Feasibility and safety of general anesthesia for bronchial thermoplasty: a description of early 10 treatments.

Bronchial thermoplasty (BT) is a recently introduced bronchoscopic treatment for patients with asthma refractory to pharmacotherapy. Intraprocedural sedation management is important for successful performance of BT. However, the results of general anesthesia in patients undergoing BT have not been well described. The aim of this study was to evaluate the feasibility and safety of general anesthesia in patients undergoing BT. We retrospectively reviewed the records of 10 consecutive BT treatments performed under general anesthesia in 4 patients. The feasibility outcomes were coughing and body movement during the procedure, procedure abandonment, and the relative frequency of thermal activation failure. The safety outcomes were bronchospasm and hypoxemia during the procedure, respiratory symptoms, and the need for oxygen after the procedure. Coughing occurred in two treatments. Neither body movement nor procedure abandonment occurred in any treatments. Neither intraprocedural bronchospasm nor hypoxemia occurred in any treatments. Respiratory symptoms occurred in 7 of 10 treatments within 1 day after the procedure and resolved within 4 days, which is comparable with a previous report. These results indicate that general anesthesia is feasible and safe for patients undergoing BT.

Goal-directed therapy reduces fluid balance while maintaining hemodynamic stability in intraoperative management of pancreaticoduodenectomy: a retrospective comparative study.

BACKGROUND: Goal-directed therapy (GDT) is beneficial for surgical patients, especially for those undergoing high-risk surgery. However, little has been reported on the hemodynamic effects of GDT in extensive surgery. We conducted a study to determine the impact of GDT on intraoperative management of extensive surgery. FINDINGS: We retrospectively collected data from 90 patients who underwent pancreaticoduodenectomy: 44 who received intraoperative GDT (GDT group) and 46 who received conventional hemodynamic management (control group). Intraoperative use of fluids and catecholamines and physiologic variables, including mean arterial pressure, heart rate, and urine output, were compared. We also examined the correlation between the amount of fluid administered and urine output. The amount of fluid administered was comparable, and urine output was significantly larger in the GDT group than in the control group. Fluid balance was significantly smaller in the GDT group (49.7 versus 61.7 mL/kg; 95% confidence interval, - 19.5 to - 4.6 mL/kg; P = 0.0019). There was a trend toward higher mean arterial pressure in the GDT group despite lower fluid balance. We found a rank correlation between the amount of fluid administered and urine output in the GDT group (rank correlation coefficient, 0.68; P < 0.001), but there was no such correlation in the control group. CONCLUSIONS: GDT increased urine output and decreased fluid balance while maintaining hemodynamic stability. The amount of fluid administered and urine output were correlated in the GDT group.

Successful Control of Pain from Malignant Psoas Syndrome by Spinal Opioid with Local Anesthetic Agents.

BACKGROUND: Malignant psoas syndrome (MPS) is a rare but distressing pain syndrome observed in advanced cancer patients. Pain due to MPS is often refractory to multimodal analgesic treatment, including opioid analgesics. As only 1 case demonstrating the efficacy of neuraxial analgesia in managing pain due to MPS has been reported, its role in MPS remains uncertain. CASES: We present 3 cases demonstrating the successful management of pain due to MPS using spinal opioids with local anesthetic agents. All patients were under the care of the palliative care consultation service in an acute care hospital and refractory to multimodal analgesic treatment, including opioid, non-opioid, and adjuvant analgesics. Switching opioid administration to the epidural or intrathecal route with a local anesthetic agent provided good pain control in all 3 patients. Moreover, all patients showed improvements in both Palliative Performance Scale and Functional Independence Measure scores after starting a spinal opioid with a local anesthetic agent. CONCLUSIONS: The findings in the present cases indicate neuraxial analgesia may be of benefit, in terms of managing pain and improving functional status, in MPS patients with insufficient pain control by multimodal analgesic treatment. Physicians should consider the use of neuraxial analgesia in cases of MPS where pain is uncontrolled with multimodal analgesic treatment to provide the best possible quality of life for patients with MPS.

Anesthetic management of cesarean section in a patient with a large anterior mediastinal mass: a case report.

BACKGROUND: Symptomatic anterior mediastinal mass in pregnancy is rare, and cesarean section for such patients poses a risk of cardiopulmonary collapse. CASE PRESENTATION: A 30-year-old woman at 40 weeks' gestation complained of breathlessness and cough, and she was not able to lie supine because of respiratory distress. Computed tomography scan revealed a large anterior-superior mediastinal mass severely compressing the trachea, bilateral main bronchus, and superior vena cava. Because clinical symptoms and computed tomographic findings suggested imminent respiratory catastrophe, urgent cesarean section was planned. The patient was able to lie in the semi-recumbent position with minimal symptoms; therefore, we considered it safe to perform cesarean section with combined spinal epidural anesthesia. In the event of cardiopulmonary collapse, emergent intubation and extracorporeal membrane oxygenation were also planned. The operation was performed successfully with combined spinal epidural anesthesia. The infant was healthy, and the postoperative hospital course was uneventful. CONCLUSIONS: Combined spinal epidural anesthesia is preferable in the anesthetic management of cesarean section with symptomatic anterior mediastinal mass. A well-designed preoperative strategy can lead to favorable outcomes even in this complicated situation.

[Interference between M-Entropy and Thermistor Probe Fixed on the Forehead during General Anesthesia].

We report a case in which M-Entropy was affected by the thermistor probe of tissue-core thermometer (Coretemp® TERUMO, Tokyo, Japan) fixed on the forehead. A 26-year-old man underwent osteosynthesis for forearm fracture under general anesthesia com- bined with brachial plexus block. General anesthesia was induced and maintained with fentanyl and target- controlled infusion of propofol. We use Coretemp* to measure core temperature and put the thermistor probe on forehead next to the M-Entropy sensor. Thirty minutes after start of the surgery, state and response entropy rose suddenly to extremely high lev- els. In spite of slow waves and sleep spindles on raw electroencephalogram (EEG) waveform, his vital signs showed no changes after the rise of entropy values. We suspected Coretemp® probe interfering with M- Entropy, and removed the probe from his forehead. M-Entropy returned to the default values immediately and this phenomenon was reproducible by attaching and detaching the probe. We therefore concluded that some electrical noise from the Coretemp® probe affected M-Entropy. The patient awoke from anesthesia smoothly, and had no memory of intraoperative awareness. This case suggests that we should always consider artifacts in EEG monitors and if their values do not correspond with clinical status, we should check raw EEG waveforms to judge the depth of anesthesia.