Oral nutritional support can shorten the duration of parenteral hydration in end-of-life cancer patients: a randomized controlled trial.

Tube feeding or hydration is often considered for end-of-life cancer patients despite the negative effects on quality of life. The efficacy of oral nutritional support in this setting is unknown. We conducted a randomized trial to compare the efficacies of an amino acid jelly, Inner Power® (IP), and a liquid enteral product, Ensure Liquid® (EL), in terminally ill cancer patients. We randomly assigned patients to 3 arms: EL, IP, and EL+IP. The primary endpoint was drip infusion in vein (DIV)-free survival, which was defined as the duration from nutritional support initiation to administration of parenteral hydration. Twenty-seven patients were enrolled in the study, of whom 21 were included in the intention-to-treat analysis. The median age of the subjects was 69 yr. There were significant differences between the arms with regard to the median DIV-free survival (0.5, 6.0, and 4.5 days in the EL, IP, and EL + IP arms, respectively; P = 0.05). The median overall survival was 7, 9, and 8 days in the EL, IP, and EL + IP arms, respectively. IP may shorten the duration of parenteral hydration in terminally ill cancer patients and does not affect their survival.

A Case Report of Femoral Hematoma following Obturator Nerve Block.

BACKGROUND: When an obturator nerve block (ONB) is performed, the conventional landmark method or ultrasound-guided method is used. The major complications of this block are hematoma, but there are very few reports of its complications. We encountered massive bleeding and a huge hematoma after ONB. Case Presentation. A 95-year-old female underwent transurethral resection of the bladder tumor. Induction of anesthesia was accomplished via spinal anesthesia and right ONB using the landmark method. Postoperatively, subcutaneous bleeding was detected in the lower right interior thigh. Concentrated red cell transfusion was conducted to address the anemia. There was no subsequent expansion of the hematoma. It resolved on postoperative day (POD) 53. The hematoma was deemed to be inadvertently introduced due to an obturator artery puncture during the obturator nerve block. CONCLUSIONS: Close attention is necessary to avoid advancing the needle too deep into the obturator during obturator nerve block.

[Two cases of bilateral upper extremity pareses during laparoscopic colectomy].

We herein report on two cases of bilateral upper extremity pareses developing after laparoscopic colectomy. The first case is a 42-year-old man undergoing laparoscopic colectomy under general and epidural anesthesia. During the operation, he was in a combined lithotomy and Trendelenburg position with his arms abducted to 80 degrees and flexed slightly on padded armboards. Postoperatively, he complained of numbness of bilateral forearms. A diagnosis of hypoperfusion caused by arm band was made. His symptoms subsided in three days by physical training. The second case is a 36-year-old woman who developed injury in the brachial plexus after laparoscopic colectomy. We suspect that the nerve injury was caused by the overstretching of her neck with her head under general anesthesia in Trendelenburg position.

[The change of difficulty in intubation as growth in patients with Treacher-Collins syndrome and Pierre-Robin syndrome].

BACKGROUND: Previous reports revealed that difficulties in tracheal intubation for patients with Treacher-Collins syndrome (TCS) progresses as growth; however it declines in those with Pierre-Robin syndrome (PRS). We tried to confirm these reports. METHODS: We retrospectively examined the anesthetic records of intubated patients with TCS and PRS without tracheotomy from January 2002 to August 2006. RESULTS: We experienced 10 times of intubation in 5 TCS patients and 6 times in 4 with PRS. No obvious change was observed in its difficulty depending on the growth in both syndromes. CONCLUSIONS: The difficulty of intubation depends on the characteristics of each patient rather than growth.

Anesthesia for patient with anti-N-methyl-D-aspartate receptor encephalitis: A case report with a brief review of the literature.

