[Tooth Mobility Evaluation -A Comparison with Dental Assessment-].

BACKGROUND: Patients with mobile teeth are at an increased risk of tooth injury related to tracheal intu- bation. Although the presence/absence of mobile teeth is confirmed through interviews during preoperative visits, patients are frequently unaware of the presence of such teeth. In our facility, dental consultation is pro- vided for all patients undergoing thoracoscopically- assisted surgery as part of the management of oral hygiene. This study examined the presence/absence of mobile teeth reported by patients during preoperative visits and those identified on dental consultation, focus- ing on the inconsistency between them. METHODS: Patients who had undergone thoraco- scopically-assisted surgery in our facility between Janu- ary and October 2014 were retrospectively studied. Tooth mobility was evaluated using the Miller index. RESULTS: Among the 76 (46 males and 30 females) patients aged 36 to 88 (mean: 67.8), mobile teeth were identified on dental consultation in 13 and reported during preoperative visits by 8. CONCLUSIONS: Based on this findings, it may be nec- essary to pay sufficient attention when inserting tubes even when mobile teeth have not been reported by patients during preoperative visits.

[Anesthesia in a Patient with Giant Goiter in Whom Tracheotomy Was Performed with Standby of Percutaneous Cardiopulmonary Support].

In a 53-year-old female patient total thyroidectomy for a giant goiter under general anesthesia was scheduled. On talking, airway stenosis sounds were heard. Cervical to thoracic CT revealed left and right lobe tumors measuring 5.3 x 5.6 x 10.0 and 9.1 x 8.6 x 10.0 cm, respectively. The trachea showed stenosis at a site 3.8 to 6.5 cm below the glottis, and the narrowest lumen diameter was 3.1 mm. Due to marked tracheal stenosis, awake intubation was not selected. To maintain the airway, tracheotomy was performed under local anesthesia. Considering the risk of difficulty in ventilation during tracheostomy, 4 Fr catheter sheaths were inserted into the right femoral artery and vein for percutaneous cardiopulmonary support (PCPS). Subsequently, tracheotomy was conducted in an area peripheral to the site of stenosis. After tracheotomy, general anesthesia was started. During general anesthesia, there were no problems regarding ventilation. The tracheal cannula was removed 7 days after surgery, and the patient was discharged after 14 days. For general anesthesia in patients with giant goiter, it is important to select an airway management method in consideration of tumor-related compression of the trachea. Airway management by tracheotomy under local anesthesia with standby of PCPS may be a treatment option.

[General Anesthesia for the Thoracoscopic Lung Resection Surgery in 12 Very Elderly Patients above 85 Years of Age].

We investigated perioperative management and clinical outcome of 12 patients who were 85 years old or older and received video-assisted thoracic surgery under general anesthesia. Although all the patients had preoperative respiratory complications or cardiovascular complications, they were discharged without any additional respiratory assistance such as home oxygen therapy. Our observation suggests that it is important to evaluate the indication of anesthesia from their daily activities and pulmonary function test even if they are oldest-old. If the patient demonstrates good physical function, he or she should not be excluded from anesthesia.

[Perioperative Management of Emergency Operation for a Patient with Carcinoid Syndrome].

We report a case of carcinoid syndrome requiring an emergency operation for an upper gastrointestinal perforation. A 46-year-old man had undergone left lower lobectomy for a lung carcinoid tumor seven years previously, and liver metastasis was found five years previously. He developed cutaneous flushing and watery diarrhea, and was diagnosed with carcinoid syndrome one year previously. Although he was treated with octreotid, his symptoms became worse and he was admitted to our hospital. During the hospital stay, he underwent an emergency operation for an upper gastrointestinal perforation. Before the operation, hemodynamics were unstable. Anesthesia was induced with sevoflurane and propofol, and maintained with sevoflurane and remifentanil. Only vasopressin was used for the treatment of hypotension. Landiolol was used for perioperative tachyarrythmia. During anesthesia, there was no severe hypotension or hypertension. After the operation, he was managed with intubation in the ICU. Octreotid was administered again for the carcinoid syndrome. Vasopressin was necessary for the treatment of hypotension in the ICU. After improvement of hemodynamics, extubation was performed on the 3rd ICU day and he was discharged from the ICU on the 4th ICU day. In conclusion, we were able to perform good perioperative management of carcinoid syndrome accompanied by hemodynamic instability.

[Two cases of general anesthesia after recovery from ARDS].

There are few reports on general anesthesia in survivors of ARDS. Patients after recovery from ARDS are at risk for compromised pulmonary function, neuromuscular weakness and cognitive dysfunction. We report 2 cases of general anesthesia in survivors of ARDS. In Case 1, a 64-year-old man who had recovered from ARDS associated with Legionella pneumonia underwent carotid endarterectomy. In Case 2, a 69-year-old man who had recovered from ARDS associated with pneumococcal pneumonia underwent hepatectomy. Concerning the preoperative assessments, the spirometry data were almost normal but Hugh-Jones classification scale was II in both cases. Diffusion disturbance might be the cause of discrepancies between good respiratory functions and limited daily activities. In both cases, anesthesia was given with propofol, fentanyl remifentanil and sevoflurane. Peak airway pressure was maintained below 15 cmH2O with pressure control ventilation. They were extubated at the end of surgery and there were no serious complications during the perioperative period.

