The repeating dislodgement of an Amplatzer Septal Occluder device during recovery from general anesthesia in an adult undergoing transcatheter closure of atrial septal defect : a case report.

Transcatheter closure with an Amplatzer Septal Occluder (ASO) has become the standard treatment for secundum atrial septal defect (ASD). However, this procedure is associated with complications, such as device dislodgement. A 52-year-old woman was admitted with exertional dyspnea. Transesophageal echocardiography showed an ASD involving a 29 mm defect. Calculated Qp/Qs was 5.6 and all the rims were ?5 mm, with the exception of the posterior rim, which was 3 mm. Transcatheter ASD closure with an ASO was performed under general anesthesia. During emergence from anesthesia, tachycardia developed and the ASO device became dislodged. Hemodynamic changes associated with the end of anesthetic administration were believed to have led to device dislodgement. In a second transcatheter ASD closure, a low dose of propofol and remifentanil was maintained during emergence from anesthesia to reduce hemodynamic changes. However, device dislodgement occurred with nonsustained ventricular tachycardia. Finally, surgical ASD closure was performed. The large defect size, high Qp/Qs, and rim deficiency may have predisposed to device dislodgement after transcatheter ASD closure with ASO. The risk of device dislodgement should be considered in advance of surgery and, in high-risk cases, the patient's cardiovascular status should be closely monitored. J. Med. Invest. 66 : 194-198, February, 2019.

[Efficacy and Indication of Fibrinogen Replacement Therapy in Thoracic Aortic Surgery A Retrospective Cohort Study].

BACKGROUND: Fibrinogen replacement therapy con- tributes to effective hemostasis and saving blood trans- fusions in critical hemorrhage. We retrospectively studied the efficacy and indication for cryoprecipitate or fibrinogen concentrate in thoracic aortic surgery. METHODS: In 169 patients undergoing thoracic aortic surgery, 92 (54.4%) patients received dryoprecipitate or fibrinogen concentrate and 77 (45.6%) patients did not We compared them with regard to postoperative bleeding and perioperative blood transfusion. We deter- mined the effective dose of the fibrinogen in cryopre- cipitate or fibrinogen concentrate for increasing the fibrinogen level. RESULTS: The cutoff value of the fibrinogen level at the end of cardiopulmonary bypass between both groups was 100 mg · dl⁻¹. For a fibrinogen level less than 130 mg · dl⁻¹ during cardiopulmonary bypass, the patients who received cryoprecipitate or fibrinogen concentrate had less postoperative bleeding (P<0.01) and fewer transfusions of total blood, fresh frozen plasma, and platelet concentrates (P<0.05). The effec- tive dose 50 of fibrinogen amount was 0.031-0.051 g - kg⁻¹. CONCLUSIONS: The fibrinogen amount of 2-3 g (per 50-70 kg in body weight) in cryoprecipitate or fibrino- gen concentrate effectively reduces postoperative bleeding and perioperative blood transfusions when a fibrinogen level is less than 100-130 mg · dl⁻¹ during cardiopulmonary bypass.

Perineural but not systemic low-dose dexamethasone prolongs the duration of interscalene block with ropivacaine: a prospective randomized trial.

PURPOSE: To determine the effects of intravenous and perineural dexamethasone on the duration of interscalene brachial plexus block (ISB) with ropivacaine in patients undergoing arthroscopic shoulder surgery. PATIENTS AND METHODS: In this prospective, randomized, placebo-controlled trial, patients presenting for arthroscopic shoulder surgery with an ISB were randomized to receive ropivacaine 0.75% (group C), ropivacaine 0.75% plus perineural dexamethasone 4 mg (group Dperi), or ropivacaine 0.75% plus intravenous dexamethasone 4 mg (group Div). The primary outcome was the duration of analgesia, defined as the time between performance of the block and the first request for analgesic. RESULTS: Thirty-nine patients were randomized. The median times of sensory block in groups C, Dperi, and Div were 11.2 hours (interquartile range [IQR] 8.0-15.0 hours), 18.0 hours (IQR 14.5-19.0 hours), and 14.0 hours (IQR 12.7-15.1 hours), respectively. Significant differences were observed between groups Dperi and C (P=0.001). Kaplan-Meier analysis for the first analgesic request showed significant differences between groups Dperi and C (P=0.005) and between groups Dperi and Div (P=0.008), but not between groups C and Div. CONCLUSION: Perineural but not intravenous administration of 4 mg of dexamethasone significantly prolongs the duration of effective postoperative analgesia resulting from a single-shot ISB with ropivacaine 0.75%.

[Lower thoracic epidural analgesia improves postoperative analgesia following vaginal total hysterectomy].

BACKGROUND: In our hospital, lumbar epidural analgesia had been used for postoperative analgesia following vaginal total hysterectomy (VTH). But some patients experienced severe abdominal pain or numbness of the legs. Therefore we planned a randomized prospective study to compare lower thoracic epidural analgesia and lumbar epidural analgesia following VTH. METHODS: Fifty patients were allocated to two groups: those who received lower thoracic epidural analgesia(T group)and the other who received lumbar epidural analgesia (L group). Both groupsreceived the same continuous epidural analgesia using fentanyl and ropivacaine after the operation. RESULTS: The T group required significantly lower frequency of analgesic agents compared with that of the L group (2.5±1.9 times vs. 1.2±1.1 times, P< 0.05). Fewer patients in the T group had felt numbness in their legs compared to the L group (8% vs. 55%, P<0.05). CONCLUSIONS: Lower thoracic epidural analgesia is more effective to provide postoperative analgesic effect following VTH compared with lumbar epidural analgesia.

