Successful Perimortem Cesarean Section With Cardiopulmonary Resuscitation and Anesthesia: A Report of an Unique Case.

Cardiac arrest after acute pulmonary edema in pregnancy is an uncommon event but one with a potentially disastrous outcome. We report the case of a pregnant woman with preeclampsia who presented with rapidly advancing pulmonary edema and subsequently went into cardiac arrest on arrival at the operating room. A perimortem cesarean section was performed in addition to cardiopulmonary resuscitation and anesthesia. These simultaneous treatments resulted in excellent maternal and neonatal outcomes. Moreover, therapeutic brain hypothermia was performed. To our knowledge, this is the first case report of a patient undergoing a cesarean section during cardiac arrest and treated with brain hypothermia. We discuss some of the issues arising from the case in this report.

Management of Labor and Anesthesia in a Patient With a History of Spontaneous Intracranial Hypotension: A Case Report With Literature Review.

Spontaneous intracranial hypotension (SIH) is a rare disorder characterized by continuous or intermittent cerebrospinal fluid (CSF) leakage from the CSF cavity, which causes symptoms such as headache or neck pain upon standing. However, no well-established measures concerning the type of delivery and anesthesia for pregnant women with a history of SIH have been reported. A woman had developed SIH 9 years earlier from lifting luggage into an overhead bin with stretching movements, which required continuous saline epidural infusion for recovery. Upon the patient's pregnancy at the age of 35 years, although an elective cesarean section (CS) under general anesthesia was planned to avoid SIH recurrence, the patient had an emergency CS at 36 weeks. Since there is no prescribed method of delivery and anesthetic management for patients with a history of SIH, it is important to plan and adapt a treatment strategy based on the patient's wishes and the institution's protocols. As a sidenote, we reviewed the available literature regarding the type of delivery and anesthesia for pregnant women with a history of SIH.

The Ropivacaine Concentration Required for Ultrasound-Guided Rectus Sheath Block in Pediatric Patients Undergoing Single-Incision Laparoscopic Hernia Repair: A Sequential Allocation Dose-Finding Study.

BACKGROUND: The local anesthetic concentration required for ultrasound-guided rectus sheath block (RSB) in children remains unknown. Knowledge of appropriate ropivacaine concentration can help clinicians reduce local anesthetic toxicity risk when performing ultrasound-guided RSB in children. This study aimed to determine the appropriate ropivacaine concentration for ultrasound-guided RSB in children undergoing laparoscopic inguinal hernia repair. METHODS: In this single-arm prospective study with an up-down sequential allocation design of binary response variables, 18 consecutive children aged 11 months to 7 years undergoing single-incision laparoscopic percutaneous extraperitoneal closure were assessed. Orotracheal intubation was performed without intravenous anesthesia or a neuromuscular relaxant. After intubation, ultrasound-guided RSB was performed with a ropivacaine dose of 0.30 ml/kg (0.15 ml/kg per side). Dixon's up-and-down method was used to determine the concentration, starting from 0.25% in 0.05% increments. Surgery commenced ≥15 min following RSB. Body movement or a 20% increase in heart rate or systolic blood pressure within 1 min of surgery initiation determined an unsuccessful RSB. The 95% effective concentration of ropivacaine needed for successful RSB was calculated using the probit test. RESULTS: The 95% effective concentration of ropivacaine needed for successful ultrasound-guided RSB was 0.31% (95% confidence interval, 0.25-7.29). The highest concentration of ropivacaine required for successful ultrasound-guided RSB in the group of patients in this study was 0.3%. CONCLUSION: The 95% effective concentration of ropivacaine (0.30 ml/kg total, 0.15 ml/kg per side) for ultrasound-guided RSB was 0.31% in children undergoing single-incision laparoscopic surgery under general anesthesia.

Successful Nerve Block Therapy for Lateral Cutaneous Nerve Entrapment Syndrome (LACNES) Triggered by Exercise.

