Preoperative Implementation of Transverse Thoracic Muscle Plane Block and Rectus Sheath Block Combination for Pediatric Cardiac Surgery.

Systemic intravenous administration of opioids is the main treatment strategy for intraoperative and postoperative pain management in patients undergoing cardiac surgery with sternotomy. However, using lower doses of opioids may achieve the well-established benefits of the fast-track approach, with minimal opioid-related side effects. Postoperative pain is coupled with a long stay in the intensive care unit. Although neuraxial anesthesia has some benefits, its use remains controversial due to the potential development of epidural hematoma after anticoagulation for cardiopulmonary bypass and coagulopathy after cardiac surgery. Therefore, there is a need for other effective postoperative analgesic strategies, such as peripheral nerve blocks other than neuraxial anesthesia, for cardiac surgery with sternotomy. The effects of real-time ultrasound-guided transverse thoracic muscle plane (TTP) block on postoperative pain after sternotomy have been reported; however, the pain and discomfort in the epigastric area caused by chest drainage tubes placed through the rectus abdominis muscle also are major postoperative problems after cardiac surgery. Herein, the authors report on a preoperative combination of TTP block and rectus sheath block (RSB) for postoperative pain management after cardiac surgery with sternotomy that addresses pain in both the chest and epigastric areas. Considering previous studies, it is presumed that preemptive analgesic effects can be expected via a combination of the TTP block and RSB, and indeed, the preemptive effect was observed in the present study's patients. In this article, the procedure and tips for combining the TTP block and RSB are introduced.

Efficacy of a novel urinary catheter for men with a local anesthetic injection port for catheter-related bladder discomfort: a randomized controlled study.

PURPOSE: The NMOC-3WAY catheter® is a novel urinary catheter for men that can be used to inject a local anesthetic into the urethra. We sought to assess whether the injection of a local anesthetic into the urethra via the NMOC-3WAY catheter® would reduce catheter-related bladder discomfort (CRBD) after endovascular aneurysm repair (EVAR). METHODS: Adult male patients who underwent elective EVAR for abdominal aortic aneurysms were randomly assigned to the 2% lidocaine group and the normal saline group (control group). CRBD was evaluated at 0, 1, 2, 4, and 6 h after surgery. The primary outcome was the incidence of CRBD at 0 h after surgery. RESULTS: Data for 37 patients (19 in the lidocaine group and 18 in the control group) were analyzed. CRBD was observed at 0 h in six patients (31.6%; mild, n = 5; moderate, n = 1) in the lidocaine group and in five patients (27.8%; mild, n = 1; moderate, n = 3; severe, n = 1) in the control group. The control group showed a tendency to have severe CRBD at 0 h, although there was no significant difference in either the incidence (P = 0.80) or severity (P = 0.21) of CRBD between the two groups. CONCLUSION: Our results suggest that the use of the NMOC-3WAY catheter® for the injection of 2% lidocaine into the urethra does not reduce the incidence of CRBD immediately after EVAR. However, it may reduce moderate or severe CRBD that may lead to postoperative distress and agitation.

Optimal Position of Inferior Vena Cava Cannula in Pediatric Cardiac Surgery: A Prospective, Randomized, Controlled, Double-Blind Study.

OBJECTIVE: To examine the authors' hypothesis that during the cardiopulmonary bypass (CPB) in children, the inferior vena cava cannula tip placed proximal to the right hepatic vein orifice would produce a higher venous drainage compared with that placed distally. DESIGN: A prospective, randomized, controlled, double-blind study. SETTING: Single university hospital. PARTICIPANTS: Thirty-two patients aged <6years, scheduled for elective cardiac surgery using CPB for congenital heart disease. INTERVENTIONS: Participants were randomized to 2 groups: the proximal group with the cannula tip placed proximally within 1cm of the right hepatic vein orifice and the distal group with the cannula placed distally within 1cm of the right hepatic vein orifice. MEASUREMENTS AND MAIN RESULTS: The primary outcome of this study was the perfusion flow rate at the time of establishment of total CPB with cardioplegia. The authors initially planned to enroll 60 patients, but before reaching the target sample size, the authors terminated this study owing to patient safety, and 18 patients in the proximal group and 14 patients in the distal group finally were analyzed. No significant differences in patient characteristics were observed between the 2 groups. The mean perfusion flow rate in the proximal group was significantly greater (2.55 ± 0.27 L/min/m2) than that in the distal group (2.37 ± 0.20 L/min/m2, p = 0.04). CONCLUSION: The inferior vena cava cannula tip placed in the proximal position was clinically superior, compared with a distal placement, in producing higher perfusion flow in children.

Pediatric Patients with High Pulmonary Arterial Pressure in Congenital Heart Disease Have Increased Tracheal Diameters Measured by Computed Tomography.

