Respiratory Complications Between Cuffed and Uncuffed Endotracheal Tubes in Pediatric Respiratory Management After Palatoplasty: Single-Center Retrospective Cohort Study.

We aimed to examine the associations between use of cuffed or uncuffed endotracheal tubes (ETTs) and complications during and after short-term intubation of post-palatoplasty patients without intrinsic lung disease. DESIGN: Retrospective cohort study. SETTING: Operating room and PICU. PATIENTS: Children without intrinsic lung disease who had undergone palatoplasty at a single institution. Inclusion criteria: intubation using ETTs with an internal diameter of 3.5 mm and postoperative management in the PICU. Exclusion criteria: 1) patients for whom ETTs with internal diameters other than 3.5 mm were used, 2) patients who had already been extubated in the operating room, and 3) patients who had a tracheostomy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-seven patients were screened for eligibility; 71 met the inclusion criteria. Of the 71 patients, 41 (58%) with polyurethane-cuffed ETTs (PUC-ETTs) and 30 (42%) with uncuffed ETTs were enrolled. We failed to identify an association between type of PUC-ETT and the development of atelectasis (odds ratio [OR], 1.06; 95% CI, 0.35-3.20; p = 1.00). Similarly, we failed to identify an association between type of PUC-ETT and development of stridor (OR, 1.58; 95% CI, 0.43-5.81; p = 0.715) or hoarseness after extubation (OR, 7.03; 95% CI, 0.83-59.6; p = 0.10). At extubation, air leak pressure was higher in the PUC-ETT group than in the uncuffed ETT group (p < 0.001), a finding which was not evident at intubation. The number of patients who received IV dexamethasone and the cases of inhaled racemic epinephrine were not statistically significant. CONCLUSIONS: In this select population of post-palatoplasty infants without intrinsic lung disease, we failed to identify any association between type of ETT (cuffed or uncuffed) and greater odds of developing respiratory complications. Taken together with the 95% CI of the effect size, our data indicate continued uncertainty about type of ETT that should be used for short-term intubation.

Differential effects of sevoflurane and propofol on an electroretinogram and visual evoked potentials.

The purpose of this study was to simultaneously evaluate the effects of sevoflurane and propofol on an electroretinogram (ERG) and visual evoked potentials (VEPs). Twenty-four patients scheduled for elective surgery under general anesthesia were allocated randomly to receive either sevoflurane (group S) or propofol (group P). An ERG and VEPs were recorded in an awake state and during anesthesia with three different minimum alveolar concentrations (MAC; 0.5, 1.0, and 1.5) of sevoflurane in group S or with three different effect-site concentrations (Ce) of 2, 3, and 4 µg/ml by using a target-controlled infusion technique in group P. Sevoflurane and propofol had little effect on amplitudes of the ERG b-wave. Sevoflurane significantly attenuated the amplitudes of VEP N75-P100 at 0.5, 1.0, and 1.5 MAC. Propofol did not significantly decrease the amplitude of VEPs at Ce of 2 or 3 µg/ml but significantly decreased it at Ce of 4 µg/ml. In summary, propofol and sevoflurane at clinical concentrations had little effect on the amplitude of an ERG. Sevoflurane attenuated the amplitudes of VEPs even at low concentrations. Propofol also attenuated the amplitudes of VEPs to a lesser extent compared to sevoflurane.

A case of thrombolytic therapy with recombinant tissue plasminogen activator for mechanical valve thrombosis at 9 weeks of pregnancy in a Japanese woman.

A 29-year-old woman was admitted to our hospital due to diagnosis of pregnancy at 5 weeks and a day. She underwent valve replacement with mechanical heart valve (MHV: SJM valve) for congenital mitral valve regurgitation, when 11 years old. Warfarin 4 mg was used for anticoagulation. After admission, warfarin was replaced by unfractionated heparin (UFH). She developed exertional dyspnea at 8 weeks of pregnancy. Echocardiogram and fluoroscopy showed an immobile leaflet in the closed position. She was diagnosed with mechanical valve thrombosis. Cardiac surgery or thrombolytic therapy (TT) were treatment options. TT is not established, but is reported to be safer than cardiac surgery. Recently, low-dose, slow infusion of recombinant tissue plasminogen activator (rt-PA) therapy showed acceptable results. About 2.5 h after an intravenous injection of rt-PA, diastolic rumble improved to the normal range of leaflet. Thereafter, warfarin was restarted and there was no recurrence of symptoms and no abortion. She was readmitted for the scheduled Caesarean section (CS) at 32 weeks of pregnancy, and warfarin was replaced with UFH. At 34 weeks of pregnancy, a baby was delivered by CS. She suffered hemostasis after surgery under the anticoagulation. Postoperative day 31, both mother and a child were healthy and left the hospital. .

Transcranial motor-evoked potentials of laryngeal muscles for intraoperative neuromonitoring of the vagus nerve during thyroid surgery.