RATIONALE: Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is an immune-mediated syndrome caused by the production of antibodies against NMDA receptors. As NMDA receptors are important targets of many anesthetic drugs, the perioperative management of patients with anti-NMDA receptor encephalitis is challenging for anesthesiologists. PATIENT CONCERNS: A 31-year-old woman presented with akinesia and aphasia, which worsened despite steroid therapy. DIAGNOSIS: Anti-NMDA receptor encephalitis associated with ovarian teratoma. INTERVENTIONS: Laparoscopic ovarian cystectomy was performed under total intravenous anesthesia (TIVA) with peripheral nerve block (PNB). OUTCOMES: The patient recovered without postoperative complications or any adverse events after surgery. LESSONS: Ideal anesthesia for a patient with anti-NMDA receptor encephalitis is still under discussion. We decided to perform TIVA with PNB because the effect of propofol on NMDA receptors is considered less than that of volatile anesthetics; moreover, PNB may reduce the amount of propofol and opioids required for anesthesia. To conclude, TIVA with PNB may be the most appropriate method for anesthesia in a patient with anti-NMDA receptor encephalitis undergoing ovarian cystectomy.

[Effects of linear polarized light irradiation around the lumbar sympathetic ganglion area upon the skin temperature of lower extremities].

BACKGROUND: The effect of linear polarized light irradiation around the lumbar sympathetic ganglion area upon the skin temperature of legs may be similar to that of irradiation of near stellate ganglion area upon arms. METHODS: Linear polarized light irradiation was induced with SUPER LIZER (Tokyo Iken, Tokyo, Japan). The C probe of SUPER LIZER was placed on the left side of the supine at the level of L2. RESULTS: Seven-minute irradiation around the lumbar sympathetic ganglion area increased significantly the skin temperature of the irradiated side leg. CONCLUSIONS: These results suggest that linear polarized light irradiation around the lumbar sympathetic ganglion area might be useful and beneficial for clinical application.

[Outline and effectiveness of support system in the surgical center by supply, processing and distribution center (SPD)].

Supply, Processing and Distribution system had been introduced to surgical center (the University of Tokyo Hospital) since October of 2002. This system had reduced stock for medicine and materials and decreased medical cost dramatically. We designed some kits for therapeutic drugs related to anesthesia. They were prepared for general anesthesia, epidural and spinal anesthesia, and cardiovascular anesthesia, respectively. One kit had been used for one patient, and new kits were prepared in the anesthesia preparation room by pharmaceutical department staffs. Equipment, for general anesthesia as well as epidural and spinal anesthesia, and central catheter set were also designed and provided for each patient by SPD system. According to the questionnaire of anesthesia residents before and after introduction of SPD system, the time spent for anesthesia preparation had been reduced and 92.3% residents had answered that preparation for anesthesia on the previous day was getting easier. Most of the anesthesia residents had been less stressed after introduction of SPD system. Beside the dramatic economical effect, coordination with SPD system and pharmaceutical department reduced anesthesia preparation time and stress of the staff. Introduction of Support system of SPD to surgical center is important for safe and effective management of operating rooms.

Thoracic epidural catheter insertion using the caudal approach assisted with an electrical nerve stimulator in young children.

OBJECTIVES: We evaluated whether thoracic epidural catheter placement using the caudal approach and assisted with an electrical stimulator could be performed in young children. METHODS: Ten young children (1-4 years) who underwent abdominal surgeries were studied. Under general anesthesia without muscle relaxants, caudal catheter placement was performed using an 18-gauge Crawford-type needle and a 20-gauge radiopaque epidural catheter with a stainless-steel stylet. A metal adapter and a 3-way stopcock were attached to the catheter to connect to an electrical stimulator and to inject physiological saline. Electrical stimulation was performed intermittently while advancing the catheter until it reached the target length. The catheter position was confirmed on postoperative roentgenogram. RESULTS: The mean age of the subjects was 32.2 +/- 10.1 months (13-48 months), and the height was 85.3 +/- 6.1 cm (72-93 cm). In 9 of 10 patients, an epidural catheter could be placed at the first insertion. In 1 patient, the catheter could be placed successfully at the second insertion. The electrical current required for muscle contraction at the target length was 5.8 +/- 1.5 mA. CONCLUSION: Electrical stimulation reliably indicated the location of the catheter tip. This technique for thoracic epidural catheter insertion was easy to perform and could be used in young children.

