Abnormal stenosis of a drainage cannula due to excessive negative pressure during venovenous extracorporeal membrane oxygenation management: a case report.

We report a case in which excessive negative pressure may have been applied to the proximal side hole of a drainage cannula during venovenous extracorporeal membrane oxygenation (V-V ECMO), resulting in abnormal stenosis of the drainage cannula. V-V ECMO was introduced in a 71-year-old male patient who was transferred from another hospital for severe respiratory failure associated with varicella pneumonia and acute respiratory distress syndrome. Drainage was performed using a PCKC-V™ 24Fr (MERA, Japan) cannula via the right femoral vein with the tip of the cannula near the level of the diaphragm under fluoroscopy. Reinfusion was performed via the right internal jugular vein. Due to poor systemic oxygenation, the drainage cannula was withdrawn caudally and refixed to reduce the effect of recirculation. Two days later, drainage pressure dropped rapidly, and frequent ECMO flow interruption occurred due to poor drainage. An abdominal X-ray revealed abnormal stenosis of the proximal side hole site of the drainage cannula. We diagnosed that the drainage cannula was damaged, and it was replaced with another, namely a Medtronic Bio-Medicus™ 25 Fr (GETINGE, Sweden) cannula. However, the removed drainage cannula was not damaged, suggesting that the cannula was temporarily stenosed by momentary excessive negative pressure. In a multi-stage drainage cannula, the main drainage site is the proximal side hole, with little negative pressure applied at the apical foramen in a mock experimental ex vivo drainage test in a water tank. Hence, improvement of a multi-stage drainage cannula is recommended, such as adequate reinforcement of the side hole site with a wire.

Retrospective study of predictive factors for postoperative complications of hepatectomies lasting 12 or more hours.

OBJECTIVES: Hepatectomy is used to treat several liver diseases, although perioperative mortality and postoperative complication rates remain high. Given the lack of relevant studies to date, the present study aimed to investigate potential predictive factors for postoperative complications in patients undergoing hepatectomies lasting 12 or more hours (termed "extremely long hepatectomies"). METHODS: Adult patients undergoing treatment in the intensive care unit (ICU) after extremely long hepatectomies at Fujita Health University Hospital between 2014 and 2017 were enrolled in the study. Postoperative complications were classified as "major complications" and "non-major complications" according to the Clavien-Dindo Classification grading system. We also divided our study population into "simple hepatectomy" and "non-simple hepatectomy" subgroups for further analysis. Statistical analyses were performed using the Mann-Whitney U test, chi-squared test, and multiple logistic regression analysis. RESULTS: In total, 114 patients (Major Complications Group, n=44; Non-Major Complications Group, n=70) were enrolled. In the Simple Hepatectomy Group, there were no significant variables. In the Non-Simple Hepatectomy Group, female sex (odds ratio [OR], 13.4; 95% confidence interval [CI], 1.00-1.81×102; p=0.04) and lactate levels at ICU admission (OR, 1.6; 95% CI, 0.99-2.59; p=0.05) were independent factors associated with major postoperative complications. CONCLUSIONS: In the Simple Hepatectomy Group, there were no significant variables. In the Non-Simple Hepatectomy Group, female sex and lactate levels at ICU admission of patients who underwent extremely long hepatectomies may be independent factors associated with major postoperative complications.

A devised strategy for tracheal extubation for predicted difficult airway in a child with unilateral vocal cord paralysis: a case report.

BACKGROUND: Extubation is a more challenging medical practice than intubation, and countermeasures against it are similar to those described in the Difficult Intubation Guidelines, but problems cannot be overcome by completely the same methods. We predicted difficult extubation in a pediatric patient with left recurrent laryngeal nerve paralysis and devised an extubation method. CASE PRESENTATION: The patient was a 2-year-and-8-month-old boy scheduled for cleft palate repair. Concomitant cardiac anomaly and first and second branchial arch syndrome-associated facial malformations, such as mandibular micrognathia and auricular malformation, were observed. He had a past medical history of difficult intubation and respiratory arrest on a catheter test under intravenous sedation at 4 months old. Left recurrent laryngeal nerve paralysis was discovered on preoperative examination of the cleft palate, based on which difficulty in postoperative extubation was predicted. A catheter for tracheal tube exchange proposed by the extubation guidelines of the Difficult Airway Society (DAS) was placed, endoscopic examination was performed while inducing spontaneous breathing and swallowing reflex by an otolaryngologist, and the tube was removed while movement of the tissue around the glottis was visually evaluated. The patient was managed in an ICU after extubation, and both the systemic and respiratory conditions were favorable. CONCLUSIONS: Extubation and airway management could be safely performed by devising extubation while conforming to the DAS guidelines.