OBJECTIVES: Determination of the appropriate tracheal tube size using formulas based on age or height often is inaccurate in pediatric patients with congenital heart disease (CHD), particularly in those with high pulmonary arterial pressure (PAP). Here, the authors compared tracheal diameters between pediatric patients with CHD with high PAP and low PAP. DESIGN: Retrospective clinical study. SETTING: Hospital. PARTICIPANTS: Pediatric patients, from birth to 6 months of age, requiring general anesthesia and tracheal intubation who underwent computed tomography were included. Patients with mean pulmonary artery pressure >25 mmHg were allocated to the high PAP group, and the remaining patients were allocated to the low PAP group. The primary outcome was the tracheal diameter at the cricoid cartilage level, and the secondary goal was to observe whether the size of the tracheal tube was appropriate compared with that obtained using predictable formulas based on age or height. MEASUREMENTS AND MAIN RESULTS: The mean tracheal diameter was significantly larger in the high PAP group than in the low PAP group (p < 0.01). Pediatric patients with high PAP required a larger tracheal tube size than predicted by formulas based on age or height (p = 0.04 for age and height). CONCLUSIONS: Pediatric patients with high PAP had larger tracheal diameters than those with low PAP and required larger tracheal tubes compared with the size predicted using formulas based on age or height.

Intraoperative Detection of Persistent Endoleak by Detecting Residual Spontaneous Echocardiographic Contrast in the Aneurysmal Sac During Thoracic Endovascular Aortic Repair.

Persistent endoleaks may lead to adverse events after endovascular aortic repair. We prospectively examined the relationship between intraoperative residual spontaneous echocardiographic contrast (SEC) within the aneurysmal sac and the incidence of postoperative endoleaks in 60 patients undergoing thoracic endovascular aortic repair. Patients with SEC had a higher incidence of postoperative endoleaks than did patients without SEC within a few days postoperatively (60.0% vs 12.5%, respectively; P < .001) and at 6 months postoperatively (40.0% vs 2.5%, respectively; P < .001). Intraoperative confirmation of the absence of SEC may identify patients at low risk for persistent endoleaks after thoracic endovascular aortic repair.

Anesthetic management in a patient with giant growing teratoma syndrome: a case report.

INTRODUCTION: Growing teratoma syndrome is a rare occurrence with an ovarian tumor. Anesthesia has been reported to be difficult in cases of growing teratoma syndrome of the cystic type due to the pressure exerted by the tumor. However, there have been no similar reports with the solid mass type. Here, we report our experience of anesthesia in a case of growing teratoma syndrome of the solid type. CASE PRESENTATION: The patient was a 30-year-old Japanese woman who had been diagnosed with an ovarian immature teratoma at age 12 and had undergone surgery and chemotherapy. However, she dropped out of treatment. She presented to our hospital with a 40cm giant solid mass and severe respiratory failure, and was scheduled for an operation. We determined that we could not obtain a sufficient tidal volume without spontaneous respiration. Therefore, we chose to perform awake intubation and not to use a muscle relaxant before the operation. At the start of the operation, when muscle relaxant was first administered, we could not obtain a sufficient tidal volume. An abdominal midline incision was performed immediately and her tidal volume recovered. Her resected tumor weighed 10.5kg. After removal of her tumor, her tidal volume was maintained at a level consistent with that under spontaneous respiration to avoid occurrence of re-expansion pulmonary edema. CONCLUSIONS: We performed successful anesthetic management of a case of growing teratoma syndrome with a giant abdominal tumor. Respiratory management was achieved by avoiding use of a muscle relaxant before the operation to maintain spontaneous respiration and by maintaining a relatively low tidal volume, similar to that during spontaneous respiration preoperatively, after removal of the tumor to prevent re-expansion pulmonary edema.

Tissue Doppler imaging is useful for predicting the need for inotropic support after cardiac surgery.

PURPOSE: Low preoperative left ventricular ejection fraction (EF) is a predictor of the need for inotropic support after cardiac surgery. However, EF can be misinterpreted and difficult to measure in some cases. The purpose of this study was to compare the value of preoperative EF and intraoperative tissue Doppler imaging variables in predicting the need for postoperative inotropic support. METHODS: Forty-eight consecutive adult patients undergoing cardiac surgery were enrolled in this study. Systolic mitral annular velocity (S(m)), early diastolic mitral annular velocity (E(m)), the ratio of E(m) to late diastolic mitral annular velocity (E(m)/A(m)), and the ratio of early diastolic transmitral velocity to E(m) (E/E(m)) were measured using transesophageal echocardiography before median sternotomy. The primary outcome was the need for inotropic support for 12 or more hours after surgery. Preoperative, intraoperative, and echocardiographic characteristics were analyzed to determine the independent predictors of the need for postoperative inotropic support. RESULTS: Postoperative inotropic support was required for ≥12 h in 26.7% of patients. Multivariate logistic regression identified only cardiopulmonary bypass (CPB) time as an independent predictor of inotropic support (odds ratio, 1.015; 95% CI, 1.004-1.025; P = 0.004). Additional analysis was performed in the 25 patients with a CPB time of ≥200 min. In this analysis, only S(m) was significantly associated with the need for inotropic support for ≥12 h. CONCLUSIONS: This study suggests that those patients who have decreased S(m) and extended CPB times are more likely to require inotropic support after surgery, independent of a preserved left ventricular EF.

