Sudden cardiac arrest immediately after aortic cross clamping during abdominal aortic aneurysm repair.

We report a case of sudden cardiac arrest immediately after aortic cross clamping during surgery for infrarenal abdominal aortic aneurysm in a patient with coronary artery disease. The cause, treatment, and necessary monitoring for the case are discussed.

Assessment of reflection pulse wave in patients with cardiomyopathy: evaluation of noninvasive measurement of wave intensity.

OBJECTIVE: We assessed the reflection pressure wave using noninvasive measurement of wave intensity (WI) in patients with cardiomyopathy. METHODS AND RESULTS: Subjects included 8 patients with hypertrophic cardiomyopathy (HCM group) and 10 patients with dilated cardiomyopathy (DCM group). Twelve healthy subjects were used as a control group. By using a combined Doppler and echo-tracking system, changes in vascular diameter (dD) and blood flow velocity (dV) were recorded simultaneously at the common carotid artery and dD x dV was measured as WI. In the components of WI, the positive component of early systolic phase (FE) and the negative component following FE (B) were significantly reduced in the DCM group. There was a significant positive correlation between FE and B in all 3 groups. The appearance time of B was significantly shorter in the HCM group and significantly longer in the DCM group compared with the control group. CONCLUSIONS: It was suggested that the value of the reflection pressure wave was influenced by the left ventricular contractility, and that the effect of the reflection pressure wave appeared earlier in patients with HCM and later in patients with DCM compared with the control subjects.

[A case of sarcoidosis with muscle nodules].

A 65-year-old man with sarcoidosis, accompanied by muscle nodules, noticed a painless and enlarged nodule in his forearm. MRI of the nodule showed that a star-shaped area of lower signal intensity was surrounded by an area of higher signal intensity. Histological examination showed granulomas composed of multinuclear giant cells and epithelioid cells. Sarcoidosis was diagnosed. Eight months later, he was admitted to our hospital because of enlargement of the nodular region with pain and stiffness. Marked uptake of 67Ga was observed in the right arm and leg. MRI revealed sarcoid nodules in these regions. An enlargement of the higher signal intensity area was observed in the right forearm nodule. We started administration of prednisolone. Forty days later, his symptoms had disappeared and the size of higher signal intensity area of the nodule had reduced dramatically. 67Ga scintigram and MRI were useful for diagnosis and monitoring during therapy in this patient.

Role of positive airway pressure on pulmonary acinar perfusion heterogeneity.

Perfusion of the pulmonary acinus has been shown to be generally homogeneous, but there is a significant component that is heterogeneous. To investigate the contribution of the alveolar septal capillary network to acinar perfusion heterogeneity, the passage of fluorescent dye boluses through the subpleural microcirculation of isolated dog lung lobes was videotaped using fluorescence microscopy. As the videotapes were replayed, dye-dilution curves were recorded from each of the tributary branches of Y-shaped venules that drained single acini. For each Y-shaped venule, the mean appearance time difference between the pair of tributary branches was calculated from the dye curves. When the complex septal capillary networks were derecruited by high positive airway pressure, venular perfusion became proportionally more homogeneous. This result shows that septal capillary resistance and pathlength differences are important contributors to intra-acinar perfusion heterogeneity.

Efficacy of primary percutaneous transluminal coronary angioplasty for acute myocardial infarction in patients aged > or = 80 years.

The therapeutic result of primary percutaneous transluminal coronary angioplasty (PTCA) in the elderly was assessed in 20 of 44 patients > or = 80 years old (range 81-92 years, mean age 84 +/- 3 years) with acute myocardial infarction who underwent primary PTCA and the results compared with 194 younger patients (< 80 years) who underwent primary PTCA during the same period. In-hospital prognosis, and long-term outcomes were investigated. Emergency coronary angiography was performed in 47.7% of the patients with acute myocardial infarction in the elderly group with 45.5% receiving primary PTCA. Primary PTCA was successful in 95.0% of the elderly group, showing no significant difference from the younger group. In-hospital mortality showed no significant difference between the elderly group and the younger group (5.0% vs 4.1%). However, the incidences of pump failure of the heart and bleeding complication requiring blood transfusion were higher in the elderly group during hospitalization. The 2-year survival rate for the elderly group was 82.5 +/- 9.3%, which was better than previous studies. These results suggest that primary PTCA has a good success rate in the elderly patients with acute myocardial infarction, and decreases the in-hospital mortality and improves the long-term outcome. However, this study was conducted retrospectively in a small group of patients. The efficacy of primary PTCA for the elderly remains to be clarified in a larger prospective trial.

Preoperative anxiety is associated with a high incidence of problematic behavior on emergence after halothane anesthesia in boys.