This report presents a case of a 59-year-old man who experienced pain in the left abdomen during abdominal exercises, which gradually improved. Pain recurred in the same area one year later and gradually worsened, rendering him unable to work. The strongest tender point, with a positive Carnett's sign, was noted on the flank. Ultrasonography revealed a 5 × 10 mm mass shadow in the internal oblique muscle. Trigger point injection at the same site was remarkably effective. Lateral cutaneous nerve entrapment syndrome caused by a crush injury due to abdominal exercises was diagnosed. Nerve block therapy provided effective pain relief.

Comparison of postoperative analgesic effects of thoracic epidural analgesia and rectus sheath block in laparoscopic abdominal surgery: A randomized controlled noninferiority trial.

INTRODUCTION: In the Enhanced Recovery After Surgery program, abdominal wall blocks are strongly recommended as postoperative multimodal analgesia for laparoscopic abdominal surgery. The purpose of this study was to compare the efficacy of single-shot rectus sheath block (RSB) with that of thoracic epidural analgesia (TEA) as a method of multimodal analgesia in patients receiving conventional laparoscopic abdominal surgery. METHODS: A noninferiority comparison was performed. Patients scheduled for laparoscopic gastric or colorectal surgery were enrolled in this study. Patients were divided randomly into two groups: TEA and RSB. The primary endpoint was the numerical rating scale (NRS) score upon coughing as of 24 hours after surgery. RESULTS: In total, 80 patients were randomly assigned to receive TEA (n = 42) or RSB (n = 38). Three patients were excluded from the TEA group after randomization. The NRS score on coughing as of 24 hours after surgery was significantly lower in the TEA group than in the RSB group (least square mean: 3.59 vs 6.39; 95% confidence interval for the difference: 1.87 to 3.74, P < .001). The NRS scores upon coughing and at rest were significantly lower in the TEA group than in the RSB group as of 4, 24 and 48 hours after surgery. Patient satisfaction with postoperative analgesia was significantly higher in the TEA group. Postoperative adverse events were not significantly different between groups. CONCLUSION: This is the first report of comparing RSB with TEA in laparoscopic surgery. TEA may be recommended as a multimodal analgesia protocol for laparoscopic gastric and colorectal surgery.

Minimum effective volume of ropivacaine for ultrasound-guided supra-inguinal fascia iliaca compartment block.

Supra inguinal fascia iliaca compartment block (FICB) is increasingly used in elderly patients with hip fractures. However, the minimum effective volume of local anesthetics required for ultrasound-guided supra-inguinal FICB has not been determined. With ethical committee approval and written informed consent from patients, we studied 21 consecutive patients of ASA physical status I-III undergoing surgery for hip fracture who met the inclusion criteria. Blocks were performed before going to the operation room. We determined the injection volumes of 0.25% ropivacaine for consecutive patients from the preceding patient's outcome. The initial volume was 30 ml. The testing interval was set at 10 ml, and the lowest volume was 5 ml. An effective block was defined as loss of sensation of pinprick in the territory of the femoral nerve and lateral cutaneous nerve of the thigh 30 min after the injection. The aim of this study was to determine the 50% effective volume (EV50) and the 95% effective volume (EV95) of 0.25% ropivacaine for ultrasound-guided supra-inguinal FICB using Logistic regression analysis. EV50 and EV95 of 0.25% ropivacaine for ultrasound-guided supra-inguinal FICB calculated with logistic regression analysis were 15.01 ml (95% confidence interval, 6.53-22.99 ml) and 26.99 ml (95% confidence interval, 20.54-84.09 ml), respectively. EV50 and EV95 of 0.25% ropivacaine for ultrasound-guided supra-inguinal FICB were 15.01 ml and 26.99 ml, respectively.Clinical trial number: UMIN000027277 (URL https://www.umin.ac.jp/ctr/index-j.htm ).

Occlusion of the pulmonary artery by a primary pulmonary artery sarcoma resulting in cardiac arrest: a case report.

