[Are transcutaneous blood gas measurement monitors (SenTec Digital Monitor system) useful for the respiratory management of chronic respiratory failure?].

BACKGROUND: The level of arterial carbon dioxide partial tension (PaCO2) is a sine qua non for the determination of the adequacy of ventilation. The aim of this study was to assess the usefulness of SenTec Digital Monitor System in measuring transcutaneous arterial carbon dioxide partial tension (PCO2) non-invasively for the management of chronic respiratory failure. METHODS: Three ICU patients suffering from chronic respiratory failure were enrolled. We recorded the data of PCO2 measured by a transcutaneous ear sensor (V-Sign : SenTec Inc.) and the data of PaCO2 (GASTAT-603ie Techno Medica Co., Ltd., Japan) obtained from arterial blood gas analysis. RESULTS: The mean PCO2 was 67.2 mmHg (min. 65.9 mmHg, max. 80.2 mmHg, n = 10), and the mean PaCO2 was 71.2 mmHg (min. 67.2 mmHg, max. 79.0 mmHg, n = 10). Regression analysis showed good correlation between PCO2 and PaCO2 (PCO2 = .95 x PaCO2-0.18 mmHg; R = 0.74). Bland-Altman analysis of PCO2 yields a bias of d = 3.9 mmHg with limits of agreement (1SD) -0.4 mmHg, +8.2 mmHg. CONCLUSIONS: SenTec Digital Monitor System enables non-invasive and reliable trend monitoring of PCO2 levels in patients with chronic respiratory failure.

[Anesthetic management of a patient with Osler-Weber-Rendu disease undergoing mitral valvuloplasty].

Osler-Weber-Rendu disease (OWRd) is an autosomal dominant disease with an incidence of 1-2 per 100,000 of population. The triad of OWRd is fibrovascular dysplasia characterized by telangiectases, arteriovenous malformations and recurrent bleeding. We experienced anesthetic management of a patient with OWRd undergoing mitral valvuloplasty. The patient was a 79-year-old woman admitted to our hospital with diagnosis of heart failure, mitral regurgitation, and chronic atrial fibrillation. Massive nasal bleeding before admission caused severe anemia (Hb 4.8 g dl(-1)), and she received transfusion. Preoperaitve examination revealed moderate mitral regurgitation with prolapsed anterior leaflet, pulmonary hypertension, high cardiac output (6.85 l min(-1)), and multiple hepatic angiomas. After induction of anesthesia, a pulmonary catheter was inserted. High cardiac output and high saturation of mixed-venous oxygen were found until the end of surgery. Blood gas analyses of samples from several sites suggested left to right shunt below the inferior vena cava. Mitral valvuloplasty and tricuspid annuloplasty were completed under mild hypothermic cardiopulmonary bypass. Despite our attention to abnormal bleeding, perioperative course was uneventful. For anesthetic management of OWRd, we must recognize the abnormal bleeding and the systemic vascular malformations preoperatively, and prepare for the possible complications.

[Questionnaire survey on perioperative management of diabetic patients undergoing cardiovascular surgery].

BACKGROUND: Not many cardiovascular surgeries of diabetic patients were performed with optimal preoperative glycemic control because there was no diabetologist in our hospital. To examine how this complication was treated in other hospitals, we conducted a questionnaire survey sent to anesthesiologists in Japan on perioperative management of diabetic patients undergoing cardiovascular surgery. METHODS: In April 2004, 250 hospitals where cardiovascular surgery was performed were chosen by Internet search. We mailed questionnaires consisting of 16 questions on perioperative management of diabetic patients to the department of anesthesiology of those hospitals. Self-addressed envelopes were attached for returning answers. RESULTS: Answers were collected from 122 hospitals (48.8%). Physicians and/or surgeons handled preoperative management of diabetes mellitus and there was little concern by anesthesiologists. This management satisfied anesthesiologists with satisfaction level of 70%. Postponement of surgery due to poor preoperative diabetic control was experienced in 55 (45%) hospitals. Seventy-one percent of anesthesiologists regarded perioperative glycemic control important, but the strict glycemic control method was not yet employed in most hospitals. CONCLUSIONS: The survey showed that many anesthesiologists regarded perioperative glycemic control important and were satisfied with the present preoperative management. For better management, better cooperation between anesthesiologists, surgeons and diabetologists is needed.

[Anesthetic management of tracheobronchial stent insertion in patients who underwent laser resection, balloon dilatation and tracheostomy in advance].

BACKGROUND: We report successful management of tracheobronchial stent insertion under general anesthesia. METHODS: In thirty-two cases, tracheobronchial stent insertion was performed under general anesthesia. The technique for airway management was chosen depending on the type of stent or the constriction level of the airway portion. We employed tracheostomy in order to avoid repeated intubations during the insertion of Dumon or Dynamic stent. In case of severe airway stenosis, laser resection or balloon dilatation was performed before stent insertion. RESULTS: We had 32 successful cases in 36 trials. Four trials failed due to insufficient expansion in one, mismatches of stent angle in one and pneumomediastinum in one. There was no exacerbation of respiratory condition in failed cases. There was no case who needed percutaneous cardiopulmonary support system. CONCLUSIONS: We managed tracheobronchial stent insertion under general anesthesia. Both the airway expansion by laser resection or balloon dilatation before stent insertion and also the insertion of Dumon or Dynamic stent through a tracheostomy were helpful strategies. These techniques facilitated more definitive airway maintenance and stable anesthetic management.