BACKGROUND: In our clinical experience, children who are crying before anesthesia are more likely to show agitated behavior on emergence. METHODS: One hundred and ten boys aged 3-6 years old (ASA 1) who underwent circumcision were studied. The children were assigned to one of two groups, depending on their attitude during induction: the anxious group and the calm group. Anesthesia was induced by inhalation of halothane in oxygen, and was maintained at 1% throughout surgery. For intra- and postoperative analgesia, caudal block with 0.5 ml/kg of 0.25% plain bupivacaine and topical infiltration with 1 to 2 ml of 1% lidocaine were provided for all patients. The incidence of delirium on emergence was compared between the groups. RESULTS: We excluded 4 boys showing signs of incomplete pain relief. Twenty of 27 boys in the anxious group showed a significantly greater incidence of problematic behavior on emergence, compared to 5 of 79 in the calm group. CONCLUSION: The boys who were anxious before anesthesia showed a significantly greater incidence of problematic behavior on emergence from halothane anesthesia, compared with the boys who were calm before anesthesia.

Complete atrioventricular block during anesthesia.

PURPOSE: To describe a case of asymptomatic first degree atrioventricular block with a bifascicular block that progressed to complete atrioventricular block during anesthesia. This potentially fatal block was successfully treated with transesophageal ventricular pacing. CLINICAL FEATURES: A 67-yr-old man was scheduled for microvascular decompression of the right trigeminal nerve under general anesthesia. His preoperative ECG showed first degree atrioventricular block with complete right bundle branch block and left anterior hemiblock, but he had experienced no cardiovascular symptoms. Anesthesia was induced with sevoflurane 5%, and maintained with isoflurane 1.5-2% in oxygen. Fifteen minutes later in the left lateral decubitus position, the systolic arterial blood pressure suddenly decreased from 80 mmHg to 0 mmHg. Then, the ECG abruptly changed from sinus rhythm to complete atrioventricular block. The heart was unresponsive to drug therapy such as atropine 1.3 mg and isoproterenol 0.5 mg, or transcutaneous pacing but transesophageal pacing was successful. CONCLUSION: Asymptomatic first degree atrioventricular block with bifascicular block advanced to complete atrioventricular block during anesthesia. The block was successfully managed with transesophageal pacing.

Heart failure in 3 patients with acromegaly: echocardiographic assessment.

We evaluated 3 patients with acromegaly who developed heart failure. Heart failure appeared to be due to acromegalic cardiomyopathy in 2 patients who did not have hypertension or evidence of coronary artery disease, and it was possibly due to acromegalic cardiomyopathy combined with familiar hypertrophic cardiomyopathy in 1 patient. The common echocardiographic findings in the present three cases were: 1) enlargement of the left atrium, 2) markedly dilated left ventricular cavity with diffuse hypokinesis, 3) decrease of indices of the left ventricular systolic function, and 4) no evidence of left ventricular hypertrophy. Echocardiographic findings in acromegaly with congestive heart failure resemble those of idiopathic dilated cardiomyopathy.

Blood pressure control during eye surgery under local anesthesia using pulse oximetry.

We measured the arterial blood pressure and percutaneous O2 saturation (SpO2) in 39 elderly patients (age range, 70-89 years) who underwent cataract surgery under local anesthesia. Nineteen patients showed a 20% or greater increase in the systolic arterial pressure (SAP) measured every minute in the operating room compared to the basal value measured in the ward. We treated elevation of the SAP by intravenous bolus injection of 0.25 mg nitroglycerin (NTG), followed by continuous infusion at 0.1-0.3 microg/kg/min. NTG caused a statistically significant but clinically irrelevant decrease in SpO2 in the patients breathing room air. Two of these patients showed extremely decreased SpO2. Our results suggest that NTG does not typically cause a severe decrease in oxygenation. It might be advisable, however, for patients with severe lung dysfunction or ischemic heart disease to receive prophylactic O2 administration.

Acute myocardial infarction induced by alternating exposure to heat in a sauna and rapid cooling in cold water.

We describe a patient with acute myocardial infarction, which was thought to result from plaque rupture or thrombosis because of coronary artery spasm. The vasospasm was most likely induced by stimulation of the alpha-adrenergic receptors during alternating heat exposure during sauna bathing and rapid cooling during cold water bathing. This report emphasizes the dangers of rapid cooling after sauna bathing in patients with coronary risk factors.

[Outcomes of primary angioplasty in patients aged 85 years old and older who have acute myocardial infarction].

Outcomes of primary angioplasty in 6 elderly patients with acute myocardial infarction who were admitted to the hospital between July of 1994 and June of 1997 were reviewed retrospectively. Emergency coronary angiography was done in 7 of 16 patients (44%) who were at least 85 years old and primary angioplasty was done in 6 patients (38%). Dilatation was successful in all 6 patients. Congestive heart failure occurred in 4 patients and cardiogenic shock occurred in 1 patient, but no patient died during hospitalization. Blood transfusion and surgical resection were done in 1 patient because of a giant hematoma and pseudoaneurysm at the puncture site. Although the creatinine level increased after angioplasty in all 6 patients, dialysis therapy was not needed. All patients were alive and none had angina at follow-up (mean follow-up period = 16.5 months). Primary angioplasty was successful in patients at least 85 years old; both short-term and long-term outcomes were good. Primary angioplasty should be considered to be an effective treatment for acute myocardial infarction in people 85 years old and older.