BACKGROUND: Primary pulmonary arterial sarcoma (PPAS) is a rare condition. Although resection is recommended to improve prognosis, optimal anesthesia management for these cases remains unclear. CASE PRESENTATION: A 62-year-old woman with a diagnosis of left pulmonary PPAS underwent surgical tumor resection and left lung pneumonectomy. Preoperative symptoms included a cough and hemoptysis. Computed tomography revealed a complete obstruction of the left pulmonary artery, with tumor extension into the right pulmonary artery, and mild tricuspid regurgitation was observed on the echocardiogram. Ninety minutes after anesthesia induction, the patient went into cardiopulmonary arrest. As the surgical field was sterilized, we proceeded with emergent sternotomy and cardiac massage. Extracorporeal circulation was established, and surgery proceeded once spontaneous circulation was recovered. The patient survived without neurological complications. CONCLUSIONS: Based on our experience and in the absence of evidence-based guidelines, the femoral artery and vein should be cannulated in all cases for extracorporeal circulation initiation before anesthesia induction.

[A Patient with Difficult Airway who Died from Acute Aortic Dissection after Intubation].

This is a case report of a patient who died from acute aortic dissection after awake intubation. An 86-year-old woman with neck abscess causing dyspnea and hypertension was scheduled for a tracheotomy. Awake intubation was chosen and fentanyl 150 µg was injected first Immediately after intubation using a McGRATH® scope, her blood pressure increased to 205/157 mmHg and about 5 minutes after induction following intubation, end-tidal CO2 suddenly decreased. Aortic dissection was found with transesophageal echocardiography, and soon after, the electrocardio- gram of the patient showed an asystole. The patient was confirmed dead after effort to resuscitate. Chest CT revealed the wide range of aortic dissection from the aortic arch to the abdominal aorta. Hemodynamic change occurs at the time of intuba- tion, and its change is greater in elderly and those with hypertension. Furthermore, an interrelation between apnea and aortic dissection or large diameter of aneu- rysms has been reported. Therefore, anesthesia for elderly, especially those with hypertension, requires greater attention to their hemodynamic changes.

[Emergent Caesarean Section in a Patient with a Mediastinal Tumor and Von Recklinghausen Disease: A Case Report].

It is rare to encounter a pregnant patient with a mediastinal tumor, and if the tumor size increases as the pregnancy progresses, this increase can cause complications such as airway constriction and vascular occlusion. We report a case of a pregnant patient diagnosed with von Recklinghausen disease at the age of seven and diagnosed with a mediastinal tumors just after her present admission. The impending suffocation progressed and fetal heart rate decreased during her hospitalization. Her trachea was intubated and she was moved to an operating room for an emergent cesarean section under general anesthesia. With this rapid response, we could rescue both patient and infant. If the size of mediastinal tumor increases as pregnancy progresses, the tumor will cause suffocation by airway compression from the outside, in addition to specific airway edema on the inward side. The present case demonstrates that appropriate desisoins must be made for airway manegement and initiation of surgery.

The Ropivacaine Concentration Required for Ultrasound-Guided Ilioinguinal/Iliohypogastric Nerve Block in Pediatric Patients.

BACKGROUND: To the best of our knowledge, the ropivacaine concentration required for ultrasound-guided ilioinguinal and iliohypogastric nerve block (INB) has not been reported. We designed this study to examine the 50% effective concentration (EC50) of ropivacaine for ultrasound-guided INB in children anesthetized with 2% sevoflurane. METHODS: We studied 30 consecutive children (age range, 6 months to 11 years) ASA physical status I to II undergoing unilateral open inguinal hernia repair. General anesthesia was induced by sevoflurane and maintained with 2% end-tidal concentration of sevoflurane in air and oxygen (FIO2 = 0.4). Ultrasound-guided INB was performed using a 3 mL ropivacaine solution. The first child received 0.3% ropivacaine, and subsequent concentrations were determined by the response of the previous patient to initial skin incision using Dixon up-and-down method. The testing interval was set at 0.1%, and the lowest concentration was 0.05% (0.05%, 0.1%, 0.2%, 0.3%, 0.4%, or 0.5%). The EC50 for INB of ropivacaine was analyzed using probit test. RESULTS: The concentration at which all patients showed complete block was 0.50%, according to the up-and-down method. The EC50 was 0.21% (95% confidence interval, 0.03-0.34). CONCLUSIONS: The EC50 of ropivacaine for ultrasound-guided INB was 0.21% (95% confidence interval, 0.03-0.34), in pediatric patients anesthetized with 2% sevoflurane.

