Challenges with two epidural catheters for labor analgesia in a patient with lumbar adhesions: a case report.

BACKGROUND: The efficacy of neuraxial analgesia varies with spinal canal pathology. Notably, a secondary epidural catheter has been shown to increase neuraxial labor analgesia in women with spinal lesions. Therefore, we present a case in which catheter withdrawal played a critical role in achieving effective labor analgesia in a woman with epidural adhesions after lumbar discectomy who had inadequate analgesia with two epidural catheters. CASE PRESENTATION: We encountered a patient with L5 lumbar epidural adhesions who reported pain even after receiving two epidural catheters. The catheters were placed in the L1/2 and L5/S intervertebral spaces. Analgesic effects were exerted when the L5/S catheter was withdrawn by 1 cm, suggesting that the catheter tip was initially placed inside the adhesion. CONCLUSIONS: Careful consideration of catheter placement and adjustments by withdrawing the catheter are crucial in managing labor analgesia in patients with known epidural adhesions.

A Case Report of a Baby Born to a Woman With Isolated Right Ventricular Apical Hypoplasia Without an Atrial Septal Defect.

Pregnancy is a major life event for most women that causes extensive physiological changes. Hence, it is associated with additional risks in women with congenital heart disease. No reports of pregnancy or a baby born to a woman with isolated right ventricular hypoplasia without an atrial septal defect have been published. In this case, the patient's right ventricle was very small with no contractility. The right atrium was highly enlarged, and its contractility resulted in pulmonary circulation without pulmonary hypertension. The size increased post-delivery than that before pregnancy. Fortunately, a healthy infant was born without any right heart failure symptoms.

Anesthetic Management of a Cesarean Delivery in a Patient With MYH11 Mutation Who Underwent Aortic Replacement.

We report a case of a pregnant woman with a history of ascending arch replacement for aortic dissection who still had a residual descending aortic dissection. She underwent urgent genetic testing to identify hereditary aortic-related diseases that might be useful in perinatal management. A mutation in the myosin heavy chain gene (MYH11), indicating a high risk of aortic dissection but a low impact on other vascular systems and organs, was identified. Due to concerns about the development of residual aortic dissection, cesarean delivery with combined spinal-epidural anesthesia was selected. Predelivery genetic testing might be useful for perinatal anesthetic management.

Continuous Spinal Anesthesia for Labor Analgesia and Cesarean Delivery in a Parturient With Familial Dilated Cardiomyopathy: A Case Report.

We report a case of successful continuous spinal anesthesia (CSA) for labor analgesia and cesarean delivery in a patient with familial dilated cardiomyopathy (DCM). A 33-year-old pregnant woman diagnosed with DCM was scheduled for a vaginal delivery under labor analgesia. An accidental intrathecal catheter was placed, and labor analgesia was provided by CSA. The vaginal delivery was converted to a cesarean delivery, and an intrathecal catheter was used for transition, which avoided hemodynamic changes and allowed the patient to safely undergo cesarean delivery. CSA is a reliable and rapidly titratable technique that provides excellent analgesia without hemodynamic changes in patients with DCM undergoing labor analgesia and subsequent cesarean delivery.

Future liver remnant volume is associated with postoperative fentanyl consumption following open donor hepatectomy: a retrospective multivariate analysis.

PURPOSE: Liver resection has a risk of postoperative hepatic dysfunction, including drug metabolism. Since fentanyl is primarily metabolized in the liver, liver resection requires exercising caution against fentanyl overdose in postoperative analgesia. The rationale for dose adjustment of fentanyl in the preoperative prescription for patients undergoing liver resection remains unclear. We examined whether postoperative fentanyl consumption is associated with the future liver remnant after liver resection and investigated factors influencing fentanyl consumption. METHODS: In this retrospective study, 89 living liver donors undergoing open liver resection received intravenous patient-controlled analgesia with fentanyl 2 mg with thoracic epidural analgesia. The primary outcome was postoperative hourly consumption of intravenous patient-controlled analgesia with fentanyl. Future liver remnant volume (ml) and the ratio of future liver remnant volume to whole liver volume (%) were estimated by computed tomography volumetry and compared to determine which correlated more strongly with fentanyl hourly consumption. Multivariable analysis identified independent factors affecting fentanyl consumption, with adjustments for patient characteristics and intravenous patient-controlled analgesia setting. RESULTS: Future liver remnant volume (ml) was significantly correlated more strongly than the ratio of future liver remnant (%) with postoperative fentanyl consumption (r = 0.53 vs. 0.36, p < 0.001). Larger future liver remnant volume (ß = 0.25, p = 0.006) and age < 45 years (ß = 0.24, p = 0.009) were independently associated with higher fentanyl consumption, while sex and weight were not. CONCLUSIONS: Future liver remnant volume was significantly associated with postoperative fentanyl consumption. Smaller remnant liver volume and older age (≥ 45 years) were independent factors reducing postoperative fentanyl consumption in patients undergoing open donor hepatectomy.

