[Anesthesia in a Patient with Giant Goiter in Whom Tracheotomy Was Performed with Standby of Percutaneous Cardiopulmonary Support].

In a 53-year-old female patient total thyroidectomy for a giant goiter under general anesthesia was scheduled. On talking, airway stenosis sounds were heard. Cervical to thoracic CT revealed left and right lobe tumors measuring 5.3 x 5.6 x 10.0 and 9.1 x 8.6 x 10.0 cm, respectively. The trachea showed stenosis at a site 3.8 to 6.5 cm below the glottis, and the narrowest lumen diameter was 3.1 mm. Due to marked tracheal stenosis, awake intubation was not selected. To maintain the airway, tracheotomy was performed under local anesthesia. Considering the risk of difficulty in ventilation during tracheostomy, 4 Fr catheter sheaths were inserted into the right femoral artery and vein for percutaneous cardiopulmonary support (PCPS). Subsequently, tracheotomy was conducted in an area peripheral to the site of stenosis. After tracheotomy, general anesthesia was started. During general anesthesia, there were no problems regarding ventilation. The tracheal cannula was removed 7 days after surgery, and the patient was discharged after 14 days. For general anesthesia in patients with giant goiter, it is important to select an airway management method in consideration of tumor-related compression of the trachea. Airway management by tracheotomy under local anesthesia with standby of PCPS may be a treatment option.

[Anesthetic Management of Open Reduction for a Femoral Neck Fracture in a Patient Complicated with Fat Embolism Syndrome.]

We experienced anesthetic management of open reduction for a femoral neck fracture in a patient com- plicated with fat embolism syndrome. An 83-year-old woman with a femoral neck fracture was admitted to our hospital after suffering an injury. She developed hypoxemia on admission. Chest X-ray showed a decrease in permeability of the right lung and chest CT scan showed ground glass opacities of the right lung. A blood test showed anemia, thrombocytopenia, and elevation of C-reactive protein. She was diagnosed with fat embolism syndrome using the classification of Tsuruta. Oxygen was administered. C-reactive protein decreased gradually after hospitalization. Echocardiog- raphy showed normal left ventricular function without pulmonary hypertension. She was scheduled for open reduction for the femoral neck fractu-e with artificial grit insertion under general anesthesia 6 days after hospitalization. Her operation was performed with- out exacerbation of the fat embolism syndrome. She was extubated in the operating room, and was dis- charged from the recovery room without any conpli- cations. After surgery, chest X-ray showed further improvement and she was transferred to a rehabilita- tion hospital on the 27th hospital day.

[General Anesthesia for the Thoracoscopic Lung Resection Surgery in 12 Very Elderly Patients above 85 Years of Age].

We investigated perioperative management and clinical outcome of 12 patients who were 85 years old or older and received video-assisted thoracic surgery under general anesthesia. Although all the patients had preoperative respiratory complications or cardiovascular complications, they were discharged without any additional respiratory assistance such as home oxygen therapy. Our observation suggests that it is important to evaluate the indication of anesthesia from their daily activities and pulmonary function test even if they are oldest-old. If the patient demonstrates good physical function, he or she should not be excluded from anesthesia.

[Perioperative Management of Emergency Operation for a Patient with Carcinoid Syndrome].

We report a case of carcinoid syndrome requiring an emergency operation for an upper gastrointestinal perforation. A 46-year-old man had undergone left lower lobectomy for a lung carcinoid tumor seven years previously, and liver metastasis was found five years previously. He developed cutaneous flushing and watery diarrhea, and was diagnosed with carcinoid syndrome one year previously. Although he was treated with octreotid, his symptoms became worse and he was admitted to our hospital. During the hospital stay, he underwent an emergency operation for an upper gastrointestinal perforation. Before the operation, hemodynamics were unstable. Anesthesia was induced with sevoflurane and propofol, and maintained with sevoflurane and remifentanil. Only vasopressin was used for the treatment of hypotension. Landiolol was used for perioperative tachyarrythmia. During anesthesia, there was no severe hypotension or hypertension. After the operation, he was managed with intubation in the ICU. Octreotid was administered again for the carcinoid syndrome. Vasopressin was necessary for the treatment of hypotension in the ICU. After improvement of hemodynamics, extubation was performed on the 3rd ICU day and he was discharged from the ICU on the 4th ICU day. In conclusion, we were able to perform good perioperative management of carcinoid syndrome accompanied by hemodynamic instability.

