Perioperative anticoagulation management during aortic valve replacement complicated by antiphospholipid syndrome.

Patients with antiphospholipid syndrome (APS) are at high-risk for thrombotic and bleeding complications during cardiopulmonary bypass. We report an APS patient who successfully underwent aortic valve replacement while heparin concentrations were monitored using a patient-specific titration curve using viscoelastic coagulation testing.

[Anesthetic management of a patient with stiff-person syndrome undergoing thymectomy].

Stiff-person syndrome is an uncommon disease characterized by muscular rigidity and painful spasms in the axial and limb muscles. We report a 58-year-old woman with stiff-person syndrome undergoing thymectomy under general anesthesia. Before surgery, her medications were 25 mg of diazepam, 2 mg of clonazepam, and 15 mg of gabapentin per day. After epidural catheterization for the postoperative analgesia, general anesthesia was induced and maintained with continuous remifentanil infusion and propofol with target controlled infusion. With train-of-four ratio (TOFR) monitoring by stimulating the ulnar nerve, her trachea was intubated after 0.6mg x kg(-1) of rocuronium intravenous administration. Since then, additional rocuronium was not given for 4 hours. After surgery, she was fully awake and TOFR recovered to 100%, but tidal volume was too low to remove the tracheal tube, and mechanical ventilation was continued in ICU. On the next day, the tracheal tube was removed, and she was discharged from ICU. Because anesthetics may delay the recovery of respiratory function in a patient with stiff-person syndrome, careful assessment of respiratory function is needed at the emergence from general anesthesia.

[Reliability in detection of tracheal intubation using cricoid palpation method].

BACKGROUND: Unrecognized esophageal intubation remains a significant cause of anesthetic morbidity. Extensive data showed that clinical signs and methods for confirming proper tracheal tube placement were not always reliable. Advancing tracheal tube into the trachea can be detected by palpating the cricoid cartilage. We evaluated the reliability of detecting tracheal intubation by cricoid palpation methods (CPM) in this study. METHODS: Three hundred and twelve patients were enrolled. After induction of general anesthesia, patients' tracheae were intubated using rigid laryngoscope. Before tracheal intubation, an assistant applied gentle pressure over the cricoid cartilage to detect tracheal or esophageal intubation. Immediately after intubation, the assistant was asked to state whether the tracheal tube was in the trachea or in the esophagus on the basis of what had been felt as the tube passed. Tracheal intubation was confirmed by capnometer and auscultation. RESULTS: In 304 tracheal intubations, the CPM correctly detected 268 cases, giving sensitivity of 88%. In 26 esophageal intubation, the CPM correctly detected 11 esophageal cases, giving specificity of 42%. Positive predictive value and negative predictive values were 95% and 23%, respectively. Increasing body mass index decreased the sensitivity for detecting tracheal intubation by the CPM. CONCLUSIONS: The CPM alone is imperfect for tracheal tube placement confirmation. Multiple methods for detecting correct tube placement should be used, since no single method has perfect reliability.

[Coronary artery spasm during one-lung ventilation].

We experienced a case of coronary artery spasm during one-lung ventilation. A 66-year-old man was scheduled for right upper lobectomy for lung cancer. He had a history of hypertension and cerebral infarction, but without any history or evidence of ischemic heart disease. After induction of general anesthesia, a left-sided double lumen tube was inserted. The patient was placed in the left lateral position, and one lung ventilation was started. Before skin incision, we noticed marked ST elevation on the ECG monitor, after which continuous infusion of nitroglycerin and two lung ventilation were initiated. In several minutes, ST elevation subsided completely. We cancelled the surgery and performed the coronary angiography, which demonstrated normal coronary arteries. A diagnosis of coronary artery spasm was made. Possible triggering factors for coronary artery spasm in this case were considered to be an increase in right ventricular pressure due to one-lung ventilation, and vagal stimulation associated with remifentanil use. The importance of evaluation of preoperative risk factors, avoidance of triggering factors and perioperative treatments are emphasized to prevent the coronary artery spasm.