Efficacy of Goreisan in Preventing Transurethral Resection Syndrome in Transurethral Resection of the Prostate: A Randomized-Controlled Study.

Objectives: Nonconductive irrigation fluids used during transurethral resection (TUR) of the prostate can cause fluid overload and dilutional hyponatremia. TUR syndrome is generally defined as serum sodium at or below 125 mmol/L with cardiovascular and neurologic symptoms. The aim of this study was to evaluate the effects of Goreisan, a traditional Japanese Kampo medicine, on serum sodium levels and the occurrence of TUR syndrome in patients undergoing TUR of the prostate. Design: This was a randomized-controlled trial. Settings/Location: This trial was conducted at the Osaka Medical College Hospital and Keneikai Sanko Hospital. Subjects: Fifty patients scheduled for TUR of the prostate were included. Interventions: Patients in the Goreisan group (n = 23) received 2.5 g Goreisan orally on the night before surgery and on the morning of surgery. The control group (n = 27) did not receive Goreisan. Surgical procedures, perioperative management, and patient monitoring were otherwise the same in both groups. Outcome Measures: The primary outcome was occurrence of TUR syndrome. The secondary outcome was serum sodium level. Results: Serum sodium remained above 125 mmol/L in all patients, so none of the patients met the criteria for TUR syndrome. However, the Goreisan group had significantly higher intraoperative sodium levels (p < 0.001) and significantly higher intraoperative (p = 0.008) and postoperative (p = 0.02) hemoglobin levels than the control group. Conclusions: These findings indicate that preoperative Goreisan administration can help maintain serum sodium levels in patients undergoing TUR of the prostate.

Factors Associated with Poor Satisfaction with Anesthesia in Patients Who Had Previous Surgery: A Retrospective Study.

BACKGROUND: As most studies investigating patient satisfaction with anesthesia have some bias, previous results may underrepresent the true level of dissatisfaction with anesthesia. OBJECTIVES: This study aimed to identify factors associated with patient satisfaction with anesthesia. METHODS: Data from patients aged ≥ 20 years who had previous surgery and were scheduled for additional surgery were obtained retrospectively through preoperative interviews conducted. Informed consent for anesthesia was obtained by an anesthesiologist prior to the additional surgery. The patients were assigned to one of four anesthesia satisfaction levels, then were categorized into two groups; a high satisfaction group and a low satisfaction group. After comparing parameters between the two groups, logistic regression analysis was performed to identify factors that were negatively associated with satisfaction with anesthesia. RESULTS: Of 478 patients interviewed subjects, 469 patients were analyzed. Five individuals were excluded because they were unable to provide informed consent, and four subjects were excluded because they were aged < 10 years at the time of their previous surgery. Age < 65 years, previous surgery for malignancy, female sex, estimated operation duration < 3 hours, and American Society of Anesthesiologists Physical Status score 1 or 2 were included in a logistic regression analysis. Age < 65 years, previous surgery for malignancy, and female sex were predictive of poor patient satisfaction with anesthesia. Reasons for poor satisfaction with anesthesia included postoperative shivering and chills, fear of surgery, ineffective spinal anesthesia, and postoperative surgery-related pain. Of the patients awaiting surgery for malignancy, 57.3% had previous surgery for malignancy. CONCLUSIONS: Age < 65 years, previous surgery for malignancy, and female sex were negatively associated with patient satisfaction with anesthesia. These factors should be considered when preparing patients for future procedures to improve postoperative patient satisfaction.

The Effects of Endotracheal Tube and i-gel® Supraglottic Airway Device on Respiratory Impedance: A Prospective Observational Study.

