Cardiac dysfunction following brain death after severe pediatric traumatic brain injury: A preliminary study of 32 children.

BACKGROUND: Cardiac dysfunction after brain death has been described in a variety of brain injury paradigms but is not well understood after severe pediatric traumatic brain injury (TBI). Cardiac dysfunction may have implications for organ donation in this patient population. MATERIALS AND METHODS: We conducted a retrospective cohort study of pediatric patients with severe TBI, both with and without a diagnosis of brain death, who underwent echocardiography during the first 2 weeks after TBI, between the period of 2003-2011. We examined cardiac dysfunction in patients with and without a diagnosis of brain death. RESULTS: In all, 32 (2.3%) of 1,413 severe pediatric TBI patients underwent echocardiogram evaluation. Most patients had head abbreviated injury score 5 (range 2-6) and subdural hematoma (34.4%). Ten patients with TBI had brain death compared with 22 severe TBI patients who did not have brain death. Four (40%) of 10 pediatric TBI patients with brain death had a low ejection fraction (EF) compared with 1 (4.5%) of 22 pediatric TBI patients without brain death who had low EF (OR = 14, P = 0.024). CONCLUSIONS: The incidence of cardiac dysfunction is higher among pediatric severe TBI patients with a diagnosis of brain death, as compared to patients without brain death. This finding may have implications for cardiac organ donation from this population and deserves further study.

Effect of intraoperative amino acids with or without glucose infusion on body temperature, insulin, and blood glucose levels in patients undergoing laparoscopic colectomy: a preliminary report.

OBJECTIVE: Amino acid administration helps to prevent intraoperative hypothermia but may enhance thermogenesis when combined with glucose infusion. The aim of this study was to examine the effect of intraoperative amino acid administration, with or without glucose infusion, on temperature regulation during laparoscopic colectomy. METHODS: Twenty-one patients whose physical status was classified I or II by the American Society of Anesthesiologists, and who were undergoing elective laparoscopic colectomy were enrolled. The exclusion criteria were a history of diabetes and/or obesity, preoperative high levels of C-reactive protein, high blood glucose and/or body temperature after anesthesia induction, and surgical time >500 minutes. Each patient received an acetate ringer solution and was randomly assigned to one of three groups. Group A patients were given only amino acids. Group AG patients were given amino acids and glucose. Group C patients were given neither amino acids nor glucose. Tympanic membrane temperatures and blood glucose and insulin levels were measured intraoperatively. RESULTS: Intraoperative amino acid infusion significantly increased body temperature during surgery as compared with either Group AG or C. The blood glucose levels in Group AG were significantly higher than those in Groups A and C. However, there were no significant differences between Groups A and C. Two hours after anesthesia induction, serum insulin levels in Groups A and AG significantly increased compared with Group C. No significant differences in the postoperative complications or patient hospitalization lengths were detected between the groups. CONCLUSION: Intraoperative amino acid infusion without glucose administration maintains body temperature more effectively than combined amino acid and glucose infusion in patients undergoing laparoscopic colectomy, despite unaltered intraoperative insulin levels.

Intraoperative secondary insults during extracranial surgery in children with traumatic brain injury.