[Preoperative screening of deep venous thrombosis: cutoff value of D-dimer, age and BMI for further examination of DVT by echo-color-Doppler].

BACKGROUND: Pulmonary embolism (PE) is morbid perioperative complication and deep vein thrombosis (DVT) is the most common cause of PE. Echo-color-Doppler examination for DVT is a specific test. But it would not be cost-effective to perform in all preoperative patients. The aim of this study was to determine the cut-off value of age body mass index (BMI) and D-dimer (DD) for further examination (echo) of DVT. METHODS: The age, BMI and DD of patients who had undergone echo-color-Doppler test were retrospectively examined. There were 94 patients scheduled for elective operation under general anesthesia from May 2004 to March 2005 in Himeji Red Cross Hospital. RESULTS: Forty five patients were with DVT and 49 patients were without DVT. There was no significant difference between the two groups in BMI. The cut-off value of age was 39 years and that of D-dimer was 0.8 µg x ml(-1). Discriminant function of DVT and D-dimer age were obtained in the formulae, Z = 0.0047 x (Age)(2) - 0.0565 x (D-D)(2) - 0.0046 (Age) x (DD) - 0.7085 x (Age) +0.546 x (DD) + 26.5674. CONCLUSIONS: We recommend that the patients above the discriminant function curve of DVT should undergo further examination for DVT.

Reliability of central venous pressure to assess left ventricular preload for fluid resuscitation in patients with septic shock.

BACKGROUND: Initial fluid resuscitation is an important hemodynamic therapy in patients with septic shock. The Surviving Sepsis Campaign Guidelines recommend fluid resuscitation with volume loading according to central venous pressure (CVP). However, patients with septic shock often develop a transient decrease in cardiac function; thus, it may be inappropriate to use CVP as a reliable marker for fluid management. METHODS: We evaluated 40 adult patients with septic shock secondary to intra-abdominal infection who received active treatment and were monitored using transthoracic echocardiography (TTE) and CVP for 2 days after admission to our intensive care unit (ICU). We measured left ventricular end-diastolic diameter (LVEDD), left atrial diameter (LAD), and the pressure gradient of tricuspid regurgitation (TR∆P). The shock status was treated with volume loading and inotrope/vasopressor administration according to the TTE findings. We assessed left ventricular fractional shortening (LVFS) as an index of left ventricular contractility and TR∆P as an index of right ventricular afterload and then examined the correlation between CVP and LVEDD/LAD/TR∆P. RESULTS: LVFS decreased to ≤30% in 42.5% and 27.5% of patients with septic shock, and severe left ventricular dysfunction with LVFS ≤20% developed in 12.5% and 15.0% of patients on the first and second ICU days, respectively, despite the use of inotropes/vasopressors. Mild pulmonary hypertension as indicated by TR∆P ≥30 mmHg was present in 27.5% and 30.0% of patients on their first and second ICU days, respectively. There was no significant correlation between CVP and LVEDD/LAD/TR∆P. The hospital mortality rate in this study was 10.0%, although the predicted mortality based on the Acute Physiology and Chronic Health Evaluation II score was 58.7%. CONCLUSIONS: Our results suggest that CVP is not a reliable marker of left ventricular preload for fluid management during the initial phase of septic shock. Assessment of left ventricular preload, right ventricular overload, and left ventricular contractility using TTE seems to be more informative than the measurement of CVP for fluid resuscitation since some patients developed left ventricular dysfunction and/or right ventricular overload.

