Association between Intraoperative Early Warning Score and Mortality and In-Hospital Stay in Lower Gastrointestinal Spontaneous Perforation.

Background: Early warning scores (EWSs) can be easily calculated from physiological indices; however, the extent to which intraoperative EWSs and the corresponding changes are associated with patient prognosis is unknown. In this study, we investigated whether EWS and the corresponding time-related changes are associated with patient outcomes during the anesthetic management of lower gastrointestinal perforation. Methods: This was a single-center, retrospective cohort study conducted at a tertiary emergency care center. Adult patients who underwent surgery for spontaneous lower gastrointestinal perforations between September 1, 2012, and December 31, 2019, were included. The National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) were calculated based on the intraoperative physiological indices, and the associations with in-hospital death and length of hospital stay were investigated. Results: A total of 101 patients were analyzed. The median age was 70 years, and there were 11 cases of in-hospital death (mortality rate: 10.9%). There was a significant association between the intraoperative maximum NEWS and in-hospital death (odds ratio (OR): 1.60, 95% confidence interval (CI): 1.10-2.32, p=0.013) and change from initial to maximum NEWS (OR: 1.60, 95% CI: 1.07-2.40, p=0.023) in the crude analysis. However, when adjustments were made for confounding factors, no statistically significant associations were found. Other intraoperative EWS values and changes were not significantly associated with the investigated outcomes. The preoperative sepsis-related organ failure assessment score and the intraoperative base excess value were significantly associated with in-hospital death. Conclusions: No clear association was observed between EWSs and corresponding changes and in-hospital death in cases of lower gastrointestinal perforation. The preoperative sepsis-related organ failure assessment score and intraoperative base excess value were significantly associated with in-hospital death.

Preoperative Risk Factors in Patients With Pancreatic Cancer.

Background: Pancreatic cancer is gastrointestinal cancer with a poor prognosis. Although surgical techniques and chemotherapy have improved treatment outcomes, the 5-year survival rate for pancreatic cancer is less than 10%. In addition, resection of pancreatic cancer is highly invasive and is associated with high rates of postoperative complications and hospital mortality. The Japanese Pancreatic Association states that preoperative body composition assessment may predict postoperative complications. However, although impaired physical function is also a risk factor, few studies have examined it in combination with body composition. We examined preoperative nutritional status and physical function as risk factors for postoperative complications in pancreatic cancer patients. Methods: Fifty-nine patients with pancreatic cancer who underwent surgical treatment and were discharged alive from January 1, 2018, to March 31, 2021, at the Japanese Red Cross Medical Center. This retrospective study was conducted using electronic medical records and a database of departments. Body composition and physical function were evaluated before and after surgery, and the risk factors between patients with and without complications were compared. Results: Fifty-nine patients were analyzed: 14 and 45 patients in the uncomplicated and complicated groups, respectively. The major complications were pancreatic fistulas (33%) and infections (22%). There were significant differences in: age, 74.0 (44 - 88) (P = 0.02); walking speed, 0.93 m/s (0.3 - 2.2) (P = 0.01); and fat mass, 16.50 kg (4.7 - 46.2) (P = 0.02), in the patients with complications. On Multivariable logistic regression analysis, age (odds ratio: 2.28; confidence interval (CI): 1.3400 - 569.00; P = 0.03), preoperative fat mass (odds ratio: 2.28; CI: 1.4900 - 168.00; P = 0.02), and walking speed (odds ratio: 0.119; CI: 0.0134 - 1.07; P = 0.05) were identified as risk factors. Walking speed (odds ratio: 0.119; CI: 0.0134 - 1.07; P = 0.05) was the risk factor that was extracted. Conclusions: Older age, more preoperative fat mass, and decreased walking speed were possible risk factors for postoperative complications.

Anesthetic Management of a Patient Undergoing Cochlear Implantation With Superficial Cervical Plexus Block and Sedation: A Case Report.