[Sudden onset of EDTA-dependent pseudothrombocytopenia in a patient scheduled for open heart surgery].

A 60-year-old woman scheduled for mitral and aortic valve replacement had sudden onset of thrombocytopenia without clinical symptoms. The platelet count was found to decrease after the sampling. Microscopic examinations confirmed platelet aggregations. Changing anticoagulant added to blood samples from EDTA to heparin resolved such platelet aggregations. This phenomenon was diagnosed as demonstrating EDTA-dependent pseudothrombocytopenia and the operation was performed as scheduled without platelet transfusion. Postoperative course was almost uneventful and the patient was discharged on 26th day after surgery. EDTA-dependent pseudothrombocytopenia must be ruled out when patients have thrombocytopenia without certain causes such as infections, drugs, or autoimmune diseases.

[Severe hypotension and atrio-ventricular block in a patient of left lung cancer associated with myocardial bridging].

A 74-year-old man with myocardial bridging was referred to our hospital for operation of the left lung cancer. He underwent upper lobectomy of the lung under general anesthesia. After lobectomy and bilateral lymph node resection, severe hypotension occurred without ECG change. The blood pressure was restored by cardiac massage and the administration of fluids and vasoactive agents. After the closure of the sternum, hypotension occurred again and complete A-V block appeared. After resuscitation, A-V block disappeared. He was extubated the day after surgery without any neurogical deficit. We consider that hypovolemia and myocardial bridging induced hypotension and complete A-V block.

[The usefulness of human lung embryonal fibroblast cells (MRC-5) for isolation of enteroviruses and adenoviruses].

Although various cell lines have been used for virus isolation, few study of virus isolation using MRC-5 cell, a human embryonic lung fibroblasts, have been reported in Japan. MRC-5 and other cell lines (Caco-2, Vero, RD-18s, LLC-MK2, HeLa, MDCK, FL, B95a and HMV-II), and suckling mouse were compared for isolation of viruses from clinical specimens. A total of 3,284 specimens, collected from clinics and hospitals in Saitama Prefecture between July 1997 and August 2001, were inoculated in these cells. A total of 1,252 viral strains were isolated and 1,190 viral strains of these were identified. MRC-5 detected 209 of specimens positive for various viruses. As for adenovirus, a total of 132 viral strains were isolated using cell lines described above, and 100 of 132 viral strains were isolated in MRC-5. MRC-5 showed the highest sensitivity for isolation of adenovirus 3 and 7 (79.1% and 100%) of all other cells. The sensitivity in isolation of these viruses in HeLa was 58.1% and 50.0%, respectively. It showed that MRC-5 is able to isolate enterovirus, especially coxsackie virus A16 and enterovirus 71 with a high sensitivity (85.7% and 73.7%). RD-18s detected 35.7% and 26.3% of coxsackie virus A16 and enterovirus 71 isolates, LLC-MK2 detected 60.7% and 47.4%, and Vero detected 48.6% and 52.6%, respectively. Coxsackie virus B group was not isolated, except for a few coxsackie virus B 5 strains. Enteroviruses except coxsackie virus A16 and enterovirus 71 were isolated more frequently in Caco-2 and RD-18s. Seven hundred thirteen strains of influenza viruses were isolated in MDCK and Caco-2, but none was isolated in MRC-5. It was probably due to the maintenance medium without trypsin. The isolation rate of herpes simplex virus in Vero was 88.9% and MRC-5 showed 77.8%, it was high secondary to Vero by MRC-5. However, the CPE was detected in a few days in MRC-5, it was earlier than in Vero. The MRC-5 is possible to be maintained without changing the maintenance medium and passaged for 2 weeks, and clear CPE was observed. On the other hand, the disadvantages in using the MRC-5 were that the passage was limited and that the split ratio was only 1:2. However, the MRC-5 was used successfully for virus isolation, especially coxsackie virus A16, enterovirus 71 and adenoviruses, from clinical specimens.

[Clinical use of the VIA Blood Gas Monitor System].

VIA Blood Gas Monitor System (Baxter) withdrawals and reinforces blood automatically and measures pH, PaCO2, PaO2, sodium, potassium, and hematocrit. We evaluated VIA for use during cardiopulmonary bypass in 8 patients and during differential lung ventilation in 6 patients. The bias and precision were calculated on all the measured parameters. A total of 127 blood samples were obtained for comparison. Blood gas data measured by VIA were clinically acceptable except sodium. These findings suggest that VIA is useful for the management of patients in whom frequent arterial gas measurements are necessary.

[Hemoglobin levels and weight gain after coronary bypass grafting by use of intraoperative hemodilution and autologous blood transfusion].

We investigated the relationship between the degree of hemodilution during cardiopulmonary bypass (CPB) and weight gain after coronary bypass grafting by use of intraoperative hemodilution and autologous blood transfusion. There is no significant difference in weight gain between the higher hemoglobin group (Hb > or = 6 g.dl-1) and the lower hemoglobin group (Hb < 6 g.dl-1). Furthermore, there is no significant correlation between hemoglobin levels during CPB and weight gain after operation. We conclude that slightly excessive hemodilution than usual during CPB does not influence weight gain when cardiac and renal functions are fair.