[Anesthetic Management for Lobectomy in a Patient with Pulmonary Arterial Hypertension].

Pulmonary arterial hypertension (PAH) is a known risk factor of perioperative complications, but the risks for non-cardiac operations have not yet been examined sufficiently. We report a case of a right lower lobectomy in a patient with PAH. A 73-year-old woman with Sjögren's syndrome was scheduled for right lowr lobectomy for primary lung cancer under general anesthesia. She was diagnosed with symptomatic PAH (estimated mean pulmonary arterial pressure, 40 mmHg) and medicated with ambrisentan. After induction of general anesthesia with propofol and fentanyl, a pulmonary artery catheter was placed to measure pulmonary artery pressure. The Pp/Ps was roughly 0.4 and the pulmonary artery clamp elevated it to 0.5. Milrinone administration gradually improved the Pp/Ps to 0.3. To avoid pulmonary artery pressure elevation during emergence of anesthesia, continuous dexmedetomidine was administered. The double-lumen tracheal tube was extubated uneventfully with minimal elevation in pulmonary arterial pressure.

Evaluation of double-lumen endotracheal tube extubation force by extraction angle: a prospective randomized clinical trial.

STUDY OBJECTIVE: Gentle and noninvasive double-lumen tracheal tube (DLT) extubation is important for both airway and circulatory management, especially after lung resection. We performed a prospective randomized clinical trial comparing DLT extubation force based on 2 different extraction angles. DESIGN: Randomized clinical trial. SETTING: Operating room. PATIENTS: Sixty adult patients scheduled for elective surgery under general anesthesia using DLT with ASA physical status 1 to 3. INTERVENTIONS: Sixty patients who underwent lung resection with a DLT were randomly assigned to extraction angles of 60° (30 patients) and 90° (30 patients) relative to the ground. MEASUREMENTS: Extubation forces and changes in vital signs were compared between groups. Results were analysed with the Mann-Whitney U test, non-paired t test, and χ(2) test. P<.05 was considered significant. MAIN RESULTS: Less extraction force was needed at 60° compared to 90° (90°, 13.9±2.3 N; 60°; 7.1±2.1 N; P<.001). The rate of increase in systolic and diastolic blood pressure (post-extubation/pre-extubation) was significantly smaller at 60° than at 90° (systolic blood pressure, P<.001; diastolic blood pressure, P=.002). CONCLUSIONS: Our findings suggest that DLT extubation at 60° requires less force than at 90° and was accompanied by a smaller increase in blood pressure. Thus, extraction at 60° may be less invasive and beneficial for patients undergoing DLT extubation.

[A Case of Severe Bradycardia Associated with Bladder Perforation during Spinal Anesthesia].

Here we report a case of severe bradycardia associated with bladder perforation during transurethral resection of the bladder. The patient was diagnosed with bladder cancer eight months ago and underwent transurethral resection of the bladder tumor. After balloon-occluded arterial infusion chemotherapy, she was scheduled for a bladder biopsy under spinal anesthesia. Spinal anesthesia was induced with 2.5 ml of 0.5% bupivacaine hydrochloride at L3-4, and sensory loss (T9) was confirmed. The operation started uneventfully 20 minutes after bupivacaine administration. However, ten minutes into the operation, bladder perforation occurred and was followed by severe bradycardia (20-30 beats x min(-1)). While preparing for transcutaneous pacing, bradycardia improved with intravenous atropine and ephedrine. The level of spinal anesthesia remained unchanged. General anesthesia was induced with propofol, rocuronium and fentanyl. The patient was extubated uneventfully after the operation and was discharged 14 days later.

[Successful Resuscitation from Cardiac Arrest due to Pulmonary Artery Rupture Utilizing Cardiopulmonary Bypass].

We report a case of successful resuscitation from cardiac arrest due to pulmonary artery rupture utilizing cardiopulmonary bypass. A 79-year-old man was diagnosed with lung cancer; segment resection of the upper lung was scheduled under general anesthesia. Anesthesia was induced uneventfully and surgery began in the right lateral position. During lung resection, the pulmonary artery was ruptured and led to cardiac arrest with pulseless electrical activity. Astriction, volume overload, and hypertensive medication led to vital sign recovery. Percutaneous cardiopulmonary support was achieved with improvements in the blood flow of the femoral vein and artery. Yet, bleeding from the ruptured artery did not stop. Cardiopulmonary bypass with pulmonary artery blood removal and femoral artery blood transmission stopped the bleeding of the damaged part, leading to the repair of the artery. Rapid establishment of cardiopulmonary bypass may be useful in cases of pulmonary artery damage.