Avoidance of general anesthesia and endotracheal intubation has been shown to reduce respiratory complications in patients with severe lung disease. We describe the case of a 75-year-old patient with chronic obstructive pulmonary disease (COPD) who underwent cochlear implantation managed with nerve block and sedation. A superficial cervical plexus block (SCPB) was performed with 1% mepivacaine before surgery. A small amount of intravenous analgesic and sedative was administered. The patient experienced only slight pain during surgery. A SCPB had a good analgesic effect on the posterior auricle. Cochlear implantation in patients with COPD can be performed using a SCPB and sedation.

A modified algorithm for choosing the most appropriate intraoperative pacemaker mode for patients with permanent pacemaker in non-cardiac surgery.

To avoid the risk of R-on-T incident and the unnecessary decrease of cardiac output, we devised an algorithm consisting of six steps for choosing the most appropriate intraoperative pacemaker (PM) mode, which is modified from Heart Rhythm Society and the American Society of Anesthesiologists expert consensus statement. Following this algorithm, we reviewed previous operations at our hospital to evaluate the appropriateness of the choices. Six of 78 cases (7.7%) were unfit to the algorithm because of an inappropriate mode change. The PM mode was changed preoperatively in four patients, even though the surgical site was under the umbilicus. In one case of the two other cases, the PM mode was changed from AAI to VOO. This case could not be avoided by the previous algorithm of the expert clinical statements. In another case, the anesthesiologist did not change PM mode even though the patient underwent parotidectomy and his heart rate depended on PM. Prospective research on this algorithm could clarify its usefulness in the future. Moreover, discussions about this algorithm could help develop this field of study and improve the intraoperative management of PMs.

Perioperative and anesthetic risk factors of surgical site infection in patients undergoing pancreaticoduodenectomy: A retrospective cohort study.

BACKGROUND: Surgical site infection is a major perioperative issue. The morbidity of surgical site infection is high in major digestive surgery, such as pancreaticoduodenectomy. The comprehensive risk factors, including anesthetic factors, for surgical site infection in pancreaticoduodenectomy are unknown. The aim of this study was to investigate the perioperative and anesthetic risk factors of surgical site infection in pancreaticoduodenectomy. METHODS: This was a retrospective cohort study conducted in a single tertiary care center. A total of 326 consecutive patients who underwent pancreaticoduodenectomy between January 2009 and March 2018 were evaluated. Patients who underwent resection of other organs were excluded. The primary outcome was the incidence of surgical site infection, based on a Clavien-Dindo classification of grade 2 or higher. Multivariable logistic regression analysis was performed to investigate the association between surgical site infection and perioperative and anesthetic factors. RESULTS: Of the 326 patients, 116 (35.6%) were women. The median age was 70 years (interquartile range; 64-75). The median duration of surgery was 10.9 hours (interquartile range; 9.5-12.4). Surgical site infection occurred in 60 patients (18.4%). The multivariable analysis revealed that the use of desflurane as a maintenance anesthetic was associated with a significantly lower risk of surgical site infection than sevoflurane (odds ratio, 0.503; 95% confidence interval [CI], 0.260-0.973). In contrast, the duration of surgery (odds ratio, 1.162; 95% CI, 1.017-1.328), cerebrovascular disease (odds ratio, 3.544; 95% CI, 1.326-9.469), and ischemic heart disease (odds ratio, 10.839; 95% CI, 1.887-62.249) were identified as significant risk factors of surgical site infection. CONCLUSIONS: Desflurane may be better than sevoflurane in preventing surgical site infection in pancreaticoduodenectomy. Cerebrovascular disease and ischemic heart disease are potential newly-identified risk factors of surgical site infection in pancreaticoduodenectomy.

The Difference Between Set and Delivered Tidal Volume: A Lung Simulation Study.

