Severe Respiratory Event Initially Thought to be Inadvertent Endobronchial Intubation: Possible Complications From Using of a Topical Metered-Dose of 8% Lidocaine Pump Spray.

INTRODUCTION: Pulmonary collapse after intubation is common, and it is caused by a variety of factors. CASE PRESENTATION: A 21-year-old man presented at our operation room to undergo an appendectomy. Except for a history of cigarette smoking, his history was negative. Anesthesia was induced with 100% oxygen and sevoflurane, remifentanil infusion, and propofol. Neuromuscular block was obtained with rocuronium. The tip and cuff of a tracheal tube were lubricated with a topical metered-dose of 8% Lidocaine pump spray. After intubation, SPO2 suddenly decreased. The chest x-ray revealed right upper lobe atelectasis. Fiber optic bronchoscopy showed that a large amount of yellow sticky mucus had been secreted into the right main bronchus. CONCLUSIONS: In Japan, 8% Lidocaine pump spray contains menthol and ethanol as additives. These additives, particularly menthol, might have led to excessive mucus production, although we did not analyze the mucus secretion.

The Lateral Position Improved Airway Patency in Anesthetized Patient With Burn-Induced Cervico-Mento-Sternal Scar Contracture.

A 78-year-old woman with burn-induced cervico-mento-sternal scar contracture was scheduled for laparoscopic cholecystectomy. During inhalational induction of sevoflurane, her airway patency deteriorated. The right lateral position and assist ventilation using a breathing bag dramatically improved her airway patency.

[A case of gastric cancer that responded to a preoperative combination therapy of S-1/CDDP plus trastuzumab].

A 79-year-old man was diagnosed with advanced gastric cancer (cT3, N1, M0, cStage II B) showing regional bulky lymph node metastasis. Invasion of the pancreas and common hepatic artery was suspected. He was treated with S-1/CDDP plus trastuzumab therapy as a neoadjuvant chemotherapy (NAC) regimen. After two courses, significant tumor reduction was observed, and the patient underwent distal gastrectomy with D2 dissection. S-1/CDDP plus trastuzumab therapy as NAC for HER2-positive, advanced gastric cancer appears to be an effective treatment.

The effect of the kampo medicine yokukansan on preoperative anxiety and sedation levels.

Background. Preoperative anxiety can lead to unfavorable physiological response such as tachycardia and hypertension. Prevention of preoperative anxiety improves surgical outcome and decreases inpatient stay. Yokukansan is one of prescriptions in Kampo, traditional Japanese herbal medicine, and is known to exert anxiolytic effects. The aim of the present study was to compare the effects of diazepam and Yokukansan on preoperative anxiety, salivary amylase activity, and sedation levels. Methods. Seventy American Society of Anesthesiologists physical status I or II patients presenting for hemicolectomy under general anesthesia combined with epidural anesthesia were enrolled. The Diazepam group received diazepam 5 mg orally and the Yokukansan group received Yokukansan 2.5 g orally. Results. Although levels of anxiety and salivary amylase activity were not different between the two groups, the modified Observer's Assessment of Alertness/Sedation Scale of the Yokukansan group was significantly higher compared to that of the Diazepam group. Conclusion. Yokukansan alleviated preoperative anxiety without undesirable sedation, when compared with diazepam.

Auricular acupuncture at the "shenmen" and "point zero" points induced parasympathetic activation.

Purpose. Since auricular acupuncture is a diagnostic and treatment system based on normalizing the body's dysfunction, auricular acupuncture has been applied for pain relief, relaxation, and so on. These techniques would modulate the autonomic nerve system, thereby inducing the above-mentioned effects. The aim was to see the effect of auricular acupuncture applied to the "Shenmen" and "Point Zero" points on the postoperative heart rate variability (HRV). Methods. Twenty-six patients who underwent hemicolectomy under general anesthesia were randomized into the control or the acupuncture group. After the operation and before emergence, the acupuncture group received auricular acupuncture. An electrocardiographic unit was placed for recording the autonomic nervous activities. Results. The low frequency (LF)/high frequency (HF) ratio of HRV increased (P = 0.0007) in the control, but the ratio in the acupuncture did not change. There were significant differences between the ratios of the two groups at 3 : 00, 4 : 00, and 5 : 00. HF of the acupuncture group tended to be higher. HFs of the acupuncture group were significantly higher than those of the control group at 3 : 00, 4 : 00, and 5 : 00. Conclusion. Auricular acupuncture kept the LF/HF ratio at lower levels and HF at higher levels during postoperative period in the patients who had undergone hemicolectomy.

Transcutaneous Electrical Nerve Stimulation on the PC-5 and PC-6 Points Alleviated Hypotension after Epidural Anaesthesia, Depending on the Stimulus Frequency.

