[Successful Anesthetic Management of a Patient with Critical Bleeding during Hepatectomy Using Recombinant Activated Factor VII and Intraoperative Blood Salvage].

A 58-year-old 79 kg male with metastatic liver cancer was scheduled for hepatectomy. Preoperative examination did not reveal any hemostatic abnormalities. Nine hours into the surgery, a vascular clip attached to the middle hepatic vein was disconnected and rapid bleeding followed. Unscheduled intraoperative cell salvage was employed. Despite surgical hemostasis as well as transfusion with fresh frozen plasma and platelets, significant oozing persisted for 10 hours, and cumulative blood loss amounted to 30,000 ml. Therefore, we administered fibrinogen products and recombinant activated factor VLL (rFVIIa, NovoSeven), a potent hemostatic initiator used in treating congenital factor VII deficient patients. After injecting 5 mg of rFVIIa, the bleeding was controlled almost immediately, and the surgery was completed within an hour. Although postoperative computed tomography detected subclinical but extensive thrombosis in the middle hepatic vein, the inferior vena cava, and the deep femoral veins, the thrombus spontaneously dissolved within seven months postoperatively. There was no evidence of metastatic disease 24 months postoperatively. Off-label use of rFVIIa and intraoperatively salvaged autologous blood transfusions are life-saving procedures for cancer patients who have massive bleeding during surgery, although we cannot completely exclude the possibility of serious postoperative thrombotic events and/or hematogenous cancer dissemination.

[Anesthetic Management of an Infant with Rapidly Developed Hyponatremia due to Bowel Perforation during Enema Reduction Using Diluted Contrast Medium].

A 7-kg 8-month-old boy was transferred to our institution after failed enema reduction of intussusception elsewhere. During the redo intervention using a 6-fold-diluted solution of Gastrografin with water as contrast medium, the bowel was perforated. Urgent surgical repair was planned and preoperative examination revealed serum sodium of 137 mEq x l(-1). On arrival in the operating room, the patient presented abdominal distension, drowsiness and tachypnea. His trachea was intubated and anesthesia was maintained with sevoflurane. Arterial blood examination immediately before the surgery (approximate by 80 minutes after the previous blood test) showed the following findings: pH 7.27, base excess -8.5 mEq x l(-1) and sodium 122 mEq x l(-1). Watery ascites estimated at 450 ml was evacuated upon a peritoneal incision. At termination of anesthesia, serum sodium recovered to 133 mEq x l(-1), resulting from replenishment of electrolytes and sodium bicarbonate administration. The patient became fully awake and his trachea was extubated in the operating room. Gastrografin has osmolarity of 1,900 mOsm x l(-1), containing sodium of 158 mEq x l(-1). Massive intraperitoneal accumulation of diluted Gastrografin is a rational explanation for the rapidly developed hyponatremia, which can lead to hyponatremic encephalopathy, especially in infants. Prompt surgical intervention is therefore essential for successful management of such cases.

Elective use of an uncuffed small-bore cricothyrotomy tube with balloon occlusion of the subglottic airway.

PURPOSE: To conduct a qualitative observational study on positive pressure ventilation through a percutaneous uncuffed small-bore cricothyrotomy tube with balloon occlusion of the subglottic airway to minimize supraglottic leak. CLINICAL FEATURES: Ten consecutive procedures were performed in the nine men enrolled in this study. The demographics of the participants were: aged 50-73 yr, weight 48-87 kg, American Society of Anesthesiologists class I-II, and scheduled for endoscopic submucosal dissection via flexible endoscopy for en bloc resection of superficial meso- and hypopharyngeal cancer. The airway was initially secured with a supraglottic airway (SGA) under sevoflurane-based anesthesia, and a cricothyrotomy was then performed using a Portex(®) Minitrach II uncuffed cricothyrotomy tube (4-mm internal diameter). Following SGA removal, a Coopdech(®) bronchial blocker was orally or nasally inserted, and the balloon was inflated to occlude the trachea immediately beneath the glottis. The ventilator setting was initially based on observation of chest motion and end-tidal carbon dioxide tension and then readjusted according to arterial blood gas levels. All procedures were completed within a median time of 149 min. Effective ventilation was achieved in all patients despite mild hypercapnia (PaCO2 of 58 mmHg at maximum) in some patients. SpO2 levels were maintained at ≥ 98%. CONCLUSION: This technique provides effective intraoperative ventilation and easy endoscopic access, and it countermeasures against the likely complication of postoperative laryngeal edema. Moreover, there is no need for conventional tracheostomy or prolonged intubation. This approach establishes a curative and less invasive pharyngeal cancer therapy. Certain adverse outcomes can be avoided, including impaired speech and swallowing, possible delayed closure of the stoma, or a compromised cosmetic outcome.

[Case of delayed awakening after remifentanil leakage out of a vein].

We report a case of delayed awakening with characteristic repeated loss of consciousness after remifentanil infusion complicated by leakage from an intravenous catheter. A 30-year-old male underwent microlaryngeal surgery for a vocal cord polyp. During anesthetic induction, infiltration from an intravenous (IV) line in the left forearm was observed 10 min after initiating a continuous infusion of remifentanil 0.5 microg x kg-1 x min -1. A second peripheral IV catheter was placed in the right forearm and general anesthesia was induced with remifentanil infusion at 0.3 microg x kg-1 x min- 1, propofol 120mg, fentanyl 100 microg, and rocuronium 70 mg. Anesthesia was maintained with remifentanil 0.05-0.3 microg x kg-1 x min -1and sevoflurane (1.5% in oxygen) for the 4 min of surgery. A few minutes after tracheal extubation, the patient developed respiratory arrest and loss of consciousness. We immediately ventilated him with a bag-valve-mask and administered naloxone 0.04 mg. Thereafter, he repeatedly awoke and was drowsy three times over the next 5hr. It was followed by an uneventful postoperative period. No remarkable deficit was observed in the patient. Blood gases, electrolytes, glucose values, and body temperature were within normal ranges throughout the perioperative period. Brain computed tomography, mag- netic resonance imaging, and electroencephalography showed no abnormalities. It was considered that the incidental subcutaneous remifentanil accumulation may have caused the respiratory suppression and delayed awakening.

