Differential Lung Ventilation Under the Veno-Arterial Extracorporeal Membrane Oxygenation Assistance in a Patient With a Giant Thoracic Tumor: A Case Report.

Airway compression resulting from thoracic tumors requires evaluation of the possibility of fatal ventilation failure when securing the airway. A woman presenting with a thoracic mass on the right side causing airway compression at the level of tracheal bifurcation required tumor removal to alleviate the compression; however, securing the airway proved challenging. Furthermore, differential lung ventilation was necessary for surgical management. We planned to secure the airway and manage breathing with the assistance of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) through an interdisciplinary conference and proceeded according to the plan. The intended tracheal tube could be placed, differential lung ventilation was initiated, and the ECMO was removed. The surgical procedure was carried out. In patients presenting with airway stenosis, the possibility of difficulty in securing the airway and ventilation should be assessed in advance. Creating a detailed treatment plan before surgery is recommended.

Nonocclusive mesenteric ischemia during treatment for ketoacidosis associated with acute-onset type 1 diabetes mellitus: A case report.

This case report describes a patient with nonocclusive mesenteric ischemia that developed due to diabetic ketoacidosis. We believe that early diagnosis and intervention may improve the prognosis of nonocclusive mesenteric ischemia that has low vascular risk, with the major risk factor being dehydration due to diabetic ketoacidosis.

[The Analgesic Sparing Effect of Ketamine for Postoperative Pain Management after Pediatric Surgery on the Body Surface].

BACKGROUND: It is reported that ketamine, a N-methyl-D-aspertate (NMDA) receptor antagonist, can provide analgesic effect improving postoperative pain management and decrease the supplementary analgesic requirement. We investigated the analgesic sparing effect of ketamine for postoperative pain in children undergoing surgery of body surface. METHODS: Fifty eight patients (0-9 yrs) who had surgery of body surface were divided into two groups (ketamine : n = 27, Group K or control : n = 31, Group N). Postoperative analgesia extracted from charts was retrospectively evaluated by the times patients used analgesics until discharge after the operations. Chi-square and Mann-Whitney U tests were used for statistical analysis. Results : The ketamine group received an intrave- nous bolus of ketamine (1 mg - kg-1) before surgical skin incision. However, there were no significant differ- ences of usage (Group K vs Group N : 4/27 vs 7/31, P=0.45) and frequency of supplementary analgesic us- ages (P=0.85) among groups. In addition, there were also no significant demographic differences between the two groups. Conclusions : Our investigation suggests that the intravenous bolus of ketamine (1 mg - kg-1) before surgical skin incision does not decrease the supple- mentary analgesic requirements on postoperative pain management in pediatric surgery of the body surface.

Propofol for Anesthesia and Postoperative Sedation Resulted in Fewer Inflammatory Responses than Sevoflurane Anesthesia and Midazolam Sedation after Thoracoabdominal Esophagectomy.

Responses to surgical stress can be modulated by anesthetics. We prospectively compared the effects of two different anesthetic/sedative techniques on the peak postoperative bladder temperature (BT) and the postoperative C-reactive protein (CRP) level. Twenty patients who were scheduled to undergo elective thoracoabdominal esophagectomy were allocated to receive either propofol anesthesia followed by propofol sedation (PP group, n = 10) or sevoflurane anesthesia followed by midazolam sedation (SM group, n = 10). In each case, the patient's peak bladder temperature was measured on the morning after surgery, and their serum CRP levels were assessed on postoperative days (POD) 1, 2, and 3. The patients' postoperative clinical courses were also evaluated. The peak postoperative BT (degrees C) (37.6 ± 0.4 vs. 38.2 ± 0.6, respectively; p < 0.05) and the CRP level on POD 2 (mg/dl) (14.3 ± 3.9 vs. 20.6 ± 3.9, respectively; p < 0.05) were lower in the PP group than in the SM group. The peak postoperative BT was positively correlated with the CRP level on POD 2 (R = 0.533, p < 0.05). There were no significant differences between the clinical course-related parameters in both groups. Propofol anesthesia and postoperative propofol sedation resulted in a reduced peak postoperative BT and lower CRP levels on POD 2 after esophagectomy than sevoflurane anesthesia followed by midazolam sedation.

[The Influence of Flurbiprofen on the Frequency of Postoperative Shivering].

BACKGROUND: Many methods to prevent postoperative shivering (POS) has been reported. However, there are few reports demonstrating the effect of flurbiprofen on POS which affects the set point in the thermocenter of the hypothalamus. METHODS: One hundred and forty six patients undergoing lung lobectomy or segmentectomy under video-assisted thoracic surgery were divided into a flurbiprofen-treated group (Group F) and a non-treated group (Group N). We retrospectively investigated the incidence of POS associated with total intravenous anesthesia with epidural anesthesia compared with or without flurbiprofen. We weighed the incidence of POS against age, body mass index, the effective site concentration of fentanyl on extubation, the mean dose of remifentanil, the minimum rectal temperature, the surgical duration and total hemorrhage volume based on the anesthetic chart Chi-square and Student t-test were used for statistical analysis. RESULTS: Although the surgical duration in Group F was shorter than that in Group N (223±83 vs. 165±80 (min), P<0.01), the incidence of POS in Group F was higher than that in Group N (1/32 vs. 28/114, P<0.01). There were no significant differences in another items between the two groups. CONCLUSIONS: The results of the study indicates that flurbiprofen has a possible beneficial effect in preventing POS.

[Successful airway management using i-gel in 7 patients undergoing awake craniotomy].

