[Usefulness of preoperative epidural catheterization under radiographic monitoring in anesthesia for endovascular abdominal aneurysm repair].

In Japan, endovascular abdominal aneurysm repair became one of the standard procedures in 2006. It has been performed in 8 patients at our hospital. We try epidural anesthesia with sedation for treatment because of the good control of blood pressure and immobilization of the patient. We usually perform epidural catheterization one day before the operation to avoid epidural hematoma due to heparinization during the operation. We usually use radiographic monitoring for safe and precise insertion of the catheter into the epidural space. Epidural catheterization with radiographic monitoring is useful for safe and reliable epidural analgesia.

Neutralization of receptor for advanced glycation end-products and high mobility group box-1 attenuates septic diaphragm dysfunction in rats with peritonitis.

OBJECTIVES: : To determine the relationship between intra-abdominal sepsis-induced high mobility group-box 1 and diaphragm contractile performance and to determine the inhibitory effects of antibodies for high mobility group-box 1 and receptor for advanced glycation end-products on septic peritonitis-induced diaphragmatic dysfunction, lipid peroxidation, and intracellular signal transduction in the rat diaphragm. In animal models of sepsis, production of reactive oxygen species has been shown to elicit diaphragmatic dysfunction. Extracellularly released high mobility group-box 1 can bind to cell surface receptors, such as receptor for advanced glycation end-products, eliciting inflammatory responses that lead to the development of sepsis. DESIGN: : Prospective laboratory study. SETTING: : University laboratory. SUBJECTS: : Wistar rats (n = 186). INTERVENTIONS: : Intra-abdominal sepsis was induced, using cecal ligation and perforation. In experiment 1, serum and diaphragm homogenates were obtained from sham-operated rats and from cecal ligation and perforation rats at 4-hr intervals postoperatively. In experiment 2, anti-high mobility group-box 1 and anti-receptor for advanced glycation end-products antibodies were administered 4 hrs and 8 hrs after cecal ligation and perforation to determine their effects on cecal ligation and perforation-induced diaphragm dysfunction, reactive oxygen species-related variables, and intracellular signal transduction. MEASUREMENTS AND MAIN RESULTS: : In experiment 1, cecal ligation and perforation induced serum and diaphragmatic high mobility group-box 1 within 8 hrs postoperatively with a decline in diaphragmatic force generation at 12 hrs after cecal ligation and perforation. In experiment 2, anti-receptor for advanced glycation end-products and anti-high mobility group-box 1 antibodies significantly attenuated cecal ligation and perforation-induced diaphragmatic dysfunction in a dose-related manner. Diaphragmatic malondialdehyde concentration and phosphorylation level of extracellular signal-regulated kinase 1/2 in the groups treated with these antibodies were significantly lower than those in the nontreated group. Anti-receptor for advanced glycation end-products antibody downregulated high mobility group-box 1 expression in the diaphragm during sepsis. CONCLUSIONS: : Cecal ligation and perforation induces high mobility group-box 1 in the diaphragm and increases serum high mobility group-box 1 level as a late-phase mediator, decreasing contractile performance by high mobility group-box 1 receptor for advanced glycation end-products interaction-mediated reactive oxygen species production. These findings suggested an important role of receptor for advanced glycation end-products-high mobility group-box 1 interaction in diaphragmatic dysfunction induced by lipid peroxidation in rats with intra-abdominal sepsis.

[Comparison of surgical versus endovascular stent-graft repair of thoracic and thoracoabdominal aortic aneurysms in terms of postoperative organ failure].

BACKGROUND: We conducted this study to clarify whether the incidence of organ failure after endovascular stent-graft repair of thoracic aneurysm (TAA) and thoracoabdominal aneurysm (TAAA) is much higher than that after surgical repair. METHODS: The diseases for surgical repair (surgical group) were TAA in 29 patients and TAAA in 19 patients. Fourteen patients underwent stent-graft repair for TAA and TAAA (stent group). Incidences of preoperative complications in the two groups were compared. Postoperative organ failures, changes in SOFA score and numbers of SIRS criteria were assessed over a period of 7 postoperative days. RESULTS: Although the incidence of preoperative complications in the stent group was significantly higher than that in the surgical group, postoperative organ failure in the surgical group was more frequent than that in the stent group. SOFA score in the stent group during the first 3 postoperative days was significantly smaller than that in the surgical group. However, the number of SIRS criteria in the stent group was significantly higher than that in the surgical group on the first postoperative day. CONCLUSIONS: Endovascular stent-graft repair for arotic aneurysm may be less invasive, leading to a reduction in the incidence of postoperative organ failure in high-risk patients.

[In vitro evaluation of lubrication properties of a suction catheter].

BACKGROUND: Lubrication is an important factor for passage of a suction catheter through a tracheal tube. This study was carried out to evaluate the effects of lubricants on resistance against removal of a suction catheter from a tracheal tube in an experimental setting. METHODS: A tracheal tube (I.D. of 7.5mm) was inserted into a mannequin, and the resistance against removal of a suction catheter from the tube was measured. RESULTS: Lubrication was improved by using a lubricant (lidocaine jelly or KY jelly), but there was no difference between the effects of the two lubricants. The use of water as lubricant markedly decreased lubrication. Differences in lubrication depending on the type of tracheal tube used, probably due to differences in coating, were also found. CONCLUSIONS: The use of water as a lubricant is not recommended for tracheal suction.

[Two cases of negative pressure pulmonary edema after induction of anesthesia and extubation].

Two cases of negative pressure pulmonary edema are described. In one case, tracheal intubation was not successful and airway obstruction occurred after induction of anesthesia. Spontaneous breathing was restored by reversal of neuromuscular blocking action, but airway obstruction persisted. Urgent tracheostomy was therefore performed. A chest x-ray and clinical features indicated pulmonary edema immediately after tracheostomy. Treatment with mechanical ventilation and positive end-expiratory pressure improved pulmonary edema. In the other case, airway obstruction occurred after extubation. Removal of secretion in the oral cavity and assisted ventilation improved airway obstruction, but pulmonary edema was found by chest x-ray. Forced diuresis using furosemide and oxygen inhalation resulted in the improvement of pulmonary edema. Fortunatetly, in both cases, significant complications associated with pulmonary edema did not occur. Care should be taken of the risk of pulmonary edema when the airway was obstructed after induction of anesthesia or extubation under spontaneous breathing.

[Myoglobinemia in a patient due to positioning during nephrectomy].

We report a case of myoglobinemia observed in the postoperative period due to forced positioning during nephrectomy. A 32-year-old male, weighing 93 kg, underwent the left nephrectomy due to renal cell carcinoma under general anesthesia with epidural block. The operation was performed uneventfully but he complained of severe pain in his right hip immediately after the recovery from anesthesia. Neither skin flush nor edema was observed and the other superficial tissue injury was not detected. On the day following the operation, severe myoglobinemia was observed and the serum myoglobin level increased to over 20,000 ng.ml-1. CT findings showed topical edema or necrosis of his right minor and medial gluteus muscle. Myoglobinemia continued only for 3 days after the operation without renal dysfunction. We may conclude that muscle injury during an operation followed by forced positioning for nephrectomy is caused not only by direct compression of the muscle, but also by obstruction of the profound intramuscular artery.