[Experience of participating in the 14th Nepal Cleft Lip and Palate Surgery Project].

Adventist Development and Relief Agency (ADRA) Japan, a non governmental organization (NGO), following an official request of Federal Democratic Republic of Nepal Government has organized Nepal Cleft Lip and Palate Surgery Project since 1995. We participated in the 14th Project as one of the anesthesiologists from 7th to 22nd November 2009 and performed general anesthesia with a Nepalese anesthetist without a medical license in Sheer Memorial Hospital. Use of unfamiliar anesthetic medications and limited medical devices made us understand the difficulty of anesthetic management. This valuable anesthetic experience will be useful for us in general anesthetic management in the future.

[Successful anesthetic management of three patients receiving pheochromocytoma resection using extremely high-dose remifentanil infusion].

We describe three consecutive cases of successful anesthetic management for pheochromocytoma resection under balanced anesthesia with sevoflurane inhalation and extremely high-dose remifentanil infusion. This case series aimed to examine whether the aggressive dosing of remifentanil, exerting both depressor and bradycardic actions with short durations, is applicable for hemodynamic control during pheochromocytoma resection. The remifentanil infusion rate was set to maintain the systolic arterial pressure below 150 mmHg and heart rate below 100 beats x min(-1). In 2 of 3 cases, intraoperative hemodynamics were controlled by titrated remifentanil infusion with up to 2 and 3 microg x kg(-1) min(-1) in each case, without additional vasoactive agents. In another case, since adequate antihypertensive control was ineffective despite incremental remifentanil infusion to a maximum of 5 microg x kg(-1) x min(-1) supplemented with repeated boluses of 200 microg remifentanil, a total of 2.4 mg of nicardipine as a depressor was needed. Ephedrine 12 mg was employed following tumor removal. This anesthetic regimen thus allowed minimal or no concomitant use of depressors during tumor manipulation and vasopressors following tumor removal. In conclusion, the liberal use of remifentanil for the anesthetic management of pheochromocytoma resection appears to be simple, safe and effective.

[Case of acute dystonia during epidural droperidol infusion to prevent postoperative nausea and vomiting].

We report a case of bilateral ocular deviation due to droperidol-induced acute dystonia that was initially undiagnosed. A 22-year-old, 72 kg, parturient at 42 weeks' gestation underwent emergency cesarean section for pregnancy-induced hypertension under combined spinal-epidural analgesia. The epidural catheter was inserted through the T11-12 interspace, followed by intrathecal hyperbaric bupivacaine with adjunctive fentanyl. The patient complained of nausea shortly after delivery, which subsided with intravenous droperidol 1.25 mg and metoclopramide 10 mg. After surgery, epidural infusion with a mixture of ropivacaine, fentanyl, and droperidol was started. Around 25 hours postoperatively, both of the patient's eyes rotated upwards, although she was fully conscious. Brain CT/MRI did not show any abnormalities. An ophthalmologist and a neurosurgeon were consulted but there was no definitive diagnosis. On subsequent consultation with anesthesiologists, it was assumed that the symptom was related to external ophthalmoplegia secondary to spinal anesthesia. Thereafter, a "wait and see" approach was adopted. After 8 hours, she gradually developed torticollis and increased muscle tone of the lower extremities, which facilitated a diagnosis based on extrapyramidal signs. Epidural infusion was discontinued without further treatment. Her symptoms completely disappeared within 5 hours. The estimated cumulative dose of intravenous and epidural droperidol was 4.6 mg over 34 hours.

[Rhabdomyolysis accompanying low back pain following prolonged urological surgery in the exaggerated lithotomy position: a case report].

A 69-year-old man (163 cm, 72 kg) with hypertension and lumbar spondylosis deformans was diagnosed as having prostate cancer and subsequently underwent perineal prostatectomy under sevoflurane anesthesia combined with epidural anesthesia using mepivacaine in the exaggerated lithotomy position. Supplemental intravenous fentanyl was also given. The patient's systolic blood pressure ranged between 80 and 120 mmHg throughout the 255-minute procedure. On emergence from the anesthesia, the patient was free from pain and epidural infusion with 0.2% ropivacaine, fentanyl 2 microg x ml(-1) and droperidol 12.5 microg x ml(-1) at a rate of 5 ml x hr(-1) was started. Shortly thereafter, the patient began to complain of severe low back pain, which required intramuscular pentazocine injection as a rescue analgesic for 5 days postoperatively. On the 6th postoperative day, creatine kinase, which had apparently passed its peak, was 4,795 IU x l(-1). MRI on the 8th day demonstrated the presence of hemorrhage in the bilateral erector spinae muscles. On day 16, CT scan also confirmed partial necrotizing changes in the bilateral gluteal and erector spinae muscles. We believe that the low back pain was due to rhabdomyolysis secondary to ischemia of the lumbar and pelvic muscles resulting from lengthy compression during surgery. The recognition and early diagnosis of rhabdomyolysis following prolonged time in the exaggerated lithotomy position are the key to prevent potentially fatal sequelae.