PURPOSE: Data on intraoperative secondary insults in pediatric traumatic brain injury (TBI) are limited. METHODS: We examined intraoperative secondary insults during extracranial surgery in children with moderate-severe TBI and polytrauma and their association with postoperative head computed tomography (CT) scans, intracranial pressure (ICP), and therapeutic intensity level (TIL) scores 24 h after surgery. After IRB approval, we reviewed the records of children <18 years with a Glasgow Coma Scale score <13 who underwent extracranial surgery within 72 h of TBI. Definitions of secondary insults were as follows: systemic hypotension (SBP <70 + 2 × age or 90 mmHg), cerebral hypotension (cerebral perfusion pressure <40 mmHg), intracranial hypertension (ICP >20 mmHg), hypoxia (oxygen saturation <90 %), hypercarbia (end-tidal CO2 >45 mmHg), hypocarbia (end-tidal CO2 <30 mmHg without hypotension and in the absence of intracranial hypertension), hyperglycemia (blood glucose >200 mg/dL), hyperthermia (temperature >38 °C), and hypothermia (temperature <35 °C). RESULTS: Data from 50 surgeries in 42 patients (median age 15.5 years, 25 males) revealed systemic hypotension during 78 %, hypocarbia during 46 %, and hypercarbia during 25 % surgeries. Intracranial hypertension occurred in 64 % and cerebral hypotension in 18 % surgeries with ICP monitoring (11/50). Hyperglycemia occurred during 17 % of the 29 surgeries with glucose monitoring. Cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension (p = 0.02 and 0.03, respectively). We did not observe an association between intraoperative secondary insults and postoperative worsening of head CT scan or TIL score. CONCLUSIONS: Intraoperative secondary insults were common during extracranial surgery in pediatric TBI. Intraoperative cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension. Strategies to prevent secondary insults during extracranial surgery in TBI are needed.

[Effect of postoperative analgesia by repeated transversus abdominis plane blocks via a placed catheter in patients undergoing ovarian cystectomy].

BACKGROUND: We evaluated the effect of repeated transversus abdominis plane (TAP) blocks on postoperative analgesia over the first 48 postoperative hours in the patients undergoing lower abdominal gynecological surgery. METHODS: Four patients undergoing ovarian cystectomy via a transverse lower abdominal wall incision were selected. All patients received general anesthesia. After the operation, bilateral TAP blocks were performed by ultrasound-guided access using 0.375% ropivacaine 15 ml, and a catheter was placed on the plane. Repeated TAP blocks were performed every 12 hours using 0.375% ropivacaine 15 ml until the second postoperative day. Each patient was assessed for the analgesic effect and complications at 3, 6, 12, 24, 36, and 48 hours postoperatively. RESULTS: The postoperative visual analogue scale pain scores at rest and on movement were approximately under 20. The median frequency of additional nonsteroidal anti-inflammatory drugs until the second postoperative day was 0.5. We did not observe any complications such as nausea, vomiting and shivering in the postoperative period. CONCLUSIONS: These findings suggest that bilateral repeated TAP blocks via a placed catheter provide good analgesia without any complications in patients undergoing ovarian cystectomy.

[Effect of amino acid and glucose infusion on perioperative body temperature and postoperative infection in patients undergoing total knee arthroplasty].

BACKGROUND: We investigated whether the perioperative amino acid infusion with glucose is effective for preventing perioperative hypothermia and postoperative infection in patients undregoing total knee arthroplasty (TKA). METHODS: Forty patients undergoing TKA under general anesthesia were enrolled in this study. The patients were randomly allocated to two groups: AA group (n = 22), to which amino acid was infused, and AAGlu group (n = 18), to which amino acid and glucose were infused. The infusions were started before the anesthetic induction. Remifentanil was administered during the surgery, and the dose of remifentanil was adjusted to keep stable hemodynamics. The levels of blood glucose and body temperature were evaluated. We also recorded the frequency of additional use of nonsteroidal anti-inflammatory drugs, the days required until the wound closure, and complications in the post-operative period. RESULTS: The levels of blood glucose in AAGlu group were significantly higher than those of AA group (P < 0.05). However, no significant differences were found in perioperative body temperature, postoperative days required until the wound closure and the frequency of additional use of analgesics between the groups. CONCLUSIONS: These results suggest that in patients undergoing TKA receiveing amino acid infusion perioperatively, thermogenic effect and prevention of postoperative infection are similar whether exogenous glucose is infused or not.

[Effect of different perioperative analgesic methods on postoperative cognitive dysfunction in elderly patients undergoing upper abdominal surgery].

