Management of Anesthesia under Extracorporeal Cardiopulmonary Support in an Infant with Severe Subglottic Stenosis.

A 4-month-old female infant who weighed 3.57 kg with severe subglottic stenosis underwent tracheostomy under extracorporeal cardiopulmonary support. First, we set up extracorporeal cardiopulmonary support to the infant and then successfully intubated an endotracheal tube with a 2.5 mm inner diameter before tracheostomy by otolaryngologists. Extracorporeal cardiopulmonary support is an alternative for maintenance of oxygenation in difficult airway management in infants.

Successful treatment of severe asthma-associated plastic bronchitis with extracorporeal membrane oxygenation.

We describe a case of near-fatal asthma requiring extracorporeal membrane oxygenation (ECMO). The patient presented with severe respiratory distress, which was not responsive to conventional pharmacological therapy. The patient also failed to respond to mechanical ventilation and thus was placed on venovenous ECMO for temporary pulmonary support. A fiberoptic bronchoscopy revealed that large amounts of thick bronchial secretions had occluded the main bronchus, which suggested plastic bronchitis secondary to asthma. Aggressive airway hygiene with frequent bronchoscopies and application of biphasic cuirass ventilation for facilitation of secretion clearance were performed to improve the patient's respiratory status. The patient achieved a full recovery and suffered no neurological sequelae. This case illustrates that aggressive pulmonary hygiene with ECMO is a useful therapy for patients with asthma-associated plastic bronchitis.

Anesthetic management of a patient with deteriorated cardiac function following cardiopulmonary resuscitation.

A 73-year-old woman suffering from an abdominal aortic aneurysm (AAA), unstable angina, and low cardiac function (32% of ejection fraction) was scheduled for abdominal aortic replacement and coronary artery bypass grafting. However, before the scheduled operation the patient fell into cardiopulmonary arrest with ventricular fibrillation due to rupture of the AAA. Immediate cardiopulmonary resuscitation (CPR) using epinephrine and electrical defibrillation restored the spontaneous circulation. Following CPR, a continuous high-dose dopamine infusion (15 µg/kg/min) was initiated and emergent abdominal aortic replacement was performed. On arrival at the operating room, the patient showed serious hypotension, atrial fibrillation with multifocal ventricular premature contractions, and metabolic acidosis. Transesophageal echocardiography (TEE) suggested that the circulatory collapse might have resulted from diastolic dysfunction and deteriorated compliance of the left ventricular (LV) wall, possibly due to myocardial stunning induced by myocardial ischemia, and tachycardia induced by hypovolemia, both of which are influenced by high doses of catecholamine. We accordingly transfused adequate amounts of blood products and gradually decreased the infusion rate of dopamine to 4 µg/kg/min, while carefully monitoring blood pressure, central venous pressure, and TEE. By the end of surgery hemodynamic parameters had recovered to near normal levels. In post-resuscitated and hypovolemic patients, caution should be taken when administering high levels of exogenous catecholamines, which can induce myocardial stunning and circulatory collapse.

[Cesarean section for case with preoperatively-suspected placenta accrete followed by hysterectomy due to uncontrollable massive bleeding].

A 42-yr-old pregnant woman highly suspicious of the placenta accreta was scheduled for cesarean section (c-section) under general anesthesia. She had received emergency c-section for the placenta previa at 36 years of age and three episodes of intrauterine curettage for spontaneous abortion. While the possibility of placenta accreta was pointed out and the risks accompanying with it were explained at the 7th week of pregnancy, she insisted on having a baby. C-section was intended at around the 30th week of pregnancy and 1,200 ml of autologus blood was stored for the predictable massive bleeding. Bilateral embolization of the internal iliac artery was also planned. The baby was delivered uneventfully. However, the adherence of the placenta was so tight that the placenta could not be separated from the uterine wall. The arterial embolization immediately after the delivery did not work as effectively as to control massive bleeding. It took about 1 hour to control the massive bleeding of up to 9000 ml by difficult hysterectomy. Since we had prepared for such a situation, we could well catch up with the massive bleeding. The mother and baby were discharged well from the hospital 29th day after the c-section.

[Combination of spinal and inhalation anesthesia for nephrectomy in a cirrhotic patient].

We report a 75-year-old man with the liver cirrhosis of Child-Pugh B who underwent nephrectomy. Preoperative serum examination revealed increases in GOT, GPT, LDH and total bilirubin, decreases in cholinesterase and albumin, and prolongation of prothrombin time. We selected spinal anesthesia using bupivacaine and fentanyl rather than epidural anesthesia in combination with isoflurane inhalation anesthesia to supplement intra-operative anesthesia and post-operative pain relief. We explained the risks of blood coagulopathy and the predictable venous dilatation in the epidural space to the patient and relatives on obtaining informed consent. The surgery was completed uneventfully in 2.5 hours. Post-operative pain control was satisfactory and hepatic dysfunction did not deteriorate in the postoperative period.

[Anesthetic management of a patient with amyotrophic lateral sclerosis (ALS)].

A 63-year-old man suffering from amyotrophic lateral sclerosis (ALS) was scheduled for a surgery of rectal cancer. Anesthetic management was planned aiming early recovery from anesthesia and reduction of muscle relaxant administration. Orotracheal intubation was carried out by intravenous administration of a comparatively large dose propofol (3 mg.kg-1) and sevoflurane as high as 5%. Adequate muscle relaxation was obtained throughout the operation by inhalation of 2-3% sevoflurane and single intravenous administration of vecuronium 1 mg. A combination of propofol and sevoflurane is a successful choice to eliminate effects of anesthesia early after surgery and also to reduce the amount of a muscle relaxant used.

An increase in body temperature during radiofrequency ablation of liver tumors.

UNLABELLED: Radiofrequency ablation (RFA) therapy using an active needle electrode inserted into liver tumors has been used clinically. To avoid hyperthermia, we investigated the relationship between the total output energy of the applied radiofrequency wave and changes in body temperature (BT) in patients receiving RFA. Fifteen patients undergoing RFA of liver tumors with general anesthesia were enrolled. The total output energy of radiofrequency waves was calculated from the power and duration of RFA. Changes in rectal (T(rect)) and tympanic temperatures were measured throughout the study. The mean number of liver tumors per patient was 1.7 +/- 1.3. The mean RFA time was 30.0 +/- 26.3 min. The mean total output energy was 125,935 +/- 114,506 J. The mean value of T(rect) increased from 36.3 degrees C +/- 0.5 degrees C to 37.0 degrees C +/- 1.0 degrees C (P < 0.01). A linear correlation was obtained between the total output energy and the changes in T(rect), indicating that T(rect) increased approximately by 1 degrees C for every 3000 J/kg of total output energy. The increase in BT during RFA of liver tumors under general anesthesia is predictable. Close observation of total output energy delivered and BT are required, and preparation of cooling measures is important, in RFA of liver tumors. IMPLICATIONS: The increase in body temperature (BT) is predictable during radiofrequency ablation (RFA) of liver tumors under general anesthesia. Close observation of total output energy delivered and BT are required, and preparation of cooling measures is important, in RFA of liver tumors.