[A New Teaching Model for Practicing Ultrasound-guided Regional Anesthesia Techniques].

We developed a simulator using "slime" composed of polyvinyl alcohol (PVA) and borax to evaluate this new ultrasound-guided nerve block training model. Seventeen subjects used the training model in the present study. They had no previous experience in performing ultrasound-guided nerve block. A plastic case measuring 25 x 18 x 12 cm was filled with 8 cm of slime. Three pieces of gauze were placed between the slime layers at 2 cm intervals. An in-plane approach was used to visualize the needle for the nerve block, and the amount of time required to stop the needle on the second gauze was measured 5 times for each subject. Significant differences were observed between the times for the first experiment and those for the third experiment to the fifth experiment In the fourth and fifth experiments, all subjects visualized the nerve block needle clearly above the target layer and were able to stop the needle at the target layer. The present simulation using our proposed ultrasound-guided nerve block training model was useful in terms of the amount of time required to perform the procedure and as well as in terms of its safety.

Influence of acidosis on cardiotonic effects of colforsin and epinephrine: a dose-response study.

OBJECTIVE: Acidosis produces a negative inotropic effect on cardiac muscle against which catecholamines and phosphodiesterase III inhibitors have limited therapeutic effects. This study evaluated the effects of colforsin, which directly activates adenylate cyclase without ß-adrenergic receptor activation, in isolated Langendorff rat hearts in a pH- and concentration-dependent manner. DESIGN: Experimental animal study. SETTING: A university laboratory. PARTICIPANTS: Sprague-Dawley rats. INTERVENTIONS: Hearts were isolated and perfused with 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid/Tyrode solution (pH 7.4) in the Langendorff preparation. The hearts were assigned randomly to the control (pH 7.4), mild acidosis (pH 7.0), or severe acidosis (pH 6.6) group (n = 8 per group) and were perfused continuously with colforsin 10(-7), 10(-6), and 10(-5) mol/L. MEASUREMENTS AND MAIN RESULTS: Maximum dP/dt was determined, and the concentration-response relation was evaluated at each pH. Colforsin at 10(-6) mol/L increased the maximum dP/dt from 2,592 ± 557 to 5,189 ± 721 mmHg/s (p < 0.001) and from 1,942 ± 325 to 3,399 ± 608 mmHg/s (p < 0.001) in the control and mild acidosis groups, respectively; whereas colforsin, 10(-5) mol/L, significantly increased the maximum dP/dt even in the severe acidosis group. No significant difference was seen in maximum dP/dt among the 3 groups after infusion with colforsin 10(-5) mol/L. CONCLUSIONS: In contrast to catecholamines and other inodilators, colforsin at a high concentration restores decreased cardiac contractility against severe acidosis to an extent similar to physiologic pH.

Magnesium sulfate attenuates tourniquet pain in healthy volunteers.