BACKGROUND: We investigated whether the early postoperative cognitive dysfunction (POCD) was affected by different perioperative analgesia methods using intravenous remifentanil or epidural ropivacaine in the elderly undergoing major upper abdominal surgery. METHODS: Twenty elderly patients (aged over 60 years) undergoing elective surgery for distal or pylorus-preserving gastrectomy under general anesthesia were enrolled in this study. The patients were randomly allocated to two groups : Group LV (n = 10) of intravenous remifentanil, and Group EPI (n = 10) of epidural ropivacaine. The dose of both analgesic agents was controlled to keep stable hemodynamics. We recorded postoperative outcome and complications, and assessed cognitive status at the preoperative period and on the 7th postoperative day using 6 cognitive assessment tests. RESULTS: POCD occurred in one case (10%) in group IV and two cases (20%) in group EPI (P = 0.50). VAS score, the days of hospital stay and the frequency of additional analgesics were similar between the groups. CONCLUSIONS: Perioperative analgesia using intravenous remifentanil and epidural ropivacaine showed no significant difference in the incidence of early POCD after upper abdominal surgery in elderly patients.

[Unexpected vomiting during anesthetic induction in a patient with a history of anterosternal esophageal reconstruction].

A 73-year-old woman with spinal canal stenosis was scheduled for a lumbar fenestration surgery. The patient had received esophagectomy for cancer and anterosternal esophageal reconstruction 5 years before. After the supper the day before the operation, the fast situation to the operation was maintained. On entering operating room, oxygenation was performed for the patient with adequate pressing of the gastric tube on the sternum, and rapid anesthetic induction was performed with propofol, remifentanil and rocuronium. During the induction, a significant amount of solid food residues appeared suddenly in the throat pharynx before positive pressure ventilation. Oral suction was done immediately, and tracheal intubation was performed. After the intubation, while the suction tube could not be inserted to the stomach tube, we positioned it at near the anastomosis between esophagus and gastric tube. Metoclopramide was administered intravenously during the surgery. At the postoperative period, no severe complications including aspiration were observed. When anesthetizing the patient with a history of anterosternal esophageal reconstruction, we should mind the possibility of nonavoidable vomiting during the induction. We strongly recommend the strict restriction of eating and drinking and suction tube insertion to remove the food residues from the patient preoperatively.

Permissive hypercapnia, instituted via reduction of pressure amplitude on pulmonary tissue protection during high frequency oscillatory ventilation, is not protective in a rat model of acid-induced lung injury.

BACKGROUND: Assuming that HFOV (high frequency oscillatory ventilation) with hypercapnia could be more protective than normocapnia, in a rat model of lung injury, we evaluated the effect of hypercapnic acidosis during HFOV. MATERIAL/METHODS: After inducing lung injury by intratracheal instillation of hydrochloric acid (HCl), we randomly assigned the animals to two groups: in the hypercapnia group (n=9), airway pressure amplitude (Pamp) was titrated to achieve PaCO2 greater than 80 mmHg; in the normocapnia group (n=9), Pamp was titrated to achieve PaCO2 less than 50 mmHg. Hemodynamics, histology, wet-to-dry ratio and inflammatory cytokines were evaluated after all the animals had received HFOV for 5 h. RESULTS: While the right-lung wet-to-dry ratio in the hypercapnia group was statistically significantly lower than in the normocapnia group (7.70+/-1.31 vs. 8.59+/-0.66, p<0.05), no statistically significant intergroup differences were found for blood pressure, heart rate, alveolar-arterial oxygen gradient, levels of cytokines (TNF-alpha, IL-6 and CINC-1) in bronchoalveolar lavage fluid and serum, and lung histological injury scores. CONCLUSIONS: Although edema formation was less pronounced in the hypercapnia group, we found no increased numbers of inflammatory cytokines or general histological evidence to suggest that permissive hypercapnia during HFOV was protective.

[Perioperative and postoperative management of two patients with uncontrolled hyperthyroidism using short acting beta blocker, landiolol].