[A case of rocuronium-induced anaphylactic shock successfully treated with sugammadex].

We report a case of a 19-year-old male with rocuronium-induced anaphylactic shock. He was scheduled for endoscopic sinus surgery for chronic sinusitis under general anesthesia. Induction of anesthesia was done with fentanyl, propofol and sevoflurane. Just after administration of rocuronium, he developed tachycardia with extended exanthema on the face, anterior chest wall and abdomen. He was difficult to ventilate manually with mask and then intubated without difficulty. The carotid arterial pulse was not palpable and adrenaline was given intermittently to maintain blood pressure. Although the systolic blood pressure increased to 80 mmHg, hemodynamics was unstable with adrenaline. Sugammadex was then given and the blood pressure became stable without adrenaline. Exanthema also disappeared gradually. He was then transferred to ICU and extubated without any sequela. The plasma beta-tryptase increased to 46 microg x l(-1) during the shock state and returned to 14.1 microg x l(-1) 8 hrs after the event. The blood hemoglobin level also increased to 21.3 g x dl(-1) during the shock state and returned to 17.2 g x dl(-1) during the recovery phase. The laboratory data showed a marked increase in vascular permeability caused by rocuronium-induced anaphylactic shock.

[General anesthesia for lung resection in 7 patients with forced expiratory volume in 1 second of less than 1l].

Preoperative forced expiratory volume in 1 second less than 1 l is a risk factor for anesthesia. We report perioperative management and prognosis of 7 patients with restricted lung function who underwent lung resection under general anesthesia. We assessed the patients preoperatively from the point of view of heart-lung functions such as predicted postoperative forced expiratory volume in 1 second greater than 0.8 l, an ability of walking on the level for more than 5 minutes at his own speed without a rest, presence of hypercapnia, and degree of pulmonary hypertension. One patient was extubated on the first postoperative day because of an asthmatic attack, whereas the remaining 6 patients were extubated in the operating room. Although 1 patient developed postoperative complications of lung air leakage and pneumonia, he recovered with conservative therapy. All patients were discharged without any sequela. We were able to manage high-risk patients with limited lung functions successfully during the perioperative period without serious complications.

[A case of delayed awakening from general anesthesia caused by psychological unresponsiveness].

We report a case of an 85-year-old woman with delayed awakening from general anesthesia caused by psychological unresponsiveness. She underwent an open reduction of the right femoral bone fracture. Induction of general anesthesia was done with fentanyl, propofol, sevoflurane, and rocuronium. Anesthesia was maintained with sevoflurane and remifentanil without any incidents. After the operation she opened her eyes and tried to extubate the endtracheal tube and then she was extubated. She developed coma and did not respond to painful stimuli after extubation, but spontaneous breathing was maintained with stable hemodynamics. Although naloxone was given, she was still comatose. Her clinical neurological findings and the brain CT scan showed no organic abnormalities. The bispectral index showed the value of 85 to 95; 2.5 hrs after operation she moved her extremities in response to pain and 3.5 hrs after operation she gradually woke up and obeyed commands. After fully awakening she showed no clinical manifestations of psychological abnormality during her postoperative period and no sequela.

[ A case of general anesthesia for the removal of extra-adrenal pheochromocytoma in a patient complicated with severe hypertrophic obstructive cardiomyopathy].