PURPOSE: Preoperative administration of an N-methyl-D-aspartate (NMDA) receptor antagonist has been shown to attenuate tourniquet-induced blood pressure increase under general anesthesia, suggesting that the mechanism of this blood pressure increase includes NMDA receptor activation. The attenuation of this increase may be associated with the pain relief induced by NMDA receptor antagonism. We tested the hypothesis that magnesium sulfate, an NMDA receptor antagonist, attenuates tourniquet pain. METHODS: Twenty-four healthy volunteers were randomly assigned to four groups (n = 6 each): control (normal saline), M1 (magnesium, 1 g), M2 (magnesium, 2 g), and M4 (magnesium, 4 g). Normal saline or magnesium solution was given intravenously over a 15-min period, in a double-blind fashion, before tourniquet inflation, which was continued for 60 min or until the "pain score" (0 = no pain, 100 = highest tolerable pain) reached 100. Pain scores were recorded before and every 5 min during tourniquet inflation. If subjects reported a pain score of 100 before the end of the 60-min period, we adopted a pain score of 100 for the remaining period. RESULTS: The duration of tourniquet inflation in the M4 group was significantly longer than that in the control group (54.3 ± 8.3 vs. 42.9 ± 9.9 min, P = 0.03). Pain scores in the M4 group were significantly lower than those in the control group from 10 through 50 min after the start of tourniquet inflation. The area under the curve for pain scores in the M4 group was significantly smaller than the areas in the other groups. CONCLUSION: Magnesium sulfate, 4 g, significantly attenuated tourniquet pain in healthy awake volunteers, suggesting that NMDA receptor activation is involved in tourniquet pain.

[Effects of catheter size and fixation device on central venous catheter fixation].

The risk of accidental removal of a central venous catheter is a major concern in anesthesia and intensive care. We hypothesized that the force required to remove a fixed catheter depends on the size of the catheter (diameter) or use of a dry or wet catheter. In this study, the force required for accidental removal of dry and wet catheters was compared by dividing the subjects into 2 groups: dry group (patients in whom dry catheters were used) and wet group (patients in whom wet catheters were used). The force required for the accidental removal of dry catheters was greater than that required for the accidental removal of wet catheters, regardless of catheter diameter. Therefore, it is essential to use dry catheters and fixtures to prevent accidental removal of central venous catheters.

[The efficacy of the "BURP" maneuver during laryngoscopy and training period necessary for residents in anesthesiology].

BACKGROUND: The "BURP" maneuver (back, upward, right lateral, pressure) improves the visualization of the larynx for experienced anesthesiologists during orotracheal intubation in patients with difficult airway. We investigated whether this maneuver has same efficacy for inexperienced residents in anesthesiology. METHODS: We compared the visual condition of the larynx using "BURP" maneuver, back pressure or no maneuver between 37 residents and 16 staff anesthesiologists in 132 patients receiving general anesthesia. Additionally, we investigated the effects of residents' training period on their advancements in visualization of the larynx. RESULTS: The "BURP" maneuver significantly improved the visualization with laryngoscope. The third month of the training period developed visualization in comparison with those of the first month. The visualization in experiencing 31-35 patients was significantly improved than experiencing 1-10 patients. CONCLUSIONS: We concluded that "BURP" maneuver was effective even for inexperienced residents. More than two months were required for the residents to develop laryngoscopy skill.

Rapid injection of propofol reduces vascular pain and facilitates Laryngeal Mask Airway insertion.

STUDY OBJECTIVE: To compare the clinical efficacy of a rapid injection of propofol in regard to pain and ability to facilitate Laryngeal Mask Airway (LMA) insertion. DESIGN: Randomized, single-blinded, placebo-controlled study. SETTING: University hospital. PATIENTS: 120 ASA physical status 1 and 2 patients undergoing elective orthopedic surgeries. INTERVENTIONS: Patients were randomly allocated to one of 4 groups. Group A patients were pretreated with normal saline followed by propofol 2.0 mg/kg at 3.3 mg/sec. Group B patients were pretreated with lidocaine 0.5 mg/kg followed by propofol 2.0 mg/kg at 3.3 mg/sec. In Group C, patients were pretreated with lidocaine 1.0 mg/kg followed by propofol 2.0 mg/kg at 3.3 mg/sec. In Group D, patients were pretreated with normal saline followed by propofol 2.0 mg/kg at 50 mg/sec. MEASUREMENTS: Pain on injection was measured using a 4-point scale. Scale and success rate of smooth LMA insertion also were recorded. MAIN RESULTS: Rapid injection was less painful than after pretreatment with lidocaine 0.5 mg/kg, but was similar to slow injection after pretreatment with lidocaine 1.0 mg/kg. Rapid injection facilitated LMA insertion, unlike slow injection with lidocaine 0.5 mg/kg pretreatment, and was similarly successful to slow injection after pretreatment with lidocaine 1.0 mg/kg. CONCLUSIONS: The rapid administration of propofol reduces pain and facilitates LMA insertion versus slow administration of propofol.