Neuraxial blockade causes arterial hypotension. Transcutaneous electrical nerve stimulation (TENS) at the Neiguan (PC-6) and Jianshi (PC-5) reduces the severity of hypotension after spinal anaesthesia, but did not clarify the optimal stimulus frequency. We hypothesized that the stimulus frequency of TENS at the PC-6 and PC-5 points would influence the severity of hypotension after epidural anaesthesia. 65 ASA I or II male patients presenting for inguinal hernia repair were randomized to five groups: the control group received no treatment; the 2 Hz, 10 Hz, 20 Hz, and 40 Hz groups received TENS at a frequency of 2 Hz, 10 Hz, 20 Hz, and 40 Hz, respectively. The lowest SBP was significantly higher in the 40 Hz group [the control, 84 (74-110) mmHg; the 2 Hz, 96 (62-116) mmHg; the 10 Hz, 100 (68-110) mmHg; the 20 Hz, 96 (64-115) mmHg; the 40 Hz, 104 (75-140) mmHg: P = 0.004]. Significantly less patients experienced hypotension in the 40 Hz group [the control, 78%; the 2 Hz, 43%; the 10 Hz, 38%; the 20 Hz, 38%; the 40 Hz, 8%: P = 0.008]. TENS on the PC-6 and PC-5 points reduced the severity and incidence of hypotension after epidural anaesthesia, depending on the stimulus frequency.

Endovascular repair for a descending thoracic aortic aneurysm with a stent-graft covering the celiac artery: report of two cases.

An adequate landing zone for fixation and sealing is necessary for endovascular aneurysm repair (EVAR). This report presents two cases of a successful EVAR for thoracic aortic aneurysms (TAA) with a stent-graft covering the celiac artery (CA) to secure a distal landing zone. Case 1 was a 61-year-old man with a chronic traumatic descending TAA 12 mm away from the CA. Case 2 was a 79-year-old man with a descending TAA proximal to the CA. Preoperative angiography and computed tomography (CT) scan revealed a normal visceral blood flow including the peripancreatic arteries. Endovascular aneurysm repair with coverage of the CA was performed in both cases. Angiography after the EVAR demonstrated good blood flow to the CA branches via the peripancreatic arteries and a CT scan showed thrombosed aneurysms. Both patients were discharged without any abdominal symptoms. Endovascular aneurysm repair with a stent-graft covering the CA may therefore be an acceptable endovascular approach in treating selected TAA patients with a limited distal landing zone.

Transcutaneous carbon dioxide tension for the evaluation of limb ischemia.

PURPOSE: Understanding the hemodynamics of critical limb ischemia caused by chronic peripheral arterial occlusive disease is important to evaluate its severity and the efficacy of treatment. We investigated the usefulness of transcutaneous carbon dioxide tension (tcPCO(2)) measurement for evaluating ischemic limbs, in conjunction with the measurement of ankle pressure (AP), toe pressure (TP), skin perfusion pressure (SPP), and transcutaneous oxygen tension (tcPO(2)). METHODS: We measured tcPCO(2) in the dorsum of the foot in 158 patients (304 limbs) with arteriosclerosis obliterans. RESULTS: The tcPCO(2) in normal limbs without any clinical sign or abnormal noninvasive measurement was 43.7 +/- 3.7 mmHg; that in noncritical ischemic limbs was 45.5 +/- 9.0 mmHg, which was not significantly different from that in the normal limbs; and that in critically ischemic limbs was 87.6 +/- 35.5 mmHg, which was significantly different from that in the normal limbs. All limbs with a tcPCO(2) of 100 mmHg or higher, indicative of critical ischemia, had a tcPCO(2) of less than 100 mmHg after revascularization. CONCLUSION: We found tcPCO(2) to be a useful measurement for diagnosing the severity of limb ischemia, and for evaluating the effect of treatment, especially in patients with critically ischemic limbs.

Quantitative assessment of therapeutic effects in the critically ischemic limb using (99m)Tc-diethylene-triamine-pentaacetic acid human serum albumin.

PURPOSE: To investigate the reliability and limitations of a new radioisotope method using (99m)Tc-diethylenetriamine-pentaacetic acid human serum albumin (Tc-99m-DTPA-HSA) and to evaluate the diagnostic ability of isotope infusion for assessing hemodynamic changes in the foot before and after treatment. METHODS: Hemodynamic changes before and after treatment were assessed in 21 limbs with ulcer or gangrene, by analyzing changes in the time-activity curve, the uptake ratio, and the values obtained with noninvasive techniques. RESULTS: There were significant differences between each pair of the three types of time-activity curve and their uptake counts. The uptake ratio was correlated with ankle blood pressure (ABP) and toe blood pressure (TBP), but not with transcutaneous oxygen pressure (tcPO(2)) or skin perfusion pressure (SPP). The hemodynamic change induced by pharmacotherapy was subtle, but that induced by arterial reconstruction was remarkable. Although there was not always a good correlation between the degree of hemodynamic change and the clinical outcome in limbs treated with pharmacotherapy, the hemodynamic change was quantitatively assessed. CONCLUSION: Our study suggests that this isotope technique is a useful quantitative method to evaluate hemodynamic change from a different perspective to conventional noninvasive methods.