BACKGROUND: The forced oscillation technique (FOT) is a non-invasive means of measuring respiratory resistance and reactance. We tested our hypothesis that endotracheal intubation would cause more substantial preoperative increases in FOT parameters than a supraglottic airway device (SGD). METHODS: Forty patients requiring general anesthesia and mechanical ventilation for transurethral bladder tumor resection underwent spirometry the day before surgery. Forced oscillation was measured using a MostGraph-01 device the day before surgery and immediately after removal of the airway adjunct. Changes in respiratory resistance and reactance were compared between those intubated and those who used SGD. RESULTS: The trachea was intubated in 23 patients and SGD was used in the remaining 17 patients. Both airway adjuncts caused significant increases in preoperative respiratory resistance and reactance; however, the magnitude of the changes was significantly greater in the intubated patients. CONCLUSIONS: The SGD appears to cause less pulmonary injury than tracheal intubation. Further study is needed to illuminate the influence of mechanical ventilation, and longer-term consequences and clinical significance of the changes we found in this study. Spontaneous ventilation through an SGD may be preferable in patients with severe respiratory disease.

Factors Causing Post-Anesthetic High Respiratory Resistance in Patients Undergoing Transurethral Resection of Bladder Tumors.

BACKGROUND: In this study, we investigated the causes of high respiratory resistance that is observed after general anesthesia. We focused on respiratory resistance at 5 Hz (R5), which were measured preoperatively and postoperatively. METHODS: Our prospective observational study enrolled 68 patients who underwent transurethral resection of bladder tumors from April to October 2015. Respiratory impedance was measured the day before surgery and immediately after general anesthesia. Participants were divided into 2 groups: Group L (postoperative R5 values < 4.0 cmH2O/L/sec; n = 33) and Group H (postoperative R5 values ≥ 4.0 cmH2O/L/sec; n = 35). Patient background, preoperative R5 values, endotracheal tube or subglottic devices, anaesthetic period, desflurane or sevoflurane, and endotracheal suctioning were compared. RESULTS: Significant parameters were height, inhalation of desflurane, endotracheal suctioning, and preoperative R5 value. Logistic regression showed that endotracheal suctioning and a higher preoperative R5 level increased postoperative respiratory resistance (> 4 cmH2O/L/sec). CONCLUSIONS: The endotracheal suctioning at the end of anesthesia influenced respiratory resistance more than use of the endotracheal tube and desflurane.

Changes in cardiac function and hemodynamics during robot-assisted laparoscopic prostatectomy with steep head-down tilt: a prospective observational study.

OBJECTIVE: Robot-assisted laparoscopic prostatectomy requires the patient to be placed in a steep head-down tilt. The aim of our study was to investigate changes in cardiac index and left ventricular end-diastolic volume in a steep had-down tilt. This is a prospective observational study. We investigated the influence of steep head-down tilt on cardiac function and hemodynamics without fluid restriction in 12 men of American Society of Anesthesiologists physical status I-II undergoing robot-assisted laparoscopic prostatectomy. We measured left ventricular ejection fraction, left ventricular end-diastolic volume and cardiac index by transesophageal echocardiography, cardiac index using a FloTrac® sensor, heart rate and arterial blood pressure, before and 5 min after tilting the operating table. RESULTS: The following variables changed significantly after tilting and establishment of the pneumoperitoneum: left ventricular ejection fraction (before 62.5%, after 55.5%; P = 0.040), systolic blood pressure (before 116 mmHg, after 128 mmHg; P = 0.001) and diastolic blood pressure (before 59 mmHg, after 70 mmHg; P = 0.002). There were no significant changes in cardiac index or left ventricular end-diastolic volume measured by transesophageal echocardiography, or cardiac index by FloTrac® sensor. Left ventricular ejection fraction decreased, whereas cardiac index and left ventricular end-diastolic volume did not change, indicating that steep head-down tilt and pneumoperitoneum during robot-assisted laparoscopic prostatectomy did not greatly influence cardiac function. This study was registered as a clinical study with the Japanese Official Clinical Trial Registry (Trial Registration Number JMA-IIA00158 on 7th January, 2014).

[A Difficult Airway after Anesthetic Induction in a Patient with Masticatory Muscle Tendon-Aponeurosis Hyperplasia].

