Temporal gene expression profiling of maslinic acid-treated Raji cells.

Maslinic acid is a novel phytochemical reported to target multiple signaling pathways. A complete gene expression profile was therefore constructed to illustrate the anti-tumourigenesis effects of maslinic acid in Raji cells across five time-points. Microarray analysis was used to identify genes that were differentially expressed in maslinic acid treated Raji cells at 0, 4, 8, 12, 24 and 48 h. Extracted RNA was hybridized using the AffymetrixGeneChip to obtain expression profiles. A total of 109 genes were found to be significantly expressed over a period of 48 hours. By 12 hours, maslinic acid regulates the majority of genes involved in the cell cycle, p53 and NF-κB signaling pathways. At the same time, XAF1, APAF1, SESN3, and TP53BP2 were evidently up-regulated, while oncogenes, FAIM, CD27, and RRM2B, were down-regulated by at least 2-fold. In conclusion, maslinic acid shows an hourly progression of gene expression in Raji cells.

Unexpected upper airway obstruction due to disseminated human papilloma virus infection involving the pharynx in a parturient.

Human papilloma virus has been implicated as the cause of juvenile-onset recurrent respiratory papillomatosis in first-born children. Thus, cesarean section is strongly recommended by obstetricians to avoid direct contact with papilloma in an infected birth canal. We report a parturient with silent hypopharyngeal papilloma, which was associated with severe clinical problems at the induction of general anesthesia. The anesthesiologist considered general anesthesia for this case because of disseminated skin warts and secondary pus across the patient's body. Although the patient's breathing was smooth before starting general anesthesia, it was difficult to maintain positive pressure ventilation despite administration of a muscle relaxant. High air-way resistance without chest wall motion was noted, despite the insertion of an oral airway. Therefore, direct laryngoscopy was immediately performed and an obstructing mass was found. This mass acted as a check valve during positive ventilation. Our report should remind clinicians that human papilloma virus infection, although benign, can be disastrous in certain circumstances, as in our case where it resulted in airway obstruction and distal spread during cesarean section. Its presence necessitated preoperative laryngoscopic evaluation and aggressive treatment.

Prosthetic mitral leaflet malfunction due to inappropriate size of implant.

We report a case of unexpected malfunction of prosthetic mitral leaflets, discovered by transesophageal echocardiography (TEE) immediately after implantation, due to selection of an inappropriate size of prosthesis; the problem was amended immediately by surgical revision. The subject was a 48-year-old man admitted for mitral valve replacement because of severe mitral stenosis. He had undergone mitral commissurotomy 21 years previously. Preoperative echo findings showed severe mitral stenosis with regurgitation and a huge thrombus in the left atrial chamber. During operation, the surgeon also discovered severe calcification over the mitral valve with rheumatic changes in both leaflets and the chordae. Because the posterior leaflet had totally fused with the annulus, resection could not be performed. A 33-mm Edwards-Carpentier porcine xenograft was then installed and sutured onto the approximate annular position. The posterior chordae were also not resected, and the atriotomy was closed. Once the aortic cross-clamp was removed and the patient was re-warmed, the left atrium distended rapidly. No ventricular wall motion was seen. Immediate TEE evaluation demonstrated that the prosthetic valve was dysfunctional and the leaflets were immobile. Total cardiopulmonary bypass was then resumed. A smaller 29-mm valve was reimplanted in the same anatomic position. The 33-mm tissue valve was then re-examined and checked for any structural abnormality or functional inadequacy. The prosthetic valve stent was intact and the leaflets were mobile upon gross inspection. The patient was successfully weaned from cardiopulmonary bypass with high dose inotropic agents and intra-aortic balloon pump support. In conclusion, TEE can provide us with immediate, accurate and detailed information to evaluate an unexpected circumstance and disclose an operative misadventure during or after cardiac surgery.

High frequency jet ventilation in exploration of tracheostomy--a case report.

Exploration of tracheostomy is not uncommon, however, in case a patient with a facial reconstruction flap, trouble may arise because of difficulty in intubation. We hereby report a patient who had a fresh facial reconstruction flap after radical resection of buccal carcinoma, sustained bleeding around the tracheostomy and was scheduled for exploration of tracheostomy. Fiberoptic oral intubation was failed because of profuse secretion and edematous oral mucosa; high frequency jet ventilation (HFJV) was thus applied and made possible with a suction catheter put through the tracheostomy tube. Exploration was performed following withdrawal of the tracheostomy tube. The tracheostomy tube was reinserted under the guidance of the in-place suction tube after uneventful exploration. The probable concomitant complications and contraindications of using HFJV are discussed here. With thorough preparation and careful monitoring, and under the supervision of experienced physicians, transtracheal HFJV can substitute fiberoptic intubation for ventilation in case of exploration of tracheostomy.

Failure to provide adequate one-lung ventilation with a conventional endotracheal tube using a transbronchial approach: a case report.

