Successful anesthetic management of separation surgery for pygopagus conjoined twins: a case report.

BACKGROUND: Conjoined twins are an extremely rare congenital occurrence, and anesthetic management for surgical separation presents unique challenges for anesthesiologists. CASE PRESENTATION: Five-month-old male pygopagus conjoined twins underwent separation surgery. We performed anesthesia induction in the supine position and surgery in the prone position. This presented a challenge because the transition from supine to prone position reversed the positional relationship between the two babies, resulting in crossing of the respiratory circuits and monitors. To solve the problem, we used anesthesia machines and monitors on the opposite side of each baby during anesthesia induction. The positional relationship between the twins and anesthesia machines and monitors normalized after the change to the prone position. Following the separation surgery, the twins were discharged without any complications. CONCLUSIONS: Our method of using opposite side anesthetic machines and monitors for anesthesia induction was useful for the safe anesthetic management of pygopagus conjoined twins.

Femoral nerve block with propofol sedation versus general anesthesia in patients with severe cardiac dysfunction undergoing autologous myoblast sheet transplantation.

PURPOSE: Regional anesthesia is more favorable than general anesthesia in patients with severe comorbidity; however, data on the superiority of peripheral nerve blocks over general anesthesia in patients with severe cardiac dysfunction are lacking. We aimed to demonstrate that peripheral nerve blocks reduce perioperative analgesic requirements and promote faster recovery compared to general anesthesia. METHODS: We retrospectively evaluated intraoperative blood pressure, perioperative medications, and postoperative recovery in patients who underwent skeletal muscle harvesting for autologous myoblast sheet transplantation. We compared patients who received general anesthesia (group G, n = 27) to those who received femoral nerve block with propofol sedation (group B, n = 22). RESULTS: Left ventricular ejection fraction was 24% on average, with no significant difference between groups. Compared with group G, a lower dose of propofol was used intraoperatively (1.25 versus 2.0 µg/mL, respectively; P < 0.001) and fewer patients required opioids (13.6 versus 100%, P < 0.01) in group B. Additionally, the lowest intraoperative mean blood pressure was higher (54 versus 48 mmHg, respectively; P = 0.02) in group B. More patients received postoperative analgesic drugs (51.9 versus 13.6%, P = 0.01) and they received them more frequently (1 [0-3] versus 0 [0-1], P = 0.02) in group G. The length of heart care unit stay was shorter in group B than group G (0 [0-18.5] versus 17 [0-47] h, respectively; P < 0.0001). CONCLUSIONS: Femoral nerve block with sedation was more beneficial than general anesthesia in patients with severe cardiac dysfunction who underwent skeletal muscle harvesting for autologous myoblast sheet transplantation.

[Comparison of Aortic Valve Replacement Combined with Coronary Artery Bypass Grafting and Transcatheter Aortic Valve Implantation Combined with Off-pump Coronary Artery Bypass Grafting].

BACKGROUND: The purpose of this study was to compare the perioperative management of aortic valve replacement combined with coronary artery bypass grafting (AVR+CABG) and transcatheter aortic valve implantation combined with off-pump coronary artery bypass grafting (TAVI+OPCAB). METHODS: A retrospective analysis was performed on patients who had undergone either AVR+CABG or TAVI+OPCAB for AS and CAD in Osaka Univer- sity Medical Hospital from January to October, 2014. RESULTS: AVR+CABG was performed in 11 pa- tients (group A) and TAVI+OPCAB was performed in 4 patients (group T) in this period. The patients in group T was significantly older than the patients in group A. There were no significant differences in other background factors. Procedure time and postoperative mechanical ventilation time were shorter in group T than in group A. Postoperative recovery was signifi- cantly faster in group T than in group A. CONCLUSIONS: TAVI+OPCAB is less invasive than AVR+CABG and an effective treatment for high risk patient with AS and CAD.

[A case of previously undiagnosed methemoglobinemia exhibiting sustained low SpO2 value at the induction of general anesthesia].

A 70-year-old woman was scheduled to undergo surgery for removal of thyroid tumor under general anesthesia. A routine preoperative evaluation confirmed that the patient was stable with no signs of cyanosis and dyspnea. However, during pre-oxygenation as well as mechanical ventilation with 100% oxygen, she showed sustained low SpO2 values (i.e., 91%). Arterial blood gas analysis at FIO2 of 1.0 showed an oxygen partial pressure (PaO2) of 297 mmHg. Unexpectedly, the analysis revealed methemoglobinemia (MetHb concentration: 15%) causing a discrepancy between the low SpO2 and normal PaO2 values in this patient. Methemoglobinemia is an uncommon cause of cyanosis; however, anesthesiologists should be aware that some drugs used during perioperative period (e.g., local anesthetics) can cause methemoglobinemia. While our case was a mild one and the patient recovered with no complications, methemoglobinemia levels above 30% could cause tissue hypoxemia and, thereby, requiring a treatment with methylene blue or ascorbic acid.

[7-year survey of anesthesia for cesarean section--comparison of tetracaine and bupivacaine as intrathecal anesthetic agents].

BACKGROUND: In our institution, spinal anesthesia is the first choice for cesarean section. After the introduction of bupivacaine in 2000 in Japan, the intrathecal anesthetic agent shifted from tetracaine to bupivacaine. We analyzed the anesthesia for cesarean section in recent 7 years and compared the anesthetic quality of tetracaine with that of bupivacaine. METHODS: The anesthetic records were reviewed in the patients who had received cesarean section between January 1998 and December 2004 at our institution. RESULTS: There were 10456 deliveries during the study period with a cesarean section rate of 28.2% (2947 cases). Ninety-one percent of cesarean section was performed under spinal anesthesia. Spinal anesthetic agent shifted from tetracaine to bupivacaine in 2000-2001, both of which was prepared as a hyperbaric solution and supplemented with 0.1 mg of morphine hydrocloride. Of the 2711 patients in whom a cesarean section was started under spinal anesthesia, 20 (0.7%) required conversion to general anesthesia. Three hundred eighteen patients (11.7%) required some analgesic supplementation. The incidence of intra-operative analgesic supplementation was greater in the patients anesthetized with hyperbaric tetracaine and morphine than in those anesthetized with hyperbaric bupivacaine and morphine (22.96% vs 4.20% ; P<0.01). The conversion rate from spinal to general anesthesia for cesarean section was 0.7%. CONCLUSIONS: Comparing these two intrathecal anesthetic agents, the rate of analgesic supplementation in those anesthetized with bupivacaine was lower than in those anesthetized with tetracaine. This suggests that bupivacaine provides the more profound blockade of the visceral pain than tetracaine, and is superior as a local anesthetic.