[The Influence of Preoperative Oral Carbohydrate Administration on Perioperative Blood Sugar Levels and Patients' Satisfaction].

BACKGROUND: After introducing preoperative oral carbohydrate as a part of enhanced recovery after surgery (ERAS) protocols, we assessed the influence of carbohydrate administration on the perioperative blood sugar levels (BS), the variation of vital signs and patients' satisfaction. METHODS: After IRB's approval and obtaining patients' consent, patients were divided into two groups; taking carbohydrate (Group AW) or not (Group NAW). Anesthesia was induced and maintained with total intravenous anesthesia using propofol, remifentanil and rocuronium. We measured BS six times during perioperative period. We also compared blood pressures and heart rates during induction of anesthesia. Moreover, we carried out questionnaire surveys about degree of satisfaction for ERAS among patients and nurses. RESULTS: Heart rates were significantly higher in Group AW (P < 0.05), but there were no significant difference in blood pressures or BS between the groups. Patients in Group AW had more anxiety for surgeries (P = 0.003), but more than 85% of patients and nurses were satisfied with carbohydrates. CONCLUSIONS: The carbohydrate administration had little influence on the perioperative vital signs. However, we gained high reputations from patients and paramedics.

[Safety and economics of fondaparinux administration in the laparoscopic surgery].

BACKGROUND: The factor Xa inhibitor, fondaparinux was used for prevention of venous thromboembolism in the clinical setting. We evaluated the antithrombotic effect, complications and economic aspects of this agent in the patients undergoing laparoscopic surgery. METHODS: Forty one patients scheduled for laparoscopic abdominal surgery were divided into two groups. In group F (N = 33), patients received once-daily subcutaneous injection of fondaparinux (2.5 mg x day(-1)) for 4 postoperative days. In group E (N = 8), patients did not receive therapy. In group F, general anesthesia with transversus abdominis plane (TAP) block was administered during surgery, and general anesthesia with epidural anesthesia was performed in group E. We evaluated incidence of DVT (deep vein thrombosis), abnormal bleeding, other postoperative complications, and economic benefit to the hospital. RESULTS: In both groups, no patient developed DVT Abnormal bleeding was observed in 7 patients of group E. Postoperative complications and pain were not different between the two groups. The revenue in group F was 34,434 yen/patient lower than that of group E due to Japanease insulance system. CONCLUSIONS: No patients developed DVT and severe complications of fondaparinux after laparoscopic abdominal cancer surgery. However, revenue to the hospital decreased 34,434 yen/patient by use of analgestic method. We must consider cost-benefit in use of fondaparinux.

[Reliability of a less-invasive cardiac output monitor in the perioperative period of a patient with severe dilated cardiomyopathy].

Recently, various less-invasive cardiac output monitors are used for a variety of cases. We used FloTrac system for a patient with severe dilated cardiomyopathy (LVDd/Ds = 75/62 mm, EF = 22%) and recognized its limitation. A 52-year-old woman underwent left partial mastectomy. There were no significant events during the operation. In the ICU, she developed symptoms of low output state, but we could not detect any significant changes on Vigileo Monitor. Arterial pressure-based cardiac output (APCO) measurement with FloTrac is based on the patient's characteristics, blood pressure waveform and basic data stored in Vigileo Monitor. Its accuracy is worse with arterial wave artifact, compromise of the arterial catheter, aortic regurgitation, intense peripheral vasoconstriction, irregular pulse and severe cardiac hypofunction. Thus, its reliability is influenced by various conditions, especially in critically ill patients. FloTrac system is very useful for the management of cardiocirculatory dynamics, but we should be familiar with its limitations.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa on a native aortic valve following infective endocarditis.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIVF) rarely forms on native aortic valve after infective endocarditis (IE). It is often fatal because of its rapid progress, high rates of rupture and recurrence, and worsening effects on the systemic condition. Echocardiography, especially transesophageal echocardiography, plays an important role in the diagnosis and assessment of this condition. We experienced a rare case of a patient with an unfortunate course following native aortic valve IE. After the patient had undergone surgical evacuation of a blood clot due to the rupturing of an embolomycotic cerebral aneurysm, a pseudoaneurysm of the MAIVF was found. Aortic valve replacement and pseudoaneurysm repair were performed 3 months after the neurosurgery. Echocardiographic still images were obtained during these two operations.

[Anesthetic management for nephrectomy using a monopolar electrocautery in a patient implanted with a biventricular pacemaker].

A 72-year-old man implanted with a biventricular pacemaker was diagnosed pyonephrosis, and left nephrectomy was performed under general and epidural anesthesia. Urologists were going to use a monopolar electrocautery during the operation. Before the operation, we attempted to convert the pacemaker from DDD mode to DOO mode with a precordial magnet because we wanted to know the effect of DOO mode in this patient implanted with a biventricular pacemaker and how a monopolar electrocautery interfered the biventricular pacemaker. His blood pressure and heart rate were stable during DOO mode by a precordial magnet, but the stroke volume was reduced a little. Then, we suggested surgeons the minimal use of the monopolar electrocautery. Actually, intraoperative use of the monopolar electrocautery did not interfere his pacemaker, and the operation was completed uneventfully. Recently in Japan, cardiac resynchronization therapy (CRT) becomes more common and operations in the patients implanted with biventricular pacemakers will become more frequent. The surgeons and anesthesiologists should take in mind that the monopolar electrocautery is appropriate or not depending on the individual patient.