BACKGROUND: Precise control of tidal volume is one of the keys in limiting ventilator-induced lung injury and ensuring adequate ventilation in mechanically ventilated neonates. The aim of the study was to compare the tidal volume (mVT) measured from the expiratory limb of the ventilator with the actual tidal volume (aVT) that would be delivered to the patient using a lung model to simulate a neonate. METHODS: This study was conducted using the ASL5000 lung simulator. Three combinations of parameters were set: resistance (cmH2O/L/sec) and compliance (mL/cmH2O) of 50 and 2 (Group 1), 100 and 1 (Group 2), and 150 and 0.5 (Group 3), respectively. The ASL5000 was connected to each of the ventilators including one anesthesia machine ventilator (Drager Fabius GS) and two ICU ventilators (Servo-i Universal and Evita Infinity V500). Each ventilator was evaluated with a set tidal volume of 30 mL (sVT) and a respiratory rate of 25 breathes/minute in both the volume-controlled ventilation (VCV) and dual-controlled ventilation (DCV) modes. RESULTS: The discrepancies between sVT, mVT and aVT were highest with the Fabius anesthesia machine ventilator and increased in the simulated lung injury groups. When comparing the ICU ventilators, the difference was greater the Servo-i and increased when using the DCV mode and with simulated lung injury. CONCLUSION: Accurate tidal volumes were achieved only with the Infinity ICU ventilator. This was true regardless of mode of ventilation and even during simulated lung injury.

Pre-anesthetic ultrasonographic assessment of the internal jugular vein for prediction of hypotension during the induction of general anesthesia.

PURPOSE: Severe hypotension caused by anesthetic administration for anesthesia induction, which might cause ischemic stroke, myocardial injury, acute kidney injury and postoperative mortality, should be prevented. Anesthesiologists are familiar with ultrasound examination of the internal jugular vein (IJV). This study aimed to clarify whether ultrasonographic IJV evaluation just before induction could predict the occurrence of such hypotension. METHODS: Adult patients undergoing surgery under general anesthesia were enrolled after excluding patients with cardiovascular disease or ASA-PS ≥ III. Ultrasonographic IJV images were recorded in both the supine and 10° Trendelenburg positions immediately before induction. Using these images, IJV area (IJV-A), diameter and change rate with posture were measured. Hypotension during induction was defined as mean BP < 60 mmHg or > 30% decrease from baseline. RESULTS: Hypotension during induction was observed in 37 of 82 patients. IJV-A in the Trendelenburg position was 2.02 ± 0.86 and 1.72 ± 0.68 in the hypotensive and non-hypotensive groups, respectively (P = 0.08). Logistic regression analysis performed using age, use of calcium antagonists, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, baseline mean BP and IJV-A in the Trendelenburg position as variables showed that IJV-A in the Trendelenburg position was an independent predictor of hypotension, with an adjusted odds ratio of 3.11 (95% CI 1.07-9.03, P = 0.04). Area under the curve was 0.595 (95% CI 0.469-0.722) for IJV-A in the Trendelenburg position. CONCLUSION: IJV-A in the Trendelenburg position was an independent predictor of hypotension during induction. Further study is required to examine the diagnostic accuracy of IJV-A as a predictor for hypotension during induction.

Simulation of pressure support for spontaneous breathing trials in neonates.

BACKGROUND: Endotracheal tubes used for neonates are not as resistant to breathing as originally anticipated; therefore, spontaneous breathing trials (SBTs) with continuous positive airway pressure (CPAP), without pressure support (PS), are recommended. However, PS extubation criteria have predetermined pressure values for each endotracheal tube diameter (PS 10 cmH2O with 3.0- and 3.5-mm tubes or PS 8 cmH2O with 4.0-mm tubes). This study aimed to assess the validity of these SBT criteria for neonates, using an artificial lung simulator, ASL 5000™ lung simulator, and a SERVO-i Universal™ ventilator (minute volume, 240-360 mL/kg/min; tidal volume, 30 mL; respiratory rate, 24-36/min; lung compliance, 0.5 mL/cmH2O/kg; resistance, 40 cmH2O/L/s) in an intensive care unit. We simulated a spontaneous breathing test in a 3-kg neonate after cardiac surgery with 3.0-3.5-mm endotracheal tubes. We measured the work of breathing (WOB), trigger work, and parameters of pressure support ventilation (PSV), T-piece breathing, or ASL 5000™ alone. RESULTS: WOB displayed respiratory rate dependency under intubation. PS compensating tube resistance fluctuated with respiratory rate. At a respiratory rate of 24/min, the endotracheal tube did not greatly influence WOB under PSV and the regression line of WOB converged with the WOB of ASL 5000™ alone under PS 1 cmH2O; however, at 36/min, endotracheal tube was resistant to breathing under PSV because trigger work increased exponentially with PS ≤ 9 cmH2O. The regression line of WOB under PSV converged with the WOB of T-piece breathing under PS 1 cmH2O. Furthermore, PS compensating endotracheal tube resistance was 6 cmH2O. The WOB of ASL 5000™ alone approached that of respiratory distress syndrome (RDS); however, the pressure of patient effort was normal physiological range at PS 10 cmH2O. PS equalizing WOB under PSV with that after extubation depended on the respiratory rate and upper airway resistance. If WOB after extubation equaled that of T-piece breathing, the PS was 0 cmH2O regardless of the respiratory rates. If WOB after extubation approximated  to that of ASL 5000™ alone, the PS depended on the respiratory rate. CONCLUSION: SBT strategies should be selected per neonatal respiratory rates and upper airway resistance.