Gastric emptying time after breakfast in healthy adult volunteers using ultrasonography.

There is little evidence of gastric excretion after ingestion of solids. We examined gastric emptying times after ingesting normal breakfast in healthy adult volunteer using ultrasonography. Eight adult volunteers fasted for 8 h, and we examined the gastric antral area in the right lateral decubitus position using ultrasonography. Sixteen adult volunteers ingested normal breakfast. We evaluated the gastric antral area in the same manner at two consecutive time points before lunch. Gastric volume was calculated by using an approximation formula based on the antral area. Correlation coefficients between gastric volume and fasting time were calculated. The calculated gastric volume from the gastric antral area after 8 h fasting was 53.1 ml. The gastric volume correlated significantly with fasting time (r = - 0.811, P < 0.001). The time when the attenuation line obtained from two measurements between breakfast to lunch in each subject overlapped the fasting stomach volume (53.1 ml) was taken as gastric empty time. The calculated gastric emptying time was 276.4 ± 58.9 min. This result shows that gastric emptying time was lower than 5 h average after a typical breakfast that contains various food in healthy adult volunteers. However, further research is necessary to establish the clinical safety implications of these findings.

Validity of ultrasonographic measurement of gastric volume in fasted pediatric patients without sedation.

Recently, gastric ultrasonography has been used as a noninvasive portable tool for evaluating gastric content and volume in adults and children. Pediatric patients are not always cooperative, especially younger ones, and it may be difficult to keep them in the appropriate scanning position without sedation. Hence, we modified the scanning method and position, and evaluated the efficacy of this alternative scanning technique in pediatric cases. We evaluated the gastric contents of 44 pediatric patients aged 4-14 years who were about to undergo elective surgery. Solid food and fluids were prohibited 8 and 2 h before anesthesia, respectively. Before anesthetic induction, we used gastric ultrasonography to measure the antral cross-sectional area in the supine position (supine CSA), irrespective of peristaltic contractions. The gastric volume was then aspirated using a multi-orifice catheter under general anesthesia. Supine CSA measured via this gastric ultrasonography method was positively correlated with gastric volume (r = 0.56, p < 0.0001). We concluded that our alternative method of measuring antral CSA may be applicable for children minimal gastric contents.

Comparison of the analgesic effect of intravenous acetaminophen with that of flurbiprofen axetil on post-breast surgery pain: a randomized controlled trial.

OBJECTIVE: Acetaminophen is known to be a relatively weak analgesic with fewer side effects than nonsteroidal anti-inflammatory drugs (NSAIDs). This study aimed to determine whether intravenous (iv) acetaminophen produces comparable analgesic effects to those of flurbiprofen (positive control drug), an intravenously injectable NSAID, after partial mastectomies. The primary outcome assessed was pain intensity during the first 24 h after the operation, and the secondary outcome was the satisfaction rating at discharge. METHODS: After obtaining Institutional Ethics Committee approval, a series of 40 consecutive female patients who were scheduled for partial mastectomies were enrolled. Participants were randomly divided into two groups: an acetaminophen (1000 mg × 3) group (group A) and a flurbiprofen (50 mg × 3) group (group F). Each drug was administered 15 min before the end of surgery, and at 6 and 12 h after the operation. Postoperative pain was evaluated using a 100-mm visual analog scale (VAS) at 3, 6, and 24 h postoperatively. Satisfaction rating was evaluated on a 5-point scale (very good, good, well, bad, and very bad). RESULTS: VAS scores (mm) with movement in groups A and F at 3, 6, and 24 h after the surgery were 22 vs. 28, 14 vs. 24, and 12 vs. 20.5 (median), respectively, with no significant differences between the two groups. Eighteen of 20 patients in group A and 20 of 20 patients in group F expressed a satisfaction rating of greater than good. CONCLUSIONS: Acetaminophen produces an equivalent analgesic effect to flurbiprofen in post-partial mastectomy patients.

[Usefullness of Beta-blocker for Hemodynamic Changes Induced by Uterotonic Drug in a Patient with Hypertrophic Obstructive Cardiomyopathy Undergoing Elective Cesarean Section].