[Perioperative management of patients with drug-eluting coronary stents presenting for non-cardiac surgery].

After the approval of the drug-eluting coronary stent in Japan in 2004, Japanese cardiologists took the benefit of this new technology to improve the post percutaneus coronary intervention complication of restenosis. Post market studies of drug-eluting coronary stent are becoming available. Unfortunately, many of the results indicate the risk of late stent thrombosis. The chance of stent thrombosis seems elevated when a patient is without antiplatelet medication, dehydrated and in a stressed state. Operation puts the patient in such adverse conditions that might render him to thrombo-producting state. As the use of drug-eluting stent becomes popular, the management of those patients in operative settings becomes inevitable. In this paper, we reviewed the medical records of 20 patients for surgery with drug-eluting coronary stents in our hospital. Time intervals between stent placement and surgery were: less than 90 days (2 cases), less than 180 days (3 cases), less than one year (8 cases), more than one year (7 cases). There was no stent thrombosis in the perioperative period. We did not take precautionary steps for stent thrombosis in the perioperative period, except in two cases where operations were performed recently (One patients received heparin and the other patients received aspirin and cilostazol). None of patients had excessive blood loss. However, many reports suggest the increasing risk of stent thrombosis in patients with the drug-eluting coronary stents presenting for non-cardiac surgery. They also suggest that, in contrast to bare metal stent, there may be no association between the risk of stent thrombosis and time intervals from stent placement to surgery. We should pay more attention to management of patients with drug-eluting coronary stents presenting for non-cardiac surgery.

[Anesthetic management for patients with compromised left ventricular function due to coronary artery disease in non-cardiac surgery].

BACKGROUND: As the number of patients suffering from coronary artery disease (CAD) increases, anesthetic management for these patients become more common than the past. But no established management strategies have been proven beneficial. METHODS: We reviewed all anesthetic management records of seven patients with compromised LV function (EF<30% or FS<30%) for CAD in our hospital, who had undergone non-cardiac operations. RESULTS: Three cases were brain surgeries and four cases were abdominal surgeries. In all cases, central venous catheters were placed before induction of general anesthesia. After inotropic agents were started through central venous catheters, patients went through induction with midazolam, fentanyl and propofol without any trouble. In three cases of abdominal surgeries, pulmonary artery catheters were placed. And in five cases, artery catheters were placed in the femoral arteries, so that, in case of cardiac shock, we could start IABP without delay. In one case, we experienced shock during operation, but without IABP, the patient recovered with pharmacological support. No patient died of cardiac cause during the hospital stay for the procedure. CONCLUSIONS: We reported anesthetic management of seven patients with compromised left ventricular function for CAD in non-cardiac surgery. However, as the reports of anesthetic management in patients with compromised left ventricular function in non-cardiac surgery is few, further study will be required.

[Preoperative evaluation, anesthetic management and postoperative complications of athetotic type cerebral palsy patients undergoing laminoplasty].

BACKGROUND: The patients with athetotic type cerebral palsy need to have their necks fixed for preventing worsening of their symptoms during surgery. Cervical fixation with a halo vest leads to difficult tracheal intubation and possibility of aspiration. Therefore careful perioperative management is necessary, especially for respiratory complications. However, since it is difficult on the patients with cerebral palsy to perform spirogram correctly, their preoperative respiratory functions are hard to be evaluated. METHODS: We evaluated the relationships between preoperative condition and postoperative complications in 50 athetotic type cerebral palsy patients who had undergone laminoplasty. In addition, we also compared them with non-cerebral palsy patients for laminoplasty without a halo vest. RESULTS: The patients with cerebral palsy showed lower preoperative ADL score, severer symptoms of myelopathy, and decreased %VC in spirogram. We found all of these were related to prolonged postoperative recovery of ADL and longer hospitalization. Two patients with cerebral palsy suffered from aspiration pneumonia after operation, whereas any non-cerebral palsy patients had no remarkable complications. CONCLUSIONS: Careful perioperative management is necessary for cerebral palsy patients undergoing laminoplasty, especially for prevention of aspiration pneumonia.

[Thoracoscopic surgery for spontaneous pneumothorax and its anesthetic considerations].

BACKGROUND: Incidence of spontaneous pneumothorax (SPT) is increasing recently. Video-assisted thoracic surgery (VATS) is, at present, accepted generally as a procedure of choice for surgical treatment of SPT. This study was designed to investigate whether pre-operative complications and epidural anesthesia contribute to post-operative outcome following VATS for SPT. METHODS: From 1999 to 2002, 88 patients (78 men and 10 women, ranging in ages from 18 to 86, with an average age of 42 years) presented with SPT and received VATS at the Osaka Police Hospital. We evaluated the relationship between peri-operative risk factors and post-operative outcome after VATS for SPT. RESULTS: Age and epidural analgesia contributed to post-operative pain (P=0.0268 and P=0.0165, respectively). Moreover, old age and long duration of surgery extended a hospitalization period (P=0.0002, r2=0.393 and P=0.0394, r2=0.224, respectively). In addition, old age contributes to post-operative pneumonia (P=0.0405). The patient with history of smoking had prolonged duration of surgery (P=0.0040) and oxygen supply after surgery (P=0.0312). CONCLUSIONS: VATS for SPT is less invasive and contribute to short hospitalization. However, VATS also requires general anesthesia with one-lung ventilation. From our study, peri-operative careful management is necessary in a patient with old age and a habit of smoking.