[Anesthetic management of a patient with multiple system atrophy undergoing adrenal gland tumor surgery].

We report anesthetic management of a 61-year-old man with multiple system atrophy undergoing adrenal grand tumor surgery. Before surgery, he was sufficiently hydrated and an elastic bandage had been applied to the legs. After epidural catheterization for the postoperative analgesia, general anesthesia was induced with midazolam 7 mg and remifentanil 0.25 microg x kg(-1) x min(-1) and his trachea was intubated. During surgery, general anesthesia was maintained with sevoflurane and remifentanil 0.12-0.25 microg x kg(-1) x min(-1). Hemodynamics was almost stable although transient hypotension occurred during surgery because of bleeding and partial clamping of the inferior vena cava. After surgery, he emerged from anesthesia and tracheal tube was removed uneventfully. However, on the first postoperative day, hypotension and respiratory failure occurred. Noradrenaline infusion was needed to treat hypotension due to vasodilation and reintubation was performed. After several days, hypotension and respiratory failure improved and he was discharged from ICU.

Minimum alveolar concentrations of sevoflurane for maintaining bispectral index below 50 in children.

OBJECTIVE: To determine minimum alveolar concentration (MAC) of sevoflurane for maintaining bispectral index (BIS) below 50 (MAC(BIS50) ) in children. BACKGROUND: MAC(BIS50) of sevoflurane in adults was reported to be 0.97%, which has not been elucidated in children. METHODS/MATERIALS: Twenty children, American Society of Anesthesiologists physical status I or II, aged 1-8, were induced and anesthetized with sevoflurane in oxygen. After tracheal intubation, we started maintenance of anesthesia with endtidal sevoflurane concentrations of 2.6%. The endtidal sevoflurane concentration at which BIS was measured was predetermined by the up-down method (with 0.2% as a step size). After 10 min at predetermined endtidal sevoflurane concentrations, BIS was measured for 1 min. MAC(BIS50) was determined using Dixon's up-down method and probit test. RESULT: MAC(BIS50) of sevoflurane was 2.83% (95% confidence intervals: 2.70-3.14) in children. CONCLUSIONS: MAC(BIS50) of sevoflurane in children was calculated to be three times as high as in adults. This indicates that high endtidal sevoflurane concentration is required to suppress electroencephalogram activity in children.

[A case of an infant who developed pneumothorax during laparoscopic gastroesophageal antireflux surgery].

Pneumothorax is a complication associated with laparoscopic surgery, but there have been few reports of this complication in the pediatric population. We experienced a case of 7-month-old girl who developed pneumothorax during laparoscopic gastroesophageal antireflux surgery. After induction of general anesthesia, the trachea was intubated with a 3.5 mm internal diameter tube without a cuff. Anesthesia was maintained with sevoflurane and intermittent bolus injections of fentanyl. The insufflation pressure of carbon dioxide was 6 mmHg. Approximately 2 hours after the start of surgery, the intra-abdominal pressure suddenly increased to above 30 mmHg followed by a decrease in Sp(O2) to below 80%. We increased FI(O2) to 1.0 and ventilated lungs by bag. Sp(O2) recovered to 98%, but the Et(CO2) increased above 50 mmHg. Fifteen minutes after the episode, the pleural injury was found. The injured diaphragm was then repaired, and the trachea was extubated after surgery uneventfully. The pneumothorax resolved on the next day.