Independent lung ventilation combined with HFOV for a patient suffering from tracheo-gastric roll fistula.

This case report describes the difficult respiratory management of an esophageal cancer patient with acute respiratory distress syndrome (ARDS) and systemic inflammatory response syndrome (SIRS) caused by a postoperative tracheogastric roll fistula. A single-lumen tracheal tube could not seal the fistula, and therefore a double-lumen tracheal tube (DLT) for the left side was used. Although the proximal cuff of the DLT failed to seal the fistula, independent lung ventilation (ILV) improved blood gas levels. During right thoracotomy, the left lung was ventilated conventionally with 5 cmH2O positive end-expiratory pressure (PEEP), and in addition, high-frequency oscillation ventilation (HFOV) to the right lung was employed. This combination allowed the maintenance of adequate oxygenation, and the HFOV to the right lung decreased the PaCO2 level during surgery without interruption of the surgical field. These techniques provided the opportunity to successfully remove a necrotic gastric roll and achieve closure of the fistula using an intercostal muscle flap. This report documents and discusses the difficulty of performing appropriate anesthetic management of a patient with these complex complications after esophageal surgery.

The degree of newly emerging mitral regurgitation during off-pump coronary artery bypass is predicted by preoperative left ventricular function.

PURPOSE: During off-pump coronary artery bypass (OPCAB), the displacement of the heart causes mitral regurgitation. We hypothesized that patients with impaired left ventricle (LV) function would be more prone to develop mitral regurgitation, due to further LV end-diastolic pressure elevation and mitral annulus distortion. Therefore, in this study, we examined the relationship between LV function and the severity of mitral regurgitation. METHODS: We studied 41 patients undergoing elective OPCAB. LV function was evaluated by LV ejection fraction (LVEF), serum brain natriuretic peptide (BNP) levels, the Tei index (myocardial performance index) and mitral inflow propagation velocity (Vp). RESULTS: Among all of the anastomoses performed mitral regurgitation was most severe during anastomosis of the left circumflex artery (LCX) territory (P < 0.001). Twenty-five patients (61%) had no to mild mitral regurgitation during anastomosis of the LCX territory (M-MR group) and 16 patients (39%) had moderate to severe mitral regurgitation during anastomosis of the LCX territory (S-MR group). There were significant differences between these groups in preoperative serum BNP levels (median, 26 pg.ml(-1) interquartile range [IQR, 14 to 75 pg.ml(-1)] versus median, 173 pg.ml(-1) [IQR, 91 to 296 pg.ml(-1)]; P < 0.001), Tei index values (median, 0.35; [IQR, 0.27 to 0.41] versus median, 0.53 [IQR, 0.47 to 0.57]; P < 0.001), and Vp (median, 63 cm.s(-1); [IQR, 57 to 72 cm.s(-1)] versus median, 47 cm.s(-1); [IQR, 40 to 57 cm.c(-1)]; P = 0.008), while there was no significant difference in LVEF between the patients in the M-MR group and those in the S-MR group. CONCLUSION: Preoperative LV dysfunction is a predictor of severe mitral regurgitation during OPCAB. When poor LV function is suggested, it is necessary to be prepared for further hemodynamic deterioration caused by mitral regurgitation.