PURPOSE: To report a case where failure to provide adequate one-lung ventilation during transbronchial intubation resulted in a potentially fatal mishap. CLINICAL FEATURES: A 61-yr-old male was scheduled for right lung lobectomy. Induction of general anesthesia was smooth, and subsequent resection of the right middle lobe was uneventful. Difficult ventilation with high airway pressure and poor right lung re-expansion prompted repositioning of the double-lumen tube after the resection. The removal of the right middle bronchial clamp and associated right mainstem manipulation caused flooding of blood into the double-lumen tube. Mindful of the risk of fatal desaturation, the surgeon immediately opened the right mainstem bronchus and cleared the airway. Confirmation of a displaced double-lumen tube prompted the surgeon to insert an endotracheal tube (internal diameter 5.5 mm) from the opened right mainstem bronchus to the left main bronchus to maintain oxygenation. Although bronchoscopic examination confirmed proper location of the reinserted tube, oxygen saturation was not sufficiently (60%) improved. Another 5.5-mm endotracheal tube was inserted, with its tip inside the right upper bronchiole, for further ventilatory support. Finally, a rise in SpO2 to around 95% allowed completion of surgery. CONCLUSIONS: Displacement of the double-lumen endobronchial tube and flooding with clotted blood will result in potentially fatal ventilation difficulties. Repositioning and cleaning of the tube must be prompt to reduce the risk of hypoxemia. Where emergency single-lung ventilation is required, we suggest the utilization of a modified single-lumen endotracheal tube with a shortened cuff-tip length to ensure an adequate margin of safety for mainstem bronchus intubation.

Vascular injury during a lumbar laminectomy.

A lumbar laminectomy is a common and routine operation. Damage to abdominal vascular structures during surgery is a relatively infrequent complication; however, when it does occur, it is sudden and life-threatening. We herein report on 2 cases of abdominal vascular injury which occurred during lumbar microdiscectomies. The first case was a 34-year-old man. A bloody surgical field was noted 45 min into the operation along with an increase in heart rate and a decrease in blood pressure. After fluid resuscitation and an ephedrine injection, his vital signs stabilized. The patient was then sent to the surgical intensive care unit for observation. An emergent abdominal computer tomography scan revealed right retroperitoneal hematoma, and an urgent exploratory laparotomy was performed to check for bleeding and to remove the hematoma. The second case was a 61-year-old woman with recurrent disc herniation. The operation was proceeding smoothly for 90 min, when a large amount of fresh blood suddenly gushed out. Her blood pressure immediately dropped to that of a state of shock. The patient was turned back to a supine position, and an emergent laparotomy was done to repair the injured vessels. Both patients had uneventful recoveries.

Anesthetic management of a parturient undergoing cesarean section with a tracheal tumor and hemoptysis.

Anesthetic management of a parturient with respiratory failure associated with hemoptysis, dyspnea, and orthopnea is difficult. An anesthesiologist should realize that the patient's major problem is not solved during the surgery. This circumstance is similar to a patient with associated cardiac disease scheduled for non-cardiac surgery. General anesthesia with endotracheal intubation can provide safe oxygenation for both the parturient and the fetus, but with possible unexpected massive hemoptysis and tumor seeding. Prolonged intubation may delay the patient's pulmonary treatment course. Laryngeal mask anesthesia can provide an airway, but must not be secured due to the risk of aspiration. The need of high doses of inhalation drugs may hinder uterine contractions. The addition of a muscle relaxant will change the patient's respiratory patterns and physiology. Regional anesthesia alone might not be tolerated. A decrease in cough strength, as well as dyspnea, orthopnea, and hyperventilation may be harmful to both the parturient and the fetus. However, we successfully managed this case using epidural anesthesia combined with assisted mask ventilation instead of spontaneous breathing usually provided by a simple mask in almost all American Society of Anesthesiology (ASA) class I-II parturients during cesarean section. The anesthetic level was maintained at T8 with 18 ml of 2% Xylocaine mixed with 2 ml of 7% sodium bicarbonate with 1:200,000 epinephrine epidurally and with the patient in a supine position with the head up at 30 degrees to prevent cephalic spreading and to ensure better pulmonary ventilation.

Red Man's syndrome following administration of vancomycin in a patient under spinal anesthesia--a case report.

Prophylactic antibiotics are frequently administered during anesthesia to reduce the incidence of infection. The most common organisms revealed in wound infections are staphylococci. Vancomycin is the antibiotic of choice for resistant staphylococcal infections and bacterial endocarditis in patient allergic to penicillin. We had a case of tibial osteomyelitis, while undergoing removal of implants under spinal anesthesia developed hypotensions, bradycardia, consciousness change and skin erythematous macular rash after 0.1% vancomycin slow infusion for 10 min. After appropriate management, the patient recovered well and was discharged on the following day. Our report is intended to alert our colleagues that vancomycin can cause hypotension secondary to histamine release, direct myocardial depression and direct peripheral vasodilation. Even cardiac arrest had been reported in the literatures.