[Three cases of latex allergy complicated with anaphylaxis during cesarean section].

UNLABELLED: We experienced three cases of latex anaphylaxis during cesarean section in one year. CASE: 1 A 26-year-old woman underwent emergency cesarean section. Combined spinal-epidural anesthesia was performed and drip infusion of cefazolin sodium was started before operation. After delivery, intravenous injection of methylergometrine maleate and intramyometrial injection of oxytocin were given. Eight minutes after delivery, she complained of dyspnea and edema of eyelids; no change in vital signs were noted. We suspected an anaphylactic reaction and administered antihistamines as well as methylprednisolone. Inhalation of beta-stimulators and sevoflurane using a face mask improved her respiratory symptoms. CASE 2: A 25-year-old woman underwent emergency cesarean section. We noticed wheals involving her eyelids and legs after operation and administered methylprednisolone. CASE 3: A 23-year-old woman underwent elective cesarean section. Five minutes after delivery and oxytocin injection, she complained of edema of eyelids, facial erythematous edema, and dyspnea. We suspected latex anaphylaxis and stopped using latex products. Then, we treated her with antihistamines, methylprednisolone and beta-stimulators. The diagnosis of latex anaphylaxis was made by positive results of skin tests to latex and an increase in the levels of latex-specific immunoglobulin E. We conclude that cesarean section is an important risk factor for latex anaphylaxis.

[Transient paraplegia due to epidural hematoma after catheter withdrawal].

A 58-year-old man with hypertension underwent laparoscopic distal gastrectomy under general and epidural anesthesia. Preoperative laboratory date revealed a normal platelet count and normal coagulation profile. Epidural puncture was successfully performed at the T9-10 intervertebral space on the first attempt without bleeding. An epidural catheter was smoothly inserted 5 cm cephalad. On the third postoperative day, paraplegia due to thoracic epidural hematoma developed shortly after extraction of the catheter. At that time, his blood pressure was 190/102 mmHg because of a pain due to walk. On using a hypotensive drug, his blood pressure fell. Ten minutes later, paraplegia disappeared spontaneously. It is suggested that the spinal cord of the patient was subjected to transient pressure hematoma. A decline in blood pressure may have caused the blood to spread through the epidural space, such that the neurologic symptoms disappeared.

[Anesthetic management for cleft palate plasty in a patient with Pierre-Robin syndrome].

A girl (15 months-old) with Pierre-Robin Syndrome was scheduled for cleft palate plasty. She had a past history of difficulty feeding, mild airway obstruction during sleeping and mental retardation. After induction of anesthesia with an inhalational anesthetic technique, conventional tracheal intubation was impossible. We introduced a laryngeal mask airway (LMA) and successfully intubated through the LMA. After extubation of the tracheal tube, she developed upper airway obstruction with arterial desaturation. We ventilated her lungs in the lateral position with an inhalation of epinephrine and injection of methylprednisolone. Airway obstruction then improved gradually. In this case, LMA was a valuable device as a guide for the tracheal intubation. Because airway obstruction after extubation is a common complication in a patient with Pierre-Robin syndrome, we need to observe the patient closely.

[Treatment of salt poisoning due to soy sauce ingestion with hemodialysis].

Fatal hypernatremia due to soy sauce ingestion is rare. We describe a 65-year-old woman who became unresponsive after ingesting 1150 ml of soy sauce. Her initial blood sodium concentration was 176 mEq/l. She was treated successfully with acute hemodialysis and her serum sodium concentration decreased to 146 mEq/l without any significant neurologic complication. We recommend hemodialysis is the best approach to correct severe hypernatremia.

Left ventricular diastolic filling during coronary artery bypass surgery in patients with diabetes mellitus and/or hypertension.

To evaluate left ventricular diastolic filling (DF) using transesophageal Doppler echocardiography in 40 patients with or without diabetes mellitus and/or hypertension, we measured DF after induction of anesthesia, before and after cardiopulmonary bypass (CPB), and at the end of coronary artery bypass surgery (CABS). In 13 patients with complete measurements, there was no significant change in DF but diastolic filling time became shorter and peak velocity during atrial contraction increased significantly following CPB. In the other patients, the assessment of DF could be performed accurately in CABS patients without diabetes and/or hypertension, but not in CABS patients with these disorders because of a high incidence of fusion of the E-A waves, which is an indicator of impaired DF. When heart rate (HR) was more than 75 beats·min-1 (RR interval of less than 800 ms), the incidence of fusion points was significantly higher in patients with diabetes and/or hypertension than without (13 of 29s 1 of 9,P<0.05). It is suggested that a slower HR (less than 75 beat·min-1) is desirable in CABS patients with these disorders to avoid impairment of DF due to either prolonged systolic time or isovolumic relaxation time.