Thyroid storm, sudden onset of life-threatening manifestations of hyperthyroidism, often appears during and after surgery in patients with uncontrolled hyperthyroidism. We report perioperative and postoperative management of two such cases with uncontrolled hyperthyroidism. The first patient is a 41-year-old man with a past history of uncontrolled Graves disease, and was scheduled for emergency video-assisted thoracoscopic surgery for spontaneous pneumothorax. The second patient is a 25-year-old man with a past history of hypertension, and was scheduled for open reduction and internal fixation for mandibular fracture. In both patients, tachycardia and hypertension were observed at admission to the operating room. Therapy included the use of landiolol infusion, a short acting beta blocker, for control of tachycardia. Heart rate was controlled around 90 beats x min(-1) using landiolol during surgery. In each case, landiolol was administered until they can take long acting beta blocker and antithyroid drug orally. In the postoperative period, delirium appeared for a few hours in the first case, but no severe complications were observed in each case. Short acting beta blocker was useful for control of tachycardia in the perioperative and postoperative management of the patient with uncontrolled hyperthyroidism.

High peak inspiratory flow can aggravate ventilator-induced lung injury in rabbits.

BACKGROUND: The study investigated the effect of peak inspiratory flow in a rabbit acute lung injury model. MATERIAL/METHODS: Twenty-five male rabbits were anesthetized and mechanically ventilated with high tidal volume (V(T)) until PaO2 dropped below 300 mmHg. Then the animals were randomly assigned to two groups: group V (n=10) receiving volume-control ventilation and group P (n=10) receiving pressure-regulated volume-control ventilation. Each animal was ventilated for 8 h at the following settings: V(T) 20 ml/kg, positive end-expiratory pressure 5 cmH2O, and respiratory rate 20 breaths/min with inspiratory-to-expiratory ratio of 1:4. Whether eleven hours of pressure-regulated volume-control ventilation at a V(T) of 20 ml/kg was harmful in rabbits with healthy lungs (control group, n=5) was also investigated. RESULTS: Group P's peak inspiratory flow was significantly (p<0.05) higher than group V's. From 4 h after the establishment of acute lung injury to the end of the experiment, group V's PaO2 values were significantly higher than group P's. Wet-to-dry ratio and upper lobe tissue injury scores were higher in group P than in group V. Control animals showed neither apparent lung injury after 11 h of mechanical ventilation nor deterioration in gas exchange during the protocol. CONCLUSIONS: Compared with volume-control ventilation with V(T) (20 ml/kg), pressure-regulated volume-control ventilation with the same V(T) worsened oxygenation, histological injury score in tipper lobes, and wet-to-dry ratio in rabbits with injured lungs. The evidence suggests that greater deterioration in gas exchange and lung injury is associated with high inspiratory flow.

Effect of humidifying devices on the measurement of tidal volume by mechanical ventilators.

PURPOSE: We hypothesized that expiratory tidal volume was underestimated, because a heat-moisture exchanger traps the expired vapor. We, therefore, designed patient and bench studies to investigate the accuracy of tidal volume monitoring. METHODS: In a patient study, applying two humidifying systems (a heat-moisture exchanger and a heated humidifier) and two tidal volumes (12 and 6 ml x kg(-1)) with a Servo ventilator 300, we recorded the displayed expiratory tidal volume and thoracic volume displacement, measured by respiratory inductive plethysmography. Temperature, relative humidity, and absolute humidity were measured at the airway opening and at the end of the expiratory limb. Using a model lung, we also tested three different ventilators (Puritan-Bennett 7200ae, Evita 4, and Servo ventilator 300) to investigate whether the effects of the heat-moisture exchanger and the heated humidifier on monitored tidal volume varied according to the brand of ventilator. RESULTS: With the use of the heat-moisture exchanger, the displayed expiratory tidal volume was significantly smaller, by 12%-14%, than that with the heated humidifier, although thoracic volume displacement was identical in the two systems. The temperature and absolute humidity at the end of the expiratory limb were significantly lower with the heat-moisture exchanger than with the heated humidifier. In the model lung study, we investigated the effects of different brands of ventilator on the expiratory tidal volume. A similar degree (8%-14%) of underestimation of tidal volume was observed with the heat-moisture exchanger, regardless of ventilator brand. CONCLUSION: Monitored expiratory tidal volume was underestimated by approximately 10%, when using a heat-moisture exchanger.