Combined spinal-epidural anesthesia (CSEA) was given to a 27-year-old woman with hypertrophic obstructive cardiomyopathy (HOCM) for a selective cesarean section. After the injection of uterotonic drug via uterine muscle and a vein after delivery, the patient developed dyspnea, tachycardia, ST-change on elecrocardiogram and hypotension. It is important in HOCM patients to control heart rate and left ventricular contractile force. We started to infuse beta-blocker (landiolol, 10 µg x kg(-1) x min(-1)) and improved these symptoms of the patient. This case demonstrates that CSEA is safe for HOCM patients and beta-blocker is effective to improve hemodynamic changes induced by uterotonic drug in these patients.

[Anesthetic management of a patient with carnitine palmitoyltransferase deficiency with a history of rhabdomyolysis].

Carnitine palmitoyltransferase (CPT) makes the fatty acids available through beta-oxidation. Deficiency of CPT causes difficulties of muscle cells to metabolize fatty acid. In affected patients, exercise, fast for a prolonged period, and stress, lead to exhaustion of the store of glucose in the body, and rhabdomyolysis may occur, since muscle can not utilize fatty acid as an alternative energy source. Therefore, anesthetic management of CPT deficiency needs infusion of glucose continuously, avoiding the use of the drugs that cause rhabdomyolysis and suppressing the surgical stress. A 67-year-old man, who had previous history of rhabdmyolysis during the postoperative period, and diagnosed CPT deficiency was scheduled for total gastrectomy. General anesthesia was induced with remifentanil, thiamylal and rocuronium after epidural catheter insertion. During surgery, general anesthesia was maintained with remifentanil, sevoflurane, and blood glucose was monitored frequently, with continuous glucose infusion. No complications occurred during anesthesia and perioperative course was uneventful.

Perioperative management of a patient with thyroid hormone resistance who underwent total thyroidectomy for thyroid cancer.

Resistance to thyroid hormone (RTH) is a rare, predominantly inherited syndrome that involves impaired tissue responsiveness to thyroid hormones. We describe the perioperative management of a patient with RTH who underwent total thyroidectomy. Although surgery performed under general anesthesia was uneventful, after the surgery the patient developed difficult-to-treat hypocalcemia that lasted until postoperative day 4. Moreover, thyroid function even after discharge remained unstable despite replacement therapy. We suggest that the parathyroid and thyroid function of patients with RTH be followed very closely and that nociceptive stimulus of the surgery and postoperative pain be reduced as much as possible.

Inducible nitric oxide synthase deficiency ameliorates skeletal muscle insulin resistance but does not alter unexpected lower blood glucose levels after burn injury in C57BL/6 mice.

Burn injury is associated with inflammatory responses and metabolic alterations including insulin resistance. Impaired insulin receptor substrate-1 (IRS-1)-mediated insulin signal transduction is a major component of insulin resistance in skeletal muscle following burn injury. To further investigate molecular mechanisms that underlie burn injury-induced insulin resistance, we study a role of inducible nitric oxide synthase (iNOS), a major mediator of inflammation, on burn-induced muscle insulin resistance in iNOS-deficient mice. Full-thickness third-degree burn injury comprising 12% of total body surface area was produced in wild-type and iNOS-deficient C57BL/6 mice. Insulin-stimulated activation (phosphorylation) of IR, IRS-1, and Akt was assessed by immunoblotting and immunoprecipitation. Insulin-stimulated glucose uptake by skeletal muscle was evaluated ex vivo. Burn injury caused induction of iNOS in skeletal muscle of wild-type mice. The increase of iNOS expression paralleled the increase of insulin resistance, as evidenced by decreased tyrosine phosphorylation of IR and IRS-1, IRS-1 expression, insulin-stimulated activation of phosphatidylinositol 3-kinase and Akt/PKB, and insulin-stimulated glucose uptake in mouse skeletal muscle. The absence of iNOS in genetically engineered mice significantly lessened burn injury-induced insulin resistance in skeletal muscle. In wild-type mice, insulin tolerance test revealed whole-body insulin resistance in burned mice compared with sham-burned controls. This effect was reversed by iNOS deficiency. Unexpectedly, however, blood glucose levels were depressed in both wild-type and iNOS-deficient mice after burn injury. Gene disruption of iNOS ameliorated the effect of burn on IRS-1-mediated insulin signaling in skeletal muscle of mice. These findings indicate that iNOS plays a significant role in burn injury-induced skeletal muscle insulin resistance.