We present a case of masticatory muscle tendon- aponeurosis hyperplasia in a patient who underwent general anesthesia for gynecologic surgery. The patient's square-shaped mandible was noticed during preoperative assessment by an anesthesiologist. Further investigation revealed masticatory muscle tendon- aponeurosis hyperplasia. Anesthetic induction agents were administered, and facemask ventilation was initi- ated easily. As the anesthesiologist had predicted, the patient's mouth opening was reduced after administration of muscle relaxants, and keeping her mouth open was more difficult than when she was conscious. Nasotracheal intubation was performed successfully using a bronchoscope. Patients with muscle tendon- aponeurosis hyperplasia do not generally have associated pain, and do not know that they have a limited mouth opening. They are therefore sometimes unaware that they have the condition. Anesthesiologists need to predict that airway intubation will be difficult when the patient has a limited mouth opening associated with a square-shaped mandible.

[Anesthetic Management of Emergency Thrombectomy for a Patient with Undiagnosed Polycythemia Vera].

Here we report successful anesthetic management of emergency thrombectomy for a patient with undiag- nosed polycythemia vera. A 67-year-old man com- plained of numbness of the right lower limb and was diagnosed with acute artery obstruction. Emergency thrombectomy was scheduled. Preoperative blood exam revealed hemoglobin 21.0 g · dl⁻¹ (hematocrit, 63.4%). During central venous catheter placement, we con- firmed high backflow blood viscosity; blood was diluted with plasma substitute. Hemoglobin was main- tained at 14-15 g · dl⁻¹ with continuous administration of plasma substitute. On re-perfusion of the right lower limb, potassium increased to 7.6 mEq · ml⁻¹, which responded to calcium carbonate, GI therapy, and furo- semide. Surgery was uneventful and the patient was diagnosed with polycythemia vera postoperatively. As perioperative management of polycythemia vera is challenging, particularly in undiagnosed and untreated cases, efforts should be made to avoid further throm- bosis and cardiac events.

Coronary ostial stenosis detected by transesophageal echocardiography after aortic valve replacement: a case report.

BACKGROUND: Coronary ostial stenosis is a life-threatening complication of aortic valve replacement (AVR). Clinical symptoms usually appear within the first 6 months after AVR (Funada and Mizuno et al., Circ J 70:1312-7, 2006), and perioperative onset is very rare. CASE PRESENTATION: An 80-year-old woman with severe aortic stenosis was scheduled to undergo AVR. AVR using cardiopulmonary bypass (CPB) was successfully carried out. However, 5 min following AVR, signs of left heart failure appeared, and transesophageal echocardiography (TEE) revealed severe hypokinetic left ventricular wall motion. Left coronary ostial stenosis was diagnosed by TEE, and CPB was immediately resumed and coronary artery bypass grafting (CABG) to the left anterior descending branch was performed. CONCLUSIONS: When circulatory failure presents in the acute phase following AVR, onset of coronary ostial stenosis should be considered.

Unexpected hemorrhage during robot-assisted laparoscopic prostatectomy: a case report.

BACKGROUND: Robot-assisted laparoscopic prostatectomy is increasingly performed as a minimally invasive option for patients with organ-confined prostate cancer. This technique offers several advantages over other surgical methods. However, concerns have been raised over the effects of the steep head-down tilt necessary during the procedure. We present a case in which head-down positioning and abdominal insufflation masked the signs of an intraoperative hemorrhage. CASE PRESENTATION: A 73-year-old Asian man developed severe hypotension caused by an unexpected hemorrhage during robot-assisted laparoscopic prostatectomy for prostate cancer. Although our patient's blood pressure steadily decreased during the procedure, his systolic blood pressure remained above 80 mmHg while he was tilted head downward at an angle of 28°. However, his blood pressure dropped immediately after he was returned to the horizontal position and abdominal insufflation - to create a pneumoperitoneum - was ceased at the end of surgery. We returned the patient to a head-down tilt to keep his blood pressure stable and began fluid infusion. Blood test results indicated that a hemorrhage was the cause of his hypotension. Open abdominal surgery was performed to stop the bleeding. The surgeons found blood pooling inside his abdomen from a longitudinal cut in a small arterial vessel in his abdominal wall, possibly a branch of his external iliac artery. The surgeons successfully controlled the hemorrhage and our patient was moved to our intensive care unit. Our patient recovered completely over the next few days, without any neurological deficits. CONCLUSIONS: We suspect that blood began to pool in our patient's superior abdomen during surgery, and that increased intra-abdominal pressure suppressed the hemorrhage. When our patient was returned to the horizontal position and insufflation of his abdomen was discontinued, the resulting increased rate of hemorrhage caused a sudden drop in blood pressure. Surgeons and anesthesiologists must understand the hemodynamic changes that result from head-down patient positioning and abdominal insufflation.