Effect of peak inspiratory flow on gas exchange, pulmonary mechanics, and lung histology in rabbits with injured lungs.

PURPOSE: The aim of this study was to evaluate, using a rabbit model, the little-known effect of different levels of peak inspiratory flow on acutely injured lungs. METHODS: Fourteen male rabbits (body weight, 2,711 +/- 146 g) were anesthetized and their lungs were injured by alveolar overstretch with mechanical ventilation until Pa(O(2)) was reduced below 300 mmHg. Injured animals were randomly assigned to: the P group-to receive pressure-regulated volume-control ventilation (PRVCV; n = 7); and the V group-to receive volume-control ventilation (VCV; n = 7). Other ventilator settings were: fraction of inspired oxygen (FI(O(2)), 1.0; tidal volume, 20 ml x kg(-1); positive end-expiratory pressure (PEEP) 5 cmH(2)O; and respiratory rate, 20 min(-1). The animals were thus ventilated for 4 h. Throughout the protocol, ventilatory parameters and blood gas were measured every 30 min. After the protocol, the lung wet-to-dry ratio and histological lung injury score were evaluated in the excised lungs. RESULTS: Throughout the protocol, peak inspiratory flow and mean inspiratory flow values in the P group were significantly higher than those in the V group (26.7 +/- 5.0 l x min(-1) vs 1.2 +/- 0.2 l x min(-1), and 4.3 +/- 0.3 l x min(-1) vs 1.1 +/- 0.1 l x min(-1); P < 0.05). The wet-to-dry ratio in the P group was also significantly higher than that in the V group (7.7 +/- 0.9 vs 6.3 +/- 0.5; P < 0.05). More animals in the P group than in the V group had end-of-protocol Pa(O(2))/FI(O(2)) ratios below 200 mmHg (43% vs 0%; P = 0.06). CONCLUSION: In rabbits with injured lungs, high peak inspiratory flow with high tidal volume (V(T)) reduces the Pa(O(2))/FI(O(2)) ratio and increases the lung wet-to-dry ratio.

Effect of Ono-EI-600 elastase inhibitor on high-tidal-volume-induced lung injury in rats.

We tested the effect of Ono-EI-600, an elastase inhibitor that suppresses cytokine release, on ventilator-induced lung injury in a rat model. After Wistar rats (aged 8-11 weeks) were anesthetized and tracheostomized, they were randomly assigned to four groups: high tidal volume (V(T)) group (H group: n = 10) receiving peak inspiratory pressure (PIP) 30 cmH(2)O for 240 min; high V(T) with drug group (HD group: n = 10) receiving the same ventilation settings as H group and also intravenous infusion 10 mg x kg(-1) x h(-1) of Ono-EI-600 during the protocol; the lower V(T) group (L group: n = 5) receiving PIP 10 cmH(2)O for 240 min; and control group (C group: n = 5) receiving the same ventilation as L group for 30 min. The cytokine levels (IL-6 and CINC-1) in the bronchoalveolar lavage fluid (BALF) of the H group were significantly higher than those of the C and L groups (P < 0.05). However, for the H and HD groups, no differences were found in arterial blood gas data, cytokine levels in BALF, and histological injury scores. Our experiment provided no evidence that elastase inhibitor Ono-EI-600 protects against lung injury induced by high V(T) ventilation.

Detection of cancer cells disseminated in bone marrow using real-time quantitative RT-PCR of CEA, CK19, and CK20 mRNA in patients with gastric cancer.

