 0.12 mg of buprenorphine in 10 ml or 20 ml of saline was administered through an epidural catheter inserted at the L3-4 interspace, or 0.12 mg was administered intramuscularly. Two of seven patients receiving epidural buprenorphine 0.12 mg in 10 ml saline were completely pain-free, and the other five patients in this group had only slight pain. Four of eight patients receiving epidural buprenorphine 0.12 mg in 20 ml saline were completely pain-free, and the other four patients in this group had only slight pain. Epidural buprenorphine 0.06 mg in 20 ml saline and intramuscular buprenorphine 0.12 mg each yielded only incomplete analgesia. The duration of analgesia of epidural buprenorphine 0.12 mg administered at the lumbar level was about 8 h. There were no significant changes over time in circulatory or respiratory variables induced by buprenorphine. No patient had serious adverse effects. Lumbar epidural administration of buprenorphine 0.12 mg diluted to 10 or 20 ml (20 ml might be preferable) with saline is recommended for induction of postoperative analgesia following hepatectomy.