Correlation between extraction force during tracheal intubation stylet removal and postoperative sore throat.

STUDY OBJECTIVE: To examine postoperative sore throat resulting from tracheal intubation stylet removal. DESIGN: Prospective cohort study. SETTING: Operating rooms and hospital ward. PATIENTS: A total of 50 American Society of Anesthesiologists physical status 1 and 2 patients who underwent elective abdominal and/or orthopedic surgery under general anesthesia. INTERVENTIONS: Patients were allocated to 2 groups: those who developed sore throat postoperatively (ST group) and those who did not (NST group). Comparative analysis of these 2 groups was performed to identify risk factors of the development of sore throat. MEASUREMENTS: The extraction force during stylet removal was measured using a force measuring device. Postoperative sore throat was assessed by an anesthesiologist. MAIN RESULTS: Nine patients (18%) complained of postoperative sore throat. Increased extraction force (P=.0054; odds ratio, 1.84; 95% confidence interval, 1.20-2.84) was the only significant risk factor for the development of postoperative sore throat. An extraction force of >10.3N was determined as a cutoff for developing postoperative sore throat. CONCLUSION: Postoperative sore throat was significantly related to increased extraction force during stylet removal.

Perioperative evaluation of respiratory impedance using the forced oscillation technique: a prospective observational study.

BACKGROUND: Intravascular fluid shifts, mechanical ventilation and inhalational anesthetic drugs may contribute to intraoperative lung injury. This prospective observational study measured the changes in respiratory impedance resulting from inhalational anesthesia and mechanical ventilation in adults undergoing transurethral resection of bladder tumors. The components of respiratory impedance (resistance and reactance) were measured using the forced oscillation technique (FOT). METHODS: Respiratory resistance at 5 Hz (R5) and 20 Hz (R20), respiratory reactance at 5 Hz (X5), resonant frequency (Fres) and area of low reactance (ALX) were measured before and immediately after surgery in 30 adults. In addition, preoperative vital capacity (VC), forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1.0) were evaluated using spirometry. All patients were intubated with an endotracheal tube and were mechanically ventilated, with anesthesia maintained with sevoflurane. Pre- and postoperative FOT measurements were compared using Wilcoxon paired rank tests, and the relationships between FOT measurements and preoperative spirometry findings were determined by Spearman's rank correlation analysis. RESULTS: Twenty-six patients were included in the final analysis: postoperative FOT could not be performed in four because of postoperative restlessness or nausea. The mean duration of surgery was 47 min. All components of respiratory resistance deteriorated significantly over the course of surgery, with median increases in R5, R20, and R5-R20 of 1.67 cmH2O/L/s (p < 0.0001), 1.28 cmH2O/L/s (p < 0.0001) and 0.46 cmH2O/L/s (p = 0.0004), respectively. The components of respiratory reactance also deteriorated significantly, with X5 decreasing 1.7 cmH2O/L/s (p < 0.0001), Fres increasing 5.57 Hz (p < 0.0001) and ALX increasing 10.51 cmH2O/L/s (p < 0.0001). There were statistically significant and directly proportional relationships between pre- and postoperative X5 and %VC, %FEV1.0 and %FVC, with inverse relationships between pre- and postoperative Fres and ALX. CONCLUSIONS: All components measured by FOT deteriorated significantly after a relatively short period of general anesthesia and mechanical ventilation. All components of resistance increased. Of the reactance components, X5 decreased and Fres and ALX increased. Pre- and postoperative respiratory reactance correlated with parameters measured by spirometry. TRIAL REGISTRATION: JMA-IIA00136 .

