[Dexmedetomidine for endoscopic submucosal dissection in a patient with severe chronic obstructive pulmonary disease].

Here we report an anesthetic management of a 74-year-old man with gastric cancer and severe chronic obstructive pulmonary disease (COPD) undergoing endoscopic submucosal dissection (ESD). We maintained spontaneous breathing during ESD under monitored anesthesia care with dexmedetomidine (DEX). ESD lasted 5.5 hours with sufficient analgesia, and he required no airway management with the exception of supplemental mask oxygen during the procedures. He tolerated the procedure well and recovered with no complications. He was discharged without sequelae on the fifth postoperative day. DEX is a selective alpha2 agonist that has both sedative and analgesic properties, and it does not suppress ventilation. It should be used judiciously, and understanding the potential adverse effects and how to treat them is of paramount importance. However, with vigilant monitoring of blood pressure, heart rate, and level of consciousness during the ESD, it can be administered safely, thus lessening the anesthetic requirements and possibly improving the surgical outcome of the high risk patients. Especially, patients with severe COPD have demonstrated an increased risk for oxygen desaturation following general anesthesia, and to avoid this complication, spontaneous breathing sedation with DEX during ESD is one of the suitable management methods for COPD patients.

[Acute pulmonary edema in adult caused by tonsillar hypertrophy following removal of laryngeal mask airway].

Negative pressure pulmonary edema (NPPE) has been described after acute airway obstruction. In the following case, we observed a rare occurrence of pulmonary edema caused by chronic tonsillar hypertrophy in a woman following removal of laryngeal mask airway (LMA). A 38-year-old woman with breast cancer underwent mastectomy under general anesthesia using the LMA. With the patient fully awake, the LMA was removed. Abruptly 7 minutes afterward, she showed signs of intense dyspnea, generalized rhonchus and progressive desaturation, and obstructive tonsillar hypertrophy was noticed. Acute lung edema was suspected and treatment started with oxygen therapy, bronchodilators, intravenous corticoids and loop diuretics. She was then intubated to secure airway and provide adequate ventilation with PEEP. Fortunately, the symptoms progressively remitted satisfactorily, and she was subsequently extubated 18 hours later with no complications. NPPE is an infrequent medical emergency and its early diagnosis and recognition are likely to lead to successful management of this potentially serious complication.

[Tube introducer catheter as an adjunct to the airway scope for tracheal intubation in a manikin model].

BACKGROUND: The Airway Scope (AWS) is a video laryngoscope and there are some problems associated with its use in insertion of the tracheal tube despite its ability to view the glottis. For the purpose of improving the problems, we devised the tube introducer catheter (TIC) for use with AWS. METHODS: Using the normal and fixed bent orotracheal tubes, wire-reinforced endotracheal tube, PORTEX and Phycon double lumen tubes, and Univent tube, TIC was attached to one of these tubes with AWS. And, we compared the efficacy and safety of the TIC with the AWS in facilitating tracheal intubation in a manikin model. RESULTS: With about all tubes, correct placement of the endotracheal tube was achieved in the TIC-facilitated tracheal intubations. In addition, the TIC can administer oxygen to prevent desaturation during the intubation. Excessive secretions in the oropharynx were effectively removed under vision with the TIC connected to the suction catheter. The topical anesthetics were sprayed on the vocal cords through the spray channels of the TIC. Furthermore, it can be used for exchange of tracheal tube in a patient. CONCLUSIONS: The TIC was significantly effective in facilitating tracheal intubation using the AWS in a manikin model.

[New lung isolation device, Fuggiano's bronchial blocker, facilitates lung isolation more effectively].

BACKGROUND: One-lung ventilation and lung isolation are frequently required in thoracic surgery. In clinical practice, lung isolation is achieved by use of a double-lumen endotracheal tube and a bronchial blocker. A novel bagel shaped bronchial blocker, the Fuggiano's bronchial blocker, has been designed to prevent displacement of the blocker from its position in the bronchus. In this study, we evaluated the clinical performance of the Fuggiano's bronchial blocker for the lung isolation. METHODS: In thirty patients undergoing thoracotomy or video-assisted thoracoscopic surgery, the Fuggiano's bronchial blockers were placed to the bronchus. Fifteen patients received a left-sided bronchial block, and fifteen a right-sided block. The position of the devices was checked using fibreoptic bronchoscope. RESULTS: In all cases, successful lung isolation and the properly collapsed lung were achieved. It took significantly longer time to place a right bronchial block. Intraoperative repositioning of the device was not required. The quality of lung deflation was judged excellent in all patients. CONCLUSIONS: We conclude that, for routine use, the Fuggiano's bronchial blocker is preferable to achieve a lung isolation because of its facility in placement and a better quality of lung deflation. Fuggiano's bronchial blocker may be an alternative airway device for one-lung ventilation, and further work is required.

Effect of ulinastatin on microcirculation during excessive hemorrhage using fluid therapy.

Microcirculation kinetics during excessive hemorrhage and fluid therapy under anesthesia, with or without treatment with ulinastatin (urinary trypsin inhibitor), was studied by using the rabbit ear chamber. Sixteen rabbits were divided into 2 groups: 8 rabbits without ulinastatin treatment (group C) and 8 rabbits treated with ulinastatin (group U). The vascular diameter, blood-flow velocity, blood-flow rate and urinary output were maintained well in the ulinastatin group as compared to those in the control group. It is concluded that ulinastatin is effective in maintaining microcirculation during excessive hemorrhage and fluid therapy at the same volume.