Stroke volume variation obtained with Vigileo/FloTrac™ system during bleeding and fluid overload in dogs.

PURPOSE: Stroke volume variation (SVV) is a parameter for estimating fluid responsiveness. Recently, the Vigileo™ and the Flo-Trac™ sensor (Edwards Lifesciences, Irvine, CA, USA) were made available for clinical use to estimate SVV. The aim of this study was to investigate the relationship between the circulating blood volume and SVV, measured by the Vigileo-FloTrac™ system (SVV-FloTrac) or by central venous pressure (CVP), during a dynamic change in circulating blood transfusion volume, using a continuous constant bleeding and fluid-overload model in dogs. METHODS: Ten anesthetized and mechanically ventilated beagles were used. SVV-FloTrac and CVP were measured during a bleeding period (2 ml/kg/min, 15 min), a stabilization period (15 min), a blood transfusion period (2 ml/kg/min, 15 min), and a 6% hydroxyethyl starch solution overload period (2 ml/kg/min, 15 min). RESULTS: SVV-FloTrac changed significantly when more than 8 ml/kg blood was withdrawn or when more than 8 ml/kg blood was transfused. The change in SVV-FloTrac directly reflected the circulating blood volume change during continuous bleeding and blood transfusion. CVP decreased significantly when more than 4 ml/kg blood was withdrawn or when more than 10 ml/kg was infused, and this indicated that the CVP change did not directly reflect the level of the circulating blood volume change. During the stable circulating blood volume period after blood withdrawal, SVV-FloTrac changed significantly but CVP remained constant. During the fluid overload period, CVP, but not SVV-FloTrac, changed significantly. CONCLUSION: SVV-FloTrac is a sensitive indicator of the dynamic circulating blood volume change during both bleeding and transfusion, but not during either the stable circulating blood volume period after blood withdrawal or the fluid-overload period, in mechanically ventilated dogs.

Development of a comb needle with five needles for securing access to large blood vessels during emergency resuscitation.

PURPOSE: Animal tests have indicated that providing venous-arterial (V-A) bypass extracorporeal circulation immediately after cardiac arrest is a useful resuscitation technique for achieving resumption of a normal cardiac function and brain resuscitation. However, pulsation of the femoral artery cannot be felt in the case of cardiac arrest, and it takes a long time to puncture the femoral artery and vein. We developed a comb needle that has five 18-gauge metallic needles fixed in parallel on a plastic board. In this study, we investigated whether the comb needle would achieve puncturing of the femoral artery and vein in cadavers. METHODS: The comb needle was used to puncture the femoral artery and the femoral vein in 45 donated bodies. We placed the center needle of the comb needle 2 cm perpendicularly caudal to a point approximately one quarter the distance along a straight line connecting the anterior superior iliac spine and the pubic tubercle. An autopsy was performed following puncturing, and it was determined whether needles of the comb needle punctured the femoral artery and/or the femoral vein. RESULTS: Puncturing of both the femoral artery and the femoral vein was achieved in 35 cases (78%). In the left groin, both the femoral artery and the femoral vein were punctured in 16 cases (94%), and in the right groin, both the femoral artery and the femoral vein were punctured in 19 cases (68%). CONCLUSION: Using a comb needle, one insertion can achieve simultaneous puncturing of the femoral artery and the femoral vein with a high success rate in cadavers.

Visual hallucinations on eye closure after orthopedic surgery under general anesthesia.

A 61-year-old woman suffering from rheumatoid arthritis without a contributory neurological, mental, or psychological history experienced visual hallucinations solely on eye closure after total hip arthroplasty under general anesthesia combined with epidural anesthesia. The visual hallucinations first appeared when she arose from sleep early on postoperative day 1, approximately 12 h after the end of surgery. Only on closing her eyes, she had a clear view of colored clothes, lace curtains, handbags, hats, and sofas, all of which were vivid, realistic, complex, of natural size, and in normal perspective without distortion and appeared independently and randomly in succession. The hallucinations disappeared when she opened her eyes even in the dark. The visual hallucinations gradually decreased as the days elapsed and they had entirely subsided on postoperative day 4. The level and content of her consciousness seemed entirely normal throughout her hospital course. Although postoperative visual hallucinations are not uncommon, they do not always show the closed-eye variation. The causes and underlying mechanisms of this type of visual hallucination remain to be elucidated.

Farnesyltransferase inhibitor, manumycin a, prevents atherosclerosis development and reduces oxidative stress in apolipoprotein E-deficient mice.