Behavior of Anesthesiology Residents in a Situation of Intravenous Route Occlusion During Syringe Pump Use in a Simulated Intensive Care Unit.

INTRODUCTION: Unintentional catecholamine flush caused by inappropriate release of an intravenous occlusion during use of a syringe pump in the intensive care unit (ICU) can have dangerous consequences in patients receiving critical care. We investigated whether anesthesiology residents understood how to deal with syringe pump occlusion in a simulated ICU setting. METHODS: We set up a mannequin that virtually simulated a sedated patient under mechanical ventilation after cardiac surgery, with epinephrine and dopamine being infused by syringe pumps to maintain blood pressure at 100/50 mm Hg. Prior to a participant entering the simulated ICU, one of the stopcocks for the catecholamine was occluded. Thereafter, the blood pressure of the mannequin dropped to 60/30 mm Hg. If the participant inappropriately released the occlusion, resulting in a catecholamine flush, an operator immediately elevated the blood pressure to 200/100 mm Hg. In the subsequent debriefing session, the simulation facilitator evaluated whether the participant could diagnose that intravenous occlusion was the cause of hypotension in this scenario. RESULTS: Sixteen anesthesiology residents participated in the study. Only 3 of 10 participants who had previous knowledge of how such situations should be handled could appropriately release back pressure. Eleven residents released the occlusion without relieving syringe pressure. After their debriefing sessions, all the participants were of the opinion that the present simulation training was impressive and useful for them. CONCLUSIONS: Anesthesiology residents might inappropriately handle a situation of intravenous occlusion in their clinical practice. It may be necessary for the manufacturers to improve the safety features of syringe pumps.

Comparison between High- and Low-Cost Transmission of Tele-Anesthesia in Japan.

Background: We previously reported a tele-anesthesia system that connected Sado General Hospital (SGH) to Yokohama City University Hospital (YCUH) using a dedicated virtual private network (VPN) that guaranteed the quality of service. The study indicated certain unresolved problems, such as the high cost of constantly using a dedicated VPN for tele-anesthesia. In this study, we assessed whether use of a best-effort system affects the safety and cost of tele-anesthesia in a clinical setting. Methods: One hundred patients were enrolled in this study. We provided tele-anesthesia for 65 patients using a guaranteed transmission system (20 Mbit/s; guaranteed, 372,000 JPY per month: 1 JPY = US$0.01) and for 35 patients using a best-effort system (100 Mbit/s; not guaranteed, 25,000 JPY per month). We measured transmission speed and number of commands completed from YCUH to SGH during tele-anesthesia with both transmission systems. Results: In the guaranteed system, anesthesia duration was 5780 min (88.9 min/case) and surgical duration was 3513 min (54.0 min/case). In the best-effort system, anesthesia duration was 3725 min (106.4 min/case) and surgical duration was 2105 min (60.1 min/case). The average transmission speed in the best-effort system was 17.3 ± 3.8 Mbit/s. The system provided an acceptable delay time and frame rate in clinical use. All commands were completed, and no adverse events occurred with both systems. Discussion: In the field of tele-anesthesia, using a best-effort internet VPN system provided equivalent safety and efficacy at a better price as compared to using a guaranteed internet VPN system.