Abdominal aortic aneurysm surgery for octogenarians.

PURPOSE: To define the indications for abdominal aortic aneurysm (AAA) surgery in octogenarians. METHODS: We reviewed septuagenarians and octogenarians with a nonspecific AAA diagnosed at our hospital between January, 1990 and June, 2006. RESULTS: Among a total 628 patients seen, 306 were in their 70s (group A) and 108 were in their 80s or older (group B). The mortality rate associated with elective surgery was 1.9% in group A and 7.0% in group B. Of the survivors, 12 (5.7%) of 210 in group A and 8 (15.1%) of 53 in group B died within 2 years. Of the patients who did not undergo surgery, 8 of 53 in group A and 8 of 31 in group B had AAAs greater than 6 cm in diameter. The rupture-free rates of AAAs greater than 6 cm in diameter were 64% at 1 year and 0% at 4 years in group A, and 88% at 1 year and 26% at 3 years in group B. The rupture-free rates of AAAs smaller than 6 cm in diameter were 95% at 3 years and 85% at 5 years in group A, and 100% at 5 years in group B. CONCLUSIONS: We concluded that AAAs over 6 cm in diameter were an appropriate indication for surgery in octogenarians.

Clinical reliability and utility of skin perfusion pressure measurement in ischemic limbs--comparison with other noninvasive diagnostic methods.

PURPOSE: We studied whether the measurement of skin perfusion pressure (SPP) is useful for evaluating ischemic limbs and predicting wound healing. METHODS: Two hundred eleven patients (age range, 45 to 90 years; mean age, 69.6 +/- 9.2 years; 170 men and 41 women), 403 limbs with arteriosclerosis obliterans, were included in this study. Half of the patients had diabetes or were receiving dialysis or both. RESULTS: Significant correlations were found between SPP and ankle blood pressure (ABP), SPP and toe blood pressure (TBP), and SPP and the transcutaneous oxygen pressure (tcPO2) (P < .0001, r = 0.75; P < .0001, r = 0.85; P < .0001, r = 0.62; respectively). In 94 limbs with ulcer or gangrene, wound healing was predicted by the SPP. The mean SPP (mean +/- SD) in the healed-wound group (25 limbs, 48 +/- 20 mm Hg) was greater than that in the unhealed-wound group (69 limbs, 23 +/- 11 mm Hg) (P <.001). According to the receiver operating characteristic (ROC) curve, the cut-off value of SPP was 40 mm Hg (sensitivity, 72%; specificity, 88%). Furthermore, we studied whether the combination of SPP and another measurement could predict wound healing more accurately than could any single variable. There was a strong correlation between SPP, TBP, and the healing rate (P < .001, r = 0.69) and healing could be accurately predicted if the SPP was greater than 40 mm Hg and if the TBP was greater than 30 mm Hg. CONCLUSIONS: Our results suggest that measurement of SPP is an objective method for assessing the severity of peripheral arterial disease or for predicting wound healing.

The Clinical Course of Buerger's Disease.

The clinical and social characteristics of 118 patients with Buerger's disease (thromboangiitis obliterans: TAO) were surveyed. The prognosis for many patients is relatively favorable. Arterial reconstruction plays a role in shortening the healing times of ischemic ulcers despite its poor long-term results. Of 118 patients, 13 underwent major lower limb amputation (11%), 33 underwent foot or toe amputation (28%), one underwent hand amputation (1%), and 12 underwent finger amputations (10%) after the onset of the disease. The progression of symptoms was surely influenced by smoking, but this was not the only deleterious factor as there were patients with stable TAO which was unaffected by their continued smoking. In 66 patients, the new occurrence of ulceration and gangrene was not observed over the age of 60. Ten of 13 patients (77%) who underwent major lower limb amputation lost their jobs, but only 7 of 105 patients without major amputation lost their jobs (7%). In all patients, the progression of symptoms was self-limited and recurrent ulcers occurred less frequently with ageing. To avoid factors that markedly influence the quality of life, early treatment and strict instructions prohibiting smoking should be conducted.

Successful treatment of an aorto-ileal-conduit fistula with an endovascular stent graft: report of a case.

