Development of a postoperative occlusive thrombus at the site of an implanted inferior vena cava filter: A case report.

RATIONALE: Although an inferior vena cave (IVC) filter is placed to prevent fatal pulmonary embolism (PE), several complications associated with an IVC filter have been reported. We describe a case with symptomatic PE, of which the origin was an occlusive IVC thrombus that developed from the placement of an IVC filer after a laparoscopy-assisted total gastrectomy (LATG). PATIENT CONCERNS: A 71-year-old man underwent LATG under general anesthesia alone. He had an IVC filter implanted 13 years ago. An intravenous infusion of unfractionated heparin was substituted for the discontinuation of oral warfarin four days before the surgery. The proposed operation was performed and took a total of 404 minutes including the total duration of pneumoperitoneum that took 374 minutes. After the surgery, he experienced severe shivering reactions that required frequent bolus infusions of antihypertensive drugs. On the third postoperative day, he complained of dyspnea after taking a short walk, and subsequently lost consciousness. While he spontaneously recovered without requiring any resuscitation efforts, we performed computed tomography (CT) examination for suspected PE. DIAGNOSES: The CT showed that a massive thrombus was occupying the intravenous space from the IVC filter to the left common iliac vein with several embolic defects in the peripheral pulmonary arteries present. INTERVENTIONS: An anticoagulant therapy was established with 10 mg of oral apixaban given twice a day for the first four days, followed by a reduction to 5 mg. OUTCOMES: On the 17th postoperative day, an ultrasound vascular examination confirmed the complete disappearance of deep venous thrombus (DVT). LESSONS: As an IVC filter itself may be a potential source of DVT, we should carefully manage patients with a previously implanted IVC filter throughout the perioperative period.

[Fiberoptic-guided tracheal intubation through the i-gel supraglottic airway].

BACKGROUND: The i-gel is a rescue device for ventilation or tracheal intubation in patients with a difficult airway. The aim of this study was to evaluate the safety and reliability of fiberoptic-guided intubation through the i-gel in anesthetized patients with no history of difficult intubation undergoing elective surgery. METHODS: Patients were enrolled in the study with prior informed consent. After insertion of the i-gel, the larynx was observed by bronchoscopy, and the bronchoscopic view through the i-gel was graded. Tracheal intubation was performed under fiberoptic guidance, and the i-gel was removed. The outcome was evaluated using the success rate of initial intubation as the primary variable, and complications were evaluated as a secondary variable. RESULTS: The first attempt at intubation was successful in all 52 patients evaluated, and there was no problem with i-gel removal. No arterial oxygen desaturation was noted throughout the induction of anesthesia, and no serious complication was observed. CONCLUSIONS: Fiberoptic-guided intubation could be performed safely through the i-gel. The i-gel is considered to be potentially useful as an alternative conduit for fiberoptic-guided intubation.

[Dexmedetomidine is useful for sedation during laryngoplasty with voice monitoring].

BACKGROUND: Laryngoplasty is an operation for voice reconstruction performed for recurrent laryngeal nerve palsy, and this operation needs intraoperative speech monitoring. Previously, all procedures were performed under local anesthesia. Therefore, patients were suffering, and otolaryngologists had difficulty because of patients' coughs and laryngeal movements. We used dexmedetomidine (DEX) with local anesthesia for laryngoplasty. METHODS: We retrospectively examined 6 patients who had undergone laryngoplasty from January 2008 to October 2010. Patients received local anesthesia for pain control and DEX for sedation. Anesthesiologists achieved adequate sedation level (Ramsay's score 3-4) with DEX. RESULTS: Sedation was induced with 6 microg x kg(-1). hr(-1) of DEX for 10 minutes. All patients were maintained at 0.2-1.2 microg x kg(-1) x hr(-1). A local anesthetic(8.6 +/- 2.3 ml of 1% lidocaine 1 : 100,000 epinephrine) was used. During the initial loading of DEX, the patients' vital signs were stable. DEX suppressed coughs and laryngeal movements and did not cause respiratory depression. They were able to respond to the otolaryngologists' demand for a voice test. CONCLUSIONS: Dexmedetomidine was useful for sedation during laryngoplasty with voice monitoring.

[Case of Leriche's syndrome treated with safe and effective analgesia after laparotomy by transversus abdominis plane block, rectus sheath block, and continuous wound infusion with ropivacaine].

Ultrasound-guided peripheral nerve blocks in the abdominal wall, such as transversus abdominis plane block (TAP block) and rectus sheath block, are now widely used. We report a case of Leriche's syndrome treated with safe and effective analgesia after laparotomy by abdominal wall block and continuous infusion. A 61-year-old man diagnosed with Leriche's syndrome underwent Y-graft replacement for an abdominal aortic aneurysm. Preoperative enhanced and 3-dimensional CTs showed many collateral arterial systems, especially in the right abdominal wall. It was suggested that the right internal iliac artery had been completely occluded, and the left one showed severe stenosis. After the induction of general anesthesia, we recognized collateral arteries through an ultrasound view as on preoperative CTs. We lowered the pulse repetition frequency more than usual in order not to injure them. We injected 0.1875% ropivacaine 60 ml as TAP block, and 20 ml as rectus sheath block. When the wound was closed, a catheter was passed through an 18-gauge Tuohy needle placed above the fascia along the supraumbilical site. After the operation, 0.2% ropivacaine was continuously delivered at a rate of 6 ml hr-1 through the catheter. We could provide the patient with effective analgesia after surgery.