Can sedation using a combination of propofol and dexmedetomidine enhance the satisfaction of the endoscopist in endoscopic submucosal dissection?

BACKGROUND AND STUDY AIMS: The aim of this pilot randomized controlled trial was to evaluate and compare the satisfaction of the endoscopist along with the effectiveness and safety of sedation between sedation protocol using a combination of propofol (PF) and dexmedetomidine (DEX) (Combination group) and sedation protocol using PF alone (PF group) during gastric endoscopic submucosal dissection (ESD). PATIENTS AND METHODS: Fifty-eight patients with gastric neoplasias scheduled for gastric ESD were enrolled and randomly assigned to the two groups. The satisfaction scores of the endoscopists and the parameters for the effectiveness and safety of sedation were evaluated by comparisons between the two groups. RESULTS: The satisfaction scores of the endoscopists, which were measured using a visual analogue scale, were significantly higher in the Combination group than in the PF group (88 vs. 69, P  = 0.003). The maintenance dose of PF was lower in the Combination group than in the PF group (2 mg/kg/h vs. 5 mg/kg/h, P  < 0.001), and the number of rescue PF injections was fewer in the Combination group than in the PF group (2 times vs. 6 times, P  < 0.001). The incidence of bradycardia (defined as a pulse rate ≤ 45 bpm) in the Combination group was higher than that in the PF group (37.9 % vs. 10.3 %, P  = 0.029). CONCLUSIONS: This study suggests that gastroenterologist-directed sedation using a combination of PF and DEX during gastric ESD can enhance the satisfaction levels of endoscopists by providing stable sedation with an acceptable safety profile.

Hyperleukocytosis Complicated by Intracerebral Hemorrhage and Spurious Hypoxemia: A Case Report and Literature Review.

We present the management of a 15-year-old girl with acute myeloid leukemia who presented with massive hyperleukocytosis and neurological deficit due to intracerebral hemorrhage. Surgical intervention was considered but ultimately not undertaken because of the presence of massive hyperleukocytosis, thrombocytopenia, hypokalemia, and considerable discrepancy between the oxygen saturation values determined mechanically and by peripheral oximetry. Aggressive treatment of the hyperleukocytosis was immediately started, which improved the patient's overall condition and rendered surgical intervention unnecessary. This report shows that immediate treatment of massive hyperleukocytosis and critical interpretation of laboratory results in patients with hyperleukocytosis are warranted.

Consequences of not relieving negative internal pressure of a medication vial: A survey and simulation study.

STUDY OBJECTIVE: The glass vial of acetaminophen as an intravenous preparation (Acelio®, Terumo, Japan) has a strong internal negative pressure. The aim of our study was to determine if this negative pressure could result in medication administration errors if not released prior to connecting to the IV set. DESIGN: Questionnaire survey and simulation study. SETTING: University hospital and its affiliated hospitals. SUBJECTS: Fifty-two anesthesiologists in 6 different hospitals in Yokohama. MEASUREMENTS: A questionnaire on current practice was sent to the subjects. The authors then first calculated the internal pressure of the Acelio® vial followed by a simulation set-up. This set-up measured the amount of saline that could be aspirated from a syringe loaded on a syringe pump connected via a secondary IV line when the Acelio® vial was attached to the primary line without prior release of the internal pressure. The volume of aspiration was tested with two syringe sizes and with a fully open IV clamp vs partially closed. MAIN RESULTS: Twenty-nine (56.9%) of 51 anesthesiologists who responded to the survey had connected the Acelio® vial at least once without releasing the internal negative pressure, and 21 experienced consequences such as backflow of the venous blood. The pressure inside the Acelio® vial was 81.8±19.6Torr. With the clamp of the simulated IV line fully open, the amount of saline aspirated before the alarm of the syringe pump went off was 1.5±0.1ml and 3.2±0.3ml when 20ml and 50ml syringes were used, respectively. When the clamp was partially closed to allow 2 drops per second, this value was 1.3±0.1ml and 2.3±0.1ml, respectively. After removing the plunger from the holder of the syringe pump, an additional 7ml (clamp partially closed) or 15-18ml (clamp fully open) was aspirated in the subsequent 1min. CONCLUSIONS: A considerable number of anesthesiologists experienced consequences caused by the negative pressure inside the Acelio® vial. This can also cause aspiration of the contents of the syringe pump.

