[Strategy for Determining the Appropriate Dose of Sugammadex with Monitoring Train-of-four (TOF) Responses at the End of Surgery].

BACKGROUND: Intraoperative monitoring of train-of-four (TOF) response is recommended to avoid inadequate dose of muscle relaxant and its antagonist. We have standardized monitoring of TOF response at the end of surgery in all the patients undergoing general anesthesia with rocuronium since October 2013. METHODS: TOF group comprised of 113 consecutive patients just after the standardization and we investigated the relationship between the dose of sugammadex and TOF count and also compared anesthetic factors in TOF group with those in control group which included 104 consecutive patients just before the standardization without TOF monitoring. RESULTS: Rate of the patients with TOF count 4 in TOF group approximately reached 70% and mean TOF ratio resulted in 0.56 ± 0.28. Mean dose of sugammadex in patients with TOF count 2-4 was 2.5 ± 0.9 mg x kg(-1), while the dose in patients with TOF count 0-1 was 3.6 ± 0.9 mg x kg(-1) and 6 patients among 11 patients with TOF count 0 was given less than 4 mg x kg(-1) of sugammadex. The percentage of the patients given 200 mg of sugammadex significantly decreased from 78% in control group to 48% in TOF group. CONCLUSIONS: We conclude that standardization of TOF response at the end of surgery reduces dose of sugammadex in patients with slight residual neuromuscular block though the dose in patients under deep muscle relaxation seems to be insufficient.

[Acute Ventilatory Failure during Prone Thoracoscopic Esophagectomy with Carbon Dioxide Insufflation in a Patient Managed by a Single Lumen Tracheal Tube].

A 67-year-old woman underwent prone thoracoscopic esophagectomy with carbon dioxide (CO2) insufflation. After insertion of an epidural catheter, general anesthesia was induced with propofol, sevoflurane, remifentanil and rocuronium. The trachea was intubated with a single lumen endotracheal tube (SLET). CO2 insufflation at 5 mmHg with the SLET deflated the right lung and provided excellent visualization without respiratory instability. The left side pleura was injured during the inferior mediastinal lymphadenectomy and the patient went into sudden profound hypoventilation with an increase in end-tidal CO2 from 43 to 64 mmHg. We observed the trachea with bronchofiberscope and the SLET was correctly located and not obstructed. We were convinced that bilateral pneumothorax occurred because the left side pleura was injured and auscultation revealed decreased breath sounds over the left hemithorax. We asked the surgeon to discontinue the insufflated CO2 and both lungs were fully expanded. The operation was then carried out successfully without further untoward event. The patient was successfully extubated at the intensive care unit on postoperative day 1. The CO2 insufflation during thoracoscopic esophagectomy can cause bilateral pneumothorax and we recommend to inflate the bilateral lungs regularly for the continuation of the surgery.

[Hyperkalemia after arterial revascularization in a patient undergoing arm replantation].

A 25-year-old man was admitted for arm replantation. His left upper arm was completely amputated by conveyer belt Anesthesia was induced with propofol (80 mg), rocuronium (50 mg), remifentanil (0.15 µg x kg(-1) x min(-1)) and maintained with sevoflurane (1-2%) and remifentanil (0.1-0.3 µg x kg(-1) x min(-1)). The plastic surgeons revascularized subclavian artery quickly but blood pressure decreased to 40-50 mmHg because of massive bleeding and plasma potassium concentration reached 5.8 mEq x l(-1). Noradrenaline (0.3 µg x kg(-1) x min(-1)) and massive albumin on behalf of red blood cells were administered. After we treated hyperkalemia and hypotension, the subclavian vein was successfully revascularized. We should maintain low potassium concentration before revascularization in patients undergoing arm replantation.

[Prolonged pain after left hepatectomy].

We have experienced a patient complaining of the prolonged pain after left hepatectomy. The patient was a 53-year-old man. He underwent left hepatectomy for cholangiocellular carcinoma, and complained of prolonged abdominal pain for more than 10 days after the operation. After detailed examinations, we noticed duodenal perforation. After the conservative treatment, his pain was improved. In this case, the causes of the prolonged pain might be peritoneal irritation caused by gastric contents and duodenal perforation. The peritoneal irritation was caused by bile leakage and the deformity of the stomach that might be due to the enlarged dead space after left hepatectomy. We should be cautious of possible pyloric obstruction as the cause of prolonged pain after left hepatectomy.

[The use of questionnaires for rotating residents in evaluating training in anesthesiology].

BACKGROUND: We prepared questionnaires for the rotating residents during their assignment for anesthesiology in the novel Japanese residency programs for the year 2004. METHODS: Questionnaires consisting of 39 items with 235 model answers for these items were prepared. The residents underwent three interviews by these questionnaires over the three-month training period. The number of correct answers for these questionnaires was recorded and evaluated using a computer database software. RESULTS: There was no significant correlation between the results of these questionnaires and the subjective evaluation by supervisors conducted during clinical training. On stepwise regression analysis, the results of the questionnaires for "American Society of Anesthesiologists Physical Status", "contraindications for epidural anesthesia", "complications of general anesthesia" and "initial procedures for patients in the operating room" correlated with the subjective evaluation by supervisors. CONCLUSIONS: Stepwise regression analysis was shown to be helpful in improving the questionnaires regarding the training in anesthesiology.

Disagreement between fourth generation FloTrac and LiDCOrapid measurements of cardiac output and stroke volume variation during laparoscopic colectomy.

STUDY OBJECTIVE: To determine the agreement between cardiac output (CO) and stroke volume variation (SVV) measured simultaneously by the fourth generation FloTrac/Vigileo system and LiDCOrapid system during pneumoperitoneum in patients undergoing laparoscopic colectomy. DESIGN: Retrospective observational study. SETTINGS: Operating room in a general hospital. PATIENTS: Ten patients (American Society of Anesthesiologist 1 or 2) without preoperative anemia. INTERVENTIONS: A 22-gauge catheter was inserted in the radial artery after induction of anesthesia. The arterial line was split to monitor CO and SVV simultaneously with the LiDCOrapid and fourth generation FloTrac/Vigileo systems. All data were downloaded from each system after surgery and simultaneous paired COFloTrac, COLiDCO and SVVFloTrac, SVVLiDCO values estimated every 1 minute during the pneumoperitoneum were analyzed. MEASUREMENTS: To assess the agreement after carbon dioxide insufflation, a scatter 4-quadrant plot was generated using paired ΔCO values (changes in COFloTrac and COLiDCO just before pneumoperitoneum and 3 minutes after the induction of pneumoperitoneum). For data in which SVVFloTrac was >9% but <16% and cardiac index measured by FloTrac/Vigileo was <2.5 L/min per m2 during stable pneumoperitoneum (the period from 5 minutes after Trendelenburg position until discontinuation of pneumoperitoneum), simultaneously measured paired SVVFloTrac and SVVLiDCO were plotted every 1 minute using the Bland-Altman method. MAIN RESULTS: A concordance ratio for changes in CO after the induction of pneumoperitoneum was 83% in 4-quadrant plot. During stable pneumoperitoneum, 702 paired SVVFloTrac and SVVLiDCO matched the criteria. These data sets were plotted by the Bland-Altman method and the bias and 95% limit of agreement of SVV were 2.01 and -2.63% to 6.65%, respectively, with 38% percentage error. The regression equation was SVVLiDCO = 0.98 × SVVFloTrac- 1.73 with Pearson correlation coefficient of 0.55. CONCLUSIONS: Our study showed disagreement between the 2 methods and the hemodynamic parameters measured by one of the two devices should be interpreted with caution before therapeutic interventions.