BACKGROUND: To determine the significance of bone marrow disseminated tumor cells in gastric cancer, we investigated the mRNA expression levels of carcinoembryonic antigen (CEA), cytokeratin 19 (CK19), and cytokeratin 20 (CK20) using the real-time quantitative reverse-transcription polymerase chain reaction (RQ-PCR). METHODS: Bone marrow samples were aspirated from the sternum at the time of surgery in 65 patients with resectable gastric cancer. Total RNA was extracted from bone marrow; and the expression levels of CEA, CK19, and CK20 mRNA were determined by RQ-PCR using an ABI PRISM 7000 and quantified against the GAPDH mRNA level. RESULTS: The detection limits of these genes were determined in the gastric cancer cell line MKN-45 and the colon cancer cell line C-1, which had been serially diluted in peripheral blood mononuclear cells (PBMCs). A rate of 1 cancer cell/million PBMCs was obtained by detecting CEA and CK19 mRNA in MKN-45 and by detecting CK20 mRNA in C-1. In the clinical samples, only 1 of the 65 gastric cancer patients (1.5%) who had stage IV disease was positive for CEA, CK19, and CK20 mRNA; none of CEA, CK19, or CK20 mRNA was positive in the remaining 64 patients. No significant correlation was observed between disseminated cancer cells in bone marrow and clinicopathological features, including simultaneous or metachronous hepatic metastasis and patient survival. CONCLUSION: The incidence of disseminated cancer cells in bone marrow in our study appears low, unlike that in previous reports. The significance of disseminated cancer cells in bone marrow may also be quite low in gastric cancer.

Postoperative hyperbilirubinemia after implantation of left ventricular assist device is associated with poor postoperative liver perfusion.

Hyperbilirubinemia, a common complication associated with left ventricular assist device (LVAD) implantation, is evidence of liver dysfunction and is often a life-threatening problem after the implantation procedure. In this study we evaluated the relationship between hemodynamics after LVAD implantation and postoperative hyperbilirubinemia. Twenty-four patients who received LVADs at Osaka University Hospital between January 1994 and June 2002 were retrospectively reviewed. Patients were grouped according to the implanted LVAD: Group A (n = 4) Novacor, group B (n = 7) HeartMate 1000IP, group C (n = 13) Toyobo pneumatic pulsatile pump. Hemodynamic data and laboratory data, including total bilirubin on postoperative days (PODs) 1, 3, 7, and 14, were collected and statistically analyzed. In group C, the cardiac index (CI) on POD 1 was significantly lower (P < 0.01) than that for groups A and B. On PODs 3 and 7, total bilirubin levels in group C increased significantly over the preoperative value (P < 0.05) and were significantly higher than those in group A on POD 3 and higher than those in groups A and B on POD 7 (P < 0.05). Regression analysis of CI on POD 1 correlated significantly with total bilirubin on POD 7, as expressed by the formula y = 5.13/(x - 1.7)(0.719), where x is CI and y is total bilirubin (r(2) = 0.327, P < 0.05). Total bilirubin after LVAD implantation correlates with postoperative CI values. We suggest that it is essential to maintain the CI at the highest levels possible to avoid postoperative hyperbilirubinemia in LVAD patients.

[A case of shoulder pain following right basilic vein catheterization].

We have experienced a case of total laryngectomy with graft of the rectus abdominis muscle skin flap because of the recurrent lingual cancer. Just before the operation, we used right basilic vein for introduction of a central venous catheter. Right shoulder pain occurred on the first postoperative day. After the operation, we found that the catheter from the right basilic vein was inserted to the right jugular vein. We pulled out it and inserted another catheter from the left subclavian vein. Shoulder pain diminished and then pyrexia and symptom of infection diminished. After recatheterization, shoulder pain was suspected to be the result of frozen shoulder. We should be aware that shoulder pain could occur by immobility of upper extremities when basilic venous catheter is in place.