Deep Breathing Improves End-Tidal Carbon Dioxide Monitoring of an Oxygen Nasal Cannula-Based Capnometry Device in Subjects Extubated After Abdominal Surgery.

BACKGROUND: Capnometry detects hypoventilation earlier than pulse oximetry while supplemental oxygen is being administered. We compared the end-tidal CO2 (PETCO2 ) measured using a newly developed oxygen nasal cannula with a CO2-sampling port and the PaCO2 in extubated subjects after abdominal surgery. We also investigated whether the difference between PaCO2 and PETCO2 is affected by resting, by spontaneous breathing with the mouth consciously closed, and by deep breathing with the mouth closed. METHODS: Adult post-abdominal surgery subjects admitted to the ICU were enrolled. After extubation, oxygen was supplied at 4 L/min using a capnometry-type oxygen cannula. The breathing frequency, PETCO2 , and PaCO2 were measured after 30 min of oxygen supplementation. PETCO2 was continuously measured during rest, during breathing with the mouth consciously closed, and during deep breathing with the mouth closed. The difference between PETCO2 and PaCO2 during various breathing patterns was analyzed using the Bland-Altman method. RESULTS: Twenty subjects were included. The bias ± SD (limits of agreement) for breathing frequency measured by capnometry compared with those obtained by direct measurement was 0.4 ± 3.6 (-6.7 to 7.4). In PETCO2 compared with PaCO2 , the biases (limits of agreement) were 14.8 ± 8.2 (-1.3 to 30.9) at rest, 10.2 ± 6.4 (-2.3 to 22.7) with the mouth closed, and 7.7 ± 5.6 (-3.2 to 18.6) for deep breathing with the mouth closed. PETCO2 determined using the capnometry device yielded unreliable and widely ranging values under various breathing patterns. However, deep breathing with the mouth closed decreased the difference between PETCO2 and PaCO2 , as compared with other breathing patterns. CONCLUSIONS: PETCO2 measurements under deep breathing with mouth closed with a capnometry-type oxygen cannula improved the prediction of the absolute value of PaCO2 in extubated post-abdominal surgical subjects without respiratory dysfunction.

[Involuntary Movement of Bilateral Lower Limbs Caused by Epidural Anesthesia: A Case Report].

Regional anesthesia, especially epidural anesthesia, rarely causes involuntary movement Here we present a case of a patient who demonstrated myoclonus-like involuntary movement of the lower limbs during continuous infusion of ropivacaine, fentanyl, and droperidol through the thoracic epidural catheter. This movement disappeared when the epidural infusion was stopped, but reappeared when the epidural infusion was restarted. Naloxone did not eliminate the movement The patient was thereafter discharged uneventfully. This case and other reports in the literature suggest that involuntary movement associated with regional anesthesia is rare and self-limiting. However, careful consideration should be given to exclude other, potentially dangerous complications.

Influence of Mental Workload on the Performance of Anesthesiologists during Induction of General Anesthesia: A Patient Simulator Study.

The aim of this study was to reveal the effect of anesthesiologist's mental workload during induction of general anesthesia. Twenty-two participants were categorized into anesthesiology residents (RA group, n = 13) and board certified anesthesiologists (CA group, n = 9). Subjects participated in three simulated scenarios (scenario A: baseline, scenario B: simple addition tasks, and scenario C: combination of simple addition tasks and treatment of unexpected arrhythmia). We used simple two-digit integer additions every 5 seconds as a secondary task. Four kinds of key actions were also evaluated in each scenario. In scenario C, the correct answer rate was significantly higher in the CA versus the RA group (RA: 0.370 ± 0.050 versus CA: 0.736 ± 0.051, p < 0.01, 95% CI -0.518 to -0.215) as was the score of key actions (RA: 2.7 ± 1.3 versus CA: 4.0 ± 0.00, p = 0.005). In a serious clinical situation, anesthesiologists might not be able to adequately perform both the primary and secondary tasks. This tendency is more apparent in young anesthesiologists.

