Internal Jugular and Subclavian Vein Thrombosis in a Case of Ovarian Cancer.

Central venous catheter insertion and cancer represent some of the important predisposing factors for deep venous thrombosis (DVT). DVT usually develops in the lower extremities, and venous thrombosis of the upper extremities is uncommon. Early diagnosis and treatment of deep venous thrombosis are of importance, because it is a precursor of complications such as pulmonary embolism and postthrombotic syndrome. A 47-year-old woman visited our department with painful swelling on the left side of her neck. Initial examination revealed swelling of the region extending from the left neck to the shoulder without any redness of the overlying skin. Laboratory tests showed a white blood cell count of 5,800/mm3 and an elevated serum C-reactive protein of 4.51 mg/dL. Computed tomography (CT) of the neck revealed a vascular filling defect in the left internal jugular vein to left subclavian vein region, with the venous lumina completely occluded with dense soft tissue. On the basis of the findings, we made the diagnosis of thrombosis of the left internal jugular and left subclavian veins. The patient was begun on treatment with oral rivaroxaban, but the left shoulder pain worsened. She was then admitted to the hospital and treated by balloon thrombectomy and thrombolytic therapy, which led to improvement of the left subclavian venous occlusion. Histopathologic examination of the removed thrombus revealed adenocarcinoma cells, indicating hematogenous dissemination of malignant cells.

[Measurement of the Minimum Pressure in the Bronchial Cuff during One-lung Ventilation Using a Capnometer].

BACKGROUND: It is recommended to avoid overinflation of the bronchial cuff, leading to ischemic pressure damages to the respiratory mucosa and bronchial rupture. We investigated the minimum bronchial cuff pressure of 35 Fr double lumen tubes (DLTs) during one lung ventilation using a capnometer. METHODS: We studied 50 patients who were scheduled to undergo thoracic surgery. General anesthesia was induced and the patients were intubated with 35 Fr left DLT. With a fiberoptic bronchoscope, the DLT was positioned appropriately. The bronchial cuff was inflated first with air 3-3.5 ml. Lung isolation was confirmed by auscultation. Measurements were performed with the patient in the lateral position. Ventilating one lung isolatedly for 5 minutes, we confirmed non ventilated condition with a capnometer displaying flat line. The bronchial cuff was deflated 0.5-ml steps just before displaying the respiratory pattern by the capnogram. The bronchial cuff pressure and volume were recorded at this point RESULTS: The minimum pressures of bronchial cuff (volume) for one lung ventilation are for male 5.46 ± 0.6 cmH2O (2.33?0.1 ml) and for female 1.5?0.5 cmH20 (1.09 ± 0.3 ml). These values are smaller than the recommended value (< 25 cmH2O). There was no case in which the collapse of the operated lung was insufficient. CONCLUSIONS: In this study, the bronchial pressure higher than 12 cmH2O was not necessary for one lung ventilation. If high intracuff pressure is necessary to seal the bronchus, there are possibilities of the incompatibility of the size of DLT and the herniation of the bronchial cuff to the proximal side. The method of confirmation of OLV using a capnometer can display the non ventilated condition on the monitor objectively. We can thus decrease troubles during operations.

[Case of sudden asystole during direct laryngoscopy].

A 78-year-old man, weighing 74 kg and 172 cm in height suddenly developed asystole during direct laryngoscopy. His heart started beating soon after chest compressions. Direct larygoscopy can stimulate the vagal nerve of the larynx. Although a gradual decrease in heart rate ordinarily occurs prior to asystole, few reports describe the sudden asystole during direct laryngoscopy. Intravenous injection of atropine could avoid the adverse event. Anesthesiologists should pay attention to the occurence of asystole and prepare for resuscitation.

[Anesthetic management of a child with fibrodysplasia ossificans progressiva (FOP)].

General anesthesia was successfully performed in a 9-year-old boy with FOP. FOP is a very rare inherited disease of the connective tissue, characterized by progressive heterotopic ossification of skeletal muscles, tendons, and ligaments. Trauma and invasive medical procedures can induce heterotopic ossification. Anesthetic concerns for FOP patients include particular attention to airway management and susceptibility to respiratory complications. Regarding the airway management in general anesthesia, excessive stretching of the jaw and extension of the head may lead to the ankylosis of the temporo-mandibular joint and the neck stiffness. Ankylosis of the costvertebral joints induces restrictive ventilatory impairment, which causes atelectasis and lung infection in the perioperative period. Relating to anesthetic management for a child with FOP, anesthesiologists should keep in mind the prevention of exacerbation of the symptoms and subsequent impairment of activities of daily living postoperatively.