PURPOSE: The aim of this study was to elucidate normative features of vagal motor-evoked potentials (MEPs) induced by transcranial electrical stimulation (TES) and to determine the influence of functional decline of the recurrent laryngeal nerve (RLN) on vagal MEPs during thyroid surgery. METHODS: A total of 54 patients undergoing elective thyroid surgery under general anesthesia were enrolled in this study. Vagal MEPs induced by TES were measured from the vocal cord using one of two types of electrodes (wire type or wide and flat type) mounted on an endotracheal tube. We investigated the effects of stimulation intensity and train pulse number on vagal MEP amplitude, the time course of vagal MEP amplitude during surgery, and the effects of functional decline of the RLN on vagal MEPs. RESULTS: The success rate of vagal MEP monitoring with wide- and flat-type electrodes was significantly higher than that with wire-type electrodes. Reliable vagal MEPs were obtained at a stimulation intensity of approximately 300 V with 3 or more pulses in 91% of the patients without preoperative RLN palsy (RLNP), and the amplitude was augmented with increasing stimulation intensity and train pulse number. Vagal MEP amplitude decreased during thyroid surgery and then partially recovered at the end of surgery. Vagal MEP amplitude recorded from the electrode ipsilateral to preoperative RLNP was significantly lower than that on the contralateral intact side. CONCLUSION: Vagal MEPs induced by TES can be obtained with a high success rate during thyroid surgery and would reflect functional status of the RLN.

Airway obstruction due to a laryngeal polyp following insertion of a laryngeal mask airway.

BACKGROUND: Laryngeal mask airway (LMA) insertion contributes to airway protection in patients with a laryngeal tumor around the glottis. There has been no report of LMA insertion itself exacerbating airway obstruction in such patients. CASE PRESENTATION: A 62-year-old male underwent elective surgical resection of a large laryngeal polyp. The polyp was attached to the right vocal fold and synchronously swung inward into the trachea and outward to the larynx with inspiration and expiration, respectively. Although manual positive pressure ventilation was easily achieved without any airway obstruction after anesthetic induction, the airway was completely obstructed by the polyp lodged between the vocal cords immediately after LMA insertion. Soon after removal of the LMA, patency of the airway was dramatically improved. CONCLUSION: Our experience indicates that we should pay attention to airway obstruction due to lodging of the polyp between the vocal cords after LMA insertion in patients with a laryngeal polyp.

Difficult Management of a Double-Lumen Endotracheal Tube and Difficult Ventilation during Robotic Thymectomy with Carbon Dioxide Insufflation.

Robotic surgery with carbon dioxide (CO2) insufflation to the thorax is frequently performed to gain a better operative field of view, although its intraoperative complications have not yet been discussed in detail. We treated two patients with difficult ventilation caused by distal migration of a double-lumen endotracheal tube (DLT) during robotic thymectomy. In the first case, migration of the DLT during one-lung ventilation (OLV) occurred after CO2 insufflation to the bilateral thoraxes was started. Oxygenation rapidly deteriorated because dependent lung expansion was restricted by CO2 insufflation. In the second case, migration of the DLT during OLV occurred while CO2 insufflation to a unilateral thorax and mediastinum was performed. In both cases, once migration of the DLT during OLV occurred with CO2 insufflation, readjusting the DLT became very difficult because our manipulation of bronchofiberscopy was prevented by the robot arms located above the patient's head and because deformation of the trachea/bronchus induced by CO2 insufflation caused a poor image of the bronchofiberscopic view. Thus, during robotic-assisted thoracoscopic surgery with CO2 insufflation, since there is a potential risk of difficult ventilation with a DLT and since readjustment of the DLT is very difficult, discontinuing CO2 insufflation and switching to double-lung ventilation are needed in such a situation.

A case of sudden onset of thyroid storm just before cesarean section manifesting congestive heart failure and pulmonary edema.

BACKGROUND: Since acute respiratory failure (ARF) is a life-threatening complication, particularly in the gestational period, differential diagnosis and rapid treatment are required. Among the various causes of sudden onset of ARF, thyroid storm is a rare cause in a parturient complicated with well-controlled hyperthyroidism. In this case report, we describe a parturient with hyperthyroidism in whom a thyroid storm manifesting congestive heart failure and pulmonary edema developed just before an emergency ceasarean section, even though hyperthyroidism was well-controlled with antithyroid drugs. CASE PRESENTATION: A 36-year-old pregnant woman was diagnosed as having clinical chorioamnionitis, and an emergency cesarean section was performed at 25 weeks of pregnancy. She had a complication of hyperthyroidism accompanied by mild mitral regurgitation, and she had been treated with methimazole. She was treated with ritodrine and MgSO4 for the threat of premature delivery. At the preoperative consultation, her percutaneous oxygen saturation (SpO2) was 98% on room air. When she was admitted to the operating room, her heart rate and blood pressure were 130 beats/min and 196/78 mmHg, respectively. SpO2 was 88% on room air without any symptoms; however, just after starting oxygen administration via a facemask, she complained of severe respiratory distress and became agitated. Partial pressure of arterial oxygen was 108 mmHg with an inspiratory oxygen fraction of 1.0. Chest radiography revealed pulmonary congestion, and transesophageal echocardiography revealed normal right ventricular function without an embolus and severe mitral regurgitation with preserved left ventricular function. Contrast-enhanced computed tomography after the operation revealed no pulmonary embolus but revealed a pulmonary effusion, and free triiodothyronine level was increased at the onset of dyspnea. Therefore, we diagnosed the causes of sudden onset of dyspnea as pulmonary edema and congestive heart failure induced by a thyroid storm. CONCLUSION: Sudden onset of a thyroid storm just before a cesarean section occurred in a patient with several risk factors of thyroid storm and pulmonary edema, including pregnancy, treatment with tocolytic agents, and infection. The involvement of these multiple factors was considered to be the cause of the sudden onset of the thyroid storm and the cause of rapidly progressive pulmonary edema.