We report a case of general anesthesia for the removal of pheochromocytoma in a patient complicated with severe hypertrophic obstructive cardiomyopathy. A 65-year-old woman complained of fatigability with hypertension and diabetes mellitus. She was diagnosed as an extra-adrenal peri-aortic pheochromocytoma with severe hypertrophic obstructive cardiomyopathy. The left ventricular outflow gradient (LVOG) was 199 mmHg and the serum noradrenaline level was 13,567 pg x ml(-1) (100-450). As a preoperative management, atenolol, verapamil and disopyramide were given to decrease LVOG. Then doxazosin was given to control hypertension and to increase the circulating blood volume without deteriorating the outflow tract obstruction. LVOG decreased to 50 mmHg preoperatively. Anesthesia was given with propofol, fentanyl, remifentanil and isoflurane with a continuous infusion of diltiazem. The circulating blood volume was maintained with adequate volume loading assessed by the measurement of the left ventricular end-diastolic diameter and LVOG with transesophageal echocardiography. After the removal of the tumor, continuous infusion of noradrenaline was given to maintain the blood pressure. She was extubated in the ICU. LVOG decreased to 20 mmHg with stable hemodynamics on the second postoperative day. She was discharged from the ICU without any adverse cardiac events during the perioperative period.

[Two cases of airway stent placement to treat tracheal and bronchial fistula using general anesthesia under spontaneous respiration].

Anesthesia for the tracheobronchial stent placement involves the risk of airway narrowing and obstruction. Controlled ventilation with relatively high airway pressure is usually used to maintain oxygenation and ventilation during anesthesia. However, controlled ventilation does not always provide tidal volume and oxygenation due to gas leakage from tracheobronchial fistula. We report 2 cases of general anesthesia under spontaneous respiration for the airway stent placement to treat tracheal and bronchial fistula. Case 1; A 55-year-old man with tracheoesophageal fistula due to the esophageal cancer was scheduled for the stent placement. Anesthesia was given with dexmedetomidine and sevoflurane preserving spontaneous respiration. The surgery was performed without complications of hypoventilation and hypoxemia throughout the procedure. Case 2; A 71-year-old woman developed empyema with large bronchopleural fistula as the result of the complication of radiation for the breast cancer. The stent placement was scheduled for closure of the fistula. Anesthesia was induced with remifentanil and sevoflurane with spontaneous respiration. When inserting the rigid bronchoscope, cough reflex occurred and propofol was added to deepen the anesthesia. The stent placement was performed with general anesthesia under spontaneous respiration without any complications.

A case of acquired hemophilia A with massive hemothorax.

Acquired hemophilia A (AHA) is an uncommon but potentially life-threatening hemorrhagic disorder caused by the development of an inhibitor against coagulation factor VIII (FVIII). AHA is very rare, affecting approximately 1 in 1 million individuals. However, the incidence may actually be higher, because diagnosis is difficult and the disease can be overlooked. We report a case of an 80-year-old man who presented with sudden onset of severe hemothorax. The patient was diagnosed with presumed AHA based on acute onset of bleeding symptoms and unexplained isolated prolonged activated partial thromboplastin time. Diagnosis was definitely established by demonstrating a decrease in FVIII activity, presence of FVIII inhibitor activity, and normal von Willebrand factor. The patient was successfully treated with recombinant activated coagulation factor VII and transcatheter artery embolization of the intercostal arteries.

[Case of general anesthesia for subtotal thyroidectomy in a pregnant woman with 27th week gestation].

We report a case of general anesthesia for subtotal thyroidectomy in a pregnant woman with 27th week gestation. A 33-year-old pregnant woman was diagnosed with thyroid carcinoma. We planned subtotal thyroidectomy at 27 weeks of gestation. We gave thiamylal, fentanyl and rocuronium for induction of anesthesia. Tracheal intubation was performed. Anesthesia was maintained with sevoflurane and fentanyl. Because of tachycardia, we tilted the operating table to displace the uterus to the left. We continued monitoring fetal heart rate during the operation. The fetal heart rate remained between 130 and 150 beats x min(-1). The operation was performed with no trouble. She gave birth to a baby at 37th week gestation. We should pay attention to maternal safety, fetal toxicity including teratogenecity, fetal asphyxia and pre-term labor. We could successfully manage her anesthesia using intraoperative fetal heart rate monitoring.