Differences in hormonal responses to preoperative emotional stress between preschool and school children.

BACKGROUND: The behavior of children under emotional stress differs according to whether they are of preschool or school age. METHODS: To examine the effect of age on hormonal responses to preoperative emotional stress, we measured the concentrations of catecholamines (adrenaline and noradrenaline) and cortisol in 56 healthy boys before surgery. RESULTS: Among preschool boys (3-5 years old), those showing anxious behavior showed significantly higher cortisol, adrenaline, and noradrenaline concentrations in the blood circulation than those not showing such behavior (P < 0.0001, P < 0.0001 and P < 0.005, respectively). However, among the schoolboys (6-11 years old), anxiety was associated only with the cortisol concentration (P < 0.01). CONCLUSION: Hormonal responses to preoperative emotional stress in preschool boys differ from those in schoolboys.

Greater incidence of delirium during recovery from sevoflurane anesthesia in preschool boys.

BACKGROUND: In the authors' clinical experience, preschool children are more likely to show delirium after sevoflurane than are older children. METHODS: Sixty-three preschool boys aged 3-5 yr (classified as American Society of Anesthesiologists [ASA] physical status I), and 53 school-age boys aged 6-10 yr (ASA physical status I) who underwent minor urologic surgery were randomly assigned to receive either halothane or sevoflurane, thus creating four groups: preschool-halothane (n = 32), preschool-sevoflurane (n = 31), school-halothane (n = 27), and school-sevoflurane (n = 26). Anesthesia was induced by inhalation of halothane or sevoflurane in oxygen and was maintained at 1 minimum alveolar concentration of each agent throughout surgery. For intra- and postoperative analgesia, caudal block with 0.5-1.0 ml/kg 0.25% plain bupivacaine and topical infiltration with 3-5 ml 1% lidocaine were provided for all patients. Recovery characteristics and incidence of delirium on emergence were compared among the four groups. RESULTS: Two patients in the preschool-halothane group, one in the preschool-sevoflurane group, and one in the school-halothane group were excluded from the comparison because of insufficient analgesia or agitation before induction. In both age groups, the time to emergence from sevoflurane was significantly faster (about 3 min) than from halothane. The incidence of delirium during recovery in the preschool-sevoflurane group (40%) was significantly greater than that in the other groups (preschool-halothane, 10%; school-halothane, 15.4%; school-sevoflurane, 11.5%). CONCLUSION: Sevoflurane provided quicker emergence and early recovery compared with halothane, but the incidence of delirium was greater in preschool boys after sevoflurane.

Ephedrine-induced increases in arterial blood pressure accelerate regression of epidural block.

We investigated the hypothesis that ephedrine-induced increases in blood pressure accelerate the regression of epidural block. In patients undergoing minor gynecologic surgery, we performed lumbar epidural blockade using 2% lidocaine containing 1:200,000 epinephrine to which was added 0.1 mg of fentanyl. Eighty minutes after the epidural injection, we started an ephedrine infusion to increase the systolic blood pressure by 20% in 10 min and maintained the value for the following 20 min. Then we compared the proximal extent of sensory analgesia at 80 min with that at 140 min. Ephedrine significantly (P = 0.001) hastened the regression of sensory analgesia. We conclude that an ephedrine-induced blood pressure increase accelerates regression of epidural blockade.

[Effect of dopamine administration on ICG-disappearance rate during prone position anesthesia].

We evaluated the effect of dopamine administration (3 micrograms.kg-1.min-1) on ICG-disappearance rate during prone position in 10 patients undergoing elective spinal cord surgery. Anesthesia was maintained with isoflurane and 50% nitrous oxide in oxygen. ICG-disappearance rate was determined at 3 points, i.e., the day before surgery, during prone position and during the administration of dopamine. Systolic arterial pressure showed no significant difference before and during dopamine administration. ICG-disappearance rate during prone position was significantly lower than the preoperative value. However, ICG-disappearance rate showed no significant difference during dopamine administration and preoperative period. We conclude that dopamine administration may attenuate the depressant effect of the prone position on the hepatic blood flow.

[ICG-disappearance rate during sevoflurane- or neurolept anesthesia].

We evaluated the effect of sevoflurane or neuroleptanesthesia on ICG-disappearance rate in 22 patients undergoing elective extra-abdominal surgery. We divided the patients into three groups, i.e., SN-group (n = 8), SH-group (n = 8) and NLA-group (n = 6). Systolic arterial pressure (SAP) in the patients of SN-group or SH-group was maintained with sevoflurane at about 100% or 70% of the preoperative value respectively. There was no significant difference in SAP between SN-group and NLA-group. In SN-group and NLA-group, there was no significant difference in the ICG-disappearance rate between the values during anesthesia and those during preoperative period. In SH-group, however, it was significantly lower than the preoperative value. We conclude that, when normal systolic arterial pressure can be maintained, sevoflurane or neuroleptanesthesia has little effect on the liver function and hepatic blood flow. Sevoflurane anesthesia with 70% of preoperative SAP, however, may depress the liver function and hepatic blood flow.