In order to secure airway during awake craniotomy, we used i-gel to perform positive-pressure ventilation in 7 patients for their anesthetic management. During removal of a tumor around the motor speech center, anesthetic management including asleep-awake-asleep technique was applied for speech testing. The technique, insertion and re-insertion of i-gel, was needed and it was easy in all the patients. During positive-pressure ventilation, peak pressure, tidal volume both for inspiration and expiration, and endtidal-CO2 were not markedly altered. Leakage around i-gel, and its differences between inspiration and expiration were negligible, while the tidal volume was adequate. We conclude that i-gel is useful for anesthetic management for awake craniotomy procedure for both securing airway and ventilation.

Continuous intravenous infusion of ketamine and lidocaine as adjuvant analgesics in a 5-year-old patient with neuropathic cancer pain.

For difficult to treat neuropathic pain from cancer, adjuvant analgesics are often used with opioids. We present the case of a 5-year-old girl who was diagnosed with meningitis caused by malignant T-cell lymphoma. She had severe neuropathic pain not relieved by increasing doses of a fentanyl infusion. Intravenous administration of ketamine and lidocaine in combination with fentanyl provided excellent analgesia without significant side effects. Ketamine and lidocaine can be safely infused together with concomitant opioids for the treatment of refractory neuropathic pain caused by cancer.

[Antiemetic-induced extrapyramidal symptoms seen by our palliative care team].

BACKGROUND: Antiemetic drugs, which are usually prescribed with opioids, occasionally induce extrapyramidal symptoms(EPS). METHODS: In 109 patients treated with our palliative care team, we retrospectively investigated the appearance of antiemetic-induced EPS; its incidence, latent period, onset age, symptoms, causing agents and clinical outcomes. RESULTS: EPS were observed in 6 of 109 patients. Six EPS patients, 2 men and 4 women, were between the age of 53 and 66 years. Prochlorperazine was used in all EPS patients. Two EPS were induced with unnecessary antiemetic drugs. Onset of EPS was from 11 to 162 days after beginning of antiemetic drugs. There were 5 patients with slow movement or speech, 3 patients with expressionless face, 2 patients with akathisia, and one patient with dysphagia. Five EPS patients were improved by using biperiden and one patient was by changing prochlorperazine to perospirone. CONCLUSIONS: EPS were found in 6 of 109 patients during palliative care. We concluded that it was important not to forget the appearance of antiemetic-induced EPS when prescribing antiemetic drugs in palliative

[Intracranial subdural hematoma following dural puncture].

BACKGROUND: Intracranial subdural hematoma (SDH) following dural puncture (DP) is a life-threatening complication. However, the characteristics and prognosis are little-known. METHODS: Reports documenting intracranial SDH following DP were surveyed by using PubMed and the Igaku-chuou-zassi (Japana Centra Reveuo Medicina) database (1979-2005) and the cases were analyzed to clarify their characteristics and prognoses. RESULTS: Sixty-nine case reports were enrolled. Seventy per cent of patients underwent anesthetic procedures including spinal and epidural anesthesia. Fifty-two per cent of patients, many of whom receiving obstetrical procedures, were under 40 years of age and majority of the rest of over 40 years were male. Eighty per cent of patients had an onset of SDH within 1 month after DP. Patients often showed disappearance of postural headache, associated with various neurological symptoms such as consciousness disorder, vomiting, hemiplegia and diplopia. The eighty-three per cent of patients recovered completely from SDH except 11 patients who died or afflicted with sequelae because of delayed diagnosis. CONCLUSIONS: Seventy per cent of SDH occured following anesthesia related procedures. Most of them had an onset within one month after DP The prognosis was relatively good as long as SDH could be diagnosed at its early stage. It was necessary to observe the disappearance of postural headache and associated symptoms carefully to avoid delayed diagnosis.

[Transluminal placed endovascular graft (TPEG) for thoracic aortic disease in fifteen patients under general anesthesia].

In 15 transluminal placed endovascular graft (TPEG) operations for thoracic aortic aneurysm either from dissection or injury, we induced general anesthesia with propofol, and maintained with propofol or sevoflurane in nitrous oxide and oxygen. The temporary balloon occlusion technique used for prevention of stent migration caused hypotension (systolic pressure 30-60 mmHg) in all cases. After releasing the occluding balloon, blood pressure in each patient recovered to the prehypotension level without use of catecholamine. We experienced two emergency operations, a thoracotomy and a celiotomy, resulting from graft failure. We had sudden hypotension in two other cases. In the first patient with aortic regurgitation, coronary air embolism was suspected because of ST segment elevation, while in the other, the hypotension was due to unexpected bleeding from the femoral artery sheath. Two additional patients developed vascular injuries occurring during manipulation of the catheter or sheath. In order to manage anesthesia for TPEG, it is necessary to be aware of its complications.

[Assessment of preoperative anxiety in patients entering the operating room on foot using state-trait anxiety inventory].

The purpose of this prospective study was to assess the effect of walking into the operating room on preoperative anxiety level. Sixty non-premedicated patients scheduled for elective surgery were randomly divided into two groups based on how they were transported into the operating room. One group was carried on a stretcher (n = 30) and the other entered on foot under their own power (n = 30). A subjective assessment of anxiety was performed using a state-trait anxiety inventory (STAI) the day before surgery and on arrival at the operating room. STAI values were not increased in the operating room as compared to the day before surgery for either group and did not differ between groups, though they showed a high level of anxiety throughout the preoperative period. We conclude that walking into the operating room has no significant influence on preoperative anxiety level.