Paraplegia caused by giant intradural herniation of a lumbar disk after combined spinal-epidural anesthesia in total hip arthroplasty.

Total paraplegia after epidural or spinal anesthesia is extremely rare. We herein report a case of total paraplegia caused by a giant intradural herniation of a lumbar disk at the L3-L4 level after total hip arthroplasty for coxarthrosis. The patient had no preoperative neurologic abnormalities. Intraoperative anesthetic management involved combined spinal-epidural anesthesia at the L3-L4 level with continuous intravenous propofol administration. Postoperatively, the patient complained of numbness and total paraplegia of the lower extremities. Magnetic resonance imaging showed a giant herniation of a lumbar disk compressing the spinal cord at the L3-L4 level. The intradural herniation was surgically treated, and the patient's symptoms completely resolved.

Unexpected Collection of Pulmonary Venous Blood from a Pulmonary Artery Catheter: A Case Report.

BACKGROUND: Pressure and waveform at the catheter tip are continuously monitored during catheterization of pulmonary artery to ensure accurate catheter placement. We present a case in which pulmonary venous blood was unexpectedly collected from the pulmonary artery catheter despite pulmonary artery pressure and waveform detection at the catheter tip, and describe the measures taken to correct the catheter placement. CASE PRESENTATION: A 74-year-old male underwent mitral valve plasty for cardiac failure caused by mitral valve regurgitation. Preoperative transthoracic echocardiography showed no septal shunt. The pulmonary artery was catheterized through a sheath introducer in the right jugular vein, and the balloon was inflated after insertion of a 15-cm catheter. The catheter was advanced until a pulmonary artery waveform was detected and the pulmonary artery wedge pressure was 21 mmHg at end-expiration. The balloon was deflated and the catheter tip was pulled back 3 cm. Pulmonary artery waveforms and appropriate a and v waves were detected, and transesophageal echocardiography confirmed the location of the catheter tip in the right pulmonary artery. The first collected blood sample had an oxygen partial pressure of 358.8 mmHg, carbon dioxide partial pressure of 20.1 mmHg, and oxygen saturation of 99%, indicating pulmonary venous blood. The pulmonary artery catheter was pulled back 5 cm, but a second blood sample showed the same results. The catheter was pulled back a further 6 cm while the location of the catheter tip was monitored on X-ray fluoroscopy. Blood gas testing through the catheter tip showed oxygen saturation of 84.4 % and oxygen partial pressure of 41.6 mmHg. Surgery was performed uneventfully. Postoperative chest radiographs showed proper placement of the pulmonary artery catheter, but radiographs on postoperative day 1 showed over-insertion, although the insertion length was unchanged. The catheter was removed. The patient was discharged 2 months postoperatively. CONCLUSIONS: Our case highlights the fact that the tip of the pulmonary artery catheter can easily advance into a peripheral branch of the pulmonary artery and cause pulmonary venous blood to be sampled instead of pulmonary arterial blood. A variety of monitoring techniques are needed to confirm accurate catheter placement.

[The Effects of Tracheal Suction on Respiratory Impedance].

BACKGROUND: Tracheal suctioning is performed just before extubation to remove sputum from the trachea. Although it is an invasive procedure, its adverse effect on the airway has not been investigated because this is difficult to achieve using conventional tests or monitoring. We performed a study using the forced oscillation technique to investigate whether tracheal suctioning affects respiratory impedance (consisting of respiratory resistance and respiratory reactance). METHODS: This prospective observational study was conducted in 43 patients undergoing transurethral resection of bladder tumors under general anesthesia. Respiratory impedance (R5, R20, and X5) was measured the day before surgery and just after surgery. R5 and R20 are representative values of respiratory resistance, while X5 is representative of respiratory reactance. Participants were divided into two groups: those with or without tracheal suctioning. RESULTS: There were no significant differences in patient backgrounds or preoperative respiratory impedance parameters. In the suctioning group, post- operative R5 and R20 were significantly higher than in the non-suctioning group (P=0.002 and 0.063, respec- tively). There was no significant difference in postop- erative X5 between the two groups. CONCLUSIONS: Tracheal suctioning caused an increase in respiratory resistance in this cohort of patients, sug- gesting that unnecessary suctioning should be avoided during surgery.