[ A case of general anesthesia for the removal of extra-adrenal pheochromocytoma in a patient complicated with severe hypertrophic obstructive cardiomyopathy].

We report a case of general anesthesia for the removal of pheochromocytoma in a patient complicated with severe hypertrophic obstructive cardiomyopathy. A 65-year-old woman complained of fatigability with hypertension and diabetes mellitus. She was diagnosed as an extra-adrenal peri-aortic pheochromocytoma with severe hypertrophic obstructive cardiomyopathy. The left ventricular outflow gradient (LVOG) was 199 mmHg and the serum noradrenaline level was 13,567 pg x ml(-1) (100-450). As a preoperative management, atenolol, verapamil and disopyramide were given to decrease LVOG. Then doxazosin was given to control hypertension and to increase the circulating blood volume without deteriorating the outflow tract obstruction. LVOG decreased to 50 mmHg preoperatively. Anesthesia was given with propofol, fentanyl, remifentanil and isoflurane with a continuous infusion of diltiazem. The circulating blood volume was maintained with adequate volume loading assessed by the measurement of the left ventricular end-diastolic diameter and LVOG with transesophageal echocardiography. After the removal of the tumor, continuous infusion of noradrenaline was given to maintain the blood pressure. She was extubated in the ICU. LVOG decreased to 20 mmHg with stable hemodynamics on the second postoperative day. She was discharged from the ICU without any adverse cardiac events during the perioperative period.

[Two cases of airway stent placement to treat tracheal and bronchial fistula using general anesthesia under spontaneous respiration].

Anesthesia for the tracheobronchial stent placement involves the risk of airway narrowing and obstruction. Controlled ventilation with relatively high airway pressure is usually used to maintain oxygenation and ventilation during anesthesia. However, controlled ventilation does not always provide tidal volume and oxygenation due to gas leakage from tracheobronchial fistula. We report 2 cases of general anesthesia under spontaneous respiration for the airway stent placement to treat tracheal and bronchial fistula. Case 1; A 55-year-old man with tracheoesophageal fistula due to the esophageal cancer was scheduled for the stent placement. Anesthesia was given with dexmedetomidine and sevoflurane preserving spontaneous respiration. The surgery was performed without complications of hypoventilation and hypoxemia throughout the procedure. Case 2; A 71-year-old woman developed empyema with large bronchopleural fistula as the result of the complication of radiation for the breast cancer. The stent placement was scheduled for closure of the fistula. Anesthesia was induced with remifentanil and sevoflurane with spontaneous respiration. When inserting the rigid bronchoscope, cough reflex occurred and propofol was added to deepen the anesthesia. The stent placement was performed with general anesthesia under spontaneous respiration without any complications.

Reliability of central venous pressure to assess left ventricular preload for fluid resuscitation in patients with septic shock.

BACKGROUND: Initial fluid resuscitation is an important hemodynamic therapy in patients with septic shock. The Surviving Sepsis Campaign Guidelines recommend fluid resuscitation with volume loading according to central venous pressure (CVP). However, patients with septic shock often develop a transient decrease in cardiac function; thus, it may be inappropriate to use CVP as a reliable marker for fluid management. METHODS: We evaluated 40 adult patients with septic shock secondary to intra-abdominal infection who received active treatment and were monitored using transthoracic echocardiography (TTE) and CVP for 2 days after admission to our intensive care unit (ICU). We measured left ventricular end-diastolic diameter (LVEDD), left atrial diameter (LAD), and the pressure gradient of tricuspid regurgitation (TR∆P). The shock status was treated with volume loading and inotrope/vasopressor administration according to the TTE findings. We assessed left ventricular fractional shortening (LVFS) as an index of left ventricular contractility and TR∆P as an index of right ventricular afterload and then examined the correlation between CVP and LVEDD/LAD/TR∆P. RESULTS: LVFS decreased to ≤30% in 42.5% and 27.5% of patients with septic shock, and severe left ventricular dysfunction with LVFS ≤20% developed in 12.5% and 15.0% of patients on the first and second ICU days, respectively, despite the use of inotropes/vasopressors. Mild pulmonary hypertension as indicated by TR∆P ≥30 mmHg was present in 27.5% and 30.0% of patients on their first and second ICU days, respectively. There was no significant correlation between CVP and LVEDD/LAD/TR∆P. The hospital mortality rate in this study was 10.0%, although the predicted mortality based on the Acute Physiology and Chronic Health Evaluation II score was 58.7%. CONCLUSIONS: Our results suggest that CVP is not a reliable marker of left ventricular preload for fluid management during the initial phase of septic shock. Assessment of left ventricular preload, right ventricular overload, and left ventricular contractility using TTE seems to be more informative than the measurement of CVP for fluid resuscitation since some patients developed left ventricular dysfunction and/or right ventricular overload.