OBJECTIVE: Statins are presumed to exert their antiatherogenic effects in part via lipid-lowering-independent mechanisms. Inhibition of protein farnesylation and/or geranylgeranylation by statins has been postulated to contribute to the lipid-lowering-independent effects. However, a role for protein farnesylation in atherogenesis has not yet been studied. Therefore, we examined the effects of farnesyltransferase inhibitor, manumycin A, on the development of atherosclerosis in apolipoprotein E (apoE)-deficient mice fed a high-fat diet. METHODS AND RESULTS: Manumycin A treatment for 22 weeks decreased Ras activity, and reduced fatty streak lesion size at the aortic sinus to 43% of that in vehicle-treated apoE-deficient mice (P<0.05), while plasma total cholesterol was unaltered. Moreover, manumycin A reduced alpha-smooth muscle actin-positive area to 29% of that in vehicle-treated apoE-deficient mice (P<0.01). The prevention of atherogenesis by manumycin A was accompanied by amelioration of oxidative stress, as judged by reduced ex vivo superoxide production and nitrotyrosine immunoreactivity. CONCLUSIONS: These results indicate that the inhibition of farnesyltransferase prevents the development of mature atherosclerosis with concomitant alleviation of oxidative stress in apoE-deficient mice. The present data highlight farnesyltransferase as a potential molecular target for preventive and/or therapeutic intervention against atherosclerosis.

Two cases of transient left ventricular apical ballooning syndrome associated with subarachnoid hemorrhage.

Electrocardiogram (ECG) abnormalities secondary to subarachnoid hemorrhage are well known, but the etiology remains unclear. Transient left ventricular apical ballooning syndrome is characterized by acute onset myocardial infarction-like symptoms, transient (reversible) cardiac dysfunction, and shapes resembling ampulla on left ventriculography. We managed general anesthesia for two patients with transient left ventricular apical ballooning and ECG abnormalities associated with subarachnoid hemorrhage. During anesthesia, their hemodynamic status was almost stable although their cardiac performance analyzed by transthoracic echocardiography and transesophageal cardiography was poor. Anesthetic management of this syndrome may be simplified if less cardiosuppressive anesthetic management is used. We recommend evaluating cardiac function with transthoracic echocardiography or transesophageal cardiography when an subarachnoid hemorrhage patient has ECG abnormalities.

A moderate dose of propofol and rapidly induced mild hypothermia with extracorporeal lung and heart assist (ECLHA) improve the neurological outcome after prolonged cardiac arrest in dogs.

BACKGROUND AND PURPOSE: Propofol has been shown to protect against neuronal damage induced by brain ischaemia in small animal models. We reported previously that mild hypothermia (33 degrees C) in combination with extracorporeal lung and heart assist (ECLHA) improved the neurological outcome in dogs with cardiac arrest (CA) of 15 min induced during normothermia. In the present study, we investigated the neuroprotective effect of propofol infusion under mild hypothermia with ECLHA in this model. METHODS: Twenty-one female dogs (15 mongrel dogs and 6 beagles) were divided into three groups: Midazolam 0.1 mg/(kg h) infusion group (M, n=7), Propofol 2 mg/(kg h) infusion group (P2, n=7), Propofol 4 mg/(kg h) infusion group (P4, n=7). Normothermic ventricular fibrillation (VF) was induced in all dogs for 15 min, followed by brief ECLHA and 168 h of intensive care. The drug infusion was initiated at a constant rate after the restoration of spontaneous circulation (ROSC) to 24 h. Mild hypothermia (33 degrees C) was maintained for 20 h. Neurological deficit scores (NDS: 0%=normal, 100%=brain death) were evaluated for neurological function from 33 to 168 h. RESULTS: One dog in the M group died, and the remaining dogs survived for 168 h. The P4 group showed better neurological recovery compared with the M group (48 h, 21+/-16% versus 32+/-15%; 72 h, 7+/-6% versus 25+/-11%; 96 h, 6+/-6% versus 21+/-6%; 120 h, 5+/-5% versus 20+/-6%; 144 h, 4+/-4% versus 20+/-6%; 168 h, 4+/-4% versus 20+/-6%, p<0.05). One dog in the P2 and three dogs in the P4 group achieved full neurological recovery (NDS: 0%). The number of intact pyramidal cells in the hippocampal CA1 was greater in the propofol groups than midazolam group (p<0.05). CONCLUSION: The combination of propofol infusion at a rate of 4 mg/(kg h), 24h and rapidly induced mild hypothermia (33 degrees C) with ECLHA might provide a successful means of cerebral resuscitation from CA.