[Postintubation Tracheal Stenosis in a Lightly Sedated Patient under a 10-day-long Mechanical Ventilation].

We report a case of severe laryngeal edema devel- oped after the trachea intubation for 10 days. A 78- year-old woman presented with pulmonary edema due to fluid administration for acute pancreatitis. Endotra- cheal intubation and mechanical ventilation therapy were required for 10 days. The cuff pressures and endotracheal tube positions were routinely checked. A light level of sedation was maintained during mechani- cal ventilation. Ten days later, her trachea was extu- bated. One hour after extubation, she was observed to have inspiratory stridor and she complained of respira- tory distress. Fiberoptic examination revealed laryngeal edema and ulceration of the tracheal mucosa, consis- tent with the lesion where the endotracheal tube cuff had been attached. To maintain the airway, re-intuba- tion and elective tracheostomy were performed. Light sedation during mechanical ventilation may predispose the patient to tracheal injury.

[Anesthetic management of bilateral PA banding in seven patients with HLHS].

Regarding the established phased operation for hypoplastic left heart syndrome (HLHS), the recent increase in cases involving Fontan operation has led to concomitant problems that seem to be caused by invasive open-heart surgery during the newborn period. In the new method to overcome this situation, one starts with the non-open-heart pulmonic artery banding (bil. PAB) during the newborn period, followed by the Norwood-Glenn operation, and finally with the Fontan operation. This is a report on seven cases treated with the pulmonic artery banding on HLHS at the Nagano Children's Hospital, in which we were personally involved as anesthesiologists.

[Anesthetic management for PDA in two patients with HLHS stent after bilateral PA banding].

Hypoplastic left heart syndrome (HLHS) is one of the most serious conditions among congenital cardiac disorders. In the course of the newly developed phased operation, we experienced some cases in which adverse side effects developed due to PGE1 preparation. I gave anesthesia in two cases that had to be treated with PDA stenting because of the above mentioned side effects.

Anaesthetic management of a patient with the intracardiac extension of Wilms' tumour.

Summary Wilms' tumour (nephroblastoma) is known to invade the inferior vena cava and extend to the intracardiac chambers. We describe the treatment and surgical removal of the intracardiac extension of a Wilms' tumour using cardiopulmonary bypass in a 4-year-old girl. Techniques to avoid paradoxical embolism in the presence of a patent foramen ovale and to deal with excessive hepatic venous blood flow using the Pringle manoevre (hepatic inflour occlusion) are described. Good communication between anaesthesiologists, surgeons and perfusionists was indispensable. The anaesthesiologist is an important member of the team during performance of a complicated procedure.

[Anesthetic management of a patient with Smith-Lemli-Opitz syndrome complicated with thrombocytopenia].

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive syndrome, characterized by severe growth failure and congenital anomalies (for example dysgenesis, mental retardation, renal and cardiac defects, and various malformation). SLOS results from error of a cholesterol enzyme and generalized cholesterol deficiency. This report describes our experience of a patient with SLOS and thrombocytopenia who underwent anesthesia twice for surgical procedures in a year. The patient received drip platelet transfusion for thrombocytopenia before operations. Anesthesia was induced with inhalation of oxygen, nitrous oxide and sevoflurane, and maintained with oxygen, propofol, fentanyl and low concentrations of sevoflurane. Airway was maintained with laryngeal mask airway. Complications were not seen in this case. One of the problems in anesthetic management of SLOS is difficult intubation because of the typical dysmorphic facial features such as micrognathia, cleft palate and abnormal tongue. We thought that laryngeal mask airway was useful and safe for SLOS patients. Two cases of malignant hyperthermia were reported in anesthetic management of SLOS by using halothane or suxamethonium. In this case, the anesthetic maintenance was mostly with propofol and fentanyl. Malignant hyperthermia did not occur but sevoflurane was used at low concentrations. SLOS presents various problems with anesthetic management and we have to administer general anesthesia carefully.