[Intraoperative coronary spasm in patients without a history of anginal chest pain].

We report three cases of intraoperative coronary spasm that developed during non-cardiac surgical procedures. None of the patients had a history of anginal chest pain. The presumed contributing factors were: 1) suction of the trachea during general anesthesia, 2) hyperventilation and hypotension during induction of general anesthesia, and 3) hyperventilation during neuroanesthesia. Coronary vasodilators were administered and all cases recovered promptly without any clinical sequelae. A review of the literature reveals that the majority of patients who developed intraoperative coronary spasm had no history of anginal chest pain. Some of common intraoperative conditions such as hyperventilation, hypotension, and inadequate depth of anesthesia, were reported to be potent precipitating factors for coronary spasm. In recent years, a larger proportion of surgical patients have coronary risk factors. Careful anesthetic management is required to prevent intraoperative coronary spasm even in patients without a history of coronary artery disease.

[The effect of intrathecal fentanyl added to hyperbaric bupivacaine for caesarean section].

BACKGROUND: Management of cesarean section with spinal anesthesia is often accompanied with intraoperative nausea and pain. In a randomized controlled study, we explored the effect of intrathecal fentanyl on the characteristics of subarachnoid block in patients undergoing cesarean section. METHODS: Twenty-four healthy parturients scheduled for elective Cesarean section were allocated to receive either fentanyl 0.3 ml (15 micrograms) or 0.9% saline 0.3 ml added to 0.5% hyperbaric bupivacaine 2.0 ml given intrathecally in the right decubitus position (n = 12 in each group). Level of sensory blockade was evaluated with cold test and intraoperative use of antiemetics and analgesics was recorded. RESULTS: The maximum level of sensory blockade was significantly higher in the fentanyl group as compared with the control group (P = 0.019). Use of intraoperative antiemetics was significantly less often in the fentanyl group (P = 0.007). The required amount of intraoperative analgesics was smaller in the fentanyl group, although the difference was not significant (P = 0.11). No remarkable side effects, such as respiratory depression and hypoxia were observed. Apgar scores in the newborn were similar. CONCLUSION: Addition of intrathecal fentanyl to hyperbaric bupivacaine in parturients undergoing cesarean section improved quality of anesthesia without producing significant side effects.

[A case of latex anaphylactoid reaction starting with respiratory symptoms].

We report a case of latex anaphylactoid reaction in a 39-year-old man with aortitis. He was scheduled to undergo stent-graft implantation. When the operation progressed into his abdomen, respiratory symptoms, wheezing and high airway pressure, occurred. However, he did not show any dermal symptoms. Thirty-five minutes after the start of respiratory symptoms, his face suddenly showed flush, and intravenous epinephrine worked successfully against anaphylactoid reactions. There are anaphylactoid reactions which occurred with respiratory symptoms, and we should be aware of these cases.

[Perioperative management for carotid endoarterectomy with induced mild hypothermia: a case report].

We report perioperative management for carotid endoarterectomy with induced mild hypothermia in a patient with severe stenosis of the bilateral carotid arteries. The patient was a 47 year-old male with familial hyperlipidemia and history of coronary artery bypass surgery. Angiography revealed severe stenotic lesions of the right internal carotid artery (ICA) and total occlusion of the left ICA. Endoarterectomy for the right ICA was planned. Anesthesia was induced and maintained with fentanyl, midazolam, pancuronium and sevoflurane. Electroencephalogram and near-infrared cerebral oxymetry were employed for monitoring intraoperatively. Temporary shunting was used during clamping of the right carotid artery because collateral blood flow could not be expected due to total occlusion of the left ICA. Furthermore, mild hypothermia down to 34 degree C was induced for brain protection with the use of a cooling blanket. After the surgery, the patient was transferred to ICU under deep anesthesia and controlled ventilation. Anesthesia was lightened gradually after rewarming to prevent postoperative shivering. The patient left ICU on the second postoperative day without any neurological deficits.