Feasibility of deep sedation with a combination of propofol and dexmedetomidine hydrochloride for esophageal endoscopic submucosal dissection.

BACKGROUND AND AIM: The aim of the present study was to evaluate the efficacy and safety of sedation with a combination of propofol (PF) and dexmedetomidine (DEX) compared with sedation with benzodiazepines in esophageal endoscopic submucosal dissection (ESD). METHODS: We retrospectively reviewed clinical data for 40 consecutive patients who had undergone esophageal ESD at the Yokohama City University Hospital between July 2012 and August 2014. Of these patients, 20 were sedated with benzodiazepines (conventional group) and another 20 patients were sedated with a combination of PF and DEX (combination group). Parameters for efficacy and safety of sedation were evaluated by comparisons between the two groups. RESULTS: Median procedural times in the combination group were shorter than those in the conventional group (61 min vs. 89 min, P = 0.03), and the percentage of patients who showed restlessness in the combination group was significantly lower than that in the conventional group (25% vs. 65%, P = 0.025). Incidences of hypotension and bradycardia in the combination group were higher than those in the conventional group (60% vs. 15%, P = 0.008, and 60% vs. 15%, P = 0.008, respectively). CONCLUSION: This retrospective study suggests that a combination of PF and DEX may provide stable deep sedation with less body movement than benzodiazepines during esophageal ESD.

Perioperative considerations in adult mitochondrial disease: A case series and a review of 111 cases.

Mitochondrial disease has been uncommon conditions, still results in death during childhood in many cases. The ideal anesthetic pharmacological management strategy for adult patients with mitochondrial disease is currently unclear. In this study, we presented features of the anesthesia methods employed and the perioperative complications of patients in our institution and in previously published case reports. We report the use of general anesthesia 7 times in 6 adult patients with mitochondrial disease during 2004-2014. All cases were performed with maintained intravenous anesthesia. One case was reintubated on the day after surgery, but the cause of death was not directly related to anesthesia. One hundred and eleven general anesthesia cases in 97 adult patients with mitochondrial disease were described in 83 the literature. Although several severe perioperative complications and deaths have been reported, malignant hyperthermia had not been reported in adult cases, and metabolic disorder called propofol infusion syndrome had also not been reported in adult patients undergone total intravenous anesthesia. Perioperative complications of lactic acidosis were reported more in inhalation anesthesia than intravenous anesthesia. Therefore we recommended intravenous anesthesia rather than inhalation anesthesia for adult mitochondrial disease.

[A Case of Combined Spinal-Epidural Anesthesia for Cesarean Section in a Patient with Right Heart Failure due to Supravalvular Pulmonary Stenosis after Jatene Operation].

In a 30-year-old pregnant woman with supravalvular pulmonary stenosis after Jatene operation, the right ventricular and pulmonary artery pressure were 54/4 and 30/10 mmHg respectively in the non-pregnant condition. She was hospitalized due to pregnancy induced hypertension at 37 weeks of gestation. At the end of pregnancy, right ventricular failure occurred due to the increased circulatory plasma volume. Induc- tion of delivery was started at 37 weeks 6 days. How- ever, emergency cesarean section was planned because of maternal fatigue and uterine inertia. It was expected that airway management might be difficult because of obesity and full stomach. We chose combined spinal and epidural anesthesia. To avoid rapid reduction of systemic vascular resistance, we selected 0.5% isobaric bupivacaine 1.9 ml and fentanyl 10 gg for spinal anesthesia. Because inadequate analge- sia might worsen right ventricular failure, we added epidural anesthesia. The loss of cold sensation had reached at the fifth thoracic dermatomal level. The hemodynamics was stable without vasopressors. The continuous infusion of 0.2% ropivacaine from epidural catheter was started immediately after the delivery of the baby. As the result of choosing the appropriate anesthesia method, type and amount of local anesthetic, we succeeded in anesthetic management of this patient with right ventricular failure.