[Anesthetic Management of Acute Pulmonary Thrombus Trapped in a Patent Foramen Ovale Detected by Transesophageal Echocardiography].

We report a case of intracardiac thrombus detected by transesophageal echocardiography (TEE). A 61-year-old man with pulmonary embolism was trans- ferred to our hospital presenting with severe respira- tory distress. Emergency surgery was scheduled to remove the thrombus identified in the right atrium by transthoracic echocardiography (TEE). Four-chamber view TEE confirmed penetration of a patent foramen ovale (PFO) to the left atrium by a thrombus ; there was no thrombus in the right ventricle or pulmonary artery. Cardiopulmonary bypass was safely established without deep hypothermic circulatory arrest and the thrombus was removed uneventfully. Subsequent TEE confirmed the absence of the thrombus. In the present case, preoperative TEE was unable to reveal the thrombus trapped in the PFO. TEE is more sensitive in identifying precise information regarding the exis- tence of thrombi. Moreover, contrast echocardiography may help detect right-to-left shunting through a PFO.

Sudden onset of severe pulmonary edema after emergency cesarean section.

Mitral valve stenosis (MS) associated with rheumatic disease no longer represents a major heart problem during the perinatal period in Japan. Here we present a case of acute heart failure due to MS after emergency cesarean section (CS). The patient was transferred due to the development of fetal distress at 36 weeks gestation and underwent an emergency CS under general anesthesia. She developed acute heart failure immediately postoperatively and was diagnosed with MS associated with pulmonary artery hypertension for the first time. She underwent percutaneous transvenous mitral commissurotomy and was discharged from our hospital in good condition.

A postoperative left ventricular-right atrial shunt due to infectious endocarditis after aortic repair with aortic valve replacement detected by transesophageal echocardiography.

Infectious endocarditis (IE) with acute heart failure is a medical emergency. In particular, postoperative IE after aortic repair with an artificial vascular graft is a life-threatening matter. We present a case in which a mobile abscess appeared on the aortic valve annulus with an intra-cardiac shunt in the left ventricle (LV) to the right atrium (RA) after ascending aortic repair with aortic valve replacement (AVR) for acute type A aortic dissection. It was diagnosed with transesophageal echocardiography (TEE), which prompted further exploration.

Usefulness of intraoperative transesophageal echocardiography for evaluation of circumflex coronary artery fistula with ruptured aneurysm draining into coronary sinus.

A coronary artery aneurysm (CAA) is defined as dilatation of a coronary artery to a diameter >1.5 times that of the adjoining normal coronary artery. Giant CAAs with a diameter ≥ 50 mm are quite rare. Coronary artery fistulas are also uncommon, and affected patients require prompt diagnosis and treatment. Coronary angiography is the most common method of diagnosing coronary artery fistulas; however, transesophageal echocardiography (TEE) can also be a key intraoperative tool. In the present report, we describe the case of an 83-year-old man urgently admitted to our hospital with pericardial tamponade. Enhanced computed tomography and coronary angiography revealed a bulging left main and circumflex artery that was connected to a 50-mm diameter CAA. Emergency intraoperative TEE clearly showed a CAA with a surrounding hematoma, bulging circumflex artery, and a fistulous connection to the coronary sinus; the fistulous vessel contained a thrombus. Surgical repair was successful. This case demonstrates that CAA can rupture because of spontaneous closure of a thrombus-containing fistula and that intraoperative TEE could help to clearly identify the location of the CAA and fistulous connection.