Can intraoperative TEE correctly measure residual shunt after surgical repair of ventricular septal defects?

PURPOSE: No groups have yet succeeded in identifying the need for re-repair of residual shunt after surgical repair of ventricular septal defect (VSD) based on quantitative evaluation of the ratio of the pulmonary blood flow to the systemic blood flow (Qp/Qs) by transesophageal echocardiography (TEE). Hence, we studied the accuracy of Qp/Qs as estimated by intraoperative TEE. METHODS: Twenty-six patients undergoing VSD closure were studied. After separation from the cardiopulmonary bypass, the presence and severity of residual leakage was evaluated by color Doppler image, and the Qp/Qs (TEE-derived Qp/Qs) was calculated by measuring the vessel diameter and the velocity-time integral of the flow profiles in the main pulmonary artery and left ventricular outflow tract. Transthoracic echocardiography (TTE) was performed at pre-discharge and at 6-12 months after the correction to confirm the presence and severity of residual leakage. RESULTS: TEE detected only minor leakage, with no indication for re-repair, in 8 of the 26 patients. Nevertheless, TEE-derived Qp/Qs varied from 0.57 to 2.07 and were incorrect in 17 patients (65.4%). This meant that when TEE-derived Qp/Qs was outside the acceptable range, the patient was judged not to be in need of re-repair. TTE at pre-discharge confirmed trivial leakage in 3 patients in whom TEE had also identified similar leakages. These leakages were not observed at the follow-up TTE. CONCLUSION: TEE-derived Qp/Qs lacks the accuracy required to play a crucial role in quantitatively measuring the severity of residual shunt, while two-dimensional TEE can reliably detect residual leakage after VSD closure and lead to optimal judgment on the need for re-repair.

[Massive hemorrhage during cesarean section for placenta accreta].

A 37-year-old multigravida presented at 37 weeks of gestation with low-lying placenta and highly suspected placenta accreta. The placenta adhered widely to the anterior wall of the uterus. Therefore, a longitudinal incision of the uterine corpus at the thinnest part of the placenta was made during surgery. Concurrent with the incision, rapid and massive hemorrhage occurred. After the delivery of the baby and confirmation of the placental adhesion, the hysterectomy was started promptly. The bladder adhered strongly to the uterus, and was injured during the dissection. The total volume of hemorrhage was estimated to be 24,480 ml (including amniotic fluid and urine). No arterial clamp for hemostasis was used during the procedure. The patient was discharged on the 12th postoperative day with no sequela. The pathological diagnosis was placenta percreta. Placenta accreta is a rare disease with a high mortality rate. The hemorrhage becomes difficult to control in case of injury of placenta accreta. The hysterectomy following cesarean section also becomes complicated. Bladder injury is one of the complications of the cesarean hysterectomy which makes the hemorrhage greader. In conclusion, when placenta accreta is suspected a strategy to minimize blood loss during surgery should be discussed by a multidisciplinary team.

Prolonged loss of leg myogenic motor evoked potentials during thoracoabdominal aortic aneurysm repair, without postoperative paraplegia.

No postoperative paraplegia occurred in a patient whose leg myogenic motor evoked potentials (mMEPs) disappeared during thoracoabdominal aortic aneurysm repair. A 69-year-old man underwent resection and repair of a type III (Crawford classification) thoracoabdominal aneurysm. An epidural catheter was placed into the epidural space for epidural cooling, and a Swan-Ganz catheter was placed into the subarachnoid space for cerebrospinal fluid (CSF) drainage. Continuous CSF pressure and temperature measurement was carried out the day before surgery. The mMEPs gradually disappeared 10 min after proximal double aortic clamping and complete aortic transection. Selective perfusion of intercostal arteries was started about 20 min after the loss of the mMEPs, but the mMEPs were not restored. Possibly, spinal cord hyperemia, induced by selective perfusion of the intercostal vessels, narrowed the subarachnoid space so that CSF could not be satisfactorily drained during surgery. The spinal cord hyperemia may have decreased spinal function and suppressed the leg mMEPs. The persistence of the loss of mMEPs was undeniably due to the influence of the anesthetic agent or a perfusion disorder in the lower-extremity muscles. Of note, moderate spinal cord hypothermia and postoperative CSF drainage probably resulted in improved lower-limb motor function.