A 55-year-old man presented with a massive hemorrhage from the ileal conduit of the left ureter. He had previously undergone a total pelvic exenteration with ileal conduit construction of the ureters due to rectal carcinoma. A right ureteroarterial fistula developed, and he underwent an excision of the right common iliac artery with a femorofemoral bypass and a right cutaneous ureterostomy. Seven months later, a pseudoaneurysm developed at the aortic stump, followed by an aorto-ileal-conduit fistula. The patient was treated successfully with endovascular stent grafting and has since showed a good recovery no sign of graft infection or a recurrence of hematuria at the 10-month follow-up.

Simultaneous open and endoluminal repair of ruptured abdominal and thoracic aortic aneurysms: report of a case.

A 66-year-old woman was transferred to our hospital for emergency treatment of a ruptured abdominal aortic aneurysm (AAA) and impending rupture of a descending thoracic aortic aneurysm (TAA) caused by a Stanford type-B dissection. She had severe coronary artery disease and a highly calcified aorta, and had been taking long-term steroids for rheumatoid arthritis. Endovascular repair of the TAA failed because the femoral artery was too small, so we performed simultaneous repair of the TAA and the AAA. A temporary axillofemoral bypass was constructed and the AAA was replaced with a bifurcated prosthetic graft. A thoracic stent graft was delivered successfully through a chimney graft of the abdominal graft. About 4 months later, the TAA extended proximally, causing hemoptysis, which was stopped by placing a new stent graft proximal to the previous one. This case report shows that a combination of open and endovascular repair is useful for treating a TAA with an AAA, especially in a small or frail patient.

Suppressed bone turnover by long-term bisphosphonate treatment accumulates microdamage but maintains intrinsic material properties in cortical bone of dog rib.

UNLABELLED: Effects of long-term suppression of bone remodeling by bisphosphonate were investigated in cortical bone of dog rib. Although microdamage was accumulated, BMD was increased without increasing cortical bone area. Consequently, the intrinsic material properties were not reduced. INTRODUCTION: Recently, we have reported that long-term suppression of bone remodeling increases microdamage accumulation but is not necessarily associated with vertebral fragility because of compensated increase of bone mass and improved microarchitecture. This study aimed to investigate the effect of long-term suppression of bone remodeling by bisphosphonate on the degree of mineralization, accumulation of microdamage, and mechanical properties of cortical bone in the same dogs. MATERIALS AND METHODS: Twenty-nine 1-year-old beagles (15 males, 14 females) were divided into three groups and treated daily with vehicle (CNT) or with incadronate at a dose of 0.3 (LOW) or 0.6 mg/kg/day (HIGH) orally for 3 years. After death, pQCT, histomorphometry, microdamage measurements, and three-point bending mechanical test were performed using the ninth rib. RESULTS: Cortical BMD was increased in the incadronate-treated groups. Cortical activation frequency was suppressed by 82% and 70% in HIGH and LOW, respectively, compared with CNT, without impairment of mineralization. Microdamage accumulation was increased in both incadronate-treated groups. Although there were no significant differences in total and cortical area among the three groups, structural mechanical properties were significantly increased after incadronate treatment while intrinsic material properties were not changed in the incadronate-treated groups. CONCLUSION: This study suggests that long-term suppression of bone remodeling by bisphosphonate increases microdamage accumulation. However, this was not necessarily associated with a reduction of intrinsic material properties probably because of an increased degree of mineralization.

Long-term treatment of incadronate disodium accumulates microdamage but improves the trabecular bone microarchitecture in dog vertebra.

This study aimed to investigate the effect of long-term suppression of bone resorption by bisphosphonate on the microstructure, accumulation of microdamage, and mechanical properties of trabecular bone. Twenty-nine 1-year-old beagles (15 males, 14 females) were divided into three groups. The control group (CNT) was treated daily with vehicle, and the other two groups were treated with incadronate at a dose of 0.3 mg/kg/day (LOW) or 0.6 mg/kg/day (HIGH) orally for 3 years. After death, the second thoracic vertebra was scanned with microcomputed tomography (micro-CT) and assigned to histomorphometric and microdamage measurements. The fourth lumbar vertebra was mechanically tested by compression. Incadronate concentration in bone was measured in the 11th thoracic vertebra. Micro-CT analysis demonstrated a platelike trabecular structure and increased concave surface of trabeculae in the thoracic vertebra of incadronate-treated groups. Three-year incadronate treatment significantly suppressed trabecular activation rates by 56% in LOW and 67% in HIGH without impairment of mineralization, and increased microdamage accumulation in both incadronate-treated groups. Trabecular bone volume was significantly increased in both LOW and HIGH groups, and vertebral strength was significantly increased in the HIGH group compared with the CNT group. However, intrinsic material properties such as normalized ultimate stress and normalized toughness were reduced in incadronate-treated groups. Incadronate concentration in bone was dose-dependent. This study suggests that long-term suppression of bone remodeling increases microdamage accumulation, but this is not necessarily associated with vertebral fragility because of compensated increase of bone mass and improved microarchitecture.