[Marked reduction of life-threatening ventricular tachyarrhythmias in a critically ill patient by intravenous administration of magnesium sulfate].

A 90-year-old man with ischemic heart disease underwent an emergent operation for a ruptured abdominal aortic aneurysm. The patient was brought to the operating room in a state of hypovolemic shock, and developed myocardial ischemia and intractable ventricular arrhythmias during the operation. Intensive cardiopulmonary resuscitation including rapid transfusion, external cardiac massage, electrical defibrillation, and extensive use of cardiovascular drugs restored hemodynamic stability temporarily. However, ventricular tachyarrhythmias readily recurred and caused cardiovascular collapse. Despite a normal value of blood ionized magnesium, we administered two grams of magnesium sulfate intravenously, which drastically reduced ventricular arrhythmias. Although a number of reports have shown the effectiveness of magnesium in correcting lethal ventricular arrhythmias, the rank of magnesium administration has not been well established in standard algorithms for arrhythmia therapy. Now that the concentration of ionized magnesium in the blood can be easily measured in clinical settings, its role as an antiarrhythmic agent should be extensively reevaluated.

Effects of deep hypothermic circulatory arrest with retrograde cerebral perfusion on electroencephalographic bispectral index and suppression ratio.

OBJECTIVE: No systematic study has been conducted to investigate effects of deep hypothermic circulatory arrest (DHCA) on electroencephalographic bispectral index (BIS) and suppression ratio (SR). Thus, the effects of DHCA were evaluated on BIS and SR. DESIGN: A prospective clinical study. SETTING: University hospital (single institute). PARTICIPANTS: Twenty consecutive patients undergoing thoracic aortic surgery using DHCA under narcotics-sevoflurane anesthesia. INTERVENTIONS: BIS and SR were monitored during cardiopulmonary bypass, simultaneously with nasopharyngeal temperature (NPT). MEASUREMENTS AND MAIN RESULTS: BIS decreased to 0 with induction of deep hypothermia and rose again with rewarming, although rates of BIS changes in response to cooling and rewarming varied widely among patients. Typically, BIS decreased slowly until NPT reached 26 degrees C during cooling and then it began to decrease rapidly and reached 0 at 17 degrees C, in inverse proportion to SR, which increased rapidly with deep hypothermia and reached 100% at 17 degrees C. When SR was 50% or more, BIS was determined by SR according to the expression: BIS = 50-SR/2. With rewarming, BIS rose again and returned to precooling baseline levels. Time to the beginning of the BIS recovery significantly correlated with duration of DHCA. CONCLUSIONS: With induction of deep hypothermia, BIS decreased in a biphasic manner to 0 at rates varying among patients. With rewarming, BIS rose again at rates extremely widely varying among patients. The rate of BIS recovery was related to duration of DHCA. BIS may be capable of conveniently tracing suppression and recovery of a part of cerebral electrical activity before, during, and after DHCA.

Change in bispectral index during epileptiform electrical activity under sevoflurane anesthesia in a patient with epilepsy.

UNLABELLED: We observed abnormal fluctuation in Bispectral Index (BIS) caused by repeated alternations between two electroencephalographic (EEG) waveform patterns in a patient with a recent history of epileptic seizure under sevoflurane anesthesia. The repetitive development of the abnormal EEG changes (slow delta with or without spike) and the fluctuation in BIS disappeared almost immediately after administration of anticonvulsants. BIS may give useful information not only on the sedative-hypnotic state, but also on the development of and recovery from abnormal epileptiform EEG activity. IMPLICATIONS: During epileptiform electroencephalographic activity (EEG), the Bispectral Index shows an abnormal fluctuation caused by repeated abrupt alterations between normal EEG and abnormal epileptiform EEG patterns.